I’ve written this post in preparation for this week’s Journal Club in partnership with the Healthcare Infection Society themed around their MRSA article collection: “‘MRSA The Enduring Foe”. Having spent a lot of time working on MRSA as part of my PhD and it regularly cropping up as an organism of concern in IPC I was interested to read about the author’s experience, particularly in a less economically developed country. 

Why I chose this article:

• I agree with Jon from his blog last week that MRSA isn’t the foe that it once was, but it is still highly relevant and topical, especially from a global health perspective.
• It’s less frequent to encounter vancomycin-resistant Staphylococcus aureus (VRSA) so I was interested in prevalence of VRSA.
• I was interested to read about the prevalence of MRSA and VRSA in wound infections in a less economically developed country. 
• MRSA has been reported at very high prevalence levels in Africa previously so I was interested if this study was comparable.

Design and methods:

• The study was undertaken at Nekemte Specialized Hospital in Western Ethiopia. 
• Over a six month period swabs were taken from patients presenting with wound infections and 384 wound swabs (from 384 patients) were taken. 
• Wound swabs were plated onto chromogenic agar and antibiotic susceptibility to vancomycin and cefoxitin was assessed using disc diffusion.

Key findings:

• The majority of wounds (63%) were deep wounds and 30.7% of study subjects had wound infections on their legs, followed by 20.6% on their feet and 16% on their hands. 
• S. aureus was isolated from 28.4% of wounds.
• 6.4% of S. aureus isolates were sensitive to all antibiotics tested. 
• The prevalence of MRSA and VRSA among the isolates was 40.4% and 7.3% respectively.
• From a total of 44 MRSA isolates, 72.7% of them showed multidrug resistance.
• MRSA resistance against other antibiotics was also shown in the present for ciprofloxacin (45.5%), cotrimoxazole (40.9%), gentamicin (36.4%), chloramphenicol (34%), clindamycin (25%), erythromycin (15.9%), and vancomycin (9.1%).
• Age, sex, educational level, and marital status were not predictors for the prevalence of MRSA.
• The depth of the wound, history of wound infection, and history of antibiotic use in the last 6 months was significantly associated with the prevalence of MRSA. 

Points for discussion:

• The prevalence of S. aureus wound infection is consistent when compared to similar geographical regions but lower than the pooled national prevalence estimate. The rates of S. aureus wound infection reported in this study seem to be quite comparable with UK data.
• The high prevalence of multidrug resistance in the MRSA isolates is concerning! 
• What is the correct method to detect VRSA? Disc diffusion is not recommended by CDC.  
• What are the treatment options given the resistance to multiple antibiotics observed in the MRSA isolates?  
• What are the best options for decolonisation of S. aureus prior to surgery given the incidence of study participants who developed wound infections following surgery. 
• Some of the prevalence rates of MRSA referenced in this study were truly staggering! 86% of all S.aureus isolate were MRSA in this study from Nigeria! 
• The prevalence of VRSA (7.3%)  was significantly higher than other studies.  
• What do these results mean in the context of the antimicrobial resistance (AMR) pandemic? 

What this means for IPC

• Depth of the wound, the patient’s setting, previous wound infections, and antibiotic treatment in the previous six months were significantly associated with MRSA wound infection so should be considered as risk factors.
• Prevention is better than cure, given the limited treatment options when resistance to multiple antibiotics is reported. 

Finally, I hope you can join us for Journal Club Wednesday (register here).