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Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial pathogen worldwide, which has emerged over the past 30 years as a leading cause of both nosocomial and community-acquired infections. Effective policy implementation is a challenging task, especially when taking into account a particular country’s large size and vast bureaucracy, such as those of the United States.
Microorganisms, particularly bacteria, have the ability to learn from the environment at an amazing rate.
In the realms of horizontal gene transfer, bacteria engage in various mechanisms to achieve antibiotic resistance. From an evolutionary standpoint, it is advantageous for bacteria to carry out horizontal gene transfer. Designed to cripple the activities at the cellular levels, antibiotics work in four different ways. Fortunately for bacteria, they are equipped with the ability to share genomic information between different species that may allow the organisms to develop ways to circumvent death.
Immediately, the ability for bacteria to spread the news of an effective method to defeat antibiotics is a rising concern among researchers. After a thorough understanding of the mechanisms, it is important to examine how the lack of knowledge with penicillin and uncontrolled drug distribution in the United States all helped contribute to the rise of antibiotic resistance. Upon closer examination of antibiotics distribution in local communities, it is not surprising to uncover that the combination of socioeconomically challenged individuals with inconsistent treatments may contribute to this developing crisis. When penicillin became obsolete, the world needed another effective antibiotic on the market.
The combination of decreased antibiotic control and a widespread lack of understanding the mechanism aided and strengthened the empowerment of the SCCmecA to develop into variant forms, each with its flavors of potency.
The more potent form, hospital-associated MRSA, possessed the SCCmecA type I-III, which allows these microorganisms to be “multidrug-resistant and manifest by infecting wounds, ventilator-associated pneumonia, line infections, and other infections” [8].
Originally, hospitals only witnessed HA-MRSA cases in elderly and younger age groups [4,5]. Comparing the two different forms of MRSA, CA-MRSA is neither as virulent nor as resistive to antibiotics as its cousin strain. Another problematic issue epidemiologists have identified is specific MRSA strains native only to certain regions of the globe.
Today, the governmental agencies are investing strongly in media and organizations to educate the consumers of excessive use of antibiotics and new strains. S.aureus lives as a part of the normal skin flora in the nose or on the skin in 20-30% of healthy people (staph carriers), (1). Staph skin infection usually appears as a red, warm, painful swelling with a blister, ulcer, or crust, and a drainage (Picture 1). Infection may spread into the deeper tissues, like the bones (Picture 2).
In 1942, only two years after introducing penicillin into infection treatment, staph resistance to penicillin was recognized in hospitals (4). S.aureus is a spherical (coccus) Gram-positive bacterium, about 1 micrometer in size, with the thick cell wall and thin capsule. Food workers should be tested for staphylococci and being treated, even if they have no active infection. Staph carriers should not work in food preparation. Surfaces in hospitals can be cleaned with alcohol, quaternary ammonium or iodine compounds, which are effective to both MSSA and MRSA (20). Effective sprays for air disinfection also exist (16). What is NOT NEEDED to prevent staph infections: antibacterial soaps, wearing masks, washing linens of staph infected persons separately from others, using disposal dishes, disinfecting surfaces with hypochlorite, denying patients from using whirlpools or foot baths, work restrict staff members who are MRSA carriers, unless they have skin lesions or active nasal infection (20). Staph colonization may be treated with mupirocin (Bactroban) nasal gel, and daily Hibiclens skin cleanser baths (17).
Severe staph infections require treatment with parenteral penicillinase-resistant penicillin like nafcillin and oxacillin, or cephalosporins of 1st or 2nd generation (e.g. Please note that any information or feedback on this website is not intended to replace a consultation with a health care professional and will not constitute a medical diagnosis. Faith, staph cellulitis (infection spreading under the mouth mucosa with reddened and swollen mucosa) and staph tonsillitis (like we say strep throat (from streptococcal tonsillitis) there can be a staph throat infection).
Hello, Question about MRSA symptoms: if one’s teeth get yellow in a fairly short period of time with light-colored slimy things on the tongue (latter part when one wakes up in the morning), and joints hurt, can these alone be MRSA symptoms? Detection of Methicillin Resistance in Staphylococcus Aureus by Polymerase Chain Reaction and Conventional Methods: A Comparative Study. Carriage of methicillin-resistant Staphylococcus aureus among hospital employees: Prevalence, duration, and transmission to households. The basis for resistance to β-lactam antibiotics by penicillin-binding protein 2a of methicillin-resistant staphylococcus aureus. The impact of Methicillin Resistance in Staphylococcus aureus Bacteremia on Patient Outcomes: Mortality, Length of Stay, and Hospital Charges.
Isolation measures in the hospital management of methicillin resistant Staphylococcus aureus (MRSA): Systematic review of the literature. Development and Evaluation of a PCR based immunoassay for the rapid detection of methicillin resistant Staphylococcus aureus. Guidelines for the laboratory diagnosis and susceptibility testing of methicillin-resistant Staphylococcus aureus (MRSA).
Comparison of cefoxitin disc diffusion test, oxacillin screen agar, and PCR for mecA gene for detection of MRSA. Rapid Detection of Methicillin Resistance in Staphylococcus aureus Isolates by the MRSA-Screen Latex Agglutination Test. Performance Standards for antimicrobial susceptibility testing, 21 st Informational Supplement. Comparison of rapid method of DNA extraction using microwave irradiation with conventional phenol chloroform technique for use in multiplex PCR for mecA and femB genes. Multiplex PCR for the identification of methicillin-resistant Staphylococci in the clinical laboratory.
Detection of methicillin-resistant Staphylococcus aureus in nosocomial infections in Gaza Strip. Evaluation of a cefoxitin30μg disk on Iso-Sensitest agar for detection of methicillin-resistant Staphylococcus aureus.
Comparison of various conventional methods with a polymerase chain reaction assay for detecting methicillin resistant and susceptible Staphylococcus aureus strains. Amplification of mecA gene in multi-drug resistant Staphylococcus aureus strains from hospital personnel. Epidemiology and susceptibility of 3,051 Staphylococcus aureus isolates from 25 university hospitals participating in the European SENTRY study .
Comparison of phenotypic versus genotypic methods in the detection of methicillin resistance in Staphylococcus aureus.
One of the many fields that require constant attention is healthcare policy.  Factors like age, social backgrounds, and community settings interact together to create a complex dynamic wave of issues to address. Transduction involves the bacterial DNA transferred from one bacterium to another via a virus, i.e.
Using the same example, the Staphylcoccus Aureus can engage in HGT to acquire immunity against drugs targeting peptidoglycan bonds linking to create the cell wall [14].
Even before Alexander Fleming unveiled penicillin to the world, he had already stumbled upon the concept of antibiotic resistance. Patients coming to the hospitals with different health backgrounds provided MRSA the ability to set up spawning pools. Counter to its partner, community-associated MRSA has similar plasmid cassette construction but a less potent type (the SCCmecA type IV cassette). Nonetheless, with MRSA becoming more rampant and immune to various antibiotics, methicillin-resistant S. In spite of lacking similar resistance, the type IV cassette allows CA-MRSA to secrete a virulent factor Panton-Valentine leukocidin (PVL) that is “capable of causing severe tissue necrosis and leukocyte destruction” [8, 20]. However, with increasing diversity trends and international traveling, MRSA strains can be carried from, for example, Europe to the United States [20].


Aureus the current problem still lies in educating the public and seeking effective alternatives.
Unlike the efforts by the current Center of Disease Control (CDC) to curb influenza infections by yearly vaccination, educating the average consumer on antibiotic resistance on alternatives is challenging. However, in even slightly injured skin or mucosa, staph may cause styes, pimples, folliculitis, furuncles, boils (Picture 1), swimmer’s ear, sinusitis, epiglotitis, whitlow, breast infection, impetigo, cellulitis, genital infection, scalded skin syndrome or other staph infections. In 1960, methicillin (later replaced by oxacillin) was used to treat penicillin resistant staph. MRSA still mainly occurs in hospitals and nursing homes, but has lately spread to general community (Community Associated MRSA or CA-MRSA). Yes, Staphylococcus aureus may be transmitted by kissing, since some people have these bacteria in their mouth. In staph infection, antibiotics are chosen on the basis of results of (urinary) culture and antibiotic sensitivity tests, as you can read in lab tests for staph. The term MRSA only tells a type of bacteria, I mean MRSA infection can cause anything from no symptoms to a severe disease. Results of Disk diffusion testing with Cefoxitin correlate with presence of mecA in Staphylococcus sp. While certain policies have alleviated some concerns, there are others that require attention. Blessed with a vast gene pool to modify their genomic blueprints, bacteria can strengthen and reinforce existing resistance against threats like antibiotics [1, 7].
Functioning independently of chromosomal DNA, plasmids are double-stranded and often appear circular [12].
The rate at which antibiotic resistance can spread to other similar species is rising, and all of this is done through bacteria cooperative sharing, labeled horizontal gene transfer.
When the world first saw the development of penicillin, the drug was the perfect agent to target the formation of cell wall, a necessary agent for defense.
Aureus to propagate the resistance blueprint, especially if the likelihood of passing the resistance genome down to its progenies or to its neighbors is highly favored. Upon releasing the drug, immediately, similar practices made with penicillin are witnessed. Primarily, two potent forms of MRSA particularly stand out, the hospital and community-associated MRSA. However, both forms target different groups of individuals from various backgrounds [2, 19].
Even though all strains of MRSA are resistant to penicillin and methicillin, almost all MRSA strains elicit similar symptoms. Even though most MRSA share similar resistive mechanisms to circumvent antibiotics, they may not share the same plasmid cassette constructs [20].
Fundamentally, the processes of horizontal gene transfer would always remain the same, but keeping up with the constant mutations in field of prokaryotes may add another layer of complication.
Over 90% of staphylococci now contain enzyme penicillaze (which breaks down penicillin), so they have to be treated with penicillase-resistant penicillins, cephalosporins or other antibiotics (5). Capsule is thin and may be seen only under the electron microscope. Sometimes more bacteria share one capsule and form a slime layer or biofilm, mostly found on the inner wall of venous and urinary catheters (13). In systemic infection, hospitalization and intravenous antibiotics are needed. Artificial heart valves and vein catheters often need to be removed or replaced. Vancomycin is reserved for MRSA and clindamycin resistant strains or for life-threatening infections.
One of these areas that require key attention is the rising concern of antibiotic resistance.
This article will delve into the realms that drive the mechanisms of antibiotics and how horizontal gene transfer translates into antibiotic resistance. Though not all plasmids are essential to the organism’s well being, it can carry essential instructions to initiate selective advantages for the microorganism [15]. Even though bacteriophages hunt bacteria, certain bacteriophages may sometimes play a favorable role.
Based on the alarming rate of bacteria conferring antibiotic resistance, the hope is to witness new stable but effective antibiotics to combat these newly mutated species. These blueprints are essential in the construction of organelles and enzymes and serve as genomic information for the next generation [13]. The discovery that penicillin rendered the microorganisms defenseless against the immune system was astonishing. He believes that this soon-to-be-dubbed “miracle drug” should sparingly be used in occasions that strictly demanded this drug instead of using it as an all-purpose drug [2]. The lack of antibiotics controls and proper understandings of the antibiotic resistance once again stormed up a heap of problems. Most importantly, however, we would like to understand how these two forms fit into the overall community and healthcare policies.
Studies indicate that there is a sudden surge in CA-MRSA cases in places like collegiate football [19]. However, due to socioeconomic disparities at the individual and community levels, physicians may often prescribe ineffective treatments, like penicillin to treat bacteria that may carry resistive plasmids.
Intermixing different plasmid constructs will not only increase antibiotic resistance possibilities, but will also complicate medical efforts to contain the problems.
A probable solution involves the governmental agencies collaborating with the current scientific findings to create usable and understandable information that the consumers will comprehend and practice. After understanding the fundamental mechanisms, the next step is to understand how these mechanisms translate in clinical and community settings through a gram-positive bacterium, called Staphylococcus Aureus. They may allow bacteria to gain resistance against certain antibiotics through genetic recombination.
Biologists have developed a theory, termed the Central Dogma of “molecular biology”, to help explain the interactive roles DNA, RNA, and protein synthesis are all interrelated to each other and all play essential roles in cell vitality and survival.
The ability for antibiotics to halt an essential process in the bacteria was never understood or thought possible. HGT is the most common mode of gene acquirement that will eventually lead to alternations in target antibiotic site and increase drug efflux to prevent further damage done to the microorganism [1, 7]. The lack of proper understanding of how antibiotics work along with unregulated drug distributions all helped to contribute to the eventual downfall of penicillin.
Eventually, the lack of drug control led to new strain of resistance that scientists had to coin a new name, methicillin-resistant S. The synergy between increased risk and prolonged exposure in collegiate football players under skin trauma and crowded environments will lead to more sightings of skin and soft tissue infections (SSTIs).  This continuation of CA-MRSA sightings continues to complicate medical treatments since local communities may not have effective treatment methods to deal with increasingly resistive S. Hence, patients may not be receiving the best form of treatment and, as a result, may cause the bacteria strain to spread and further inflict more damage [4].
Thus, antibiotic treatment alternatives must be readily available and cost-effective compared to today’s antibiotics treatment costs.
The research has indicated that using bacteriophages to target bacteria strains, like CA-MRSA, can be an effective alternative.
Successfully incorporating all these elements can educate the public on how excessive antibiotic usages may have severe consequences. Such genomic plasmids may allow the bacteria to synthesize an enzyme called beta-lactam that cleaves antibiotics, like penicillin, thus rendering them useless. Finally, the last method involves cell-to-cell contact where bacteria use their sex pilus to transfer genomic material to another bacteria [7].
Hence, the nature of antibiotics to target the essential core element of the Central Dogma of “molecular biology” would impede survival.
Despite the antibiotic’s abilities, bacteria were able to develop alternative methods to circumvent penicillin.
Additionally, HGT serves different functions, such as  “drug modifications, target protection, bypass resistance, replacement of susceptible drug target and acquisition of novel efflux pumps” [7].


Not only is targeting specific bacteria strains with bacteriophages a cost-effective method, it is also a highly effective technique to ward off antibiotic resistance [9]. The World Health Organization and the CDC along with other major organizations are teaming together to develop effective policies to deal with drug usages, public awareness, and drug distributions.
It is particularly important to mention that not all bacteria practice all three modes of HGT since it highly depends on their physiologically characteristics and genetic construct.
Meanwhile, the multipurpose horizontal gene transfer provides a perfect cyclic ecosystem of community sharing among the microorganism world, while it brings both complexity and complications to the medical community and patients, in the form of treatment failure and antibiotic resistance. During this time, what helped worsen the dilemma was that scientists did not completely understand how S. The collaborative efforts are certainly a positive trend to bringing the warfare on antibiotic resistance to a close. Aureus has to constantly maintain its thick peptidoglycan cell wall in order to prolong survival.
Aureus gained resistance against various antibiotics, although they suspected conjugated plasmids had a role in horizontal gene transfer.
Any disruption to the construction of its thick peptidoglycan cell wall would prove lethal to the microorganism. HGT allowed susceptible strains to attain the SCCmecA staphylococcal chromosomal cassette, a plasmid that can successfully integrate itself into the chromosome for replication and usage [3, 5, 7, 8].
Aureus gained the ability to overt cell death induced by antibiotics, it can construct conjugated plasmids and pass it along to other strains [3]. Destroying enzymes crucial to catalyzing certain cellular functions at certain times would make the S.
Aureus is able to produce a penicillin binding protein called PBP2a that, when unregulated, will allow this organism to have low binding affinity against beta-lactam antibiotics like penicillin, methicillin, oxacillin [8]. Accurate and rapid detection of MRSA permits timely implementation of effective antimicrobial therapy, preventive infection control strategies like immediate patient isolation (and occasional ward closure), screening of the patient contacts and staff, and appropriate disinfection measures which in turn reduce the costs. Discrepancies in detection have an adverse effect on patient management, thereby highlighting the importance of accuracy in detection. Hence, methods used to detect MRSA in clinical samples should have high sensitivity and specificity and, most importantly, the result should be available within a short time.
Various methods have evolved for rapid detection of methicillin-resistant staphylococci, but the optimal method for the detection remains controversial. The most commonly used method in the laboratories is culture and antibiotic sensitivity test (AST) [oxacillin disk diffusion (ODD)].
Other methods available for diagnosing MRSA include mannitol salt agar (MSA) with oxacillin (agar screening method), minimum inhibitory concentration (MIC) tests, agar dilution tests etc., All these tests are the conventional phenotypic methods of MRSA identification. This in turn helps to prevent the emergence of new antibiotic-resistant strains as well as the spread of MRSA.
The study was started after getting the ethical clearance from the Scientific Research Committee of the institution.
They were tested for methicillin resistance based on modified Kirby-Bauer disk diffusion method using oxacillin disks (1 μg) on Mueller-Hinton agar in accordance with the Clinical and Laboratory Standards Institute (CLSI) guidelines using the criteria of standard zone sizes of inhibition to define sensitivity or resistance. Bacteria were lysed by irradiation in a microwave oven using seven pulses of 60 s each with a 60 s interval in between.
Twenty microliters of the reaction mixture was loaded onto a 1.0% agarose gel with ethidium bromide.
The ODD and the MSA method results were compared with the mecA PCR results using two-way contingency table analysis. The conventional microbiological method, culture and sensitivity using oxacillin antibiotic disk (ODD), detected 75 (45.45%) MRSA. Four of the PCR-positive samples were detected as MSSA (not detected as MRSA) by ODD method.
Eight of the PCR-positive samples were detected as MSSA (not detected as MRSA) by oxacillin screen agar method.
Of the 103 PCR-negative samples, 11 samples were detected as MRSA by oxacillin screen agar method.The ODD and the MSA method results were compared using two-way contingency table analysis. All the tests were compared for different parameters like speed, cost of treatment, sensitivity, and specificity with PCR for mecA gene, which is considered gold standard. These findings revealed by our study are similar to those of many studies conducted in different parts of the world.
The lower levels of the confidence intervals of both sensitivity and specificity are far below 90%, which cannot be accepted for a method used for diagnosing methicillin resistance in S. Misdiagnosing seven MRSA isolates is not acceptable because if these isolates are not diagnosed as MRSA, the treatment pattern changes. The patient, instead of receiving vancomycin, will be prescribed other line of treatment normally given for MSSA. More alarming situation is that by this time, MRSA would have been spread to other patients or health personnel.
Ultimately, the cost of the whole treatment increases and the spread of MRSA in the hospital as well as the community will result.
So, on comparison, the expenses due to the wrong diagnosis (missing MRSA) will be far more than the cost of PCR. Four isolates were detected as MSSA by ODD test (phenotypically methicillin-susceptible strains) and eight isolates by MSA with oxacillin method.The reason for these four to eight MRSA isolates detected as MSSA by the conventional methods can be attributed to the fact that accurate determination of methicillin resistance in staphylococci by conventional tests is subject to variations in inoculum size, incubation time, medium pH, medium salt concentration, etc.
MSA with oxacillin method detected 92 MSSA and 11 MRSA.The reason for this phenomenon (17 false positives) has been ascribed to the heterogeneous expression of methicillin resistance in many strains. Most of these isolates expressed resistance at the borderline of the inhibition zone and were thus termed "moderately resistant S. Under some test conditions, low-level resistance may also be seen in isolates which produce large amounts of penicillinase (penicillinase hyper producers), and these isolates have been referred to as "borderline oxacillin- resistant S.
With homogenous expression, virtually all cells express resistance when tested by standard in vitro tests.
However, testing of hetero-resistant isolates may result in some cells that appear susceptible and others resistant. Often only 1 in 10 4 to 1 in 10 8 mecA positive cells in the test population express resistance and heterogeneous expression results in isolates that appear to be borderline.
The clinical problem posed by such isolates is that during chemotherapy with β-lactam antibiotics, production of PBP-2a may be induced, converting them into oxacillin-resistant strains. Hence detection of mecA gene is indispensable for precise differentiation of MRSA, and thus the PCR is a useful technique in clinical laboratories.The PCR technique has many added advantages over the conventional techniques.
The false-negative results of the conventional methods can be picked up by the PCR at a very early stage of the disease. PCR could accurately demonstrate the presence of mecA gene within 5 h of bacterial isolation and is a useful tool for rapid and unequivocal identification of MRSA. The expenses and workload of single PCR exceed the demand of testing one clinical specimen for the presence of MRSA.
But if the daily number of MRSA screening tests increases, the workload per PCR decreases and finally outweighs the expenses for molecular reagents The time taken for diagnosing MRSA by conventional methods is 48-72 h, which is more as compared to PCR which takes 18-24 h. But statistical analysis of the cost effectiveness revealed that PCR is the best option.Our study concludes that the commonly used phenotypic tests are not completely reliable for the detection of methicillin resistance in S. Increasing the number of samples for PCR on a regular basis will decrease the cost of a single PCR.
This study advocates PCR for mecA gene on a regular basis for detecting methicillin resistance in S. Nilotpal Chowdhury, Associate Professor, Department of Pathology, is acknowledged for helping us with statistical analysis.



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