Clinical practice guideline: acute otitis externa executive summary

Bacterial Etiologies of Ear Infection and Their Antimicrobial Susceptibility Pattern at the University of Gondar Comprehensive Specialized Hospital, Gondar, Northwest Ethiopia: A Six-Year Retrospective Study

BACKGROUND

An ear infection is responsible for up to 40% of preventable hearing impairment; one of the reasons for frequent and unwise antibiotic usage, especially in the developing world. Since the incidence of antibiotic resistance is increasing, especially in resource-limited countries, up-to-date knowledge on the susceptibility of ear-discharge isolates to antibiotic is important for better patient treatment. Therefore, this study aimed at determining the bacterial etiologies and their antibiotic susceptibility profiles among patients suspected with ear infections.

METHODS

We collected retrospective data from bacteriological results of ear discharge samples from 2013 to 2018. Sample collection, culture preparation, and bacterial identification were performed using standard microbiological techniques. Antimicrobial susceptibility testing was performed following Clinical and Laboratory Standard Institute (CLSI) guidelines. We extracted and inputted the data using Epi-info version 7 and exported it to SPSS version 20 for analysis.

RESULTS

The overall ear-discharge culture positivity rate was 283/369 (76.7%) (95% CI = 72.4-81.3), with 14/283 (4.95%) mixed infections. Staphylococcus aureus (27.9%), Proteus spps (20.8%), Streptococcus spps (10%), and Pseudomonas spps (8.92%) were the main isolates. High-level resistance rates for tetracycline (77.6%), penicillins (67.2%), erythromycin (52.6%), and co-trimoxazole (52%), and low-level resistance rates for fluoroquinolones (23.3%), aminoglycosides (23.7%), and cephalosporins (29.8%) were observed. More than 45% of isolates, with 50.9% of Gram-negative and 37.3% of Gram-positive, were multidrug-resistant.

CONCLUSION

Staphylococcus aureus, Proteus mirabilis, Proteus vulgaris, Escherichia coli, and Pseudomonas aeruginosa were the leading cause of ear infections. The presence of high number of multidrug-resistant strains calls for the need for periodic and continuous follow-up of antibiotic usage in the study area. Further studies are recommended to explore the types of ear infections, with their etiologic agents and possible risk factors.

Norfloxacin loaded nano-cubosomes for enhanced management of otitis externa: In vitro and in vivo evaluation

The research's goal is to design and formulate nano-structured cubosomes loaded with norfloxacin (NFX)formanagement of otitis externa. In this study, glyceryl monooleate (GMO) as lipid phase, Cremophor EL as surfactant and either Pluronic F108 or Pluronic F127 as stabilizer were the used ingredients. The nano-cubosomal formulation "CUB 1" (its dispersed phase is composed of GMO (95%), Cremophor EL (2.5%) and Pluronic F108 (2.5%)) was the best achieved one. It had small particles size (216.75 ± 2.47 nm), good polydispersity index (0.339 ± 0.012) and acceptable zeta potential (-41.2 ± 2.262 mV). Images obtained after transmission electron microscopy examination ensured nearly cubic shape of formed nanoparticles with excellent dispersibility. Moreover, micrographs of rabbit ear skin specimens examined by confocal laser microscopy ensured good permeation capability of nano-structured cubosomes.In addition, in vivoskin deposition results revealed that higher amount of NFX was deposited in the rabbit ear skin throughout the study period (10 h) compared to drug suspension. Additionally, histopathological results proved that NFX loaded cubosomes can be safely applied topically on ear skin without any signs of inflammation nor skin irritation. Accordingly, these results anticipated the nano-structured cubosomal capabilities as a favorable nano-carrier for dermal NFX delivery to external ear skin for enhancing the management of otitis externa.

Adherence to Subspecialty Guidelines in the Emergency Department

OBJECTIVES/HYPOTHESIS

The American Academy of Otolaryngology-Head and Neck Surgery has published clinical practice guidelines (CPGs) to guide management of common otolaryngologic (ENT) conditions. While these CPGs have been disseminated within specialty journals, many patients' first presentation of certain ENT complaints is to primary and acute care settings, including the emergency department (ED). It is less clear whether practice in these settings is concordant with specialty CPGs.

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective review of medical records was performed at an academic tertiary care center with ED diagnoses of 1) Bell's palsy/facial weakness (BP) or 2) acute otitis externa (AOE) from May 2014-June 2018. Individual chart abstraction was performed for all encounters with these diagnoses for the purpose of assessing providers' adherence to CPGs.

RESULTS

During the study period, 224 patients were diagnosed with BP and 465 patients were diagnosed with AOE. Of the patients diagnosed with BP, 94% (n = 211/224) were prescribed oral steroids, concordant with guidelines, while 36% of these patients received head computed tomography (CT) scans and 43% received laboratory tests, counter to the guidelines. For those with a diagnosis of AOE, 28.6% received topical antibiotics only as primary treatment (n = 133/465) in accordance with guidelines while systemic antibiotics were prescribed in 42.2% (n = 196/465) discordant with the guidelines and 29.2% received both topical and systemic antibiotics (n = 136/465).

CONCLUSIONS

CPGs developed by subspecialty societies provide evidence-based recommendations for the care of patients with particular conditions, but may not be disseminated broadly outside of the specialty. Further research is required to understand the reasons behind divergent management of such conditions.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1266-1270, 2021.

Upper Respiratory Tract Diseases in Athletes in Different Sports Disciplines

Upper respiratory tract diseases in athletes are a very common medical problem. Training conditions in different sports disciplines increase the risk of upper respiratory disease. Epidemiological evidence suggests that heavy acute or chronic exercise is related to an increased incidence of upper respiratory tract infections in athletes. Regular physical exercise at high intensity may lead to transient immunosuppression due to high prevalence of allergic diseases in athletes. Regardless of the cause they can exclude athletes from the training program and significantly impair their performance. In the present work, the most common upper respiratory tract diseases in athletes taking into account the disciplines in which they most often occur were presented. The focus was laid on symptoms, diagnostic methods and pharmacotherapy. Moreover, preventive procedures which can help reduce the occurrence of upper respiratory tract disease in athletes were presented. Management according to anti-doping rules, criteria for return to training and competition as an important issues of athlete’s health were discussed.

Medical Care of the Aquatics Athlete

Competitive swimmers are affected by several musculoskeletal and medical complaints that are unique to the sport. 'Swimmer's shoulder,' the most common overuse injury, is usually caused by some combination of impingement, rotator cuff tendinopathy, scapular dyskinesis, and instability. The condition may be treated with training modifications, stroke error correction, and strengthening exercises targeting the rotator cuff, scapular stabilizers, and core. Implementation of prevention programs to reduce the prevalence of shoulder pathology is crucial. Knee pain usually results from the breaststroke kick in swimmers, and the 'egg beater' kick in water polo players and synchronized swimmers. Lumbar back pain also is common in aquatics athletes. Among the medical conditions of particular importance in swimmers are exercise-induced bronchoconstriction, respiratory illnesses, and ear problems. Participants in other aquatics sports (water polo, diving, synchronized swimming, and open water swimming) may experience medical ailments specific to the sport.