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.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

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
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,
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,
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
(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)
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

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
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : March | Volume : 17 | Issue : 3 | Page : DC01 - DC06 Full Version

Isolation of Methicillin-Resistant Staphylococcus aureus from Wound Samples during the COVID-19 Pandemic: A Retrospective Study

Published: March 1, 2023 | DOI:
Shugufta Roohi, Tufail Ahmed, Insha Altaf, Bashir Fomda

1. Assistant Professor, Department of Microbiology, SKIMS, Srinagar, Jammu and Kashmir, India. 2. Senior Resident, Department of Microbiology, SKIMS, Srinagar, Jammu and Kashmir, India. 3. Senior Resident, Department of Microbiology, SKIMS, Srinagar, Jammu and Kashmir, India. 4. Professor, Department of Microbiology, SKIMS, Srinagar, Jammu and Kashmir, India.

Correspondence Address :
Dr. Bashir Fomda,
Professor, Department of Microbiology, SKIMS, Srinagar-190011, Jammu and Kashmir, India.


Introduction: On March 11th, 2020, the World Health Organisation (WHO) declared the outbreak of the novel coronavirus disease caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) as a pandemic. This recently discovered β-coronavirus spread instantaneously across mainland China due to human-to-human transmission and crossed international borders aided by intercontinental travel. In most nations, the logarithmic growth of the cases very quickly overwhelmed the healthcare system which led to the overcrowding of the hospitals and led to a sudden surge in Hospital-Acquired Infections (HAIs). Implementation of contact precautions was implemented to control cross-infection.

Aim: To determine the effect of Coronavirus Disease-2019 (COVID-19) on the prevalence of HAIs with special emphasis on Staphylococcus aureus (S. aureus).

Materials and Methods: This three year retrospective study (September 2018 to August 2021) was undertaken at Department of Microbiology, Sher-i-Kashmir Institute of Medical Sciences, Kashmir, an apex tertiary care institute in Northern India. A total of 2548 wound swabs samples were collected and processed in the laboratory for the presence of aerobic bacterial isolates. S. aureus was identified using conventional methods and antimicrobial sensitivity was performed by the Kirby-Bauer disc diffusion method. Data was entered in Microsoft excel and later analysed in International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) version 22.0.

Results: A steady increase in the isolation of Methicillin-resistant Staphylococcus aureus (MRSA) was noted during the study period (60.5% in 2018 to 78.1% in 2021). A statistically significant increase was noted in the detection of MRSA after the onset of the COVID-19 pandemic (p=0.018) despite the reduced number of surgeries conducted in the institution and rigorous execution of contact precautions.

Conclusion: There was an increase in the rate of MRSA isolation during the study period. The increase was significantly affected by the onset of COVID-19. To contain the spread of MRSA, novel methods including preoperative screening of patients undergoing elective surgeries and periodic screening of hospital staff need to be implemented along with standard infection control precautions at all times.


Contact precautions, Hospital-acquired infections, Hospital infection control, Pandemic, Severe acute respiratory syndrome coronavirus-2

Staphylococcus aureus is a human pathogen with a wide range of disease spectrum which encompasses mild skin and soft tissue infections to severe life-threatening sepsis. With the advent of methicillin-resistant strains, especially in the hospital environment, treatment options have become limited. These strains, being Multidrug Resistant (MDR), lead to higher morbidity and mortality (1). World Health Organisation (WHO) describes Hospital Acquired Infections (HAIs) as an emerging health hazard having a major economic impact both on the community and the individual. Although, progress has been made in the control and prevention of HAIs over the last decade, the resilient nature of the organism makes its eradication difficult and continues to be a major cause of the increased cost of care (2). The bacterial flora of hospitals comprises MDR species which vary with time and location inside the hospital. Working knowledge of the antibiogram of the hospital is of vital importance in the treatment of such infections. Additionally, diagnostic tests have to be performed without delay to identify the aetiologic agents associated with HAIs to guide the choice of antibiotics (3).

Staphylococcus aureus is well known for boasting several drug resistant mechanisms, the most menacing being methicillin resistance. MRSA arises due to the transfer of novel Deoxyribonucleic Acid (DNA) which induces the production of a new Penicillin-binding Protein-(PBP2a). PBP2a has a low affinity for methicillin and other β-lactams (4). In an institution, the prevalence of Hospital Acquired-MRSA (HA-MRSA) is indicative of the overall infection rate and is influenced by various factors such as the inflow of patients, magnitude of overcrowding in the wards and nursing load. One of the main sources of transmission of MRSA within hospitals is via the hands of Healthcare Workers (HCWs) (5). The main reservoirs of HA-MRSA are the infected and colonised patients. The colonisation of patients is proportional to the length of hospital stay, nutritional status of the patient, recurrent or recent antibiotic treatment, and presence of wound and/or invasive devices (6). Wound infections are defined as the discharge of pus from the wound, or a clinical suspicion of wound infection, based on inflammatory signs such as raised temperature, redness and tenderness of the wound. Wound infections caused by HA-MRSA are associated with high morbidity and mortality (7).

The COVID-19 pandemic further increased the burden on infection prevention practices which had been prevalent in healthcare settings (8). Due to the contagious nature of the pathogen, unprecedented measures were introduced to prevent the spread of the disease among the patients admitted to the hospitals (9). Prior to the advent of the pandemic, these measures were implemented only in high-risk units due to concerns about cost-effectiveness (10). Although, these measures led to the control of the pandemic at various levels, other areas of patient care and control programmes for other HAIs suffered as a consequence of all the efforts being diverted to COVID-19 mitigation (11). During the outbreak of SARS-CoV-2 in 2003, various reports suggested increased rates of MRSA in healthcare settings (12). Given the above, continuous surveillance of microorganisms and a regular update of their antibiotic resistance pattern is essential to maintain good infection control practices in the hospital. Keeping this perspective in view, authors designed this retrospective study to estimate the prevalence of the major aerobic bacterial isolates especially MRSA from wound samples of patients. Also, the trend for the past three years was studied with special emphasis on the later part of the study period which coincided with the emergence of the COVID-19 pandemic. Baseline information was recorded for further detailed and large epidemiological and drug resistance investigations in an attempt to develop a comprehensive treatment protocol.

Material and Methods

This retrospective study was carried out in the Department of Microbiology, Sher-i-Kashmir Institute of Medical Sciences, a 1200 bedded apex tertiary care centre of the valley of Srinagar, Jammu and Kashmir, India. The study protocol was approved by the Institutional Ethics Committee (IEC-SKIMS/2022-365).

Inclusion criteria: All wound swab samples sent to the bacteriology laboratory during the study period of three years (September 2018 to August 2021) were included. The data were subsequently analysed (August 2022 to September 2022).

Exclusion criteria: Improperly labelled samples and any repeat isolate from the same patient received on more than one occasion were excluded from the study.

Study Procedure

Specimen collection: Specimens were collected on the day when patients reported clinical evidence of infection (purulent drainage from wound site). Sterile cotton wool swabs were used for sample collection. Before sample collection, the wound was thoroughly cleansed with sterile normal saline or sterile water. The swab was rotated over a 1 cm2 area of viable tissue for five seconds using sufficient pressure to extract fluid from the wound tissue (Levine method) (13). It was ensured that the sample was collected from viable tissue and not necrotic slough, purulent material or eschar that was heavily contaminated with colonising bacteria. A total of two swabs were collected and immediately transported to the laboratory for processing.

Sample processing: Samples were processed within two hours after receipt in the laboratory.

Direct microscopy: One swab was used for making smears which was stained and screened for pus cells and the presence/absence of bacteria, their gram reaction along with the morphology and arrangement.

Culture for aerobic organisms: The second swab was inoculated onto plates of sheep blood agar containing blood agar base (HiMedia) and 5% sheep blood and MacConkey agar (HiMedia) by rolling the swab over the agar and streaking. Also, a backup was put on Robertson’s Cooked Meat (RCM). The plates were incubated overnight at 35oC±2 in bacteriological incubators. After performing preliminary identification tests such as gram stain, oxidase and catalase from the isolated colonies, identification and susceptibility testing were done. All isolates were identified by conventional biochemical tests (carbohydrate fermentation patterns and activity of amino acid decarboxylases and other enzymes). Antimicrobial susceptibility testing was performed by the Kirby-Bauer disc diffusion method on Mueller-Hinton agar according to Clinical and Laboratory Standards Institute (CLSI) guidelines (14). S. aureus was reported as methicillin resistant if the disk diffusion zone for 30 μg cefoxitin disc was <22 mm.

Test control organisms: American Type of Culture Collection (ATCC) strains of S. aureus (25923), E. coli (25922), and P. aeruginosa (27853) were used as test control organisms (Hi-Media Laboratories Pvt., Ltd., Maharashtra, India).

Statistical Anlaysis

Data was entered in Microsoft excel and later analysed in International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) version 22.0. Statistical analysis was performed by using a Chi-square test. Statistical significance was defined for p<0.05. Test results are presented both graphically and in tabular form.


A total of 2548 samples were received and analysed in the laboratory during the study period. The mean age of the studied population was 33.83 years (1-85 years). The positivity of the swab culture was 97.8%. Out of the culture positive samples, 1843 (73.9%) were gram negative organisms, while 648 (26.1%) were gram positive bacteria. The most common organism isolated was Escherichia coli (n=504) among the gram negative organisms whereas, amongst the gram positive organisms, the most frequently isolated was S. aureus (n=310) (Table/Fig 1). Confirmation of S. aureus was done by gram staining, catalase test and a tube coagulase test. Methicillin resistance was confirmed by the 30 μg disk diffusion method, as per CLSI guidelines (Table/Fig 2). The majority of the S. aureus samples were from the Outpatient Department (OPD) section while in the Inpatient Department (IPD) section, the majority of samples were from the Department of Plastic Surgery (Table/Fig 3). The percentage of MRSA isolated during the study period was 66.1%. The incidence of gram positive and gram negative organisms changed little over the three years. However, there was a constant and significant increase in the incidence of MRSA from 60.5% during the first year of study to 78.1% during the third year of study (Table/Fig 4). The mean age of patients with MRSA was 28 years as opposed to those with Methicillin-sensitive Staphylococcus aureus (MSSA) (42 years). There was no significant association between various demographic factors except COVID-19, wherein a statistically significant rise in MRSA was noted between the prepandemic and postpandemic period (Table/Fig 5). MSSA strains showed considerable sensitivity to co-trimoxazole (80%), erythromycin (32.3%) and clindamycin (84%) (Table/Fig 6). As S. aureus showed high resistance to standard antibiotics, the second line of drugs, were also tested (Table/Fig 7).


Ever since MRSA was isolated in 1961, it has established itself as an endemic pathogen in healthcare facilities throughout the world. According to reports, more than half of the strains of S. aureus isolated from the Asia-Pacific region show methicillin resistance; mainly associated with skin and soft tissue infections. The increased virulence of MRSA strains makes them more virulent and leads to higher morbidity, mortality and healthcare costs. Due to its significant impact, WHO has included MRSA in the high-priority list of drug resistant bacteria for the targeted development of novel antibiotics (15). As the incidence of HAI associated with MRSA increases, the detection of such strains has become imperative for treatment and epidemiological purposes (3).

In the present study, a total of 2548 samples were received during the study period. A high culture positivity of 2491 (97.8%) was observed in patients with wound infections. S. aureus was isolated in 310 (12.17%) of the samples. A study conducted by Vidhani S et al., also reported similar rates (17.6%) of staphylococcal wound infection (16). Among the 310 S. aureus strains isolated, 205 were MRSA while the remaining 105 were MSSA. A high proportion of MRSA (66.1%) was identified in the study. A lesser rate of 28.5% and 27.3% have been reported by Manian FA et al., and Cerveira JJ et al., respectively (17),(18). The hospital is a referral hospital that caters to the entire population of the division. This might explain the high incidence of MRSA in the hospital. The epidemiology of MRSA displays wide geographic variation. Care has to be taken when data from different regions were compared as different definitions may be used in defining data collection, study population and surveillance methods. Nonetheless, such data is of vital importance in benchmarking and monitoring the effectiveness of control strategies (15). The increase in the rate of isolation of MRSA strains in hospitalised patients requires rapid and reliable characterisation. Efforts should be made to formulate guidelines to prevent the spread of such strains. Despite numerous eradication measures implemented over the past decade, MRSA continues to be a major nosocomial pathogen worldwide (7). The mean age of patients infected with MRSA (28 years) was less than that of MSSA (42 years). Several reports have mentioned that increasing age is a risk factor for MRSA colonisation (19),(20). A multicentric study done in the United States found that persons older than 65 years, women, diabetics and those admitted to long-term care in the past year had a higher risk for MRSA colonisation (21). Present study comprised of a younger subset population (mean age=33.83 years), which might explain the lower age of colonisation by MRSA.

On further analysis, an upward trend was noted in the isolation of MRSA from the hospital; 60.5% in 2018 to 78.1% in 2021. Previous studies conducted in this institute reiterate the fact that MRSA isolation has been on the rise and this worrisome trend has further increased post-COVID-19 (22),(23),(24). United States reported a steadily increasing rate of MRSA from 1998 up to 2005, when it reached 53% of S. aureus clinical isolates (25). Rigorous infection control practices implemented thereafter led to a 17% annual reduction (26). Similar trend was noted across Europe (27). This downward trend was mainly attributed to a multimodal strategy involving universal MRSA screening, contact precautions, and the promotion of hand hygiene. Similar practices may be instituted across all high prevalence areas of the hospital (15).

The MRSA strains were found to be resistant to many antibiotics in this study while MSSA strains showed considerable sensitivity to cotrimoxazole (80%), erythromycin (32.3%), and clindamycin (84%). A statistical significance was observed between sensitivities of clindamycin and erythromycin for MRSA and MSSA strains, while cotrimoxazole showed no such significance. Similar findings have been reported elsewhere. In a study conducted by Kothari A et al., all MRSA isolates showed 72% for macrolides and cotrimoxazole, whereas the MSSA isolates showed a lower rate of resistance (55%) (28).

In the United States, HAI affects 1 out of 31 hospitalised patients. MRSA is a major contributing factor to HAI, especially in patients with immunocompromising conditions. Centre for Disease Control and Prevention (CDC) has advised the implementation of contact precautions to control and prevent cross-transmission between patients (29). There have been no standard recommendations for routine screening of HCWs for MRSA carriage. The available guidelines recommend screening only during outbreaks. The current hospital guidelines suggest that all MRSA carriers be referred to a physician for decolonisation therapy with a follow-up resampling 10 days after the therapy has been completed. Healthcare facilities may consider pre-employment screening and periodic cross-sectional screening of HCWs in between outbreaks (30). In addition, MRSA carriers need to be informed regarding the risk that they carry of developing postoperative MRSA Surgical Site Infections (SSI). Studies have reported a 2.5 times higher risk in MRSA carriers and the consequences of such a complication are severe (23). During the postoperative period, these patients need to be monitored closely for signs of wound infection so that prompt treatment may be started. Also, the high morbidity in such cases suggests that elective surgeries may be delayed until either MRSA status is known or the patient is sent for decolonisation therapy. In case of emergency surgeries, measures such as prophylactic use of antibiotics active against MRSA have been shown to reduce postoperative MRSA wound infection (31). MRSA SSI is very troublesome to eradicate once set in and such prophylactic antibiotics have a definite advantage.

Several innovative measures need to be implemented to prevent MRSA SSIs in a high load hospital. Universal screening for MRSA in dated patients, along with improved staff and patient education, timely and regular screening of HCWs, implementation of hand hygiene before and after interacting with patients, and a search and destroy policy may help in reducing the spread and reduce cross-contamination and overall MRSA burden (32).

At the start of 2020, when the first patients infected with COVID-19 were admitted to the hospital, several measures were initiated to avoid transmission among patients and HCWs. These included having a dedicated infectious disease block, rigorous use of Personal Protective Equipment (PPE), and extensive use of hand sanitisers. Hand sanitiser use in the hospital increased many folds during the pandemic. However, the incidence of nosocomial MRSA was unaffected and showed a continual upward trend (33).

The COVID-19 pandemic spread rapidly and hospitals around the world have been overwhelmed by patients. During the initial phase of the pandemic, antibiotics were massively prescribed because of a lack of knowledge and guidelines for management. As many as 95% of the patients were prescribed antibiotics during the first few months of the pandemic (34). Apart from rare cases of bacterial coinfection antibiotics had no documented role in the treatment of such cases. Moreover, antibiotics were prescribed without samples being sent for microbiological testing (35). There was no clear benefit that was documented due to excessive use of antibiotic use and if any was counterbalanced by the magnitude of side-effects especially the increase in antibiotic resistance rates (36).

Before the advent of COVID-19 pandemic, WHO had targeted its efforts to reduce and prevent antimicrobial resistance. COVID-19 highlighted several issues regarding the healthcare setup and along with it, brought new threats to the forefront including excessive use of antibiotics even without evidence of their utility (35). Several studies have indicated that antibiotic use is high among patients hospitalised for COVID-19 (37). This highlights the importance of having a proactive antibiotic stewardship committee. While uncertainty regarding the management of COVID-19 led to the widespread use of antibiotics, several studies suggested the restrictive use of antibiotics. Antibiotics may be withheld in milder cases. In addition, the prescribing of antibiotics in the “Watch”, “Reserve” and “Not recommended” groups of the WHO’s AWaRe classification system need to be restricted. An ecological study in England found that broad-spectrum antibiotics were being prescribed in larger proportions despite an overall decrease in antibiotic use in the community (38). The increase in MRSA isolation rate was in spite of the lower admission rates in hospitals across the valley and the lesser number of procedures done during the COVID-19 pandemic (39),(40).


This study had several limitations, including the fact that it was a monocentric study and retrospective in nature. Another limitation was the small sample size. Also, the potential role of HCW with the most patient contact was not examined. The COVID-19 history of the subjects was not known. It was presumed that antibiotic usage had increased and it was extrapolated to the study subjects. Nevertheless, this study is one of the first to focus on the misuse of antibiotics against COVID-19, and the increase in MRSA prevalence in a tertiary care centre. This study could be complemented by an analysis of the risk factors that led to the continued surge of MRSA rates despite the rigorous implementation of contact precautions following the COVID-19 pandemic.


The MRSA is a major cause of morbidity and mortality. MRSA isolation rates have continued to increase in the hospital although the magnitude of elective surgeries done during the pandemic was low as compared to earlier years. Clinicians should be cautious about antibiotic prescriptions in the absence of strong evidence of infection especially patients with COVID-19, as their prevalence is not high, a certain diagnosis is not accessible, and the benefit/risk ratio is not clear. Novel methods should be implemented in the hospital to contain the spread of MRSA, an epidemic of MRSA may propagate during the COVID-19 pandemic.


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DOI and Others

DOI: 10.7860/JCDR/2023/60256.17558

Date of Submission: Sep 16, 2022
Date of Peer Review: Nov 26, 2022
Date of Acceptance: Jan 04, 2023
Date of Publishing: Mar 01, 2023

• 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

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