doi:

Nig. J. Pure &Appl. Sci. Vol. 30 (Issue 1, 2017) ISSN 0794-0378 (C) 2017 Faculty of Physical Sciences and Faculty of Life Sciences, Univ. of Ilorin, Nigeria www.njpas.com.ng doi: http://dx.doi.org/10.19240/njpas.2017.a10 Page 2965 Aerobic bacteriology of throat swabs in adult patients with chronic rhinosinusitis in Lokoja, Kogi state, Nigeria S.A. Ogah, 1 * J.I. Ogah, 2 I.E. Enesi, 3 D.I. Oseji 3 1 Consultant Oto-rhino-laryngologist, Head and Neck Surgeon, Otolaryngology Division, Department of Surgery, Federal Medical Centre, P.M.B. 1001, Lokoja, Nigeria. 2 Infectious Diseases and Environmental Health Research Group, Department of Microbiology, Faculty of Life Sciences, University of Ilorin, Kwara State, Nigeria. 3 Department of Ophthalmology, Federal Medical Centre, P.M.B. 1001, Lokoja, Nigeria. Abstract Allergy, pollutants, infections, anatomical variation, and immunological factors are involved in chronic rhinosinusitis. As the bacterial flora kept changing and with frequent antibiotic resistance to the commonly used drugs, there is need for a bacteriological study to identify the causative pathogens and their antibiotic susceptibility for cost effective management of the disease. Eighty six patients with chronic rhinosinusitis and 25 well adults (control) had swab taken from their posterior nasal mucosa with the aid of a head light and angle metallic tongue depressor. Blood and MacConkey s agar plates were used for overnight incubation at 37 C. Bacterial growth identified using colonial morphology, Gram stain results and key biochemical reactions. Kirby-Bauer s method was used for the antimicrobial susceptibility testing for all isolates. Results showed that patients were 41males and 45female, male to female ratio was 1:1.2, mean age was 25.34±12SD years and the modal age group was 31-40years (25.6%).Of the 86 patients, 44(51.2%) were culture positive for aerobic bacteria, 2(2.3%) fungi and 40(46.5%) had no growth. Controls were 12males and 13females with a male to female ratio of 1:1.1. Eleven (44%) of the control had no growth and 14(56%) had Staphylococcus aureus only. The predominant bacterial isolate from patients was Pseudomonas aeruginosa 12(14.0%) followed by S. aureus (11.6%) and Imipenem had the highest drug susceptibility followed by ciprofloxacin. Keywords: aerobic, bacteriology, chronic, rhinosinusitis, susceptibility. Introduction Rhinosinusitis is an inflammatory condition of the nose and sinus mucosae characterized by major and minor signs/symptoms (Benninger et al., 2008). Major signs/symptoms include facial pain, facial congestion, nasal obstruction, nasal discharge, hyposmia and fever. The minor ones include headaches, dental pain, ear pain, ear fullness, fever, halitosis, fatigue, and cough. Having two major symptoms/signs or one major and two minor symptoms/signs is enough to make the diagnosis (Hamilos et al., 2011). Corresponding Author: S.A. Ogah, Department of Surgery, Federal Medical Centre P.M.B. 1001, Lokoja, Kogi State, Nigeria. Email: stephenogah@yahoo.commobile: +2348075224222

Page 2966 The paranasal sinuses are a common site of infection in human beings with frequent morbidity and rare mortality (Aanan et al., 2005). Infections in them almost always spread into the nasal cavity hence the use of the encompassing word rhinosinusitis. Based on the disease duration, it is classified into acute (1-4 weeks), sub-acute (4-12 weeks), chronic (greater than 12 weeks) and recurrent (4 or more episodes per year) by the Rhinosinusitis Task Force of the American Academy of Otolaryngology (Report of the Rhinosinusitis Task Force Committee Meeting. Alexandria, Virginia, August 17, 1996). Common predisposing factors include acute upper respiratory tract viral infections, allergic conditions, anatomical variation of the nasal structures, obstruction of the sinus drainage and defect in the mucocilliary function (van Cauwenberge et al., 2006). By reason of frequent failure in antibiotic treatment, acute exacerbations and recurrences, the disease usually requires many courses of antibiotics with occasional surgical procedures. Cost effective management of rhinosinusitis therefore will depend on the knowledge of causative microorganisms and their antimicrobial sensitivity test (Ogah and Ogah, 2016). Several hypotheses are now available to help explain the pathophysiology of chronic rhinosinusitis but none of them is sufficient enough to explain the cascades of event that are noticed in the disease course (Mantovani et al., 2010). Suggested four sites of effective sample collection in chronic rhinosinusitis include (1) from the sinus itself (via sinus puncture), (2) from the sinus ostium at the middle meatus with the aid of an endoscope, (3) from the posterior nasal mucosa and (4) from the anterior nasal mucosa based on the available facilities. A major drawback of all the collecting sites is frequent sample contamination if adequate sterility measures are not put in place during the procedure. Varalakshmi et al. (2016) had also shown that collected samples from the middle meatus using an endoscopic technique is as good as that collected from the sinus with a puncture. Rhinosinusitis is an inflammatory condition of the nose and paranasal sinus mucosae. Materials and Methods This is a hospital based prospective study carried out in the ENT clinic of the Federal Medical Center Lokoja between January 2014 and December 2015. One hundred and eleven subjects were recruited for the study by convenience sampling method. They consist of 86 adult patients with a clinical diagnosis of chronic rhinosinusitis and 25 well adults to serve as control. The patients were 41males and 45females, and the control were 12males and 13 females with age ranging from 21-80 years. With aseptic condition strictly followed, all subjects had a throat swab taken from their posterior nasal mucosa with the aid of a good head light and an angle metallic tongue depressor. Blood and MacConkey s agar plates were used for overnight incubation at 37 C. Bacterial growth identified using colonial morphology, Gram stain results and key biochemical reactions. Kirby-Bauer s method was used for the antimicrobial susceptibility testing for all isolates. Results The total number of patients were 86, consisting of 41 males and 45 females and male to female ratio was 1:1.2. Mean group

Page 2967 age of 25.34years and the modal age group was 31-40 years (25.6%) as shown in Table 1. Out of the 86 samples, 44(51.2%) were culture positive for bacteria, 40(46.5%) samples had no growth in them and 2 (2.3%) samples had fungi as shown in Figure1 and Anaerobes where not cultured due to lack of the facility. The predominant bacterial isolate was Pseudomonas aeruginosa (14.0%) followed by Staphylococcus aureus (11.6%), E. coli (9.3%), S. epidermidis (9.3%) and Klebsiella spp (4.6%) as shown in Table2. Imipenem (93.2%) had the highest susceptibility followed by ciprofloxacin (90.9%) as shown in Table3. For the control group, the male to female ratio was 1:1.1, 11(44%) samples had no growth and 14(56%) had S. aureus only. Table1: Age and Gender distribution of patients with chronic rhinosinusitis Age group Number of Males (%) Number of Females (%) Total (%) 21-30 8(9.3) 6(7.0) 14(16.3) 31-40 10(11.6) 12(14.0) 22(25.6) 41-50 6(7.0) 9(10.4) 15(17.4) 51-60 9(10.4) 6(7.0) 15(17.4) 61-70 4(4.7) 7(8.1) 11(12.8) 71-80 4(4.7) 5(5.8) 9(10.5) Total 41(47.7) 45(52.3) 86(100.0) Male/female ratio=1:1.1 and group mean=25.34years 50 45 40 35 30 25 20 15 10 44 40 5 0 Bacteria No Growth Fungi 2 Figure1: Culture Results of adult patients with chronic Rhinosinusitis in Lokoja, Nigeria.

Page 2968 Table2: Aerobic bacteria found in adult patients with chronic rhinosinusitis in Lokoja, Nigeria. Bacteria isolate Number of Patients (%) Pseudomonas aeruginosa 12(14.0%) Staphylococcus aereus 10(11.6%) Escherichia coli 8(9.3%) Staph. epidermidis 8(9.3%) Klebsiella 6(7.0%) Total 44(51.2%) Table3: Drug sensitivity pattern in patients with chronic rhinosinusitis in Lokoja, Nigeria. Tested Isolate N Drugs in microgram/disc AMP(10) AUG(30) CRO(30) OB(5) CN(10) IPM(10) CIP(5) OFX(5) P. aeruginosa 12 0(0.0) 8(18.2) 7(15.9) 6(13.6) 10(22.7) 11(25.0) 10(22.7) 8(18.2) S. aereus 10 5(11.4) 6(13.6) 5(11.4) 4(9.1) 8(18.2) 9(20.5) 10(22.7) 8(18.2) E. coli 8 3(6.8) 5(11.4) 5(11.4) 3(6.8) 7(15.9) 8(18.2) 7(15.9) 6(13.6) S. epidermidis 8 2(4.6) 4(9.1) 3(6.8) 4(9.1) 6(13.6) 7(15.9) 8(18.2) 5(11.4) Klebsiella spp 6 2(4.6) 4(9.1) 4(9.1) 3(6.8) 6(13.6) 6(13.6) 5(11.4) 4(9.1) Total 44 12(27.4) 27(61.4) 24(54.6) 20(45.4) 37(84.0) 41(93.2) 40(90.9) 31(70.5) N=Number of isolate tested, AUG = amoxicillin clavulanate; CIP = ciprofloxacin; OFX = ofloxacin. CRO = ceftriaxone; OB = cloxcillin; CN=gentamicin; AMX = amoxicillin; IPM = Imipenem. Figures in parenthesis are in percentages Discussion In our study chronic rhinosinusitis was found commonest in the 31-40 (25.6%) age group and this is different from another study in which it was more in the younger age group of 21-30years (Incorvaia et al., 2010). A little more than half (51.2%) of our patients had aerobic bacteria being the aetiologic agents of their diseases. This study appears to be in support of an earlier study that showed chronic rhinosinusitis is a disease caused essentially by aerobic bacteria and a few facultative anaerobes (Araujo et al., 2003). It is therefore not out of place to do an aerobic bacterial study to aid the treatment of our patients especially when facilities for identifying anaerobic organisms were not available as noticed in our study. A large proportion of our patients had negative culture results which may probably be due to their previous antibiotic usage or that the culture period was not long enough to allow the growth of some pathogenic organisms. The two fungi cultured in this study may either be due to some contamination of the samples or that the involved patients have depressed immunity that should be further investigated. The commonest aerobic bacterium found in this study was pseudomonas aeruginosa which is a gram negative organism, followed by S. aureus

Page 2969 and S. pneumonia. This is similar to some studies in the past that found more of Gram Negatives in chronic rhinosinusitis in adults (Tantilipikorn et al., 2002; Rombaux et al., 2002). It may be necessary to say that Gram negatives organisms are increasingly gaining ground in this disease entity and that effort should be made to always identify them during treatment. Half of our well subjects also had S. aureus cultured and this raises the question whether S. aureus should be regarded as a pathogen in chronic rhinosinusitis. Ciprofloxacin should be consider in patients with chronic rhinosinusitis who cannot afford the high cost of imipenem which is the drug of choice in this study. Conclusion The isolation, identification and antimicrobial agent susceptibility/resistance pattern of the aetiologic microbiological agents in chronic adult rhinosinusitis will assist the attending Physician in cost effective management of the patient with this chronic debilitating disease. References Aanan, J.B. (2005). Current management of acute bacterial rhinosinusitis and the role of moxifloxacin. Clinical Infectious Diseases. 41:167-S176. Araujo, E., Bruno, P.C., Vladimir, C., Alexander, P., Mariante, Afonso, M. (2003). Microbiology of Middle Meatus in Chronic Rhinosinusitis. American Journal of Rhinology, 17(1):9-15 Benninger, M.S. (2008). Rhinosinusitis in Scott-Brown s Otolaryngology & Head- Neck Surgery; 7 th edition; Hodder Arnold 13: 1439-1440. Bezerra, T.F.P., Padna, F.G., Gebrim, E.M.M.S., Saldiva, P.H.N. and Voegels, R.L.(2009) Biofilms in chronic rhinosinusitis with nasal polyps. Braz. J. Otolaryngology, 75(6):788-793 Hamilos, D.L. (2011). Chronic rhinosinusitis: Epidemiology and medical management. Journal of Allergy & Clinical Immunology, 128:693 707. Incorvaia, C. and Leo, G. (2010) Treatment of rhinosinusitis: other medical options. International Journal of Immunopathology and Pharmacology, 23 (1):70-3 Kilty, S.J. and Desrosiers, M.Y. (2008). The role of bacterial biofilms and the pathophysiology of chronic rhinosinusitis. Current Opinion in Allergy and Asthma Rep, 8:227-233. Mantovani, K., Bisanha, A.A., Demarco, R.C., Tamashiro, E., Martinez, R., Anselmo-Lima, W.T. (2010). Maxillary sinuses microbiology from patients with chronic rhinosinusitis. Brazilian. Journal of otorhinolaryngology, 76(5): 548-551 Ogah, S.A. and Ogah, J.I. (2016). Aerobic Bacteriology of Chronic Suppurative Otitis Media (CSOM) in Federal Medical Centre Lokoja, Nigeria. Nigerian Journal of Pure & Applied Sciences, 29: 2695-2699 Report of the Rhinosinusitis Task Force Committee Meeting. Alexandria, Virginia, August 17, 1996. Otolaryngology, Head and Neck Surgery. 117(3):1-68 Rombaux, P., Gigi, J., Hamoir, M., Eloy, P. and Bertrand, B. (2002). Bacteriology of chronic sinusitis: the bulaethmoidalis content. Rhinology, 40(1): 18-23. Tantilipikorn, P., Fritz, M., Tanabodee, J., Lanza, D.C. and Kennedy, D.W. (2002). A comparison of endoscopic culture

Page 2970 technique for chronic rhinosinusitis. American Journal of Rhinology, 16(5):255-60. Van Cauwenberge, P., van Hoecke, H. and Bachert C. (2006). Pathogenesis of chronic rhinosinusitis. Current opinion in Allergy and Asthma Rep. 6:487-494 Varalakshmi, Y.U. and Sarada, D. (2016). Microbiological Study of Paranasal Sinusitis. International Journal of Current Microbiology and Applied Science, 5(2): 309-316.