Review of Otorrhea Microbiology: Is there a Pathogenic Role of

Corynebacter?

Matthew G. Crowson, M.D.OHNS Resident, Duke University Medical Center, Durham, NCKatherine CallahanHamilton College, Clinton, NYJames E. Saunders, M.D.Section of Otolaryngology, Dartmouth-Hitchcock Medical Center, Lebanon, NH

Disclosures• The authors have nothing to disclose

Introduction• Corynebacteria spp. commonly found on the skin, and

are biofilm producers on skin and medical devices5 – Often reported as “Normal Cutaneous Flora”– Shown to produce toxins such as diphtheria-like toxin,

dermonecrotic toxin, and soluble hemolysin.1

– Have been associated with pharyngitis, cutaneous infections.2

– Cultured from suppurative otitis media, otitis externa, myringitis, otitis media with perforation, cholesteatoma, post-tube otorrhea, and mastoiditis. (Saunders et al. 2010)

• Do non-diptherioid Corynebacteria species play a role in the pathophysiology of chronic purulent ear disease?

http://eyemicrobiology.upmc.com/Images/Sub/PhotoGallery/Bacteria/PhotoDiphGram.jpg

Methods• 140 microbiology cultures from purulent otorrhea in 77 patients• Microbiology laboratory was asked to speciate Corynebacteria,

provide antibiotic sensitivities

Group ‘A’ Corynebacteria spp. and all other pathogens

OR

Corynebacteria spp. only

Group ‘B’All other pathogens

• Pre-culture• Clinical diagnosis• Otorrhea, Otalgia• Hearing loss, hearing aid

use • History of otologic surgery

• Post-culture• Clinical diagnosis• Antibiotic requirement, first-

line & second-line antibiotic • Otologic surgery

Results – Species Censusn (%) n (%)

NCF 68 (30.9) Serratia marcescens 4 (1.8)Staph Aureus spp. (all) 54 (24.5) Stenotrophomonas maltophilia 4 (1.8)

Staph Aureus (MSSA) 26 Alcaligenes 3 (1.4)Staph Aureus (MRSA) 21 Proteus Penneri 3 (1.4)

Staph Aureus (Coag Negative) 6 Citrobacter koseri 2 (0.9)Staph (other) 1 Bacteroides Fragilis 1 (0.5)

Corynebacterium spp. 38 (17.3) Brevibacterium 1 (0.5)Pseudomonas 11(5.0) Burkholderia cepacia 1 (0.5)

Streptococcus (all) 8 (3.6) Enterobacter cloacae 1 (0.5)Group B Streptoccocus 4 Klebsiella oxytoca 1 (0.5)Group G Streptoccocus 1 Klebsiella pneumoniae 1 (0.5)Group A Streptoccocus 1 Klebsiella ornithinolytica 1 (0.5)Group F Streptococcus 2 Morganella morgagni 1 (0.5)

Achromobacter xylosoxidans 6 (2.7) Providencia rettgeri 1 (0.5)Turicella 5 (2.3) S. Pneumoniae 1 (0.5)

Acinetobacter lwoffi 4 (1.8) Total number of strains isolated 220

Corynebacterium Positive Cultures

• 6 unique patients (8.33%) produced cultures with Corynebacterium spp. without other potential pathogens present

• Corynebacterium spp. with cohabitating bacteria identified in 32 (24.1%) of all cultures in 24 (33.3%) unique patients

n (%)Staph Aureus Spp. (all) 7 (22)

Staph Aureus (MSSA) 6Staph Aureus (MRSA) 1

Staph Aureus (Coag Negative) 0Isolated Corynebacterium Spp. 6 (19)

Acinetobacter lwoffi 2 (6.3)Streptococcus (all) 2 (6.3)

Group B Streptoccocus 1Group G Streptoccocus 1

Alcaligenes 1 (3.1)Citrobacter koseri 1 (3.1)

Klebsiella oxytoca 1 (3.1) Serratia marcescens 1(3.1)

Stenotrophomonas maltophilia 1 (3.1) Turicella 1 (3.1)

Pseudomonas 0 (0) Other (NCF) 16 (50)

Diagnoses and Clinical Historyn (% of patients)

Diagnoses Corynebacteria-Positive Other Pathogens p-valueChronic otitis media 8 (33.3) 17 (35.4) 1.00Chronic granular myringitis 7 (29.2) 4 (9.1) 0.035Chronic mastoiditis 6 (25.0) 8 (16.7) 0.53Cholesteatoma 2 (8.3) 3 (6.3) 1.00Chronic otitis externa 1 (4.2) 11 (22.9) 0.051Acute mastoiditis 0 (0) 1 (2.1) 1.00Acute otitis media 0 (0) 3 (6.3) 0.55Chronic TM perforation 0 (0) 1 (2.1) 1.00

n (% of patients)  Clinical History Corynebacteria-Positive Other Pathogens p-value

Hearing Loss 21 (87.5) 33 (68.8) 0.15Previous Otologic Surgery 20 (83.3) 32 (66.7) 0.17Otorrhea 19 (79.2) 41 (85.4) 0.52Hearing Aid Use 11 (45.8) 9 (18.8) 0.025Otalgia 1 (4.2) 13 (27.1) 0.026

Antibiotic therapy for patients with otologic infections and Corynebacteria-positive cultures versus other pathogens

Antbiotic Required Topical Monotherapy Oral Monotherapy Combination Therapy0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%100%

46%

8%

46%

94%

44%

9%

47%

Corynebacteria-positive

Other pathogens

Antibiotic susceptibilities of Corynebacteria isolates

58.0% of Corynebacteria isolates were resistant to topical ciprofloxacin compared to 32.0% of non-Corynebacteria species isolates (p = 0.01).

Ciprofloxacin Clindamycin Penicillin Tobramycin Vancomycin Clarithromycin0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

35%

8%

68%

89%

100%

58%

71%

24%

11%

100%

Susceptible

Resistant

Discussion Points• Corynebacteria spp. were the second most common

pathogenic species identified behind Staphylococci spp.• Corynebacteria-positive infections were associated with:– Pre-culture diagnosis of chronic granular myringitis– Hearing aid use prior to presentation– Less otalgia.

• Majority of patients with Corynebacteria-positive infections harbored at least one resistant strain and Corynebacteria isolates were highly resistant to first-line fluoroquinolone therapy

Conclusions• Cornyebacteria spp. are:

– Common in these otologic infections– May be the only pathogen– Often highly resistant to ciprofloxacin ototopical

therapy

• Due to the resistance profile demonstrated in this study– Culture recalcitrant infections– Microbiology laboratories should report

Cornyebacteria sensitivities for otologic infections

Acknowledgements

• American Otologic Society• Joan Buchinski, RN – Dartmouth Hitchcock

Medical Center• Canadian Medical Association

Librarians

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