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 Table of Contents  
Year : 2022  |  Volume : 17  |  Issue : 1  |  Page : 140-145

Methicillin resistant Staphylococcus aureus infection among orthopedic patients in South-East Asia region: A systematic review and meta-analysis

1 Department of Medical Surgical Nursing, Manipal College of Nursing, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
2 Manipal School of Nursing, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
3 Department of Child Health Nursing, Manipal College of Nursing, Manipal, Karnataka, India
4 Department of Data Science, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission16-Dec-2020
Date of Decision05-Dec-2021
Date of Acceptance23-Jan-2022
Date of Web Publication25-Jul-2022

Correspondence Address:
Dr. T Latha
MCON Manipal, Manipal Academy of Higher Education, Manipal - 576 102, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_447_20

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Hospital Associated infections are on the rise globally. Methicillin-resistant Staphylococcus aureus (MRSA) is one of the common pathogens resulting in increased morbidity and mortality among orthopedic patients. Though individual reports are available, no systematic review on the prevalence of MRSA infection among orthopedic patients in South-East Asia Region (SEAR) is accessible and hence, the systematic review and meta-analysis is conducted. We systematically searched eight databases (Scopus, PubMed-Medline, IndMed, CINAHL, Proquest, Web of Science, Ovid-Medline, and Google-Scholar) and included the articles published from 2006 to 2019 from SEAR. A total of 22 studies were eligible for the review. STATA 13.0 with metaprop package in STATA was used to find the rate of MRSA infection. Among 1135 orthopedic patients, the pooled prevalence of MRSA infection was 27% (95% confidence interval 17%–38%; P = 0.001, I2 95.99%). Based on this infection rate, the policymakers are recommended to develop guidelines to effectively manage infection in healthcare settings to reduce the burden of MRSA infection among orthopedic patients.

Keywords: cefoxitin, infection, methicillin-resistant Staphylococcus aureus, orthopedics, prevalence, South East Asia

How to cite this article:
Latha T, Sequira L, Hebbar S, Nayak BS, Ravishankar N. Methicillin resistant Staphylococcus aureus infection among orthopedic patients in South-East Asia region: A systematic review and meta-analysis. J Datta Meghe Inst Med Sci Univ 2022;17:140-5

How to cite this URL:
Latha T, Sequira L, Hebbar S, Nayak BS, Ravishankar N. Methicillin resistant Staphylococcus aureus infection among orthopedic patients in South-East Asia region: A systematic review and meta-analysis. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2022 Aug 18];17:140-5. Available from: http://www.journaldmims.com/text.asp?2022/17/1/140/352242

  Introduction Top

The hospital environment has many disease-causing pathogens. Hence, infection in the hospital is common. This is because of the nature of the problems, prolonged hospitalization, multiple surgeries, contaminated wounds, etc.[1],[2],[3] The identified organisms causing infection in the hospital are Staphylococcus aureus, Acinetobacter species, Pseudomonas species, Enterococcus species,  Escherichia More Details coli, Klebsiella pneumoniae, Proteus species, Pseudomonas aeruginosa, etc.[4]

Methicillin-resistant S. aureus (MRSA) infection is increasing globally and infection in developing countries is on the significant rise.[4] Orthopedic patients have more risk of acquiring infection.[5],[6] MRSA is the leading pathogen causing infection among orthopedic patients. MRSA is a Gram-positive bacteria which causes simple skin infection to life-threatening bacteremia.[7] The mortality rate due to MRSA infection is tripled than Methicillin sensitive S. aureus infection.[8] Infection among orthopedic patients results in prolonged hospital stay, increases the hospital cost, and prone to re-hospitalization and thereby reducing their quality of life.[9]

Acquiring MRSA in the hospital is multifactorial. The risk factors are emergency admissions, prior antibiotic use, multiple or prolonged hospital stay, advanced age, invasive devices (catheters, gastric/endotracheal tubes, surgical drains), immunosuppression, damaged skin or open wounds, invasive procedures, and intensive care unit admission.[1],[10],[11]

The clinical significance of MRSA infection is heightened by the fact that most of the MRSA are multidrug resistant[5] and multidrug-resistant infections have limited treatment options.[12] More than 30% of infection is caused by MRSA in the hospital.[13] In some of the hospitals/clinics, antibiotics are prescribed without sensitivity testing due to the lack of facilities.[12],[14]

The rate of MRSA is not homogenous at the global level. Even though individual study reports are available, there is no evidence available on the prevalence of MRSA infection among orthopedic patients in the South-East Asian Region (SEAR). Therefore, the present systematic review and meta-analysis aim to evaluate the prevalence of MRSA infection among orthopedic patients in SEAR. Studying the prevalence among orthopedic patients becomes important as it allows the policymakers to design detailed and targeted programs to improve the health of the public.


This systematic review and meta-analysis were performed using the checklist based on the “meta-analysis of observational studies in epidemiology (MOOSE)” guidelines[15] and “preferred reporting items for systematic reviews and meta-analyses (PRISMA)” guidelines.[16] The detailed methodology is explained in the following sections.

Search strategy

The studies were retrieved from eight electronic databases; Scopus, PubMed-Medline, IndMed, CINAHL, Proquest, Web of Science, Ovid-Medline, and Google Scholar. The following search strategies were developed according to the databases. The terms used were: orthopedic patients, clients, cases; Methicillin Resistant Staphylococcus aureus superbug; prevalence, incidence, rate, proportion, cohort studies, case-control studies, cross-sectional studies, observational studies; region as WHO defined SEAR countries: Bangladesh, Bhutan, Democratic People's Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste. The reference lists of all included studies were also hand-searched for additional articles.

Selection of the studies

The studies carried out among orthopedic patients of all age group, both the gender and published from first January 2006 to December 31, 2019, were considered. The rate of infection accessible in frequency or percentage was incorporated. The studies conducted among the entire hospital population and the rate of MRSA infection is not available separately for orthopedic patients were excluded. The articles published from SEAR countries in the English language were included for the review.


Methicillin resistant Staphylococcus aureus infection

The biological sample obtained from the patients admitted to hospitals, nursing homes, or clinics. MRSA was isolated from these samples using cefoxitin 30 μg disc diffusion methods by employing clinical and laboratory standards institute guidelines.[17]

Quality assessment

The quality of studies was assessed by using the Joanna Briggs Institute Checklist for Systematic Reviews and Research Syntheses.[18] The checklist had of the following areas: the study details including author's information, title of the study, aim, and objectives; the study methods such as study design, study duration, sample characteristics, dependent variable, outcome measured, ethical considerations, method of the diagnostic test, method of data analysis; and the study results stating prevalence or incidence, authors comments or limitation of the study. Two reviewers independently assessed each of the characteristics mentioned in the checklist with “yes” or “no.” Each “yes” answer was given one score and “no” was zero with the total possible maximum score of 10. The study method and result section were considered for quality assessment. The studies with the score of six or more than six were considered for review and meta-analysis.

Data extraction

Two reviewers independently read the title and abstract of identified studies to determine whether the study was in compliance with the review criteria (LT and SH). The controversies between the two reviewers were resolved with the help of the third reviewer (LS). The data were extracted using the “data extraction form” prepared based on the “MOOSE” guidelines[15] and “PRISMA” guidelines.[16] The data extraction form included the last name of the first author, name of the journal, year of publication of the study, aims and objectives, setting of the study, number of orthopedic patients included in the study, methodology of the study, source of the sample obtained, method of testing the presence of MRSA and prevalence of MRSA infection. The third reviewer rechecked the data and the data table was prepared.

Statistical analysis

Stata 13.0 software By StataCorp was used to perform meta-analysis. The Forest plot was constructed with the help of metaprop package in STATA. This review on MRSA infection has included cross-sectional studies only. As cross-sectional studies are observational, a significant quantity of heterogeneity is anticipated. Hence, a random-effects model was adopted instead of fixed-effect model. The pooled prevalence of MRSA infection among orthopedic patients with a 95% confidence interval (CI) along with I2 statistic which helps in quantifying the heterogeneity of the studies was reported.

  Results Top

Among 1503 studies identified, 22 studies were eligible to proceed with systematic review. Further adhering to inclusion criteria and quality assessment, seven studies were appropriate for meta-analysis [Figure 1]. The characteristics of the included studies are given in [Table 1]. Among studies included in meta-analysis three studies have been conducted among orthopedic patients only.[20],[23],[25] Rest of the studies were conducted among general patients.[6],[19],[21],[24] However, the MRSA infection rate was available separately for orthopedic patients and hence included in the meta-analysis.
Figure 1: Flow chart showing identification of studies

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Table 1: Characteristics of included studies with rate of methicillin resistant staphylococcus aureus Scientific Name Search  infection

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Most of the included studies were published from India in recent years. Fourteen studies identified for the review were unable to include in the meta-analysis as all the information were not available. [Table 2] reports the characteristics of excluded studies along with the reason for exclusion.
Table 2: The characteristics of excluded studies with reason for exclusion

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The total population included in the meta-analysis of MRSA infection was 1,135 orthopedic patients. The forest plot [Figure 2] constructed among orthopedic patients from the countries of SEAR shows the overall pooled prevalence of MRSA infection with 95% CI was 27% (17%, 38%; P = 0.001, I2 95.99%).
Figure 2: Forest plot of prevalence of methicillin resistant staphylococcus aureus infection among orthopedic patients

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  Discussion Top

Very little data on MRSA infection among orthopedic patients is available from SEAR to the best of our knowledge. This systematic review and meta-analysis report the prevalence of MRSA infection as 27% (95% CI 17%–38%; P = 0.001) among orthopedic patients of SEAR countries among confirmed S. aureus [Table 1]. The findings of the current prevalence were comparable with the results of previous studies from the United States (26.3%). On the contrary, studies have reported a higher rate of infection in the Asia-pacific region - 45.9%, Iran 43%, and Latin America – 34.9%, whereas lower rate of MRSA infection is reported from Canada 5.77%.[37],[38] The epidemiology of MRSA infection is gradually increasing. Varied rate of infection is due to the infection surveillance program, prepost of antibiotics policy, hospital environment, surgical equipment, healthcare professional's attire, and resident bacteria on the patients' skin.[20]

Most of the studies are from India. Lack of data from other countries is probably due to (1) not yet explored the rate of MRSA among orthopedic patients, (2) did not publish in journals which are included in the databases incorporated in this review, (3) difference in the method of testing the presence of MRSA, (4) lack of resources for detection and reporting data. Moreover, the healthcare facilities available in each country plays a major role in infection control. According to World Bank data.[39] few countries have the beds available from 1000 population is < 1 (Bangladesh - 0.6, Myanmar - 0.6, India - 0.7, Indonesia - 0.9), few countries have beds ranging from 1 to 4/1,000 population (Bhutan - 1.8, Thailand - 2.1, Sri Lanka - 3.6,) and some of the countries have more than 4 beds/1,000 population (Maldives - 4.3, Nepal – 5, Timor-Leste - 5.9, Korea - 13.2) available. One of the methods of reducing MRSA infection is the isolation of infected patients. However, isolation may be unrealistic in many hospitals of the countries included in the review. For instance, India being a highly populated country where patient-to-bed strength is 0.7:1000, and the rate of MRSA infection diverges from 30% to 70%.[25] Availability of isolation rooms for MRSA-infected patients is a big challenge.

Consequences of MRSA infection among orthopedic patients may lead to treatment failure, repeated admissions, failure of implants/prosthesis and thereby increased economic burden. MRSA infection imposes intensified morbidity and mortality and thereby increased the burden on healthcare resources.[40]

Vancomycin was regarded as the best treatment for MRSA and unfortunately, Vancomycin-resistant cases are reported.[41] Therefore, addressing the problem such as indiscriminate use of antibiotics, insufficient infection control measures, lack of hospital infection control program and inadequate staff training may facilitate in reduction of MRSA infection. Insufficient management of MRSA thus leads to the MRSA spread in healthcare settings.

The present review has the following limitations; (1) with any systematic review, the possibilities of publication bias, (2) the varied sample size between the studies giving rise to heterogeneity irrespective of using random-effect model, (3) the result cannot be generalized to entire SEAR as the representation of studies from many countries were not available.

  Conclusion Top

The prevalence we obtained in this review would be a tip of the iceberg; with better representatives from all the countries, the prevalence may change. The MRSA infection among orthopedic patients is a public health problem and calls for attention to the hospital administrator to implement specific guidelines to reduce the threat of infection in healthcare settings.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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