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Bloodstream infections with emphasis on Methicillin-resistant Staphylococcus aureus at the University of Gondar Comprehensive Specialized and Referral Hospital, Northwest Ethiopia

BMC Infectious Diseases volume 25, Article number: 663 (2025) Cite this article

Abstract

Background

Staphylococcus aureus is the most common cause of bloodstream infections worldwide. Methicillin-resistant S. aureus is becoming more prevalent in bacteremia and septicemia cases. Thus, this study determined Staphylococcal bacteremia, Methicillin-resistant S. aureus infections, and antimicrobial susceptibility patterns of the isolates in Northwest Ethiopia.

Methods and materials

This retrospective cross-sectional study was conducted on all age bloodstream suspected patients at the University of Gondar Comprehensive Specialized and Referral Hospital from January 1th 2022 to June 30th, 2022. Data were collected using a designed data extraction tool. Blood samples were collected and inoculated to a sterile Tryptic Soya Broth. Bottles with bacterial growth were subcultured to blood agar, chocolate agar, MacConkey agar, and mannitol salt agar plates. Antimicrobial susceptibility testing was performed using the Kirby Bauer disc diffusion technique. The data were entered using Epi-info version 7 and exported to SPSS version 20 for analysis.

Results

Among 1200 patients included in this study, 719 (59.9%) were males. The prevalence of S. aureus and Methicillin-resistant S. aureus was 26.2% (111/424) and 68.5% (76/111), respectively. The blood culture growth rate was 35.3% (424/1200). Among the isolated organisms, Gram-positive cocci account for 217 (51.2%) and Gram-negative bacilli were 173 (41.0%). Among S. aureus isolates, 63.7% were sensitive to gentamicin and 91.9% were resistant to penicillin. A high prevalence of bacteremia was found in males (60.1%) and ward locations at the neonatal intensive care unit (57.1%). Specifically, Methicillin-resistant S. aureus was highly prevalent in males, followed by pediatric age groups, and neonatal intensive care unit, which were 59.2%, 56.6%, and 44.7%, respectively.

Conclusion

In this study, the prevalence of Methicillin-resistant S. aureus bacteremia was high, indicating its spread in hospital settings such as intensive care units. This requires routine detection, molecular characterization of mecA gene, and improved infection prevention at the healthcare facility.

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Introduction

Staphylococcus aureus, a Gram-positive cocci remains a significant cause of mortality and morbidity in tropical countries [1]. It is one of the most common causes of bloodstream infections (BSI) worldwide and is challenging the treatment because of its multi-drug resistance [2]. Before the antibiotic era, S. aureus bacteremia had a mortality of approximately 80%. Despite advances in antimicrobial therapy and intensive care support, the overall rate of mortality continues to be high, ranging from 10.0% to more than 40.0% [3, 4].

Methicillin-resistant S. aureus (MRSA) was first described in 1961, and since then, it has become a worldwide problem [2, 5]. During the last decade, infections due to MRSA have become increasingly common in hospitals worldwide [6]. Sepsis caused by MRSA is widely recognized by the public and the general medical community as a problem associated with health care [7]. Mortality associated with MRSA bacteremia has been reported to be significantly higher than Methicillin-sensitive S. aureus, adding to the unresolved issue of increased virulence of MRSA [8]. A systematic review and meta-analysis reported a 14.7% global pooled prevalence of MRSA in residents of elderly care centers [9]. The presence of mecA, which codes for a penicillin-binding protein, reduces the affinity of beta-lactam antibiotics and causes resistance to methicillin [10].

The burden of antimicrobial resistance on economic growth is much greater in low-income countries, such as Ethiopia countries. According to the previous studies in the study area, the prevalence of MRSA causing a variety of infections ranging from 11.1 to 63.0% [11,12,13,14]. However, there is no report on the resistance profiling of MRSA causing BSI in the study area. Hence, this study determined the burden of MRSA in blood culture specimens and antimicrobial susceptibility patterns of S. aureus isolates. It would be beneficial for medical practitioners for selecting effective antimicrobial therapy to minimize the emergence rate of antimicrobial resistance.

Methods and materials

Study setting, period, and design

This retrospective cross-sectional study was conducted at the University of Gondar Comprehensive Specialized and Referral Hospital (UoGCSRH), Gondar from January 1th 2022 to June 30th, 2022. Gondar town is 747 km far from Addis Ababa, the capital city of Ethiopia, and 170 km from Bahir Dar, the Amhara Regional State. According to the central statistics agency, the town has a total population of 315,856(154,767 females and 161,087 males). The UoGCSRH is one of the biggest tertiary-level teaching hospitals in the region with more than 500 beds. The hospital is used as a referral center for more than 10 million people in its catchment population [15]. The microbiology laboratory is the main section to process a high number of the specimens per day for identification of infection causative agents and selection of antimicrobial agent for better decision of the physician.

Study population

All patients suspected with BSI attending UoGCSRH for health services during the study period with recorded necessary information were taken as a study population. Data recorded from 2019 to 2022 in the microbiology culture registration book that has at least sex, age, and type of ward were included in the study. Data recorded with incomplete age, sex, and ward type were excluded from the study.

Operational definition

Sepsis: Presence of two or more of the following conditions: axillary temperature > 38 C or < 36 C, cardiac frequency > 90, respiratory frequency > 20 breaths/min or PaCO2 < 32 mmHg, leukocyte count > 12 000 leucocytes/mm3 or < 4000 leucocytes/mm3, or 10% of immature forms [16].

Data collection procedure

A consecutive data was collected using a retrospective review of laboratory records of blood specimen cultures from all patient departments at UoGCSRH. A data collection tool was used to collect patients’ sociodemographic and laboratory data such as age, sex, type of ward, culture results, bacterial isolate, and antimicrobial susceptibility pattern results from the laboratory registration books.

Laboratory methods

Blood sample collection, processing, and identification of bacterial isolates

Every patient who had a fever at the time of diagnosis had blood samples taken for culturing (10 mL for adults and 3 mL for children). Before using antibiotics, skilled nurses aseptically (by cleaning with 70% alcohol and 2% tincture of iodine) took blood samples from two separate peripheral vein sites. Following collection, the blood samples were placed in sterile tryptic soy broth culture vials (Oxoid Ltd., Basingstoke, UK). For up to seven days, bottles were incubated at 37 °C and monitored daily for indications of bacterial development, such as turbidity, hemolysis, and clot formation. Bottles exhibiting growth were then subcultured on mannitol salt agar, blood agar, chocolate agar, and MacConkey agar. These plates were then incubated at 35 to 37 °C in an aerobic environment for 18 to 24 h. The colony morphology and Gram staining reaction were used to identify the bacterial isolates in the first place. Biochemical tests were therefore performed on the identified isolates (indole, citrate, triple sugar iron agar, oxidative/fermentative, urease, coagulase, catalase, and oxidase test for confirmation). Several phenotypic assays, such as Gram-positive cocci, catalase-positive, coagulase-positive, mannitol-fermentative, and beta-hemolytic in the blood agar plate, were used to confirm S. aureus.

Antimicrobial susceptibility testing

Using the Kirby-Bauer method on Mueller-Hinton agar, all S. aureus isolates were tested against penicillin (10 µg), gentamicin (10 µg), tobramycin (10 µg), and cefoxitin (30 µg) (Oxoid Ltd., Basingstoke, UK). The test organism was made into a suspension in peptone water and matched to 0.5 McFarland standards. The suspension was turned into a culture on a Mueller–Hinton agar plate using a sterilized cotton swab. The antibiotic discs were incubated at 35–37°C for 16–18 h after being arranged on the agar plate with a 25 mm gap between each disk. Each antibiotic’s zone of inhibition was assessed and the results were classified as sensitive, intermediate, and resistant according to CLSI recommendations from 2022 [17]. Methicillin resistance among S. aureus isolates was detected using cefoxitin (30 µg) antibiotic disc as a surrogate marker [18].

Quality control

The sterility of prepared culture media was checked by incubating 5% of the batch at 35-37°C overnight and evaluated for possible contamination. The control strains of S. aureus ATCC 25,923 and E. coli ATCC 25,922 were used to ensure the performance of culture media. Internal quality control was carried out to prevent technical problems that can arise during data collecting. Every day, each data collector’s data collection form was reviewed by the principal investigator and other data collectors to ensure it contained all pertinent information about meetings and supervision throughout data collection.

Data analysis and interpretation

Data were entered into Epi-info version 7 and exported into SPSS version 20 for statistical analysis. Descriptive statistics were computed to correlate the sociodemographic characteristics of the participants and the bacteriological profiles. The results were presented by percent and number using a table and chart.

Results

Sociodemographic characteristics of the study participants

A total of 1200 patients were given blood specimens for culture analysis. Among those, males were the predominant which was 719(59.9%) The mean age of the study participants was 20.92 with a standard deviation of 19.454 with a minimum age of 1 day and a maximum age of 96 years. The pediatric age (596; 49.7%) was predominant followed by neonate (437; 36.4%) respectively. Based on the patient location, neonatal intensive care unit (NICU), and pediatric emergency accounts are high, which were 542(45.1%) and 346(28.8%) (Table 1).

Table 1 Sociodemographic characteristics of the study participants
Full size table

Prevalence of bacterial isolates in blood culture

The overall prevalence of bacteria isolated from blood cultures of bacteremia-suspected patients was 35.3% (424/1200). Among those, males were high prevalent of bacteremia than females, 60.1% and 39.9% respectively. Based on location, a high prevalence of bacteremia was found in the NICU (57.1%) (Table 2). All infections were due to a single organism. Among the isolated organisms, Gram-positive cocci account for 217 (51.2%) and Gram-negative bacilli were 173 (41.0%) (Fig. 1).

Table 2 Blood culture positivity rate
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Fig. 1
figure 1

Distribution of organisms isolated from blood samples. Abbreviations: CONS; Coagulase-negative Staphylococcus aureus, GNB; Gram-negative bacilli

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Fig. 2
figure 2

Prevalence of MRSA among blood culture

Full size image

Prevalence of Staphylococcal bacteremia

From the isolated Gram-positive cocci, S. aureus accounts for 51.1% and CoNS (25.0%). The overall prevalence of S. aureus bloodstream infection was 26.2% (111/424) (Fig. 1). Among the isolated Staphylococcal bacteremia, 76 (68.5%) were MRSA (Fig. 2). It was highly prevalent in males, followed by pediatric age groups and NICU, which were 59.2%, 56.6%, and 44.7%, respectively (Table 3).

Table 3 Characteristics of patients from which MRSA was isolated
Full size table

Antimicrobial profile of Staphylococcal bacteremia

Among the antimicrobials tested, S. aureus was resistant to 91.9% penicillin and 68.5% cefoxitin which was MRSA while sensitive to 63.9% gentamicin and 62.2% tobramycin (Table 4).

Table 4 Antimicrobial susceptibility patterns of S. aureus
Full size table

Discussion

Methicillin-resistant Staphylococcus aureus has become a significant problem in medical facilities worldwide, accounting for 40-86% of nosocomial bacteremia [6]. Even though there are improvements in diagnosis and care, bacterial BSI continues to be a leading cause of morbidity and death, especially for newborns in underdeveloped nations. Recently, the etiologic agents that cause BSI and their patterns of antibiotic susceptibility have been changed. Thus, this study determined the burden of MRSA causing BSI and antimicrobial susceptibility pattern in a tertiary teaching hospital, Northwest Ethiopia.

In this study, S. aureus was the most predominant Gram-positive bacteria identified (26.2%). The finding was in line with a study conducted in Saudi Arabia; 25% [19], but lower than a study conducted in Arba Minch, Ethiopia; 31.8% [20], Mekele, Ethiopia; 37.5% [21], Nepal; 52% [22], and India 38.6% [23]. Our result was higher than a study conducted in Gondar, Ethiopia; 23.9% [24] in 2013, Addis Ababa, Ethiopia; 23.2% [25], India; 10.6% [26], USA; 16.5% [27], and Italy; 18.3% [28]. A probable reason for the highest prevalence of S. aureus could be its widespread presence in hospital environments as a contaminant, which might have invaded the admitted patients, eventually establishing infections. Moreover, it is also a commensal of skin and mucous membranes and may further invade the patient during surgery or instrumental manipulations [29].

In the present study, S. aureus was 64% sensitive to gentamicin, which was supported by studies in Arba Minch, Ethiopia [20], Nigeria [1], India [26], Pakistan [30], and Nepal [22]. In our study, the prevalence of MRSA was 68.5%. This finding was higher than a study conducted in Arba Minch, Ethiopia; 57% [20], Addis Ababa, Ethiopia; 38.5% [25], Saudi Arabia; 29% [19], Saudi Arabia; 42.8% [31], New Zealand; 24.1% [7], Australia; 40% [4], Taiwan; 49.8% [6], Birmingham; 59% [8], Canada; 26.1% [32], Latin America; 44.7% [2], Spain; 24.8% [33], and Hong Kong; 46% [34]. Our finding was lower than a study conducted in Iran which was 79% [35] and India; 70.6% [23]. This difference could be due to prolonged hospital stays, instrumentation, and other invasive procedures. As the usage of antibiotics has increased, bacteria have had to adapt and develop sophisticated mechanisms to survive. Different single nucleotide sequences and mutations in the genome of MRSA cause it to develop resistance against long-used antibiotics used for MRSA treatment [36].

In this study, the prevalence of MRSA was high in males, followed by pediatric age groups and NICU, which were 59.2%, 56.6%, and 44.7%, respectively. This finding was supported by a study conducted in Iran [5]. A meta-analysis reported a 7.2% estimated cumulative incidence rate of MRSA colonization in neonates within NICU [37]. It is related to the weak defense mechanisms and interventions such as catheterization, mechanical ventilation, and surgical procedures [38]. On the other hand, some studies suggested that it was high in older age groups and females [16, 39]. This variation might be due to the number of study participants, which was high neonates included in our study.

Limitations of the study

The main drawback of this study was the lack of patient details recorded in the laboratory registration book, which restricts performing the association of possible associated factors with the presence of S. aureus. Another limitation was the absence of full antibiotic susceptibility pattern of all the bacterial isolates because of missing recorded data and our intention to focus on the frequently isolated MRSA in the hospital. Moreover, the detection of mecA gene was not conducted because of resource limitation of the hospital with no trend for the use of molecular techniques for routine patient diagnosis.

Conclusion and recommendations

In this study, a high prevalence of MRSA was detected in BSI, with higher burden in males, pediatric age groups, and intensive care units. Strict laboratory aseptic techniques and infection prevention practices in healthcare facility should be implemented. Additionally, application of advanced techniques is vital for molecular characterization of resistance genes such as mecA gene.

Data availability

All the necessary data are available within the manuscript and additional information could be provided by the corresponding author upon reasonable request.

Abbreviations

BSI:

Bloodstream infection

MRSA:

Methicillin-resistant Staphylococcus aureus

NICU:

Neonatal Intensive Care Unit

UoGCSRH:

University of Gondar Comprehensive Specialized and Referral Hospital

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Acknowledgements

We want to acknowledge the University of Gondar Comprehensive Specialized and Referral Hospital administrative office for their willingness during the data collection.

Funding

There is no specific fund received for this study.

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Authors and Affiliations

  1. University of Gondar Comprehensive Specialized and Referral Hospital, University of Gondar, Gondar, Ethiopia

    Minichil Worku, Solomon Belay & Tigist Molla

  2. Department of Medical Microbiology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia

    Azanaw Amare, Mitkie Tigabie & Muluneh Assefa

  3. Department of Medical and Surgical Nursing, Faculty of Nursing, University of Tabuk, Tabuk, Saudi Arabia

    Wesam Taher Almagharbeh

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Contributions

MW, TM, and SB have been involved in the conception of the research idea, data collection, and data analysis. MW, AA, MT, MA, and WTA have been involved in rationalizing the method, data analysis, interpretation of the result, evaluation of the scientific content of the study, and manuscript preparation. MA and WTA also reviewed and edited the manuscript. All authors read and approved the final manuscript for submission.

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Correspondence to Muluneh Assefa.

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Ethical permission to conduct this study was obtained from the ethical review committee of the School of Biomedical and Laboratory Sciences, University of Gondar. Informed consent was obtained from each study participant and their legal guardians after describing the purpose of the study. Information concerning the participants was kept confidential and specimens collected from them were used only for the intended purposes. All procedures in this study were conducted following the amended Declaration of Helsinki.

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Worku, M., Belay, S., Molla, T. et al. Bloodstream infections with emphasis on Methicillin-resistant Staphylococcus aureus at the University of Gondar Comprehensive Specialized and Referral Hospital, Northwest Ethiopia. BMC Infect Dis 25, 663 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12879-025-11074-3

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BMC Infectious Diseases

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