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Loomba A, Grover P, Nokwal A, Arora B. Nasal Screening of Health Care Workers (Nursing staff) to Study the Prevalence of Methicillin Resistant Staphylococcus Aureus (MRSA) Carriage and its Antibiotic Sensitivity Profile in a Rural Tertiary Health Care Center. Journal of Research in Applied and Basic Medical Sciences 2024; 10 (1) :65-71
URL: http://ijrabms.umsu.ac.ir/article-1-259-en.html
URL: http://ijrabms.umsu.ac.ir/article-1-259-en.html
Assistant Professor, Department of Microbiology MAMC Agroha (Hisar), Haryana, India , pragatigrover79@gmail.com
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Table 1. Characteristics of study participants
The nasal carriage rate of S.aureus was 20%(12/60) ,out of which MRSA was 13.3%(8/60) whereas Methicillin sensitive S.aureus (MSSA) was 6.7%(4/60) (Table-2).
Table 2. MRSA carriage status
Table 3. Characteristics of MRSA carriers
Table 4. Antibiotic sensitivity profile of MRSA isolates
Discussion
S.aureus can colonize multiple sites in the body like the anterior nares, axilla, perineum, pharynx and gastrointestinal tract; however, the most common site is anterior nares (1,12). Nasal colonization with S.aureus has been reported to range from 6.3% to 17.8% in the general population while in healthcare workers from 18.2% to 28.2%(13,14). In our study, the carriage of S.aureus in the anterior nares of nursing staff is 20% of which MRSA is 13.3% and MSSA is 6.7. The prevalence of MRSA varies among different institutions and geographical areas. The differences in the study design such as sample size and the methodology which has been employed for MRSA detection, may account for the disparity in the carriage thus detected.
The prevalence of MRSA carriage worldwide among health care workers is reported to be around 10-40% (15).Various studies in health care settings report different rates of MRSA carriage among healthcare workers. Studies in Indian health care settings report MRSA carriage of 1.8% in Pondicherry, 6.6% in Delhi and 2% in Madurai (16-20). In our study, MRSA carriage among nursing staff is 13.3% (Table-3) which is in accordance with the findings of study from Assam (11.4%) and Bangalore (10%) (26,27). A study by Kalyani K et al. reports a carriage of 7.5% among nursing staff(17). Another study in Saudi Arabia showed a carriage of 23% in nursing staff (22). These differences in the prevalence of MRSA might be due to the variability in geographical distribution, hospital settings, hospital specialties and areas within the hospital where the study was conducted.
In our study, nasal carriage was found to be higher in female staff (62.5%) as compared to males (37.5%) (Table-4). A study conducted at Bhubaneswar also reports higher carriage of MRSA among females (21). This might be due to the fact that more females constituted the study population. The highest rate of MRSA carriage (75%) is among the nursing staff who have worked for >5 years in the hospital (Table-4). In a study by Al Humaiden et al. in Saudi Arabia the highest rate of MRSA carriage was among the health care workers who have worked for 4-6 years (26%) (22). This can be due to the time required for developing resistance and colonizing the host.
All the MRSA isolates were 100% sensitive to Linezolid, Vancomycin and Teicoplanin (Table-5). A study conducted by Radhakrishnan et al. reported 100% sensitivity to Vancomycin, Linezolid and sensitivity of 80% to Teicoplanin.(24), However, sensitivity to vancomycin was 84.3% in a study done by El Aila et al.(25)In our study, the sensitivity of MRSA isolates to Amikacin was 37.5%, Ciprofloxacin 12.5%, Clindamycin 37.5% and Cotrimoxazole 87.5%. All the MRSA isolates showed 100% resistance to Ampicillin, Amoxiclav and Erythromycin. In a study conducted by Radhakrishna et al., sensitivity of Erythromycin is 40%,gentamicin is 80% and Ciprofloxacin is 20% (24).
Thus, our study showed considerable MRSA carriage among the nurses and also reported a decreased sensitivity to commonly used drugs. Also, no resistance was detected against higher antibiotics like Vancomycin, Teicoplanin and Linezolid which points to their use in eradication of infection caused by MRSA. The Hospital Infection Committee was informed regarding the detected resistance in nursing staff so that appropriate measures can be taken and regular extensive screening can be done to curb the spread of resistant nosocomial infections.
Conclusion
In this study, the nasal carriage of MRSA among the nursing staff posted in the Medicine and allied branches is 13.3%. Considering the fact that nurses are more involved in patient care activities, it is necessary that they should be sensitized regarding this issue. Importance of hand-washing should be emphasized for all healthcare workers as it is the single most appropriate method to combat the spread of nosocomial infections including MRSA.
There is hence a need to strictly implement and follow the hospital infection control guidelines so as to reduce the spread of MRSA to susceptible persons.
Acknowledgments
Nil.
Conflict of interests
The authors declare that they have no conflicts of interest.
Funding/Support
No funding was required for the study.
Data Availability
The raw data supporting the conclusions of this article are available from the authors upon reasonable request.
Ethical Statement
The study was carried out under the Department of Microbiology for a duration of 2 months (July-December) after obtaining ethical clearance from the Institute.
Full-Text: (480 Views)
Introduction
Staphylococcus aureus is a gram-positive coccus colonizing external skin surfaces and upper respiratory tract commonly nares (1). It can invade through any breach in skin and mucosal lining to cause infections ranging from minor skin infections like impetigo to fatal sepsis and toxic shock syndrome. At the time of introduction of penicillin in 1944, about 94% strains of S.aureus were susceptible to it. Until the 1950s S.aureus was sensitive to treatment with penicillin but later developed resistance due to production of β-lactamase enzyme. This problem was overcome in 1959 with the introduction of methicillin (1), However, methicillin resistance was identified shortly after the introduction of methicillin in clinical practice (2,3). First case of methicillin-resistant S.aureus (MRSA) was identified in Europe from the nares of an infant admitted in the medicine ward (3). The use of various antibiotics has led to the development of multidrug-resistant strains of MRSA (1,4).
Since then, MRSA has spread worldwide, becoming a notorious bug responsible for difficult-to-treat infections both at community and hospital level. In context to the Indian scenario, MRSA prevalence grew from 12% in 1992 to 80.33% in 1999.(5) Many of the carriers of MRSA harbor pathogen in areas like nares, hand surfaces, axilla and are generally asymptomatic. Colonization in healthcare workers has increased the incidence of serious nosocomial infection wherein healthcare workers act as vectors for transmission of infection in already immuno-compromised patients (6,7). Furthermore, no stringent following of hospital infection control norms and overlooking of antimicrobial stewardship adds to the current disaster of pan drug resistance in microbes including MRSA, thereby making study of this organism significant.
Since nursing staff is often the first to come in contact with patients and also responsible for regular looking after of patients in wards, screening them for carriage of MRSA will not only detect carriers but also help the hospital infection control committee to take appropriate steps in limiting its spread. Also, little work has been done in peripheral healthcare settings regarding MRSA - contrast to most of the Indian population residing in rural settings - this study will thus help increase awareness among currently practicing healthcare workers and various other epidemiological studies being carried out. Keeping in mind all this the present study is carried to determine nasal carriage of MRSA among nursing staff posted in Medicine and allied wards of a rural tertiary healthcare center in North India and antibiotic sensitivity profile of the isolated MRSA strains.
Material & Methods
The study was carried out under the Department of Microbiology for a duration of 2 months (July-December) after obtaining ethical clearance from the Institute. The study undertaken was a cross-sectional type where in nursing staff was analyzed for nasal carriage of MRSA and antibiotic sensitivity profile of MRSA. The study was done on the nursing staff posted in medicine and allied wards of a rural tertiary healthcare center of North India.
Inclusion criteria included: Complete nursing staff posted in medicine and allied wards were studied.
Exclusion criteria included: staff members suffering from an active upper respiratory tract infection or skin infection were excluded. Nursing students were not included in this study. Staff members who did not give consent for being enrolled in the study were also excluded.
Procedure:
Two sterile nasal swabs were taken from both the anterior nares of participants. Swab was inserted about 2 cm into the anterior nares and rolled clockwise thrice and collected in an airtight container was labeled and sent to the microbiology laboratory immediately. One swab was used for gram staining & another for culture on blood agar. Inoculated plates were incubated for at 37°C for 18-24 hours. S.aureus was identified by colony morphology, microscopic appearance on gram stained smears, catalase test, slide and tube coagulase test (8). Isolated strains of S.aureus were screened for methicillin susceptibility by modified Kirby-Bauer method using cefoxitin(30 ug) discs on Muller Hinton Agar(MHA) by using an inoculum density which was equivalent to MacFarland’s 0.5 standards ( 1.5 X 10^8 CFU/ml) and then incubated at 35°C overnight (9). Isolates which showed inhibition zone size of diameter ≤21 mm were considered as MRSA stains (10). The isolated MRSA strains were further studied for antimicrobial sensitivity profile by automated identification and antimicrobial susceptibility system using Vitek-2 compact system ( Biomerieux, India) (11). In case of Vancomycin, the strains showing MIC of >4ug/ml by Vitek-2 compact system was considered as vancomycin-resistant S.aureus (VRSA)(12).
The data was complied, tabulated and subjected to SPSS version 17.0 software statistical package for analysis. A p-value of < 0.05 was considered as
significant.
Results
A total of 60 nursing staff members posted in medicine and allied wards were recruited in this study. A total of 34 (56.6%) were female and 26 (43.3%) were male. Their age ranged from 21 to 60 years of which maximum belonged to 21-30 years age group - 29(48.3%). Maximum nursing staff 32(53.3%) have a working experience of >5 years (Table-1).
Staphylococcus aureus is a gram-positive coccus colonizing external skin surfaces and upper respiratory tract commonly nares (1). It can invade through any breach in skin and mucosal lining to cause infections ranging from minor skin infections like impetigo to fatal sepsis and toxic shock syndrome. At the time of introduction of penicillin in 1944, about 94% strains of S.aureus were susceptible to it. Until the 1950s S.aureus was sensitive to treatment with penicillin but later developed resistance due to production of β-lactamase enzyme. This problem was overcome in 1959 with the introduction of methicillin (1), However, methicillin resistance was identified shortly after the introduction of methicillin in clinical practice (2,3). First case of methicillin-resistant S.aureus (MRSA) was identified in Europe from the nares of an infant admitted in the medicine ward (3). The use of various antibiotics has led to the development of multidrug-resistant strains of MRSA (1,4).
Since then, MRSA has spread worldwide, becoming a notorious bug responsible for difficult-to-treat infections both at community and hospital level. In context to the Indian scenario, MRSA prevalence grew from 12% in 1992 to 80.33% in 1999.(5) Many of the carriers of MRSA harbor pathogen in areas like nares, hand surfaces, axilla and are generally asymptomatic. Colonization in healthcare workers has increased the incidence of serious nosocomial infection wherein healthcare workers act as vectors for transmission of infection in already immuno-compromised patients (6,7). Furthermore, no stringent following of hospital infection control norms and overlooking of antimicrobial stewardship adds to the current disaster of pan drug resistance in microbes including MRSA, thereby making study of this organism significant.
Since nursing staff is often the first to come in contact with patients and also responsible for regular looking after of patients in wards, screening them for carriage of MRSA will not only detect carriers but also help the hospital infection control committee to take appropriate steps in limiting its spread. Also, little work has been done in peripheral healthcare settings regarding MRSA - contrast to most of the Indian population residing in rural settings - this study will thus help increase awareness among currently practicing healthcare workers and various other epidemiological studies being carried out. Keeping in mind all this the present study is carried to determine nasal carriage of MRSA among nursing staff posted in Medicine and allied wards of a rural tertiary healthcare center in North India and antibiotic sensitivity profile of the isolated MRSA strains.
Material & Methods
The study was carried out under the Department of Microbiology for a duration of 2 months (July-December) after obtaining ethical clearance from the Institute. The study undertaken was a cross-sectional type where in nursing staff was analyzed for nasal carriage of MRSA and antibiotic sensitivity profile of MRSA. The study was done on the nursing staff posted in medicine and allied wards of a rural tertiary healthcare center of North India.
Inclusion criteria included: Complete nursing staff posted in medicine and allied wards were studied.
Exclusion criteria included: staff members suffering from an active upper respiratory tract infection or skin infection were excluded. Nursing students were not included in this study. Staff members who did not give consent for being enrolled in the study were also excluded.
Procedure:
Two sterile nasal swabs were taken from both the anterior nares of participants. Swab was inserted about 2 cm into the anterior nares and rolled clockwise thrice and collected in an airtight container was labeled and sent to the microbiology laboratory immediately. One swab was used for gram staining & another for culture on blood agar. Inoculated plates were incubated for at 37°C for 18-24 hours. S.aureus was identified by colony morphology, microscopic appearance on gram stained smears, catalase test, slide and tube coagulase test (8). Isolated strains of S.aureus were screened for methicillin susceptibility by modified Kirby-Bauer method using cefoxitin(30 ug) discs on Muller Hinton Agar(MHA) by using an inoculum density which was equivalent to MacFarland’s 0.5 standards ( 1.5 X 10^8 CFU/ml) and then incubated at 35°C overnight (9). Isolates which showed inhibition zone size of diameter ≤21 mm were considered as MRSA stains (10). The isolated MRSA strains were further studied for antimicrobial sensitivity profile by automated identification and antimicrobial susceptibility system using Vitek-2 compact system ( Biomerieux, India) (11). In case of Vancomycin, the strains showing MIC of >4ug/ml by Vitek-2 compact system was considered as vancomycin-resistant S.aureus (VRSA)(12).
The data was complied, tabulated and subjected to SPSS version 17.0 software statistical package for analysis. A p-value of < 0.05 was considered as
significant.
Results
A total of 60 nursing staff members posted in medicine and allied wards were recruited in this study. A total of 34 (56.6%) were female and 26 (43.3%) were male. Their age ranged from 21 to 60 years of which maximum belonged to 21-30 years age group - 29(48.3%). Maximum nursing staff 32(53.3%) have a working experience of >5 years (Table-1).
Table 1. Characteristics of study participants
| PARAMETERS | FREQUENCY (%) N=60 |
| Age (in years) | |
| 21-30 | 29 (48.3) |
| 31-40 | 19 (31.6) |
| 41-50 | 10 (16.6) |
| 51-60 | 2 (3.3) |
| Sex | |
| Female | 34 (56.6) |
| Male | 26 (43.3) |
| No of years working in hospital (years) | |
| <1 | 2 (3.3) |
| 1-5 | 26 (43.3) |
| >5 | 32 (53.3) |
The nasal carriage rate of S.aureus was 20%(12/60) ,out of which MRSA was 13.3%(8/60) whereas Methicillin sensitive S.aureus (MSSA) was 6.7%(4/60) (Table-2).
Table 2. MRSA carriage status
| No. of health care workers screened | No. positive for S.aureus | No. positive for MRSA |
| 60 | 12(20%) | 8(13.3%) |
Our study showed maximum carriage of MRSA in the 31-40 age group of 50% (4/8), followed by 41-50 years of 25% (2/8). Females reported a higher carriage of 62.5%(5/8) compared to males 37.5% (3/8). Nursing staff members who have a longer work duration in hospital (>5 years) reported a higher nasal carriage of MRSA 75%(6/8) compared to those with lesser years of work in hospital (1-5 years) 25%(2/8) (Table-3).
Table 3. Characteristics of MRSA carriers
| PARAMETERS | MRSA FREQUENCY(%) N=8 |
| Age(years) | |
| 21-30 | 1(12.5) |
| 31-40 | 4 (50) |
| 41-50 | 2 (25) |
| 51-60 | 1 (12.5) |
| Sex | |
| Female | 5 (62.5) |
| Male | 3 (37.5) |
| No. of years of working in the hospital(years) | |
| <1 | 0 (0) |
| 1-5 | 2 (25) |
| >5 | 6 (75) |
MRSA isolated was further analyzed for antibiotic sensitivity profile. All isolates showed resistance of 100% to Ampicillin, Erythromycin, Amoxyclav whereas sensitivity of 12.5% to Ciprofloxacin,37.5% to Clindamycin and Amikacin, 87.5% to Co-trimoxazole. All MRSA isolates were 100% sensitive to Linezolid, Vancomycin, Teicoplanin and Rifampin (Table-4).
Table 4. Antibiotic sensitivity profile of MRSA isolates
| ANTIBIOTIC | SENSITIVITY (%) N=8 |
| Amikacin | 3 (37.5) |
| Amoxiclav | 0 (0) |
| Ampicillin | 0 (0) |
| Ciprofloxacin | 1 (12.5) |
| Clindamycin | 3 (37.5) |
| Cotrimoxazole | 7 (87.5) |
| Erythromycin | 0 (0) |
| Linezolid | 8 (100) |
| Rifampin | 8 (100) |
| Teicoplanin | 8 (100) |
| Vancomycin | 8 (100) |
S.aureus can colonize multiple sites in the body like the anterior nares, axilla, perineum, pharynx and gastrointestinal tract; however, the most common site is anterior nares (1,12). Nasal colonization with S.aureus has been reported to range from 6.3% to 17.8% in the general population while in healthcare workers from 18.2% to 28.2%(13,14). In our study, the carriage of S.aureus in the anterior nares of nursing staff is 20% of which MRSA is 13.3% and MSSA is 6.7. The prevalence of MRSA varies among different institutions and geographical areas. The differences in the study design such as sample size and the methodology which has been employed for MRSA detection, may account for the disparity in the carriage thus detected.
The prevalence of MRSA carriage worldwide among health care workers is reported to be around 10-40% (15).Various studies in health care settings report different rates of MRSA carriage among healthcare workers. Studies in Indian health care settings report MRSA carriage of 1.8% in Pondicherry, 6.6% in Delhi and 2% in Madurai (16-20). In our study, MRSA carriage among nursing staff is 13.3% (Table-3) which is in accordance with the findings of study from Assam (11.4%) and Bangalore (10%) (26,27). A study by Kalyani K et al. reports a carriage of 7.5% among nursing staff(17). Another study in Saudi Arabia showed a carriage of 23% in nursing staff (22). These differences in the prevalence of MRSA might be due to the variability in geographical distribution, hospital settings, hospital specialties and areas within the hospital where the study was conducted.
In our study, nasal carriage was found to be higher in female staff (62.5%) as compared to males (37.5%) (Table-4). A study conducted at Bhubaneswar also reports higher carriage of MRSA among females (21). This might be due to the fact that more females constituted the study population. The highest rate of MRSA carriage (75%) is among the nursing staff who have worked for >5 years in the hospital (Table-4). In a study by Al Humaiden et al. in Saudi Arabia the highest rate of MRSA carriage was among the health care workers who have worked for 4-6 years (26%) (22). This can be due to the time required for developing resistance and colonizing the host.
All the MRSA isolates were 100% sensitive to Linezolid, Vancomycin and Teicoplanin (Table-5). A study conducted by Radhakrishnan et al. reported 100% sensitivity to Vancomycin, Linezolid and sensitivity of 80% to Teicoplanin.(24), However, sensitivity to vancomycin was 84.3% in a study done by El Aila et al.(25)In our study, the sensitivity of MRSA isolates to Amikacin was 37.5%, Ciprofloxacin 12.5%, Clindamycin 37.5% and Cotrimoxazole 87.5%. All the MRSA isolates showed 100% resistance to Ampicillin, Amoxiclav and Erythromycin. In a study conducted by Radhakrishna et al., sensitivity of Erythromycin is 40%,gentamicin is 80% and Ciprofloxacin is 20% (24).
Thus, our study showed considerable MRSA carriage among the nurses and also reported a decreased sensitivity to commonly used drugs. Also, no resistance was detected against higher antibiotics like Vancomycin, Teicoplanin and Linezolid which points to their use in eradication of infection caused by MRSA. The Hospital Infection Committee was informed regarding the detected resistance in nursing staff so that appropriate measures can be taken and regular extensive screening can be done to curb the spread of resistant nosocomial infections.
Conclusion
In this study, the nasal carriage of MRSA among the nursing staff posted in the Medicine and allied branches is 13.3%. Considering the fact that nurses are more involved in patient care activities, it is necessary that they should be sensitized regarding this issue. Importance of hand-washing should be emphasized for all healthcare workers as it is the single most appropriate method to combat the spread of nosocomial infections including MRSA.
There is hence a need to strictly implement and follow the hospital infection control guidelines so as to reduce the spread of MRSA to susceptible persons.
Acknowledgments
Nil.
Conflict of interests
The authors declare that they have no conflicts of interest.
Funding/Support
No funding was required for the study.
Data Availability
The raw data supporting the conclusions of this article are available from the authors upon reasonable request.
Ethical Statement
The study was carried out under the Department of Microbiology for a duration of 2 months (July-December) after obtaining ethical clearance from the Institute.
Type of Study: orginal article |
Subject:
Microbiology
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