community acquired methicillin resistant Staphylococcus aureus in new patients attending a government hospital in Gangtok, Sikkim.
ABSTRACT Prevalence of methicillin resistant Staphylococcus aureus (MRSA) is increasing in the community and has become an emerging public health problem. Community acquired MRSA (CA-MRSA) strains differ from Hospital acquired MRSA (HA-MRSA) by causing aggressive infections like furunculosis and necrotizing pneumonia in otherwise young, healthy individuals Aim - This study was carried out to determine the prevalence of CA-MRSA in patients attending hospital from April 2010 till March 2011. Materials and Methods - 2,282 clinical samples from outpatient and hospitalized patients were screened for MRSA. CA-MRSA were identified based on the CDC definition for community acquired infection. Antibiotic resistance pattern was studied by using the Kirby baeur disk diffusion method. Risk factors for hospital associated infections were recorded Results - Of the 184 strains of S. aureus isolated, 29.3% were MRSA and 48.14% was CA-MRSA. Conclusion Methicillin resistance is an increasing menace and routine screening of all isolates is necessary.
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ABSTRACT: Methicillin-resistant Staphylococcus aureus (MRSA) is a common bacterial pathogen responsible for a variety of infections in both children and adults. Treatment of infections caused by this organism is problematic due to its resistance to many drugs. Recent reports of community-associated MRSA (CA-MRSA) infections in patients with no known risk factors have serious public health implications. Therapeutic options for these infections are untested; therefore, the potential exists for high morbidity and mortality. Recently, clinical definitions have been established, and new molecular approaches have allowed investigators to distinguish CA-MRSA more easily from traditional nosocomial-derived MRSA strains. Identifying potential risk factors for CA-MRSA acquisition and fully characterizing the epidemiologic, clinical, and molecular properties of these strains are necessary to provide effective therapeutic guidelines.Pharmacotherapy 02/2005; 25(1):74-85. · 2.31 Impact Factor
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ABSTRACT: Methicillin-resistant Staphylococcus aureus (MRSA), one of the most common causes of infections, has been traditionally recognized as a nosocomial pathogen. However, in recent years, its epidemiology has radically changed, being now observed even more frequently in the community, and accounting for > 50% of staphylococcal infections in the US outpatient setting. Community-acquired (CA)-MRSA strains typically cause infections among otherwise healthy individuals, with risk factors differing from those of nosocomial MRSA. The clinical manifestations may range from a furuncle to life-threatening infections, such as necrotizing fasciitis and pneumonia. The antibiotic treatment of these infections may also differ because CA-MRSA strains often retain susceptibility to antimicrobials other than glycopeptides and newer agents. Moreover, the production of toxins, such as the Panton-Valentine leukocidin (PVL), should influence the antibiotic choice because in these cases the use of a combination therapy with antimicrobial agents able to decrease toxin production is suggested. There are still many unanswered key questions regarding the epidemiology, prevention, and treatment of CA-MRSA infections. This article reviews current knowledge of CA-MRSA.Postgraduate Medicine 11/2010; 122(6):16-23. · 1.97 Impact Factor
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ABSTRACT: Methicillin-resistant Staphylococcus aureus (MRSA) is an important nosocomial pathogen. It can also cause community-acquired infections. Indian reports about MRSA in community-acquired infections are rare. To evaluate the rate of MRSA in community-acquired pyoderma and the nasal colonisation with S. aureus in such patients. Two hundred and fifty patients with community-acquired pyoderma, who attended outreach camps around Mangalore, south India between January 2000 and July 2001, were studied. Swabs collected from the skin lesions and anterior nares were inoculated onto blood agar and MacConkey's agar. Antimicrobial sensitivity testing was performed using Kirby-Bauer disk diffusion, agar dilution, and agar screen. Of 250 pyoderma cases, S. aureus was isolated from 202 (80.8%) patients. Twenty-two (10.9%) S. aureus isolates were methicillin resistant, 179 (88.6%) were resistant to penicillin, and 114 (56.4%) were resistant to erythromycin. S. aureus colonization in the anterior nares was observed in 136 (54.4%) cases, 11.8% of which were MRSA. Antibiograms of clinical isolates of S. aureus matched with nasal isolates in 99 (49%) cases. The emergence of MRSA in the community is a warning. A high nasal carriage rate may contribute to recurrent pyoderma. A correct antimicrobial policy and the avoidance of inappropriate antimicrobial usage are mandatory to reduce the spread of MRSA in the community.International Journal of Dermatology 07/2004; 43(6):412-4. · 1.34 Impact Factor
Gurung Shrijana et al. / JPBMS, 2012, 19 (03)
1 Journal of Pharmaceutical and Biomedical Sciences © (JPBMS), Vol. 19, Issue 19
Available online at www.jpbms.info
JOURNAL OF PHARMACEUTICAL AND BIOMEDICAL SCIENCES
Community acquired methicillin resistant Staphylococcus aureus in new patients
attending a government hospital in Gangtok, Sikkim
*Gurung Shrijana1,Bhutia Pema Y2 ,Pradhan Jagat2 ,Mukhopadhyay Chiranjay3, Pradhan Uttam2 .
*1M.D, Mirobiologist, 2 Consultant Microbiologist, Sir Thotub Namgyal Memorial Hospital, Gangtok, Sikkim,India.
3 Professor and HOD, Department of Microbiology, Kasturba Medical College, Manipal, Karnataka,India.
Prevalence of methicillin resistant Staphylococcus aureus (MRSA) is increasing in the community and has become an
emerging public health problem. Community acquired MRSA (CA-MRSA) strains differ from Hospital acquired MRSA (HA-
MRSA) by causing aggressive infections like furunculosis and necrotizing pneumonia in otherwise young, healthy
Aim: - This study was carried out to determine the prevalence of CA-MRSA in patients attending hospital from April 2010
till March 2011.
Materials and Methods: - 2,282 clinical samples from outpatient and hospitalized patients were screened for MRSA. CA-
MRSA were identified based on the CDC definition for community acquired infection. Antibiotic resistance pattern was
studied by using the Kirby baeur disk diffusion method. Risk factors for hospital associated infections were recorded
Results: - Of the 184 strains of S. aureus isolated, 29.3% were MRSA and 48.14% was CA-MRSA.
Conclusion:- Methicillin resistance is an increasing menace and routine screening of all isolates is necessary.
Keywords: CA-MRSA; MRSA; Staphlycoccus aurues; D test; risk factors; Gangtok.
MRSA is no longer confined to the hospital environment as
they now circulate in the community among previously
healthy patients. Prevalence of MRSA infection is
increasing in the community and it accounts for > 50% of
community acquired S aureus infections in many US
centers. These community isolates differ from HA-MRSA
in their epidemiology and spectrum of disease.
Distinguishing HA-MRSA from CA- MRSA is useful in
defining epidemiology, identifying those at risk and
choosing empirical antibiotic therapy when required. True
burden of CA-MRSA cannot be determined by phenotypic
study alone as it is the acquisition of the SCCmec IVelement
by MSSA strains in the community that given rise to the
community acquired MRSA strains  thus making it
imperative to carry out molecular study for the detection
of SCCmec IV. This study was conducted to find out the
prevalence and antibiotic profile of community acquired
MRSA in patients attending the Government Hospital.
Materials and Methods:
2,282 clinical samples for culture and antibiotic sensitivity
were obtained from 120,919 outpatients and 10,199
inpatients fulfilling the inclusion criteria from April 2010
till March 2011. Patients included in the study was based
on the Centre for Disease control definition of community
acquired MRSA [3, 4]. Samples obtained from patients in the
outpatient setting or within 48 hours of hospitalization
were considered to be community acquired and those with
the following risk factors for HA-MRSA were not included
in the study: hospitalization in the previous 12 months,
receipt of dialysis or any other invasive procedure,
residence in chronic care facility or presence of in dwelling
catheter, previous use of antibiotics and contact with
health care workers. The distribution of departments were
as follows: Outpatient department- 47.59%, Medicine ward
– 15.78%Paediatric ward – 12.40%, Orthopaedic ward-
8.41%, Surgical – 6.18%, OBG- 3.46%, cardiac ICU – 2.89%,
Neonatal ICU – 1.58%, ENT – 0.96%, Eye- 0.74%. The most
common sample processed was urine (40.98%) followed
by pus, wound aspirate and wound swabs (19.54%), blood
(9.82%), throat swabs (8.55%) and sputum (6.66%). Total
number of isolated organisms was 754. Identification of S.
aureus was based on colony morphology and biochemical
reactions like catalase, coagulase. They were screened for
Methicillin resistance by the Cephoxitin (30mcg) disk
diffusion method. For quality control Staphylococcus
aureus ATCC 33400 was used as negative control and
Staphylococcus aureus ATCC 49619 was used as positive
control. The study was conducted after ethical committee
clearance from the hospital ethical committee.
The isolates were tested for antibiotic resistance to
Gentamicin (10mcg), Ciprofloxacin (5mcg), TMP-SMX
(1.25/23.75 mcg), Doxycycline (30mcg), Teicoplanin
(15mcg) and Vancomycin (30mcg) by the Kirby-Baeur disc
diffusion method. Inducible MLSB resistance was detected
by double disc diffusion method (D test) using Clindamycin
(2mcg) and Erythromycin (15mcg) placed 15 mm apart
(edge to edge).
184 strains of Staphylococcus aureus were isolated from
754 positive bacterial cultures. 54 (29.3%) MRSA was
isolated from 29 In Patients (19 patients > 48 hours of
ISSN NO- 2230 – 7885
NLM Title: J Pharm Biomed Sci.
Gurung Shrijana et al. / JPBMS, 2012, 19 (03)
2 Journal of Pharmaceutical and Biomedical Sciences© (JPBMS), Vol. 19, Issue 19
admission, 10 patients < 48 hours of admission) and 28
outpatients. The type of infections caused by MRSA is
shown in Figure 1.
Figure 1:-Infection caused by MRSA
26 strains (48.14%) were CA-MRSA out of which 17 of the
isolates were from outpatient department (7- Orthopaedic,
5- ENT, 5- Surgery) and 9 from various wards (5- Medicine,
2 –Surgery, 2-Orthopaedic). The resistance profile of the
antibiotics tested is shown in Figure 2.
Figure 2: Antibiotic resistance profile of CA- MRSA and HA- MRSA
All isolates were sensitive to Vancomycin by the disc
diffusion method. MLSB resistance profile of CA- MRSA is
shown in Table 1. The risk factors studied for acquisition
of HA-MRSA infection are shown in Table 2. Past history of
antibiotic use was the most common risk factor for the
acquisition of HA drug resistance. In patients with CA-
MRSA isolates 11 patients had close contact with domestic
animals, poultry and cows. 21 patients had more than two
types of risk factors.
Table 1: MLSB resistance profile
resistance. (D test
positive) (Resistant to both
Sensitive to Clindamycin)
Table 2: Risk factors for MRSA infection
Previous use of antibiotics
Visit to Hospital > 1 Year
Contact with Health care Worker
Presence of Chronic Underlying
Table 3: Recent studies done in India on CA-MRSA.
Place of study Year Patient
Healthy contacts of
from rural, urban
Hand swabs from
from hostels and
adults from slum
from Oct 2006-June
Since it was first reported in 1982 several outbreaks of
infection with CA-MRSA have been reported [3, 4]. In India
burden of CA- MRSA cannot be assessed due to paucity of
studies on prevalence of CA- MRSA. In a study done in
South India 11.8%  and 1.4%  of CA pyoderma cases
were due to MRSA. Other studies from various states in
India were focused on detecting colonisers in healthy
adults and children. A few of the Indian studies are shown
in Table 2. In our study 48.14% of the MRSA isolates were
CA- MRSA which is an alarming number and can pose a
significant public health problem.
CA MRSA is susceptible to wide range of non-beta lactam
antibiotics like Tetracycline, Clindamycin and TMP-SMX. 
But we encountered high degree of resistance to TMP-SMX
(84.61%) which may be due to free access to this drug in
all the primary health care centers and district hospitals in
Clindamycin is a viable treatment option for CA-MRSA but
inducible resistance can lead to treatment failure. This
necessitates the need for D-test to be implemented in
routine clinical laboratory.
resistance was seen in 7.69% (2 isolates) of CA- MRSA
which is lower when compared to the results in two south
Indian studies 15.65%  and 48.7% .
Previous use of antibiotics as a risk factor was seen in 22
patients with beta lactam antibiotics being the most
common drug used followed by floroquinolones. Use of
ciprofloxacin and cephalosporins promote colonization
and spread of MRSA in hospitals. A retrospective study
done in Canada showed patients infected with MRSA had
history of consumption of antibiotics, particularly beta
lactam antibiotics, levofloxacin and macrolides. There
are no known mechanisms for floroquinolones to select
resistance to beta-lactam antibiotics in S. aureus but
evidence is mounting that floroquinolones exhibit some
type of influence on MRSA
floroquinolone has been associated with elimination of
MSSA strains from the nasal mucosa, which might
predispose to colonization by MRSA strains .
Domestic pets, livestock, wild birds and other animals have
recently been identified as carriers of MRSA. In the
present study we found close contact with domestic
animals to be a common association in patients with
. Increased use of
Gurung Shrijana et al. / JPBMS, 2012, 19 (03)
3 Journal of Pharmaceutical and Biomedical Sciences© (JPBMS), Vol. 19, Issue 19
community acquired infections, with 14 patients owning
one type of livestock (Pig, Cow or Poultry) at home. The
most common antibiotic used in our state government
veterinary hospital, for an average of two years (2008-
2010) was Tetracycline (63%) in porcine, beta-lactam
antibiotics (43.44%) in bovine and TMP-SMX (45.5%) in
avian population. Live-stock are known to be reservoirs of
antibiotic resistant bacteria as antibiotics are used in them
as growth promoters, prophylactically for disease
prevention or therapeutically
infections. Humans are infected by direct contact with
these animals or through contaminated food and water.
Since animals were not tested for colonization with MRSA
we cannot regard this as a risk factor, and further extensive
study needs to be done.
Colonisation with multiple multi drug resistant organisms
in the hospitals is a known fact and thus a holistic infection
control practice is required that targets all MDR
organisms- MRSA, VRE and MDR- gram negative bacilli.
Injudicious use of antibiotics must be controlled by
formulating antibiotic prescribing policy in the hospitals.
The author expresses gratitude to Tashi Bhutia, Tenzing
Choden and Manju Neopaney who have helped with the
processing of clinical samples and storage of isolates.
1. Zetole N, Francis S J, Nuermberg E, Bishai W R.
Staphylococcus aureus: an emerging health threat.
Lancet Infect Dis 2005; 5: 275-86.
2. Rybak MJ, La Planta KL. Community Associated
Methicillin Resistant Staphylococcus aureus: A review.
Pharmacotherapy 2005; 25(1): 74-85.
3. Maree CL, Daum RS, Boyle-Vavra S, Matayoshi K, Miller
LG. Community associated
Staphylococcus aureus isolate causing health care
associated infection. Emerg Infect Dis 2007; 13:2.
4. Cataldo MA, Taglietti F, Petrosillo N. Methicillin –
Resistant Staphylococcus aurues; A community health
threat. Postgraduate Medicine 2010;1226(16): 16-23
5. Nagaraju U, Bhat G, Kurnila M, Pai GS, Jayalakshmi,
Babu RP. Methicillin resistant Staphylococcus aureus in
Dr Shrijana Gurung,
Department of Microbiology, S.T.N.M Hospital, Gangtok – 737101, Sikkim,India.
Cell no: - +91-96791-29388
for treatment of
community acquired pyoderma. Int J Dermatol 2004;
6. Patil R, Baveja S, Nataraj G, Khipan U. Prevalence of
community acquired primary pyoderma. Ind J Dermatol
Venereol 2006; 72: 126-28.
7. Saxena S, Singh K, Talwar V. Methicillin-resistance
Staphylococcus aureus prevalence in community in the
east Delhi area. Jpn J Infect Dis 2003; 56:54-6.
8. Chaterjee SS, Ray P, Aggarwal A, das A, Sharma M. A
community based study on nasal carriage of
staphylococcus aurues. Ind J Med Res 2009; 130: 742-
9. Tambekar DH, Dhanorkar DV, Gulhane SR, Dudhane
MN. Prevalence and antimicrobial susceptibility pattern
of methicillin resistant Staphylococcus aureus from
healthcare and community associated sources. Afr J
Infect Dis. 1(1): 52-58.
10. Parasa LS, Kumar LCA, Para S, Alturi VSR, Kumar PR,
Shetty CR. Epidemiological survey of methicillin
resistant staphylococcus aureus in the community and
hospitals. RIF 2010; 1(2): 117-23.
11. D’Souza N, Rodrigues C, Mehta A. Molecular
characterization of Methicillin Resistnat Staphlococcus
aureus with emergence of epidemic clones of sequence
type (ST) 22 and ST772 in Mumbai, India. J Clin
Microbiol 2010; 48(5): 1806-11.
12. Shenoy MS, Bhat GK, Kishore A, Hassan MK.Significance
of MRSA in community associated skin and soft tissue
infections. Ind J Med Microbiol. 2010; 28(2):152-4.
13. Vandana KE, Singh J, Chiranjay M, Bairy I. Inducible
Clindamycin reistance in Staphylococcus aureus: Reason
for treatment for failure. J Global Infec Dis 2009;1:76-7.
14. Graffunder EM, Venezia RA. Risk factors associated with
nosocomial methicillin- resistant Staphlococcus aureus
(MRSA) infections including
antimicrobials. J Antimicrob Chemo 2002; 49: 999-1005
15. David MZ, Daum RS. Community – Associated
Methicillin – Resistant
Epidemiology and Clinical Consequences of an
Emerging Epidemic. Clin Microbiol Rev 2010, 23; 3:
16. The medical impact of antimicrobial use in food
animals. Report of a WHO meeting Berlin, Germany, 13-
17 October 1997. WHO/EMC/ZOO/97.4.
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