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

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
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Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



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)
E-mail: drrajendrak1@rediffmail.com
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.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : DC06 - DC10 Full Version

Detection and Distribution of Low Level and High Level Mupirocin Resistance among Clinical Methicillin Resistant Staphylococcus aureus Isolates


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55943.16298
P Ganesh Perumal, Subisha Kannan, B Appalaraju

1. Assistant Professor, Department of Microbiology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India. 2. Student, Department of Microbiology, San International College of Arts and Science, Coimbatore, Tamil Nadu, India. 3. Professor and Head, Department of Microbiology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India.

Correspondence Address :
Dr. P Ganesh Perumal,
Assistant Professor, Department of Microbiology, PSG Institute of Medical Sciences and Research, Peelamedu, Coimbatore-641004, Tamil Nadu, India.
E-mail: drganeshp2014@gmail.com

Abstract

Introduction: Prolonged and improper use of antibiotics increases the resistance among pathogens and leads to life threatening implications and increases mortality. The incidence of mupirocin resistance in Methicillin Resistant Staphylococcus aureus (MRSA) clinical isolates were reportedly increasing.

Aim: To determine the rate of high level and low level mupirocin resistance in clinical MRSA isolates in a tertiary care hospital.

Materials and Methods: A cross-sectional study was carried out for a period of three months from December 2019-February 2020 in Department of Microbiology, PSG Institute of Medical Sciences and Research (PSG IMSR), Coimbatore, Tamil Nadu, India. A total of 100 non duplicate Staphylococcus aureus isolates from different specimens were subjected to mupirocin susceptibility by Kirby-Bauer disc diffusion method as per Clinical and Laboratory Standards Institute (CLSI) 2019 standards. The low (MuL) and high (MuH) level mupirocin resistance were detected by using 5 and 200 μg mupirocin discs (Himedia) respectively. The isolate exhibiting diameter of ≥14 mm indicates its susceptibility. The isolate exhibiting diameter ≤13 mm for both 5 and 200 μg indicates MuL and MuH strains respectively. Pearson’s Chi-square test calculated, p-value of <0.05 was considered as statistically significant.

Results: About 51 out of 100 (51%) Staphylococcus aureus isolates were found to be MRSA. In present study, 6 out of 51 (11.7 %) MRSA isolates were found to exhibit MuL and 5 out of 51 (9.8%) MRSA isolates were found to be having MuH. Low level and high level mupirocin resistance were not observed in Methicillin Sensitive Staphylococcus aureus (MSSA).

Conclusion: The incidence of MuH and MuL resistance among MRSA were found to be 9.8% and 11.7% respectively. Screening for mupirocin resistant MRSA to be carried out periodically and stringent infection control practices to be in place to prevent further spread of mupirocin resistant MRSA.

Keywords

Clinical isolates, Inducible clindamycin resistance, Mupirocin resistant Staphylococcus aureus

Staphylococcus aureus is one of the most commonly reported nosocomial pathogen known to cause wide range of infections mainly from skin and soft tissue infections to bloodstream infections (1). MRSA was considered as a potential pathogen in both community and hospital acquired infections associated with increasing morbidity and mortality among the hospitalised patients (2). Being a normal flora, S. aureus colonise in nasal area and skin has been indiscriminately exposed to various antibiotics, thus acting as a potential risk for the acquisition of MRSA (3). Removal of Staphylococcus aureus from the carriage sites reduces the spread of MRSA and it serves as a perfect modality for treating superficial infections (4). As MRSA isolates were resistant to most of the antibiotics, Pseudomonic acid A derived from Pseudomonas fluorescens commonly known as mupirocin was used for treating topical infections. Mupirocin acts as a protein synthesis inhibitor by binding to isoleucyl-tRNA synthetase of bacteria (5). Irrational use of mupirocin leads to alteration of isoleucyl-tRNA synthetase gene mutation resulting in development of resistance towards mupirocin (5). The level of resistance can be two types, low level (MuL) and high level (MuH). The concomitant use of mupirocin with the varying concentration of 5 μg and 200 μg helps in differentiating MuL and MuH strains, and for disk diffusion zone diameter of ≥14 mm with a 5 μg and 200 μg disc were considered as susceptible while zones of ≤13 mm as resistant (6). The strain with low level resistance (MuL) exhibit the MICs between 8-256 μg/mL whereas, high level resistance (MuH) with MICs ≥512 μg/mL (6). Mupirocin use has been linked to the formation of resistance due to increased selective pressure and cross-transmission. Mupirocin therapy for wounds and pressure sores available for over the counter use is strongly linked to resistance (4).

However, the emergence of mupirocin resistance following increased use has not been consistently reported; the degree of mupirocin resistance in our area needs to be monitored for effective antibiotic recommendation; and a comprehensive understanding of all these factors underlying the dynamics of mupirocin resistance in hospitals needs to be researched extensively. Thus present study, aims to determine the rate of resistance towards commonly used antibiotics, mupirocin resistance among MRSA/ MSSA and also in determining the inducible resistance towards clindamycin.

Material and Methods

The cross-sectional study was conducted for the period of three months from December 2019-February 2020 in PSG Institute of Medical Sciences and Research (PSG IMSR), Coimbatore, Tamil Nadu, India. The study was approved by the Institutional Ethical Committee (IEC) (Ref No: PSG/IHEC/2020/Appr/Exp/035) and informed consent was taken.

Inclusion criteria: Various samples like pus, blood, wound swab, urine and sputum were processed for the isolation of S. aureus isolates. All staphylococcal isolates obtained in the study period were included in the study.

Exclusion criteria: All other isolates containing other than Staphylococcus aureus were excluded.

Sample procedure: The samples were initially subjected to microscopic observation and cultured onto blood agar and Mac Conkey agar. A total of 100 non-duplicate ataphylococcal aureus isolates were identified by appropriate biochemical reactions (Catalase test, slide and tube Coagulase test and mannitol fermentation test) and selectedd for the further study for the further study.

Antibiogram of isolates: Antibiogram of all the isolates were studied as per CLSI 2019 guidelines (7) using Kirby-Bauer’s disk diffusion method. Test isolates were originally inoculated onto peptone water and the inoculum turbidity was adjusted to 0.5 McFarland standard after incubation. The susceptibility testing was done using amoxy-clavulanic acid (30 μg), cloxacillin, clindamycin (2 μg), co-trimoxazole (1.25 μg/23.75 μg), cephalothin (30 μg), cefazolin (5 μg), doxycycline (30 μg), erythromycin (15 μg), gentamicin (10 μg), linezolid (30 μg), penicillin (10 units), rifampicin (5 μg), vancomycin (30 μg) discs onto Mueller-Hinton agar (MHA) plate. Cefoxitin (30 μg) disc is the surrogate marker for the detection of MRSA. Zone diameter ≤21 mm was recorded to be MRSA and zone diameter ≥22 mm was recorded to be MSSA. Cefoxitin disc (30 μg) was used to assess the sensitivity of cloxacillin as recommended by CLSI guidelines (7). The zone diameters were read by using both reflected and transmitted light after overnight incubation. S. aureus American Type Culture Collection (ATCC) 25923 has been used as control.

The ‘D’ test was performed for determining the inducible clindamycin resistance among the test isolates. Erythromycin (a macrolide) and clindamycin (a lincosamide) represent two distinct classes of antimicrobial agents that acts by inhibiting protein synthesis. In staphylococci, resistance to both of these antimicrobial agents can occur through methylation of their ribosomal target site. Isolates with inducible resistance are resistant to erythromycin but appear susceptible to clindamycin in routine in-vitro testing (8). Clinical failures of clindamycin therapy for the treatment of MRSA infections have been documented for strains that were clindamycin sensitive but erythromycin resistant. The failures were due to inducible resistance to clindamycin. It can be detected by using erythromycin disc placed at the distance of 15 mm from clindamycin disc on the MHA plate. The flattening ‘D’ zone around clindamycin between two antibiotics after incubation indicates the inducible clindamycin resistance (8).

Detection of mupirocin resistance: The low (MuL) and high (MuH) level mupirocin resistance were detected by disc diffusion method (Himedia, Mumbai, India) using 5 and 200 μg mupirocin discs respectively. The isolate exhibiting diameter of ≥14 mm indicates its susceptibility. The isolate exhibiting diameter ≤13 mm for both 5 and 200 μg indicates MuL and MuH strains respectively (6).

Statistical Analysis

MSSA, MRSA, mupirocin susceptible, and resistant isolate proportions were estimated and the pattern of susceptibility to regularly used antibiotics, were tabulated using frequency tables. Pearson's Chi-square test was calculated, the p value of <0.05 was considered statistically significant. Statistical analysis was performed by using the Statistical Package for the Social Sciences (SPSS) version 21.0 Chicago, USA.

Results

Among various samples processed during the study period, only 100 isolates were identified as S. aureus. Based on the cefoxitin susceptibility, the isolates were categorised as MRSA (51%) and MSSA (49%). In determining the sample wise distribution, the majority of MRSA were isolated from blood 22 (43.1%) followed by wound swab 20 (39.2%) whereas, majority of MSSA were isolated from wound swab 30 (61.2%) followed by pus 11 (22.4%) (Table/Fig 1).

The incidence of inducible resistance towards clindamycin was screened by ‘D test’ method. Among the MRSA (51) isolates, 18 (35.3%) isolates were found to exhibit the inducible clindamycin resistance. Among MSSA (49) isolates, 5 (10.2%) isolates were found to show inducible clindamycin resistance. The incidence of inducible clindamycin resistance was found to be higher in MRSA isolates (Table/Fig 2).

All staphylococcal isolates were screened for mupirocin sensitivity. About 6 (11.7%) MRSA isolates exhibited low level resistance to mupirocin, whereas 5 (9.8%) isolates were found to be high level mupirocin resistance (Table/Fig 3). All MSSA isolates obtained in the study were found to be susceptible for mupirocin.

Majority of MRSA isolates from blood samples were found to be mupirocin resistant. Among these, around 4 (18%) isolates were found to be low level mupirocin resistant and 3 (14%) isolates were found to be high level mupirocin resistant. In pus samples, none of them were found to show low level and high level mupirocin resistant (Table/Fig 4).

All the staphylococcal isolates were tested with antibiotics, all the MRSA isolates were found to be sensitive to linezolid (100%) and vancomycin (100%). All MRSA isolates were found to be resistant to penicillin (100%), cloxacillin (100%), cefazolin (100%), cephalothin (100%) and amoxy-clavulanic acid (100%). Co-resistance was found in erythromycin (76.4%), doxycycline (68.6%) and rifampicin (58.8%). Co-trimoxazole and gentamicin were less resistant.

All the MSSA isolates were found to have maximum sensitivity to cloxacillin (100%), cefazolin (100%), cephalothin (100%), amoxy-clavulanic acid (100%), linezolid (100%) and vancomycin (100%) followed by doxycycline (89.8%) and erythromycin (89.8%). Rate of resistance for MSSA isolates were found to be higher to penicillin (83.7%), followed by clindamycin (24.5%). The rate of resistance was statistically significant to all tested antibiotics including mupirocin (both MuH & MuL) except gentamicin (Table/Fig 5).

Discussion

Mupirocin has been widely used for management of colonisation and infection of S. aureus in both medical personnel and patients. Soon after two years of mupirocin introduction. First mupirocin resistant S. aureus isolate was reported from the UK (1987). Globally mupirocin-resistance was increased in MRSA as irrational, uncontrolled, prolonged and multiple courses of this drug are the main reasons for the development of resistance (9). This study focuses on determining the low level and high level mupirocin resistance in Staphylococcus aureus isolates. In the present study, about 100 non-duplicated isolates (S. aureus) obtained during the study period were included for the further analysis of which 51 isolates (51%) were MRSA and 49 isolates (49%) were MSSA. The rate of high level and low level mupirocin resistance among MRSA were found to be 9.8 % and 11.7 % respectively. Similarly, in a study conducted by Dardi CK and Rudresh MS et al., the rate of high level mupirocin-resistant MRSA was 5.99% and 14.7 respectively, and low-level mupirocin resistance was 15.35% and 10.5% respectively (10),(11), which concords with the present study. Whereas Orrett FA and Vasquez JE et al., observed the higher rate of low level and high level mupirocin resistance to the tune of 26% and 44%, 58 and 42% respectively (12),(13). In above studies the rate of resistance varies according to the demographic condition, local antibiotic policy and sample number.

In the present study, the incidence of MRSA were found to be high in blood samples (43%) followed by wound swab (39%). Nada KK et al, reported lower incidence of Staphylococcus aureus from blood (14%) and deep wounds (13.5%) (14).

Clindamycin has emerged as an effective treatment for various Staphylococcus aureus infections, particularly skin and soft tissue infections, and as a penicillin substitute in penicillin-allergic patients. Reporting S. aureus without checking for inducible resistance may result in treatment failure. In present study, the incidence of inducible resistance were studied against all isolates and the rate were found to be high in MRSA isolates (35.2%) when compared to MSSA isolates (10.2%). Similarly, the incidence of inducible clindamycin resistance were found to be high in MRSA isolates (24.8%) in the study conducted by Majhi S et al (15). In present study, MRSA isolates were found to show 76.4% and 56.8% being resistance to erythromycin and clindamycin respectively. Similar result reported by Adhikari RP et al., in which MRSA isolates showed higher rate of resistance to erythromycin (68.42%) and clindamycin (45.71%) and none of the MRSA isolates were found to be resistant to vancomycin and linezolid (16).

In present study, all the isolates (100) were found to be sensitive towards linezolid and vancomycin. All MRSA isolates were found to be resistant to penicillin, cefazolin, cefalothin, cloxacillin, and amoxy-clavulanic acid as expected. This report was concords with the study conducted by Ghosh S and Banerjee M, where all isolates sensitive to vancomycin (100%) and linezolid (100%) (17).

MRSA isolates were found to show higher rate of resistance to all beta lactam antibiotics (100%) followed by erythromycin (76%) and doxycycline (68%). The rate of resistance coincides with the study conducted by Madhumati et al., where all isolates were resistant to beta lactam antibiotics followed by erythromycin (86%) and tetracycline (60%) (4).

Similarly, in screening of inducible clindamycin resistance, it was found to be higher in MRSA as compared to MSSA. In present study, MRSA isolates showed higher rate of resistance than MSSA isolates to erythromycin (76.4% vs 10.2%) and clindamycin (56.8% vs 24.5%). Thus present study correlates with the study conducted by Adhikari RP et al., in which MRSA isolates showed higher rate of resistance than MSSA isolates to erythromycin (88.2% vs 39.1%) and clindamycin (71.4% vs 41.9%) (16). Similar to present study, none of the MRSA isolates were found to be resistant to vancomycin and linezolid, as reported by Adhikari RP et al., (16).

Vancomycin or linezolid are two medicines routinely used to treat MRSA infections. Mupirocin is a topical antibiotic that is efficient in eradicating MRSA in carriers (3). It is approved for the treatment of superficial skin and soft tissue infections, and some evidence suggests that widespread use in the community for this purpose can lead to an increase in resistance (5). Nasal application of mupirocin in MRSA carriers may result in the presence of low levels of the antibiotic in the pharynx, which could induces the emergence of mupirocin resistant MRSA. Detecting and distinguishing between the two types (MuL and MuH) has significant therapeutic implications. High-level mupirocin resistance (MuH) precludes its usage in therapeutic settings; however, low-level mupirocin resistance (MuL) can be overcome by prescribing a higher-than-usual dose (5). The risk of emergence of resistance appears to be greater among MRSA, and is often associated with widespread use of mupirocin (16). As a result, clinical laboratories must be able to distinguish between susceptible and resistant strains as well as determine the level of resistance (MuL and MuH) (17).

In sample wise distribution, the MRSA isolates from blood samples predominantly revealed mupirocin resistance. About 4 (18%) isolates were found to be low level mupirocin resistant and 3 (14%) isolates were found to be high level mupirocin resistant. Among wound swab (20 isolates), 1 (5%) isolate exhibited low and 1 (5%) isolate exhibited high level mupirocin resistance. Among sputum (3 isolates) samples, 1 (33%) isolate exhibited low level and 1 (33%) isolate exhibited high level mupirocin resistance in present study. In urine samples, none of them were found to show mupirocin resistance. Similarly in sample wise distribution, higher rate of mupirocin resistance (MuL and MuH) were from pus (26.92% and 10.25%), followed by blood (17.14% and 5.71%), sputum (15.38% and 6.15%), and the lowest was in urine (1.42% and 0%) respectively, as reported by various studies (Table/Fig 6) (9),(10),(11),(18),(19),(20).

The mupA gene is typically found on mobile genetic elements most of time. The "gold standard" method for detection of mupirocin resistance is Minimum Inhibitory Concentrations (MIC) determination by the agar dilution method (21). In present study, authors used the disc diffusion method for detection of low- and high-level mupirocin resistance. Malaviolle et al., have previously tested sensitivity and specificity of this method. The results of the disc diffusion test were obtained with the concurrent use of 5 μg and 200 μg mupirocin discs. They found that the sensitivity and specificity of 5 μg disc was 100% and 98.1%, respectively, whereas that of 200 μg disc was 100% and 92.3%, respectively, separating MuH in MuL (22). As a result, the disc diffusion susceptibility test is a less expensive and straight forward option for frequent use.

The presence of mupirocin resistance among MRSA isolates is concerning because mupirocin resistant bacteria have few effective options. Although polysporin triple ointment has been used in the field, no research on its effectiveness has been conducted. When coupled with other antibiotics like vancomycin, fusidic acid has been demonstrated to be successful in the systemic treatment of MRSA, but not when taken alone (23). As a topical alternative to mupirocin, hydrogen peroxide cream has been suggested (24).

When MRSA is discovered in a healthcare worker, it is routinely treated with 7-day chlorhexidine baths and topical 2% mupirocin ointment, as well as time off or displacement from duty until two negative culture reports are obtained. As a result, all isolates obtained from nasal carriers should be screened with mupirocin (with 5 μg discs and 200 μg discs) before to starting medication, so that MuH strains can be treated with alternate options such as fusidic acid, neomycin, or possibly the newer reptapamulin (23),(25).

If various actions are made in the near future, the emergence of mupirocin resistance can be restricted. First of all, more research is needed to determine the efficacy and unintended consequences of using mupirocin as a preventative measure. Then if mupirocin is to be consistently used, a method for monitoring the rate of resistance should be created and executed. The monitoring strategy should not just focus on mupirocin resistance, but also on determining whether mupirocin use could increase the spread of multidrug resistance by linking it to other resistance determinants. Currently, there are no commercially accessible test kits available. Even as testing methods become more widely available, more information is needed to instruct doctors and health care facilities on how to appropriately use these tools to guide therapeutic and prophylactic mupirocin use.

Limitation(s)

Mupirocin resistant MRSA isolates can be detected by genotypic methods, such as Polymerase Chain Reaction (PCR) as a final confirmatory test. The lack of confirmatory test is a limitation of present study. Additional studies with larger sample size would be helpful to understand the clinical significance of both high level and low level mupirocin resistance.

Conclusion

The rate of high level (9.8%) and low level mupirocin resistance (11.7%) in MRSA is a cause for concern. As a result, even in hospitals where mupirocin is not used, routine testing of MRSA for mupirocin resistance is suggested. This will aid in the early detection of resistance, as well as the control and spread of mupirocin-resistant MRSA in a healthcare settings.

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DOI and Others

DOI: 10.7860/JCDR/2022/55943.16298

Date of Submission: Feb 26, 2022
Date of Peer Review: Mar 10, 2022
Date of Acceptance: Apr 05, 2022
Date of Publishing: May 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 03, 2022
• Manual Googling: Mar 04, 2022
• iThenticate Software: Apr 05, 2022 (24%)

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