Microbial Prevalence and Antimicrobial Resistance in Children and Adolescents with Chronic Rhinosinusitis in South Indian Population

Chronic rhinosinusitis (CRS) is a common multifactorial upper respiratory disease with a key role of microbes in worsening of disease and its associated co-morbidities. Further, significant region specific variation in patient demographics and antibiotic resistance of causative bacteria are reported to pose difficulty in diagnosis and treatment. In India, studies on the etiology and antibiotic resistance in chronic rhinosinusitis are very meager, especially in children. The present study aimed to determine the prevalence of common causative microbes and their antibiotic resistance in children and adolescents with chronic rhinosinusitis in South Indian population.  The present study was conducted on 89 children and 99 adolescents with chronic rhinosinusitis who visited MAA ENT Institute, Hyderabad, South India. The study samples were collected under the nasal endoscopic guidance from the middle meatus at first visit and sinuses at surgery. Conventional and VITEK-2 methods were used for identification and antibiotic sensitivity of the microbes. Chi-square test and multinomial logistic regression was applied to determine statistical differences between the variable using PASW v. 18.0 software (SPSS Inc., Chicago, IL).  The male-female ratio was 2:1 with an average children age of 8.9 ± 3.65 years and 16.1 ± 1.23 years in adolescents. The risk for adenoids was seen in 49.2 % of children (OR; 2.6: 95% CI: 1.63-4.06) while allergic fungal sinusitis (18.1%, OR: 2.7; 95% CI: 1.12-6.57) and nasal polyps (26.6%, OR: 2.3; 95% CI: 1.07-4.86) was commonly seen in adolescents. About 26.6% of adolescents with fungal positivity also showed bacterial infection. Aspergillus flavus (68%) was the most common fungi identified. Bacterial culture rate was positive in 46.8% of the total subjects of which Streptococcus aureus was the most common bacteria (59.1%) followed by Streptococcus pnuemoniae (21.2%), Klebsiella sp. (11.4%), Pseudomonas aeruginosa (11.4%) and β hemolytic streptococci (1.1%). No Methicillin-resistant Staphylococcus aureus strains could be identified. Streptococcus pneumonia (63.2%) was commonly identified in younger children and Pseudomonas aeruginosa (80%) was mostly seen in adolescents. The frequency of bacterial positivity in adolescents with CRS when compared to CRS children was high and varied between different associated co-morbidities. High antibiotic resistance in Staphylococcus aureus was seen towards gentamicin (73%) and co-trimoxazole (64%), Streptococcus pnuemoniae to gentamicin (58%), cotrimoxazole (68%) and meropenem (32%), Pseudomonas aeruginosa to co-trimoxazole (100%), cefatoximine (60%) and cefatazidime (50%) while Klebsiella sp. to gentamicin (80%) and co-trimoxazole (60%). Streptococcus aureus showed high sensitivity to cefatoximine (95.8%) and Streptococcus pnuemoniae for ofloxacin (100%), ciprofloxacin (89.5%) and cefazolin (89.5%). Pseudomonas aeruginosa showed high sensitivity for amikacin (100%) and ciprofloxacin (80%) and Klebsiella sp. for amikacin (100%)  Significant regional specific variation in bacterial etiology that differed with age, severity and comorbidities was observed in children and adolescents with chronic rhinosinusitis. High antimicrobial resistance in the cultures of chronic rhinosinusitis patients at their first visit and also at sinus surgery warrants urgent need for early initiation of personalized interventions for better management of the infectious disease.