Otitis media (OM) is an inflammatory illness that results in temporary or permanent hearing impairment due to fluid effusion or pathological alterations in the tympanic membrane of the middle ear. Otitis media is a significant contributor to hearing loss in people of all ages but is more common among children under-five years of age.
Key factors contributing to its development include lack of vaccination, inadequate breastfeeding, overcrowding, and malnutrition. In sub-Saharan Africa and other developing nations including Ethiopia, OM is increasingly prevalent and the most predominant pathogenic bacteria associated with these infections include weree S. aureus, P. mirabilis, P. aeruginosa, Klebsiella spp. and H. influenzae.
Globally, among 709 million patients with AOM, 51% were children under five years old. On the other hand, AOM is responsible for approximately 25% of antibiotic prescriptions among children.
An estimated 1.23 billion individuals are affected with bacterial ear infections worldwide, contributing to morbidity, mortality, and preasure on healthcare systems. Bacteria are the most common agents for OM. The most common causative agents are Pseudomonas aeruginosa (P. aeruginosa), Staphylococcus aureus (S. aureus), Proteus mirabilis (P. mirabilis), Klebsiella pneumoniae (K. pneumoniae), Streptococcus pyogenes (S. pyogenes), Streptococcus pneumoniae ( S. pneumoniae), Haemophilus influenzae (H. influenzae) and Moraxella catarrhalis (M. catarrhalis).
The World Health Organization (WHO) report highlights a significant global health crisis attributed to drug-resistant pathogens. With an estimated 25,000 deaths annually and 1.5 billion people affected, the economic and healthcare burdens are profound. As a result of excessive and indiscriminate antibiotic use, resistance pathogen and spread of resistant bacteria are increasing and poses a global public health treat.
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Limited laboratory resources in developing nations often compel physicians to treat patients empirically with broad-spectrum antibiotics, leading to the emergence of drug-resistant bacterial strains. This shift has affected the management of otitis media and its complications. Understanding the transmission and resistance genes of bacterial species is vital for effective antibiotic selection.
In low-income countries, otitis media treatment frequently relies on clinical symptoms without laboratory testing or drug susceptibility assessments, heightening the risk of resistant infections and leading to preventable complications like deafness and meningitis.
In Ethiopia, S. aureus isolates displayed high resistance levels to penicillin, tetracycline, and oxacillin, respectively. P. aeruginosa, Proteus spp., E. coli, and K. pneumoniae demonstrated resistance to amoxicillin/clavulanic acid and ampicillin. However, ceftazidime, piperacillin, ceftriaxone, gentamicin, amikacin, ciprofloxacin, chloramphenicol, and cotrimoxazole were effective antibiotics against most Gram-negative bacterial isolates.
Bacterial ear infections, particularly OM, are significantly influenced by socio-environmental factors such as lack of vaccination, inadequate breastfeeding, overcrowding, and malnutrition. Vaccination against pathogens like Streptococcus pneumoniae and Haemophilus influenzae is crucial for reducing infection rates, especially in vulnerable children. In Ethiopia, the high prevalence of bacterial ear infections presents a serious health risk across all age groups, often leading to complications like hearing impairment.
The rise of multidrug-resistant bacterial pathogens raises significant concern within the healthcare community, limiting treatment options.
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This systematic review and meta-analysis aim to fill this knowledge gap by consolidating data from relevant studies conducted in Ethiopia. By integrating findings from various sources, we investigate the pooled prevalence of bacterial ear infections and patterns of multidrug resistance (MDR) among patients suspected of ear infections. This research aims to inform the development of targeted and effective management strategies.
Otitis Media: Anatomy, Pathophysiology, Risk Factors, Types of OM, Symptoms and Treatment, Animation
Methods
This systematic review and meta-analysis sought to establish the collective occurrence of bacterial ear infections and the trends in multidrug resistance among patients suspected of ear infections in Ethiopia. The study adhered to the guidelines outlined in the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. The review protocol was registered in the International Prospective Register of Systematic Review (PROSPERO) under registration number CRD42023439437.
The review includes articles published from January 1, 2010, to April 16, 2023, focusing on studies related to bacterial isolates and multidrug-resistant patterns in patients with ear infections in Ethiopia. A thorough search was conducted across several electronic databases, including PubMed, Google Scholar, Scopus, ScienceDirect, African Index Medicus, African Journal Online (AJOL), Ethiopian Journals, and the WHO Afro Library, between April 6 and April 16, 2023. Additionally, a supplementary search of reference lists from relevant articles was performed to ensure comprehensive coverage.
The search was guided by the CoCoPop framework, leading to the development of targeted search terms such as “prevalence,” “epidemiology,” “magnitude,” “bacterial ear infections,” “antimicrobial resistance,” “antibiotic resistance,” “antibiotic susceptibility,” “otitis externa and otitis media,” “ear inflammation,” and “Ethiopia.” These terms were systematically combined using “OR” and “AND” to enhance article retrieval efficiency.
This systematic review and meta-analysis was to determine the prevalence of bacterial ear infections among patients suspected of having ear infections in Ethiopia. The primary objective was to assess the pooled prevalence of bacterial profiles, while the secondary objective focused on analyzing the multidrug resistance patterns of pathogens among these Ethiopian patients.
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Before selecting pertinent full-text articles published in English from both local and international journals, a checklist was developed to evaluate study eligibility. The inclusion criteria focused on articles that addressed bacterial ear infections and their antimicrobial resistance profiles across all age groups, specifically targeting laboratory-based observational studies, such as cross-sectional and retrospective studies. Conversely, the exclusion criteria eliminated articles lacking information on bacterial isolates, as well as qualitative inquiries, review articles, commentaries, case series, case reports, conference proceedings, and abstracts This systematic approach ensured that only relevant studies were included, thereby enhancing the understanding of bacterial ear infections and their associated antimicrobial resistance patterns.
Independent reviewers conducted the data extraction using a standardized format based on the Joanna Briggs Foundation (JBI) data extraction template, which was validated by an additional group of reviewers. The extracted data were meticulously documented in a Microsoft Excel spreadsheet. Each article was independently assessed by two reviewers to ensure a comprehensive and unbiased evaluation. The extracted information included the first author’s name and publication year, study period and design, geographical location of the study, total sample size and isolates, diagnostic criteria for bacterial ear infections, counts and proportions of Gram-positive and Gram-negative bacteria, and prevalence of multidrug resistance. This rigorous approach enhances the reliability and validity of our findings.
The quality of the articles was methodologically assessed by five authors using the JBI quality appraisal tool. The full texts of the articles were reviewed to ensure they met the selection criteria and to identify any concerns regarding their eligibility. Using the critical appraisal checklists, studies that scored between 50 and 75% were deemed of good quality, while those scoring above 75% were classified as high quality. Consequently, articles meeting either the good or high-quality criteria were included in the analysis of bacterial profiles and the prevalence of multidrug resistance.
Data analysis was conducted using STATA statistical software version 14.0. The pooled estimates and multidrug resistance (MDR) of the isolates were calculated using a random-effects model. Additionally, subgroup and meta-regression analyses were performed to identify potential sources of heterogeneity. Heterogeneity among studies was evaluated using Cochran’s Q test and I2 statistics, with a p-value of < 0.05 considered indicative of significant heterogeneity and the Der Simonian-Laired random-effects model was used. Subgroup analyses were conducted based on region, study design, sample size, and population type. The results were presented in a table and a forest plot. Publication bias was assessed by examining the symmetry of the funnel plot and utilizing Egger’s test statistics. For asymmetrical funnel plots, trim-and-fill analysis was applied to account for missing studies and estimate an adjusted effect size. Additionally, meta-regression was used to further explore the sources of heterogeneity.
Results
The initial search across the databases yielded a total of 1,220 articles. After removing 470 duplicates, approximately 750 articles remained. A preliminary review of titles, abstracts, and study objectives led to the exclusion of 680 articles. Ultimately, 70 full-length articles were rigorously assessed against the established eligibility criteria, resulting in the inclusion of 14 studies in the final meta-analysis.
Table 1 summarizes the characteristics of the 14 original articles included in our systematic review and meta-analysis, which originate from various regions of Ethiopia. These studies, conducted between 2000 and 2023, contribute to the evaluation of the pooled prevalence and multidrug resistance (MDR) of bacterial isolates linked to ear infections.
A total of 14 studies were selected, which yielded 3,667 bacterial isolates from 4,566 samples collected from patients suspected of having bacterial ear infections at healthcare facilities. This systematic review and meta-analysis found that the pooled prevalence of bacterial ear infections in Ethiopia was 73.391% (95% CI 65.148-81.634), indicating significant heterogeneity (I2 = 98.5%, p < 0.001) among studies.
Subgroup analyses indicated that the prevalence of bacterial ear infections was 73.18% (95% CI: 64.32-82.05, I2 = 97.6%, p < 0.001) in studies conducted in the Amhara region, and 51.95% (95% CI: 5.50-98.41, I2 = 98.7%, p < 0.001) in the South nationality. In contrast, Oromia showed a significantly higher prevalence of 94.46% (95% CI: 37.26-43.66, I2 = 0%, p = 0.764). Further subgroup analysis by study populations revealed a prevalence of 71% (95% CI: 57.18-84.81, I2 = 98.9%, p < 0.001) among all age groups, and 73.45% (95% CI: 45.04-101.88, I2 = 98.9%, p < 0.001) specifically in children, with heterogeneity between groups at p = 0.243. Additionally, analysis based on study design showed that retrospective studies had a prevalence of 8.18% (95% CI: 78.72-78.84, I2 = 83.0%, p < 0.001), while cross-sectional studies reported a prevalence of 68.22% (95% CI: 52.69-83.76, I2 = 99.1%, p < 0.001), with heterogeneity between groups at p = 0.086.
The prevalence of multidrug resistance (MDR) among bacterial ear infections ranged from 32.4% to 97%. The pooled prevalence of MDR in Ethiopia was found to be 72.45% (95% CI: 66.86-78.04), demonstrating a high degree of heterogeneity a... AbstractBackground Otitis media is among the leading causes of illnesses responsible for causing hearing problems and adding significant costs to the public health system.
Bacteria are the most common causative agents for otitis media. Sociodemographic and clinical data were obtained by trained nurses and/or health officers in face-to-face interviews using structured questionnaires. Middle ear discharge samples were collected by Ear, Nose and Throat (ENT) specialists (Otolaryngologist) following all aseptic techniques. Conventional culture, different biochemical tests and antimicrobial susceptibility testing were performed for all the isolated bacteria. Reference strains were used as a positive and negative controls. The data were checked for completeness and consistency, entered into EpiData version 4.6.06 and analyzed by SPSS version 25. Logistic regression analysis was performed to determine the associated factors of otitis media. Adjusted odds ratio was used to determine strength of association. Statistical significance was obtained at p-value of below 0.05. The data were interpreted using graphs, tables, and results statements.
A total of 242 middle ear discharge samples were collected from the study participants and analyzed. Males and females accounted for 129 (53.3%) and 113 (46.7%) of the participants, respectively. The age of the participants ranged from 1 to 65 years, with mean and median ages of 17.1 and 14.0 years, respectively. Ninety-one (37.6%) of them were aged less than five years, while 73 (30.2%) were aged 25 years and older. One hundred sixty-five (68.2%) and 77 (31.8%) of the participants were from urban and rural areas, respectively (Table 1).
Two hundred twelve middle ear discharge samples were positive for culture resulting in an overall 87.6% prevalence of bacterial isolates. Among cultured middle ear discharges, 196 (92.5%) yielded double growth while 16 (7.5%) showed single (mono) growth. A total of 228 bacterial pathogens were recovered from positive cultures constituting (107, 46.9%) Gram-positive and (121, 53.1%) Gram-negative bacteria. From the total bacterial isolates, S. aureus (92, 40.4%) and P. aeruginosa (33, 14.5%) were the predominant bacterial species followed by E. coli (24, 10.5%) and K. pneumoniae (16, 7.0%) (Table 2).
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