Comparative accuracy of molecular assays for detecting methicillin-resistant Staphylococcus aureus: Evidence from 32 studies

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) remains a major global health concern due to its multidrug resistance and associated morbidity. Conventional culture-based antimicrobial susceptibility testing is time-consuming and may delay optimal treatment. Molecular assays have emerged as rapid alternatives, but their diagnostic performance across clinical settings has not been comprehensively synthesized. OBJECTIVE: To evaluate the diagnostic accuracy of molecular assays for MRSA detection and explore potential sources of variability related to assay type, specimen type, and study setting. METHODS: Following the PRISMA-DTA statement, we systematically searched PubMed, Embase, Web of Science, and the Cochrane Library from database inception to March 2026. Studies evaluating molecular assays against culture-based antimicrobial susceptibility testing were included. Pooled sensitivity, specificity, and summary area under the curve (AUC) were estimated using a bivariate random-effects model. Subgroup analyses were performed based on assay modality, specimen type, and country income level. RESULTS: Thirty-two studies involving 5342 clinical specimens were included. Molecular assays demonstrated high diagnostic accuracy, with a pooled sensitivity of 0.92 (95% CI: 0.91-0.93) and specificity of 0.95 (95% CI: 0.92-0.96). The summary AUC was 0.98 (95% CI: 0.96-0.99). Subgroup analyses showed that real-time PCR outperformed conventional PCR, and nasal swabs yielded the highest diagnostic performance among specimen types. Diagnostic accuracy was slightly higher in high-income countries than in low- and middle-income settings. Deeks' test indicated no significant publication bias (P = 0.22). CONCLUSIONS: Molecular assays demonstrate excellent diagnostic accuracy for MRSA detection and can substantially reduce diagnostic turnaround time. Their integration into clinical workflows may support earlier infection control and antimicrobial decision-making. Further standardization and validation are warranted to optimize their use across diverse healthcare settings.