Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Important Notice

Original article / research
Year : 2010 | Month : August | Volume : 4 | Issue : 4 | Page : 2673 - 2677

Community Associated- Methicillin Resistant Staphylococcus aureus in skin and soft tissue infections.


*III MBBS, Kasturba Medical College, Mangalore **Professor and Head, Dept. Of Microbiology, Kasturba Medical College, Mangalore Department(s) and institution(s) : Department of Microbiology, Kasturba Medical College, Mangalore Guarantor: Dr. Shalini Shenoy Professor and Head, Dept. Of Microbiology, Kasturba Medical College, Mangalore Email address:

Correspondence Address :
Chetan Mandelia
404, Main Block, KMC Menā€™s Hostel, Kaprigudda, Mangalore, Karnataka, India
Phone numbers: +91 9845508568
Facsimile numbers: 0824 2428183
E-mail address:


Methicillin-Resistant Staphylococcus aureus (MRSA) is well recognized as a major cause of nosocomial infections worldwide. Infections due to MRSA have become increasingly common among healthy members of the community with no other known risk factors for acquiring HA-MRSA infection. They are termed CA-MRSA and differ significantly from HA-MRSA in their virulence and epidemiological properties. In this study, we detected the infections caused by CA-MRSA and studied their anti-biotic sensitivity pattern. Settings and Design : A prospective study which included 60 subjects attending the Surgery OPD with ailments like abscesses, carbuncles, osteomyelitis and skin infections in whom MRSA infection was newly identified in the microbiology laboratory and who fulfilled the inclusion & exclusion criteria for CA-MRSA..
Materials and Methods: The specimens were cultured in the laboratory and identified as Staphylococcus aureus and subsequently, as MRSA using standard methods. Anti-biotic sensitivity pattern of these MRSA was studied using the modified Kirby Bauers disc diffusion method. Antibiotics used were Amoxyclav, Gentamicin, Netilmycin, Erythromycin, Trimethoprim + Sulfamethoxazole, Ciprofloxacin, Clindamycin, Linezolid and Vancomycin. Statistical Analysis was done using SPSS Version 11.5 and association was found by using chi square test.
Results: A total of 60 CA-MRSA strains were isolated in Skin and Soft Tissue Infections (SSTIs), these strains were highly susceptible to Vancomycin (100%), Clindamycin (93.3%) and Linezolid (96.7%), moderately susceptible to Gentamicin (75%) and Netilmycin (90%) and a low susceptibility was recorded to Ciprofloxacin (18.3%) and Cotrimoxazole (31.7%), indicating the emergence of resistance to these valuable antibiotics. The results indicate that Vancomycin, Linezolid and Clindamycin, are to be used as ā€˜Reserve Drugsā€™ for resistant cases.
Conclusion: A high proportion of resistance was found among CA-MRSA isolates. Susceptibility to Gentamicin, Ciprofloxacin and Cotrimoxazole was much lower than what was previously reported. This suggests that, the face of CA-MRSA has changed in both, epidemiological and microbiological features and calls for the formulation of specific treatment guidelines to prevent emergence of resistance to currently used drugs.


Community- associated MRSA, Skin and soft tissue Infections, Antibiotic Sensitivity, Drug Resistance.

Community Associatedā€“Methicillin Resistant Staphylococcus aureus (CA-MRSA) infections are an emerging problem in India and many parts of the world. These infections originate in communities as opposed to Hospital associatedā€“Methicillin resistant Staphylococcus aureus (HA-MRSA)(1).
CA-MRSA differs from HA-MRSA in several important ways. These include, the lack of traditional risk factors associated with MRSA among patients, a bacterial susceptibility pattern with resistance to fewer classes of anti-microbial drugs, and the inclusion of specific virulence factors(2). Historically, MRSA has been linked to patients in hospitals or nursing home settings, but outbreaks have been reported among previously healthy members of the community, further increasing the awareness of CA-MRSA3. In these outbreaks, environmental sources, such as sharing of clothing, sports equipment, towels, balms, lubricants, razors and soaps; improper care of skin trauma, direct skin-to-skin contact with MRSA lesions and crowded living conditions, such as military recruits, sports teams, inmates of jails, were identified as possible risk factors(3). Due to its changing epidemiology, CA-MRSA may become a serious problem for the clinicians in the near future.
In this study, we studied the infections caused by CA-MRSA and their anti-biotic sensitivity pattern.

Material and Methods

A prospective study was conducted in the Department of Microbiology, Kasturba Medical College, Mangalore. After obtaining permission from the Institutional Ethics Committee, pus samples were collected from 60 patients attending the Surgery OPD with ailments like abscesses, carbuncles, osteomyelitis and skin infections who fulfilled the criteria of absence of risk factors for CA-MRSA like prior hospitalization, out patient visit, antibiotic exposure in the past 12 months, chronic illness, IV drug use and close contact with health care personnel. Demographic data and other relevant history were collected from the eligible patients using a pre-tested semi structured questionnaire after obtaining the informed consent. Drained pus sample or a swab from the depth of the skin lesion was collected and transported to the laboratory within 30 minutes.
In the laboratory, pus or swab was cultured on to 5% sheep blood agar incubated at 37Ā°c for 24 - 48 hours. Growth was identified by colony morphology, Gram staining, Catalase and Coagulase test. MRSA was detected by agar screen method using Muller- Hinton agar containing 4% Nacl and 6Āµg /ml of Oxacillin incubated at 35Ā°c. The isolates grown on Oxacillin screen agar were considered as MRSA(4).
Anti-biotic sensitivity pattern of these MRSA strains were studied using modified Kirby Bauers disc diffusion method and interpretation was done as per CLSI guidelines. Antibiotics (Hi Media Pvt. Ltd, Mumbai) used were Amoxyclav (20/10 Āµg), Gentamicin (30Āµg), Netilmycin (30 Āµg), Erythromycin (15Āµg), Trimethoprim+Sulfamethoxazole (25 Āµg), Ciprofloxacin (5 Āµg), Clindamycin (2 Āµg), Linezolid (30 Āµg) and Vancomycin (30 Āµg). Minimum inhibitory concentration for Vancomycin was detected by broth micro-dilution method for two resistant isolates and MIC values less than 2Āµg/ml was considered as sensitive.
The collected data was fed into the computer in Excel, and analysis was done using Statistical Package for Social Sciences (SPSS) Version 11.5 and association was found by using chi square test.


The study sample consisted of 60 subjects, which included 27(45%) males and 33(55%) females. The mean age was 33.28 yrs with a std. deviation of 14.80. Majority of the infections (83.3%) were deep abscesses, while the rest (16.7%) were superficial skin infections. Pus samples were collected from abscesses and skin swabs were taken from the superficial infections.
Table 1, shows the antibiotic susceptibility of the CA-MRSA strains to various antibiotics. It was found that the CA-MRSA strains showed high sensitivity to Vancomycin (100%) - Two resistant strains showed MIC less than 2 / Āµg/ml, therefore considered as sensitive, Linezolid (96.7%), Clindamycin (93.3%) and Netilmycin (90%), while Ciprofloxacin (18.3%), Amoxyclav (28.3%) and Cotrimoxazole (31.7%) showed relatively low sensitivity.
Table 2, shows the differences between the antibiotic susceptibility of CA-MRSA strains causing deep abscesses and superficial skin infections. Significant difference (p=0.035) in susceptibility was observed for Cotrimoxazole, it showed 60% susceptibility for superficial infections in contrast to only 26% for deep abscesses.
A comparison between the three highest susceptibility drugs, i.e. Vancomycin, Linezolid and Clindamycin revealed that there was no cross-resistance between them. Only 1 strain was found to be resistant to both Clindamycin and Linezolid, but it was sensitive to Vancomycin.


The findings of our study have confirmed our clinical impression that CA-MRSA has spread in our community. Most of the CA-MRSA infections were skin and soft-tissue type. We found that 83.3% of the infections were deep abscesses while 16.7% were superficial skin infections. The deep abscesses included abscesses on various parts of the body viz. gluteal abscess, thigh abscess, axillary abscess, perianal abscess, chest- wall abscess, scalp abscess, wound infections, infected ulcers etc. These findings are consistent with various studies showing that CA-MRSA is most likely to cause skin and soft tissue infections (SSTIs) (5),(6). Skin and soft tissue infections by CA- MRSA can be treated with antibiotics like Erythromycin, Cotrimoxazole and Clindamycin. In our study, Erythromycin susceptibility of CA-MRSA strains was 51.7%, at par with the study done by Wylie et al (9) and Naimi et al (5) where susceptibility was 40% and 44% respectively. This is in contrast to the 7% susceptibility noted by Huang et al (6). A large difference was noted in the susceptibility to Trimethoprim-Sulfamethoxazole (Cotrimoxazole) by us compared to studies done elsewhere. In our study, only 31.7% CA-MRSA strains were sensitive to Cotrimoxazole, while various other studies have noted susceptibility ranging between 90-100% 5,6,9. Susceptibility to Ciprofloxacin was 18.3%, which is quite low as compared to 79% noted by Naimi et al (5), 88% observed by Wylie et al (9) and 53% seen by Huang et al (6). This may be attributed to the inadvertent use of Cotrimoxazole and Ciprofloxacin for various infections. Gentamicin susceptibility was seen in 75% strains, which is low as compared to 87% observed in a study conducted in Manitoba, Canada 9 and 94% seen in Minnesota (5). Huang et al (6) reported 100% susceptibility to Gentamicin. In our study, susceptibility to Netilmycin was 90%, which is higher compared to Gentamicin (75%). High degree of susceptibility was shown to Vancomycin (100%), Linezolid (96.7%), and Clindamycin (93.3%). The emergence of low level Clindamycin and Linezolid resistant Staphylococcus aureus in the community is a matter of concern. Clindamycin susceptibility was reported to be 89% by Wylie et al (9) and 96% by Huang et al (6), which is similar to the findings of our study, where as ,100% susceptibility to Vancomycin among CA-MRSA strains is maintained as reported by Huang et al (6), Wen-Tsung Lo et al (7) and Conly & Johnston (8).

Though, we did not perform the susceptibility testing for Rifampin, it has excellent CA-MRSA coverage. Various studies have reported susceptibility of up to 100% with Rifampin (6).The problem with Rifampin is that, it must be used in a combination regimen, or resistance quickly emerges.(10)
The antibiotic susceptibility of CA-MRSA strains obtained from abscesses and skin infections was similar for all the antibiotics except Cotrimoxazole, which showed significant differences. While only 26% of strains obtained from abscesses were susceptible to Cotrimoxazole, 60% of strains obtained from superficial skin infections were susceptible to it (p=0.035).
Overall, a high proportion of resistance was found among CA-MRSA isolates, suggesting that the face of CA-MRSA has changed in both epidemiological and microbiological features. This calls for the formulation of specific treatment guidelines to prevent emergence of resistance to currently used drugs.
There were several limitations to our study. Firstly, due to the inclusion of only lab-reported MRSA positive subjects, we were unable to estimate the true prevalence of CA-MRSA infection in the general population. Secondly, although patients were carefully interviewed, there is a risk of misclassifying MRSA acquisition due to incomplete history of hospital-related exposures and failure to elicit an accurate history of injecting drug use. Thirdly, due to limited resources, we did not test for the existence of the Panton-Valentine leucocidin gene harbored among CA-MRSA isolates. Despite limitations, this study can contribute to our expanding understanding of CA-MRSA.
Scope for Future Research
CA-MRSA is emerging as an important public health problem. The infections are on the rise in epidemic proportions. More community based surveillance studies are required, to determine the specific risk factors associated with acquisition and transmission of CA-MRSA, and to establish preventive measures within the community.

Key Message

ā€¢ CA-MRSA is mostly associated with skin and soft-tissue infections and a high proportion of resistance was found among the isolates.
ā€¢ Detection of CA- MRSA infections and resistance to commonly used antibiotics, helps to prevent the treatment failure.


Sanjay K. Shukla. Community- Associated Methicillin-Resistant Staphylococcus aureus and Its Emerging Virulence. Clinical Medicine and Research. 2005;3:57-60.
Mukesh Patel. Community-Associated Methicillin-Resistant Staphylococcus aureus Infections. Drugs. 2009;69:693-716
Joel W. Beam, Bernadette Buckley. Community-Acquired Methicillin-Resistant Staphylococcus aureus: Prevalence and Risk Factors. Journal of Athletic Training. 2006; 41:337-340.
Isenberg HD. Essential Procedures for Clinical Microbiology. American Society for Microbiology, Washington DC. 1998; p. 2302.
Timothy S. Naimi, Kathleen H. LeDell, Kathryn Como-Sabetti, Stephanie M. Borchardt, David J. Boxrud, Jerome Etienne et al. Comparison of Community- and Health Careā€“Associated Methicillin-Resistant Staphylococcus aureus Infection. JAMA. Dec 2003; 290: 2976 - 2984.
Huang Hsin, Flynn M. N., King H. Jeff, Monchaud Caroline, Morita Margaret, and Cohen H. Stuart. Comparisons of Community-Associated Methicillin-Resistant Staphylococcus aureus (MRSA) and Hospital-Associated MRSA Infections in Sacramento, California. J Clin Microbiol. July 2006; 44(7):2423-2427.
Lo Wen-Tsung et al. Nasal Carriage of a Single Clone of Community-Acquired Methicillin-Resistant Staphylococcus aureus Among Kindergarten Attendees in Northern Taiwan. BMC Infectious Diseases. 2007; 7:51.
Conly M. John, Johnston Lynn B. The Emergence of Methicillin-Resistant Staphylococcus aureus as a Community-Acquired Pathogen in Canada. Can J Infect Dis. September/October, 2003; 14(5):249-251.
Wylie JL, Nowicki DL. Molecular Epidemiology of Community- and Health Care-Associated Methicillin-Resistant Staphylococcus aureus in Manitoba, Canada. J Clin Microbiol. June 2005; 43(6): 2830-2836.
Dellit T. et al. Interim guideline for evaluation and management of community- associated methicillin resistant Staphylococcus Aureus skin and soft tissue infections in outpatient settings. 2004. Infectious Disease Society of Washington, Public Health Seattle and King County, Washington State Department of Health, Tacoma and Pierce County Department of Health.

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