Methicillin-Resistant Staphylococcus epidermidis in Iran: A Systematic Review and Meta-Analysis


Shabnam Razavi 1 , Masoud Dadashi 2 , Ali Pormohammad 2 , Seyed Sajjad Khoramrooz 3 , Mehdi Mirzaii 4 , Abolfazl Gholipour 5 , Davood Darban-Sarokhalil 1 , *

1 Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, IR Iran

2 Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran

3 Medicinal Plants Research Center, Yasuj University of Medical Sciences, Yasuj, IR Iran

4 Department of Microbiology, School of Medicine, Shahroud University of Medical Sciences, Shahroud, IR Iran

5 Department of Microbiology and Immunology, School of Medicine, Shahrekord University of Medical Sciences, Shahrekord, IR Iran

How to Cite: Razavi S, Dadashi M, Pormohammad A, Khoramrooz S S, Mirzaii M, et al. Methicillin-Resistant Staphylococcus epidermidis in Iran: A Systematic Review and Meta-Analysis, Arch Clin Infect Dis. 2018 ; 13(4):e58410. doi: 10.5812/archcid.58410.


Archives of Clinical Infectious Diseases: 13 (4); e58410
Published Online: July 1, 2018
Article Type: Review Article
Received: April 3, 2017
Revised: July 21, 2017
Accepted: September 19, 2017


Objective: Methicillin-resistant Staphylococcus epidermidis (MRSE) remains one of the most prevalent drug-resistant bacteria causing health care infections. Limited data are available about how the frequency of MRSE changed in Iran over the past years. The current study aimed at determining the frequency of MRSE in different cities of Iran.

Methods: Databases including Web of Sciences, Scopus, Embase, Medline, and Iranian databases were searched to find studies addressing the frequency of MRSE in Iran published from Mar 2006 to Jan 2016. The data were analyzed using comprehensive meta-analysis version 2.2 (Biostat). Of the 139 records identified in the databases, 15 studies met the inclusion criteria.

Results: The analyses showed that the frequency of MRSE infections was 73.9% [95% confidence interval (95% CI) 61.4 - 83.4] among culture-positive cases of S. epidermidis in different parts of Iran. The frequency of MRSE was higher in the studies conducted from 2011 to 2015, based on further stratified analyses.

Conclusions: The regular surveillance on antimicrobial susceptibility pattern and formulation of definite antibiotic policy may control high rate of MRSE associated infections in Iran. Moreover, rapid and reliable diagnosis of MRSE isolates and regular screening of the personnel and surfaces of hospitals in terms of MRSE are indispensable.

1. Context

Health care complication due to coagulase negative staphylococci (CoNS) are increased worldwide (1, 2). CoNS were known as major human skin resident organisms and nowadays they are considered as one of the most important agents of frequent nosocomial infections (3-5). Based on recent studies, in patients that should be hospitalized and use indwelling medical devices, Staphylococcus epidermidis (S. epidermidis) is characterized as one of the main opportunistic pathogens and the number of life threatening cases of biomaterial related infections are intensified in many communities (6-9). The number of methicillin-resistant S. epidermidis (MRSE) infections is dramatically increased and is a serious problem in terms of nosocomial infections worldwide (10). In the past 10 years, an alarming increase in the prevalence of MRSE is observed (11, 12). Previously, S. epidermidis was described as a commensal human skin and mucosa micro flora (13, 14). Its appearance in laboratory samples was interpreted as a confusing accidental contamination, but now with the development of implanted devices in modern medicine, researcher gradually observed a relationship between chronic infections and the use of these prosthetic tools (15, 16). The vast majority of studies insisted on the role of S. epidermidis in catheter-associated infections that relies on bacterial capacity to colonize on such devices and protect itself from host immunity or antibiotic therapy (17-20). Emergence of S. epidermidis strains resistant to strong antibiotics increased recently and made momentous severity to manage the disease and health care control (21, 22). Moreover, MRSE is one of the main post surgery infectious elements (23). The close scrutiny of the rising number of MRSE isolates divulges concern for diagnosis, control, and treatment (24). To the best authors knowledge, there was no comprehensive analysis of MRSE infection prevalence in Iran. Furthermore, few studies reported the prevalence of MRSE infections. The current study mainly aimed at assessing the prevalence of MRSE infection in Iran.

2. Methods

2.1. Search Strategies

From 2006 to June 2016, all studies discussing MRSE infections in Iran were collected from databases of Web of Science, PubMed, Scopus, Embase, Cochrane Library, Iranmedex, Google Scholar, and Scientific Information Database (SID). The search was restricted to original research articles published in English or Persian and presenting the frequency or incidence of MRSE infections in Iran. The following keywords containing Medical Subject Headings (MeSh) or keywords in titles or abstracts were used with Boolean operators (“and” or “or”): ‘‘Staphylococcus epidermidis”, ‘‘S. epidermidis”, ‘‘coagulase negative staphylococcus”, “CoNS”, ‘‘MRSE”, ‘‘methicillin-resistant Staphylococcus epidermidis”, and ‘‘Iran”. Meanwhile, bibliographies from retrieved papers were revised for any additional studies. In addition to English papers, all relevant articles in Iranian databases such as Magiran (, Iranmedex (, Scientific Information Database (, Iranian National Library (, and Irandoc ( were searched with similar strategy and the related Persian keywords. Furthermore, no contact was made with the authors regarding the previous experiences (25-28).

2.2. Inclusion and Exclusion Criteria

All original articles presenting cross sectional studies on the frequency of MRSE in Iran were considered. The selection of articles for review was completed based on three stages: titles, abstracts, and full texts. The inclusion criteria were application of standard methods for drug susceptibility testing (DST) of S. epidermidis against beta-lactam antibiotics (penicillin, methicillin, oxacillin and cefoxitin) and presenting data on the number of S. epidermidis and MRSE isolates. Standard DST methods include the oxacillin screening plate, broth microdilution (BMD), Epsilon test (E test), disk diffusion method (DDM) for cefoxitin, and polymerase chain reaction (PCR) technique for mecA detection. Studies were excluded from analysis for any of the following reasons: considering only specific subpopulation, irrelevancy of the title, studies on non-human samples, not reporting S. epidermidis numbers, application of non-standard methods for MRSE detection, and not reporting MRSE numbers. Review articles, meta-analyses or systematic reviews, duplicate publications of the same study and articles available only in abstract form were also excluded from the current study.

2.3. Data Extraction and Definitions

For all studies, the following data were extracted: the first author’s name, year of publication, year of study, study setting, number of cases investigated, method of studies, source of samples, sample size, frequency of S. epidermidis and MRSE, and if existed, other information. All the included studies were extracted independently by two investigators and results were reviewed by a third investigator and finally inconsistencies were discussed to achieve consensus. PRISMA guidelines were used for the current study (29).

2.4. Quality Assessment

Included studies were appraised for quality, using a quality assessment checklist designed by the Joanna Briggs Institute (29).

2.5. Meta-Analysis

Comprehensive meta-analysis version 2.0 (Biostat) was used for analysis. The point estimate of effect size, the frequency of MRSE, and its 95% confidence interval (95% CI) were approximated for each survey. Random-effects models were utilized. Cochran Q-statistic was used to consider the possibility of heterogeneity between the studies. To assess possible publication bias, Egger weighted regression methods were applied. P < 0.05 was considered indicative of statistically significant publication bias.

3. Results

3.1. Characteristics of the Reviewed Articles

Primarily, 139 studies were selected and in the next screening, 26 of them were included based on title and abstract screening (Figure 1). In the third phase, 20 of the 26 article were selected upon a full text search and finally 15 eligible articles were selected (Figure 1). Table 1 shows the details of the reviewed studies (30-44). Geographical location of studies mostly covered center and west of Iran. Moreover, MRSE isolates were isolated from different clinical samples, especially blood.

Table 1. Characteristics of Studies Included in Meta-Analysis
StudyTime of StudyPublication DataCityNo. of S. epidermidisNo. of MRSE IsolatesDiagnostic Methods for MRSE (CLSI)Source of Samples
Ebrahimzadeh Namvar (36)20142014Isfahan11596PCR/DDMBlood, catheters
Pishva (37)20092013Isfahan146103E test-
Eftekhar (31)20072011Tehran5550DDMBlood, wound
Pourmand (38)20082011Tehran9956DDMNasal swab
Taheri (43)20132014Arak5440E test/PCRSurfaces and Staff
Soroush (42)2012 - 20132016Tehran25680PCRDifferent
Havaei (34)20142015Isfahan7061DDM/PCRBlood, catheters
Najar-Peerayeh (35)2010 - 20112014Tehran6459PCRDifferent
Shoja (41)20062006Tabriz10089DDM/PCRBlood
Fateh Rahimi (32)20142014Tehran19372E test/PCRBody fluid and wound
Raei (39)20072010Tehran5542PCRBlood
Ramazanzadeh (40)2011-20122015Sanandaj170151DDMClinical sample, staff
Ghotaslou (33)2012 - 20132014Tabriz5746PCRBlood, tracheal tube
Sotoudeh Anvari (30)2007 - 20122015Tehran207DDMPericardial effusions
Talebi (44)2010 - 20122015Tehran9058PCR/BMD-

Abbreviations: BMD, broth microdilution; DDM, disk diffusion method; E test, Epsilon test; PCR, polymerase chain reaction.

3.2. The Frequency of MRSE Infections

The rate of MRSE infections among culture-positive cases of S. epidermidis was 73.9% (95% CI: 61.4 - 83.4) (Table 2). The heterogeneity evaluation showed heterogeneity among articles (I2 = 95.327, P < 0.001). Forest plot of meta-analysis on the rate of MRSE infections are indicated in Table 2 and Figure 2. According to Table 2 and Figure 3, there was no publication bias in the current study (P > 0.05 for Egger weighted regression analysis). Table 3 demonstrated the stratified analyses based on the geographical locations of the reviewed articles. Distribution of MRSE infections in different parts of Iran is revealed in Figure 4.

Table 2. Meta-Analysis of the Prevalence of MRSE Infections in Iran
SubgroupNo. of StudyPrevalence of MRSE (95%CI)n/NHeterogeneity Test, I2 (%)Heterogeneity Test, P ValueEgger Test, tEgger Test, P Value
Overall effects1573.9 (61.4 - 83.4)1010/154495.327< 0.0013.8870.001
Researches from 2006 to 2010673.3 (58.0 - 84.5)347/47588.596< 0.0010.6190.569
Researches from 2011 from 2015974.3 (55.9 - 86.9)663/106996.627< 0.0014.9970.001
Figure 2. Forest plot of meta-analysis on the prevalence of MRSE infection
Figure 3. Funnel plot of meta-analysis on the prevalance of MRSE infections
Table 3. Meta-Analysis of the Prevalence of MRSE Infections in Different Parts of Iran
CityNo. of StudyPrevalence of MRSE (95%CI)n/NHeterogeneity Test, I2 (%)Heterogeneity Test, P ValueEgger Test, tEgger Test, P Value
Overall effects1573.9 (61.4 - 83.4)1010/154495.327< 0.0013.8870.001
Tehran863.3 (46.6 - 77.4)424/83294.221< 0.0013.2240.017
Isfahan380.6 (68.5 - 88.8)260/33179.842< 0.0012.7270.223
Tabriz, Arak, Sanandaj484.3 (76.4 - 89.9)326/38166.090< 0.0010.9440.444
Figure 4. Distribution of MRSE infection in Iran based on the rate of incidence

4. Discussion

The incidence of MRSE is gradually rising since its emergence was reported. Although there were occasional reports of MRSE infections in the past, it is one of the recently established nosocomial pathogens (45). The current systematic review reports the frequency of MRSE infections in Iran. The current study analyses showed that the frequency of MRSE infections was 73.9% (95% CI: 61.4 - 83.4) among culture-positive samples of S. epidermidis in different parts of Iran (Table 2). According to the results of the current study, the MRSE had higher incidence rate in Tabriz, Arak, Sanandaj, and Isfahan than Tehran. Despite the large population in Tehran, capital of Iran, better infection control policies in Tehran may reduce the MRSE incidence than other parts of Iran. Although no article was related to the studies in the east of Iran, data showed that the rate of MRSE infections were higher in the western parts of Iran than the other parts. Also, the obtained results showed that MRSE incidence rates increased from 2011 to 2015 [74.3% (95% CI: 55.9 - 86.9)] in comparison with other studies, from 2006 to 2010. This event had several reasons such as increasing rate of MRSE during the recent years, the increase of knowledge about MRSE recognition, and use of advanced devices and methods such as E test and PCR for MRSE identification, etc.

Hospital-acquired infections, according to centers for disease control (CDC), are the infection that is acquired in a hospital or other health care facilities after 2 days of admission. High population societies, such as Iran, with less attention to hygienic practices and standards in some parts of the country can be regarded as the main factor for hospital-acquired infections (46). There is little information about the different SCCmec types of MRSE in Iran. In agreement with prior information, the rate of SCCmec in types I and II was low, while type IV was comparatively prevalent (47, 48). According to the results of an investigation, SCCmec type IV was the most prevalent type followed by type V and III in MR-CoNS strains, respectively (49). Also, another study indicated that 36% of MRSE isolates had a type IV of SCCmec (50). Based on the recent information, origin of SCCmec is more various in MR-CoNS via novel types of ccr genes (51). Other factors that can raise MRSE incidence are the intensity of disease, transition of pathogenic bacteria among the hospital wards, the disorganized implementation of prophylactic hygiene measures, inadequate staff training, and lack of hospital infection control programs. Thus, insufficient MRSE management leads to the continued spread of MRSE in hospitals of Iran. Moreover, the association of multidrug resistance with MRSE adds to the problem (52). B-lactam antibiotics such as penicillin and cephalexin were not effective against MRSE (53, 54). The maximum impressive antibacterial drugs against S. epidermidis were cefoxitin, ciprofloxacin, and gentamicin. Therapy for patients with staphylococcal infections is made hard by bacterial resistances to beta-lactams and other antibacterial agents such as aminoglycosides and glycopeptides. Lately offered or empirical drugs such as dalfopristin and quinupristin belonging to streptogramin class, and linezolid may be beneficial in the treatment of patients with multi-drug resistant staphylococci infections (30, 55). MRSE can be nosocomial or community-acquired. MRSE can be defined as community-acquired if the positive culture is obtained in less than two days of admission or outside hospital settings (56). Due to the lack of enough information, it is not exactly claimed whether the MRSE were from community or hospital. Another notable point is some limitations to perform this investigation, which should be discussed. First of all, only published studies were accepted for including in the current meta-analysis. Then, biases between publications and systematic reviews were inevitable. Second, heterogeneity was observed among the studies. Third, since there was no study on MRSE infections in many regions of Iran, it cannot fully represent the frequency of MRSE in Iran. Fourth, since it was a prevalence survey, it is not possible to determine the risk factors for MRSE colonization or infection.

In conclusion, high rate of MRSE isolates is a public health problem in Iran that needs further attention by microbiologists, health authorities, and physicians. The regular surveillance on antimicrobial susceptibility patterns and formulation of definite antibiotic policy may control high rates of MRSE associated infections in Iran. Moreover, rapid and reliable diagnosis of MRSE isolates and regular screening of the hospitals surfaces and personnel in terms of MRSE are indispensable.


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