Description of Methicillin-resistant Staphylococcus aureus Infection at

Arifin Achmad General Hospital, Riau Province from 2015-2019

Dewi Anggraini

1,2

, Dewi Santosaningsih

, Kuntaman

, Muhammad Ihsan

and Syifa Farhani Ridha

Department of Microbiology, Faculty of Medicine, Universitas Riau, Pekanbaru, Indonesia

Doctoral Program, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia

Department of Clinical Microbiology,

Faculty of Medicine, Universitas Brawijaya/Dr. Saiful Anwar Hospital, Indonesia

Department of Clinical Microbiology,

Faculty of Medicine, Universitas Airlangga/Dr.Soetomo Hospital, Indonesia

Department of Surgery,

Faculty of Medicine, Universitas Riau, Pekanbaru, Indonesia

Medical Education Program, Faculty of Medicine, Universitas Riau, Pekanbaru, Indonesia

Keywords: MRSA, Hospital, Staphylococcus aureus

Abstract: Methicillin-Resistant Staphylococcus aureus (MRSA) is one of the most important pathogen causing hospital-

associated infections worldwide. This study aimed to determine the prevalence of MRSA infections at Arifin

Achmad General Hospital, Riau Province, Indonesia. This study was a retrospective study using MRSA

infected patients' medical record data in Arifin Achmad General Hospital during 2015-2019. There were 600

isolates of Staphylococcus aureus enrolled in this study. Of this, the prevalence of MRSA ranged between

23.8% and 42.7%. The highest prevalence of MRSA infections was found in the surgical ward (44.8%). The

MRSA isolates were mostly found among pus specimens (66.5%) and obtained from patients with skin, and

soft tissue infections.. vancomycin, tigecycline, and linezolid were highly susceptible to the MRSA isolates.

The MRSA infections were frequently found among male patients (51.2%), 46-55 years old (27.9%), length

of stay 7-13 days (26.7%), onset more than two days (54.7%), no history of surgery (51.2%), and not referred

patients (81.4%). In conclusion, the prevalence of MRSA at Arifin Achmad General Hospital was relatively

high. A further hospital surveillance system should be set up to monitor this.

1 INTRODUCTION

Staphylococcus aureus (S. aureus) is a skin flora in

humans. However, it is an important pathogen,

particularly among susceptible hosts (Erikawati et al.,

2016). These bacteria are the most common cause of

pyogenic infections of the skin and soft tissues

(Kliegman et al., 2016). Methicillin-resistant

Staphylococcus aureus (MRSA) is a specific strain of

S. aureus with resistance to almost all β-lactam

antibiotics such as penicillin, methicillin, and

cephalosporin (Gayatri et al., 2015). MRSA is

resistant to β-lactam due to a change of penicillin-

binding protein (PBP2) to PBP2a, which has a low

https://orcid.org/0000-0001-7507-2445

https://orcid.org/0000-0002-0156-6976

https://orcid.org/0000-0003-4897-8879

https://orcid.org/0000-0003-2883-3541

https://orcid.org/0000-0003-3196-3865

affinity for β-lactam (Conly, 2018). The emergence

of MRSA has become a significant problem because

of the limited antibiotic therapy of MRSA infections.

Since MRSA was first discovered in the 1960s

(Wong et al., 2018), the prevalence of MRSA

infections has increased (Negara, 2016).

Little is

known regarding the epidemiology of MRSA

infections in Indonesia, especially in Riau. MRSA

infection features must be investigated continuously

because of changes in the prevalence and patterns of

antibiotic resistance. This study aimed to determine

the epidemiology of MRSA infections at Arifin

Achmad General Hospital, Riau Province, during

2015-2019.

184

Anggraini, D., Santosaningsih, D., Kuntaman, ., Ihsan, M. and Ridha, S.

Description of Methicillin-resistant Staphylococcus aureus Infection at Ariﬁn Achmad General Hospital, Riau Province from 2015-2019.

DOI: 10.5220/0010489801840189

In Proceedings of the 1st Jenderal Soedirman International Medical Conference in conjunction with the 5th Annual Scientiﬁc Meeting (Temilnas) Consortium of Biomedical Science Indonesia

(JIMC 2020), pages 184-189

ISBN: 978-989-758-499-2

2 MATERIALS AND METHODS

A retrospective study was conducted at Arifin

Achmad General Hospital, Riau Province, Indonesia,

during April-June 2020. The MRSA isolates were

obtained by clinically indicated culture in the

Microbiology Laboratory of Arifin Achmad General

Hospital from 2015-2019. The Vitek 2 system carried

out confirmation of identification and antibiotic

susceptibility test. Antibiotics tested included

clindamycin, erythromycin, tigecycline, vancomycin,

linezolid, amoxicillin, amoxicillin/clavulanic acid,

piperacillin/tazobactam, ampicillin/sulbactam,

cefazolin, ceftriaxone, ceftazidime, cefepime,

cefoxitin, ertapenem, meropenem, gentamicin,

ciprofloxacin, trimethoprim/sulfamethoxazole, and

rifampicin.

The patient's clinical data were collected from the

medical record data and analyzed using the SPSS

statistical software version 23.

3 RESULTS

3.1 Prevalence of MRSA Infections

Overall, 600 samples of S. aureus were collected, 197

of MRSA (32.8%). The highest MRSA prevalence

was found in 2019 (42.7%), while the lowest was

2016 (23.8%). The highest prevalence was in the

surgical ward (43.8%).

Table 1: MRSA prevalence at Arifin Achmad General

Hospital, Riau Province 2015-2019.

Variable

MRSA

(n=197)

S. aureus

(n=600)

Period 2015 16 (30,2%) 53

2016 24 (23,8%) 101

2017 45 (32,8%) 137

2018 48 (30,2%) 159

2019 64 (42,7%) 150

Total 197 (32,8%) 600

Ward Intensive Care Uni

21 (30,0%) 70

Neonatal Care Uni

2 (11,1%) 18

Surgical Ward 57 (43,8%) 130

Medical Ward 62 (32,3%) 192

Mix Ward 18 (24,3%) 74

Fetomaternal Ward 3 (30,0%) 10

Outpatient clinic 31 (33,3%) 93

Emergency Uni

3 (23,1%) 13

3.2 Distribution of MRSA based on

Source of Specimen

MRSA was mostly found in pus and sputum (66.6%

and 19.3%, respectively). Only three MRSA isolates

were found in tissue and urine each (1.5%).

Table 2: Distribution of MRSA isolates based on the type

of specimens at Arifin Achmad General Hospital, Riau

Province 2015-2019.

Specimen Frequency

(N=197)

Percentage (%)

Pus 131 66,5

Tissue 3 1,5

Bloo

13 6,6

Sputum 38 19,3

Urine 3 1,5

Othe

9 4,6

3.3 Diagnosis and Characteristics

based on MRSA Patients

Based on 197 culture results identified as MRSA,

there were 86 medical records that could be accessed

in this study. MRSA cases were mostly found in

patients with skin and soft tissue disorders (59%),

followed by lung disorders (16%). The frequency of

MRSA was higher in men (51.2%) than in women

(48.8%). MRSA was mostly found in patients with

46-55 years (27.9%), and the least was 12-16 years

old (1.2%). MRSA infections were common in

patients with a treatment duration of 7-13 days

(26.7%) with an onset of more than 2 days (54.7%).

MRSA patients mostly did not have a history of

surgery (51.2%) and were not transferred from other

healthcare facilities (81.4%).

3.4 Antimicrobial Sensitivity Pattern

The antibiotics that have the highest sensitivity were

tigecycline, vancomycin, and linezolid (100%). All

isolates were resistant to amoxicillin,

amoxicillin/clavulanic acid, piperacillin/tazobactam,

ampicillin/sulbactam, cefazolin, ceftriaxone,

ceftazidime, cefepime, cefoxitin, ertapenem, and

meropenem.

Description of Methicillin-resistant Staphylococcus aureus Infection at Ariﬁn Achmad General Hospital, Riau Province from 2015-2019

185

Table 3: Diagnosis and Characteristics of MRSA patients at Arifin Achmad General Hospital, Riau province in the period

2015-2019.

Varia

le Frequency (N= 86) Percentage (%)

Diagnosis Skin and Sof

-Tissue 51 59,3

Heart and bloodstream 3 3,5

Lungs 14 16,3

Bone and join

11 12,8

Nervous system 3 3,5

Other 4 4,7

Gende

Male 44 51,2

Female 42 48,8

Age 0

–

5 8 9,3

–

11 3 3,5

–

16 1 1,2

–

25 8 9,3

–

35 9 10,5

–

45 17 19,8

–

55 24 27,9

–

65 12 14

> 65 4 4,7

Mean + SD 39,7 + 19

Length of Stay <1 day 17 19,8

–

6 days 15 17,4

–

13 days 23 26,7

14 -20 days 7 8,1

–

27 days 8 9,3

–

34 days 5 5,8

–

41 days 1 1,2

–

48 days 2 2,3

–

55 days 2 2,3

–

62 days 1 1,2

>62 days 5 5,8

Mean + SD 17,7 + 26,7

Onse

–

2 days 39 45,3

>2 days 47 54,7

Mean+ SD 7,8 + 14,9

History of Surgery 42 48,8

Transferred from another hospital 16 18,6

4 DISCUSSION

The mean prevalence of MRSA at Arifin Achmad

General Hospital from 2015-2019 was 32.8%.

Research conducted at Dr. Saiful General Hospital

Anwar obtained an MRSA prevalence of 38.2%

(Erikawati et al., 2016). The study conducted at 427

centers in 45 countries found an MRSA prevalence

of 40.3% (Diekema et al., 2019). Arifin Achmad

General Hospital has made efforts to reduce MRSA

infections, including handwashing education,

isolating patients, using personal protective

equipment, disinfection of equipment and rooms, and

using antibiotics according to culture results. The

variation in prevalence found at Arifin Achmad

General Hospital is probably due to the absence of

screening in the patient, so it is difficult to identify

whether the infection source came from the Arifin

Achmad General Hospital or from outside the

hospital.

The highest MRSA prevalence in this study was

found in the surgical ward (44.8%). A study

conducted at the Port-of-Spain General Hospital

showed that MRSA's prevalence in the surgical ward

was 39.4% (Ramdass et al., 2018). Research

conducted at Dr. Soetomo Hospital, Surabaya, in

2018 found that the highest prevalence of MRSA

carriers was found in surgical wards (Kuntaman et

al., 2016). MRSA contamination in surgical wards is

more significant than in medical wards (Nkuwi et al.,

2018), which results in a greater risk of infection.

MRSA infections are common in skin and soft

tissue disorders. S. aureus is a typical skin floral that

can cause a skin infection when the skin barrier is

damaged, which can produce pus (Erikawati et al.,

2016).

This also causes pus to be the most common

specimens of isolated MRSA, as the results of

JIMC 2020 - 1’s t Jenderal Soedirman International Medical Conference (JIMC) in conjunction with the Annual Scientiﬁc Meeting

(Temilnas) Consortium of Biomedical Science Indonesia (KIBI )

186

Figure 1: MRSA antimicrobial sensitivity patterns in the Arifin Achmad General Hospital, Riau province in the period of

2015-2019.

previous studies (Erikawati et al., 2016; Garoy et al.,

2019).

This study found that MRSA infections at Arifin

Achmad General Hospital were more common in

men. This study's results are the same as in previous

studies (Garoy et al., 2019; Nuryah et al., 2019; Sit et

al., 2017). Gender is not associated with MRSA

infection (Garoy et al., 2019),

but men are more

susceptible due to less adherence to hygiene behavior

than women (Humphrey et al., 2015).

The 46-55 year age group is the most common

group infected by MRSA. This result is because this

age group is at a productive age, where they do much

physical activity. There is a greater risk of injury,

making it easier for bacteria to enter the body (Nuryah

et al., 2019).

Most patients are hospitalized from 7-13 days.

Patients with a treatment duration of 7-13 days had a

2.7 times greater risk of becoming infected with

MRSA than those with 1-6 days of stay, and this risk

will increase along with the increasing length of stay

(Loke et al., 2015).

Most MRSA infections were found with the onset

of more than 2 days. This result is consistent with

Diekema's research in 2019 in which MRSA

infections were more common in nosocomial isolates

(Diekema et al., 2019).

In this study, it was found that more patients with

MRSA infection at Arifin Achmad General Hospital

were found without a history of surgery. Previous

studies have found MRSA is common in patients with

a history of surgery (Abidin et al., 2020; Alrabiah et

al., 2016) and concluded that a history of surgery is a

risk factor for MRSA infection (Graffunder and

Venezia, 2002).

MRSA infection occurring soon after

surgery is usually rare. MRSA infection after surgery

can usually be surgical site infection (SSI) or

bacteremia. Emergency surgery, contaminated

surgery, decreased immunity, and the presence of

comorbid in a patient can increase the risk of MRSA

infection (Gurusamy et al., 2013).

In this study, MRSA infections at Arifin Achmad

General Hospital were less common in referral

patients. An increase in MRSA infections in one

hospital can accelerate the transmission among

hospitals. In other words, it increases infection in

other hospitals, depending on the relationship among

the hospitals (Lee et al., 2011).

The antibiotics with the best sensitivity for MRSA

at Arifin Achmad General Hospital are tigecycline,

vancomycin, and linezolid. These antibiotics are an

option in empiric therapy for MRSA (VanEperen and

Segreti, 2016).

0,00,00,00,00,0000000

30,2

100

74,6

62,2

64,3

100

31,3

71,6

0,0

20,0

40,0

60,0

80,0

100,0

120,0

Amoxicillin

Amoxicillin/ClavulanicAcid

Ampicillin/Sulbactam

Piperacillin/Tazobactam

Cefazolin

Ceftriaxone

Ceftazidime

Cefepime

Cefoxitin

Ertapenem

Meropenem

Gentamicin

Ciprofloxacin

Tigecycline

Trimethoprim/Sulfamethoxazole

Clindamycin

Erythromycin

Vancomycin

Linezolid

Levofloxacin

Rifampicin

Description of Methicillin-resistant Staphylococcus aureus Infection at Ariﬁn Achmad General Hospital, Riau Province from 2015-2019

187

5 CONCLUSION

The prevalence of MRSA at Arifin Achmad General

Hospital from 2015-2019 was quite high and varied

due to the difficulty of detecting the source of

infection. The highest prevalence of MRSA was

found in the surgical ward, with the most specimen

source was pus. MRSA infection was mostly found in

male patients aged 46-55 years, with an onset of more

than 2 days, have no history of surgery, and were not

referred from other hospitals. The antibiotics with the

best sensitivity for MRSA at Arifin Achmad General

Hospital are tigecycline, vancomycin, and linezolid,

which are recommendations for MRSA empirical

therapy.

6 ETHICAL STATEMENT

Ethical approval was obtained from the Ethics Unit

for Medical and Health Research Ethics, Faculty of

Medicine, University of Riau Number:

B/021/UN.19.5.1.1.8/UEPKK/2020.

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