Original article | Volume 34, Article 196, 12 Dec 2019 | 10.11604/pamj.2019.34.196.16645

Molecular characteristics of Staphylococcus aureus nasal carriage among health care workers at a referral hospital in Zabol, Iran

Hamid Vaez, Zahra Rashki Ghalehnoo

Corresponding author: Zahra Rashki Ghalehnoo, Department of Microbiology, School of Medicine, Zabol University of Medical Sciences, Zabol, Iran

Received: 24 Jul 2018 - Accepted: 05 Nov 2019 - Published: 12 Dec 2019

Domain: Infectious disease

Keywords: Hospital-acquired infection, methicillin-resistant S. aureus, nasal carriage, S. aureus

©Hamid Vaez et al. Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite this article: Hamid Vaez et al. Molecular characteristics of Staphylococcus aureus nasal carriage among health care workers at a referral hospital in Zabol, Iran. Pan African Medical Journal. 2019;34:196. [doi: 10.11604/pamj.2019.34.196.16645]

Available online at: https://www.panafrican-med-journal.com/content/article/34/196/full

Home | Volume 34 | Article number 196

Original article

Molecular characteristics of Staphylococcus aureus nasal carriage among health care workers at a referral hospital in Zabol, Iran

Molecular characteristics of Staphylococcus aureus nasal carriage among health care workers at a referral hospital in Zabol, Iran

Hamid Vaez1, Zahra Rashki Ghalehnoo1,&


1Department of Microbiology, School of Medicine, Zabol University of Medical Sciences, Zabol, Iran



&Corresponding author
Zahra Rashki Ghalehnoo, Department of Microbiology, School of Medicine, Zabol University of Medical Sciences, Zabol, Iran




Introduction: Staphylococcus aureus (S. aureus) is known as one of the most important hospital pathogens responsible for a wide range of infections. Limited data concerning the prevalence of nasal carriage of S. aureus and its molecular characteristics are available in Zabol province, Iran. Therefore, the aim of the present study was to determine the prevalence of nasal carriage of S. aureus and its molecular characteristics isolated from health care workers (HCWs).


Methods: totally, 251 nasal swabs were collected from HCWs at a referral hospital, from March to September 2017. Disk diffusion method was used to identify Methicillin-Resistant S. aureus (MRSA). PCR amplification method was used for the detection of following genes; sea, seb, sec, sed, see, tst, eta, etb, lukF-PV, lukS-PV and SCCmec types.


Results: of 251 collected swabs, 31 (12.4%) cases were identified as S. aureus carriers, which 14 (14/31; 45.2%) isolates were MRSA. The most prevalent detected genes were sea and tst, with 22.6% and 9.7%, respectively. The most prevalent SCCmec type was SCCmec type IV (28.6%).


Conclusion: we found that the prevalence of MRSA nasal carriage is at high level and must be considered as a significant health care problem at the investigated hospital. Strict implementation of infection-control policies and rational use of antibiotics are the main pillars for controlling the spread of S. aureus at hospital.



Introduction    Down

Staphylococcus aureus (S. aureus) is recognized as one of the most important community-acquired and hospital-associated pathogens that is responsible for a wide range of infections including blood stream infections, soft tissue infections, pneumoniae and urinary tract infections [1]. In human, S. aureus colonizes various sites of the body; however, the anterior nares are the main ecological niches for S. aureus and it has been reported that 20-30% of individuals are persistent carriers of S. aureus and around 30% are transient carriers [2]. S. aureus can evade host immune system defense barriers by producing different enzymes and toxins. In fact, a strong correlation between toxins and disease has been reported. The main S. aureus toxins have been divided into following three groups; 1) pore-forming toxins (Hemolysin-α, Hemolysin-β, Leukotoxin and γ- Hemolysin), 2) exfoliative toxins (ETs) and 3) superantigens toxins (toxic shock syndrome toxin and the staphylococcal enterotoxins) [3]. When first introduced, penicillin has a substantial impact on S. aureus, however, it was gradually replaced with other beta-lactam antibiotics due to the emergence of beta-lactamase producing strains of S. aureus [4,5]. Methicillin was introduced to treat infection caused by penicillin resistant isolates, but occurrence of resistance for isolates of S. aureus (MRSA) to methicillin resulted in reducing the efficacy of antibiotic. In fact, MRSA isolates harbor mecA gene responsible for production of modified penicillin-binding-protein (PBP) called PBP2a with low affinity for beta-lactam antibiotics [4,5]. This resistance gene (mecA) is located on a genetic element called staphylococcal cassette chromosome (SCC). Based on genetic elements and composition, two types of MRSA have been identified, community acquired methicillin-resistant S. aureus (CA-MRSA) and hospital acquired methicillin-resistant S. aureus (HA-MRSA). Five main types of SCCmec have been characterized. Types I, II and III are the most prevalent types in HA-MRSA, whereas types IV and V are the most often associated with CA-MRSA [4,5]. Health care workers (HCWs), identified as nasal carrier of S. aureus, play an important role in the transmission of S. aureus infections within and between wards [6]. To reduce the spread of S. aureus infections for hospital screening of HCWs and obtain knowledge about virulence factors, genetic diversity can provide useful information for adapting infection control programs. Therefore, the aim of this study was to determine the prevalence of nasal carriage of S. aureus and its molecular characteristics isolated among HCWs at a referral hospital in Zabol province, southeast of Iran.



Methods Up    Down

Study design and setting: this cross-sectional study was carried out from March to September 2017 at Amir-al-momenin hospital affiliated to Zabol University of Medical Sciences, Iran. This hospital is the only referral hospital in the region with 224 beds, serving about four hundred thousand people.


Sample collection and bacterial identification: we collected samples from staffs who were consent to participate in the study. Participants were excluded if they had history of antibiotics consumption in three weeks prior to sample collections. Sterile cotton swab was used to collect sample from nasal cavity of participated HCWs. For all participants, sex and job were recorded. Nasal swabs were immediately inoculated onto Mannitol Salt Agar (Himedia, India). After 24-48 hours incubation at 37oC, S. aureus were identified by common standard microbiological tests including catalase, Gram staining, DNase and coagulase [7].


Antimicrobial susceptibility testing: to identify MRSA isolates, disk diffusion method (cefoxitin 30 g, MAST, UK) was used according to Clinical Laboratory Standard Institute (CLSI) guidelines [8]. All isolates were confirmed by mecA-specific primers and PCR [9].


Molecular identification of SCCmec types by multiplex-PCR: bacterial genomic DNAs were extracted according to previously described methods [5]. All mecA positive isolates were subjected to SCCmec typing by using previously designed primers and conditions [10].


Molecular detection of virulence genes: the PCR amplifications were carried out on extracted DNAs for the detection of following genes; sea, seb, sec, sed, see, tst, eta, etb, lukF-PV and lukS-PV [11,12]. All PCR amplifications were carried out by Ampliqon (Denmark) ready to use master mix. The PCR products were separated by electrophoresis on a 1% agarose gel. Separated bands were stained with Sybr safe (Thermo Fisher Scientific Inc.) and visualized picture was captured on Gel-documentation system (Uvitec, UK).


Statistical analysis: data entry and statistical analysis were performed using SPSS version 16 (SPSS Inc., Chicago, IL) software and Chi-square or exact Fisher´s tests. P < 0.05 was considered statistically significant.


Ethical considerations: this study was approved by the Ethics committee of Zabol University of Medical Sciences, Zabol, Iran (Code: zbmu.1.REC.1396.34).



Results Up    Down

In this study, 251 nasal swabs were totally collected from HCWs. Of 251 taken swabs, 180 (71.7%) and 71 (28.3%) ones belonged to female and male, respectively. The most percentage of samples were taken from nurses with 59.3% (149), followed by midwives with 14.4% (36), operating room technicians with 12% (30), laboratory staffs with 9.6% (24), nurse assistants with 4.4% (11) and physicians with 0.3% (1) of total samples. Among these samples, 31 (12.4%) cases were S. aureus carriers including nurses 15 (15/149; 10%), laboratory staffs five (5/24; 20.1%), midwives four (4/36; 11.1%), operating room technicians three (3/30; 10%), nurse assistants three (3/11; 27.2%) and physicians one (1/1; 100%). Out of 31 isolated S. aureus 14 (14/31; 45.2%) isolates were MRSA. As shown in Table 1, the results of PCR analysis revealed that 21.4% of MRSA and 23.5% of methicillin-susceptible S. aureus (MSSA) were sea positive (p =0.8). The prevalence of tst among MRSA and MSSA isolates were 14.3% and 5.8%, respectively (p = 0.4). Other virulent genes were not detected. The results of SCCmec typing showed that 28.6% and 7.1% of MRSA harbored SCCmec type IV and I, respectively. The rest of the isolates were untypable.



Discussion Up    Down

S. aureus is one of the most important nosocomial pathogens and is the leading cause of life-threating infections such as bacteremia, pleuropulmonary, infective endocarditis and soft tissue infections [13]. The transmission of S. aureus at hospitals is usually occurred by direct skin-to-skin contact or indirect contact via contaminated medical devices and surfaces [14]. Regarding to the important role of HCWs in performing health-care practices, rapid identification of HCWs carriers will result in reduction of life-threating infections caused by this microorganism. To best our knowledge, the prevalence of S. aureus nasal carriage among HCWs in Zabol province has not been determined and this is the first report. In this study, nasal carriage of S. aureus was identified in 12.4% of studied HCWs. This prevalence is lower than previous reports from different provinces of Iran. For example, a study conducted by Askarian et al. in Shiraz province, southwest of Iran, showed that 31% of studied HCWs were S. aureus carriers [15]. Furthermore, in Isfahan and Ilam provinces, the prevalence of S. aureus among HCWs was 19% and 37%, respectively [4,16]. A comprehensive study conducted by Emaneini et al. revealed that the average mean prevalence of HCWs carriers in different provinces of Iran was 22.7% [2]. It has been reported that differences in nasal carriage rate of S. aureus are dependent on different factors, such as age, alcoholism, chronic disease, as well as variations in sample size, identification methods and infection control measures [2,4]. Based on our results, the prevalence of MRSA was 45.2%. This finding is remarkably higher in comparison with study conducted by Khanal et al. (21.9%) and Dulon et al. (0.2% -14.5%) in Nepal and European countries, respectively [17,18]. Moreover, similar studies conducted in other provinces of Iran revealed that the prevalence of MRSA was between 30% and 77% [2,19,20]. There are several factors that may explain these differences, for example, sample size, culture techniques, infection control measures, such as hand hygiene, limited infrastructure, lack of sufficient personnel protective equipment and most important of all, lack of sufficient knowledge about transmission routes are known to be the most important reasons [21]. In this study the prevalence of the most important virulence factors of S. aureus was investigated. Our results revealed that the most prevalent virulence factor was enterotoxin A (22.6%) followed by toxic shock toxin (9.7%) and enterotoxin C (3.2%). Other virulence genes such as seb, sed, see, eta and etb were not detected. These results are in agreement with other reports from Malaya and Spain [22,23]. We did not identify any significant correlation between the existence of virulence factors and resistance to methicillin. However, other studies have suggested significant association between enterotoxin and resistance to methicillin, and have reported that etb was more prevalent in MRSA and eta was mainly prevalent in MSSA [24]. This discrepancy can be related to origin of bacteria, selective pressure and host conditions [23,25,26]. For example, results of other study conducted by Schlievert et al. revealed that some clonal types of S. aureus with as specific genotypes are mostly prevalent in severe infections and are contributed to poor patients' outcomes [25].



Conclusion Up    Down

We found that the prevalence of S. aureus nasal carriage at the investigated hospital is lower than most provinces of Iran. However, the prevalence of MRSA is alarmingly high and must be taken into consideration for designing infection control programs. This high rate nasal MRSA carriage among HCWs of investigated hospital can be attributed to misuse of antibiotics, poor compliance to hand hygiene, and ineffective implementation of infection control rules. Our results revealed that in order to prevent infection by S. aureus with considerable virulence factors at the investigated hospital constant monitoring and appropriate eradication of nasal carriage must be performed.

What is known about this topic

  • Staphylococcus aureus strains are considered a serious public health concern worldwide, causing different kind of infections including blood stream infections, wound infections and pneumoniae;
  • methicillin-resistant Staphylococcus aureus (MRSA) is identified as a hospital-acquired pathogen that due to production of different virulence factors and emergence of several antibiotic resistance mechanisms are associated with high mortality and morbidity in hospitals

What this study adds

  • The prevalence of methicillin-resistant Staphylococcus aureus strains in Zabol hospital is alarmingly high;
  • molecular analysis revealed that sea and tst were the most prevalent virulence factors in identified S. aureus strains;
  • staffs of investigated hospital could be potential sources of MRSA, therefore elimination of strains from nasal carriage can hamper spread of MRSA infections in Zabol hospital.



Competing interests Up    Down

The authors declare no competing interests.



Authors' contributions Up    Down

Study design, data collection, data interpretation, funds collection: Zahra Rashki Ghalehnoo; Data interpretation, literature review, laboratory procedures, manuscript preparation: Hamid Vaez. All the authors read and approved to the final version of the manuscript.



Acknowledgments Up    Down

We would like to thank the staff of the laboratory of microbiology.



Table Up    Down

Table 1: molecular characteristics of MRSA and MSSA from nasal carriage of HCWs



References Up    Down

  1. David MZ, Daum RS. Community-associated methicillin-resistant Staphylococcus aureus: epidemiology and clinical consequences of an emerging epidemic. Clin Microbiol Rev. 2010;23(3):616-87. PubMed | Google Scholar

  2. Emaneini M, Jabalameli F, Rahdar H, Leeuwen WB, Beigverdi R. Nasal carriage rate of methicillin resistant Staphylococcus aureus among Iranian healthcare workers: a systematic review and meta-analysis. Rev Soc Bras Med Trop. 2017;50(5):590-7. PubMed | Google Scholar

  3. Oliveira D, Borges A, Simes M. Staphylococcus aureus Toxins and Their Molecular Activity in Infectious Diseases. Toxin Rev. 2018;10(6):1-19. PubMed | Google Scholar

  4. Karimi M, Esfahani BN, Halaji M, Mobasherizadeh S, Shahin M, Havaei SR et al. Molecular characteristics and antibiotic resistance pattern of Staphylococcus aureus nasal carriage in tertiary care hospitals of Isfahan, Iran. Infez Med. 2017;25(3):234-40. PubMed | Google Scholar

  5. Vaez H, Tabaraei A, Moradi A, Ghaemi EA. Evaluation of methicillin resistance Staphylococcus aureus isolated from patients in Golestan province-north of Iran. Microbiol Res J Int. 2011;5(4):432-6. Google Scholar

  6. Albrich WC, Harbarth S. Health-care workers: source, vector, or victim of MRSA? Lancet Infect Dis. 2008;8(5):289-301. PubMed | Google Scholar

  7. Mahon C, Lehman D, Manuselis G. Texbook of diagnostic microbiology. 2011;4th ed.Elsevier.

  8. Clinical and Laboratory Standards Institute. CLSI Document.M100-S24. Wayne, Pa, USA: Clinical and Laboratory Standards Institute.Performance standards for antimicrobial susceptibility testing.

  9. Murakami K, Minamide W, Wada K, Nakamura E, Teraoka H, Watanabe S. Identification of methicillin-resistant strains of staphylococci by polymerase chain reaction. J Clin Microbiol. 1991;29(10):2240-4. PubMed | Google Scholar

  10. Zhang K, McClure JA, Elsayed S, Louie T, Conly JM. Novel multiplex PCR assay for characterization and concomitant subtyping of staphylococcal cassette chromosome mec types I to V in methicillin-resistant Staphylococcus aureus. J Clin Microbiol. 2005;43(10):5026-33. PubMed | Google Scholar

  11. Jarraud S, Mougel C, Thioulouse J, Lina G, Meugnier H, Forey F et al. Relationships between Staphylococcus aureus genetic background, virulence factors, agr groups (alleles) and human disease. Infect Immun. 2002;70(2):631-41. PubMed | Google Scholar

  12. Lina G, Piémont Y, Godail-Gamot F, Bes M, Peter MO, Gauduchon V et al. Involvement of Panton-Valentine leukocidin-producing Staphylococcus aureus in primary skin infections and pneumonia. Clin Infect Dis. 1999;29(5):1128-32. PubMed | Google Scholar

  13. Tong SY, Davis JS, Eichenberger E, Holland TL, Fowler VG. Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management. Clin Microbiol Rev. 2015;28(3):603-61. PubMed | Google Scholar

  14. Bihan CL, Zahar JR, Timsit JF. Staphylococcus aureus transmission in the intensive care unit: the potential role of the healthcare worker carriage. Ann Infec. 2017;1(3). Google Scholar

  15. Askarian M, Zeinalzadeh A, Japoni A, Alborzi A, Memish ZA. Prevalence of nasal carriage of methicillin-resistant Staphylococcus aureus and its antibiotic susceptibility pattern in healthcare workers at Namazi Hospital, Shiraz, Iran. Int J Infect Dis. 2009;13(5):241-7. PubMed | Google Scholar

  16. Hematian A, Monjezi A, Abiri R, Mohajeri P, Farahani A, Soroush S et al. Clonal lineage diversity, antibiotic resistance, and virulence determinants among methicillin-resistant and methicillin-susceptible Staphylococcus aureus isolated from nurses at a teaching hospital in Ilam, Iran: Successful nares decolonization by mupirocin. J Global Infect Dis. 2018;10(2):67-73. PubMed | Google Scholar

  17. Khanal R, Sah P, Lamichhane P, Lamsal A, Upadhaya S, Pahwa VK. Nasal carriage of methicillin resistant Staphylococcus aureus among health care workers at a tertiary care hospital in Western Nepal. Antimicrob Resist Infect Control. 2015;4:39. PubMed | Google Scholar

  18. Dulon M, Peters C, Schablon A, Nienhaus A. MRSA carriage among healthcare workers in non-outbreak settings in Europe and the United States: a systematic review. BMC Infect Dis. 2014;14:363. PubMed | Google Scholar

  19. Afrough P, Pourmand MR, Sarajian AA, Saki M. Molecular investigation of Staphylococcus aureus, coa and spa genes in Ahvaz hospitals, staff nose compared with patients´ clinical samples. Jundishapur J Microbiol. 2013;6(4):1-7. Google Scholar

  20. Kalhor H, Validi M, Nafisi MR. Evaluation of the frequency of methicillin resistant Staphylococcus isolated from nose of nursing personnel of Hajar Hospital of Shahrekord. Qom Univ Med Sci J. 2013;7(1):42-9. Google Scholar

  21. Alp E, Damani N. Healthcare-associated infections in intensive care units: epidemiology and infection control in low-to-middle income countries. J Infect Dev Ctries. 2015;9(10):1040-5. PubMed | Google Scholar

  22. Lim KT, Hanifah YA, Mohd Yusoff MY, Thong KL. Investigation of toxin genes among methicillin resistant Staphylococcus aureus strains isolated from a tertiary hospital in Malaysia. Asian Pac J Trop Biomed. 2012;29(2):212-9. PubMed | Google Scholar

  23. Lozano C, Gmez-Sanz E, Benito D, Aspiroz C, Zarazaga M, Torres C. Staphylococcus aureus nasal carriage, virulence traits, antibiotic resistance mechanisms, and genetic lineages in healthy humans in Spain, with detection of CC398 and CC97 strains. Int J Med Microbiol. 2011;301(6):500-5. PubMed | Google Scholar

  24. Netsvyetayeva I, Fraczek M, Piskorska K, Golas M, Sikora M, Mlynarczyk A et al. Staphylococcus aureus nasal carriage in Ukraine: antibacterial resistance and virulence factor encoding genes. BMC Infect Dis. 2014;14(1):128. PubMed | Google Scholar

  25. Schlievert PM, Strandberg KL, Lin YC, Peterson ML, Leung DY. Secreted virulence factor comparison between methicillin-resistant and methicillin-sensitive Staphylococcus aureus, and its relevance to atopic dermatitis. J Allergy Clin Immunol. 2010;125(1):39-49. PubMed | Google Scholar

  26. Otto M. Basis of virulence in community-associated methicillin-resistant Staphylococcus aureus. Annu Rev Microbiol. 2010;64:143-62. PubMed | Google Scholar






























Original article

Molecular characteristics of Staphylococcus aureus nasal carriage among health care workers at a referral hospital in Zabol, Iran

Original article

Molecular characteristics of Staphylococcus aureus nasal carriage among health care workers at a referral hospital in Zabol, Iran

Original article

Molecular characteristics of Staphylococcus aureus nasal carriage among health care workers at a referral hospital in Zabol, Iran