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Pilot Study to Detect the Presence of MRSA among Healthcare Workers Who Practice Ablution


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Background: Methicillin-resistant Staphylococcus aureus (MRSA) have emerged in the 1960s and is now commonly seen in hospitals, clinics and the community. In Saudi Arabia, MRSA prevalence was different from region to another, and the overall estimation was 35.6%. However, the infection with this pathogen can be prevented using many topical antiseptics or antibiotics. Moreover, colonization by this organism might be reduced by good washing using clean water. Thus, the aim of this study was to detect the presence of MRSA among healthcare workers who practice ablution. Methods: Nasal swabs were collected from 22 healthcare workers (64% female and 36% male) at Albaha city, Saudi Arabia. Participants were working at three different departments in the hospital including; clinical laboratory, emergency room and infection control unit with 55%, 36% and 9%, respectively. Identification of MRSA was performed by real time polymerase chain reaction‬ (PCR) (BD GenoOhm MRSATM Assay). Findings: The results of this study showed that MRSA was not isolated from any participants who use to practice ablution. On the other hand, MRSA was isolated from 3 (27%) samples, which were collected from healthcare workers who do not perform ablution. However, the difference between the two groups was not statistically significant. Conclusions: MRSA nasal colonization can be reduced by nasal washing in ablution, which can be an easy and effective method to reduce or prevent colonization by this organism and thereby decrease the infection with serious staphylococcal diseases.
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Journal of Transmitted Diseases and Immunity
Vol. 1 No. 1:7
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iMedPub Journals
Research Article
Zaini RG1, Ismail KA1,2,
Rezk HM1,3, and Dahlawi H1
1 Clinical Laboratory Department, Faculty
of Applied Medical Sciences, Taif
University, Taif, Saudi Arabia
2 Department of Parasitology, Faculty of
Medicine, Ain-Shams University, Cairo,
3 Department of Pathology, Faculty of
Medicine, Al-Azhar University, Cairo,
Corresponding author: Zaini RG
Head of Clinical Laboratory Department,
College of Applied Medical Sciences, Taif
University, Taif, Saudi Arabia.
Tel: 0966 555530937
Citation: Zaini RG, Ismail KA, Rezk HM, et al.
Pilot Study to Detect the Presence of MRSA
among Healthcare Workers Who Pracce
Abluon. J Transm Dis Immun. 2017, 1:1.
Staphylococcus aureus is commensal gram-posive microorganisms,
colonizing in the respiratory tract, nose and the skin of humans
with an esmated prevalence of 30% [1,2]. These pathogens
are usually cause asymptomac skin and mucosal carriage. Yet,
they are paradoxically recognized as amongst the most frequent
causave agents of hospital associated infecon (HAI) as well as
device associated infecon (DAI) [3-5].
Methicillin-resistant Staphylococcus aureus (MRSA), which is an
anbioc resistant strains, have been idened as a signicant
threat in both the hospital and community environment [6]. In
the USA, it has been esmated that MRSA causes between 11,000
and 18,000 deaths, and 80,000 invasive infecons every year [7].
In Saudi Arabia, AL Yousef and his colleagues reported that the
MRSA prevalence was dierent from region to another, ranged
from 5.97% to 94% in Dahran and Riyadh cies, respecvely.
Addionally, the overall prevalence esmaon was 35.6% [8].
MRSA infecons are generally linked with higher death rate
and increased nancial costs because of the limited opons of
Pilot Study to Detect the Presence of
MRSA among Healthcare Workers Who
Pracce Abluon
Background: Methicillin-resistant Staphylococcus aureus (MRSA) have emerged
in the 1960s and is now commonly seen in hospitals, clinics and the community.
In Saudi Arabia, MRSA prevalence was dierent from region to another, and the
overall esmaon was 35.6%. However, the infecon with this pathogen can be
prevented using many topical ansepcs or anbiocs. Moreover, colonizaon
by this organism might be reduced by good washing using clean water. Thus, the
aim of this study was to detect the presence of MRSA among healthcare workers
who pracce abluon.
Methods: Nasal swabs were collected from 22 healthcare workers (64% female
and 36% male) at Albaha city, Saudi Arabia. Parcipants were working at three
dierent departments in the hospital including; clinical laboratory, emergency
room and infecon control unit with 55%, 36% and 9%, respecvely. Idencaon
of MRSA was performed by real me polymerase chain reacon (PCR) (BD
GenoOhm MRSATM Assay).
Findings: The results of this study showed that MRSA was not isolated from any
parcipants who use to pracce abluon. On the other hand, MRSA was isolated
from 3 (27%) samples, which were collected from healthcare workers who do
not perform abluon. However, the dierence between the two groups was not
stascally signicant.
Conclusions: MRSA nasal colonizaon can be reduced by nasal washing in abluon,
which can be an easy and eecve method to reduce or prevent colonizaon by
this organism and thereby decrease the infecon with serious staphylococcal
Keywords: MRSA; Staphylococcus aureus; Staphylococcal bacteremia; Methicillin-
Received: February 03, 2017; Accepted: February 08, 2017; Published: February 15,
Vol. 1 No. 1:7
Journal of Transmitted Diseases and Immunity
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the treatment [9,10]. Methicillin-resistant coagulase-negave
staphylococci (MRCoNS), is commonly observed within the
surgical site infecon (SSI) and DAI, where biolm formaon on
implants and on ssue further reduces therapy success [11].
Idenfying the source, reservoirs and vectors for the spread of
anbioc resistant bacteria presents challenges. Many factors
play a signicant role in this regard; the hospital environment,
paent's endogenous microora, and healthcare workers (HCWs)
[12-15]. Several research studies have indicated that the paent
endogenous microora may be crical, since clinical studies
have found that S. aureus skin colonizaon increases the risk of
a subsequent infecon by three mes and up to 80% of cases
of staphylococcal bacteremia are caused by strains idencal to
those in the paent's nasal cavity [16,17]. In addion, S. aureus
colonizaon is signicantly associated with a 2-9-fold higher
risk of infecon [18]. Based on these possible threats, many
healthcare instutes introduce roune screening of paents for
colonizaon with S. aureus or MRSA upon hospital admission
[19,20]. Such acve surveillance programs play a role in reducing
outbreaks of nosocomial MRSA infecons [21].
Personal hygiene is crucial for various openings especially the
nose which considers the main source of harmful bacteria.
Muslims perform twenty six cleansing acons, which is known as
abluon, for ve mes a day and some mes more. According to
the instrucons of the Prophet Muhammad (PBUH), nasal wash
should be done by sning the nose three consecuve mes
which, helps to keep the nostril clean and free of inammaon
and germs.
The present study was aim to idenfy the prevalence and density
of nasal colonizaon of anbioc resistant staphylococci among
healthcare workers who daily repeated nasal washing through
pracce abluon and who do not.
Cross secon study was held on 22 healthcare workers (64%
female and 36% male) at Albaha city, Saudi Arabia. Enrollment
was voluntary and the parcipants were working at three
dierent departments at the hospital including; clinical
laboratory, emergency room and infecon control with 55%,
36% and 9% respecvely. All parcipants signed a wrien
consent and completed a quesonnaire of demographic and
professional informaon. They also provided a nasal swab.
Bacterial idencaon was correlated to parcipants’ personal
informaon including; personal medical history. This study
divided the parcipate into two groups: the rst group was
included 11 parcipants, who were usually washed their nose
by inhalaon of water for three mes during each abluon. The
second group was included 11 parcipants, who rarely wash their
nose and did not perform abluon. Nasal swabs were collected at
random me from inside of the nostrils. The swab was inserted
into one nostril to a depth of 1 cm, rotated three mes on the
nasal lining. The obtained swabs were saved in sterile tubes.
Idencaon of MRSA was performed by real me polymerase
chain reacon (PCR) (BD GenoOhm MRSATM Assay) according to
the manufacturer instrucons.
Stascal analysis
The data were collected and analyzed stascally using SPSS
version 16.
Ethical consideraon
Ethical approval for this study was obtained from the Ethics
Review Commiee of the College of Applied Medical Sciences at
Al-Taif University. All informaon obtained at each course of the
study was kept condenal.
The rates of presence and colonizaon of MRSA among
healthcare workers who perform abluon and who do not
perform abluon are shown in table 1. MRSA was not isolated
from any parcipants who use to pracce abluon. On the other
hand, MRSA was isolated from 3 (27%) samples, which were
collected from healthcare workers who do not perform abluon.
However, the study did not show any stascally signicant
dierence between the two groups (p>0.05) (Table 1).
The nose is the main reservoir for S. aureus, which can be
distributed into the respiratory tract and to the surface of the
skin and even to the surrounding air during exhalaon [22].
However, colonizaon of S. aureus can be seen in several human
body sites, the anterior nares are the most common carriage site
for this organism [23]. Moreover, S. aureus grows in the nose
and spread to the skin and in the atmosphere. If these bacteria
are decreased or eliminated in the nose, the quanes on the
skin surface and in the atmosphere will be decrease as well
[24]. In this study, MRSA was isolated from healthcare workers
who perform abluon as well as who do not. Results from this
study have shown insignicant dierence (p>0.05). This might
indicates that abluon had no eect on reducing MRSA. On the
other, many several studies have been contradicted this result.
A study was conducted by Ghonaim and El-Edel, showed higher
rate of S. aureus were isolated from non-worshipers compared to
worshipers before abluon. Also the study showed no signicant
dierence [25]. Interesngly it has been reported that the
density of S. aureus was signicantly lower in worshipers than
in non-worshipers. These results might suggest the important
role of ritual abluons in decreasing colonizaon of the nose
by this organism [26]. Ghonaim and El-Edel studies have also
shown that, among worshipers, there was stascally signicant
reducon of S. aureus isolaon when samples were collected
directly following abluon when compared to that collected
before performing abluon. Following two hours, an increase
in the rate of isolaon was demonstrated. Such crucial results
indicate that proper nasal washing in abluon has a signicant
eect on S. aureus nasal colonizaon. Moreover, Al-Khayat,
has performed a study, and concluded that praccing abluon,
combined with mupirocin intranasal applicaon, was an eecve
measure against S. aureus carriage and decreased the incidence
of connuous ambulatory peritoneal dialysis-associated S. aureus
peritonis [27]. A number of dierent studies in several countries
Vol. 1 No. 1:7
Journal of Transmitted Diseases and Immunity
© Under License of Creative Commons Attribution 3.0 License
which 11 of them were performing abluon and the remaining 11
were not. Thirdly, the study might have been biased in favor of a
certain gender as the majority of the samples were obtained from
female health workers. Fourthly, no samples were obtained from
males who do not perform abluon due to the unavailability of
male sta who do not perform abluon. Fihly, this experiment
was costly as PCR is considered a highly expensive procedure,
thus has caused a limitaon in the size of the study. Sixthly, this
experiment is highly sensive as DNA can be easily aected by
any environmental debris such as dust, heat, or gloves powder.
Strengths include eecve data collecon throughout the study.
In conclusion, this study was conducted to idenfy if there was
any dierence in MRSA rate between healthcare workers who
perform abluon and those who did not. Results have has
shown that there was insignicant dierence between the two
We would like to thank Ms. Amani Al-shehri and Ms. Rana Al-
ansari, students at the department of clinical laboratory for
helping with collecon of samples and distribuon of the
were conducted by Ghonaim et al. [28], El-Ghamdi et al. [29],
and by Biswajit et al. [30] have shown that S. aureus is not only
resistant to anbiocs, but also has several other mechanisms
of resistance including: staphylokinase [31], membrane lipid
modicaon [32], Caonic anmicrobial pepdes, including
defensins and cathelicidins, present in the nasal mucosa.
Furthermore, all S. aureus strains are also lysozyme-resistant
since they possess the pepdoglycan specic O-acetyltransferase
[32]. Thus, the proper act of abluon or/and nasal wash seems
to be an appropriate soluon for reducing the colonizaon by
this pathogen. Performing abluon properly is not only to clean
the vital parts of the body from dust and dirt but also soens
and refreshes the skin and posively aecng the inner coang
of the nostrils. In Alexandria University, a study performed and
concluded that the cleansing act can be one of the best methods
to remove germs trapped in the nostrils [33].
This study has some limitaons. Firstly, the study has targeted
health workers only and did not include any paents whom are
also prone to being infected with MRSA. Given that MRSA is a
cross cung problem aecng both health-care sengs as well
as the community, it is essenal to include evidence from these
sengs too. Secondly, the small size of the study (22 samples) in
Study samples No MRSA results
X2P value
Posive No (%) Negave No (%)
Perform abluon 11 0 (0%) 11 (100%) 3.4 P˃0.05
Non sig
Do not perform abluon 11 3 (27%) 8 (73%)
Table 1: Chi-Square Test for Associaon: number of posive and negave MRSA results between health employees who perform abluon and who
do not perform abluon.
Vol. 1 No. 1:7
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A comparison of methicillin-resistant Staphylococcus aureus (MRSA) prevention and control recommendations, as stated in national/regional guidelines of 13 European countries was performed based on a structured questionnaire filled by representatives of professional societies or institutions. The aim of this study was to be a source of guidelines, references and views which can inform discussions at national/regional/local levels. Countries were devided in two groups based on proportion of MRSA in blood cultures positive with Staphylococcus aureus retrieved from EARSS 2008: low proportion (4 countries) and higher proportion (9 countries). Guidelines from all respective countries have several common general recommendations: MRSA-positive patients have to have the same care as those that are not carrying MRSA, hand hygiene measures including the use of alcohol hand rubs are identified as important in the prevention of MRSA spread, environmental cleaning and/or disinfection has to be performed routinely, and personal protective equipment has to be used whilst working with MRSA positive patients. Surveillance and screening is also a part of all guidelines. Major differences among low and higher MRSA proportion countries, identified as successful practices, were: have guidelines and update it regularly, have guidelines not only for hospitals, but also for nursing homes and home practice, isolate MRSA positive patients in single room, perform MRSA screening based on risk categories in hospitals and nursing homes, and perform decolonisation of MRSA carriers.
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In recent years, methicillin-resistant Staphylococcucs aureus (MRSA) have become a truly global challenge. Systemic review and meta-analysis was performed to summarize the prevalence of MRSA in different regions of Kingdom of Saudi Arabia (KSA). A search of the PubMed, Google and Google Scholar databases for studies published during the period of 1 January 2002 through 31 December 2012 was conducted. We included studies that looked at the number and prevalence of MRSA among total S. aureus. Meta-analyst and comprehensive meta-analysis were used for statistical analysis. Twenty six studies were included in the review, representing five regions of KSA. Pooled estimation of 22,793 S. aureus strains showed 35.6% (95% Confidence interval (CI), 0.28 –0.42; P < 0.01) of the strains were MRSA with significant heterogeneity. Prevalence of MRSA ranged from 5.97% to 94% in Dahran and Riyadh cities, respectively. MRSA proportion among KSA regions is slightly high and varied from one city to the other.
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Objectives: Swab-based nasal screening is commonly used to identify asymptomatic carriage of Staphylococcus aureus in patients. Bacterial detection depends on the uptake and release capacities of the swabs and on the swabbing technique itself. This study investigates the performance of different swab-types in nasal MRSA-screening by utilizing a unique artificial nose model to provide realistic and standardized screening conditions. Methods: An anatomically correct artificial nose model was inoculated with a numerically defined mixture of MRSA and Staphylococcus epidermidis bacteria at quantities of 4×10(2) and 8×10(2) colony forming units (CFU), respectively. Five swab-types were tested following a strict protocol. Bacterial recovery was measured for direct plating and after elution into Amies medium by standard viable count techniques. Results: Mean recovered bacteria quantities varied between 209 and 0 CFU for MRSA, and 365 and 0 CFU for S. epidermidis, resulting swab-type-dependent MRSA-screening-sensitivities ranged between 0 and 100%. Swabs with nylon flocked tips or cellular foam tips performed significantly better compared to conventional rayon swabs referring to the recovered bacterial yield (p<0.001). Best results were obtained by using a flocked swab in combination with Amies preservation medium. Within the range of the utilized bacterial concentrations, recovery ratios for the particular swab-types were independent of the bacterial species. Conclusions: This study combines a realistic model of a human nose with standardized laboratory conditions to analyze swab-performance in MRSA-screening situations. Therefore, influences by inter-individual anatomical differences as well as diverse colonization densities in patients could be excluded. Recovery rates vary significantly between different swab-types. The choice of the swab has a great impact on the laboratory result. In fact, the swab-type contributes significantly to true positive or false negative detection of nasal MRSA carriage. These findings should be considered when screening a patient.
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Health care-associated infections with methicillin-resistant Staphylococcus aureus (MRSA) have been an increasing concern in Veterans Affairs (VA) hospitals. A "MRSA bundle" was implemented in 2007 in acute care VA hospitals nationwide in an effort to decrease health care-associated infections with MRSA. The bundle consisted of universal nasal surveillance for MRSA, contact precautions for patients colonized or infected with MRSA, hand hygiene, and a change in the institutional culture whereby infection control would become the responsibility of everyone who had contact with patients. Each month, personnel at each facility entered into a central database aggregate data on adherence to surveillance practice, the prevalence of MRSA colonization or infection, and health care-associated transmissions of and infections with MRSA. We assessed the effect of the MRSA bundle on health care-associated MRSA infections. From October 2007, when the bundle was fully implemented, through June 2010, there were 1,934,598 admissions to or transfers or discharges from intensive care units (ICUs) and non-ICUs (ICUs, 365,139; non-ICUs, 1,569,459) and 8,318,675 patient-days (ICUs, 1,312,840; and non-ICUs, 7,005,835). During this period, the percentage of patients who were screened at admission increased from 82% to 96%, and the percentage who were screened at transfer or discharge increased from 72% to 93%. The mean (±SD) prevalence of MRSA colonization or infection at the time of hospital admission was 13.6±3.7%. The rates of health care-associated MRSA infections in ICUs had not changed in the 2 years before October 2007 (P=0.50 for trend) but declined with implementation of the bundle, from 1.64 infections per 1000 patient-days in October 2007 to 0.62 per 1000 patient-days in June 2010, a decrease of 62% (P<0.001 for trend). During this same period, the rates of health care-associated MRSA infections in non-ICUs fell from 0.47 per 1000 patient-days to 0.26 per 1000 patient-days, a decrease of 45% (P<0.001 for trend). A program of universal surveillance, contact precautions, hand hygiene, and institutional culture change was associated with a decrease in health care-associated transmissions of and infections with MRSA in a large health care system.
Staphylococcus aureus has long been recognized as an important pathogen in human disease. Due to an increasing number of infections caused by methicillin-resistant S. aureus (MRSA) strains, therapy has become problematic. Therefore, prevention of staphylococcal infections has become more important. Carriage of S. aureus appears to play a key role in the epidemiology and pathogenesis of infection. The ecological niches of S. aureus are the anterior nares. In healthy subjects, over time, three patterns of carriage can be distinguished: about 20% of people are persistent carriers, 60% are intermittent carriers, and approximately 20% almost never carry S. aureus. The molecular basis of the carrier state remains to be elucidated. In patients who repeatedly puncture the skin (e.g., hemodialysis or continuous ambulatory peritoneal dialysis [CAPD] patients and intravenous drug addicts) and patients with human immunodeficiency virus (HIV) infection, increased carriage rates are found. Carriage has been identified as an important risk factor for infection in patients undergoing surgery, those on hemodialysis or CAPD, those with HIV infection and AIDS, those with intravascular devices, and those colonized with MRSA. Elimination of carriage has been found to reduce the infection rates in surgical patients and those on hemodialysis and CAPD. Elimination of carriage appears to be an attractive preventive strategy in patients at risk. Further studies are needed to optimize this strategy and to define the groups at risk.
Importance: Estimating the US burden of methicillin-resistant Staphylococcus aureus (MRSA) infections is important for planning and tracking success of prevention strategies. Objective: To describe updated national estimates and characteristics of health care- and community-associated invasive methicillin-resistant Staphylococcus aureus (MRSA) infections in 2011. Design, setting, and participants: Active laboratory-based case finding identified MRSA cultures in 9 US metropolitan areas from 2005 through 2011. Invasive infections (MRSA cultured from normally sterile body sites) were classified as health care-associated community-onset (HACO) infections (cultured ≤ 3 days after admission and/or prior year dialysis, hospitalization, surgery, long-term care residence, or central vascular catheter presence ≤ 2 days before culture); hospital-onset infections (cultured >3 days after admission); or community-associated infections if no other criteria were met. National estimates were adjusted using US census and US Renal Data System data. Main outcomes and measures: National estimates of invasive HACO, hospital-onset, and community-associated MRSA infections using US census and US Renal Data System data as the denominator. Results: An estimated 80,461 (95% CI, 69,515-93,914) invasive MRSA infections occurred nationally in 2011. Of these, 48,353 (95% CI, 40,195-58,642) were HACO infections; 14,156 (95% CI, 10,096-20,440) were hospital-onset infections; and 16,560 (95% CI, 12,806-21,811) were community-associated infections. Since 2005, adjusted national estimated incidence rates decreased among HACO infections by 27.7% and hospital-onset infections decreased by 54.2%; community-associated infections decreased by only 5.0%. Among recently hospitalized community-onset (nondialysis) infections, 64% occurred 3 months or less after discharge, and 32% of these were admitted from long-term care facilities. Conclusions and relevance: An estimated 30,800 fewer invasive MRSA infections occurred in the United States in 2011 compared with 2005; in 2011 fewer infections occurred among patients during hospitalization than among persons in the community without recent health care exposures. Effective strategies for preventing infections outside acute care settings will have the greatest impact on further reducing invasive MRSA infections nationally.
The skin is the human body's largest organ, colonized by a diverse milieu of microorganisms, most of which are harmless or even beneficial to their host. Colonization is driven by the ecology of the skin surface, which is highly variable depending on topographical location, endogenous host factors and exogenous environmental factors. The cutaneous innate and adaptive immune responses can modulate the skin microbiota, but the microbiota also functions in educating the immune system. The development of molecular methods to identify microorganisms has led to an emerging view of the resident skin bacteria as highly diverse and variable. An enhanced understanding of the skin microbiome is necessary to gain insight into microbial involvement in human skin disorders and to enable novel promicrobial and antimicrobial therapeutic approaches for their treatment.