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Burden of Infection Caused by Methicillin-

Resistant Staphylococcus aureus in Bangladesh:
a Systematic Review

Article December 2013

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Global Advanced Research Journal of Microbiology (ISSN: 2315-5116) Vol. 2(11) pp. 213-223, December, 2013 Special Anniversary
Review Issue
Available online http://garj.org/garjm/index.htm
Copyright 2013 Global Advanced Research Journals

Full Length Research Paper

Burden of Infection Caused by Methicillin-Resistant

Staphylococcus aureus in Bangladesh: a Systematic
Review
M. Abdullah Yusuf1, Professor KM Shahidul Islam2, AKM Shamsuzzaman3, Iftikhar Ahmed4, AFM
Arshedi Sattar5
1
Assistant Professor, Department of Microbiology, National Institute of Neurosciences and Hospital, Dhaka.
2
Professor and Head, Department of Microbiology, Dhaka Medical College, Dhaka
3
Chief Scientific Officer, Department of Virology, Institute of Epidemiology, Disease Control and Research, Dhaka
4
Professor and Head, Department of Microbiology, Enam Medical College, Dhaka
5
Assistant Professor, Department of Pathology, Dhaka Medical College, Dhaka
Accepted 02 December, 2013

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is becoming an important public-health

problem worldwide as well as in Bangladesh. Objective: The aim of this present review is to see the
clinical burden of MRSA in the health care setting and well as the community of Bangladesh.
Methodology: Studies conducted on humans in Bangladesh concerning MRSA colonization or infection
were identified through computerized literature searches using free text searching, Google Scholar,
Banglajol, MEDLINE (National Library of Medicine Bethesda MD) and EMBASE and by reviewing the
references of the retrieved articles. Studies were excluded that did not provide appropriate data on the
prevalence of MRSA. The search was restricted to full articles published from January 2000 to December
2013. Only English language was applied. Result: Of 125 studies identified during systematic review, 19
studies met the criteria for analysis. The level of evidence and freedom from bias of these studies were
generally low. The isolation rate of MRSA among all culture isolates ranged from 4.8-78.7%. All studies
had been reported from the hospital setting and only two studies had been reported from community
settings though the CDC definition was not followed either study. Conclusion: MRSA have created a huge
clinical burden in the hospital settings as well as in the community of Bangladesh.

Keywords: Staphylococcus aureus, Methicillin-resistant Staphylococcus aureus, CA-MRSA, HA-MRSA, antibiotic

therapy, evolution, systematic review

INTRODUCTION

Community and hospital pathogens are emerged after
*Corresponding Authors Email: ayusuf75@yahoo.com;
Tel: +8801817565830
survival in different environments which can interact
successfully with the host (Zetola et al., 2005). Among
those pathogens Staphylococcus aureus is one of the most
successful and adaptable human pathogens (David and
Daum 2010). This remarkable ability of the bacterium to
214. Glo. Adv. Res. J. Microbiol.
acquire antibiotic-resistance mechanisms and
advantageous pathogenic determinants has contributed to
its emergence in both nosocomial and community settings.
It is also the most commonly isolated human bacterial
pathogen and is an important cause of skin and soft-tissue
infections (SSTIs), endovascular infections, pneumonia,
septic arthritis, endocarditis, osteomyelitis, foreign-body
infections, and sepsis (Lowy 1998). Some of the strains of
Staphylococcus aureus have developed drug resistance.
Within them Methicillin-resistant S. aureus (MRSA) isolates
are resistant to all available penicillins and other beta-
lactam antimicrobial drugs (David and Daum 2010).
However these were confined largely to hospitals, other
health care environments, and patients frequently visiting
these facilities. On the contrary, there has been an outburst
of MRSA infections reported for those populations who
have lacking the risk factors for exposure to the health care
system (Adcock et al., 1998; Baggett et al., 2003;
Buckingham et al., 2004; CDCP 1999; CDCP 2003).This
increase has been associated with the recognition of new
MRSA strains which is called community-associated MRSA
(CA-MRSA) strains. It is responsible for a large proportion
of the increased disease burden observed in the last
decade (Charlebois et al., 2002). These CA-MRSA strains
appear to have rapidly disseminated among the general
population in most areas of the United States and affects
patients with and without exposure to the health care
environment (Chen et al., 2006). In this context
Bangladesh is very vulnerable to develop CA-MRSA due to
irrational use of antibiotics. This will create a huge burden
to the physician as well as the patient. In this review it is
tried to summarize the available information regarding
community-acquired MRSA infections as well as the health
care associated MRSA (HA-MRSA), emphasizing the
characteristics that have prompted the emergence of
MRSA in the community setting and the virulence factors
associated with its typical clinical presentations and to find
out the future burden of CA-MRSA and HA-MRSA in this
country.
METHODOLOGY
Studies conducted on humans concerning the role of
antimicrobial therapy as a risk factor for MRSA colonization
or infection were identified through computerized literature
searches using free text searching, Google Scholar,
Banglajol, MEDLINE (National Library of Medicine
Bethesda MD) and EMBASE and by reviewing the
references of the retrieved articles. Index search terms
included the Medical Subjects Heading methicillin-resistant
Staphylococcus aureus AND Bangladesh or community-
associated methicillin-resistant Staphylococcus aureus or
CA-MRSA or Health-care associated methicillin-resistant
Staphylococcus aureus AND Bangladesh or HA-MRSA or
antibiotic resistant AND community-associated methicillin-
resistant Staphylococcus aureus or community-associated
methicillin-resistant Staphylococcus aureus AND
Bangladesh. The search was restricted to full articles
published from January 2000 (publication date of the first
study identified by the research) to December 2013. Only
English language was applied. No attempt was made to
obtain information on unpublished studies. The animal
studies were excluded from these searches. Reviewed
articles were maintained in a master log, and any reason
for exclusion from analysis was documented in the rejected
log.
RESULT
A total number of 2405 article were indentifies containing
the research question of which 125 studies were taken into
consideration; from the 125 articles 19 studies were met
the criteria for systematic review analysis. The level of
evidence and freedom from bias of these studies were
generally low. The isolation rate of MRSA among all culture
isolates ranged from 4.8-78.7%. All studies had been
reported from the hospital setting and only two studies had
been reported from community settings though the CDC
definition was not followed either study.
DISCUSSION
Emergence of MRSA
Global Perspective: Strains of S. aureus resistant to
methicillin were identified in the United Kingdom (Jevons
1961). in 1961. In Europe (Wielders et al., 2002), MRSA
infections were limited largely to hospital outbreaks caused
predominantly by S. aureus phage type 83A. In the United
Kingdom (Griffiths et al., 2002), MRSA was progressively
created a burden as a nosocomial pathogen. In 1965 the
first case of MRSA infection recorded in Australia (Givney
et al., 1996), was detected as nosocomial MRSA infections
occurred in many cities. In Japan (Kayaba et al., 1997),
MRSA isolates have been prevalent in academic hospitals
since the late 1980s and spread into community hospitals
in the 1990s. In contrast, in Norway (Andersen et al.,
2007), Finland (Kerttula et al., 2007), Sweden (Stenhem et
al., 2006), the Netherlands (Skov et al., 2008), and
Denmark (Tiemersma et al., 2004), MRSA infections have
remained rare even in the health care setting, which has
been attributed by many to strict surveillance programs. In
India (Kini et al., 1997; Gowrishankar et al., 2013; Juyal et
al., 2013), there has been a marked increase in the
incidence of MRSA since early 1980s.
Bangladesh Perspective: (Khan et al., 1991), was
reported about MRSA isolates from clinical specimen in
1991 which is the first documented report published in
Bangladesh. However, prior to the mid-1990s, investigation

Figure: Diagram showing the searches of the articles
into the epidemiology of MRSA was limited largely to the
health care setting because it was rare that MRSA strains
would infect otherwise healthy people. However, MRSA
was reported in several times in many studies (Zahan et
al., 2009; Murphy et al., 2013; Dutta et al., 2013), in
Bangladesh where the burden of MRSA was focused.
Classification of MRSA in Literatures
The community-associated MRSA (CA-MRSA) and
hospital acquired-MRSA (HA-MRSA) have been first
classified strains described by CDC; however, these two
strains have some genotypic, epidemiological as well as
clinical differences (David and Daum 2010). An essential
component of epidemiological studies has been to define
the clinical burden of CA-MRSA and HA-MRSA isolates. In
2000, the CDC created a case definition for a CA-MRSA
infection. CA-MRSA is defined as any MRSA infection
diagnosed for an outpatient or within 48 hours of
hospitalization if the patient lacks the health care-
associated MRSA risk factors like hemodialysis, surgery,
residence in a long-term care facility or hospitalization
during the previous year, the presence of an indwelling
catheter or a percutaneous device at the time of culture, or
previous isolation of MRSA from the patient (Dutta et al.,
2013; CDCP 2005).. All other MRSA infections were
considered to be HA-MRSA. This case definition at first
was used to demonstrate that MRSA infections were
occurring among healthy people in the community without
health care exposure (Morrison et al., 2006; Naimi et al.,
Yusuf et al. 215
2003; Fridkin et al., 2005). A simpler, temporal definition is
often used to designate CA-MRSA2. By this criterion, all
infections occurring among outpatients or among inpatients
with an MRSA isolate obtained earlier than 48 hour after
hospitalization would be considered CA-MRSA. Infections
meeting either of these temporal criteria are sometimes
referred to as community-onset MRSA (CO-MRSA)
infections (Fridkin et al., 2005; Lee et al., 2013). Other
criteria used to define CA-MRSA infections relate to
relevant isolate characteristics. CA-MRSA isolates have
been pedigreed by their antimicrobial susceptibility profiles
(David and Daum 2010), their DNA fragment patterns upon
pulsed-field gel electrophoresis (PFGE) (Maslow et al.,
1993; McDougal et al., 2003; Tenover et al., 1995), protein
A (spa) gene typing (Koreen et al., 2004; Stranden et al.,
2003; Strommenger et al., 2007), carriage of PVL genes
(Lina et al., 1999), multilocus sequence typing (MLST)
(Enright and Spratt 1999; Enright et al., 2000), and the type
of SCCmec element carried (IWG-SCC 2009). Definitions
based on one or more of these isolate characteristics have
been used to quantify the MRSA disease burden inside
and outside the health care setting, but each one actually
provides a different perspective (David et al., 2008).
Importantly, none of the genotypic isolate characteristics
are helpful to a clinician caring for an acutely ill patient
because assessing them requires molecular strain testing
that is not routinely or rapidly available. Regarding this
issue, nosocomial colonization with MRSA usually goes
undetected and may lead to infection many months after
hospital discharge even when the patient is in the
community. Then it may be difficult to establish the origin of
216. Glo. Adv. Res. J. Microbiol.
strains causing MRSA infections in the community. This
difficulty differentiating nosocomial MRSA from community-
acquired MRSA has led to confusion regarding the
prevalence of MRSA in the community. Even significant
heterogeneity is found during definition of community-
acquired MRSA (David et al., 2008). A third category of
MRSA infections has been used by CDC investigators as
health care-associated, community-onset MRSA (HACO-
MRSA) infection (David et al., 2008). In this category it
includes cases that would be HA-MRSA infections by
history of health care exposure though these have onset in
the community. This tripartite classification scheme, HA-,
CA-, and HACO-MRSA, still has limitations because a
history of exposure to a health care setting does not
exclude the possibility of MRSA acquisition and infection in
the community (Klevens et al., 2007; Deurenberg et al.,
2006).
HA-MRSA versus CA-MRSA: Importance in
Bangladeshi Literature
The distinctions between CA-MRSA and HA-MRSA
isolates have become increasingly blurred since about
2003 (David and Daum 2010). Defining a case as being
community acquired is usually based on the timing of
isolation of MRSA in relation to the time of hospitalization.
As a result, the vast majority of cases attributed to
community-acquired MRSA are associated with recent
direct or indirect exposure to the health-care setting like
hospitalization, outpatient visit, nursing home admission,
antibiotic exposure, chronic illness, or close contact with
people with these risk factors which are suggesting that
these infections are caused by nosocomial strains that
have been carried into the community. These isolates
circulate in the community especially among adults47. In
addition to that, many reports have demonstrated the
MRSA clones bearing SCCmec type IV especially USA300
(Chen et al., 2009). PFGE types of CA-MRSA now cause
nosocomial MRSA outbreaks and infections among
patients with chronic illnesses in the developed countries
like Taiwan (Gastelum et al., 2005; Maree et al., 2007),
USA5 (Mean et al., 2007; Saunders et al., 2007; Zhanel et
al., 2008). Canada (OBrien et al., 1999; Naas et al.,
2005). Australia (Bogut et al., 2008). France (David et al.,
2006). Poland (Seybold et al., 2006), and UK (Chua et al.,
2008). In USA, it is reported that 34% of nosocomially
transmitted isolates belonged to the USA300 CA-MRSA
genotype (Patel et al., 2007; Patel et al., 2008). A study of
surgical skin site infections from 2004 to 2005 in USA
demonstrated that USA300 was a common nosocomial
pathogen (Klevens et al., 2006), which was first appeared
in this setting in 2004 (Tattevin et al., 2009). The
appearance of CA-MRSA strains in hospitals in the United
States is likely responsible for the decreasing non-beta-
lactam antimicrobial resistance rates noted for MRSA
isolates in ICUs (Chambers 1997). The presence of
USA300 increased among MRSA isolates from 11.3% in
2002 to 64% in 2006 which was reported in USA (Sabath
1982).
Evolution of Methicillin Resistance: Genetic
Perspective
Penicillin resistant S aureus is now widespread and may
be conferred by the production of a beta-lactamase coded
by the blaZ gene (Zetola et al., 2005). Methicillin resistance
results from the production of an altered penicillin binding
protein known as PBP2a and it has decreased affinity for
most beta-lactam antibiotics (Sabath 1982; Ito et al., 2003).
The mecA gene encodes PBP2a and it is carried on a
mobile genetic element known as the staphylococcal
cassette chromosome (SCC) mec (Oliveira and de
Lencastre 2002). Besides the mecA gene itself, the
SCCmec element contains regulatory genes, an insertion
sequence element (IS431mec), and a unique cassette of
recombinase genes (ccr) responsible for the integration
and excision of SCCmec (Oliveira and de Lencastre 2002).
Based on the class of mecA gene complex and the type of
ccr gene complex, at least five types of SCCmec elements
have been identified and are numbered from I to V (Ma et
al., 2002). Another SCCmec typing system has also been
used by multiplex PCR assay to accurately identify types I
IV (Hiramatsu et al., 2002). Type I SCCmec contains the
mecA gene as the sole resistance determinant, whereas
SCCmec types II and III contain multiple determinants for
resistance to non-beta-lactam antibiotics and are
responsible for the multidrug resistance commonly found in
nosocomial MRSA isolates Zetola et al., 2005). However,
most probably due to their larger size, the horizontal
transfer of SCCmec types II and III occurs with less ease
compared with type IV (Daum et al., 2002; Hiramatsu et al.,
2003), and spread of MRSA strains harbouring these
elements mainly occurs as a result of the selective
pressure of antibiotic exposure over time which is known
as vertical spread (Ma et al., 2002). Several subtypes of
type IV SCCmec are now recognized based on the
polymorphism of the region upstream of the ccr genes, a
location known as L-C (Ma et al., 2002; Wisplinghoff et al.,
2003). Like type I, type IV elements lack other resistance
determinants (Luong et al., 2002). Strains of community-
acquired MRSA that have emerged over the past decade
have mostly harboured the SCCmec type IV element
(Luong et al., 2002; Babu et al., 2009), and they are
typically susceptible to multiple antibiotics with non-beta-
lactam susceptibility patterns resembling those of
methicillin-susceptible Staphylococcus aureus (MSSA)
strains prevalent in the community (Zetola et al., 2005).
Therefore, most authorities feel that it is the acquisition of
the SCCmec IV element by MSSA strains in the community
that has given rise to the emerging community-acquired

MRSA strains (Wisplinghoff et al., 2003; Armand-Lefevre et
al., 2005). In addition to intra-species transfer of resistant
determinants, other commensal Staphylococcal species
may act as a reservoir for antibiotic resistance islands
which may be transferred to Staphylococcus aureus
(Zetola et al., 2005). From the 1970s the SCCmec type IV
element was found to be prevalent in isolates of
Staphylococcus epidermidis and rarely in Staphylococcus
aureus isolates even before 1990 (Haque et al., 2011). In
addition to that three other SCCmec elements which
contain genes encoding biosynthetic enzymes for capsular
polysaccharides have been identified in MSSA,
Staphylococcus epidermidis and Staphylococcus hominis
strains (Alam et al., 2011; Hossain et al., 2002). These
elements share most of the essential characteristics of
SCCmec, including regulatory genes and insertion
sequences, but lack the mecA gene (Islam et al., 2008).
Interestingly, sequences found within the L-C region of
SCCmec type IV were found to be virtually identical to
those found in Staphylococcus epidermidis, suggesting
extensive horizontal exchange between staphylococcal
species (Rahman et al., 2002). In Bangladesh the genomic
analysis has been performed of which Hossain et al
(Hossain et al., 2002) was done a gemonic analysis.
Global Burden of MRSA Infection in Bangladeshi
Literatures
Majority studies (Khan et al., 1991; Zahan et al., 2009;
Dutta et al., 2013; Haque et al., 2011; Iqbal et al., 1999),
published in Bangladesh have highlighted about the
burden of MRSA in the hospital settings globally.
However, it is very surprising that no study has mentioned
about the burden of CA-MRSA in the community of
Bangladesh. Once the CDC case definition is used to
define the burden of disease caused by CA-MRSA
isolates, two interesting event can be demonstrated. The
application of the definition to the cases of infection with
MRSA with onset in the community accurately identifies
patients with infections caused by CA-MRSA isolates
(David et al., 2008). However, if one uses the case
definition to identify patients with infection caused by CA-
MRSA isolates, the burden of disease caused by CA-
MRSA isolates will be greatly underestimated (David et al.,
2008), and this analysis yields a reciprocal overestimation
of health care-associated MRSA disease (David and Daum
2010). If the CDC case definition of CA-MRSA were used
in the acute-care setting to aid in the selection of empiric
antibiotic therapy, many people who could be managed
with clindamycin, would be unnecessarily treated with
intravenous antimicrobial drugs because they have an
illness caused by a CA-MRSA isolate and not a multiple
resistant HA-MRSA isolate (Rahman et al., 2002).
Yusuf et al. 217
Clinical Burden of MRSA infection in Bangladesh
Several studies have been done in Bangladesh to see the
burden of MRSA infection with their sensitivity pattern.
(Haque et al., 2011), has reported that the current
prevalence of -lactamase-producing methicillin-resistant
S. aureus (MRSA) in clinical samples is 437% isolates.
This study was carried out in the two private clinics at
Dhaka city. For this reason it doesnt represent the whole
country scenario about the prevalence of MRSA. In
another study (Alam et al., 2011), has investigated the
distribution of the mecA gene in a total of 94 clinical strains
of Staphylococcus aureus which are isolated from patients
admitted in Bangladeshi Medical Hospital. The mecA gene
was detected by PCR in 25.0% of human clinical isolates
of Staphylococcus aureus. This is an interesting findings
comparing with the previous one. In this study author
doesnt mention the number of hospitals from where the
human samples are collected. This gives a Berksonian
bias to the result and thus it doesnt represent the actual
burden of MRSA. (Hossain et al., 2002); has done an
antimicrobial susceptibility testing against Staphylococcus
aureus isolated at a tertiary care hospital outside Dhaka
and found a high rate of MRSA isolates. (Shamsuzzaman
et al., 2007), has identified the pattern of aerobic bacteria
with their antibiotic susceptibility isolated from infected
patients in one of the surgical units at a tertiary care
hospital outside Dhaka and reported that out of 74 clinical
samples, Staphylococcus aureus was found in 8 cases. It
was suggested to be careful regarding selection of
antibiotic regime in surgical cases to minimize incoming
higher magnitude of drug resistance among bacteria in
near future. B (Begum et al., 2011), has reported eight
Staphylococcus aureus isolates from different specimens
and surprisingly has found no MRSA strains. The reason
may be due to small sample size and the study was
performed 14 years back. However, among the all
Staphylococcus aureus two strains are resistant to oxacillin
85
which is very rare. Khan et al has performed coagulase
typing of Staphylococcus aureus isolates, with particular
emphasis to Methicillin Resistant Staphylococcus aureus
(MRSA) among strains isolated from various types of
specimens collected at a tertiary care hospital outside
Dhaka. A newly developed panel of anti-sera against
different coagulase enzymes was used for coagulase
typing. The study included 79 strains of S aureus and of
those, 40(62.6%) were identified as MRSA on the basis of
86
resistance to oxacillin discs. Murshed et al has compared
the detection rate of MRSA between two tertiary care
hospital at Dhaka city and has found a high rate of MRSA
in both hospitals. (Shahidullah et al., 2012), has reported
from specialized cardiology hospital at Dhaka from different
specimens and found only 10.5% isolates of
Staphylococcus aureus. In this study MRSA was not
218. Glo. Adv. Res. J. Microbiol.
detected. (Ahmed et al., 2008), has reported aerobic
bacterial agents isolated from puerperal sepsis among the
patients admitted at a tertiary care hospital and found that
46.2% cases are MRSA strains. Interestingly the all strains
are vancomycin sensitive. (Barai et al., 2010), has
performed a study to know the antibiotic resistance pattern
of the common isolates from blood, urine, respiratory
secretions and pus/wound swab of patients admitted in
ICU at BIRDEM (Bangladesh Institute of Research and
Rehabilitation in Diabetes, Endocrine and Metabolic
Disorder) hospital, during a one year period from March
2006 to February 2007. A total of 1660 samples were
analyzed of which about 77.0% of isolated Staphylococcus
aureus were methicillin resistant (MRSA). (Jinnah et al.,
1998); has published that 139(12.6%) Staphylococcus
aureus are isolated from 1100 wound specimens from the
diabetic patients at diabetic specialized hospital in Dhaka
and the rate of isolation of MRSA was 78.7% which is very
high like the previous study. The reason of disproportionate
rate of MRSA isolation is due to the sample collection from
the diabetic patients. (Kawsar et al., 2008), has reported a
three months long study carried out the Department of
Pathology at Armed Forces Medical College, Dhaka and
has found 50 cases of Staphylococcus infection of which
42(84.0%) cases are Staphylococcus aureus. Interestingly
out of 42 cases of Staphylococcus aureus 37(85.7%) are
found as beta lactamase producers and only 2(4.8%)
cases are MRSA.
CA-MRSA infection in Bangladesh
There is only study that has been performed on CA-MRSA
in Bangladesh which was done by (Iqbal et al., 1999). In
that study it has been reported that CA-MRSA was present
in the community in 25.0%. Interestingly, the author has
mentioned that urine collected from the OPD of the hospital
has found 40.0% MRSA isolates. (Haq et al., 2005),
reported the findings of a multicentre study on the
incidence of MRSA in Bangladesh and has mentioned that
a total of 14.1% Staphylococcus aureus was isolated from
different specimens. The rates of isolation of
Staphylococcus aureus in the Dhaka hospital and
outpatients were 14.1% and 11.7%, respectively, whereas
rates were 20.7% in Chittagong, 14.7% in Rajshahi and
18.3% in Mymensingh. The lower rate of isolation of S.
aureus in Dhaka hospital and the outpatients was because
urine constituted 82.5% and 59.7% of samples,
respectively. On the other hand, a higher rate of isolation of
S. aureus in Chittagong, Rajshahi and Mymensingh was
due to fewer urine sample and more samples of pus. About
11.0% S. aureus were isolated from urine samples in
Dhaka, as many of the samples came from patients with
urinary catheters. The rate of isolation of MRSA in the four
hospitals ranged between 32.0% and 63.0%, but was
40.0% in outpatient isolates of Dhaka hospital. The origin
of these communities acquired MRSA is not known. One
possibility is that they had come from patients who had
previously been admitted to Dhaka hospital and had then
been seen as outpatients. However, exact data regarding
the proportion of patients with a history of hospital stay was
not recorded. MRSA were detected in pus, urine and
sputum. All MRSA were sensitive to vancomycin (MIC <
4mg/L). Over 90.0% of all Staphylococcal isolates from all
regions were resistant to penicillin and ampicillin. Beta-
lactamase production was similar in both MRSA and non-
MRSA (85.11% versus 85.0%). The prevalence of MRSA
has increased substantially over the last 4-5 years in
hospital patients in Bangladesh and this multicentre study
showed there was a high incidence of MRSA in large
hospitals in four different regions of Bangladesh and in the
community in Dhaka.
Sensitivity Pattern of MRSA in Bangladesh
(Islam et al., 2008), has detected the MIC of cloxacillin
against 10 MRSA strains and has found 100.0% resistant
to penicillin as well as amoxicillin. However, this 10 MRSA
are 100.0% sensitive to vancomycin, ciprofloxacin,
erythromycin, fusidic acid and rifampicin. Interestingly
ceftriaxone (20%) and cephradine (40%) are also resistant
to MRSA. (Haque et al., 2011), has identified the pattern of
aerobic bacteria with their antibiotic susceptibility isolated
from infected patients in one of the surgical units at a
tertiary care hospital outside Dhaka and reported that out
of 74 clinical samples, Staphylococcus aureus was found
in 8 cases. Majority (61.5%) of culture positive results were
found in wound swabs. Over 87.0% strains of S. aureus
were resistant to penicillin but sensitive to erythromycin
whereas, 100% of those strains were sensitive to
cloxacillin. (Rahman et al., 2002), has reported similar
result. In another study in Bangladesh, (Shamsuzzaman et
al., 2007), has reported about the trend of increase
resistant of Staphylococcus aureus which has been
markedly increase in resistance against almost all
antibiotics even against ciprofloxacin (17% to 43%; p<0.05)
and ceftriaxone (28% to 83%; p<0.001) except co-
trimoxazole (55% to 57%); on the other hand, oxacillin
resistance increased from 22% to 42% but no resistance
against vancomycin was noted during this period. (Begum
et al., 2011), was found reduced sensitivity pattern to some
important antibiotics. (Khan et al., 2007), has performed
antimicrobial susceptibility testing and coagulase typing of
Staphylococcus aureus isolates, with particular emphasis
to Methicillin Resistant S. aureus (MRSA) among strains
isolated from various types of specimens collected at a
tertiary care hospital outside Dhaka. A newly developed
panel of anti-sera against different coagulase enzymes
was used for coagulase typing. The study included 79
strains of S. aureus and of those, 40 were identified as
MRSA on the basis of resistance to oxacillin discs. The
 Yusuf et al. 219

Table 1. Studies of MRSA in Bangladesh

Authors Name Year Study Type Place of Study Isolation rate

27
Dutta et al 2013 Original Article Hospital 46.0%
78
Haque et al 2011 Original Article Diagnostic centers 43.5%
79
Alam et al 2011 Original Article Hospital 25.0%
80
Hossain et al 2002 Original Article Hospital 42.5%
81
Islam et al 2008 Original Article Hospital NM
83
Shamsuzzaman et al 2007 Original Article Hospital 22.0-42.0%
84
Begum et al 2011 Original Article Hospital 0.0%
85
Khan et al 2007 Original Article Hospital 50.6%
86
Murshed et al 2011 Original Article Hospital 43.2%
87
Shahidullah et al 2012 Original Article Hospital NM
88
Ahmed et al 2008 Original Article Hospital 46.15%
89
Barai et al 2010 Original Article Hospital 77.0%
90
Jinnah et al 1998 Original Article Hospital 78.7%
92
Kawsar et al 2008 Original Article Hospital 4.8%
94
Iqbal et al 1999 Research Note Community 25.0%
82
Rahman et al 2002 Original Article Hospital 47.2%
91
Afroz et al 2008 Short Communication Hospital 44.1%
93
Haq et al 2005 Letters to Editorial Multicentre study 32.0-63.0%

*NM= not mentioned

rate of resistance of S. aureus was 88.61% to penicillin and
48.10% to oxacillin. However, none of the isolates showed
vancomycin resistance. Both MRSA and non-MRSA strains
90
were found belonging to Coagulase type VI. Jinnah et al
has published that 139(12.6%) S aureus are isolated from
1100 wound specimens from the diabetic patients at
diabetic specialized hospital in Dhaka and the rate of
isolation of MRSA was 78.7% which is very high like the
previous study. The reason of disproportionate rate of
MRSA isolation is due to the sample collection from the
diabetic patients. The study reported that 77.0% strains
were penicillin and ampicillin resistant which is very
alarming; however, cloxacillin resistant was in 37.2%
cases. (Iqbal et al., 1999), has documented the incidence
of ciprofloxacin-resistance among MRSA patients. In this
study clinical isolates from outdoor patients were tested to
see the ciprofloxacin resistance among MRSA strains,
using in vitro susceptibility tests by standard disk diffusion
technique. Results show significantly high incidence of
ciprofloxacin resistance among MRSA isolates in these
patients.
Prevention of MRSA Infections
The standard hospital guidelines regarding MRSA
prevention stress that antibiotic-resistant pathogens are
sensitive to routinely used hospital disinfectants, but it is
essential that correct and meticulous cleaning and use of
disinfectants be performed (Tacconelli et al., 2004).
However, most specific interventions like isolation of
colonized individuals, active identification of MRSA
carriage by surveillance cultures of high-risk populations,
decolonization of MRSA carriers, environmental
disinfection by chemical means or even light or some
combination of the above-described interventions, have
failed to reliably limit transmission or spread (Goering et
al., 2008). In community and other institutional settings,
there is far less evidence to support the use of these
approaches even after this uncertainty and as the CA-
MRSA epidemic continues, the need for effective
interventions has become more acute. The Government of
this country is very much concern regarding the antibiotic
resistant and try to establish different programs to prevent
this. Infection Control & Prevention Program in Bangladesh
(ICPPB) with the collaboration of USA is successfully
continuing the infection prevention in different sectors of
this country.

Antibiotic resistant occurs due to irrational use of antibiotics

(Tattevin et al., 2009; Waness 2010). In the health care CONCLUSION
setting infection control practice depends on guidelines
from professional, governmental as well as non- MRSA have created a huge clinical burden in the hospital
governmental bodies (Morgan 2007; Toeda et al., 2001). settings as well as in the community. Clinicians and the
220. Glo. Adv. Res. J. Microbiol.
health care workers of this country must be aware of the
wide and unique spectrum of disease caused by MRSA.
Increased vigilance should be employed in the diagnosis
and management of suspected and confirmed
Staphylococcal infections.
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