Indian Journal of Medical Microbiology IAMM  | About us |  Subscription |  e-Alerts  | Feedback |  Login   
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size
 Home | Ahead of Print | Current Issue | Archives | Search | Instructions  
Users Online: 107 Official Publication of Indian Association of Medical Microbiologists 
 ~ Next article
 ~ Previous article 
 ~ Table of Contents
 ~  Similar in PUBMED
 ~  Search Pubmed for
 ~  Search in Google Scholar for
 ~  Article in PDF (119 KB)
 ~  Citation Manager
 ~  Access Statistics
 ~  Reader Comments
 ~  Email Alert *
 ~  Add to My List *
* Registration required (free)  

 ~  References
 ~  Article Tables

 Article Access Statistics
    PDF Downloaded675    
    Comments [Add]    
    Cited by others 1    

Recommend this journal


Year : 2009  |  Volume : 27  |  Issue : 4  |  Page : 379-380

Cefoxitin disk diffusion test - Better predictor of methicillin resistance in Staphylococcus aureus

Department of Microbiology, UCMS & GTB Hospital, Delhi - 110 095, India

Date of Submission29-Jun-2008
Date of Acceptance02-Jun-2009
Date of Web Publication4-Sep-2009

Correspondence Address:
N P Singh
Department of Microbiology, UCMS & GTB Hospital, Delhi - 110 095
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0255-0857.55447

Rights and Permissions

How to cite this article:
Gupta M, Singh N P, Kumar A, Kaur I R. Cefoxitin disk diffusion test - Better predictor of methicillin resistance in Staphylococcus aureus. Indian J Med Microbiol 2009;27:379-80

How to cite this URL:
Gupta M, Singh N P, Kumar A, Kaur I R. Cefoxitin disk diffusion test - Better predictor of methicillin resistance in Staphylococcus aureus. Indian J Med Microbiol [serial online] 2009 [cited 2020 Nov 28];27:379-80. Available from:

Dear Editor,

Cefoxitin, a cephamycin, is a more potent inducer of the mecA regulatory system than are the penicillins. [1] Several studies have reported that the Cefoxitin disk diffusion (DD) test is a good alternative method for detection of Methicillin resistance Staphylococcus aureus Scientific Name Search  ( MRSA) though Oxacillin is the agent recommended by the CLINICAL AND LABORATORY STANDARDS INSTITUTE (CLSI). [2],[3] This study was undertaken to assess the usefulness of Cefoxitin DD in predicting MRSA.

This study included 155 strains of S. aureus , isolated from various clinical samples in the department of Microbiology, GTB Hospital, Delhi. These isolates were studied to evaluate Cefoxitin DD test for routine detection of MRSA. All the strains were screened for methicillin resistance by Oxacillin (1mg) and Cefoxitin (30 mg) DD test as per standard guidelines. Zone diameters as recommended by CLSI were read both at 18h and 24 h.

To assess the reproducibility of the Cefoxitin DD method, 10 strains each of MRSA and MSSA (both by Oxacillin and Cefoxitin disk) were taken and the inhibition zone diameters were obtained consecutively on 30 occasions. In addition, five strains of S. aureus which were sensitive by Oxacillin DD and resistant by Oxacillin MIC (between 4-6mg/ml), Cefoxitin DD and Cefoxitin MIC (>8mg/ml) were also taken.

The CLSI broth macro dilution (BMD) reference method was used to determine the MIC of Oxacillin and Cefoxitin. (MIC cut off criteria as recommended by CLSI for Oxacillin less than or equal to 2 mg/ml for susceptible and greater than or equal to 4 mg/ml for resistance. Modified breakpoint criteria for Cefoxitin less than or equal to 4 mg/ml for susceptible and greater than or equal to 8 mg/ml for resistance). Isolates that had MIC value of greater than or equal to 4 mg/ml for Oxacillin and greater than or equal to 8 mg/ml for Cefoxitin were taken as Methicillin resistant.

Of the 155 strains which were tested, 48.39% strains were Methicillin resistant by Oxacillin DD method compared to Oxacillin agar screen method which detected 50.32% strains including three strains of S. aureus which had Oxacillin zone diameters of 11-12 mm. These strains were further tested by Cefoxitin DD method. 54.54% strains were found to be resistant. No difference in zone diameters was seen at 18hrs and 24hrs. Cefoxitin MIC's are shown in [Table 1]. No benefit of added salt was noticed.

Staphylococcus aureus is human pathogen with a remarkable propensity for development of antibiotic resistance. Previous CLSI recommendation for detecting MRSA included agar dilution, BMD, DD, the Oxacillin screen test and detection of mecA or product of mecA gene, PBP2a, by PCR and latex agglutination respectively. All these methods used for S. aureus , aside from mecA detection by PCR, are prone to errors. The laboratories that cannot afford to perform the PBP2a, latex agglutination test or do not have access to PCR, need alternative methods for detecting mecA -mediated resistance. Several studies have been done to investigate the utility of Cefoxitin DD for detection of MRSA [2],[3] In our study, Oxacillin DD test detected Methicillin resistance in 48.39% strains whereas Cefoxitin DD method detected 54.54% MRSA strains including 10 strains which had intermediate resistance to Oxacillin. The Cefoxitin DD zones were distinct and easy to read. Oxacillin agar screen detected three additional MRSA strains which were not detected by Oxacillin DD method but were detected resistant by Cefoxitin DD test. Moreover, Oxacillin agar screen is cumbersome to perform. Oxacillin MIC detected 52.26% MRSA strains as compared to Cefoxitin MIC, which could detect 54.54% MRSA strains. The use of Cefoxitin MIC test has not been recommended by the CLSI-AST, but its performance was equivalent to Cefoxitin DD when using modified breakpoints of less than or equal to 4 mg/ml for susceptible and greater than orequal to 8 mg/ml for resistance. The results of Cefoxitin DD method were better for isolates with Oxacillin MIC between 4-6 mg/ml [Table 1]. Both Oxacillin DD and Cefoxitin DD gave reproducible results on 30 occasions for 10 MRSA and 10 MSSA strains however, Oxacillin DD gave inconsistent results for five strains with MIC 4-6mg/ml on several occasions in comparison to Cefoxitin DD which gave consistent resistant results for these five intermediate resistant strains. Our study also revealed that low level Oxacillin resistance was detected better by Cefoxitin DD test.

Detecting mecA gene characterization by PCR/PBP2a is recognized as gold standard for detection of MRSA. However, use of PCR assay is generally limited to reference laboratories, especially in developing countries. Our study clearly showed, the substitution of a Cefoxitin DD for an Oxacillin DD test, will result in an easier to read test with greater accuracy for detection of Methicillin resistance in S. aureus .

 ~ References Top

1.Drew WL, Barry AL, O'Toole R, Sherris JC. Reliability of the Kirby-Bauer Disc Diffusion Method for Detecting Methicillin-Resistant Strains of Staphylococcus aureus . Appl Microbiol 1972;24:240-7.  Back to cited text no. 1    
2.McKinney TK, Sharma VK, Craig WA, Archer GL. Transcription of the gene mediating methicillin resistance in Staphylococcus aureus (mecA) is corepressed but not coinduced by cognate mecA and â-lactamase regulators. J Bacteriol 2001;183:6862-8.  Back to cited text no. 2    
3.Boutiba-Ben Boubaker I, Ben Abbes R, Ben Abdallah H, Mamlouk K, Mahjoubi F, Kammoun A, et al . Evaluation of a cefoxitin disk diffusion test for the routine detection of methicillin-resistant Staphylococcus aureus . Clin Microbiol Infect 2004;10:762-5.  Back to cited text no. 3    


  [Table 1]

This article has been cited by
1 Epidemiology of Methicillin-Resistant Staphylococcus aureus Isolated From Health Care Providers in Mofid Children Hospital
Masoumeh Navidinia,Fatemeh Fallah,Behnaz Lajevardi,Mehdi Shirdoost,Jamshid Jamali
Archives of Pediatric Infectious Diseases. 2015; 3(2)
[Pubmed] | [DOI]


Print this article  Email this article
Previous article Next article


2004 - Indian Journal of Medical Microbiology
Published by Wolters Kluwer - Medknow

Online since April 2001, new site since 1st August '04