ArticlePDF Available

Abstract and Figures

S. aureus is a common commensal of the skin and mucosal membranes of humans, with estimates of 20% (range from 12% to 30%) of healthy people are persistent S. aureus nasal carriers, 30% (range from 16% to 70%) are intermittent carriers, and 50% (range from 16% to 69%) are non-carriers. The aim of this article is to explore the factors associated with Methicillin Resistant Staphylococcus Aureus carriage among food handlers. Across sectional study was done to involve 200 persons who are handling foods in 40 restaurants in Duhok city in the study. Methicillin Resistant Staphylococcus Aureus was detect among 27% of studied population. Methicillin Resistant Staphylococcus Aureus carrier rate showed a significant association with skin and soft tissue infections, health facilities visits and certain jobs of food handlers. Age, duration of work in the restaurants, personal protective measures and antibiotic use showed no significant association with the prevalence of MRSA. Methicillin Resistant StaphylococcusAureus carrier rate was higher among food handlers working in popular restaurants when compared to other restaurants. Ongoing screening of all persons who handled foods is crucial to detect and treat those are MRSA carrier as one of major public health issues.
Content may be subject to copyright.
Kurdistan Journal of Applied Research (KJAR)
Print-ISSN: 2411-7684 | Electronic-ISSN: 2411-7706
Website: Kjar.spu.edu.iq | Email: kjar@spu.edu.iq
Factors Associated with Methicillin
Resistant Staphylococcus aureus
Carriage
Masood
Abdulkareem
Abdu
lr
ahman
Arazoo Issa Taher
Community Health Department
Nursing Department
Shekhan Technical College of Health
Bardarash Technical Institute
Duhok Polytechnic University
Duhok Polytechnic University
Duhok, Iraq
Duhok, Iraq
masood.abdulkareem@dpu.edu.krd
Arazoo.taher@dpu.edu.krd
Volume 4 – Special Issue:
3rd International
Conference on Health &
Medical Sciences: Insight
into Advanced Medical
Research (ICHMS 2019)
DOI:
10.24017/science.2019
.ICHMS.9
Received:
6 June 2019
Accepted:
8 July 2019
Abstract
S. aureus is a common commensal of the skin and mucosal
membranes of humans, with estimates of 20% (range from
12% to 30%) of healthy people are persistent S. aureus
nasal carriers, 30% (range from 16% to 70%) are
intermittent carriers, and 50% (range from 16% to 69%) are
non-carriers. The aim of this article is to explore the factors
associated with Methicillin
Resistant
Staphylococcus Aureus
carriage among food handlers. Across sectional study was
done to involve 200 persons who are handling foods in 40
restaurants in Duhok city in the study. Methicillin
Resistant
Staphylococcus Aureus was detect among 27% of studied
population. Methicillin
Resistant
Staphylococcus Aureus
carrier rate showed a significant association with skin and
soft tissue infections, health facilities visits and certain jobs
of food handlers. Age, duration of work in the restaurants,
personal protective measures and antibiotic use showed no
significant association with the prevalence of MRSA.
Methicillin
Resistant
Staphylococcus Aureus carrier rate was
higher among food handlers working in popular restaurants
when compared to other restaurants. Ongoing screening of
all persons who handled foods is crucial to detect and treat
those are MRSA carrier as one of major public health issues.
Keywords: Methicillin
Resistant
Staphylococcus aureus ,
Fact
carrier state , Duhok
1. LITERATURE REVIEW
Kurdistan Journal of Applied Research | 3rd International Conference on Health & Medical
Sciences: Insight into Advanced Medical Research (ICHMS 2019)| 89
Staphylococci are worldwide bacteria, which include over 32 species and subspecies [1].
S. aureus is among the most ubiquitous and important pathogens among Staphylococci
species. The discovery of S. aureus was in 1880 by Alexander Ogston. It is particularly
resistant to unfavorable environmental conditions and it resists drying beside high NaCl
concentrations. This permits a probably temporary and even permanent colonization of
skin and nasal mucosa [2].It is frequently found in both community and nosocomial and
it is a commensal bacterium of human skin and anterior nares, but commonly causes severe
infections in humans when the immune system weakness [3,4].
It is also associated with life-threatening conditions including; septicemia , infection
of lung, bone ,endocardium and toxic shock syndrome. In addition, it causes various mild
dermis and subskin infections. It colonizes not only the nasal cavity but also other
anatomical sites namely, the axilla, pharynx and genital area [5,6]. Moreover, S. aureus
considered an important causative agent of food poisoning. The carriage, also called
colonization, can be defined as the presence of bacteria on or in the body without causing
illness. Although different sites of human body may be colonized but the anterior nasal cavity
are the predominant site for S. aureus carriage. Another anatomical sites that commonly
sanctuary S. aureus include the skin, anal region, and oral cavity. Most published articles
on nasal carrier of the organism used with one nasal culture to decide whether the studied
population harbor the organism or not. S. aureus carriers classified into persistent carriers and
intermittent carriers [6,7].
Approximately 50% of healthy individuals classified as S. aureus nasal
carriers [20% persistent and 30% intermittent carriers]. Persistent carriers ordinarily bear
the same strain of the organism for prolonged time, while for intermittent carriers they harbor
various strains during different times [8]. These features are crucial because the persistent
carriers have excessive bacterial loads and are at greater hazards for developing S. aureus
infection. It is especially significant in the healthcare facilities like hospital environment where
the carrier persons and infected patients act as the most crucial source of MRSA in these
facilities. Preceding antibiotic therapy, long stay in hospitals, history of surgical operations,
living in a nursing house, and close contacts to a sick person either carrier or infected with
MRSA are considered to be factors related to MRSA carriage. The prevalence rate of MRSA
among persons without typical risk factors persists approximately low (≤0.24%) in spite of
the increasing CA- MRSA infections . According to a nationwide survey done by the Centre
for Disease Control and Prevention (Atlanta), 32.4% of Americans’ populations carried S.
aureus in their noses and 0.8% of them are MRSA carries. Although carriers do not have
infections, they can spread Staphylococcus to people with whom they have physical contact
and can shed Staphylococcus into the environment. This can result in further people becoming
carriers or harboring an infection [6,9].
The morbidity and mortality of S. aureus infections continue to exist despite utilizing
antibiotics to treat these infections, relatively it may be due to the capability of S.
aureus to become resistant to multiple commonly used antibiotics. S. aureus is regularly
carried by healthy individuals in the nose and, in the skin and mucous membranes. Carriers
are considered as a source of infection to others and themselves [10]. The major sources
of infections inhuman being are fomites contaminated, airway tract and skin. Direct
transmission of infection has supposed added significance in hospitals, where a large
proportion of the staff and patients may carry antibiotic- resistant staphylococci in the nose
and or on the skin, especially those that resist MRSA and VRSA (Vancomycin resistance
Staphylococcus aureus). About two billion people worldwide carry S. aureus and 53 million
(2.7%) of carriers carry MRSA [11]. MRSA is one of the main human pathogens throughout
the world. The epidemiological trend of MRSA is regularly altering, and both circulating
clones and their antibiotic resistance profiles differ significantly over regions and
countries. Epidemiologic information collected via continuous surveillance is important to
support clinicians and infection control committees in their try to inhibit and treat the infection.
The development of colonization in patients and hospital workers frequently happens.
Kurdistan Journal of Applied Research | 3rd International Conference on Health & Medical
Sciences: Insight into Advanced Medical Research (ICHMS 2019)| 90
Transmission of S. aureus may occur through direct contact with unwashed, contaminated
hands and by inanimate objects (fomites). Both nosocomial and community infections caused
by MRSA have become a main health care concern[12,13]. The aim of this article is to explore
the factors associated with MRSA carriers among food handlers.
2. SUBJECTS AND METHODS
This study was conducted in restaurants in Duhok city. Duhok is one of the four
governorates of Kurdistan Region of Iraq. There were (314) restaurants of different types in
Duhok city at the study time. These restaurants were classified into three types (groups)
including basic, fast food and high-class restaurants depending on the type of services.
1. Basic restaurants: They constitute about 69.7 % (219) of total restaurants. They are middle
priced restaurants and provide table services. Basic restaurants come between fast food
establishments and high-class restaurants in terms of pricing.
2. Fast food restaurants: They are the second common type of restaurants in Duhok city and
defined by Oxford as a “food that is easily prepared, processed and served in snack bars and
restaurants as a quick meal or to be taken away” [14]. They constitute 54(17.2%) restaurants
in this city. Most of fast food restaurants are close to markets and shopping malls. These meals
consist primarily of burgers, Doner kebab, potato chips , pizzas, falafel and sandwiches .
3- High class restaurants: They represent only 41 (13.1%) restaurants in Duhok city. These
restaurants located in different areas in the city. These restaurants provide full services and
frequented by stars and high-profile persons.
200 persons who are handling foods (cooks, waiters and kitchen assistants) are selected from
40 different restaurants by multi stage sampling methods. For each food handlers’ swabs are
taken from nostrils and both hands involving wrist of hands and in between fingers about five
seconds for each hand. The swabs transferred into transport media then cultured in Mannitol
salt agar and incubated aerobically at 37oC for 24 to 48 hours. Then isolates were considered
S. aureus by using gram staining, standard biochemical reactions (catalase and coagulase
tests) and fermentation on mannitol salt agar. Antimicrobial susceptibility was performed on
MuellerHinton agar using Kirby-Bauer disk diffusion method according to diameter
interpretation standards charts.
Ethical considerations
All required administrative and ethical approvals were arranged and obtained at both
academic level ( Technical College of Health -DPU) and the Research Ethical Committee of
the Directorate General of Health in Duhok Governorate before conducting this research, and
at individual level an oral informed agree was acquired .
Data analysis
All data related to demographic information were entered and edited using Microsoft Word
2010. Descriptive statistics was provided for the demographic data and responses of the
questionnaire. For testing association of the studied variables with MRSA SPSS 23 and Chi-
square test was used. P-values 0.05 was used to indicate significant association of age, type
of work, type of restaurants, duration of work, and antibiotic used with MRSA status of workers
who participated in the study.
3. RESULTS
Kurdistan Journal of Applied Research | 3rd International Conference on Health & Medical
Sciences: Insight into Advanced Medical Research (ICHMS 2019)| 91
Out of 200 collected samples from food handlers, 74 (34%) isolates were identified as S.
aureus by producing golden yellow colonies on MSA and gram- stain showed G+ irregular
cluster of cocci, catalase and coagulase were also positive. Moreover, 27% of isolates were
confirmed as MRSA by giving inhibition zone of less than ≥ 9 for methicillin disc.
Furthermore, no VRSA isolates could be detected within food handlers.4
3.1 Association between duration of work and MRSA status
No significant statistical association was found between duration of work in the restaurants
and MRSA status, however, the number of MRSA carrier cases increased with years of
work. It was from 20.3% for less than one-year work duration and 31.2% for 5 years or more
Table 1.
Table 1: Duration of work in the restaurants and MRSA status
Duration of work in
restaurants
MRSA status
Total
No. (%)
Positive (%)
Negative (%)
>1year
15 (20.3)
59 (79.7)
74 (37)
2-4 years 19 (31.2) 42 (68.8) 61 (35)
5 years and more 20 (31.2) 44 (68.8) 64 (32)
Total 54 (27) 146 (73) 200
P-Value= 0.259
3.2 Association between health facilities visits and MRSA status
A significant association between a number of hospital visits and MRSA carrier rates was
detected. The highest MRSA carrier rate 100% (23 cases) was observed among those who
visited hospitals 5-6 times. In contrary, the lowest MRSA carrier rate (2.6%) was seen among
those who did not visit hospitals Table 2.
Table 2 Association between health facilities visits and MRSA status
Number of health
f
acilities visits during the
last 6 months
MRSA status Total
No. (%)
Positive (%) Negative (%)
2-4 visits
16 (100)
0 (0.0)
16
5-6 visits
23 (100)
0 (0.0)
23
7and more
11 (100)
0 (0.0)
11
No visits
4 (2.6)
146 (97.3)
150
Total
54 (27)
146 (73)
200
P-Value< 0.001
3.3 Association with antibiotic utilization
There was no significant association between antibiotic utilization and MRSA carrier rate. The
highest percentage 30.4% of MRSA carrier was isolated from food handlers who did not use
antibiotics Table 3.
Table 3: Association with antibiotic utilization
Have you been using
a
ntibiotics continuously
in the last 30 days
MRSA status
Total
No.
Positive (%) Negative (%)
Yes
9 (17.3)
43 (82.6)
52
No
45 (30.4)
103 (69.5)
148
Total
54 (27)
146 (73)
200
P-Value= 0.067
3.4 Distribution between Jobs of food handlers and MRSA status
Kurdistan Journal of Applied Research | 3rd International Conference on Health & Medical
Sciences: Insight into Advanced Medical Research (ICHMS 2019)| 92
Job of food handlers has a significant association with MRSA carrier rate was seen. The
highest proportion of MRSA was observed among cooks (36.9%), followed by waiters and
kitchen assistants (22.5%), (22.9%), respectively Table 4.
Table 4: Distribution between Jobs of food handlers and MRSA status
Duration of work in
restaurants
MRSA status
Total
No.
Positive (%)
Negative (%)
Cooks
27 (36.9)
46 (63.0)
73
Waiters
16 (22.5)
55 (77.4)
71
Kitchen assistants
11 (22.9)
37 (77.0)
48
Others
0 (0.0)
8 (100.0)
8
Total
54 (27)
146 (73)
200
P-Value =0.05
3.5 Frequency between age groups and MRSA status
The highest percentage (35.2) of MRSA carrier rate was detected among the younger age
group 20-29 years and a fewer percentage 20.7% was identified among the age groups of less
than 20 years as well as the group of 40 years or above. Nevertheless, there was no
significant association with different age groups and carrier rate Table 5.
Table 5: Frequency between age groups and MRSA status
Age group
MRSA status
Total
No.
Positive (%) Negative (%)
<20
11 (20.4)
18 (12.3)
29
20-29
19 (35.2)
61 (41.8)
80
30-39
13 (24.1)
25 (17.1)
38
40 and above
11 (20.4)
42 (28.8)
53
Total
54 (27)
146 (73)
200
P-Value= 0.23
3.6 Association between personal protective measures and MRSA status
The majority of food handlers 59.5% used personal protective measures. A (25%) of positive
MRSA cases used personal protective measures and the rest (29%) did not. The association
between using personal protective measures and MRSA status was not significant Table 6.
Table 6: Association between Personal protective measures and MRSA status
Using personal
protective measures
MRSA status
Total
No.
Positive (%)
Negative (%)
Yes
30 (25)
89 (75)
119
No
24 (29)
57 (61)
81
Total
54 (27)
146 (73)
200
P- Value=0.49
3.7 Skin and soft tissue infection and MRSA status
Kurdistan Journal of Applied Research | 3rd International Conference on Health & Medical
Sciences: Insight into Advanced Medical Research (ICHMS 2019)| 93
All food handlers (9) with skin infection had positive MRSA status, while 83.3% of
all positive MRSA did not have skin lesions. The presence of skin lesions has a highly
significant association with carrier status Table 7.
Table 7: Association between skin and soft tissue infection and MRSA status.
Presence of infection
MRSA status
Total
No.
Positive (%)
Negative (%)
Yes
9 (100)
0 (0.0)
9
No
45 (33)
146 (100.0)
191
Total
54 (27)
146 (73)
200
P-Value < 0.001
3.8Types of restaurants and MRSA status
MRSA carrier rate has a highly significant association with different types of restaurants.
A significant proportion (60%) of MRSA was diagnosed in basic restaurants as it
accommodated the largest number of food handlers. In comparison, high class restaurants and
fast food restaurants had fewer MRSA rates 16%, Table 8.
Table 8: Association between Types of restaurants and MRSA status
Using personal protective
measures
MRSA status
Total
No.
Positive (%) Negative (%)
Basic restaurants
41(60)
64 (43.8)
105
Fast food restaurants
5 (16)
31 (21.2)
36
High class restaurants
8 (16)
51(29.5)
59
Total
54 (27)
146 (73)
200
P-Value < 0.00
4. DISCUSSION
In different communities the MRSA carrier status shows steadily increasing in the prevalence
rate and this appears mainly among individuals that are not exposed to healthcare-associated
risk factors for MRSA acquisition [15]. Infections due to community acquired -CA MRSA
have been identified in a variety of populations, involving neonates, children, athletes,
prisoners, military personnel. The most popular infections of CA-MRSA are soft tissue and skin
infections. Successfully, many of this CA-MRSA strains have so far included susceptibility
to a number of non-beta-lactam antimicrobials, though the majority of nosocomial MRSA
infections are hardly cured because they resist multi-antibiotics [16]. Utilizing antibiotics is
deem as a risk factor for the emergence of CA-MRSA infection [17].
4.1 Duration of work
The relation between duration of work and MRSA in the present study was not significant.
Similar results were obtained by [18,19]. Though, a study done by Eveillard et al (2004)
on hospital employees showed that the duration of work increases the risk of MRSA
rate [20].
4.2 Health facility visits
Previous hospital visits considered one of the risk factors to harbor S. aureus so that in various
studies done on CA-MRSA considered visiting the hospitals as a risk factor for getting the
bacteria from the hospital. In the study on progress; a significant association between hospital
visits and MRSA was found. Supporting this theory Pathare et al (2015) demonstrated that
MRSA among the healthy hospital's visitors 18% is higher compared to 13.8% among health
Kurdistan Journal of Applied Research | 3rd International Conference on Health & Medical
Sciences: Insight into Advanced Medical Research (ICHMS 2019)| 94
care staff in the hospitals [21]. This may be due to the continuous effective infection
control policies and proper personal hygiene practices like hand washing in hospitals which
might cause a lower prevalence of MRSA among healthcare personnel, contradictory, the
higher prevalence among health community visitors might be they acquired in and out of
hospital setting. In a meta-analysis review of 57 studies on CA-MRSA and human acquired
HA-MRSA, the researchers detected that the prevalence of MRSA among community was
somewhat low.
Nevertheless, 47.5% of healthy MRSA carriers and up to 85% of hospitalized patients
diagnosed with CA carriers were found to have at least more than one year contact with health
facilities related risk factors like recent hospital admission, health care facilities visits,
chronic diseases like diabetes, and renal failure[22]. In a large meta-analysis study, the
researchers detected that most of healthy people with CA- MRSA had more than one-
year healthcare-associated risk, which explained the low prevalence of MRSA among persons
without risks remains low[15].
4.3 Antibiotic use and MRSA status
Salgado et al mentioned that continuous use of broad-spectrum antibiotics may be regarded
ae a risk factor that associated with CA- MRSA spread in the community [15]. However,
in this study, no significant statistical association between antibiotic usage and MRSA status
was detected. In Atlanta, Georgia, a study done on common risk factors that associated with
bacterial colonization with MRSA in hospitalized patients , Hidron et al (2005) found that
receipt of antibiotics was one of the independent factors for MRSA colonization[23]. Similar
to our findings was a study done in a military training center in San Diego, USA; the
researchers found that there is no association between past antibiotic usage and MRSA status
[24].
4.4 Job type and MRSA
It is proven by many researchers that the favorable prevalence is among workers who have
contacts with foods that allow S. aureus to grow. However, the differences in results might
be attributed to different factors like, educational level, cleaning behavior, the hygiene
equipment and the work environment [19,25].
The highest proportion of MRSA was observed among cooks (36.9%), followed by waiters
and kitchen assistants. These results as supported by Ho et al who showed that colonizing
rate was considerably higher in workers (chefs) handling raw meats 30% than in non-exposed
workers (other staff) 13%[25] .Moreover, Kasturwar and Shafee (2011) found the
highest MRSA prevalence among participants working in serving and preparing food
19.30%, 9.6% respectively[26]. The authors explained that the majority of workers
50 (60.2%) were involved in serving the food to consumers and they are the core group among
food handlers who are mainly involved in the transmission of FBDs. While Ferreira et al
(2014) concluded that the presence of MRSA was not related to a certain job duty of the
food handlers in the restaurants of governmental health facilities [27].
4.5 Personal protective measures
The majority of food handlers 25% in our study used personal protective measures and there
was no significant association between using protective measures and MRSA status in this
study. Although, theoretically using protective measures like glove, hats, masks, apron …etc.
may inhibit the hazard of microbial cross-contaminations but the researchers reported that
neither the use of gloves nor even the pursuit of hand washing will decrease the risk of
microbial cross-contaminations. Nonetheless, combining both practices together will decrease
the risk of cross-contaminations. No or scarce published articles documented that food cater
by gloved hands is safer than food cater by ungloved (bare) hands. This may be due to the fact
that the many microorganisms like bacteria will adhere to the external surfaces of gloves and
if not changed regularly, it could be a source of cross-contamination similar to unwashed hands
Kurdistan Journal of Applied Research | 3rd International Conference on Health & Medical
Sciences: Insight into Advanced Medical Research (ICHMS 2019)| 95
and poor personal hygiene practices of food handlers which frequently contributes to food
borne diseases outbreaks [28,29].
Continuous changing of gloves and effective hand washing before wearing and good quality
gloves may increase the effectiveness of wearing gloves when touching unwrapped food.
Furthermore, the puncture of gloves during working may increase the risk of contamination.
It is important to educate food handlers about proper hand washing and wearing protective
measures (Montville and [28,30].
Meanwhile, wearing hats is also an important protective measure neglected by many workers
because the foods may be contaminated by falling hair or dandruff. Using protective measures
during sneezing or cleaning nostrils is also significant to decrease cross-contamination [31].
These findings illustrate that proper hand washing and using gloves should be applied parallel
to each other so as to forbid cross-contamination and limit the risk of food poisoning.
4.6 Cutaneous and soft tissue infection and MRSA
In this study, a highly significant association was found between skin and soft tissue infection
and MRSA. This result was similar to what if found in Denmark, and in Georgia [32,33].
Furthermore to a large systematic review done in Custodial population between the years
of 1997 to 2015, nearly seventeen studies concluded that cutaneous and soft tissue infections
are related to highest documented rates of MRSA rate [34]. While, in Egypt (El-Shenawy el
al, 2014) showed that the MRSA carrier rate has no any significant statistical association
with cutaneous and soft tissue infections [19].
4. CONCLUSION
Methicillin
Resistant
Staphylococcus aureus carrier rate was higher among food handlers
working in popular restaurants when compared to other restaurants. MRSA carrier rate showed
a significant association with cutaneous and soft tissue infections, hospital visits, and certain
jobs of food handlers. Age, duration of work in the restaurants and antibiotic use showed no
significant association with the prevalence of MRSA. Ongoing screening of all persons who
handled foods is crucial to detect and treat those are MRSA carrier as one of major public
health issues. Personal protective measures such as gloves, head covers and continuous
changing it are highly advisable among food handlers.
REFERENCE
[1] M Haghkhah . Study of Virulence Factors of Staphylococcus aureus. Ph.D Thesis, Faculty of Biomedical
and Life Sciences . Glasgow University Glasgow, Scotland, 2003.
[2] N Plipat.. Methicillin-resistant Staphylococcus aureus (MRSA) exposure assessment in hospital environment.
University of Michigan, USA.pp.1-26,2012.
[3] DP Kateete , C N Kimani , F A Katabazi , A Okeng ,MS Okee, A Nanteza et al . Identification of Staphylococcus
aureus: DNase and Mannitol salt agar improve the efficiency of the tube coagulase test. Ann Clin Microbiol
Antimicrob; 9 (23): 1-7,2010. doi:10.1186/1476-0711-9-23.
[4] T Kitti , K Boonyonying , S Sitthisak . Prevalence of methicillin-resistant Staphylococcus aureus among university
students in Thailand. Southeast Asian J Trop Med Public Health; 42(6): 1498-1504 ,2011.
[5] Q Rao , X Rao , X Hu , W Shang . Staphylococcus aureus ST121: a globally disseminated hypervirulent
clone. J Med Microbiol; 64: 1462-73,2015. DOI 10.1099/jmm.0.000185.
[6] A Aryee and JD Edgeworth . Carriage, Clinical Microbiology and transmission of Staphylococcus aureus. In: F
Bagnoli , R Rappuoli , G Grandi , editors. Staphylococcus aureus: Microbiology, Pathology, Immunology,
Therapy and Prophylaxis. Springer International Publishing Switzerland.pp.1-14,2017. DOI 10.1007/ 82_
2016_5.
[7] K Becker. Pathogenesis of Staphylococcus aureus. In: Fetsch A, editor. Staphy. aureus. UK: Elsevier Inc.pp. 13-
16,2018. Available from https://doi.org/10.1016 /B978-0-12-809671-0.00002-4.
[8] YA Que and PH Moreillon . Gram-Positive Cocci: Staphylococcus aureus (Including Staphylococcal Toxic
Shock Syndrome). In: J E Bennett , M J Blaser , R Dolin, R G Douglas , G L Mandell , editors.
Mandell, Douglas, and Bennett's Principles and practice of infectious diseases. 8th ed. Canada:
Elsevier Saunders.pp. 2237-371,2015.
Kurdistan Journal of Applied Research | 3rd International Conference on Health & Medical
Sciences: Insight into Advanced Medical Research (ICHMS 2019)| 96
[9] R E Rohde . Prevention, Treatment, and Containment of Staphylococcal Infections in Communities. USA: Texas
State University-San Marcos.pp.1-47, 2007.
[10] R P Harvey , P C Champe , B D Fisher . Lippincott's Illustrated Reviews: Microbiology. 2nded. Hagerstown,
MD. USA: Lippincott Williams and Wilkins. pp.69-75, 2007.
[11] K C Carroll . The staphylococci In:G F Brooks , E Jawetz, J L Melnick , E A Adelberg , editors. Jawetz,
Melnick & Adelberg's medical microbiology. 26 th ed. London: McGraw-Hill. pp.199-205,2013.
[12] L S Monson . Staphylococci. In: C R Mahon, DC Lehman, G Manuselis , editors. Textbook of diagnostic
microbiology. 5th ed. China: Elsevier, Inc. pp. 314-25,2015.
[13] L G Baptistão , N C Silva ,E C Bonsaglia , B F Rossi , I G Castilho , A R Fernandes et al. Presence of
Immune Evasion Cluster and Molecular Typing of Methicillin-Susceptible Staphylococcus aureus Isolated
from Food Handlers. J Food Prot; 79(4): 682-86,2016. doi: 10.4315/0362-028X.JFP-15-401.
[14] English Oxford Living Dictionary. Definition of fast food in English [Cited 2018 October 20] available
https:// en. Oxford dictionaries. Com /definition / fast_food.
[15] CD Salgado, B M Farr , D P Calfee . Community-acquired methicillin- resistant Staphylococcus aureus: a meta-
analysis of prevalence and risk factors. Clin Infect Dis; 36(2): 131-39,2003.
[16] World Health Organization. Antimicrobial resistance: global report on surveillance, France: WHO.pp.19,2014.
[17] P H Blomquist. Methicillin-resistant Staphylococcus aureus infections of the eye and orbit (an American
Ophthalmological Society thesis). Trans Am Ophthalmol Soc; 104: 322-45,2006.
[18] A H Mohammed. Community and Healthcare Acquired Nasal Carriage of Methicillin-resistant
Staphylococcus aureus in Duhok Governorate /Kurdistan Region. Ph.D. thesis. College of
Medicine, Duhok University, Iraq,2013.
[19] M El-Shenawy ,M Tawfeek , L El-Hosseiny , MEl-Shenawy ,A Farag , H Baghdadi et al (2014). Cross
Sectional Study of Skin Carriage and Enterotoxigenicity of Staphylococcus aureus among Food
Handlers . Open J Med Microbiol; 4(1): Article ID: 43014,7 ,2013. DOI:10.4236 /ojmm.2014.
41003.
[20] M Eveillard ,Y Martin ,N Hidri ,Y Boussougant ,M LJoly-Guillou. Carriage of methicillin-resistant
Staphylococcus aureus among hospital employees: prevalence, duration, and transmission to
households. Infect Control Hosp Epidemiol.; 25(2): 114-20 ,2004.
[21] N A Pathare , S Tejani , H Asogan , G Al Mahruqi S , Al Fakhri ,R Zafarulla eal . Comparison of methicillin
resistant Staphylococcus aureus in healthy community hospital visitors [CA-MRSA] and hospital
staff [HA- MRSA]. Mediterr J Hematol Infect Dis;7(1):1- 6, 2015. doi.org /10. 4084 / MJHID.2015.053.
[22] J W Beam and B Buckley . Community-acquired methicillin-resistant Staphylococcus aureus: Prevalence
and risk factors. J Athl Train; 41(3):337-40,2006
[23] A I Hidron , E V Kourbatova , J S Halvosa , B J Terrell , L K McDougal , F C Tenover et al. Risk factors for
colonization with methicillin-resistant Staphylococcus aureus (MRSA) in patients admitted to an urban
hospital: emergence of community-associated MRSA nasal carriage. Clin Infect Dis; 41(2): 159-
66,2005.
[24] K M Campbell ,A F Vaughn , K L Russell, B Smith,D L Jimenez,C P Barrozo et al. Risk factors for community-
associated methicillin-resistant Staphylococcus aureus infections in an outbreak of disease among military
trainees in San Diego, California, in 2002. J Clin Microbiol.; 42(9): 4050-3,2004.
[25] J Ho, M O’Donoghue , M Boost . Occupational exposure to raw meat: a newly-recognized risk factor for
Staphylococcus aureus nasal colonization amongst food handlers. Int J Hyg Environ Health; 217: 247-
53,2014.
[26] N B Kasturwar and M Shafee. Knowledge, Practices and Prevalence of MRSA among Food Handlers. IJBMR;
2(4): 889 -94,2011.
[27] J S Ferreira ,W L Costa , E S Cerqueira , J S Carvalho , L C Oliveira , R C Almeida et al. Food handler-
associated methicillin-resistant Staphylococc aureus in public hospitals in Salvador, Brazil. Food Control;
37: 395-400, 2014. doi.org/10.1016 /j. foodcont.2013.09.062.
[28] J F R Lues and I Van Tonder. The occurrence of indicator bacteria on hands and aprons of food handlers in the
delicatessen sections of a retail group. Food control; 18(4): 326-32, 2007.
[29] H Shojaei , J Shooshtaripoor, M Amiri . Efficacy of simple hand-washing in reduction of microbial
hand contamination of Iranian food handlers. Food Res Int; 39(5): 525-29,2006. doi:10.1016/j.
foodres. 2005.10.007.
[30] R Montville , Y Chen , D W Schaffner . Glove barriers to bacterial cross- contamination between hands to food.
J Food Prot; 64(6): 845-9, 2001.
[31] A R Isara , E C Isah , P V Lofor , C K Ojide. Food contamination in fast food restaurants in Benin City, Edo
State, Nigeria: Implications for food hygiene and safety. Public health; 124(8):467-71,2010. doi:10.1 016
/j. puhe. 2010. 03.028.
[32] S Böcher , A Gervelmeyer , D L Monnet ,K Mølbak , R L Skov. Methicillin- resistant Staphylococcus
aureus: risk factors associated with community-onset infections in Denmark. J Clin Microbiol Infect;
14(10):942-8, 2018.
[33] L C Immergluck, S Jain , S M Ray , R Mayberry, S Satola , T C Parker et al. Risk of skin and soft tissue infections
among children found to be Staphylococcus aureus MRSA USA300 carriers. West J Emerg Med
;18(2): 2017.
[34] L Haysom , M Cross ,R Anastasas , E Moore , S Hampton . Prevalence and Risk Factors for Methicillin-Resistant
Staphylococcus aureus (MRSA) Infections in Custodial Populations: A Systematic Review. J
Correct Health Care; 24(2):197-213,2018.
Full-text available
Book
Summary Staph. aureus is a normal flora and opportunistic pathogen. It is the most common in skin and soft tissue. This microbe can cause more diseases, for example: burn inflammation and tonsillitis through the production of virulence factors that are acquired by some plamidic virulence genes. The main research objective explored the prevalence of (edin-c, sej and etb genes) in each patients and healthy and its relationship with the development of infection in different clinical sources. This study was conducted in the Laboratory of Department of the Pathological analysis, Faculty of Science, University of Thi-Qar from October 2019 - March 2020, A total of 640 samples were collected from patients and healthy human. The research samples include 170 of patients suffered from burns in the department of burns in Al-Hussein Teaching Hospital, also 150 samples of patients were clinically diagnosed as having tonsillitis infections in the “E.N.T” department in the AL Habboby Hospital while human healthy samples were 320 which collected from different parts of the body. These samples were cultured on routine bacterial culture media which include: blood agar, MacConkey agar, Mannitol Salt and DNAse, tested by Gram's stain, catalase test, coagulase test and confirmed through API staph 20(BioMereux, France). Antibiotic susceptibility test was performed by the modified Kirby-Bauer disc diffusion method according to CLSI guidelines, while molecular diagnosis was depended on 16srRNA gene to indicate Staph.aureus. The data were statistically analyzed using the Chi-square test in SPSS version 20; P-value ≤ 0.05 at 95%( The level of confidence) was considered for statistical association. According to the cultural, morphological, and biochemical characteristics, Prevalence of Staph. aureus were 17.6% (n=30), 13.3% (n=20), and 5.94% (n=19) to Burn patients, tonsillitis patients and healthy human. Production of some virulence factors by Staph. aureus were been investigated. The results showed its ability to produce hemolysin toxins, protease enzyme, and urease enzyme that contributed to escape from the host immune response. The study included testing all isolates against 12 antibiotics by the disc diffusion method. The results revealed that Staph. aureus isolates were resistant to Penicillin-G 100% in tonsillitis and healthy human isolates, but 90% in burn isolates. Vancomycin resistance in tonsillar isolates was 15 % and 3.3 % in burn isolates, but 0% in healthy humans. The outcomes of the study indicated that resistance of Staph. aureus to Ciprofloxacin was 23.3% and 20% in burn, tonsillitis patients, respectively, but 15.78 % in healthy humans. This study has registered Sequential proportions related to Azithromycin. These were 50% for burn patients and 60% for tonsillitis patients, but 42.10 % in healthy humans. Clindamycin resistance in burn and tonsillitis were 73.3% and 75%, but in healthy human were 5.26%, respectively. Nitrofurantoin 's resistance showed 13.3% to burn and 10% to isolates of tonsillitis. Levofloxacin displayed the same resistance levels(13.3% & 10%, respectively) to both clinical sites, but it was compared with healthy humans, was zero %, and 10.52% to Levofloxacin, Nitrofurantoin, respectively. The current study showed a noticeable rise in Erythromycin resistance, which reached to 80% and 57% for both tonsillitis and burn isolates, respectively, but 42.10% in healthy human. The antibiotic resistance values for tonsillitis isolates of Ofloxacin and Gentamycin were the same at 15%, although both antibiotics were recorded at 13 % and 10 % for burn isolates respectively, whereas for healthy humans the levels of Ofloxacin and Gentamycin were 10.52 %.It was observed in study that the rate of antibiotic resistance to tetracycline 30% and 23.3% for tonsillitis and burn isolates, respectively but in healthy humans was 36.84%. Close ranges of doxycycline resistance obtained at 20 % and 16.7 % for tonsillitis and burn isolates, respectively, but were 21.05 % for healthy humans. The results of phenotypic diagnostic were confirmed by polymerase chain reaction (PCR) technique employing 16SrRNA gene that showed only 48\50 certain bacterial isolates of this microbe from patients while in healthy humans were in line with phenotypic diagnostic (19\19), but results of molecular screening of prevalence edin-c, sej and etb genes in burn patients had showed 48.27%, 62.06% and 62.06% respectively while in tonsillitis patients was 42.10%, 73.68% and 47.36%. comparing to healthy humans, there were no results to determine edin-c, sej except etb (21.05%).
Full-text available
Article
Objective: To evaluate the presence of methicillin-resistant Staphylococcus aureus (MRSA) in areas close to patients in a General Intensive Care Unit. Methods: This is a cross-sectional study, in which microbiological samples were collected from five surfaces (left / right bed siderails, bed crank, table, buttons on the infusion pump, and cotton gowns) from each of ten patient rooms, totaling 63 samples. To collect samples, the Petri FilmTM Staph Express Count System 3MTM was used to screen for methicillin resistance, with the Mueller-Hinton agar supplemented with 4% sodium chloride and 6 μg / ml of oxacillin. Descriptive analysis was conducted to determine the frequency (n) and percentage (%) of contamination of environmental surfaces. Results: Of 48 samples positive for Staphylococcus aureus, 29 (60.4%) were resistant to methicillin. The incidence on the siderails and bed cranks, table, buttons on the infusion pumps and aprons were, respectively, 55.5%, 57.1%, 57.1%, 60.0% and 75.0%. Conclusion: The results suggest that the surfaces around the patient constitute a major threat, as they represent secondary reservoirs of MRSA.
Article
Oxacillin-resistant Staphylococcus aureus (ORSA) infection is an important cause of hospital morbidity and mortality. The objective of this study was to identify the main factors associated with death in patients colonized or infected with Staphylococcus aureus in a cancer center. A matched-pair case-control study enrolled all patients infected or colonized with ORSA (cases) admitted to the Hospital do Câncer in Rio de Janeiro from 01/01/1992 to 12/31/1994. A control was defined as a patient hospitalized during the same period as the case-patients and colonized or infected with oxacillin-susceptible Staphylococcus aureus (OSSA). The study enrolled 95 cases and 95 controls. Patient distribution was similar for the two groups (p > or = 0.05) with respect to gender, underlying diseases, hospital transfer, prior infection, age, temperature, heart and respiratory rates, neutrophil count, and duration of hospitalization. Univariate analysis of putative risk factors associated with mortality showed the following significant variables: admission to the intensive care unit (ICU), presence of bacteremia, use of central venous catheter (CVC), ORSA colonization or infection, pneumonia, use of urinary catheter, primary lung infection, prior use of antibiotics, mucositis, and absence of cutaneous abscesses. Multivariate analysis showed a strong association between mortality and the following independent variables: admission to ICU (OR [odds ratio]=7.2), presence of Staphylococcus bacteremia (OR=6.8), presence of CVC (OR=5.3), and isolation of ORSA (OR=2.7). The study suggests a higher virulence of ORSA in comparison to OSSA in cancer patients.
Full-text available
Article
Methicillin-resistant Staphylococcus aureus (MRSA) in prisons can result in serious morbidity and death. We reviewed rates and risk factors for MRSA infection in custody, searching Medline, EMBASE, and CINAHL databases. Between 1997 and 2015, 17 studies reported MRSA skin and soft tissue infections (SSTIs), with four case reports of MRSA non-SSTI (necrotizing pneumonias, brain abscess, and epiduritis). Significant associations with MRSA SSTI were found: MRSA colonization, previous skin infection, sharing soap or personal items, SSTI presenting as an abscess or furuncle, younger age, non-Caucasian, overweight, communal laundering, infrequent handwashing, lower hygiene score. Recommendations: early identification, isolation, and treatment of skin infections at admission; education on maintaining skin integrity and presenting early with skin infections; increasing hygiene by not sharing items and encouraging handwashing; improved handling and disinfection of communal laundering; influenza vaccination for all prisoners and staff; and population-based longitudinal studies including younger detainees.
Full-text available
Article
Introduction The purpose of this study was to examine community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) carriage and infections and determine risk factors associated specifically with MRSA USA300. Methods We conducted a case control study in a pediatric emergency department. Nasal and axillary swabs were collected, and participants were interviewed for risk factors. The primary outcome was the proportion of S. aureus carriers among those presenting with and without a skin and soft tissue infection (SSTI). We further categorized S. aureus carriers into MRSA USA300 carriers or non-MRSA USA300 carriers. Results We found the MRSA USA300 carriage rate was higher in children less than two years of age, those with an SSTI, children with recent antibiotic use, and those with a family history of SSTI. MRSA USA300 carriers were also more likely to have lower income compared to non-MRSA USA300 carriers and no S. aureus carriers. Rates of Panton-Valentine leukocidin (PVL) genes were higher in MRSA carriage isolates with an SSTI, compared to MRSA carriage isolates of patients without an SSTI. There was an association between MRSA USA300 carriage and presence of PVL in those diagnosed with an abscess. Conclusion Children younger than two years were at highest risk for MRSA USA300 carriage. Lower income, recent antibiotic use, and previous or family history of SSTI were risk factors for MRSA USA300 carriage. There is a high association between MRSA USA300 nasal/axillary carriage and presence of PVL in those with abscesses.
Full-text available
Article
The hands and noses of food handlers colonized by Staphylococcus aureus are an important source of food contamination in restaurants and food processing. Several virulence factors can be carried by mobile elements in strains of S. aureus, including the immune evasion cluster (IEC). This gene cluster improves the capacity of S. aureus to evade the human immune response. Many studies have reported the transmission of strains between animals and humans, such as farm workers that have close contact with livestock. However, there are few studies on the transmission between food and food handlers. The aim of this study was to detect the IEC and the mecA gene in strains isolated from food handlers and to type these strains using the spa typing method. Thirty-five strains of S. aureus isolated from the noses and hands of food handlers in three different kitchens were analyzed for the presence of the mecA gene and IEC and by spa typing. All strains were negative for the mecA gene, and the presence of IEC was observed in 10 (28.6%) strains. Fifteen different spa types were observed, with the most frequent being t127 (42.85%) and t002 (11.42%). Strains from the two most prevalent spa types and a novel spa type were typed by multilocus sequence typing. spa types t127, t002, and t13335 were determined to be multilocus sequence types (ST) ST-30, ST-5, and ST-45, respectively. The food handlers may have been contaminated by these strains of S. aureus through food, which is suggested by the low frequency of IEC and by ST that are observed more commonly in animals
Full-text available
Article
Background: The prevalence of community associated methicillin resistant Staphylococcus aureus [CA-MRSA] in unknown in Oman.Methods: Nasal and cell phones swabs were collected from hospital visitors and health-care workers on sterile polyester swabs and directly inoculated onto a mannitol salt agar containing oxacillin, allowing growth of methicillin-resistant microorganisms. Antibiotic susceptibility tests were performed using Kirby Bauer’s disc diffusion method on the isolates. A brief survey questionnaire was requested be filled to ascertain the exposure to known risk factors for CA-MRSA carriage.Results: Overall, nasal colonization with CA-MRSA was seen in 34 individuals (18%, 95% confidence interval [CI] =12.5%-23.5%), whereas, CA-MRSA was additionally isolated from the cell phone surface in 12 participants (6.3%, 95% CI =5.6%-6.98%). Nasal colonization prevalence with HA-MRSA was seen in 16 individuals (13.8%, 95% confidence interval [CI] =7.5%-20.06%), whereas, HA-MRSA was additionally isolated from the cell phone surface in 3 participants (2.6%, 95% CI =1.7-4.54). Antibiotic sensitivity was 100% to linezolid and rifampicin in the CA-MRSA isolates. Antibiotic resistance to vancomycin and clindamycin varied between 9-11 % in the CA-MRSA isolates. There was no statistically significant correlation between CA-MRSA nasal carriage and the risk factors (P>0.05, Chi-square test).Conclusions: The prevalence of CA-MRSA in the healthy community hospital visitors was 18 % (95% CI, 12.5% to 23.5%) as compared to 13.8% [HA-MRSA] in the hospital health-care staff. In spite of a significant prevalence of CA-MRSA, these strains were mostly sensitive. Recommendation the universal techniques of hand washing, personal hygiene and sanitation are thus warranted.
Full-text available
Article
Staphylococcus aureus is a leading cause of bacterial infections in hospitals and communities worldwide. With the development of typing methods, several pandemic clones have been well-characterized, including the extensively spreading hospital-associated methicillin-resistant S. aureus (HA-MRSA) clone ST239 and the emerging hypervirulent community-associated (CA) MRSA clone USA300. The multilocus sequence typing method was set up based on seven housekeeping genes; S. aureus groups were defined by the sharing of alleles at ≥ 5 of the 7 loci. In many cases, the predicted founder of a group would also be the most prevalent ST within the group. As a predicted founder of major S. aureus groups, approximately 90% of ST121 strains are methicillin-susceptible S. aureus (MSSA). The majority of ST121 strains carry accessory gene regulator type IV, whereas staphylococcal protein A gene types for ST121 are exceptionally diverse. More than 90% of S. aureus ST121 strains have Panton-Valentine leucocidin; other enterotoxins, hemolysins, leukocidins, and exfoliative toxins also contribute to the high virulence of ST121 strains. The patients suffered S. aureus ST121 infections often need longer hospitalisation and prolonged antimicrobial therapy. In this review, we tried to summarize the epidemiology of the S. aureus clone ST121 and focused on the molecular types, toxin carriage, and disease spectrum of this globally disseminated clone.
Full-text available
Article
The prevalence of enterotoxigenic Staphylococcus aureus was investigated among 200 participants working in three different food processing plants in Egypt. Using skin swabs, 75 (38%) of the 200 tested persons were positive for the presence of S. aureus. Of the S. aureus positive persons, 28 (14%) harboured S. aureus produced staphylococcal enterotoxins. The serotypes of these entero- toxins were enterotoxin A (68%), enterotoxin B (36%), enterotoxin C (46%) and enterotoxin D (18%). Some of these isolates produced more than one type of enterotoxins namely AB, AC, BC, BD, ABC and ACD. Analysis of risk factors implicated in skin carriage of S. aureus as age, gender, marit- al status, education, duration in employment, frequency and method of hand wash and incidence of chronic skin infection revealed insignificant association with staphylococcal skin carriage. The obtained results put forth the risk of food contracting contamination with enterotoxigenic strains of S. aureus owing to skin colonization of S. aureus among food handlers.
Chapter
In this chapter, the pathogenic potential of the opportunistic species Staphylococcus (S.) aureus is described. It offers insight into the large array of the pathogen´s virulence factors, which are hallmarked in many cases by overlapping and redundant functions. Mechanisms are described that enable the colonization of skin and mucous membrane surfaces of the human host and - once the skin barrier has been overcome - infection processes that may lead to a wide range of mild to severe, not seldom also fatal clinical entities. In particular, the genetic basis for the virulence of this versatile species is given and aspects of S. aureus adhesion, aggression, and host defence evasion including internalization and intracellular persistence are discussed.
Article
Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of healthcare-associated infections. Contaminated hands of healthcare workers (HCWs) are vectors of transmission, but the contribution of the contaminated environment is not well characterized. The goal of this dissertation is to provide insights into the role of the hospital environment in MRSA exposure to patients. First, a 20-month prospective study was conducted using nasal swab surveillance data in an intensive care unit (ICU) to examine MRSA acquisition risk associated with having MRSA-positive patients in the ICU during the ICU stay. The study showed that the more recent exposure to MRSA-positive patients in the ICU and the greater number of MRSA-positive patients in the ICU led to a greater hazard of MRSA acquisition among MRSA-negative patients. Second, we developed an MRSA fate and transport model for two hypothetical hospital rooms based on the Environmental Infection Transmission System (EITS) framework. We demonstrated a significant role of environmental surfaces in contaminating and re-contaminating HCWs. The model revealed the effect of S. aureus continuous shedding from the colonized patient onto room surfaces. The surfaces are quickly re-contaminated with MRSA even after the most efficacious decontamination. Our findings highlight the importance of decontamination frequency in addition to decontamination efficacy. Third, we constructed a stochastic agent based model using the same structure as the previous model, but with more realistic features. We demonstrated that HCW???s compliance is essential in determining the effectiveness of hand hygiene, although the time when it is performed and its efficacy are also important. The model emphasizes the significance of the hand hygiene opportunity before and after touching a patient???s surrounding environment, in addition to at the entry and exit of a patient???s room. Despite 100% compliance at the entry and exit of a patient???s room, we show that contaminated environmental surfaces are the dominant contamination sources to HCWs??? hands. Additionally, this model shows the value of hand hygiene efficacy. With 100% compliance and 70% efficacy, HCWs??? hands remain contaminated enough to subsequently contaminate the uncolonized patient???s environment, which later become another exposure route to the patient.
Article
The aims of this study were to evaluate the presence of methicillin-resistant Staphylococcus aureus on the hands and anterior nares of food handlers in public hospitals in the city of Salvador, Bahia, in northeastern Brazil and to evaluate the effectiveness of antiseptics for controlling contamination. Swabs from the nose and hands were collected from 140 food handlers in ten public hospitals, and methicillin-resistant S aureus (MRSA) isolates were confirmed by assessing their growth on selective media, coagulase testing and evaluating their antibiotic susceptibilities. Seventy (50.0%) food handlers were colonized with coagulase-positive Staphylococci on their hands and/or nares, and 40 (28.6%) food handlers were colonized with MRSA. The evaluation of susceptibility to the most commonly used anti-MRSA drugs demonstrated that 72.9% of the isolates from the handlers' hands and 82.5% of the isolates from the anterior nares showed resistance to vancomycin. The presence of MRSA was not correlated with the specific job function of the food handlers (p > 0.05). The logistic regression analysis of the antimicrobial activity of antiseptics against MRSA isolates indicated that 2% chlorhexidine had a significantly higher removal rate than those of alcohol gel and 10% PVP-I (iodophor) (p < 0.05); only 2.2% of the MRSA strains were resistant to chlorhexidine.