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62 http://journals.cihanuniversity.edu.iq/index.php/cuesj CUESJ 2022, 6 (2): 62-67

ReseaRch aRticle

Microbiological Survey of Ear Infections in Inhabitants of 
Erbil City
Ameena S. M. Juma, Treska Dh. Kamil, Muhsin H. Ubeid

Department of Medical Microbiology, Cihan University-Erbil, Kurdistan Region, Iraq

ABSTRACT

This study was carried out to indicate the number of infected individuals with ear infection from different genders and ages determine 
the antibiotic sociability for the ear swab bacterial isolates. A total of 82 ear swabs were obtained in Erbil City from various hospitals and 
laboratories. Males made up 48 (59%) of the 81 samples, while females made up 33 (41%). 0–10 years had the most bacteria isolated from 
ear swabs, followed by 11–20 years and then 21–40 years. Pseudomonas spp. was the most prevalent bacteria found in all of the swabs 
(43%). Pathogenic bacteria were found in 70% of the samples, while no growth was seen in 30% of the swabs. Many bacterial isolates were 
found to be sensitive to the antibiotic Amikacin, which was determined to have the best effect on 35 of them. Clotrimazole was shown to 
be the least effective antibiotic on numerous bacterial strains, with 19 being resistant.

Keywords: Ear infection, antibiotic sensitivity test, Pseudomonas, amikacin

INTRODUCTION

Infections of the ear can affect either the inner or outer ear. Ear infections are divided into three different forms, according to the Centers for Disease Control and Prevention. 
Acute otitis media (AOM), otitis media with effusion (OME), 
and otitis externa, sometimes known as swimmer’s ear, are the 
three forms. Children are the ones that get ear infections the 
most. According to the National Institutes of Health (NIH), 
three out of every four children will have at least one ear 
infection by the age of three (NIH).[1]

A bacterial or viral infection of the middle ear is known 
as an ear infection. Inflammation and fluid accumulation in 
the ear’s interior canals are caused by this illness. The middle 
ear is a space behind the eardrum which is exposed to air. It 
has vibrating bones that translate sound from outside the ear 
into impulses that the brain can understand. Ear infections are 
unpleasant, because he inflammation causes the eardrum to 
swell.[2]

The most common respiratory infection in children is 
middle ear infection, also recognized as otitis media. Middle 
ear infection is caused mainly by Streptococcus pneumoniae 
(pneumococcus). Pneumococcal conjugate vaccines are being 
used to protect young children from severe pneumococcal 
infections such as meningitis and pneumonia.[3]

Ear infections can occur as a result of poor needle 
technique, excessive needle retention, or the patient’s inability 
to properly care for his or her ear just after treatment. Because 
the ear has a lower blood circulation than the rest of the body, 

once an infection occurs or involves the cartilage, it will be 
extremely difficult to treat. Infections that are severe enough 
can cause the ear to swell and the cartilage to deteriorate.[4]

In general, there are three types of ear infections: AOM 
(inflammation of the middle ear). The term “ear infection” 
is commonly used to refer to AOM. If there is fluid in the 
middle ear, indications or symptoms of infection, and the 
onset of symptoms was relatively rapid, the doctor will most 
likely make this diagnosis. Medial otitis with effusion, where 
the clinician finds evidence of fluid in the middle ear if the 
diagnosis is OME, but no signs or symptoms have appeared. 
Chronic otitis media with suppuration is when a doctor 
confirms chronic suppurative otitis media (CSOM), he or she 
discovers that a persistent ear infection caused the eardrum to 
tear or perforate. Antibiotics are not always effective to control 
ear infections. What is best for the patient is determined by 
several of factors, including the patient’s age and the severity 
of his or her symptoms.[5]

Corresponding Author:  
Treska Dh. Kamil, Department of Medical Microbiology, Cihan 
University-Erbil, Kurdistan Region, Iraq.  
E-mail: treska.kamil@cihanuniversity.edu.iq

Received: June 20, 2022 
Accepted: July 11, 2022 
Published: August 20, 2022

DOI: 10.24086/cuesj.v6n2y2022.pp62-67

Copyright © 2022 Ameena S. M. Juma, Treska Dh. Kamil, Muhsin H. Ubeid. This 
is an open-access article distributed under the Creative Commons Attribution 
License (CC BY-NC-ND 4.0).

Cihan University-Erbil Scientific Journal (CUESJ)



Juma, et al.: Microbiological Survey of Ear Infections in Inhabitants of Erbil City

63 http://journals.cihanuniversity.edu.iq/index.php/cuesj CUESJ 2022, 6 (2): 62-67

Infections of the ears are still a problem in the community. 
Hearing loss affects 360 million individuals globally, 32 million 
of them are children.[6] During a year, 653,025 instances of 
middle ear infection were recorded in Iraq, 1,737,214 cases 
in Iran, 144,405 cases in Jordan, 58,098 cases in Kuwait and 
463,669 cases in Syria, and many other nations in the area 
(Right Diagnosis from Health Grades Inc., 2015). Otitis media 
was reported to affect 36.7% of the population in Erbil City.[7]

Ear infections are a huge issue all across the world, as 
the below data demonstrate. In recent years, there has been 
some new information about this virus in the area. As a result, 
the following objectives were set for this research: Record the 
number of ear infection cases in Erbil City in relation to age 
and gender and to investigate the antibiotic sensitivity and 
resistance of the isolated bacteria to a variety of antibiotics.

MATERIALS AND METHODS

Study design this was a 4-month prospective research that 
was conducted from December 2017 to March 2018. In Erbil 
City, the patients have been treated for ear infections at several 
hospitals and private laboratories.

The samples of the study were collected from 82 patients, 
48 men and 33 women.

Sample Collection

The presence of purulent material in all of the ear infections 
led the expert healthcare workers to conclude that they were 
infected. Only one swab (Sterilin, U.K.) was taken from 
each patient. Each ear’s exudate was meticulously collected 
according to departmental regulations. To avoid the swabs 
drying out, the samples were delivered to the microbiology 
laboratory within 1 h of being collected.

Isolation and identification of bacteria swabs were 
inoculated on MacConkey agar, Chocolate agar, and Blood 
agar (Oxoid, U.K.) right away and incubated aerobically for 
24–48 h at 37°C. Due of logistical issues, anaerobic cultures 
were not performed. Bacterial colonies on agar plates were 
identified using Gram staining. Bacterial isolates were 
identified and classified using biochemical techniques.

Standard microbiological procedures were used to characterize 
bacterial isolates.[8] Gram stain, morphological and cultural features 
on agar, spore stain, motility and carbohydrate fermentation tests, 
nitrate reduction, catalase, hydrogen sulfide production, and indole 
production were among the tests that were performed.

Citrate utilization, gelatin liquefaction, the Methyl Red-Voges 
Proskaeur test, coagulase, hemolysis on blood agar, morphological 
and cultural characteristics on mannitol salt, and eosin-methylene 
blue agar are along with the other tests performed.

ANTIBIOTIC SENSITIVITY TEST

The Kirby–Bauer disk diffusion method was used to test antibiotic 
susceptibility, and the results were interpreted using the National 
Committee for Clinical Laboratory Standards’ recommendations. 
Antibiotics that were applied included in the study:

Table 1 shows the antibiotics used in the susceptibility test 
on bacteria isolated from ear swabs.

RESULTS

Swabs the total number of swabs collected in the current 
study was 81 ear swabs from different hospitals and private 
laboratories in Erbil City. Gender of patients from the 
81 samples, 48 (59%) were male and 33 (41%) were female 
[Figure 1].

Table 1:List of Antibiotics used to record the sensitivity and 
resistance of the isolated bacteria.

Abbreviation (MIC*) Antibiotic

A (10 µg) Actinomycin

AK (10 µg) Amikacin

AM (10 µg) Ampicillin

AMC (25 µg) Amoxicillin-clavulanic acid

AMK (30 µg) Amikacin

AMP (10 µg) Ampicillin

AT (10 µg) Aztreonam

AUC (25 µg) Amoxicillin-clavulanic Acid

AZ (30 µg) Azlocillin

C (30 µg) Chloramphenicol

CAZ (30 µg) Ceftazidime

CD (30 µg) Cefdinir

CEC (30 µg) Cefaclor

CEF (30 µg) Cefazoline

CEP (30 µg) Ceftriaxone

CIP (5 µg) Ciprofloxacin

CIT (30 µg) Citalopram

CLT (25 µg) Clotrimazole

CPO (5 µg) Ciprofloxacin

CRO (30 µg) Ceftriaxone

CTA (25 µg) Closthioamide

CTR (30 µg) Ceftriaxone

CTX (30 µg) Cefaotaxime

E (15 µg) Erythromycin

G (10 µg) Penicillin

GEN (10 µg) Gentamicin

IMP (30 µg) Imipenem

IP (30 µg) Imipenem

IPM (30 µg) Imipenem

MT (25 µg) Metronidazole

NA (30 µg) Nalidixic Acid

NET (30 µg) Netilmicin

P (10 µg) Penicillin

PI (100 µg) Piperacillin

TCC (25 µg) Ticarcillin-clavulanic acid

TI (30 µg) Ticarcillin

TOB (10 µg) Tobramycin

VA (30 µg) Vancomycin



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35

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Figure 3: Types and numbers of bacterial species cultured from ear infections

0 5 10 15 20 25 30

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71-80

Figure 4: Ages of patients included in ear infections study

Bacterial Isolates

Pseudomonas spp. was found to be the predominant 
bacteria isolated from ear infection, 35 (43%). No growth 
of bacteria represented 24 (30%) of the samples, while 
the other bacterial species showed a lower percentage 
[Figures 2 and 3].

Age of patients ear infections was found to be common in 
children, but they were found in all ages. The results showed 
that the children age group of (0–10) years had the highest 
number of cases for ear infections, compared to the other age 
groups [Figure 4].

Antibiotic sensitivity and resistance the antibiotic 
Amikacin were found to have the best effect on many 
bacterial isolates, where 35 isolates were sensitive 
[Figure 5a and b].

The antibiotic Clotrimazole was found to be the least 
effective on many bacterial isolates, where 19 isolates were 
resistant [Figure 6a and b].

DISCUSSION

The most common cause of ear infections is a bacterial or viral 
infection of the middle ear, which is the air-filled space behind 
the eardrum that contains the tiny vibrating bones of the ear.[8] 
In many parts of the world, it is a public health issue.[9]

Another ear infection that affects the middle ear is Otitis 
media, which is a common and major healthcare concern due 

to the significant economic burden it spots on the health-care 
system. Eskimos, American Indians, and Australian aboriginal 
children, as well as dark-skin South Africans, have been 
found to have a high prevalence. Another major factor is poor 
living conditions and congestion. The widespread occurrence 
of CSOM in impoverished nations has been linked to poor 
hygiene and diet.[7]

Males were more affected (59%) than females, according 
to the findings of the present study (41%). According to 
other research, men are more likely than women to acquire 
ear infections.[10] The reason for sex dependence is still 
unknown.[11]

Ear infections are more common in children than in 
adults. Due to the inflammation and fluid buildup in the 
middle ear, ear infections are typically severe. Many studies 
in other regions, such as Australia, found that indigenous 
children were more likely than non-indigenous children to get 
ear infections faster and much more severe.[12] Similar results 
were obtained in our current study, where the highest number 
of cases was among the age group (0–10) followed by (11–20) 
years.

Aboriginal status was one of the most significant risk 
factors for otitis media in a population-based birth cohort 
research in Canada.[13] The National Longitudinal Survey 
of Children and Youth in 1994/1995, on the other hand, 
found that 53% of newborn to three-year-old children, 
excluding those living on First Nations reserves, had ear 
infections.[13]

Figure 1: Males and females included in ear infections study

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Figure 2: Percentage of bacterial species cultured from ear infections 
of patients included in the study



Juma, et al.: Microbiological Survey of Ear Infections in Inhabitants of Erbil City

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According to some sources, approximately 80% of 
children will be reported to have at least one episode of AOM 
and between 80% and 90% will suffer at least one episode 
of OME before reaching school age. During an acute viral 
upper respiratory tract infection, AOM is a complication of 
Eustachian tube dysfunction. In 50% to 90% of instances of 
AOM and OME, bacteria can be identified from middle ear 
fluid cultures.[14]

Furthermore, many studies have shown that breastfeeding 
protects against the development of otitis media.[10] This could 
be related to breast milk’s immunological features, which 
include antibodies to respiratory infections. Furthermore, 
exposure to cigarette smoke has been linked to the development 
of ear infections in children, according to another study.[15]

Pseudomonas spp. was discovered to be the most 
common bacterial species (43%). Pseudomonas infections are 
caused by gram-negative bacteria of the genus Pseudomonas, 
particularly Pseudomonas aeruginosa. They can be found 
in soil and water all around the planet. These bacteria can 
be found in wet environments such as sinks, toilets, poorly 
chlorinated swimming pools and hot tubs, and antiseptic 
treatments that are old or inactive. These bacteria are 
occasionally found in the armpits and genital tract area of 
healthy humans.[16]

A high majority of cases (30%) showed no bacterial 
growth on the culture media used in the study. This could be 
due to bacteria that require media or incubation conditions to 
develop, or the bacteria could be anaerobic, or the cause could 
be fungal or viral.

The antibiotic Amikacin was shown to have the best 
effect on numerous bacterial isolates in this research, with 
35 isolates being sensitive, while Clotrimazole was found 
to be the least effective, with 19 isolates being resistant. 
Antibiotic resistance is a regular phenomenon in most 
infections, with ear infections being among the most 
known.[17,18]

In general, variations between the current study 
and other studies could be attributable to changes 
in inclusion criteria, sample sizes, microbiological 
approach, climate, and geographical areas, among other 
things.[19]

CONCLUSION

A total of 81 ear swabs were collected in the present study 
from various hospitals and commercial laboratories in Erbil 
City. Of the 81 samples, 48 (59%) were male and 33 (41%) 
were female. The age group that had the highest number of 
bacteria isolated from ear swabs was 0–10 years followed 
by 11–20 years. The most common bacterial species isolated 
from all swabs were Pseudomonas spp. (43%). Most of the 
samples collected demonstrated the presence of pathogenic 
bacteria (70%), whereas 30% of the swabs demonstrated 
no growth. The antibiotic Amikacin was found to have the 
best effect on many bacterial isolates, where 35 isolates were 
sensitive. The antibiotic Clotrimazole was found to be the 
least effective on many bacterial isolates, where 19 isolates 
were resistant.

Figure 5 (a and b): Antibiotic resistance of bacterial isolates from ear infection

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Figure 6 (a and b): Antibiotic sensitivity of bacterial isolates from ear infection

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