IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)

e-ISSN: 2279-0853, p-ISSN: 2279-0861. Volume 8, Issue 4 (Jul.- Aug. 2013), PP 09-13
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Prevalence and Risk Factors for Carriage of Methicillin-Resistant

Staphylococcus aureus (MRSA) among Healthcare workers in a
tertiary Institution in Nigeria.
Egwuatu, C.C.1, Ogunsola, F.T.2, Egwuatu T.O.2, Oduyebo O.O.2
1
Department of Medical Microbiology, NnmadiAzikiwe, Nnewi, Anambra State, Nigeria.
2
Department of Medical Microbiology and Parasitology College of Medicine, University of Lagos, Lagos,
Nigeria.

ABSTRACT: Detection of carriers among healthcare workers is an important component of strategies for
controlling the spread of Methicillin resistant Staphylococcus aureus (MRSA) in a hospital setting. We
conducted a cross sectional study on clinical and non-clinical healthcare workers at Lagos University Hospital,
Nigeria. A total of 250 healthcare workers from medical and surgical units, hospital attendants (ward maids),
laboratory and laundry departments were randomly sampled and screened for MRSA using nasal swabs. The
overall carriage rate of MRSA was 13.6% and the prevalence was seen higher among the clinical healthcare
workers than the non-clinical staff (10% vs. 3.6%; P<0.0001). Poor adherence to infection control practices,
antibiotic use within the past three months, contact with patients with cutaneous lesions were among factors
associated with MRSA in this study. Other risk factors observed included the Length of service of workers as
well as use of protective clothing. However, the prevalence of MRSA carriage among healthcare workers is still
low in this endemic setting compared to others in same Sub-Saharan African region or developed countries
hence screening is however highly useful to identify the imported cases and also to allow prompt isolation
precautions.
Keywords: carrier, infection control, prevalence, risk factors, Staphylococcus aureus

I. Introduction
Methicillin-resistantStapkylococcusaureus(MRSA) is a strain of Staphylococcusaureus that develops
resistance through the possession of mec-A gene and which has become a major problem around the world
causing hospital acquired infections and, more recently, infections in the community1.Nosocomial acquisition of
MRSA has been an increasing problem worldwide and at present, this strain frequently causes hospital
infections and leads to a considerable increase in morbidity and mortality2. According to the data from the
National Nosocomial Infection Surveillance System (NNIS) of the Centers for Disease Control and Prevention,
the rate of infections with MRSA in the intensive care units (ICU) in the US has approached 50%3.
However, nasal Staphylococcus aureuscarriage has been on increase, affecting about 20% of the
population and has been identified as a major risk factor for the pathogenesis of hospital acquired
staphylococcal infections4. In Africa, the carriage rate is however low especially amongst the West African
countries. A study by Kesahet al. (2003) on prevalence of Methicillin-resistant Staphylococcus aureus amongst
the clinical health care workers in eight African countriesreported carrier ratesof 12.5% in Senegal and 16.8% in
Cote D'Ivoire5.
Several studies have also reported MRSA carriage by hospital staff. Muderet al.6 described five
hospital employees infected with MRSA which they noted to include folliculitis, cellulites, impetigo,
paronychia, and conjunctivitis while another study showed persistent MRSA carriage for 27 months in a health-
care worker (HCW) 7.
Various risk factors have been associated with increase nasal colonization rate of Staphylococcus
aureus among health-care workers8. These factors include, staying in long-term care units, recent
hospitalization, long-term antibiotic treatment, surgical intervention, presence of skin or soft tissue
infections,and chronic underlying disease9. MRSA carriage by hospital staff normally responds to treatment
with mupirocin nasal ointment, antiseptic solution for washing and shampooing and hexachlorophene powder
for perineal carriers10. Despite advances in antibacterial therapy, this organism continues to pose a serious health
problem and this is as a result of its development of resistance to multiple antibiotics. This in part has been
attributed to high rate of antibiotic abuse and misuse especially in the developing countries like Nigeria11, 12.
This multiple resistance to antibiotics has thus brought about limited therapeutic choices available for
staphylococcal infections hence many hospitals try to put in place infection control measures to curb the
excesses of this bacterium through frequent surveillance. This study was therefore set out todetermine
the carriage rate of MRSA among health workersas well as the risk factors associated with its spread.

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 Prevalence and Risk Factors for Carriage of Methicillin-Resistant Staphylococcus aureus (MRSA)

II. Material And Methods

Study design and setting
A total of 250 health workers working in the theatre, surgical, neonatal, postnatal, labour ward as well
as in the laboratory at the Lagos University Teaching Hospital were sampled. Exclusion criteria included
smokers and those with respiratory infections. A questionnaire that covered demographics, previous and current
antibiotic use, use of protective clothing, and general infection control procedures was administered.
All isolates of S. aureus were identified in the Department of Medical Microbiology of the College of Medicine,
University of Lagos, Nigeria.

Microbiological Analysis
Samples from the anterior nares of each health worker (HW) were swabbed with sterile moistened
swabto a depth of approximately 1 cm, and rotated five times.For each specimen, both nostrils were sampled
using the same swab. Trypticase soy broth (TSB) was used as the transport medium. The samples were quickly
sent to the laboratory and were inoculated onto mannitol salt agar plates and incubated at 35 °C for 24 h. The
isolates were identified as S. aureus based on morphology, Gram stain, catalase test, coagulase test, and
mannitol salt agar fermentation. Methicillin-susceptible S. aureus strains (MSSA) were differentiated from
MRSA using Oxacillin screening test. This was done by subjecting all staphylococcus aureus isolates to plates
containing 6 μg/ml of oxacillin in Mueller-Hinton agar supplemented with NaCl (4% w/v; 0.68 mol/L) using
Clinical and Laboratory Standards Institute (CLSI) method.

III. Results
A total of 250 healthcare workers were sampled to detect carriers of S. aureus as well as the multi-
antibiotic resistant strain of S. aureus, (MRSA) strains. Of these, 77 (30.8%) were from the Laboratory, 118
from the clinical units, 55 from the theatre/ ICU/ neonatal units (Table-I). Out of these, 89 (35.6%) were nasal
carriers of S. aureus while 34 (38.2%) of the 89 harboured MRSA. Overall carriage rate was 13.6%.The
prevalence of MRSA however, varied significantly among categories of workers ranging from 70% in the
postnatal ward to 26.7% in the theatre/Intensive care unit (ICU) (Table-I). In general, there was a higher
prevalence among the healthcare workers in the clinical units, theatre/ICU/neonatal, 25 (13.6%) of 173than in
the Laboratory 26 (34.6%) of 77 (Table-I). It was higher among the nurses than medical doctors in the clinical
setting although the difference was not significant (p < 0.0001). It was also observed that the prevalence was
higher amongst those who had worked longer in hospital especially those who had been employed for over 10
years. In this study, 56 of the 89 healthcare workers had been employed for over 10 years (Table-II).
On questioning about the knowledge of MRSA and infection control procedures, even though 23
(29.9%) of 77 laboratory healthcare workers were aware of MRSA, 55(71.4%) of them sometimes replaced
gloves whenever they left their benches while 50 (64.9%) did not use any disinfectants to wash their hands.
Despite the fact that most doctors and nurses (96.2%) were aware of nosocomial infections, only (54.3%)
always used gloves, while (53.1%) always replaced gloves in-between patients and 32.9% always used face
masks (Table-III). Antibiotic use in the preceding month was a risk factor for carriage of S. aureus. It was
observed that 24 healthcare workers that had use antibiotic in the proceeding one month were carriers of S.
aureus. Among these, 9 (37.5%) had used ciprofloxacin, 8 (33.3%) ampiclox, 5 (20.8%) erythromycin, and one
(4.2%) Cefuroxime axetil and Sulfamethoxazole-Trimethoprim respectively.

Table 1:Colonization And Prevalence Rates of S.aureus Isolates Among Health workers
Ward Health-care worker Number of Health Positivity (%)
workers sampled
Doctor (%) Nurse (%) Lab. Scientist (%)
Laboratory 24(31.1) 0 53(68.8) 77 26(33.8)
Labour Ward 12(17.1) 58(89.9) - 70 16(22.9)
Neonatal Ward 8(38.1) 13(61.9) - 21 10(47.6)
Post natal Ward 4(20.0) 16(80.0) - 20 10(50.0)
Surgical Ward 2(7.2) 26(92.9) - 28 12(42.9)
Theartre/ICU 11(32.4) 23(67.7) - 34 15(44.1)
Total 61 136 53 250 89

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 Prevalence and Risk Factors for Carriage of Methicillin-Resistant Staphylococcus aureus (MRSA)

Table II: Association between colonization of MRSA and Length of Stay in Service.
Laboratory
Length of stay (years) Colonized Not colonized Total
<1 0 0 0
1-5 0 3 3
5-10 2 8 10
>10 2 11 13
Total 4 22 26
Clinical wards
<1 0 1 1
1-5 0 2 2
5-10 4 8 12
>10 6 17 23
Total 7 31 38
Theatre/ICU and Neonatal
<1 0 1 1
1-5 0 1 1
5-10 1 2 3
>10 7 13 20
Total 8 17 25

Chi-square =49.239, DF = 3, P <0.0001

Table III: Association between colonization of MRSA and adherence to UP among Healthcare workers
Laboratory
Use of gloves Always Usually Sometimes Never Total
Colonized 1 3 10 12 26
Not colonized 25 19 5 3 51
Total 26 21 15 15 77
Use of face mask Always Usually Sometimes Never Total
Colonized 2 6 8 10 26
Not colonized 20 13 10 8 51
Total 22 19 18 18 77
Replacement of gloves after leaving the bench Always Usually Sometimes Never Total
Colonized 2 6 8 10 26
Not colonized 20 13 10 8 51
Total 22 19 18 18 77
Clinical areas
Use of gloves Always Usually Sometimes Never Total
Colonized 2 6 12 16 36
Not colonized 35 27 11 5 78
Total 37 33 23 21 114
Use of face mask Always Usually Sometimes Never Total
Colonized 1 4 12 19 36
Not colonized 38 24 9 7 78
Total 39 28 31 26 114
Replacement of gloves in-between patients Always Usually Sometimes Never Total
Colonized 4 8 17 7 36
Not colonized 20 23 19 16 78
Total 24 31 36 23 114
Theatre/ICU and Neonatal
Use of gloves Always Usually Sometimes Never Total
Colonized 3 4 7 11 25
Not colonized 8 6 4 2 25
Total 11 10 11 13 45
Use of face mask Always Usually Sometimes Never Total
Colonized 0 2 10 13 25
Not colonized 7 5 4 4 20
Total 7 5 4 4 20
Replacement of gloves in-between patients Always Usually Sometimes Never Total

Colonized 2 5 10 8 25
Not colonized 15 5 3 2 20
Total 17 10 13 10 45

Chi-square =29.647, DF =3, P <0.0003 (UP – Universal precautions)

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 Prevalence and Risk Factors for Carriage of Methicillin-Resistant Staphylococcus aureus (MRSA)

IV. Discussion
This study looked at the nasal carriage rate of S. aureus among healthcare workers to determine their
carrier rates. The carrier rate of S. aureus was 35.6% while that of MRSA was 13.6%. The figure for the MRSA
is lower than what has been reported in other West African countries like Senegal which was 12.5% and Cote
D'Ivoire 16.8%5. This may be because of the laboratory workers that were studied in addition. Carrier rates
amongst clinical staff were 14.5% which is much higher than the results from Senegal and Cote D'Ivoire5.
It has been shown that a high carriage rate usually precedes epidemics of MRSA and other pathogens 13
and even though the colonization rate among patient was not studied, the high carriage rate among healthcare
worker is an indication of poor infection control practices in the hospital. This was borne out by the fact that
despite good knowledge of infection control, 4.6% of doctors and nurses did not wear gloves while 6.9% did not
replace their gloves in-between patients. In studies done in USA between 1975 to 2002, prevalence of MRSA
rose from 2.4% to over 50% in 200214 and this was attributed mainly to poor infection control practices as well
as ineffective chemotherapeutic control of MRSA 15.
Several studies have recently proven that the longer the length of service being offered by a healthcare
worker, the more the risk of becoming a colonizer of this organisms 16, 17. Several risk factors for MRSA were
identified in this study. Length of stay was significantly associated with MRSA carriage. It was observed that
workers with greater than 10 years of service were more likely to harbour MRSA. This was seen with 62.9% of
healthcare workers with greater than 10 years of service having MRSA compared with 37.1% of less than 10
years.
MRSA has caused many hospital epidemics especially amongst patients in the ICU 18and has been
responsible for many deaths. Some strains are resistant to all classes of antibiotics except vancomycin 19. The
vancomycin resistant Staphylococcus arueus (VRSA) is now identified in many ICU in particular 20. Amongst
the ICU/theatre/neonatal wards, the MRSA carriage was 12.7%. This figure was very high as the patients here
(surgical and neonates) were patients most vulnerable.
In the last few years, various chemotherapeutic agents have been identified and used to eradicate nasal
carriage of MRSA and these include rifampin, clindamycin, fucidic acid, vancomycin, muprocin and recently
lysostaphin. The most commonly used is muprocin, anisoleucyl-t-RNA synthase inhibitor. It inhibits bacterial
isoleucyl-tRNA synthesis and thus interferes with protein synthesis. Lysostaphin, a
glycylglycinendopeptidasewas developed as another alternative 21. However, it has now been shown that this
drug has developed resistance against this strain 22. Moreover, Muprocin is expensive and widely not available
in Nigeria. In addition, resistant strains have been identified 23; 24hence a lot of works need to be done to find
other effective chemotherapeutic agents as well as enforcing infection control practices among the healthcare
workers in order to reduce the rate of MRSA acquisition.

DECLARATION.
The authors hereby declare no conflict of interest.

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