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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 64-67

Nasal carriage of methicillin-resistant Staphylococcus aureus amongst healthcare workers of intensive care unit of a tertiary care centre in South India: An observational cross-sectional study


1 Department of Neurosurgery, Sree Gokulam Medical College, Venjaramoodu, Kerala, India
2 Department of Microbiology and Infection Control, Sree Gokulam Medical College, Venjaramoodu, Kerala, India
3 Department of Gastroenterology, Bharath Hospital, Kottayam, Kerala, India
4 Staff Nurse Infection Control, Sree Gokulam Medical College, Venjaramoodu, Kerala, India

Date of Submission16-May-2020
Date of Decision20-Aug-2020
Date of Acceptance20-Aug-2020
Date of Web Publication21-Dec-2020

Correspondence Address:
Dr. Abhishek Thanuja Jayadhar
Department of Neurosurgery, Sree Gokulam Medical College, Venjaramoodu - 695 607, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_9_20

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  Abstract 


Staphylococcus aureus is one of the dangerous pathogens causing infections in both community level and hospital setting. This study aims to find the carrier rate of S. aureus and a resistant strain of the bacterium–methicillin-resistant S. aureus (MRSA). Sterile cotton swabs (saline moistened) were used to collect the nasal samples from the healthcare workers (HCWs) of different intensive care units. The isolation S. aureus was done by standard bacteriological procedures. Antibiotic susceptibility testing of all isolates was performed by modified Kirby–Bauer disc diffusion method. Methicillin resistance of S. aureus was identified using cefoxitin disc diffusion test. One hundred and forty-one nasal swabs were processed (104 nurses, 27 doctors and 10 non-medical staff). Amongst the 141 nasal swabs processed, 18.4% of HCWs were carriers of S. aureus, out of which 9.9% tested positive for MRSA. To prevent the colonisation of HCWs by S. aureus and avoid cross infection amongst patients, proper hand hygiene practices are vital. Creating an awareness and periodic screening is yet another task needed to tackle this crisis.

Keywords: Healthcare workers, methicillin-resistant Staphylococcus aureus, nasal carriage, screening


How to cite this article:
Jayadhar AT, Jitendranath A, Thomas AA, Sarika G S. Nasal carriage of methicillin-resistant Staphylococcus aureus amongst healthcare workers of intensive care unit of a tertiary care centre in South India: An observational cross-sectional study. J Patient Saf Infect Control 2020;8:64-7

How to cite this URL:
Jayadhar AT, Jitendranath A, Thomas AA, Sarika G S. Nasal carriage of methicillin-resistant Staphylococcus aureus amongst healthcare workers of intensive care unit of a tertiary care centre in South India: An observational cross-sectional study. J Patient Saf Infect Control [serial online] 2020 [cited 2021 May 6];8:64-7. Available from: https://www.jpsiconline.com/text.asp?2020/8/2/64/304219




  Introduction Top


Methicillin-resistant Staphylococcus aureus (MRSA) has been identified as an endemic in the world for the last two decades even in primary health centres.[1] The prevalence in Asian countries varied from 28% to >70% in the early 2010s.[2] In Europe, the proportion of MRSA strains isolated in infected patients varied in 2011 from <0.5% to >50%.[3] Due to the antibiotic resistance, the organism can increase the mortality (59.4% as compared to MSSA) and morbidity for the patients.[4],[5]

Anterior nares are the main reservoir of MRSA, although other body sites are frequently colonised.[6] Likely transmission of MRSA from carrier healthcare worker (HCW) to the patient was found in 63 (98%) of 68 studies that undertook genotyping.[7],[8] Even though there is a high chance of infection, there are some ethical as well as practical issues for conducting regular screening programmes amongst HCWs.[9],[10]

This study concentrates in identifying the proportion of nasal carriage of MRSA amongst the intensive care unit (ICU) healthcare workers of a hospital. We also discuss the advantages and disadvantages of screening and eradication policies for MRSA control and give recommendations for the management of colonised healthcare workers in ICU setting.


  Materials and Methods Top


This cross-sectional study is done in a tertiary healthcare centre in Kerala, India, during the month of December 2019. The study is done in coordination with the infection control team of the hospital. Informed verbal consent was taken from all the participants, and all the ethical guidelines were taken into consideration. One hundred and forty-one HCWs of different ICUs were screened for nasal carriage of MRSA. This group includes nurses, doctors and ICU technicians who were in regular contact with the patients. Staff members with recent upper respiratory tract infection, recent nasal surgery and recent antibiotic usage[1] were excluded from the study.

Nasal swabs are considered to be the standard method in screening for MRSA.[11] Sterile cotton swabs (saline moistened) were used to collect the nasal samples from the HCWs. The swab was introduced 2–3 cm into anterior nares on both sides of the nose. It is then rotated 4–5 times both clockwise and anticlockwise. The swabs were then immediately transported to the microbiology laboratory within 30 min for further processing. Specimens were inoculated onto Mannitol salt agar and incubated at 37°C for 48 h. Mannitol-fermenting colonies that were yellow or golden yellow were selected and sub-cultured on nutrient agar (NA). Colonies on NA were subjected to Gram's staining, catalase test and coagulase test. Gram-positive cocci that were catalase positive and coagulase positive were identified as Staphylococcus aureus. Antibiotic susceptibility testing of all isolates was performed by modified Kirby–Bauer disc diffusion method as recommended by the Clinical and Laboratory Standards Institute guidelines.[11] Methicillin resistance of S. aureus is identified using cefoxitin disc diffusion test.

Statistical analysis

A convenient sample technique was used for sample selection. Results were compiled and tabulated, and all data were subjected to IBM SPSS Statistics version 16.0, Armonk, NY, United States software for analysis. P < 0.05 was considered as statistically significant.


  Results Top


Out of 141 HCWs, 104 (73.8%) were nurses, 27 (19.1%) were doctors and 10 (7.1%) were non-medical staffs who were in regular contact with the ICU patients. Twenty-six (18.4%) of the samples (141) were positive for S. aureus. Amongst that, 14 of them were cefoxitin resistant (MRSA). Hence, the overall nasal carriage rate of MRSA is 9.9% (14 out of 141). From the above data, amongst the positive cases (14 carriers of MRSA), 64.3% (9 out of 14 cases) were nurses and 35.7% (5 out of 14) were doctors, which is shown in [Figure 1]. We have conducted our screening on non-medical staffs also which include the attenders, radiology technicians and laboratory staffs who were in regular contact with the ICU patients. However, all the samples were negative for both S. aureus and MRSA.
Figure 1: Distribution of healthcare workers amongst carriers (n = 14)

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[Table 1] and [Figure 2] represent the ICU-wise distribution of MRSA carriers. The highest rate of S. aureus carriers was from surgical ICU (44%), whereas the rate of MRSA-positive samples from the S. aureus samples was higher in neurosurgery, gastro and urology ICU (100%). Even though the carrier rate of S. aureus in neonatal ICU is 16.7%, none of them were positive for MRSA.
Table 1: Intensive care unit-wise distribution of Staphylococcus aureus and methicillin-resistant Staphylococcus aureus amongst healthcare workers

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Figure 2: Pie chart showing intensive care unit-wise distribution of methicillin-resistant Staphylococcus aureus carriers

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Amongst the positive cases of MRSA, the highest carrier rate was found in medical and surgical ICUs (22% each). Neonatal ICU has the lowest carrier rate (0).


  Discussion Top


Our study showed an overall nasal carriage rate of S. aureus to be 18.4%, of which 9.9% tested positive for MRSA, which is actually within the international carrier rate of MRSA (5.8%–17.8%) amongst the HCWs.[5] There are many similar and contrasting studies from different institutions and epidemiological areas.[12],[13] The prevalence of MRSA also varies between institutions and geographic areas. In comparison to a similar study conducted in Kasturba Medical College,[11] the carrier rate is significantly high. The study was conducted in 2013 amongst 200 critical care HCWs of Kasturba Medical College, India. 17.5% (35 out of 200) were nasal carriers of S. aureus, and amongst them, 14.3% (5 out of 35) were MRSA positive, which gave an overall MRSA carrier rate of 2.5%. In our study, the highest carrier rate was found in HCWs of medical and surgical ICUs (22%) which was similar to this study showing a carrier rate of 40% in general ICUs (including ICU for adults).[11] Yet, another one conducted at MES Medical College, Kerala, India, showed that 34.80% of HCWs carried S. aureus in their anterior nares among that, 18.39% were Methicillin resistant.[14] The study was conducted amongst 250 healthcare providers from ICU, general ward and laboratory.

A similar study conducted in a tertiary care hospital in Western Nepal,[12] observed that an overall nasal carriage of MRSA was 3.4%, which is significantly low as compared to our observation, whereas a study conducted amongst HCWs of Al Shifa Hospital in Gaza Strip showed an overall MRSA carrier rate of 25.5% which is on the higher side.[15] We have observed a higher nasal carriage amongst doctors (18.5%) followed by nurses which can be accounted to the good hygienic practices followed by nurses in our hospital, whereas in both of these studies, nurses had a higher carrier rate of MRSA (7.8% and 30.4%, respectively).

A higher carrier rate is seen amongst the HCWs of surgical as well as medical ICUs, which can actually be attributed to the workload as well as exposure to positive MRSA cases. Similar findings were found in the study conducted in Kasturba Medical College.

Detection of MRSA carrier status amongst the apparently healthy hospital personnel, particularly those working in the critical care areas, is essential as these individuals can act as a potential source of infection amongst patients, increasing morbidity and mortality or resulting in their extended stay in the hospital. Infection control measures and proper screening measures has to be strictly followed in the hospitals.[1] The differences in the design of the study such as the sample size and the method of MRSA detection may account for the disparity in the carriage rate.[10]


  Conclusion Top


We found that the nasal carriage rate of MRSA amongst HCWs was 9.9%, which was comparatively higher than similar studies conducted in the state as well as in other parts of the country. It is worth mentioning that in contrast to other studies conducted in different parts of the world, the results are within the normal international carrier rate.[16]

All the healthcare providers who tested positive were treated according to the hospital protocol in coordination with the hospital infection control team. They were prescribed mupirocin in paraffin base to be applied on both nostrils thrice daily for 5 days. Along with that, they were advised to do Betadine gargle four times a day and to take chlorhexidine bath daily for 7 days.[13] Three consecutive swabs were taken, one on each week which was found to be negative and marked the treatment completion.

Since HCWs are responsible for cross contamination, it is vital to follow proper hand hygiene practises, use of face masks and protective gloves to protect both HCWs and patients. Hence, priority should be given to prevent the colonisation of MRSA, especially amongst HCWs, as this professional group is in contact with the public on a day-to-day basis. Better standardisation of screening strategies of HCWs is needed, as sampling site, frequency and timing of screening are the most important reasons for misclassification.[6] Data gathered by this study point towards the need for creating an awareness amongst healthcare givers regarding hand hygiene and possible MRSA colonisation.

Limitations

This article mainly concentrates on nasal carriage of MRSA amongst HCWs. However, there are other sites in the body like axilla where the organism can colonise and cause nosocomial infection.

Acknowledgement

We would like to take this opportunity to thank all the members of the department of microbiology and infection control team of the tertiary care centre, statistician and the healthcare workers who participated in our study for helping us in completing this work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mondal H, Gupta I, Nandi P, Ghosh P, Chattopadhyay S, Mitra GD. Nasal screening of healthcare workers for nasal carriage of methicillin resistance Staphylococcus aureus, vancomycin resistance Staphylococcus aureus and prevalence of nasal colonization with Staphylococcus aureus in Burdwan Medical College and Hospital. Int J Contemp Med Res 2016;3:3342-6.  Back to cited text no. 1
    
2.
Chen CJ, Huang YC. New epidemiology of Staphylococcus aureus infection in Asia. Clin Microbiol Infect 2014;20:605-23.  Back to cited text no. 2
    
3.
Appelbaum PC. MRSA-The tip of the iceberg. Clin Microbiol Infect 2006;12:3-10.  Back to cited text no. 3
    
4.
Radhakrishna M, D'Souza M, Kotigadde S, Saralaya KV, Kotian MS. Prevalence of methicillin resistant Staphylococcus aureus carriage amongst health care workers of critical care units in Kasturba Medical College Hospital, Mangalore, India. J Clin Diagn Res 2013;7:2697-700.  Back to cited text no. 4
    
5.
Rutvi V, Sangeeta DP, Sima KB, Piyush AP. Nasal carriage rate of methicillin resistant Staphylococcus aureus (MRSA) among Civil Hospital Health care workers. Int J Med Public Health 2016;6:180-3.  Back to cited text no. 5
    
6.
Dulon M, Peters C, Schablon A, Nienhaus A. MRSA carriage among healthcare workers in non-outbreak settings in Europe and the United States: A systematic review. BMC Infect Dis 2014;14:363.  Back to cited text no. 6
    
7.
World Health Organization. WHO Antimicrobial Resistance: Global Report on Surveillance; 2014. Available from: http://www.who.int/drugresistance/documents/surveillancereport/en/. [Last accessed on 2016 Oct 28].  Back to cited text no. 7
    
8.
Alzoubi H, Al Madadha M, Al Mnayyis A, Azzam M, Aldawoud A, Hwaiti D, et al. Detection of Methicillin Susceptible and Resistant Staphylococcus aureus Nasal Carriage and Its Antibiotic Sensitivity among Basic and Clinical Years Medical Students. Healthcare 2020, 8(2), 161; https://doi.org/10.3390/healthcare8020161.  Back to cited text no. 8
    
9.
Simpson AH, Dave J, Cookson B. The value of routine screening of staff for MRSA. J Bone Joint Surg Br 2007;89:565-6.  Back to cited text no. 9
    
10.
Dancer SJ. Considering the Introduction of Universal MRSA Screening Published: May 17; 2010.  Back to cited text no. 10
    
11.
Shih H, Shen F, Lee Y, Hsu HC, Wu C, Chang CM, et al. Nasal carriage of Staphylococcus aureus among health care workers in relation to patient contact. doi:10.21203/rs.2.9188/v2.  Back to cited text no. 11
    
12.
IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp.  Back to cited text no. 12
    
13.
Hayden MK, Lolans K, Haffenreffer K, Avery TR, Kleinman K, Li H, et al. Chlorhexidine and mupirocin susceptibility of methicillin-resistant Staphylococcus aureus Isolates in the REDUCE-MRSA Trial. J Clin Microbiol 2016;54:2735-42.  Back to cited text no. 13
    
14.
Ahmed SM, Shakir VP, Arya P, Pullani F. Nasal screening for MRSA among the health care workers of a tertiary care hospital of North Kerala; Scholars Research Library. Arch Appl Sci Res 2013;5:167-71.  Back to cited text no. 14
    
15.
El Aila NA, Al Laham NA, Ayesh BM. Nasal carriage of methicillin resistant Staphylococcus aureus among health care workers at Al Shifa hospital in Gaza Strip. BMC Infect Dis 2017;17:28.  Back to cited text no. 15
    
16.
Khanal R, Sah P, Lamichhane P, Lamsal A, Upadhaya S, Pahwa VK. Nasal carriage of methicillin resistant Staphylococcus aureus among health care workers at a tertiary care hospital in Western Nepal. Antimicrob Resist Infect Control 2015;4:39.  Back to cited text no. 16
    


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