European Journal of Cardiovascular Medicine

Staphylococcus aureus remains one of the most significant pathogens responsible for healthcare-associated infections worldwide, causing a range of serious conditions including bacteremia, surgical site infections, and ventilator-associated pneumonia.(1–3) The emergence of methicillin-resistant Staphylococcus aureus (MRSA) shortly after the introduction of methicillin in the early 1960s marked a critical turning point in hospital infection control.(4)  MRSA has since evolved into a formidable global public health threat, contributing to increased morbidity, mortality, prolonged hospital stays, and higher healthcare costs.(5)

MRSA colonizes the anterior nares and skin surfaces asymptomatically, facilitating silent dissemination within healthcare facilities.(6) The primary vectors of transmission include contaminated hands of healthcare workers (HCWs) and close patient-to-patient contact, underscoring the critical role of effective screening and decolonization strategies.(7) Asymptomatic carriers among patients and HCWs not only are the major sources of MRSA in the hospital environment but also they face an elevated risk of subsequent invasive infections themselves.(8)

Hence, routine screening for MRSA carriage, particularly in high-risk hospital units, is an essential infection control measure advocated by various health authorities to reduce nosocomial outbreaks.(9) Topical decolonization using 2% mupirocin nasal ointment has been the standard approach for eliminating MRSA colonization.(10) However, widespread and sometimes indiscriminate use of mupirocin has contributed to the emergence of high-level mupirocin-resistant MRSA strains, compromising its effectiveness.(11) Additionally, vancomycin, a mainstay therapy for severe MRSA infections, faces a growing threat from strains exhibiting intermediate and complete resistance (VISA and VRSA), further limiting therapeutic options.(12)

In India, MRSA prevalence among hospitalized patients has been reported to range between 30% and 70%, depending on geographic region and hospital type (Mehta et al., 2014; India MRSA Surveillance Network, 2019).(13) Moreover, MRSA carriage among healthcare workers (HCWs) and patients in tertiary care hospitals is a significant concern. Several studies reported varying MRSA carriage rates, with higher prevalence in patients (15.6-32.7%) compared to HCWs (1.8-19.1%) and nasal carriage rates being in the range of  25-29.2% .(14,15) But, there is a dearth of data regarding the carriage rate of MRSA and VRSA among patients and HCWs, not only in our tertiary care teaching hospital but also in the eastern part of India at large. This cross-sectional epidemiological study, the first of its kind in eastern India, will address this issue by screening asymptomatically colonized patients and HCWs for MRSA and assessing the susceptibility status of those MRSA isolates to mupirocin and vancomycin. The results of this study will benefit our healthcare facility and society at large by assessing the carriage rate of multidrug-resistant organisms (MDROs), such as MRSA and VRSA. The increasing incidence of MDROs presents a substantial challenge to patient safety and public health worldwide. Understanding local colonization rates and resistance patterns is crucial for guiding targeted interventions, improving infection control measures, and preventing hospital outbreaks. Moreover, the prevalence of high-level mupirocin resistance among MRSA isolates will reveal the scope of this drug in MRSA decolonization therapy in our facility, and data on vancomycin susceptibility will help  design effective treatment regimens.

Study setting

This cross-sectional study was conducted at Burdwan Medical College and Hospital, a prominent tertiary care teaching institution in Purba Bardhaman, West Bengal. Serving as a major referral center, it caters to a large rural and semi-urban population from the surrounding districts. The hospital has diverse clinical departments with high patient turnover and substantial healthcare worker engagement, providing an ideal setting for assessing MRSA colonization dynamics. Regional cultural practices, resource constraints, and variable infection control compliance further contextualize the findings and offer valuable insights applicable to similar healthcare settings across eastern India.

Study design

This was a cross-sectional epidemiological study spanning a three-month period.

Study population

In this study, 200 subjects (100 inpatients, 50 outpatients, and 50 health care workers) were screened for MRSA after obtaining approval from the Institutional Human Ethics Committee and written informed consent from the participants. All eligible subjects were serially enrolled during the study period.

Inclusion Criteria-

1. One hundred (100) patients from different ICUs and wards, including the burn unit, Oncology and Surgery ward of Burdwan Medical College and Hospital, West Bengal, who provided informed consent, were included in the study.
2. Fifty (50) patients from different outpatient departments of Burdwan Medical College and Hospital, West Bengal, who provided informed consent, were included in the study.
3. Fifty (50) healthcare workers, including doctors, nursing staff, and attendants of Burdwan Medical College & Hospital, West Bengal, who provided informed consent, were included in the study. 

Exclusion Criteria-

1. Persons with upper respiratory tract infections were excluded from the study.
2. Outpatients with a history of visiting the hospital in the previous 1 year or with a history of contact with any healthcare worker were excluded from the study.
3. Healthcare workers who had entered the hospital setup for less than 1 year were excluded from the study.

Study procedure

A total of 200 participants (100 inpatients, 50 outpatients, and 50 healthcare workers) were enrolled after obtaining informed consent. Demographic and clinical data were recorded using pre-designed forms. Nasal swabs were collected, cultured on HiCrome Rapid MRSA agar, and MRSA isolates were identified using Gram staining, catalase and coagulase tests, and the cefoxitin disk diffusion method. Isolates will be tested for high-level mupirocin resistance using 200 μg disks, and growth within the inhibition zone will be indicative of resistance. Vancomycin susceptibility will be assessed using the E-test MIC. According to CLSI, isolates are classified as sensitive (≤2 μg/mL), intermediate (4–8 μg/mL), or resistant (≥16 μg/mL).

Screening of patients & HCWs for MRSA

Using pre-moistened sterile cotton swabs, specimens were collected from the anterior nares of patients and healthcare workers. The specimens were inoculated onto HiCrome Rapid MRSA agar plates and incubated at 37°C in ambient air for 24 h. Colonies were identified using Gram stain, catalase and slide and tube coagulase tests and were confirmed as MRSA by Kirby-Bauer disk diffusion method using 30 μg cefoxitin disk considering inhibition zone measuring 21 mm or less as resistant.(16)

Detection of High Level Mupirocin Resistance

MRSA isolates were then tested for high-level mupirocin resistance using the Kirby-Bauer disk diffusion method with a 200 μg mupirocin disk. High-level mupirocin resistance was detected in the presence of light growth within the zone of inhibition after careful examination with transmitted light. However, the presence of any zone of inhibition surrounding the 200 μg mupirocin disk signified the absence of high-level mupirocin resistance in the isolate.

Detection of Vancomycin Resistance

Again, these MRSA isolates were tested for vancomycin resistance using the MIC method (E test). According to CLSI guidelines, staphylococci with MIC of 2 µg/mL or less (for vancomycin) were sensitive, while isolates with MIC of  4-8 µg/mL were defined as intermediate sensitive (vancomycin-intermediate Staphylococcus aureus, VISA). Isolates with MIC of 16 µg/mL or more (for vancomycin) will be designated as resistant (vancomycin-resistant Staphylococcus aureus, VRSA).

Data collection

Detailed demographic information, including age, sex, and residential background of all eligible serially recruited participants, was recorded in a pre-designed and pre-tested case record form (CRF). For HCWs, additional data on professional category, department, and duration of hospital services were documented. Clinical details of the patients, such as the date of hospital visit (for outpatients), duration of hospital stay (for inpatients), provisional diagnosis, current or recent antibiotic intake, comorbidities, and invasive device use, were systematically recorded in the same CRF.

Laboratory data, including culture results, cefoxitin disk diffusion findings for MRSA screening, and subsequent susceptibility testing for mupirocin and vancomycin, were carefully documented in laboratory registers and cross-verified with CRFs.

Data entry was performed using Microsoft Excel with a double data entry to reduce transcription errors. Regular data validation checks, including range, consistency, and logic checks were implemented to ensure accuracy and completeness. Any discrepancies identified during the data cleaning process were resolved by verifying the source documents. Unique study identification numbers were assigned to each participant to maintain confidentiality and to facilitate data tracking.

This structured and rigorous approach to data collection and management enhances the reliability and reproducibility of the study findings, allowing for meaningful comparisons with the existing literature and providing robust evidence to guide infection control policies and antimicrobial stewardship programs in similar healthcare settings.

Data analysis

Data were analyzed using both descriptive and analytical statistical methods. Descriptive statistics, including the mean, standard deviation (SD), and proportions with 95% confidence intervals (CI), were calculated for demographic variables and prevalence estimates. Analytical statistics were used to assess the associations between categorical variables. Pearson’s Chi-square test or Fisher–Freeman–Halton exact test (when expected counts <5) was used to compare MRSA carriage, high-level mupirocin resistance, and vancomycin susceptibility across groups. Pairwise comparisons were adjusted using the Bonferroni correction. Statistical significance was set at p < 0.05. All analyses were performed using the IBM SPSS Statistics software (version 26.0, IBM Corp., Armonk, NY, USA).

Human participant protection

This study was approved by the Institutional Human Ethics Committee of Burdwan Medical College, Purba Bardhaman. Written informed consent was obtained from all the participants, ensuring confidentiality and voluntary participation. No deviations from the approved study protocol were observed during the study period..

Prevalence of MRSA isolates obtained during screening of inpatients, outpatients and health care workers

A total of 200 subjects were screened, including 100 inpatients, 50 outpatients, and 50 healthcare workers (HCWs). The prevalence of MRSA carriage was 33.0% (95% CI: 23.9–43.2) among inpatients, 24.0% (95% CI: 13.5–37.8) among outpatients, and 28.0% (95% CI: 16.5–41.7) among healthcare workers. Inpatients had the highest proportion of MRSA carriage, followed by HCWs and outpatients. However, there was no statistically significant difference in MRSA carriage rates among inpatients, outpatients, and healthcare workers (p = 0.147). Even, pairwise proportion tests revealed no statistically significant difference in MRSA carriage prevalence between inpatients and outpatients (p ≈ 0.12) or between inpatients and healthcare workers (p ≈ 0.31). Similarly, no significant difference was observed between outpatients and healthcare workers (p ≈ 0.42). (Table 1)

Table 1: Prevalence of MRSA isolates obtained during screening of inpatients, outpatients, and health care workers.

Demographic characteristics of inpatients screened positive for MRSA

Of the 100 inpatients screened, 33 (33.0%) were positive for MRSA colonization. The mean age of these MRSA-positive inpatients was 35.6 years (SD ±20.2), demonstrating a wide age distribution from younger to older patients. Female patients constituted the majority, with 20 of 33 cases (60.6%), whereas males accounted for 13 (39.4%). The mean duration of hospital stay among MRSA carriers was 4.1 days (SD ±3.9), although some patients had significantly longer admissions, contributing to variability. Comorbidities were recorded in six patients (18.2%). Specifically, diabetes mellitus was present in one patient (3.0%), chronic kidney disease in three (9.1%), and hypertension in two (6.1%); none had chronic obstructive pulmonary disease. The remaining 27 patients (81.8%) had no major comorbidities present. (Table 2)

Table 2: Demographic characteristics of inpatients screened positive for MRSA. (N= 33)

Demographic characteristics of outpatients screened positive for MRSA

Among the 50 outpatients screened, 12 (24.0%) were positive for MRSA. The mean age of these carriers was 32.3 years (SD ±18.2), reflecting a younger distribution than that of inpatients. Females formed the majority, with 7 of 12 cases (58.3%), while males accounted for 5 (41.7%). On average, MRSA-positive outpatients reported four visits in the last three months (SD ±2), indicating frequent healthcare contact. Comorbidities were documented in five of the 12 patients (41.7%). Specifically, diabetes mellitus was present in 1 (8.3%), chronic obstructive pulmonary disease in 1 (8.3%), chronic kidney disease in 1 (8.3%), and hypertension in 2 (16.7%). The remaining seven patients (58.3%) did not have any major comorbidities. (Table 3)

Table 3: Demographic characteristics of outpatients screened positive for MRSA. (N= 12)

Demographic characteristics of healthcare workers screened positive for MRSA

Among the 50 healthcare workers screened, 14 (28.0%) were identified as MRSA carriers. The mean age was 41 years (SD ±14.6), which was slightly higher than that of the inpatient and outpatient groups. Females were predominant, with 10 out of 14 cases (71.4%), compared to four males (28.6%). The average duration of employment in the hospital among carriers was 18.9 years (SD ±14.3), indicating that long-term occupational exposure may be a risk factor. None of the MRSA-positive HCWs reported antibiotic use in the preceding three months. Comorbidities were documented in six of the 14 HCWs (42.3%), including diabetes mellitus in two (14.3%), chronic kidney disease in one (7.1%), and hypertension in three (21.4%), while none had COPD. (Table 4).

Table 4: Demographic characteristics of healthcare workers screened positive for MRSA. (N= 14)

Distribution of high-level mupirocin resistance among MRSA isolates obtained during screening of inpatients, outpatients and health care workers

High-level mupirocin resistance (MuH) was detected across all groups, with the highest prevalence among healthcare workers (42.9%, 95% CI: 17.7–71.1), followed by inpatients (27.3%, 95% CI: 13.3–45.5) and outpatients (25.0%, 95% CI: 5.5–57.2). However, comparison of high-level mupirocin resistance among MRSA isolates from inpatients, outpatients, and healthcare workers did not show a statistically significant difference (p ≈ 0.46). Moreover, pairwise comparison of MuH prevalence among MRSA isolates showed no statistically significant differences between inpatients and outpatients (p ≈ 0.84), inpatients and healthcare workers (p ≈ 0.26), or outpatients and healthcare workers (p ≈ 0.36) after Bonferroni correction (α = 0.017). (Table 5).

Table 5: Distribution of high-level mupirocin resistance among MRSA isolates obtained during screening of inpatients, outpatients and health care workers.

Distribution of spectrum of vancomycin susceptibility among MRSA isolates obtained during screening of inpatients, outpatients and health care workers

The prevalence of VISA among MRSA isolates was 3.0% (95% CI: 0.1–15.7) in inpatients, 0% (95% CI: 0–23.1) in outpatients, and 7.1% (95% CI: 0.2–33.4) in healthcare workers. All isolates were vancomycin-susceptible, except for a small proportion that exhibited intermediate susceptibility (VISA) among inpatients and healthcare workers. No vancomycin-resistant isolates (VRSA) were detected in this study. Comparison of the spectrum of vancomycin susceptibility among MRSA isolates from inpatients, outpatients, and healthcare workers revealed no statistically significant differences (Fisher–Freeman–Halton exact test, p ≈ 0.72). Pairwise Fisher’s Exact tests showed no statistically significant differences in vancomycin susceptibility distribution between inpatients and outpatients (p = 1.00), inpatients and healthcare workers (p = 0.59), or outpatients and healthcare workers (p = 0.50). (Table 6).

Table 6: Distribution of spectrum of vancomycin susceptibility among MRSA isolates obtained during screening of inpatients, outpatients and health care workers.

This study provides a comprehensive overview of MRSA carriage among inpatients, outpatients, and healthcare workers in a tertiary care setting, along with their susceptibility to mupirocin and vancomycin. The results highlighted distinct epidemiological patterns in different groups, variations in demographic and clinical characteristics, and the influence of healthcare exposure and comorbidities on colonization. Additionally, the findings underscore significant trends in mupirocin resistance and vancomycin susceptibility, which are further interpreted and contextualized in the subsequent discussion.

Prevalence of MRSA isolates obtained during screening of inpatients, outpatients and healthcare workers

The present study documented an overall MRSA colonization prevalence of 29.5% among the screened individuals, with inpatients showing the highest carriage (33%), followed by healthcare workers (28%) and outpatients (24%). However, much lesser inpatient colonization rates have been reported in Indian tertiary-care hospitals, ranging from 12–15% (Mathanraj et al., 2009; Azzam et al., 2025).(14,17) The observed 28% carriage among HCWs is consistent with findings from Verma et al. (2017), highlighting occupational exposure and transient colonization as contributors to nosocomial spread.(18) Interestingly, no statistically significant difference was found across the groups, a trend which was contrasted by Cesur et al. (2004) stating hospital staff were 2.3-fold more likely to carry MRSA than were outpatients (6% vs 2.6%, p = .013).(19) Future studies with larger sample sizes may shed light on this issue.

Demographic characteristics of inpatients screened positive for MRSA

In the present study, MRSA colonization was detected in 33.0% (33/100) of inpatients, a prevalence significantly higher than reports from tertiary care centres in India (2.3–15.6%), and also from Western data (4.4-25%).(14,20–22) The relatively young mean age (35.6 ± 20.2 years) contrasts with studies showing higher MRSA carriage among elderly patients, suggesting that colonization in our setting may not be age-dependent.(23,24) The female predominance (60.6%) aligns with some Indian studies, though global data often show male predominance; this difference could reflect demographic patterns or healthcare-seeking behaviour and warrants further investigation.(25,26) Interestingly, most carriers (81.8%) had no significant comorbidities, unlike prior findings linking MRSA carriage with chronic illness and prolonged hospitalization.(27,28) This unexpected observation may indicate an increase in community-associated MRSA acquisition among hospitalized individuals, highlighting the need for routine screening beyond traditionally “high-risk” groups. The short mean hospital stay (4.1 ± 3.9 days) also suggests that colonization may occur early during admission, underlining the importance of early detection and decolonization strategies.(29)

Demographic characteristics of outpatients screened positive for MRSA

In our study, 24.0% (12/50) of outpatients were MRSA carriers, a prevalence similar to other Indian reports (16.5–23.5%) but higher than many other Asia-Pacific countries (0.3-3.5%).(30) The younger mean age (32.3 ± 18.2 years) and female predominance (58.3%) are consistent with community-associated MRSA (CA-MRSA) trends described by Wong et al., suggesting transmission beyond traditional inpatient settings.(30) Frequent healthcare contact, with an average of four visits in three months, supports the hypothesis that repeated exposure to healthcare environments facilitates colonization, as noted by Jernigan et al.(31) Although 41.7% of carriers had comorbidities, the majority (58.3%) lacked significant illness, indicating that MRSA carriage may not require underlying disease.(32) This unexpected observation highlights the potential role of asymptomatic carriers in outpatient settings as reservoirs for transmission, emphasizing the need for targeted screening and preventive strategies beyond hospitalized populations.

Demographic characteristics of healthcare workers screened positive for MRSA

In our study, 28.0% (14/50) of healthcare workers (HCWs) were MRSA carriers, a prevalence higher than the reports from Indian tertiary centres (10-21%) and definitely much higher than than the pooled MRSA colonisation rate 1.8% (95% confidence interval [CI], 1.34%-2.50%) observed  in Europe and the United States.(33,34) The slightly higher mean age (41 ± 14.6 years) and female predominance (71.4%) mirror observations by Askarian et al., possibly reflecting greater patient contact among senior nursing staff.(35) The long average employment duration (18.9 years) suggests cumulative occupational exposure as a risk factor, consistent with previous findings linking length of service with colonization. (36) Notably, 42.3% of carriers had comorbidities that may impair host immunity and facilitate the persistence of colonization. The absence of recent antibiotic use among carriers was unexpected, indicating that MRSA acquisition in HCWs may occur independently of direct antimicrobial selection pressure, possibly through repeated low-level environmental exposure, which warrants further investigation.

Distribution of high-level mupirocin resistance among MRSA isolates obtained during screening of inpatients, outpatients and healthcare workers

In the present study, high-level mupirocin resistance (MuH) was observed across all MRSA isolates, with a notably higher proportion among healthcare workers (42.9%) than among inpatients (27.3%) and outpatients (25%). This aligns with reports from Iranian tertiary hospitals, where healthcare personnel often serve as asymptomatic carriers facilitating nosocomial transmission (Abbasi-Montazeri et al., 2013).(37) The elevated MuH among healthcare workers may reflect frequent mupirocin exposure during decolonization or selective antibiotic pressure in hospital environments. Unexpectedly, the proportion of MuH in outpatients was similar to that in inpatients, suggesting potential community-linked dissemination, warranting further molecular epidemiological studies. These findings underscore the need for regular MRSA surveillance, targeted decolonization protocols, and stewardship strategies to mitigate resistance in both clinical and carrier populations of MRSA.

Distribution of spectrum of vancomycin susceptibility among MRSA isolates obtained during screening of inpatients, outpatients and health care workers

In this study, the majority of MRSA isolates from inpatients (97.0%), outpatients (100%), and healthcare workers (92.9%) were vancomycin-susceptible (VSSA), consistent with reports from Indian tertiary care settings (Sharma et al., 2021).(38) However, vancomycin-intermediate S. aureus (VISA) was detected in one inpatient and one healthcare worker isolate, while no VRSA was observed. The occasional emergence of VISA may reflect prolonged vancomycin exposure or stepwise acquisition of cell wall–thickening mechanisms (Cui et al., 2006).(39) The presence of VISA among healthcare workers, albeit rare, raises the hypothesis of asymptomatic carriage as a potential reservoir for intermediate resistance, highlighting the necessity for continuous surveillance, judicious vancomycin use, and molecular characterization to preempt progression toward VRSA in tertiary care hospitals.

Implications of the findings

The present study has important implications for infection control and antimicrobial stewardship in tertiary care teaching hospitals. By screening for MRSA among both patients and healthcare workers and evaluating susceptibility to mupirocin and vancomycin, this study provides a comprehensive overview of local resistance patterns. Moreover, this study provides actionable data supporting regular MRSA surveillance, targeted decolonization, and prudent antibiotic use, thereby contributing to infection control policies and antimicrobial stewardship strategies in tertiary care settings in West Bengal.

Strengths of the study

The strengths of this study lie in its feasibility, as routine screening and susceptibility testing were integrated into existing laboratory workflows, and in its novelty, given the limited data on high-level mupirocin resistance (MuH) among healthcare workers in West Bengal. The ethical conduct, with appropriate informed consent and institutional review board approval, ensured that human subjects were protected, and the study’s relevance was underscored by the potential role of healthcare workers as reservoirs for MRSA transmission.

Limitations of the study

However, this study has certain limitations. The sample size, particularly among healthcare workers and outpatients, was relatively small, which may limit the generalizability of the findings. Additionally, molecular characterization of resistance determinants, including mupirocin resistance genes (ileS-1 and ileS-2) and vancomycin-intermediate mechanisms, was not performed, restricting insights into clonal relationships and transmission dynamics. The cross-sectional design precludes the establishment of temporal or causal associations between colonization and resistance patterns. Future studies should include larger cohorts across multiple centers and incorporate molecular epidemiology to elucidate the genetic basis of resistance and potential transmission pathways.

Screening revealed MRSA colonization among patients and healthcare workers, with high-level mupirocin resistance notably higher among healthcare workers, while vancomycin susceptibility largely persisted. These findings highlight the need for routine surveillance, targeted decolonization, and judicious antibiotic use, directly addressing the study objectives and informing infection-control strategies in tertiary care settings. Regular MRSA surveillance among patients and healthcare workers should be implemented with periodic assessment of mupirocin and vancomycin susceptibility. Targeted decolonization protocols, judicious antibiotic stewardship, and multicenter longitudinal studies are recommended to monitor resistance trends, evaluate the effectiveness of interventions, and inform infection control policies in tertiary care teaching hospitals.

Conflicts of Interest

The authors declare no conflict of interest.

Acknowledgement

I express my heartfelt thanks and gratitude to the administration, faculty members, and staffs of the Department of Microbiology, Burdwan Medical College and Hospital for allowing me to conduct this study.

Funding

Funding: This study was supported by the authors’ own funding.

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