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Year : 2013  |  Volume : 2  |  Issue : 1  |  Page : 14-17

Nasal methicillin-resistant Staphylococcus aureus colonization in HIV-infected patients from eastern India

Department of Microbiology, R.G. Kar Medical College, Kolkata, India

Date of Web Publication29-May-2013

Correspondence Address:
Simit Kumar
Department of Microbiology, R.G. Kar Medical College and Hospital, Kolkata
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-0521.112625

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Background: Human immunodeficiency virus (HIV)-infected patients are now recognized as one of the higher risk groups for increased rates of both methicillin-resistant Staphylococcus aureus (MRSA) colonization and infections over the past decade. Staphylococcus aureus are known to colonize the anterior nares of HIV-infected patients with greater frequency than that of the general population, leading authors to postulate that this higher colonization burden might translate into a higher incidence of infections. Settings and Design: The study was a prospective study, including HIV-infected patients. Exclusion criteria: Patients having diabetes or any other immunodeficient conditions besides HIV. Materials and Methods: One hundred and forty two non-duplicate patients with HIV infection, attending the anti-retroviral therapy (ART) center at a tertiary care hospital were studied for nasal carriage of MRSA and associated factors affecting nasal colonization. Nasal swabs were used for isolation of S. aureus. MRSA were detected by using cefoxitin (30 μg) disc as per the Clinical Laboratory Standards Institute (CLSI) guidelines. Careful examination for dermatoses was carried out. Statistical Analysis: Descriptive statistics and testing of hypothesis were used for the analysis using SPSS 16 software. Results and Conclusions: Seventy two (50.70%) of the 142 patients were colonized with S. aureus in the anterior nares. Significant number of S. aureus carriers were in the 31-40 year age group. Methicillin resistance was found in 26 (36.11%) isolates. Cotrimoxazole prophylaxis was found to be a risk factor for MRSA colonization (P < 0.0001). Decreased CD4 counts was found to be a significant risk factor for MRSA colonization (P < 0.0001).

Keywords: Human immunodeficiency virus, methicillin-resistant Staphylococcus aureus, muiprocin resistance, nasal colonization

How to cite this article:
Kumar S, Bandopadhyay M, Banerjee P, Laskar S. Nasal methicillin-resistant Staphylococcus aureus colonization in HIV-infected patients from eastern India. Saudi J Health Sci 2013;2:14-7

How to cite this URL:
Kumar S, Bandopadhyay M, Banerjee P, Laskar S. Nasal methicillin-resistant Staphylococcus aureus colonization in HIV-infected patients from eastern India. Saudi J Health Sci [serial online] 2013 [cited 2022 Aug 19];2:14-7. Available from: https://www.saudijhealthsci.org/text.asp?2013/2/1/14/112625

  Introduction Top

The relationship between colonization with Staphylococcus aureus and human immunodeficiency virus (HIV) infection is of particular interest due to the morbidity and mortality associated with staphylococcal infections in these patients. HIV has been considered a known risk factor for colonization with S. aureus.[1],[2] Results of a previous study have shown that 31% of bacteremias in HIV infections are caused by S. aureus. [3] Recent antibiotic use, CD4 T-cell count <200/mm 3, presence of central venous catheter, underlying dermatologic disease, broad spectrum antibiotic treatment and duration of hospital stay are considered to be the risk factors for methicillin-resistant S. aureus (MRSA) colonization in HIV-infected patients. [4],[5] Varying prevalence of nasal carriage of S. aureus and MRSA among HIV-positive outpatients have been reported. [6],[7],[8] To the best of our knowledge, there are no reports on the carriage rates of S. aureus in HIV patients from this part of the country. There is also a lack of knowledge on the factors predisposing to nasal carriage of MRSA in HIV-positive patients. In a study by Nguyen et al., [6] 34% were nasal carriers and carriage was significantly more common in patients with dermatologic conditions and those not receiving cotrimoxazole prophylaxis. In a study among drug users, 24% patients had positive S. aureus nasal cultures. [4] MRSA carriage rates were more frequent in HIV-positive individuals (14%) than in non-infected individuals (3%). A previous study in Taiwan showed that 30% were colonized by S. aureus, 24% being methicillin-sensitive S. aureus (MSSA) and 6% being MRSA. The objectives of the present study were to determine the rate of nasal carriage of S. aureus in HIV-infected persons with special reference to MRSA and to determine the factors affecting MRSA colonization.

  Materials and Methods Top

One hundred and forty two non-duplicate patients with HIV infection, attending the anti-retroviral therapy (ART) center at a tertiary care hospital from February 2011 to April 2011 were prospectively enrolled for the study after obtaining informed consent. Patients having diabetes, and other conditions leading to immunodeficiency were excluded from the study. The records of the patients were carefully scrutinized and details regarding duration of HIV infection from time of diagnosis, ART, steroid intake, number of hospital admissions, duration of admission, number of hospital visits, invasive procedures carried out in the recent past, most recent CD4 T cell count in the records, details of previous opportunistic infections and current medications, with special reference to antitubercular medications were noted. A careful examination for dermatoses was performed.

Sterile swabs were swirled in both the anterior nares and transported immediately to the laboratory for processing. The specimens were inoculated on blood agar and MacConkey's agar and incubated at 37°C for 24 h. The staphylococci were identified by standard laboratory methods. [9] Antimicrobial susceptibility was performed using the modified Kirby-Bauer disk diffusion method using S. aureus ATCC 25923 as controls. Methicillin resistance in the strains was determined by using susceptibility to cefoxitin (30 μg) discs test on Mueller Hinton agar as per CLSI guidelines. [10] The strains showing a zone diameter ≤21 mm were considered to have methicillin resistance.

Statistical analysis of the risk factor association with MRSA colonization was calculated using the Chi-square test (SPSS software).

  Results Top

Of the 142 HIV-infected persons, 72 (50.70%) were colonized with S. aureus, 11 with S. epidermidis and two with Diphtheroids. The antibiotic susceptibility pattern of S. aureus is presented in [Table 1].
Table 1: Antibiotic susceptibility pattern of Staphylococcus aureus colonizers in anterior nares of HIV patients

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Of the 142 patients, 62 (43.46%) were in the age group of 30-39 years. Methicillin resistance was found in 26 (36.11%) isolates. The rate of methicillin resistance did not show any correlation with the age of the subject. Among these 142 patients, 64 were males, 77 were females and one patient was transgender. The duration of HIV infection after laboratory diagnosis ranged from less than a year in 37 cases to more than 5 years. The S. aureus carriage rate and the rate of methicillin resistance showed no relation to the duration of the disease. The number of hospital visits did not show any relationship with staphylococcal carriage or methicillin resistance. None of the invasive procedures independently or as a group were found to have a significant association with either S. aureus carriage or methicillin resistance (P < 0.105).

The risk of MRSA colonization was found to be significantly associated with decreasing CD4 counts (P < 0.0001). The CD4 T cell counts among the subjects ranged between 14 and 642/mm 3 . MRSA carriage rates were higher (81.15%) in those patients with CD4 T cell counts <200/mm 3 . No MRSA was found in patients with CD4 T cell counts more than 400/mm 3 .

Of the 142 cases studied, 75 (52.86%) had a history of suffering from tuberculosis. There was no significant association of MRSA colonization with history of tuberculosis (P < 0.156). Among current medications, 31 (51.67%) were on antitubercular drugs. Current antitubercular medication was not found to have statistically significant association with MRSA colonization (P < 0.470).

Clindamycin resistance was observed in 10 (13.89%), of which 4 cases showed inducible clindamycin resistance. Eighty-three (58.45%) patients were on antiretroviral treatment and 65 (45.77%) on cotrimoxazole. Of the 65 patients who received cotrimoxazole, 59 (90.77%) were colonized with S. aureus and this relationship was significant (P < 0.001). Among the dermatological manifestations present during examination, candidiasis was the most common, followed by dermatophytoses but these had no significant association with MRSA colonization.

  Discussion Top

In the present study, among the few studies from India, the majority of the patients were in the age group of 31-40 years, but there was no increased colonization observed in case of males as observed by Chacko et al. [11] The overall MRSA carriage rate of 18.31% in the present study is consistent with the study by Miller et al. (14%) and Chacko et al.[11] Different studies have shown MRSA colonization rates from 0 to 17% for HIV outdoor patients. The study by Szumowski et al. suggests an association between MRSA colonization and skin and soft tissue infection. [12] Pulsed-field gel electrophoresis (PFGE) profiles for infecting and colonizing strains in a recent study showed identical macrorestriction profiles, emphasizing the role of MRSA colonization with infection. Furthermore, colonization with S. aureus has been identified as an independent risk factor for S. aureus infections in HIV-positive patients. [13]

A few of the isolated MRSA strains showed good susceptibility to different antibiotics, despite these strains being found to be methicillin-resistant. These MRSA strains need to be studied further to determine if some of them are actually community-acquired MRSA (CA-MRSA) strains or not, as these CA-MRSA strains are known to cause severe soft tissue infections and necrotizing pneumonia, which could lead to high morbidity and mortality in this immunodeficient group of patients. Community-onset necrotizing pneumonia due to CA-MRSA is an emerging clinical entity, especially following a viral infection, with substantial morbidity and mortality. [14] The findings by Hidron et al. signifies the importance that merely the history of health care contact could not be considered a reliable way of differentiating between the CAMRSA and hospital-acquired MRSA (HA-MRSA) types. [15] Prospective studies could be undertaken to determine whether persons colonized with CA-MRSA strains could have an increased risk of developing infections, compared with persons colonized with HA-MRSA strains. A limitation of this study was that, colonization at the time of infection was not assessed, so the absence of a temporal association could not be ascertained.

The duration of HIV infection after laboratory diagnosis ranged from less than a year to more than 5 years, but the duration of HIV infection did not have any impact on the colonization rates. Among the dermatoses present, candidiasis was the commonest. The patients on ART also did not show an increased association with MRSA colonization. Administration of multiple drugs modifying the nasal flora could be a factor contributing to colonization of MRSA in this group. There was no significant association noted between anti-tubercular medications and the development of MRSA colonization. The relationship between cotrimoxazole usage and nasal carriage was found to be significant in this study, as was found by Chacko et al.[11] This finding is in contrast to the study by Cenizal et al. who found cotrimoxazole prophylaxis to be protective for MRSA colonization.[16]

The study found a significant correlation of MRSA colonization with decreasing CD4 counts.

Based on the findings in this study, strategies could be developed to reduce the risk of colonization or infection with S. aureus in HIV patients, with special reference to HIV patients with low CD4 counts, who have both the risk factors of low CD4 counts and cotrimoxazole prophylaxis for colonization with MRSA strains. Further studies could be undertaken to demonstrate whether decolonization with mupirocin in these group of HIV-infected patients could bring about a decrease in the morbidity and mortality associated with MRSA bacteremia and other severe infections produced by MRSA in these group of patients.

  References Top

1.Mathews WC, Caperna JC, Barber RE, Torriani FJ, Miller LG, May S, et al. Incidence of and risk factors for clinically significant methicillin-resistant Staphylococcus aureus infection in a cohort of HIV-infected adults. J Acquir Immune Defic Syndr 2005;40:155-60.  Back to cited text no. 1
2.Sissolak D, Geusau A, Heinze G, Witte W, Rotter ML. Risk factors for nasal carriage of Staphylococcus aureus in infectious disease patients, including patients infected with HIV, and molecular typing of colonized strains. Eur J Clin Microbiol Infect Dis 2002;21:88-96.  Back to cited text no. 2
3.Tumbarello M, de Gaetano Donati K, Tacconelli E, Citton R, Spanu T, Leone F, et al. Risk factors and predictors of Methicillin Resistant Staphylococcus aureus (MRSA) bacteremia in HIV infected patients. J Antimicrob Chemother 2002;50:375-82.  Back to cited text no. 3
4.Miller M, Cespedes C, Vavagiakis P, Klein RS, Lowry FD. Staphylococcus aureus colonization in a community sample of HIV infected and HIV uninfected drug users. Eur J Clin Microbiol Infect Dis 2003;22:463-9.  Back to cited text no. 4
5.Onorato M, Borucki MJ, Baillargeon G, Paar DP, Freeman DH, Cole CP, et al. Risk factors for colonization or infection due to methicillin resistant Staphylococcus aureus in HIV positive patients: A retrospective case control study. Infect Control Hosp Epidemiol 1999;20:26-30.  Back to cited text no. 5
6.Burkey MD, Wilson LE, Moore RD, Lucas GM, Francis J, Gebo KA. The incidence of and risk factors for MRSA bacteraemia in an HIVinfected cohort in the HAART era. HIV Med 2008;9:858-62.  Back to cited text no. 6
7.McDonald LC, Lauderdale TL, Lo HJ, Tsai JJ, Hung CC. Colonization of HIV infected outpatients in Taiwan with methicillin resistant and methicillin susceptible Staphylococcus aureus Int J STD AIDS 2003;14:473-7.  Back to cited text no. 7
8.Villacian JS, Barkham T, Earnest A, Paton NI. Prevalence of and risk factors for nasal colonization with Staphylococcus aureus among human immunodeficiency virus positive outpatients in Singapore. Infect Control Hosp Epidemiol 2004;25:438-40.  Back to cited text no. 8
9.Kloos WE, BannermanTL. Staphylococcus and micrococcus. In: Murray PR, Baron EJ, Pfaller MA, Tenover FC, Yolken RH, editors. Manual of clinical microbiology. Chapter 18. 7 th ed. Washington: ASM Press; 1991. p. 1526.  Back to cited text no. 9
10.Performance standards for Antimicrobial Susceptibility Testing; Seventeenth Informational Supplement. Clinical Laboratory Standards Institute 2010;M100 − S20;29:60-70.  Back to cited text no. 10
11.Chacko J, Kuruvila M, Bhat GK. Factors affecting the nasal carriage of methicillin-resistant Staphylococcus aureus in human immunodeficiency virus-infected patients. Ind J Med Microbiol 2009;27:146-8.  Back to cited text no. 11
12.Szumowski JD, Wener KM, Gold HS, Wong M, Venkataraman L, Runde CA, et al. Methicillin-resistant Staphylococcus aureus colonization, behavioral risk factors, and skin and soft-tissue infection at an ambulatory clinic serving a large population of HIV-infected men who have sex with men. Clin Infect Dis 2009;49:118-21.  Back to cited text no. 12
13.Shet A, Mathema B, Mediavilla JR, Kishii K, Mehandru S, Jeane-Pierre P, et al. Colonization and subsequent skin and soft tissue infection due to methicillin-resistant Staphylococcus aureus in a cohort of otherwise healthy adults infected with HIV type 1. J Infect Dis 2009;200:88-93.  Back to cited text no. 13
14.Hidron AI, Kourbatova EV, Halvosa JS, Terrell BJ, McDougal LK, Tenover FC, et al. Risk factors for colonization with methicillin-resistant Staphylococcus aureus (MRSA) in patients admitted to an urban hospital: Emergence of community associated MRSA nasal carriage. Clin Infect Dis 2005;41:159-66.  Back to cited text no. 14
15.Hidron A, Kempker R, Moanna A, Rimland D. Methicillin-resistant Staphylococcus aureus in HIV-infected patients. Infect Drug Resist 2010;3:73-86.  Back to cited text no. 15
16.Cenizal MJ, Hardy RD, Anderson M, Katz K, Skiest DJ. Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization in HIV-infected ambulatory patients. J Acquir Immune Defic Syndr 2008;48:567-71.  Back to cited text no. 16


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