Prevalence of Mupirocin and Methicillin-Resistant Staphylococcus aureus in Nasal Carriage Among Healthcare Workers in an Intensive Care Unit and Post-decolonization Screening Outcomes at a Tertiary Care Hospital: A Prospective Study

Introduction: Nasal carriage of Staphylococcus species plays an important role in the epidemiology and pathogenesis of both community and healthcare-associated infections. Coinciding the emergence of methicillin-resistant Staphylococcus aureus (MRSA) is a challenge for clinicians to prevent their spread. Mupirocin is a topical antimicrobial agent approved for eradicating nasal carriage of staphylococcal species in adult patients and healthcare workers (HCWs). The increasing prevalence of mupirocin resistance among Staphylococcus aureus and coagulase-negative staphylococci species could be an important threat to the future use of mupirocin against MRSA. Objective: The aim of this study is to determine the prevalence of MRSA from nasal swabs of HCWs in intensive care units and its level of resistance pattern of mupirocin in all isolates of Staphylococcus species by disk diffusion and epsilometer test (E-test) and to determine post decolonization screening. Materials and methods: A total of 67 HCWs (doctors, nursing staff, technicians, and housekeeping staff) in the medical and surgical intensive care units were included in the study. Nasal swabs were collected from the subjects and cultured onto nutrient and blood agar, which were then incubated at 37oC for 18 to 24 hours. Staphylococcus aureus and coagulase-negative Staphylococcus species (CoNS) were identified by standard biochemical techniques. Methicillin resistance was detected by the disk diffusion method using a 30 mu g cefoxitin disk as per the Clinical and Laboratory Standards Institute (CLSI) guidelines, and mupirocin resistance was detected using a 5 mu g mupirocin disk. The resistance strains were further subjected to E-strip testing to determine the level of mupirocin resistance. Results: A total of 72 isolates were grown from the 67 subjects used in this study. Nine strains (12.5%) grew S. aureus, and 52 strains (72.2%) grew CoNS. Methicillin resistance was seen in five isolates (6.9%) of S. aureus and 45 isolates (62.5%) of CoNS. Mupirocin resistance was seen in 11 isolates of methicillin-resistant coagulase-negative Staphylococcus species (MRCoNS), where three isolates (4.1%) showed low-level mupirocin resistance MuL and eight isolates (11.11%) showed high-level mupirocin resistance MuH. None of the isolates of MRSA, methicillin-sensitive Staphylococcus aureus (MSSA), and methicillin-sensitive coagulase-negative Staphylococcus species (MSCoNS) were resistant to mupirocin. Seven out of nine HCWs (77.8%) showed clearance of the organism after decolonization therapy. Conclusion: The prevalence of emerging resistance to mupirocin in MRSA and MRCoNS is of great concern, especially in the nasal carrier state of HCWs. Hence, methicillin and mupirocin resistance in S. aureus and CoNS must be detected in HCWs as a routine protocol, and decolonization measures should be undertaken to prevent healthcare-associated infections.