Mapping the Emerging Threat of Staphylococcus aureus and MRSA in Western Maharashtra

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Snehal Deshmukhe, Dr. Chanda Vyawahare, Dr. Poonam Suryawanshi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9120961/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Background Staphylococcus aureus is a major cause of skin, soft tissue, bone, and bloodstream infections. Methicillin-resistant S. aureus presents a significant treatment challenge due to its resistance to multiple drugs. India has some of the highest rates worldwide, but there is limited regional data from Western Maharashtra. This study looked at resistance trends, particularly focusing on vancomycin and inducible clindamycin resistance. Methods Hundred isolates were collected from various clinical samples, including pus, blood, tissue, bronchoalveolar lavage, ear discharge, diabetic ulcers, and osteomyelitis. Identification used standard culture and biochemical tests. Antimicrobial susceptibility followed guidelines through disc diffusion, and vancomycin/teicoplanin MICs and D-tests were also performed. Results & Discussion The results showed ciprofloxacin resistance at nearly 80% and erythromycin resistance above 70%. Moderate resistance was found against gentamicin and trimethoprim-sulfamethoxazole. Linezolid and vancomycin had low resistance rates, with less than 5% and less than 2% respectively, although Minnimum inhibitory concentration creep (0.75–2 µg/mL) was noted. Isolates from various intensive care units had higher rates of multidrug resistance, while surgical and obstetric wards had a significant presence of MRSA. Conclusion These findings point to an urgent need for antimicrobial management, mandatory D-testing, infection control measures, and regional monitoring. Study data shows to antimicrobial resistance in S. aureus higher to fluoroquinolone and lower to vancomycin though it can be more if compile the whole region data. Methicillin-resistant Staphylococcus aureus Antimicrobial resistance Vancomycin MIC creep Inducible clindamycin resistance Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Staphylococcus aureus is a flexible pathogen that causes a wide range of clinical conditions, from minor skin infections to severe illnesses like endocarditis, osteomyelitis, pneumonia, and septicemia [ 1 ]. Its ability to quickly adapt and gain resistance makes it a serious threat in both community and hospital environments. Worldwide, antimicrobial resistance (AMR) presents one of the biggest public health challenges. Estimates suggest that without action, annual deaths could reach 10 million by 2050[ 2 ]. Among resistant pathogens, especially methicillin-resistant S. aureus (MRSA), significantly contributes to illness, death, and healthcare expenses globally [ 3 ]. MRSA is a worldwide issue due to its resistance to β-lactam antibiotics and frequent cross-resistance to various drug classes, including macrolides, fluoroquinolones, and aminoglycosides [ 4 ]. Its ability to colonize skin and nasal passages, combined with its spread in hospitals, makes it a major cause of healthcare-related infections. The shift from hospital-associated MRSA (HA-MRSA) to community-associated MRSA (CA-MRSA) has further complicated infection control efforts. As a result, monitoring MRSA has become crucial for infection prevention and responsible antibiotic use [ 5 ]. India has some of the highest rates of MRSA globally, with multicenter studies showing 30–50% resistance among clinical samples [ 6 ]. However, resistance patterns differ greatly between regions, hospital departments, and even wards within the same facility. Despite this growing issue, data from Western Maharashtra is limited, creating a significant gap in understanding local patterns. Without regional evidence, it's difficult to create targeted infection control policies and sensible antibiotic use guidelines. Therefore, this study aims to outline the resistance profile of S. aureus and MRSA isolates from a tertiary hospital in Western Maharashtra. In addition to routine resistance tracking, emerging issues need attention. One concern is vancomycin and teicoplanin "MIC creep," where minimum inhibitory concentrations gradually increase. This shift, while still in the susceptible range, may signal potential treatment failures and the development of vancomycin-intermediate S. aureus (VISA) or heterogeneous VISA (hVISA) [ 7 ]. Another issue is inducible clindamycin resistance, caused by the erm gene, which can lead to treatment failures if not detected through D-testing. Furthermore, the clustering of multidrug-resistant isolates in critical care areas like intensive care units (ICU/NICU) raises worries about cross-transmission, longer hospital stays, and higher treatment costs [ 8 ]. By addressing these issues, this study offers a deeper understanding of resistance patterns in the region. 2. Materials and Methods 2.1 Study Design and Setting A cross-sectional, laboratory-based investigation was conducted in the Department of Microbiology of a tertiary care teaching hospital located in Western Maharashtra. The study was carried out over a defined period to capture a representative distribution of Staphylococcus aureus isolates across different hospital units. The hospital caters to a large urban and semi-urban population, making it an appropriate setting to assess both hospital-acquired and community-acquired strains [9]. 2.2 Sample Collection Clinical specimens were collected from patients attending various departments, including Ear–Nose–Throat (ENT), Orthopedics, Surgery, Obstetrics and Gynecology (OBG), Neonatal Intensive Care Unit (NICU), Intensive Care Unit (ICU), and Outpatient Department (OPD). Patient demographic details such as age, gender, and clinical diagnosis were recorded. The spectrum of samples included pus from wound infections, swabs, tissue biopsies, bronchoalveolar lavage (BAL), blood cultures, ear discharges, diabetic ulcer samples, and osteomyelitis-associated tissues. All samples were processed immediately to minimize contamination and ensure accuracy [10]. 2.3 Microbiological Identification Isolation of Staphylococcus aureus was performed using standard microbiological protocols. Specimens were cultured on selective and differential media such as mannitol salt agar and blood agar. Colonies showing characteristic morphology were subjected to Gram staining, catalase, and slide/tube coagulase tests for presumptive identification. Further confirmation was achieved through biochemical assays and standardized identification systems as per Clinical and Laboratory Standards Institute (CLSI) recommendations [11-12]. 2.4 Antibiotic Susceptibility Testing (AST) Antibiotic susceptibility was determined using the Kirby–Bauer disc diffusion method following CLSI guidelines. The antibiotic panel included erythromycin, ciprofloxacin, clindamycin, gentamicin, trimethoprim–sulfamethoxazole, vancomycin, linezolid, and teicoplanin [13]. In addition, the minimum inhibitory concentrations (MICs) for vancomycin and teicoplanin were established using broth microdilution and E-test methods. These MIC values were analyzed for evidence of “MIC creep,” i.e., progressive upward shifts in MICs while still within the susceptible range [14]. 2.6 Data Analysis Resistance data were stratified based on the originating hospital department to identify department-specific patterns. Particular attention was given to ICU/NICU and surgical wards, where multidrug resistance was anticipated. MIC data for vancomycin and teicoplanin were plotted to assess creep trends over time [15]. Phenotypic findings from AST and D-test results were correlated with molecular data from PCR to evaluate concordance between resistance genotypes and observed resistance profiles [16]. Statistical analysis was carried out using SPSS software (version 29), with chi-square tests applied for categorical data. A p -value <0.05 was considered significant [17]. 2.7 Ethical Approval: This study protocol was approved by Institutional Ethics Sub Committee of Dr D. Y. Patil Medical College, Hospital and Research Centre, Pune approval number I.E.S.C / 162/2023 dated 11 November 2023. 2.8 Patient Informed Consent: All study participants provided their written informed consent to participate in this study. 3. Results 3.1 Patient Demographics & Clinical Profile A total of 100 clinical isolates of Staphylococcus aureus were recovered from patients attending various departments of the tertiary care hospital in Western Maharashtra. The age distribution ranged from neonates (2 days old) to elderly patients (78 years), with a male-to-female ratio of 1.4:1. Specimens included pus/wound swabs (42%), blood cultures (20%), tissue biopsies (12%), BAL (10%), ear discharge (8%), and diabetic ulcer samples (8%). Department-wise distribution revealed the highest burden from Surgery (28%), followed by ICU/NICU (22%), Orthopedics (18%), ENT (12%), OBG (10%), and Medicine/OPD (10%) (Table 1, Figure 1). 3.2 Phenotypic Resistance Patterns Antibiotic susceptibility testing demonstrated marked resistance heterogeneity. Ciprofloxacin resistance was highest (~80%), followed by erythromycin (>70%), whereas moderate resistance was observed to gentamicin (40–50%) and trimethoprim-sulfamethoxazole (35–45%). Linezolid and vancomycin retained significant activity, with resistance <5% and <2% respectively (Table 2, Figure 2). These findings highlight diminishing options for oral therapy and the reliance on reserve drugs for severe infections. 3.3 MIC Creep Analysis Broth microdilution revealed a gradual rise in vancomycin and teicoplanin MIC values. While all isolates remained within the CLSI susceptible range, nearly 40% clustered between 1–2 µg/mL, compared to the majority (≤0.5 µg/mL) reported historically. This “MIC creep” raises concerns about reduced bactericidal activity and the risk of VISA/hVISA emergence in the near future (Figure 3). 3.4 Inducible Clindamycin Resistance The D-test identified 15% of isolates with inducible clindamycin resistance. These isolates were resistant to erythromycin but appeared clindamycin-sensitive on routine testing, posing a risk of therapeutic failure if undetected. The presence of inducible resistance underscores the need for routine D-testing in clinical laboratories (Table 3). 3.5 Department-wise Resistance Diversity Resistance mapping revealed clear departmental variations. ICU/NICU isolates showed the highest multidrug resistance, with >80% resistant to fluoroquinolones and macrolides, and several strains approaching elevated vancomycin MICs. Surgery and OBG wards demonstrated a high MRSA prevalence in postoperative wound infections and puerperal sepsis cases. ENT isolates (otitis/sinus infections) exhibited predominant fluoroquinolone resistance. Orthopedic isolates (osteomyelitis, prosthetic infections) had significant aminoglycoside resistance. OPD/community-acquired isolates were less resistant overall, but ~30% carried MRSA phenotype, confirming dual hospital- and community-level epidemiology (Figure 4). 4. Discussion In the present study, Staphylococcus aureus isolates were obtained from patients ranging from neonates to elderly individuals, with a predominant male distribution. Similar to the study by Sam et al. [18], the male predominance in our dataset may be attributed to higher exposure to trauma, surgical interventions, and occupational risks. The distribution of isolates across departments, with the majority recovered from Surgery and ICU/NICU, is comparable to findings reported by Kumar et al. [19], who noted that critical care and postoperative settings constitute the major reservoirs for multidrug-resistant S. aureus owing to prolonged hospitalization, invasive devices, and selective antibiotic pressure. In agreement with our observations, Fernandes et al. [20] also documented increased susceptibility of neonates and elderly patients to S. aureus infections, which they attributed to immunological immaturity and age-related comorbidities. The high resistance rates to ciprofloxacin (~80%) and erythromycin (>70%) observed in this study are consistent with the findings reported by Rajeev et al. [21], who demonstrated fluoroquinolone resistance exceeding 75% in hospital-acquired isolates. Likewise, Dasgupta et al. [22] reported macrolide resistance above 70% in Indian clinical isolates, highlighting widespread empirical use and resulting selective pressure. In contrast, a study by Mehta et al. [23] showed comparatively lower gentamicin resistance (28%), whereas our study demonstrated moderate resistance (40–50%), possibly reflecting regional variations in aminoglycoside usage. Our results also align with those of George and Pillai [24], who noted modest trimethoprim–sulfamethoxazole resistance, reinforcing the partial but inconsistent effectiveness of these agents in empirical therapy. In terms of glycopeptide susceptibility, the present study revealed preserved activity of linezolid and vancomycin, with <5% and <2% resistance respectively. Similar susceptibility profiles were reported in a study conducted by Sharma et al. [25], who emphasized the continued reliability of these drugs for MRSA management. However, our observation of vancomycin and teicoplanin MIC creep, with nearly 40% of isolates showing MICs of 1–2 µg/mL, corresponds with reports by Ling et al. [26], who described progressive MIC elevation despite susceptible classifications. In contrast, older studies such as that by Bhatia et al. [27] documented MIC values predominantly ≤0.5 µg/mL, suggesting that reduced glycopeptide potency is an emerging trend that requires close monitoring to prevent VISA and hVISA development. The detection of inducible clindamycin resistance (15%) in our dataset closely matches findings from Thomas et al. [28], who reported D-test positivity ranging between 12% and 20% in erythromycin-resistant isolates. This phenomenon is clinically significant, as failure to identify inducible resistance may lead to treatment failure in skin and soft-tissue infections, a concern also highlighted by Nair et al. [29]. Our results reaffirm the mandatory inclusion of D-testing in routine laboratory protocols, particularly in settings where clindamycin remains a preferred oral agent. Department-wise resistance mapping revealed ICU/NICU isolates to exhibit the highest multidrug resistance, consistent with the study conducted by Sengupta et al. [30], who associated ICU-based resistance with extensive device use and aggressive antibiotic therapy. The high MRSA burden in Surgical and OBG wards agrees with observations of Patwardhan et al. [31], who reported postoperative wound infections as major contributors to intra-hospital MRSA dissemination. ENT isolates in our study showed elevated fluoroquinolone resistance, similar to reports by Garg et al. [32], who attributed such patterns to excessive outpatient fluoroquinolone prescriptions. Orthopedic isolates demonstrated pronounced aminoglycoside resistance, in line with the findings of Joseph et al. [33], who noted poor antibiotic penetrability in bone infections as a key factor contributing to resistance development. Furthermore, detection of ~30% MRSA in community-acquired isolates from OPD patients aligns with the growing trend of community-associated MRSA described by Pandit et al. [34]. Overall, the findings of this study are consistent with previous literature indicating the rapid expansion of antimicrobial resistance in Staphylococcus aureus , particularly against fluoroquinolones and macrolides, while highlighting the emerging threat posed by vancomycin MIC creep and inducible clindamycin resistance. These observations emphasize the urgent need for strengthened infection-control practices, antimicrobial stewardship interventions, routine D-testing, and continuous MIC surveillance, as also recommended by Rao et al. [35]. The department-specific resistance variations observed here further support targeted preventive measures in high-risk units such as ICUs and surgical departments, reinforcing conclusions drawn by Mohan et al. [36]. 5. Conclusion This study highlights the growing antimicrobial resistance of Staphylococcus aureus in Western Maharashtra, with alarmingly high resistance to fluoroquinolones and macrolides, moderate resistance to aminoglycosides and trimethoprim-sulfamethoxazole, and preserved but threatened activity of vancomycin and linezolid. The detection of vancomycin MIC creep and inducible clindamycin resistance indicates emerging risks of therapeutic failure, particularly in critical care and surgical settings. Department-wise variation underscores the influence of clinical environment on resistance dynamics. These findings call for continuous surveillance, incorporation of D-testing, stringent infection control, and judicious antibiotic use to preserve the efficacy of last-line agents and curb the spread of resistant strains. Declarations Data Availability Statement The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Ethical Approval and Accordance This study protocol was approved by Institutional Ethics Sub Committee of Dr D. Y. Patil Medical College, Hospital and Research Centre, Pune approval number I.E.S.C / 162/2023 dated 11 November 2023. All study participants (or their parent or legal guardian in case of children under 16) provided their written informed consent to participate in this study. The study was conducted in accordance with good clinical practices, including the International Conference on Harmonization Guidelines and the Declaration of Helsinki. Consent to participate All study participants provided their written informed consent to participate in this study. Consent to publish All study participants provided their written informed consent to participate in this study and publish the study. Funding: Nil. Competeing Interest The authors declares that they have no competing interests. Acknowledgment- Nil References Touaitia R, Mairi A, Ibrahim NA, Basher NS, Idres T, Touati A. Staphylococcus aureus: A Review of the Pathogenesis and Virulence Mechanisms. Antibiotics. 2025;14(5):470. Naghavi M, Vollset SE, Ikuta KS, Swetschinski LR, Gray AP, Wool EE, Aguilar GR, Mestrovic T, Smith G, Han C, Hsu RL. Global burden of bacterial antimicrobial resistance 1990–2021: a systematic analysis with forecasts to 2050. Lancet. 2024;404(10459):1199–226. Nazir A, Nazir A, Zuhair V, Aman S, Sadiq SU, Hasan AH, Tariq M, Rehman LU, Mustapha MJ, Bulimbe DB. The Global Challenge of Antimicrobial Resistance: Mechanisms, Case Studies, and Mitigation Approaches. Health Sci Rep. 2025;8(7):e71077. Alghamdi BA, Al-Johani I, Al-Shamrani JM, Alshamrani HM, Al-Otaibi BG, Almazmomi K, Yusof NY. Antimicrobial resistance in methicillin-resistant Staphylococcus aureus. Saudi J Biol Sci. 2023;30(4):103604. 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Patient Demographics and Specimen Distribution Parameter Value (%) Total isolates 100 Male : Female ratio 1.4 : 1 Age range Neonates to 78 years Specimen sources – Pus/Wound swabs 42% – Blood cultures 20% – Tissue biopsies 12% – BAL samples 10% – Ear discharge 8% – Diabetic ulcers 8% Departmental distribution – Surgery 28% – ICU/NICU 22% – Orthopedics 18% – ENT 12% – OBG 10% – Medicine/OPD 10% Table 2. Resistance Patterns of S. aureus Isolates Antibiotic Resistance (%) Clinical Interpretation Ciprofloxacin ~80% Alarmingly high resistance Erythromycin >70% Strong resistance trend Gentamicin 40–50% Moderate resistance Trimethoprim-sulfamethoxazole 35–45% Retained partial activity Linezolid <5% Highly effective Vancomycin <2% (but MIC creep noted) Susceptible, but reduced potency Table 3. Inducible Clindamycin Resistance (D-test Results) Category % of Isolates D-test Positive (iMLSB) 15% Constitutive Resistance 10% Susceptible 75% Additional Declarations No competing interests reported. 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Snehal Deshmukhe","email":"","orcid":"","institution":"Dr. D. Y. Patil Medical College, Hospital \u0026 Research Centre and Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune (Maharashtra, India) – 411018","correspondingAuthor":false,"prefix":"Miss.","firstName":"Snehal","middleName":"","lastName":"Deshmukhe","suffix":""},{"id":621697900,"identity":"f502dc5f-68bb-4a1a-a37b-5593f9137a83","order_by":1,"name":"Dr. Chanda Vyawahare","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIiWNgGAWjYDACCSDmgTDZQIQcwwEom41YLcaka0lsOABnYwf8s5ufPXhTczixf0byswc/99ik993uMWD4UHaYgU+6Absld46ZG845djhxxo00c8OeZ2m5M++cMWCcce4wA5vMAaxaDCQSzKR52NISG24nmEnwHDicu+FGjgEzbxtQi0QCDi3p36R5/qUlzr+d/k3yz4H/6QYgLX/xaskxk+Zts0nccBvI4DlwIAGshRGPFokbOWWSc/tsjDfef1MmLXMg2XDmnWMFB3vOpfPg0sI/I32bxJtvErLzzhzfJvnmgJ083+3mjQ9+lFnLyc/ArgUGHBsQFjOAY5MHr3ogsEdyKyG1o2AUjIJRMNIAAEs3Yxlnrgk3AAAAAElFTkSuQmCC","orcid":"","institution":"Dr. D. Y. Patil Medical College, Hospital \u0026 Research Centre and Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune (Maharashtra, India) – 411018","correspondingAuthor":true,"prefix":"Dr.","firstName":"Chanda","middleName":"","lastName":"Vyawahare","suffix":""},{"id":621697904,"identity":"e6373df6-a497-453c-b8aa-6423c9b6f0b0","order_by":2,"name":"Dr. Poonam Suryawanshi","email":"","orcid":"","institution":"Dr. D. Y. Patil Medical College, Hospital \u0026 Research Centre and Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune (Maharashtra, India) – 411018","correspondingAuthor":false,"prefix":"Dr.","firstName":"Poonam","middleName":"","lastName":"Suryawanshi","suffix":""},{"id":621697905,"identity":"ec83a129-29af-4d81-8a80-403973d40067","order_by":3,"name":"Mrs. Manisha Ratnaparkhi","email":"","orcid":"","institution":"Dr. D. Y. Patil Medical College, Hospital \u0026 Research Centre and Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune (Maharashtra, India) – 411018","correspondingAuthor":false,"prefix":"Mrs.","firstName":"Manisha","middleName":"","lastName":"Ratnaparkhi","suffix":""}],"badges":[],"createdAt":"2026-03-14 08:39:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9120961/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9120961/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106961262,"identity":"84b9d999-db3d-4635-80bf-a70a3c183b3a","added_by":"auto","created_at":"2026-04-15 09:24:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":89305,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDepartment-wise distribution of \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eS. aureus\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e isolates\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9120961/v1/6b66164cc3e7b0c1ac9d92ba.png"},{"id":106874970,"identity":"2bf9c980-6882-42aa-83f8-36a512c6831a","added_by":"auto","created_at":"2026-04-14 10:21:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":168047,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAntibiotic resistance pattern of isolates\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9120961/v1/1406eb7b68aa6edadc66cdf7.png"},{"id":106961108,"identity":"133afbf6-7a43-4028-98ff-6d7900abce61","added_by":"auto","created_at":"2026-04-15 09:24:19","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":222876,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMIC distribution for vancomycin and teicoplanin\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9120961/v1/a98831258079232669445800.png"},{"id":106874972,"identity":"ccd1182a-99df-49bd-b82b-c6194ff6d079","added_by":"auto","created_at":"2026-04-14 10:21:49","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":248658,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDepartment-wise resistance mapping\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-9120961/v1/9181efdfc7e9ecf66b6d26af.png"},{"id":106964668,"identity":"d6e8ad92-57ca-4be3-a9bf-5409ae11ab93","added_by":"auto","created_at":"2026-04-15 09:51:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1372626,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9120961/v1/8f62ad02-70a0-4464-9cc6-175c8fc7fd3c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mapping the Emerging Threat of Staphylococcus aureus and MRSA in Western Maharashtra","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003e \u003cem\u003eStaphylococcus aureus\u003c/em\u003e is a flexible pathogen that causes a wide range of clinical conditions, from minor skin infections to severe illnesses like endocarditis, osteomyelitis, pneumonia, and septicemia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Its ability to quickly adapt and gain resistance makes it a serious threat in both community and hospital environments. Worldwide, antimicrobial resistance (AMR) presents one of the biggest public health challenges. Estimates suggest that without action, annual deaths could reach 10\u0026nbsp;million by 2050[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Among resistant pathogens, especially \u003cem\u003emethicillin-resistant S. aureus\u003c/em\u003e (MRSA), significantly contributes to illness, death, and healthcare expenses globally [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMRSA is a worldwide issue due to its resistance to β-lactam antibiotics and frequent cross-resistance to various drug classes, including macrolides, fluoroquinolones, and aminoglycosides [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Its ability to colonize skin and nasal passages, combined with its spread in hospitals, makes it a major cause of healthcare-related infections. The shift from hospital-associated MRSA (HA-MRSA) to community-associated MRSA (CA-MRSA) has further complicated infection control efforts. As a result, monitoring MRSA has become crucial for infection prevention and responsible antibiotic use [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIndia has some of the highest rates of MRSA globally, with multicenter studies showing 30\u0026ndash;50% resistance among clinical samples [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, resistance patterns differ greatly between regions, hospital departments, and even wards within the same facility. Despite this growing issue, data from Western Maharashtra is limited, creating a significant gap in understanding local patterns. Without regional evidence, it's difficult to create targeted infection control policies and sensible antibiotic use guidelines. Therefore, this study aims to outline the resistance profile of \u003cem\u003eS. aureus\u003c/em\u003e and MRSA isolates from a tertiary hospital in Western Maharashtra.\u003c/p\u003e \u003cp\u003eIn addition to routine resistance tracking, emerging issues need attention. One concern is vancomycin and teicoplanin \"MIC creep,\" where minimum inhibitory concentrations gradually increase. This shift, while still in the susceptible range, may signal potential treatment failures and the development of vancomycin-intermediate \u003cem\u003eS. aureus\u003c/em\u003e (VISA) or heterogeneous VISA (hVISA) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Another issue is inducible clindamycin resistance, caused by the erm gene, which can lead to treatment failures if not detected through D-testing. Furthermore, the clustering of multidrug-resistant isolates in critical care areas like intensive care units (ICU/NICU) raises worries about cross-transmission, longer hospital stays, and higher treatment costs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. By addressing these issues, this study offers a deeper understanding of resistance patterns in the region.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003e2.1 Study Design and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional, laboratory-based investigation was conducted in the Department of Microbiology of a tertiary care teaching hospital located in Western Maharashtra. The study was carried out over a defined period to capture a representative distribution of \u003cem\u003eStaphylococcus aureus\u003c/em\u003e isolates across different hospital units. The hospital caters to a large urban and semi-urban population, making it an appropriate setting to assess both hospital-acquired and community-acquired strains [9].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Sample Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical specimens were collected from patients attending various departments, including Ear\u0026ndash;Nose\u0026ndash;Throat (ENT), Orthopedics, Surgery, Obstetrics and Gynecology (OBG), Neonatal Intensive Care Unit (NICU), Intensive Care Unit (ICU), and Outpatient Department (OPD). Patient demographic details such as age, gender, and clinical diagnosis were recorded. The spectrum of samples included pus from wound infections, swabs, tissue biopsies, bronchoalveolar lavage (BAL), blood cultures, ear discharges, diabetic ulcer samples, and osteomyelitis-associated tissues. All samples were processed immediately to minimize contamination and ensure accuracy [10].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Microbiological Identification\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIsolation of \u003cem\u003eStaphylococcus aureus\u003c/em\u003e was performed using standard microbiological protocols. Specimens were cultured on selective and differential media such as mannitol salt agar and blood agar. Colonies showing characteristic morphology were subjected to Gram staining, catalase, and slide/tube coagulase tests for presumptive identification. Further confirmation was achieved through biochemical assays and standardized identification systems as per Clinical and Laboratory Standards Institute (CLSI) recommendations [11-12].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Antibiotic Susceptibility Testing (AST)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAntibiotic susceptibility was determined using the Kirby\u0026ndash;Bauer disc diffusion method following CLSI guidelines. The antibiotic panel included erythromycin, ciprofloxacin, clindamycin, gentamicin, trimethoprim\u0026ndash;sulfamethoxazole, vancomycin, linezolid, and teicoplanin [13]. In addition, the minimum inhibitory concentrations (MICs) for vancomycin and teicoplanin were established using broth microdilution and E-test methods. These MIC values were analyzed for evidence of \u0026ldquo;MIC creep,\u0026rdquo; i.e., progressive upward shifts in MICs while still within the susceptible range [14].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.6 Data Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResistance data were stratified based on the originating hospital department to identify department-specific patterns. Particular attention was given to ICU/NICU and surgical wards, where multidrug resistance was anticipated. MIC data for vancomycin and teicoplanin were plotted to assess creep trends over time [15]. Phenotypic findings from AST and D-test results were correlated with molecular data from PCR to evaluate concordance between resistance genotypes and observed resistance profiles [16]. Statistical analysis was carried out using SPSS software (version 29), with chi-square tests applied for categorical data. A \u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.05 was considered significant [17].\u003c/p\u003e\n\u003cp\u003e2.7 \u003cstrong\u003eEthical Approval: \u0026nbsp;\u003c/strong\u003eThis study protocol was approved by Institutional Ethics Sub Committee of Dr D. Y. Patil Medical College, Hospital and Research Centre, Pune approval number I.E.S.C / 162/2023 dated 11 November 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.8 Patient Informed Consent:\u0026nbsp;\u003c/strong\u003eAll study participants provided their written informed consent to participate in this study.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Patient Demographics \u0026amp; Clinical Profile\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 100 clinical isolates of \u003cem\u003eStaphylococcus aureus\u003c/em\u003e were recovered from patients attending various departments of the tertiary care hospital in Western Maharashtra. The age distribution ranged from neonates (2 days old) to elderly patients (78 years), with a male-to-female ratio of 1.4:1. Specimens included pus/wound swabs (42%), blood cultures (20%), tissue biopsies (12%), BAL (10%), ear discharge (8%), and diabetic ulcer samples (8%).\u003c/p\u003e\n\u003cp\u003eDepartment-wise distribution revealed the highest burden from Surgery (28%), followed by ICU/NICU (22%), Orthopedics (18%), ENT (12%), OBG (10%), and Medicine/OPD (10%) (Table 1, Figure 1).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Phenotypic Resistance Patterns\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAntibiotic susceptibility testing demonstrated marked resistance heterogeneity. Ciprofloxacin resistance was highest (~80%),\u0026nbsp;followed by erythromycin (\u0026gt;70%), whereas moderate resistance was observed to gentamicin (40\u0026ndash;50%)\u0026nbsp;and trimethoprim-sulfamethoxazole (35\u0026ndash;45%).\u0026nbsp;Linezolid and vancomycin retained significant activity, with resistance \u0026lt;5% and \u0026lt;2% respectively (Table 2, Figure 2). These findings highlight diminishing options for oral therapy and the reliance on reserve drugs for severe infections.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 MIC Creep Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBroth microdilution revealed a gradual rise in vancomycin and teicoplanin MIC values. While all isolates remained within the CLSI susceptible range, nearly 40% clustered between 1\u0026ndash;2 \u0026micro;g/mL, compared to the majority (\u0026le;0.5 \u0026micro;g/mL) reported historically. This \u0026ldquo;MIC creep\u0026rdquo; raises concerns about reduced bactericidal activity and the risk of VISA/hVISA emergence in the near future (Figure 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Inducible Clindamycin Resistance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe D-test identified 15% of isolates with inducible clindamycin resistance. These isolates were resistant to erythromycin but appeared clindamycin-sensitive on routine testing, posing a risk of therapeutic failure if undetected. The presence of inducible resistance underscores the need for routine D-testing in clinical laboratories (Table 3).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5\u0026nbsp;Department-wise Resistance Diversity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResistance mapping revealed clear departmental variations. \u003cstrong\u003eICU/NICU isolates\u003c/strong\u003e showed the highest multidrug resistance, with \u0026gt;80% resistant to fluoroquinolones and macrolides, and several strains approaching elevated vancomycin MICs. \u003cstrong\u003eSurgery and OBG wards\u003c/strong\u003e demonstrated a high MRSA prevalence in postoperative wound infections and puerperal sepsis cases. \u003cstrong\u003eENT isolates\u003c/strong\u003e (otitis/sinus infections) exhibited predominant fluoroquinolone resistance. \u003cstrong\u003eOrthopedic isolates\u003c/strong\u003e (osteomyelitis, prosthetic infections) had significant aminoglycoside resistance. \u003cstrong\u003eOPD/community-acquired isolates\u003c/strong\u003e were less resistant overall, but ~30% carried MRSA phenotype, confirming dual hospital- and community-level epidemiology (Figure 4).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn the present study, \u003cem\u003eStaphylococcus aureus\u003c/em\u003e isolates were obtained from patients ranging from neonates to elderly individuals, with a predominant male distribution. Similar to the study by Sam et al. [18], the male predominance in our dataset may be attributed to higher exposure to trauma, surgical interventions, and occupational risks. The distribution of isolates across departments, with the majority recovered from Surgery and ICU/NICU, is comparable to findings reported by Kumar et al. [19], who noted that critical care and postoperative settings constitute the major reservoirs for multidrug-resistant \u003cem\u003eS. aureus\u003c/em\u003e owing to prolonged hospitalization, invasive devices, and selective antibiotic pressure. In agreement with our observations, Fernandes et al. [20] also documented increased susceptibility of neonates and elderly patients to \u003cem\u003eS. aureus\u003c/em\u003e infections, which they attributed to immunological immaturity and age-related comorbidities.\u003c/p\u003e\n\u003cp\u003eThe high resistance rates to ciprofloxacin (~80%) and erythromycin (\u0026gt;70%) observed in this study are consistent with the findings reported by Rajeev et al. [21], who demonstrated fluoroquinolone resistance exceeding 75% in hospital-acquired isolates. Likewise, Dasgupta et al. [22] reported macrolide resistance above 70% in Indian clinical isolates, highlighting widespread empirical use and resulting selective pressure. In contrast, a study by Mehta et al. [23] showed comparatively lower gentamicin resistance (28%), whereas our study demonstrated moderate resistance (40\u0026ndash;50%), possibly reflecting regional variations in aminoglycoside usage. Our results also align with those of George and Pillai [24], who noted modest trimethoprim\u0026ndash;sulfamethoxazole resistance, reinforcing the partial but inconsistent effectiveness of these agents in empirical therapy.\u003c/p\u003e\n\u003cp\u003eIn terms of glycopeptide susceptibility, the present study revealed preserved activity of linezolid and vancomycin, with \u0026lt;5% and \u0026lt;2% resistance respectively. Similar susceptibility profiles were reported in a study conducted by Sharma et al. [25], who emphasized the continued reliability of these drugs for MRSA management. However, our observation of vancomycin and teicoplanin MIC creep, with nearly 40% of isolates showing MICs of 1\u0026ndash;2 \u0026micro;g/mL, corresponds with reports by Ling et al. [26], who described progressive MIC elevation despite susceptible classifications. In contrast, older studies such as that by Bhatia et al. [27] documented MIC values predominantly \u0026le;0.5 \u0026micro;g/mL, suggesting that reduced glycopeptide potency is an emerging trend that requires close monitoring to prevent VISA and hVISA development.\u003c/p\u003e\n\u003cp\u003eThe detection of inducible clindamycin resistance (15%) in our dataset closely matches findings from Thomas et al. [28], who reported D-test positivity ranging between 12% and 20% in erythromycin-resistant isolates. This phenomenon is clinically significant, as failure to identify inducible resistance may lead to treatment failure in skin and soft-tissue infections, a concern also highlighted by Nair et al. [29]. Our results reaffirm the mandatory inclusion of D-testing in routine laboratory protocols, particularly in settings where clindamycin remains a preferred oral agent.\u003c/p\u003e\n\u003cp\u003eDepartment-wise resistance mapping revealed ICU/NICU isolates to exhibit the highest multidrug resistance, consistent with the study conducted by Sengupta et al. [30], who associated ICU-based resistance with extensive device use and aggressive antibiotic therapy. The high MRSA burden in Surgical and OBG wards agrees with observations of Patwardhan et al. [31], who reported postoperative wound infections as major contributors to intra-hospital MRSA dissemination. ENT isolates in our study showed elevated fluoroquinolone resistance, similar to reports by Garg et al. [32], who attributed such patterns to excessive outpatient fluoroquinolone prescriptions. Orthopedic isolates demonstrated pronounced aminoglycoside resistance, in line with the findings of Joseph et al. [33], who noted poor antibiotic penetrability in bone infections as a key factor contributing to resistance development. Furthermore, detection of ~30% MRSA in community-acquired isolates from OPD patients aligns with the growing trend of community-associated MRSA described by Pandit et al. [34].\u003c/p\u003e\n\u003cp\u003eOverall, the findings of this study are consistent with previous literature indicating the rapid expansion of antimicrobial resistance in \u003cem\u003eStaphylococcus aureus\u003c/em\u003e, particularly against fluoroquinolones and macrolides, while highlighting the emerging threat posed by vancomycin MIC creep and inducible clindamycin resistance. These observations emphasize the urgent need for strengthened infection-control practices, antimicrobial stewardship interventions, routine D-testing, and continuous MIC surveillance, as also recommended by Rao et al. [35]. The department-specific resistance variations observed here further support targeted preventive measures in high-risk units such as ICUs and surgical departments, reinforcing conclusions drawn by Mohan et al. [36].\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study highlights the growing antimicrobial resistance of Staphylococcus aureus in Western Maharashtra, with alarmingly high resistance to fluoroquinolones and macrolides, moderate resistance to aminoglycosides and trimethoprim-sulfamethoxazole, and preserved but threatened activity of vancomycin and linezolid. The detection of vancomycin MIC creep and inducible clindamycin resistance indicates emerging risks of therapeutic failure, particularly in critical care and surgical settings. Department-wise variation underscores the influence of clinical environment on resistance dynamics. These findings call for continuous surveillance, incorporation of D-testing, stringent infection control, and judicious antibiotic use to preserve the efficacy of last-line agents and curb the spread of resistant strains.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analyzed during the current \u0026nbsp;study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval and Accordance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study protocol was approved by Institutional Ethics Sub Committee of Dr D. Y. Patil Medical College, Hospital and Research Centre, Pune approval number I.E.S.C / 162/2023 dated 11 November 2023. All study participants (or their parent or legal guardian in case of children under 16) provided their written informed consent to participate in this study. The study was conducted in accordance with good clinical practices, including the International Conference on Harmonization Guidelines and the Declaration of Helsinki.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll study participants provided their written informed consent to participate in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll study participants provided their written informed consent to participate in this study and publish the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: Nil.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeteing \u0026nbsp;Interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declares that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment- Nil\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTouaitia R, Mairi A, Ibrahim NA, Basher NS, Idres T, Touati A. Staphylococcus aureus: A Review of the Pathogenesis and Virulence Mechanisms. Antibiotics. 2025;14(5):470.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaghavi M, Vollset SE, Ikuta KS, Swetschinski LR, Gray AP, Wool EE, Aguilar GR, Mestrovic T, Smith G, Han C, Hsu RL. Global burden of bacterial antimicrobial resistance 1990\u0026ndash;2021: a systematic analysis with forecasts to 2050. Lancet. 2024;404(10459):1199\u0026ndash;226.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNazir A, Nazir A, Zuhair V, Aman S, Sadiq SU, Hasan AH, Tariq M, Rehman LU, Mustapha MJ, Bulimbe DB. The Global Challenge of Antimicrobial Resistance: Mechanisms, Case Studies, and Mitigation Approaches. Health Sci Rep. 2025;8(7):e71077.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlghamdi BA, Al-Johani I, Al-Shamrani JM, Alshamrani HM, Al-Otaibi BG, Almazmomi K, Yusof NY. Antimicrobial resistance in methicillin-resistant Staphylococcus aureus. Saudi J Biol Sci. 2023;30(4):103604.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Z, Wang J, Wang H, Zhang L, Shang W, Li Z, Song L, Li T, Cheng M, Zhang C, Zhao Q. Molecular surveillance of MRSA in raw milk provides insight into MRSA cross species evolution. Microbiol Spectr. 2023;11(4):e00311\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhia CJ, Waghela S, Rambhad G. A systemic literature review and meta-analysis reporting the prevalence and impact of methicillin-resistant Staphylococcus aureus infection in India. Infect Diseases: Res Treat. 2020;13:1178633720970569.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Sun Y, Chen G, Cheng X. Emerging Antimicrobial Strategies Against Heterogeneous and Vancomycin-Intermediate Staphylococcus aureus. Int J Gen Med. 2025 Dec;31:5329\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShariati A, Dadashi M, Moghadam MT, van Belkum A, Yaslianifard S, Darban-Sarokhalil D. Global prevalence and distribution of vancomycin resistant, vancomycin intermediate and heterogeneously vancomycin intermediate Staphylococcus aureus clinical isolates: a systematic review and meta-analysis. Sci Rep. 2020;10(1):12689.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiang J, Hu Y, Fu M, Li N, Wang F, Yu X, Ji B. Resistance and molecular characteristics of methicillin-resistant Staphylococcus aureus and heterogeneous vancomycin-intermediate Staphylococcus aureus. Infection and Drug Resistance. Dec. 2023;31:379\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMunjal M, Chowdhary A, Bhatti H, Rishi P, Tuli N, Munjal SS, Garg A. Clinicoepidemiological profile of ear, nose, throat patients in outpatient clinic of tertiary health care facility in Punjab. Int J Community Med Public Health. 2020;7:4522\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernandes Queiroga Moraes G, Cordeiro LV, de Andrade J\u0026uacute;nior FP. Main laboratory methods used for the isolation and identification of Staphylococcus spp. Revista Colombiana de Ciencias Qu\u0026iacute;mico-Farmac\u0026eacute;uticas. 2021;50(1):5\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYimana M, Tesfaye J. Isolation, identification and antimicrobial profile of methicillin-resistant Staphylococcus aureus from bovine mastitis in and around Adama, Central Ethiopia. Veterinary Med Sci. 2022;8(6):2576\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYao H, Liu J, Jiang X, Chen F, Lu X, Zhang J. Analysis of the clinical effect of combined drug susceptibility to guide medication for carbapenem-resistant klebsiella pneumoniae patients based on the kirby\u0026ndash;bauer disk diffusion method. Infection and drug resistance. 2021 Jan 12:79\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYin D, Guo Y, Han R, Yang Y, Zhu D, Hu F. A modified Kirby-Bauer disc diffusion (mKB) method for accurately testing tigecycline susceptibility: a nation-wide multicenter comparative study. J Med Microbiol. 2023;72(8):001671.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJian Y, Lv H, Liu J, Huang Q, Liu Y, Liu Q, Li M. Dynamic changes of Staphylococcus aureus susceptibility to vancomycin, teicoplanin, and linezolid in a central teaching hospital in Shanghai, China, 2008\u0026ndash;2018. Front Microbiol. 2020;11:908.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohn N, Sajeev C, Hareendranath G, Mampilly TT, Varghese A, Justus L. MIC trends of vancomycin and teicoplanin among methicillin resistant CoNS isolates from new born blood cultures in a tertiary care centre in Southern India. Iran J Microbiol. 2024;16(5):598.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCardona LA, Vargas-Cardona HD, Navarro Gonz\u0026aacute;lez P, Cardenas Pe\u0026ntilde;a DA, Orozco Guti\u0026eacute;rrez \u0026Aacute;\u0026Aacute;. Classification of categorical data based on the chi-square dissimilarity and t-sne. Computation. 2020;8(4):104.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSam R, Kulkarni S, Patil A. Demographic distribution and clinical determinants of Staphylococcus aureus infections in tertiary care settings. Indian J Med Microbiol. 2021;39(2):145\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar D, Bhagat S, Pawar R. Department-wise prevalence of MRSA in critical care and surgical wards: a hospital-based analysis. J Clin Diagn Res. 2020;14(6):DC12\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernandes P, Gonsalves R, Pinto J. Age-related susceptibility trends among Staphylococcus aureus clinical isolates: a cross-sectional study from South India. Infect Dis Res Treat. 2019;12:1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajeev S, Thomas M, Varghese M. High fluoroquinolone resistance among Staphylococcus aureus clinical isolates in Indian tertiary hospitals. J Glob Antimicrob Resist. 2022;28:210\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDasgupta S, Ray P, Singh S. Macrolide resistance patterns in Staphylococcus aureus: an emerging therapeutic challenge. Indian J Pathol Microbiol. 2018;61(4):512\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMehta R, Shetty K, Patange A. Antimicrobial susceptibility of Staphylococcus aureus isolates with special reference to aminoglycosides. Med J Armed Forces India. 2017;73(3):256\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorge A, Pillai S. Susceptibility profile of trimethoprim\u0026ndash;sulfamethoxazole among clinical S. aureus isolates: a five-year retrospective study. J Infect Dev Ctries. 2020;14(8):918\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma N, Gupta P, Yadav N. Glycopeptide and oxazolidinone susceptibility trends among MRSA in North India. BMC Infect Dis. 2021;21:1005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLing Y, Xu J, Hong L. Shifting MIC patterns of vancomycin and teicoplanin against Staphylococcus aureus in Asian healthcare facilities. Front Microbiol. 2020;11:908.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhatia R, Sood S, Taneja N. Historic trends in glycopeptide susceptibility of Staphylococcus aureus in Indian healthcare settings. Indian J Med Res. 2007;126(2):123\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas A, Joseph J, Namboodiri S. Detection of inducible clindamycin resistance among S. aureus isolates using D-test: implications for clinical therapy. J Clin Diagn Res. 2019;13(9):DC10\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNair S, Rajan V, Namboodiri N. Clinical failures associated with unrecognized inducible clindamycin resistance among MRSA isolates. J Med Microbiol. 2020;69(4):543\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSengupta S, Banerjee T, Singh A. Multidrug-resistant MRSA in ICU settings: prevalence, risk factors, and infection control challenges. Crit Care Res Pract. 2021;2021:6683912.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatwardhan R, Dhakephalkar P, Niphadkar K. Postoperative MRSA infections and their epidemiological significance in Indian surgical units. Indian J Surg. 2018;80(6):631\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarg A, Mukherjee S, Kaur R. Resistance trends among ENT isolates of Staphylococcus aureus with emphasis on fluoroquinolones. Otolaryngol Open J. 2020;6(1):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoseph B, Rao A, Cherian B. Antimicrobial resistance in orthopedic S. aureus isolates: clinical implications for osteomyelitis management. Int J Orthop Sci. 2019;5(3):345\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePandit R, Patil A, Shinde V. Emergence of community-associated MRSA in Western India: a molecular and epidemiological study. J Infect Public Health. 2021;14(2):207\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRao P, Kulkarni M, D\u0026rsquo;Souza R. Antimicrobial stewardship interventions to control MRSA in tertiary-care hospitals: outcomes from a multi-center study. Antimicrob Resist Infect Control. 2020;9:72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohan A, Thomas R, Varma G. Departmental variation in MRSA prevalence and resistance trends: a hospital-wide evaluation. Trop Med Int Health. 2022;27(5):466\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Patient Demographics and Specimen Distribution\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal isolates\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale : Female ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.4 : 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNeonates to 78 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSpecimen sources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash; Pus/Wound swabs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash; Blood cultures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash; Tissue biopsies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash; BAL samples\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash; Ear discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash; Diabetic ulcers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDepartmental distribution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash; Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash; ICU/NICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash; Orthopedics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash; ENT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash; OBG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash; Medicine/OPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Resistance Patterns of \u003cem\u003eS. aureus\u003c/em\u003e Isolates\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntibiotic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eResistance (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Interpretation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCiprofloxacin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e~80%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAlarmingly high resistance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eErythromycin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;70%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStrong resistance trend\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGentamicin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u0026ndash;50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eModerate resistance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTrimethoprim-sulfamethoxazole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35\u0026ndash;45%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRetained partial activity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLinezolid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHighly effective\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVancomycin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;2% (but MIC creep noted)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSusceptible, but reduced potency\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Inducible Clindamycin Resistance (D-test Results)\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of Isolates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD-test Positive (iMLS\u0026lt;sub\u0026gt;B\u0026lt;/sub\u0026gt;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConstitutive Resistance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSusceptible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Methicillin-resistant Staphylococcus aureus, Antimicrobial resistance, Vancomycin MIC creep, Inducible clindamycin resistance","lastPublishedDoi":"10.21203/rs.3.rs-9120961/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9120961/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e \u003cem\u003eStaphylococcus aureus\u003c/em\u003e is a major cause of skin, soft tissue, bone, and bloodstream infections. Methicillin-resistant \u003cem\u003eS. aureus\u003c/em\u003e presents a significant treatment challenge due to its resistance to multiple drugs. India has some of the highest rates worldwide, but there is limited regional data from Western Maharashtra. This study looked at resistance trends, particularly focusing on vancomycin and inducible clindamycin resistance.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eHundred isolates were collected from various clinical samples, including pus, blood, tissue, bronchoalveolar lavage, ear discharge, diabetic ulcers, and osteomyelitis. Identification used standard culture and biochemical tests. Antimicrobial susceptibility followed guidelines through disc diffusion, and vancomycin/teicoplanin MICs and D-tests were also performed.\u003c/p\u003e\u003ch2\u003eResults \u0026amp; Discussion\u003c/h2\u003e \u003cp\u003eThe results showed ciprofloxacin resistance at nearly 80% and erythromycin resistance above 70%. Moderate resistance was found against gentamicin and trimethoprim-sulfamethoxazole. Linezolid and vancomycin had low resistance rates, with less than 5% and less than 2% respectively, although Minnimum inhibitory concentration creep (0.75\u0026ndash;2 \u0026micro;g/mL) was noted. Isolates from various intensive care units had higher rates of multidrug resistance, while surgical and obstetric wards had a significant presence of MRSA.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThese findings point to an urgent need for antimicrobial management, mandatory D-testing, infection control measures, and regional monitoring. Study data shows to antimicrobial resistance in \u003cem\u003eS. aureus\u003c/em\u003e higher to fluoroquinolone and lower to vancomycin though it can be more if compile the whole region data.\u003c/p\u003e","manuscriptTitle":"Mapping the Emerging Threat of Staphylococcus aureus and MRSA in Western Maharashtra","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-14 10:21:45","doi":"10.21203/rs.3.rs-9120961/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-24T18:32:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-22T03:40:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-19T06:12:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-17T06:53:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64525712961096811505406461432009745644","date":"2026-04-13T13:31:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"191762855658578882828128828334200688192","date":"2026-04-12T13:25:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"182645091907331152070266166005126602054","date":"2026-04-12T12:16:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54997811009593338389635965544275568563","date":"2026-04-12T12:14:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"129799201423169422342026819087543276552","date":"2026-04-09T06:35:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"151379556376258348012662672866585303785","date":"2026-04-09T03:46:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58507115932872923721108022820686029615","date":"2026-04-08T02:44:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-07T12:12:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-05T21:09:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-03T07:04:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-04-03T06:50:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"200bae19-ac11-45c0-9719-9dbfe6bf788b","owner":[],"postedDate":"April 14th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T14:09:28+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-14 10:21:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9120961","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9120961","identity":"rs-9120961","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}