NOSOCOMIAL INFECTION: SOURCE AND PREVENTION

NOSOCOMIAL INFECTION: SOURCE AND PREVENTION

Mahavir Joshi, Sukhminderjit Kaur, Hemant Preet Kaur and Tulika Mishra ^*

Department of Biotechnology, UIBT, Chandigarh University, Gharuan, Mohali - 140413, Punjab, India.

ABSTRACT: Nowadays, Hospital-acquired infection is one of the significant issues, as the mortality rate is frequently increasing. This may be due to the unhygienic environment of various medical clinics and hospitals, a wide range of antibiotic uses. Nosocomial infections are those which are acquired by the patient within 48-72 h or 3 days of admission in the hospital or medical care unit. The microbes cause nosocomial infections originated in hospitals, clinics, and medical care center. The mode of transfer of hospital-acquired infection can be either by direct or by indirect contact. Vectors involve the organisms that act as a carrier for the spread of disease by dispersion of causative pathogens. Cockroaches, ants, and flies come in direct contact with faces of the patient, and contaminated objects can cause disease by cross-contamination of other objects which can lead to infection. Nosocomial infection can be prevented by minimizing the spread of causative agents, isolation for the patient suffering from infectious disease and maintaining well sanitary conditions in hospitals and medical care unit. A medical device or surgical instrument which comes in contact with the patient during treatment or operation procedure has an associated risk of disease transmission which is due to failure of sterilization or disinfection. Microbial air contamination is monitored by colony forming unit per cubic meter (CFU/m³) count. This can be done either by passive or active sampling methods. Nosocomial infection can be prevented by minimizing the spread of causative agents, isolation for the patient suffering from infectious disease and maintaining well sanitary conditions in hospitals and medical care unit.

Nosocomial infections, Pathogens, Disease transmission, Microbial air contamination, Hospitals

INTRODUCTION: Nosocomial infections are those which are acquired by the patient within 48-72 h or 3 days of admission in the hospital or medical care unit. Immuno-compromised and patient admitted to the Intensive Care Unit (ICU) are at high risk of acquiring the nosocomial infection. It has been reported that out of 10 patients every one patient gets infected by nosocomial infection, increasing the stay of the patient in the hospital for treatment.

This causes a significant increase in the cost of the treatment for patient ¹. In a study conducted by Sahni et al., 2005 on nosocomial infection caused by Candida species, it has been reported that out of the total 200 known species of Candida, about 10% cause infection in humans. They screened 101 patients of the age from 18 to 80 years showing signs of nosocomial infection and observed that 42.8% of patients were suffering from a disease caused by Candida albicans.

From this study, they concluded that nosocomial infection caused by Candida species is a significant problem in hospitals ². Nosocomial infections are one of the significant causes of mortality and morbidity in hospitals. The rate of nosocomial infections is more in neonatal hospital followed by second to burn in hospitals.

In immunocompromised patients, patients with multiple organ failure, burn victims, the mortality rate is high. In the neonatal ward, the common pathogen causing nosocomial infections are S. aureus, Klebsiella, E. coli and Staphylococcus epidermis ³. Stay of patients in ICUs can also lead to nosocomial infections and the factors are increasing the length of ICU stay (>48 h) mechanical ventilation, diagnosis of trauma, central venous, pulmonary artery and urinary catheterization and stress ulcer prophylaxis. The pathogens which are found to be causative of agents include Enterobacteriaceae, Staphylococcus aureus (60% resistant to methicillin), Pseudomonas aeruginosa, coagulase-negative Staphylococci and fungi ⁴. Most frequent infection sites associated with nosocomial infection include urinary tract infection pneumonia, primary bloodstream, use of contaminated mechanical ventilation; urinary catheters are a source of nosocomial pneumonia and urinary tract infection respectively. Bloodstream infections are caused by coagulase-negative Staphylococcus and S. aureus. Nosocomial Pneumonia is caused by Gram-negative aerobic microorganism, Pseudomonas aeruginosa, and Staphylococcus aureus. Candida albicans is found in urinary tract infection ⁵.

Medical devices are also associated with the spread of nosocomial infections. Stethoscopes are also a source of nosocomial infection. Sengupta et al., 2000 have isolated such as coagulase-negative Staphylococcus, coagulase-negative Staphylococcus, Enterococci, Escherichia coli, Klebsiella species and Acinetobacter species found to be sensitive to ciprofloxacin, netilmicin, and amikacin from stethoscopes. Nosocomial infection caused by extended-spectrum beta-lactamases (ESBL) producing Klebsiella species and methicillin-resistant Staphylococcus aureus (MRSA) in neonatal intensive care unit affect the recovery of neonates and can also lead to prematurity, low birth weight, hospitality stay. Associated microbes in nosocomial infection include Klebsiella species, Enterobacter species, E. coli and Citrobacter Species Acinetobacter species ⁶. Gram-positive bacteria, like methicillin-resistant Staphylococcus aureus (MRSA), spread more drastically in burn unit than not burn area. About 1 to 18% contaminated in the non-burn group compared to 64% in the Burn Unit at the hospital.

Other gram-positive bacteria which contaminate inanimate object like mattress etc. include Pseudomonas aeruginosa, Vancomycin-resistant Enterococci (VRE) and Acinetobacter sp. Enteric Gram-negative bacteria very rarely spread through the dry inanimate environment. However, Acinetobacter baumannii non-fermentative bacteria have been found to cause ventilator-associated pneumonia, and bloodstream infection showed resistant and cause antibiotic recalcitrant nosocomial infection outbreak. Acinetobacter baumannii has been isolated from the beds colonized patients and nearly surface. Clostridium difficile has been isolated from surfaces and equipment like commodes, bedpans, blood pressure cuffs, walls, floors, washbasins, and furniture ⁷. More use of antibiotic also increases in some multidrug-resistant bacteria. Non-fermenting Gram-negative bacilli belong to the opportunistic pathogen and can service a wide range of environment. Not a single antibiotic found to be 100% sensitive against MDR bacteria ⁸.

1. Source of Nosocomial Infection: The microbes cause nosocomial infections originated in hospitals, clinics, and medical care center. Fig. 1 represents a direct and indirect mode of pathogen spread. The method of transfer of hospital-acquired infection can be either by direct or by indirect contact. Touching an infected person, animals or reservoir of infection count to be in direct contact. Contaminated hands are one of the principal routes of disease transmission. Communicable infectious agents cause indirect disease transmission does not require direct connection of an infected person with a healthy one. Pathogens present in inanimate object and utilization of these objects can lead to transmission of pathogens. Aerosols originated by coughing and sneezing of patients may carry pathogens that can transmit the diseases.

FIG. 1: SPREAD OF NOSOCOMIAL INFECTION

Table 1 represents the spread of various pathogens from patients and staff carries, contaminated aerosols and electrical or other appliances. The respiratory tract infection is mainly spread through the aerosol. It has also been observed that infectious agents are already present in the patient’s body but do not show any symptoms of the infection, but when the patients are admitted in the hospital, the infection developed. It has been reported that weakness in the immunity and reduced resistance of the patient towards the infectious agent can lead to diseases. This type of infection is known as Endogenous infection, self-infection or autoinfection. Cross-contamination followed by cross infection is another route of infection transmission.

In this case, the admitted patient can be exposed to a new infective agent leading to the development of another infection. Contaminated water can also be a source of nosocomial infection. In a study conducted by Anaissie et al., 2002 it was observed that nosocomial infection due to Pseudomonas aeruginosa causes the death of 1400 people each year in the United States of America.

They have recommended the use of sterile water for the patients more prone to infection and avoid using hospital water ⁹. Monitoring and quality of air in the hospitals, clinics and medical care units is also an essential aspect of dealing with as these places are visited by patients suffering from illness; communicable infectious agents cause some. β-lactam resistant strains such as Acinetobacter and Staphylococcus have been detected in hospital environment ¹⁰.

Biofilm developed by microbes has an essential role in the ecosystem. If the pathogenic microbes are present in the biofilm they can cause infection even in the presence of high a concentration of antibiotic “recalcitrant” can lead to one of the primary cause of disease. Microbial growth can occur on various types of medical device favors microbial film growth. Implanted devices such as studs in the blood vessels have a high chance of microbial growth which can cause severe infection if not treated in time. Staphylococcus aureus has been reported to causes bloodstream infection which is associated with pacemaker ¹¹.

TABLE 1: REPRESENTS SPREAD OF VARIOUS PATHOGENS FROM PATIENTS AND STAFF CARRIES, CONTAMINATED AEROSOLS AND ELECTRICAL OR OTHER APPLIANCES

Direct contact involved cross transmission through the hands of health care workers who are involved in patient care. They come in direct contact with the patient, patient body secretion and the contaminated site where the patient releases the pathogen. It has been reported that the pathogens survive on the hands of the health workers it can be and transmitted further. Staphylococcus aureus is carried by at least 25% of the staff in their nostrils and transmitted through sneezing. The suspended particles carry pathogens which settled down as fomites and are spread through contact ¹². Currently, digitalization is an effective method for keeping the record and effective governance. In the hospital, computers are one of the components placed in every hospital and health care department. The computers may harbor infectious pathogens and serve as their reservoir of pathogens. Microbes associated with computer-based reservoir include primitive pathogens like MRSA, Acinetobacter and normal microbes which can be opportunistic pathogens. Direct contact with contaminated computers, hospital floor, and other objects transmits the infection ¹³. Fig. 2 represents a common vehicle involved in the transmission of nosocomial infection. Air born nosocomial infections spread through the patients, care-workers, and carriers of pathogens not showing symptoms of the disease. Pathogens are disseminated from various sites including nares, anus, skin, skin scales, etc. Viruses are believed to spread through the air; Table 2, represents viruses and origin source spread through the air.

TABLE 2: REPRESENTS AIR BORN DISEASE CAUSED BY VIRUSES

Air born disease caused by various source listed in Table 3. The common vehicle of transmission involves the use of the contaminated medical instrument, inhalation of infected air, consuming contaminated water and food. Microorganisms, except viruses, multiply in inanimate objects. Consuming unprocessed water and food products can also cause infection ¹⁴.

TABLE 3: REPRESENTS AIR BORN DISEASE CAUSED BY VARIOUS SOURCES

Animal MRSA isolated from different sources including dairy cow and chicken specimen are closely related to human MRSA, and it can cause infection to human by consumption of unprocessed food products ¹⁵. Salmonella infection mostly occurs due to the use of contaminated food. The occurrence of disease is widely reported in immuno-comprised patients. It has been reported that eleven patients in the Philippines were admitted in hospital for the treatment of diaries acquired Salmonella enteric serotype Schwarzengrund. The pathogen was found to be resistant against fluoroquinolone and leads to a major outbreak in the United States of America in 2001 ¹⁶. Different types of fungus are involved spread on nosocomial infection listed in Table 4.

TABLE 4: REPRESENTS FUNGUS INVOLVED IN NOSOCOMIAL INFECTION INVOLVED ⁵²

Vectors involve the organisms that act as a carrier for the spread of infection by dispersion of causative pathogens. Cockroaches, ants, and flies come in direct contact with faces of the patient, and contaminated objects can cause disease by cross-contamination of other objects which can lead to infection. More than 80 bacterial species across 51 genera have been identified including antimicrobial resistance. Some of the vector transmitted diseases are enlisted in Table 5.

TABLE 5: REPRESENTS VECTOR TRANSMITTED DISEASE ⁵³

FIG. 2: COMMON VEHICLE INVOLVED IN TRANSMISSION OF NOSOCOMIAL INFECTION

2. Prevention of Nosocomial Infection: Nosocomial infection can be prevented by minimizing the spread of causative agents, isolation for the patient suffering from infectious disease and maintaining well sanitary conditions in hospitals and medical care unit. In the present review, we have selected five significant areas, in which efforts can be made to prevent nosocomial infections.

2. Maintenance of hygiene
3. Avoid surgical site infection
4. An isolation unit for a patient infected by an infectious disease
5. Sterilization of medical equipment
6. Validation and cleaning of hospitals environment

2.1 Maintain Hand Hygiene: One of the most important routes of disease transmission of the infectious agent is hand. According to WHO while visiting in hospital one should follow the standard practices as shown in Fig. 3. ¹⁷

FIG. 3: REPRESENTS FIVE STEPS AT WHICH HAND IN HEALTH CARE [ADOPTED FROM WHO GUIDELINE]

Improper hand wash does not lead to complete eradication of germs and can be a reason for infection. Factors involved lack of education, poor hygiene habit, perceived lack of importance, lack of time, dry skin, skin irritation or dermatitis, the absence of suitable cleansing agent and inadequate hand washing ^{18, 19}. Spread of antibiotic-resistant strains MRSA through the hands were reported by researchers ²⁰. The rate of infection agent spread through hands can be reduced by merely following hand hygiene practice involved 11 steps of hand washing shown in Fig. 4. ²¹

The normal flora of the body generally doesn’t cause illness. But in the case of an immuno-compromise patient who has undergone surgery or invasive procedure, the vegetation moves to another site of body and start colonization which can disrupt the normal flora leading to illness ²².

FIG. 4: SOURCE REPRESENTS STEPS OF HAND WASHING RECOMMENDED BY WHO ¹⁷

2.2 Avoid Surgical Site Infection: Surgical site infection (SSI) is the infection that occurs within 30 days up to 1 year of the surgical process. SSI is one of the significant causes of mortality; therefore; it must be prevented and taken in critical concern ^{23, 24}. Table 6 depicts different risk factor involved in surgical site infection viz., age, health, a habit like (smoking, drinking, etc.,) and immunity.

TABLE 6: REPRESENTS RISK FACTOR INVOLVED IN SURGICAL SITE INFECTION

2.2.1 Preoperative Phase:

• Treat remote infection from the site of surgery before operative procedure.
• Only remove hair if they interfere in surgery and use electric clipper with a single Avoid use of the razor; it may increase the SSI.
• Blood sugar level must be controlled before surgery.
• To reduce staphylococcus infection nasal decolonized by intranasal mupirocin ointment for
• Antibiotic prophylaxis must be given to a patient undergoing surgery, and it must be well defined. The antibiotic must not be given rottenly to the patient as it has an adverse effect also. The antibiotic should be administrated intravenously timely so meaning that serum and tissue contain bactericidal concentration at the time of incision and the concentration can be maintained after a few hours of surgery.
• Appropriate skin antiseptic for skin incision preparation.
• For hand hygiene to maintain nails should be short, no artificial nails to be applied and perform preoperative scrub for 25 min using appropriate antiseptic, Scrub hands and forearms up to the elbow and keep hands up and away from the body. Flex the elbow after performing surgical scrub. Dry the side with a sterile

2.2.1 Intraoperative Phase:

• Ventilation
• A positive pressure must be maintained in the operation theater compared to corridors, and fifteen air changes should be maintained per hour, and three should be of fresh air.
• Recirculated air must be fresh and filtered through the appropriate filters. The UV radiation is prohibited in Operation Theater and door should be closed except for the passage of essential
• Cleaning and disinfection
• Disinfection should be performed before and after the operation procedure and clean visible soiling and blood/fluid spread contamination by appropriate disincentive agents.
• Avoid use of trace mat at the entrance of Operation Theater.
• Microbiological sampling.
• Routine microbiological sampling is not required daily, but monitoring of operation theater surface and air sampling can be performed as a part of the epidemiological
• Sterilization of surgical instruments.
• All the surgical instruments must be sterilized according to the guidelines provided by CDC ²¹.
• Flash sterilization for the patient care instrument that will be used immediately. For example to reprocess a dropped device.
• Surgical attire and drapes.
• Before entering the operation theater wear a surgical mask that thoroughly covers the mouth and nose.
• For effective barrier for liquid wear surgical gowns and drapes that inhibit penetration.
• Change Scrub suits contaminated with visibly soiled Blood or other potentially infectious material.
• Asepsis and surgical technique.
• The aseptic condition should be maintained during the entire operative procedure.
• Dead space must be eradicated at the surgical Maintenance hemostasis, minimize devitalized of tissue should be kept in concern.
• If the surgical site is found to be contaminated, it must leave to heal incision by the second
• Use close suction drainage for the drain and a separate incision distance from the operative incision is preferred and remove waste as soon as possible.

2.2.3 Postoperative Incision Care: Incision must have to close by sterile dressing for 24-48 h postoperative. Before and after changing dressing and surgical contact wash hand with appropriate antiseptic.

2.3 Isolation Unit for Patient Infected by Communicable Disease: Isolation refers to the separation of the patient to control the infection or communicable disease. Patients are isolated according to the mode of transmission of the disease.

• Strict Isolation: To prevent the transmission of highly communicable disease, susceptible to transfer through contact as well as air born route for example chicken pox and rabies.
• Respiratory Isolation: To prevent the respiration spread of organism through droplet sneezed or breathed into by infected patient into the environment. Examples of Mycobacterium tuberculosis.
• Protective Isolation: To prevent contact between potentially pathogenic microbes and the unaffected person who is undergoing certain therapy resulting suppression of immunity. Example patient undergoing chemotherapy for the treatment of leukemia is more prone to infection.
• Enteric Isolation: The disease transmitted through direct and indirect oral contact with infected feces or contaminated items. Examples of dysentery and hepatitis.
• Wound and Skin Precautions: To prevent the spread of microorganism found in infected wounds (including burns and open sores) and contaminated articles. Precaution should be taken in infected burns, infected wounds, and infections with purulent discharge. It includes herpes, impetigo, and ringworm.
• Blood Precaution: It includes the prevention of the spread of blood-transmitted diseases which are due to use of infected blood-contaminated items for example use of contaminated needle; razor can be a reason of spread of blood-transmitted Examples of this infection includes are HIV and HBV ¹⁹.

2.3.1 Isolation Techniques Involved:

1. Private room with minimum ventilation of six air changes per hour. Cross circulations of air are prohibited and only allowed if there are high air filters installed.
2. An anteroom for the storage of gowns, gloves, and masks. They make a barrier between the isolated rooms and hall and possibly avoid air born spread of infectious agents from the rooms and corridors whenever the door is opened. Always maintain the negative pressure in the anteroom compared to the hall and separate air supply and exhaust for ventilation. 5 represents differential air pressure control to confine air outflow in a single direction so that cross-contamination could be avoided.
3. Hospital personnel hygiene: It includes wearing of masks, gowns, gloves, caps, and These once used should not be reused. Masks should cover the nose and mouth. High efficient disposable masks that prevent the inhalation of the infectious agent and trap infectious agent outside preferable. Before entering the isolation area, one must wear the mask and other things required include gowns, caps, and booties if required. Patients with extensive infected burns or extensive infected wounds are recommended to wear a sterile gown before dressing. Caps and booties are not required in any isolation category. Gloves should be wearing before in contact with the patient and other contaminated object and discard after use. If the used cap must cover all scalp hairs and booties should cover open ends of trousers.
4. Hands washing with soap before and after contact with the patient and other contaminated objects are must to prevent the rate of infection spread ²⁵.

2.4 Sterilization of Medical Equipment: A medical device or surgical instrument which comes in contact with the patient during treatment or operation procedure has an associated risk of disease transmission which is due to failure of sterilization or disinfection. The procedure of sterilization is based on the object to be sterilizing which can be divided into critical, semi-critical and non-critical objects Table 7.

FIG. 5: REPRESENTS AIR PRESSURE CONTROL IN INFECTIOUS ISOLATED ROOM ⁶⁰

The hospital staff must be educated to avoid nosocomial infection, and special attention should be given to teach them about infection control and prevention.

General practices including hand wash before and after patient care, avoid touching inanimate object, wearing of gloves and mask while cleaning contaminated goods and learning than about sterilization of equipment used in patient care ¹⁹.

Diarrhea caused by rotavirus is frequent in children both in developing and developed countries. Now many potent rotaviruses vaccine are tested as a potent vaccine. Two companies MErk and GlaxoSmithKline (GSK) are licensed to manufacture rotavirus-vaccines. The Merck prepared vaccine RotaTeq TM is composed of 5-rotavirus strains. The GSK Rotarix Tm vaccine is derived from a human rotavirus strain G1. These vaccines are prepared by attenuation of rotavirus to be non-pathogenic but immunogenic ²⁶.

TABLE 7: REPRESENTS DIVISION OF SUBJECT ACCORDING TO STERILIZATION REQUIREMENT

2.5 Microbiological Validation and Cleaning of Hospitals Environment: Microbial air contamination is monitored by colony forming unit per cubic meter (CFU/m³) count. This can be done either by passive or active sampling methods. Passive air sampling includes measuring of Index of Microbial Air (IMA) Contamination, which is defined as the count of microbial fall out on a Petri plate of 9 cm diameter placed in area according to 1/1/1/ scheme (1 h / 1m above the floor, about 1 m away from walls or any major obstacle) and incubate at 36 ± 1 °C for 248 h ²⁰. IMA has been divided into five classes described in Table 8 and 9.

TABLE 8: REPRESENTS CLASSES OF INDEX OF MICROBIAL AIR (IMA)

TABLE 9: REPRESENTS ACCEPTABLE RANGE OF INDEX OF MICROBIAL AIR (IMA) IN HOSPITALS

Air monitoring surveillance is essential in the hospitals and area high in bio-risk ^{27, 28}. Active air sampling referred to the use of an air sampler, which collects known air volume that is blown on a nutrient medium. Different type of air samplers are available in the market viz., impingers, impactors (slit type), impactors (sieve type), filtration sampler, centrifugal sampler, electrostatic precipitation sampler, thermal precipitation samplers, etc. Each of these gives different result in the same place for the same duration of time. In an empty operation room where the air is provided by a conditioned and controlled ventilation system (CCVS), 500 L of air was sampled compared to the one-hour exposure of settle plate for sampling ²⁹. Air sampling should be done at regular intervals of time as there is some persons are present and active sampling should be performed for an hour and at a different site of operation room ³⁰. A considerable range of microbial contamination with turbulent airflow ranges from ≤ 35cfu/m³ at rest and ≤ 180cfu/ m³ in Operation Theater ³¹.

CONCLUSION: From the present study, it is concluded that immuno-compromised patients, children and old age people are more prone to nosocomial infection and advised to avoid unnecessary visit or exposure to the contaminant environment. Routine surveillance of medical center should be monitored and required action to keep the climate contaminant free.

ACKNOWLEDGEMENT: Nil

CONFLICT OF INTEREST: The authors declare no conflict of interest.

REFERENCES:

1. Inweregbu K, Dave J and Pittard A: Nosocomial infections. Continuing Education in Anaesthesia. Critical Care and Pain 2005; 5(1): 14-7.
2. Sahni V, Agarwal SK, Singh NP, Anuradha S, Sikdar S and Wadhwa A: Candidemia-An under-recognized nosocomial infection in Indian hospitals: Journal of the Association of Physicians of India 2005; 53: 607-11.
3. Salamati P, Rahbarimanesh AA, Yunesian M and Naseri M: Neonatal nosocomial infections in Bahrami children hospital. Indian Journal of Pediatrics 2006; 73(3): 197-00.
4. Ki V and Rotstein C: Bacterial skin and soft tissue infections in adults: a review of their epidemiology, pathogenesis, diagnosis, treatment and site of care: Canadian Journal of Infectious Diseases and Medical Microbiology 2008; 19(2): 173-84
5. Richards MJ, Edwards JR, Culver DH and Gaynes RP: Nosocomial infections in medical intensive care units in the United States. Critical Care Medicine 1999; 27(5): 887-92.
6. Sengupta S, Sirkar A and Shivananda PG: Stethoscopes and nosocomial infection. Indian Journal of Pediatrics 2000; 67(3): 197.
7. Weinstein RA and Hota B: Contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infection? Clinical Infectious Diseases 2004; 39(8): 1182-9.
8. Bhuvaneshwari G: Multiple antibiotic resistance indexing of non-fermenting gram-negative bacilli: Asian Journal of Pharmaceutical and Clinical Research 2017; 10(6): 78-80.
9. Anaissie EJ, Penzak SR and Dignani MC: The hospital water supply as a source of nosocomial infections: a plea for action: Archives of Internal Medicine 2002; 162(13): 1483-92.
10. Mirhoseini SH, Nikaeen M, Shamsizadeh Z and Khanahmad H: Hospital air: A potential route for transmission of infections caused by β-lactam-resistant bacteria. American Journal of Infection Control 2016; 44(8): 898-904.
11. Lebeaux D, Ghigo JM and Beloin C: Biofilm-related infections: bridging the gap between clinical management and fundamental aspects of recalcitrance toward antibiotics. Microbiology and Molecular Biology Reviews 2014; 78(3): 510-43.
12. Kolmos HJ: Health Care-Associated Infections: Sources and Routes of Transmission. In infection Control-Updates 2012. InTech.
13. Atanda AA and Nwaoha NN: Nosocomial infections transmitted via computers: A Literature Review 2010.
14. Cabral JP: Water microbiology. Bacterial pathogens and water. International Journal of Environmental Research and Public Health 2010; 7(10): 3657-703.
15. Lee JH: Methicillin (oxacillin)-resistant Staphylococcus aureus strains isolated from major food animals and their potential transmission to humans. Applied and Environmental Microbiology 2003; 69(11): 6489-94
16. Olsen SJ, Bishop R, Brenner FW, Roels TH, Bean N and Tauxe RV: The changing epidemiology of Salmonella: trends in serotypes isolated from humans in the United States, 1987-1997. The Journal of Infectious Diseases 2001; 183(5): 753-61.
17. Challenge FG: WHO Guidelines on Hand Hygiene in Health Care: a Summary. World Health Organization, Geneva, Switzerland 2009.
18. Pittet D, Allegranzi B, Sax H, Dharan S, Pessoa-Silva CL and Donaldson L: Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infectious Diseases 2006; 6(10): 641-52.
19. Choudhury J and Mahapatra A: Knowledge of hand hygiene practices among health-care workers in neonatal and pediatric intensive care unit of a tertiary care hospital of odisha. Asian Journal of Pharmaceutical and Clinical Research 2017; 10(4): 272-274.
20. Debnath A and Chikkaswamy BK: Antibiogram and susceptibility pattern of methicillin-resistant Staphylococcus aureus collected from various clinical samples in bengaluru. Asian Journal of Pharmaceutical and Clinical Research 2015; 8 (6): 260-264
21. Rutala WA and Weber DJ: Guideline for disinfection and sterilization of prion-contaminated medical instruments. Infection Control and Hospital Epidemiology 2010; 31(2): 107-117.
22. Aas JA, Paster BJ, Stokes LN, Olsen I and Dewhirst FE: Defining the normal bacterial flora of the oral cavity. Journal of Clinical Microbiology 2005; 43(11): 5721-32.
23. Owens PL, Barrett ML, Raetzman S, Maggard-Gibbons M and Steiner CA: Surgical site infections following ambu-latory surgery procedures. Jama 2014; 311(7): 709-16.
24. Fusco SD, Massarico NM, Alves MV, Fortaleza CM, Pavan ÉC and Palhares VD: Surgical site infection and its risk factors in colon surgeries. Revista da escola de enfermagem da USP 2016; 50(1): 43-9.
25. S. Army medical department center and school. Fort sam houston, texas 78234-6100
26. Patel M, Shane AL, Parashar UD, Jiang B, Gentsch JR, and Glass RI: Oral rotavirus vaccines: how well will they work where they are needed most? Journal of Infectious Diseases 2009; 200(1): S39-48.
27. Napoli C, Tafuri S, Montenegro L, Cassano M, Notarnicola A, and Lattarulo S: Air sampling methods to evaluate microbial contamination in operating theatres: results of a comparative study in an orthopedics Journal of Infectious Diseases 2012; 80(2): 128-32.
28. Pasquarella C, Pitzurra O and Savino A: The index of microbial air contamination. Journal of Infectious Diseases 2000; 46(4): 241-56.
29. Qudiesat K, Abu-Elteen K, Elkarmi A, Hamad M and Abussaud M: Assessment of airborne pathogens in healthcare settings. African Journal of Microbiology Research 2009; 3(2): 66-76.
30. Banerjee B, Mukhopadhyay C, Vandana KE, Bupendra A and Varma M: “News on air!” - air surveillance report from intensive care units of a tertiary care hospital. Asian Journal of Pharmaceutical and Clinical Research 2016; 9(S-3): 247-9.
31. Hoffman PN, Williams J, Stacey A, Bennett AM, Ridgway GL and Dobson C: Microbiological commissioning and monitoring of operating theatre suites. Journal of Hospital Infection 2002; 52(1): 1-28.
32. Weinstein RA and Hota B: Contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infection? Clinical Infectious Diseases 2004; 39(8): 1182-9.
33. Brown IH: The epidemiology and evolution of influenza viruses in pigs. Veter Microbiology 2000; 74(1-2): 29-46.
34. Aintablian N, Walpita P and Sawyer MH: Detection of Bordetella pertussis and respiratory syncytial virus in air samples from hospital rooms. Infection Control and Hospital Epidemiology 1998; 19(12): 918-23.
35. Castro‐Rodriguez JA, Daszenies C, Garcia M, Meyer R and Gonzales R: Adenovirus pneumonia in infants and factors for developing bronchiolitis obliterans: A 5‐year follow‐ Pediatric Pulmonology 2006; 41(10): 947-53.
36. Carducci A, Verani M, Lombardi R, Casini B and Privitera G: Environmental survey to assess viral contamination of air and surfaces in hospital settings. Journal of Hospital Infection 2011; 77(3): 242-7.
37. Gustafson TL, Lavely GB, Brawner ER, Hutcheson RH, Wright PF and Schaffner W: An outbreak of airborne nosocomial varicella. Pediatric 1982; 70(4): 550-6.
38. Hamdan HZ, Abdelbagi IE, Nasser NM and Adam I; Seroprevalence of Cytomegalovirus and Rubella among pregnant women in western Sudan. Virology Journal 2011; 8(1): 217.
39. O'brien KL, Beall B, Barrett NL, Cieslak PR, Reingold A and Farley MM: Epidemiology of invasive group A streptococcus disease in the United States, 1995-1999. Clinical Infectious Diseases 2002; 35(3): 268-76.
40. Rodvold KA and McConeghy KW: Methicillin-resistant Staphylococcus aureus therapy: past, present, and future. Clinical Infectious Diseases 2014; 58(1): S20-7.
41. Castelblanco RL, Lee M and Hasbun R: Epidemiology of bacterial meningitis in the USA from 1997 to 2010: a population-based observational study. Lancet Infectious Diseases 2014; 14(9): 813-9.
42. Pizza M and Rappuoli R: Neisseria meningitidis: pathogenesis and immunity. Current Opinion in Microbiology 2015; 23: 68-72.
43. Aintablian N, Walpita P and Sawyer MH: Detection of Bordetella pertussis and Respiratory Syncytial Virus in air samples from hospital rooms. Infection Control and Hospital Epidemiology 1998; 19(12): 918-23.
44. Pearson ML, Jereb JA, Frieden TR, Crawford JT, Davis BJ and Dooley SW: Nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis: a risk to patients and health care workers. Annals of Internal Medicine 1992; 17(3): 191-6.
45. Micek ST, Wunderink RG, Kollef MH, Chen C, Rello J and Chastre J: An international multicenter retrospective study of aeruginosa nosocomial pneumonia: impact of multidrug resistance. Critical Care 2015; 19(1): 219.
46. Richards AM, Abu Kwaik Y and Lamont RJ: Code blue: baumannii, a nosocomial pathogen with a role in the oral cavity. Molecular Oral Microbiol 2015; 30(1): 2-15.
47. Cunha BA, Burillo A and Bouza E: Legionnaires' disease. The Lancet 2016; 387(10016): 376-85.
48. Goldstein EJ, Johnson S, Maziade PJ, McFarland LV, Trick W and Dresser L: Pathway to the prevention of nosocomial Clostridium difficile Clinical Infectious Diseases 2015; 60(2): S148-58.
49. Leffler DA and Lamont JT: Clostridium difficile The New England Journal of Medicine 2015; 372(16): 1539-48.
50. Lai CC, Tsai HY, Ruan SY, Liao CH and Hsueh PR: Fatal pneumonia and empyema thoracis caused by imipenem-resistant Nocardia abscessus in a cancer patient. Journal of Microbiology, Immunology and Inf 2015; 48(6): 706-8.
51. Bagaitkar J, Demuth DR and Scott DA: Tobacco use increases susceptibility to bacterial infection. Tobacco induced diseases 2008; 4(1): 12.
52. Fridkin SK and Jarvis WR: Epidemiology of nosocomial fungal infections. Clinical Microbiology Reviews 1996; 9(4): 499-511.
53. Pesquero MA, Carneiro LC and Pires DD: Insect/Bacteria association and nosocomial infection. In Salmonella-A diversified Superbug 2012. InTech.
54. Bochicchio GV, Joshi M, Knorr KM and Scalea TM: Impact of nosocomial infections in trauma: does age make a difference Journal of Trauma and Acute Care Surgery 2001; 50(4): 612-619.
55. Canturk Z, Cantürk NZ, Çetinarslan B, Utkann NZ and Tarkun I: Nosocomial infections and obesity in surgical patients. Obesity Research 2003; 11(6): 769-775.
56. Sharma AK, Sharma S and Sharma R: Port Site Infection in Laparoscopic surgeries. Ind Med Gazette 2013; 224-229.
57. Bagaitkar J, Demuth DR and Scott DA: Tobacco use increases susceptibility to bacterial infection. Tobacco Induced Diseases 2008; 4(1): 12.
58. Rubin RH, Wolfson JS, Cosimi AB and Tolkoff-Rubin NE: Infection in the renal transplant recipient. The American Journal of Medicine 1981; 70(2): 405-411.
59. Rutala WA and Weber DJ: Disinfection and sterilization in health care facilities: what clinicians need to know. Clinical Infectious Diseases 2004; 39(5): 702-9.
60. Wei J and Li Y: Airborne spread of infectious agents in the indoor environment. American Journal of Infection Control 2016; 44(9): S102-8.
    

    ---

    How to cite this article:

    Joshi M, Kaur S, Kaur HP and Mishra T: Nosocomial infection: source and prevention. Int J Pharm Sci & Res 2019; 10(4): 1613-24. doi: 10.13040/IJPSR.0975-8232.10(4).1613-24.

    ---

    All © 2013 are reserved by International Journal of Pharmaceutical Sciences and Research. This Journal licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.

    ---