Enhanced Detection of Methicillin Resistant

Staphylococcus aureus Using Chromogenic MRSA Media

Compared to Traditional Culture Methods
D. FLAYHART, R. WALTHER, C. LEMA, H. SNYDER, K. CARROLL
The Johns Hopkins Medical Institutions, Baltimore, Maryland
Methicillin Resistant S. aureus (MRSA) has become a
widespread nosocomial pathogen. The use of active surveillance
cultures to detect nasal carriage of MRSA is recommended to
identify carriers and initiate contact precautions.
OBJECTIVE: To evaluate time to detection (TTD) to MRSA
using Chromogenic media compared to traditional culture
methods from nasal surveillance cultures.
METHODS: A total of 1133 nasal samples were plated to Sheep
Blood Agar (SBA) and BBL

CHROMagar

MRSA (C-MRSA).
Plates were incubated per manufacturers recommendations.
MRSA appear as mauve colonies on C-MRSA. All other organisms
including methicillin susceptible staphylococci are inhibited or
produce a distinctly different colony color. If mauve colonies are
detected at 24 h, MRSA may be reported without further testing.
At 48 h detection, a slide coagulase test needs to be completed.
MRSA was identified from SBA by Gram stain and slide
coagulase. Oxacillin (methicillin) resistance was determined
using five methods of susceptibility testing.
RESULTS: Of the 1133 cultures tested, 78 (7.4%) were positive
for MRSA. 41/78 (53%) had a TTD of 24 h from C-MRSA and
48 h from SBA. 11/78 (14%) had a TTD of 24 h from C-MRSA
and greater than 48 h from SBA. At 24 h, an additional 11 (14%)
isolates were recovered on C-MRSA that were not detected on
SBA. After 48 h incubation, 7/78 (9%) were detected on both
media while an additional 5/78 (6%) had TTD of 48 h on
C-MRSA and equal or greater than 72 h on SBA. An additional
two isolates were recovered on C-MRSA at 48 h that were
not detected on SBA and one isolate had a TTD of 72 h from
SBA and was not recovered on C-MRSA.
CONCLUSION: 63/78 (81%) of the MRSA were reported at
24 h using the CHROMagar MRSA versus 48 h or greater using
the traditional culture method. 11/63 (17%) were reported three
or more days later than the CHROMagar MRSA result. A more
rapid positive report from nares surveillance cultures may assist
the infection control practitioner in identifying colonized patients,
initiate contact precautions, and potentially decrease the spread
of MRSA.
INTRODUCTION
Methicillin resistant Staphylococcus aureus (MRSA) remains
an important nosocomial pathogen. According to the latest
report from the National Nosocomial Infection Surveillance
System (NNIS), approximately 60% of all S. aureus nosocomial
infections in intensive care units (ICUs) were methicillin resistant
in 2003, representing an 11% increase in resistance compared to
the preceding five year period (7). Infections caused by MRSA
are associated with longer hospital stay, more days of antibiotic
administration and higher costs than infections caused by
methicillin susceptible Staphylococcus aureus (MSSA) (5). More
importantly, several studies (2,5) and one large meta-analysis (4)
have shown that patients who develop MRSA bacteremia have a
higher mortality than patients with MSSA infections after
adjusting for underlying severity of illness.
Active surveillance for MRSA in the nares of at-risk
populations is an important component of the Society for
Healthcare Epidemiology of America (SHEA) recommendations
for control of nosocomi al transmi ssi on of MRSA (6).
Identification of patients and healthcare workers (in outbreak
settings) colonized with MRSA, combined with contact
precautions and improvements in hand hygiene, have been
successful in reducing transmission and controlling spread.
These and other guidelines, combined with the increase in
community acquisition and colonization of MRSA, have led to
an increase in the targeted surveyed population in many
healthcare facilities.
This study evaluated the BBL

CHROMagar

MRSA
selective and differential media to conventional isolation and
identification methods for the detection of MRSA from clinical
specimens of patients who were routinely screened for
Staphylococcal nasal carriage.
REVISED ABSTRACT
As presented at the Annual Association for Practitioners
in Infection Control, Baltimore, MD, 2005.
RESULTS MATERIALS AND METHODS
Speci men Processi ng. Nasal swabs from
surveillance patients were plated to Sheep Blood
Agar (SBA) (BBL, Sparks, MD), and CHROMagar
MRSA (C-MRSA) {BBL, Sparks, MD}. C-MRSA
was plated after routine media. The plates were
streaked and incubated at 37 with 5-10% CO
2
for
18 20 h.
Reading of Plates. After 20 h of incubation, plates
were read for S. aureus as follows. On C-MRSA,
each plate was examined for the presence of
moderately sized smooth mauve-colored colonies.
All other colonies (white, colorless, blue, green)
were not identified. On SBA, all white colonies
with/without beta hemolysis were worked up to rule
out S. aureus. If culture was negative for MRSA,
plates were reincubated for an additional 24 h.
Identification of MRSA. All MRSA isolates from
SBA were identified using the following
conventional laboratory tests: Gram stain and slide
coagulase. Mauve-colored colonies on C-MRSA
were considered MRSA by colony morphology,
Gram stain, and coagulase testing.
Susceptibility testing. (Determination of Oxacillin
[Methicillin] Resistance) S. aureus isolates had the
following susceptibility testing completed: 1) broth
microdilution MICs for oxacillin at concentrations
ranging from 0.12 g/mL to 4.0 g/mL (PASCO,
Roseville, CA); 2) oxacillin salt agar screen (BD,
Sparks, MD); 3) PBP2 latex agglutination (Remel,
Lenexa, KS); 4) cefoxitin disk diffusion; and 5)
mecA gene detection by PCR. Oxacillin broth
microdilution MICs, oxacillin salt agar screen agar,
cefoxitin disk (30 mg) diffusion tests were
performed as described by the Clinical and
Laboratory Standards Institute (CLSI). The PBP2
latex agglutination test was performed per
manufacturers instructions. PCR detection of the
mecA gene was performed using the LightCycler
instrument (Roche Molecular Systems, Pleasanton,
CA) for amplification of the mecA gene.
Media
Total No. of Total No. Percent Recovery
Specimens of MRSA of MRSA
SBA 1133 65 83.3 %
C-MRSA 1133 77 98.7 %
Table 1. Study Totals
Recovery on C- MRSA at 24 h
11/78 (14%)
No Recovery on SBA
Recovery on C-MRSA at 48 h
2/78 (2.6%)
No Recovery on SBA
No Recovery on C-MRSA
1/78 (1.3%)
Recovery on SBA at 72 h
Table 4. TTD of MRSA Recovered on One Media Only
TTD (h) on:
Recovery
C-MRSA SBA
of MRSA
24
48 41/78 (53%)
> 48 11/78 (14%)
Table 2. 24 h TTD on C-MRSA versus SBA TTD
TTD (h) on:
Recovery
C-MRSA SBA
of MRSA
48
48 7/78 (9%)
> 72 5/78 (6%)
Table 3. 48 h TTD on C-MRSA versus SBA TTD
0
10
20
30
40
50
60
70
N
u
m
b
e
r

o
f


M
R
S
A

R
e
c
o
v
e
r
e
d
24 48 > 72
TTD (h)
C-MRSA
SBA
Figure 1. Number of MRSA detected at 24 h, 48 h, and 72 h
REFERENCES
1. Bannerman, T.L., 2003. Staphylococcus and Micrococcus, p.385-404.
In P. R. Murray, E. J. Baron, J.H. Jorgensen, M.A. Pfaller, R. H. Yolken (ed.),
Manual of Clinical Microbiology, 8th ed. American Society for Microbiology,
Washington, D. C.
2. Blot, S. I., K. H. Vandewoude, E. A. Hoste, and F. A. Colardyn. 2002.
Outcome and attributable mortality in critically ill patients with bacteremia
involving methicillin-susceptible and methicillin-resistant Staphylococcus
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Standard for Antimicrobial Susceptibility Testing; Fifteenth Informational
Supplement. M100-s15. Clinical and Standards Institute, Wayne, PA.
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A. W. Karchmer, and Y. Carmeli. 2003. Comparison of mortality associated
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bacteremia: A meta-analysis. Clin. Infect. Dis. 36:53-9.
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economic outcomes attributable to methicillin resistance among patients with
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6. Muto , C. A., J. A. Jernigan, B. E. Ostrowsky, H. M. Richet, W. R. Jarvis,
J. M. Boyce and B. M. Farr. 2003. SHEA guideline for preventing
nosocomial transmission of multidrug-resistant strains of Staphylococcus
aureus and Enterococcus. Infect. Control Hosp. Epidemiol. 24:362-86.
7. NNIS System. 2004. National Nosocomial Infections Surveillance (NNIS)
System Report, data summary from January 1992 through June 2004,
issued October 2004. Am. J. Infect. Control 32:470-85.
Figure 2. Workflow for Identification of MRSA from SBA
Figure 3. Workflow for Identification of MRSA from C-MRSA
SBA
Oxacillin
Screen
Agar
1824 hours
At 1824 hours:
At 48 hours:
Suspicious
colonies
<30 Minutes
Staph
Latex
Susceptibility testing 24 hours
Low Level
Resistants
30 min 6 hours
24 hours
mecA PCR,
Or PBP2a
At 48 h Report MRSA
Report MRSA
Report MRSA Slide Coagulase/ Latex
CONCLUSIONS
I C-MRSA has improved recovery of MRSA as compared to SBA.
recovering an additional 13 (17%) isolates of MRSA.
I 63/78 (81%) of the MRSA were reported at 24 h using the C-MRSA
versus 48 h or greater using the traditional culture method.
11/63 (17%) were reported three or more days later than
the C-MRSA result.
I A more rapid positive report from nares surveillance cultures
may assist the infection control practitioner with:
identifying colonized patients,
initiating contact precautions,
potentially decreasing the spread of MRSA.

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