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Staphylococcus Aureus Carriers Among Individuals Exposed and Not Exposed to the Hospital Environment and Their Antimicrobial Sensitivity Pattern

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Staphylococcus Aureus Carriers Among Individuals Exposed and Not Exposed to the Hospital Environment and Their Antimicrobial Sensitivity Pattern Screening for methicillin-resistant Staphylococcus aureus carriers among individuals exposed and not exposed to the hospital environment and their antimicrobial sensitivity pattern Bhadravathi Virupaksha Renushri, Avinandan Saha, Elkal Rajappa Nagaraj, NK Rama, Veena Krishnamurthy, SC Chandrashekar Department of Medical Microbiology, Sri Siddharta Medical College, Tumkur, Karnataka, India ABSTRACT ORIGINAL ARTICLE Aims: This study evaluated the inluence of exposure to the hospital environment on methicillin-resistant Staphylococcus aureus (MRSA) carriage. The antibiograms of the MRSA isolates were examined. Materials and Methods: Nasal, throat, and web-space swabs were collected from 119 nursing students of the age group 18-23 years (exposed group) and 100 age-matched pharmacy students (nonexposed group). S. aureus was identiied and antibiogram obtained as per Clinical and Laboratory Standards Institute (CLSI) guidelines. MRSA was detected by cefoxitin disc diffusion test and by growth on oxacillin screen agar as per CLSI guidelines. The presence of the mecA gene was conirmed by conventional polymerase chain reaction. Results: The MRSA carrier rates were 11.8% and 4% in the exposed and nonexposed groups, respectively. Association of exposure to the hospital environment with MRSA colonization was statistically signiicant. All MRSA isolates showed sensitivity to netilmicin, linezolid, tetracycline, vancomycin and teicoplanin. Among the exposed group, 71.4% MRSA isolates were resistant to ciproloxacin, 64.3% to cotrimoxazole, 64.3% to erythromycin, 28.6% to gentamicin and 21.4% to clindamycin. Among the nonexposed group, 75% MRSA isolates were resistant to ciproloxacin, 25% to cotrimoxazole, 25% to erythromycin, 25% to gentamicin and 25% to clindamycin. Conclusion: Exposure to the hospital environment was found to be a signiicant risk factor for MRSA carriage. Hospital-acquired MRSA (HA-MRSA) isolates showed greater resistance toward antimicrobials compared with community-acquired MRSA (CA-MRSA) isolates. This highlights the need for the appropriate institution of pharmacotherapy in cases of HA-MRSA and CA-MRSA infections and control of transmission by carriers. Key words: Antibiotic resistance, hospital infection, infectious disease transmission, methicillin-resistant Staphylococcus aureus Introduction β-lactamase resistant semisynthetic penicillins like methicillin. These strains are called methicillin-resistant Staphylococcus aureus is a Gram-positive coccus, S. aureus (MRSA).[2,3] MRSA strains resistant to other causing both localised and systemic infections. In commonly used antibiotics such as aminoglycosides and the preantibiotic era, mortality due to S. aureus was lincosamides have also emerged.[2,4] estimated to be 90%.[1] With the introduction of β-lactam antibiotics such as penicillin, treatment of S. aureus Strains of MRSA are known to colonize single or infections was made easier. However, most strains are multiple body sites, and this colonization may be either now not only resistant to β-lactams, but also to newer transient or persistent.[2,3] The anterior nares, throat, axillae, palms, web spaces, rectum and perineum are Access this article online important reservoirs of MRSA.[2,3,5-7] Quick Response Code: Website: www.atmph.org Carriers of MRSA are not only at increased risk for developing subsequent infections with the strains DOI: they carry, but also transmit the pathogen between 10.4103/1755-6783.145003 individuals.[2,3] Breaches of host integrity caused by wounds, aspiration, catheterization, and surgery can lead to infection by colonizing strains.[8] Correspondence: Dr. Avinandan Saha, 331, Sobha Zircon, Jakkur Plantations, Bengaluru - 560 064, Karnataka, India. E-mail: [email protected] Annals of Tropical Medicine and Public Health | Jan-Feb 2014 | Vol 7 | Issue 1 19 Renushri, et al.: Screening and antibiogram of MRSA carriers Methicillin-resistant Staphylococcus aureus is a major or regular visits to a hospital in the last 6 months. problem within healthcare organizations. It is an They represented the group not exposed to the hospital important nosocomial pathogen worldwide, accounting environment. for 20-80% of nosocomial infections in different healthcare set-ups.[1] MRSA acquired in a healthcare institution None of the subjects had a history of illness or treatment is called hospital-acquired MRSA (HA-MRSA). The with an antibiotic in the last 6 months. Informed established risk factors for HA-MRSA infections are recent written consent was obtained from all subjects. hospitalisation, surgery, dialysis, long-term indwelling catheters, implantation of percutaneous medical device Collection of samples and history of MRSA infection in the past.[1] Nasal swabs Specimens from both anterior nares were obtained from However, the epidemiology of MRSA is changing with each subject by carefully inserting sterile cotton swabs infections appearing in healthy community-dwelling moistened with sterile saline into each nostril so that the individuals without any apparent risk factors for the tip was entirely at the nasal osteum level (about 2.5 cm acquisition of MRSA.[9] Strains causing such infections from the edge of the nare) and gently rolling 2-3 times. are called community-acquired MRSA (CA-MRSA).[1,8] Although, there are significant differences in the clinical Throat swabs features, antimicrobial resistance patterns and treatment Specimens were obtained by carefully inserting sterile requirements of HA-MRSA and CA-MRSA, both have cotton swabs into the oral cavity (after depressing been linked to greater morbidity and mortality, as well as the tongue) and gently rolling it over the fauces and to increased hospital stays and treatment costs.[1,8] posterior wall of oropharynx. At present, sustained research that evaluates the Palmar swabs and swabs from web-spaces impact of exposure to hospital environment vis -à-vis Specimens were obtained by gently rolling sterile cotton that of exposure in the community on MRSA carriage swabs moistened with sterile saline over the palm and is lacking in India. The present case-control study web spaces. evaluates the influence of exposure to the hospital environment on MRSA carrier rates by comparing the All swabs were immediately processed for culture and prevalence of HA-MRSA and CA-MRSA carriage. isolation. The antimicrobial sensitivity patterns of MRSA Culture isolates from carriers are also examined. This could Swabs were immediately inoculated on 10% mannitol enable appropriate institution of pharmacotherapy in salt agar (HiMedia, Mumbai) and 5% sheep blood agar cases of HA-MRSA and CA-MRSA infections, besides and incubated at 35°C in ambient air.[10,11] leveraging control of transmission by carriers. The blood agar plates were examined for growth after Materials and Methods 24 h of incubation and the mannitol salt agar plates after 48 h of incubation.[11] Inclusion and exclusion criteria One hundred and nineteen students of the age group Identification 18-23 years of the college of nursing attached to our Identification of Staphylococcus aureus hospital were included in the study. All students β-hemolytic and yellow colored mannitol fermenting attended rotating sessions for at least 4 h daily in colonies were picked up and sub-cultured on nutrient various hospital departments for the last 6 months. agar plates for further processing. They represented the group exposed to the hospital environment. However, exposure of these students to Staphylococcus aureus was identified by golden-yellow specific wards or patients was not considered as they pigment production, Gram’s-stain, catalase test and were posted to multiple wards in a day. Moreover, slide and tube coagulase tests.[10,12] several patients were discharged, referred or otherwise lost to follow-up for the purposes of this study. Identification of methicillin-resistant Staphylococcus aureus One hundred age-matched students of the college of Cefoxitin disc diffusion test pharmacy in our city were also studied. None of the Each of the S. aureus isolates was subjected to cefoxitin students in this group had a history of hospitalization disc diffusion test using a 30 μg cefoxitin disc (HiMedia, 2020 Annals of Tropical Medicine and Public Health | Jan-Feb 2014 | Vol 7 | Issue 1 Renushri, et al.: Screening and antibiogram of MRSA carriers Mumbai). A 0.5 McFarland standard suspension of the colonization was carried out using the Chi-square test. isolate was made and lawn culture done on Mueller- Odds ratio was also calculated. Hinton agar plate (HiMedia, Mumbai). Plates were incubated at 37°C for 18 h, and zone diameters were Resistance among MRSA to other antibiotics was measured. An inhibition zone diameter of ≤21 mm examined. was reported as oxacillin or methicillin-resistant and a zone diameter of ≥22 mm was considered sensitive, Results as per Clinical Laboratory Standards Institute (CLSI) guidelines.[13,14] A total of 14 students were found to be carriers of MRSA in the group exposed to hospital environment Using oxacillin screen agar and four students were found to be carriers in the group A suspension equivalent to McFarland 0.5 was prepared not exposed to a hospital environment [Table 1]. from each S. aureus isolate. A swab was dipped in this suspension and spotted over an area 10 mm in The MRSA carrier rate was found to be 11.8% [Figure 1] diameter on the surface of a Mueller-Hinton agar plate in the group exposed to the hospital environment and supplemented with 4% NaCl and 6 μg/ml of oxacillin 4%
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