• Users Online: 141
  • Print this page
  • Email this page

 Table of Contents  
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 6-11

Methicillin-resistant Staphylococcus aureus: Carriage rate, knowledge, attitude, and practice levels among healthcare workers

1 Department of Microbiology, BLDEU’s Shri B. M. Patil Medical College, Vijayapura, Karnataka, India
2 BLDEU’s Shri B. M. Patil Medical College, Vijayapura, Karnataka, India
3 Statistician Department of Community Medicine, BLDEU’s Shri B. M. Patil Medical College, Vijayapura, Karnataka, India

Date of Submission16-Jul-2021
Date of Decision11-Jun-2022
Date of Acceptance28-Oct-2021
Date of Web Publication19-Sep-2022

Correspondence Address:
Smita S Mangalgi
Department of Microbiology BLDEDU. Vijayapura Karnataka
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/DYPJ.DYPJ_41_21

Rights and Permissions

Background: Ever-increasing numbers of infections by methicillin-resistant Staphylococcus aureus (MRSA) strains are being reported in the hospitals. Healthcare workers (HCWs) become colonized with MRSA and act as source as well as vectors for the transmission of MRSA infections to the patients. Aim and Objectives: The aim of this article is to detect the carrier rate of methicillin-sensitive Staphylococcus aureus (MSSA) and MRSA among the HCWs and to determine the antimicrobial susceptibility of the isolates to commonly used antimicrobial agents. Materials and Methods: Nasal swabs from 265 HCWs were collected between October 2018 and April 2019. The swabs were processed using standard laboratory techniques. Results: Of the 265 samples collected from HCWs, 46 (17.35%) showed the growth of S. aureus and among them 38 were found to be MRSA. The overall carrier rate of MRSA was 14.33%. The maximum carriage rate for MRSA was seen among nursing staff and that for MSSA among undergraduate medical students. Overall knowledge and attitude levels of HCWs though were found to be better proper preventive practices were not followed. Most of the MRSA strains were sensitive to vancomycin and linezolid, but more than 50% were resistant to commonly used antimicrobial agents in our hospital. Conclusion: Along with strict enforcement of infection control practices, regular surveillance of HCWs for MRSA colonization is necessary to limit the spread of MRSA by HCWs to susceptible patients.

Keywords: Carriage rate, HCWs, MRSA, MSSA

How to cite this article:
Mangalgi SS, Agarwal A, Sajjan AG, Math M. Methicillin-resistant Staphylococcus aureus: Carriage rate, knowledge, attitude, and practice levels among healthcare workers. D Y Patil J Health Sci 2022;10:6-11

How to cite this URL:
Mangalgi SS, Agarwal A, Sajjan AG, Math M. Methicillin-resistant Staphylococcus aureus: Carriage rate, knowledge, attitude, and practice levels among healthcare workers. D Y Patil J Health Sci [serial online] 2022 [cited 2022 Oct 6];10:6-11. Available from: http://www.dypatiljhs.com/text.asp?2022/10/1/6/356515

  Introduction Top

Staphylococcus aureus is known to cause a variety of diseases ranging from skin and soft-tissue infections to invasive diseases such as pneumonia, osteomyelitis, endocarditis, etc. Nowadays, infection due to methicillin-resistant Staphylococcus aureus (MRSA) is a growing concern as it leads to serious disease, expensive treatment, extended and even doubles the hospital stay, and increased mortality.[1],[2],[3]

Nasal, axillary, or inguinal colonization with MRSA poses a risk factor for MRSA infection.[4] Higher nasal colonization of MRSA among healthcare workers (HCWs) than the general population makes HCW an important source of nosocomial transmission.[5],[6],[7]

Literature shows wide variation in the MSSA and MRSA carriage rates in different HCWs depending upon the country, hospital settings, and the specialty which it caters.[8],[9],[10],[11] Such type of study has not been published in the recent past from our tertiary care hospital from North Karnataka, India.

This study aimed to determine the nasal carriage rate of MSSA and MRSA among HCWs, to find out the antibiotic susceptibility pattern of the isolates, and to know the knowledge, attitude, and practice (KAP) levels regarding MRSA among various HCW groups.

  Materials and Methods Top

After taking approval from the Institutional Ethical Committee, a cross-sectional study was designed for the collection of nasal swab specimens from HCWs.

The study period was from October 2018 to April 2019. Doctors, nurses, laboratory technicians, and intern students were included in the study.

Nasal swab collection

For sample collection, sterile cotton swabs were used. The sample was collected by rotating the swabs gently four to five times in both nares of the participating HCW. The swabs were transported to the laboratory in Stuart Transport media. Inguinal and axillary swabs were collected from HCWs who showed nasal colonization with MRSA and processed similarly.

Repeat nasal swabs were collected from all MRSA-positive staff after 1 week of first swab collection for the confirmation of their MRSA persistent carrier state.

Isolation and identification

Swabs were inoculated onto mannitol salt agar and blood agar plates within 1 h of collection. Culture plates were incubated at 37°C overnight. Slide coagulase test was performed for suspected staphylococcal colonies (β-hemolytic, golden yellow colonies that were mannitol fermenter on MRSA).[12] Slide coagulase-positive isolates were presumptively considered to be S. aureus. Confirmatory tube coagulase test and antibiotic sensitivity test were performed.

Antimicrobial susceptibility testing

Antimicrobial susceptibility testing was performed using the modified Kirby-Bauer disc diffusion method as per the Clinical and Laboratory Standards Institute (CLSI) guidelines.[12]

Detection of methicillin resistance

Cefoxitin disc diffusion method was used to identify MRSA.[13]S. aureus ATCC 25923 was used as the control strain.


After confirming the persistent carrier state, all the MRSA carrier HCWs were asked to follow the decolonization protocol, which included intranasal application of mupirocin ointment and gargle with an octenidine-based solution, both thrice a day for 6 days. They were also instructed to change and wash the clothes and bed-linen on daily basis.

HCWs with skin colonization along with nasopharyngeal colonization (positive inguinal or axillary swabs for MRSA) were advised to use octenidine-based soap for bathing. Repeat swabs were collected after completion of decolonization protocol from MRSA-positive HCWs.

Knowledge, attitude, and practice level determination

All the HCWs enrolled in the study were assessed for basic knowledge regarding MRSA carriage, its mode of transmission, and threats posed. Attitude toward MRSA as a problem and practice followed to prevent spread of MRSA during patient care and collection of specimens for investigation were evaluated.

  Results Top

Nasal swabs from 265 HCWs were collected for the study. The age ranged between 21 and 54 years (mean = 31.59±6.99); 155 (58.5%) were males and 110 (41.5%) were females. The mean number of years in service was 9.11±0.36. Overall, 17.35% (46) of HCWs were healthy carriers for S. aureus, of which 38 (82.6%) were MRSA and 8 (14.8%) were MSSA [Table 1]. Inguinal and axillary swabs from all the staff with MRSA nasal colonization also grew MRSA. Similarly, the second nasal swabs collected after 1 week from all the positive staff revealed the presence of MRSA, indicating the persistent MRSA carrier status.
Table 1: Distribution of MRSA and MSSA carriage among HCWs

Click here to view

Overall KAP levels of HCWs toward MRSA are shown in [Table 2]. Comparison of KAP scores and pairwise comparisons among various categories of HCWs has been described in [Table 3] and [Table 4].
Table 2: Overall knowledge, attitude, and practice levels of HCWs toward MRSA

Click here to view
Table 3: Comparison of KAP scores among various categories of health workers

Click here to view
Table 4: Pairwise comparisons of KAP levels

Click here to view

Antibiotic sensitivity pattern of MRSA isolates is depicted in [Figure 1]. None of the staff was found positive for MRSA, 1 week after the completion of decolonization protocol indicating 100% sensitivity to mupirocin in this area.
Figure 1: Antibiotic resistance pattern of MRSA and MSSA isolated from HCWs

Click here to view

  Discussion Top

MRSA is a major healthcare-associated pathogen causing significant morbidity and mortality. In the past two decades, these MRSA strains have become endemic in many hospitals across the globe leading to a significant increase in the incidence of MRSA infections.[14],[15],[16],[17]

Anterior nares of the HCWs are known niche for S. aureus strains, which then may get transferred to the patients within and between the wards.[9] Depending upon the time period for which S. aureus colonizes the nares, three types of carriers are known: persistent carriers, intermittent carriers, and non-carriers.

The nasal carriage rate varying between 2% and 24.84% for MRSA among the HCWs has been reported in Indian studies.[17],[18],[19],[20] Our study results demonstrate nasal carriage of S. aureus among HCWs to be 17.35% and that of MRSA was 14.33%.

Across the sex comparison, nasal carriage rate showed a significant difference with male preponderance (P = 0.026), which is in contrast to the studies by Abimana et al.[11] who did not find significant difference and by Singh et al.[21] who have reported female preponderance. No relation could be found between age group and MRSA carriage rate in our study as has been noted by some studies.[11],[21] Significant association was seen between the working ward and MRSA carrier state. Majority of the carriers were from surgery ward (47.4%), followed by obstetrics and gynecology ward (37%).

When professional designation was considered, MRSA carriage was particularly high among nursing staff (16.7%) followed by laboratory workers (15.4%) indicating that the nursing staff were the potential colonizers of MRSA. Similar findings have been reported by few other studies.[10],[11],[22] Frequent patient contact, lack of knowledge regarding hand hygiene, contact precautions, and infection control policies might be the reasons for high prevalence of MRSA among the nursing staff. Doctors showed the carriage rate of 12.8% which is in contrast to the study by Agarwal et al.[18] and Radhakrishna et al.[19] who have reported highest positivity of 42.9% and 50%, respectively.

Overall knowledge and attitude levels though were better in HCWs, proper preventive practices were not followed. Most of the HCWs did not perform hand hygiene before touching a patient and also before and after wearing gloves. About 40% of HCWs did not wear gloves regularly while touching/examining a patient. Statistically significant difference was noted in knowledge, attitude, and practice scores among various categories of health workers using the Kruskal–Wallis H test. Similar results have been reported by Yoo et al.[23] among dental healthcare professionals.

Pairwise comparison showed statistically significant difference with respect to knowledge and practice levels among the various pairs, whereas for attitude the difference was not significant.

In the studies by Khanal et al.[10] and Radhakrishna et al.,[19] all the isolates were sensitive to vancomycin, whereas in our study 3 out of 38 (7.9%) strains were resistant to vancomycin. Many studies have reported 100% sensitivity to linezolid but in our study 13.2% of the strains were resistant to linezolid.[19],[21],[22]

All our MRSA isolates were resistant to penicillin which is in accordance with studies by Abimana et al.[11] and Agarwal et al.[18] Study by Agarwal et al.[18] has demonstrated 50% of the MRSA strains to be sensitive to ciprofloxacin. In contrast, in our study, only 2.6% of the strains were sensitive to ciprofloxacin and tetracycline.

Major finding of the study is that more than 50% of the MRSA isolates showed resistance to commonly used antibiotics for the treatment of staphylococcal infections in our hospital. Our findings of antibiotic resistance for MRSA and MSSA correlate with the findings of few other studies.[10],[18],[19] Though knowledge and attitude of HCWs toward MRSA were better, the practices followed were not up to the mark.

  Conclusions Top

MRSA nasal colonization in our hospital is particularly high among the nursing staff. To control the spread of MRSA in the hospital, screening of HCWs could be adopted as a protocol. Also, regular awareness programmes regarding hand hygiene, contact precautions, and strict enforcement of infection control practices might help to address the issue of MRSA.

Authors’ contributions

SSM—concept, design, data acquisition, literature search, manuscript preparation

AA—experimental studies, data acquisition

AGS—manuscript editing and manuscript review

MM—statistical analysis

Financial support and sponsorship

Source(s) of support in the form of grants – BLDE Deemed to be University

Conflicts of interest

There are no conflicts of interest.

  References Top

Tarai B, Das P, Kumar D Recurrent challenges for clinicians: Emergence of methicillin-resistant Staphylococcus aureus, vancomycin resistance, and current treatment options. J Lab Physicians 2013;5:71-8.  Back to cited text no. 1
Siddiqui AH, Koirala J Methicillin resistant Staphylococcus aureus (MRSA) [Updated December 22, 2019]. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482221/.  Back to cited text no. 2
Lee AS, de Lencastre H, Garau J, Kluytmans J, Malhotra-Kumar S, Peschel A, et al. Methicillin-resistant Staphylococcus aureus. Nat Rev Dis Primers 2018;4:18033.  Back to cited text no. 3
Stenehjem E, Rimland D MRSA nasal colonization burden and risk of MRSA infection. Am J Infect Control 2013;41:405-10.  Back to cited text no. 4
Hanssen AM, Kindlund B, Stenklev NC, Furberg AS, Fismen S, Olsen RS, et al. Localization of Staphylococcus aureus in tissue from the nasal vestibule in healthy carriers. BMC Microbiol 2017;17:89.  Back to cited text no. 5
Seibert DJ, Speroni KG, Oh KM, DeVoe MC, Jacobsen KH Knowledge, perceptions, and practices of methicillin-resistant Staphylococcus aureus transmission prevention among health care workers in acute-care settings. Am J Infect Control 2014;42:254-9.  Back to cited text no. 6
Malini J, Harle SA, Padmavathy M, Umapathy BL, Navaneeth BV, Keerthi Mannan J, et al. Methicillin-resistant Staphylococcus aureus carriage among the health care workers in a tertiary care hospital. J Clin Diagn Res2012;6:791-793.  Back to cited text no. 7
Hawkins G, Stewart S, Blatchford O, Reilly J Should healthcare workers be screened routinely for methicillin-resistant Staphylococcus aureus? A review of the evidence. J Hosp Infect 2011;77:285-9.  Back to cited text no. 8
Ma XX, Sun DD, Wang S, Wang ML, Li M, Shang H, et al. Nasal carriage of methicillin-resistant Staphylococcus aureus among preclinical medical students: Epidemiologic and molecular characteristics of methicillin-resistant S. aureus clones. Diagn Microbiol Infect Dis 2011;70:22-30.  Back to cited text no. 9
Khanal R, Sah P, Lamichhane P, Lamsal A, Upadhaya S, Pahwa VK Nasal carriage of methicillin resistant Staphylococcus aureus among health care workers at a tertiary care hospital in western Nepal. Antimicrob Resist Infect Control 2015;4:39.  Back to cited text no. 10
Abimana JB, Kato CD, Bazira J Methicillin-resistant Staphylococcus aureus nasal colonization among healthcare workers at Kampala International University Teaching Hospital, Southwestern Uganda. Can J Infect Dis Med Microbiol 2019;2019:4157869.  Back to cited text no. 11
Cheesbrough M District Laboratory Practice in Tropical Countries. Vol. 2. 2nd ed. New York: Cambridge University Press; 2006.  Back to cited text no. 12
Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing. Twenty‑Second Informational Supplement. Wayne, PA, USA: Clinical and Laboratory Standards Institute; 2012. p. M100‑S22.  Back to cited text no. 13
Lu SY, Chang FY, Cheng CC, Lee KD, Huang YC Methicillin-resistant Staphylococcus aureus nasal colonization among adult patients visiting emergency department in a medical center in Taiwan. PLoS One 2011;6:e18620.  Back to cited text no. 14
Honda H, Krauss MJ, Coopersmith CM, Kollef MH, Richmond AM, Fraser VJ, et al. Staphylococcus aureus nasal colonization and subsequent infection in intensive care unit patients: Does methicillin resistance matter? Infect Control Hosp Epidemiol 2010;31:584-91.  Back to cited text no. 15
Gurieva T, Bootsma MC, Bonten MJ Cost and effects of different admission screening strategies to control the spread of methicillin-resistant Staphylococcus aureus. Plos Comput Biol 2013;9:e1002874.  Back to cited text no. 16
Bhagavatula S, Ekyshwarya S, Setty CR Nasal carriage of methicillin resistant Staphylococcus aureus (MRSA) among health care workers in a tertiary care hospital. IOSR-JDMS 2018;7:44-8.  Back to cited text no. 17
Agarwal L, Singh AK, Sengupta C, Agarwal A Nasal carriage of methicillin- and mupirocin-resistant S. aureus among health care workers in a tertiary care hospital. J Res Pharm Pract 2015;4:182-6.  Back to cited text no. 18
[PUBMED]  [Full text]  
Radhakrishna M, D’Souza M, Kotigadde S, Saralaya KV, Kotian MS Prevalence of methicillin resistant Staphylococcus aureus carriage amongst health care workers of critical care units in Kasturba Medical College Hospital, Mangalore, India. J Clin Diagn Res 2013;7:2697-700.  Back to cited text no. 19
Tiewsoh JBA, Dias M Screening of methicillin-resistant Staphylococcus aureus in healthcare workers and students and its susceptibility to mupirocin in a tertiary care teaching hospital in South India. J Lab Physicians 2017;9:239-42.  Back to cited text no. 20
Singh S, Malhotra R, Grover P, Bansal R, Galhotra S, Kaur R, et al. Antimicrobial resistance profile of methicillin-resistant Staphylococcus aureus colonizing the anterior nares of health-care workers and outpatients attending the remotely located tertiary care hospital of north India. J Lab Physicians 2017;9: 317-21.  Back to cited text no. 21
[PUBMED]  [Full text]  
Sadek SE, Abdelrahman AT, Abdelkader NG, Abdelrahim M Clinical and microbiological effect of linezolid on methicillin-resistant Staphylococcus aureus (MRSA) colonization in healthcare workers in Egypt. Middle-East J Sci Res 2013;15:1440-9.  Back to cited text no. 22
Yoo YJ, Kwak EJ, Jeong KM, Baek SH, Baek YS Knowledge, attitudes and practices regarding methicillin-resistant Staphylococcus aureus (MRSA) infection control and nasal MRSA carriage rate among dental health-care professionals. Int Dent J 2018;68:359-66.  Back to cited text no. 23


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
   Materials and Me...
   Article Figures
   Article Tables

 Article Access Statistics
    PDF Downloaded28    
    Comments [Add]    

Recommend this journal