PART X  INFECTIOUS DISORDERS
CHAPTER 89 
NOSOCOMIAL INFECTIONS AND ZOONOSES
Shelley C. Rankin, BSc (Hons), PhD
KEY POINTS
• Nosocomial (hospital-acquired) infection is defined as any
infection that is neither present nor incubating when a patient is
admitted to a hospital.
• Risk factors for nosocomial infection in intensive care unit (ICU)
patients include severity of underlying illness, prolonged length of
stay, mechanical ventilation, indwelling devices, and antibiotic use.
• Multiple antibiotic resistance is common among nosocomial
pathogens.
• Methicillin-resistant Staphylococcus spp. are emerging in dogs
and cats.
• The reservoirs of nosocomial pathogens include people, animals,
fomites, air currents, water, food sources, insects, and rodents.
The spread of pathogens in hospitals occurs primarily via the
hands of personnel.
• Establishment of biosecurity nosocomial infection control
programs must become a priority in veterinary hospitals.
• Zoonosis is a disease that can be transmitted from animals to
humans. A more technical definition is a disease that normally
exists in animals but that can infect humans. Many organisms
can cause zoonotic disease.
In human health care settings, nosocomial infection is defined as any
infection that is neither present nor incubating when a patient is
admitted to a hospital. In 1988 the Centers for Disease Control and
Prevention proposed more specific definitions, and it now is accepted
generally that infections are considered to be nosocomial if they
develop at least 48 hours after hospital admission without proven
prior incubation.1 In addition, if infections occur up to 3 days after
discharge or within 30 days of a surgical procedure, they are attrib-
uted to the admitting hospital.1 These definitions are accepted in
human health care and, although they may require refinement in
veterinary medicine, they stand unchallenged.
Hospitalization of sick animals can lead to an increased risk of
infection, and various policies have been proposed to reduce the risk
of nosocomial infection in veterinary medicine.2-4 In addition to
patient care concerns, many nosocomial pathogens are well recog-
nized as zoonotic agents, so infection control policies should address
the issue of animal-to-human transmission.2
NOSOCOMIAL INFECTIONS IN DOGS AND CATS
One of the first published reports of nosocomial infection in a vet-
erinary hospital described Klebsiella infection in dogs and one cat in
the intensive care unit (ICU) at the New York State College of Veteri-
nary Medicine in 1978.5 Since that time there have been a few well-
characterized studies, but many of these have centered on large
animal facilities with various Salmonella enterica serotypes as the
causative organisms.6-8 Specific reports of nosocomial infection in
dogs and cats remain limited.5 Since 1978 organisms such as Serratia
marcescens, Salmonella species, Clostridium perfringens, Acinetobacter
baumannii, Escherichia coli, and Clostridium difficile have been impli-
cated as causes of nosocomial infection in dogs and cats.6,9-13 The
bacteria responsible for nosocomial infection in ICUs originate either
from the patient’s own endogenous flora or from exogenous sources.
Nosocomial infections derived from endogenous flora may occur in
patients receiving chemotherapy, glucocorticoid therapy, or antimi-
crobial therapy. In contrast to endogenous infections, exogenous
infections are prevented more easily by standard or specific precau-
tions devised to reduce the overall rate of transmission.14 Reviews of
nosocomial infections in veterinary medicine provide data on the
pathogenesis, diagnosis, treatment, and strategies for the prevention
of urinary tract infections, surgical site infections, bloodstream infec-
tions, pneumonia, and diarrhea.15,16
RISK FACTORS
Although ill-defined in veterinary medicine, independent risk factors
for nosocomial infection acquisition in the critically ill patient can
be extrapolated from human studies. Prolonged length of hospital
stay, mechanical ventilation, and indwelling devices (i.e., intravascu-
lar or urinary catheters and nasogastric or endotracheal tubes) are
well-recognized risk factors.1 Many intrinsic, patient-related factors
also have been identified and include patient demographics (e.g., age,
gender), comorbidities, and severity of underlying illness, which is
the most widely reported risk factor. Patient-specific risk factors are
related to general health and immune status, respiratory status, neu-
rologic status, and fluid status. The most significant risk factors in
the ICU are trauma, especially when associated with open fractures
and antimicrobial use. Risk factors for dogs becoming carriers of
multidrug-resistant (MDR) E. coli during hospitalization have been
shown to include hospitalization for more than 6 days, treatment
with cephalosporins before admission, treatment with cephalospo-
rins for less than 1 day, and treatment with metronidazole while
hospitalized.17 Several less well-acknowledged factors also have been
suggested as contributing factors. Among them, understaffing and
overcrowding in the ICU have been well documented as causes of
cross-transmission of nosocomial infections.1
MULTIPLE ANTIBIOTIC–RESISTANT
NOSOCOMIAL PATHOGENS
In an excellent review of the problem of antimicrobial drug use and
resistance in veterinary medicine, Prescott and colleagues state that,
463
464 PART X  •  INFECTIOUS DISORDERS
“Despite a possible wealth of data in filing cabinets in veterinary
clinical microbiology laboratories around the world, there have been
virtually no systematic investigations of changes in antimicrobial
drug resistance in bacteria isolated from companion animals over
time, using standard methodologies for assessing resistance.”18 The
situation has changed little since that statement was made in 2002.
Although it often is speculated that organisms isolated from
nosocomial infection outbreaks in veterinary patients now have an
increasingly broad spectrum of antimicrobial resistance, there are no
active nosocomial infection surveillance systems in this field. Much
of the antibiotic resistance data are derived from “local” surveillance,
and a lack of standardization results in data that are incomparable
from one setting to another.19,20 In terms of the impact of multidrug-
resistant (MDR) bacteria with regard to nosocomial infection, the
data that have been published agree that resistant bacteria can reduce
the effectiveness of management.18
Data on trends in resistance patterns among nosocomial patho-
gens from veterinary sources are few, but the wealth of surveillance
data from human health care systems often can be used as a predictor
of what to expect from nosocomial pathogens in veterinary
patients.21-23 Local surveillance of antibiotic resistance in animal iso-
lates is preferred, but in the absence of such data, extrapolation from
human surveillance data is encouraged.
Bacterial resistance to β-lactam antibiotics and the β-lactamase
inhibitors is becoming increasingly common and threatens to reduce
the clinical spectrum of these drugs. In particular, organisms that
produce extended-spectrum β-lactamases (ESBLs) and plasmid-
mediated AmpC enzymes are posing unique challenges in clinical
situations.20 Although the prevalence of ESBLs is not known, it is
thought to be increasing, and in many parts of the world 10% to 40%
of strains of E. coli and K. pneumoniae produce such enzymes. Novel
β-lactamases also are becoming especially important among diverse
gram negative pathogens such as Pseudomonas aeruginosa, S. enterica
serotype Typhimurium, Proteus mirabilis, and A. baumannii.24 The
source of these novel enzymes is unknown, but their presence on
plasmids and ready transferability among pathogens of different
genera is of concern. Organisms that produce ESBLs are found com-
monly in those areas of the hospital environment where antimicro-
bial use is frequent and the patient’s condition is critical, and these
resistant organisms cause increased morbidity and mortality.24
ZOONOSES
The simplest definition of a zoonosis is a disease that can be transmit-
ted from animals to humans. A more technical definition is a disease
that normally exists in animals but that can infect humans. Some
authors further subdivide the concept into zooanthroponosis, infec-
tions that humans can acquire from animals, and anthropozoonosis,
a disease of humans that is transmissible to other animals. A com-
prehensive literature review has identified 1415 species of infectious
organism known to be pathogenic to humans and out of these, 868
(61%) are zoonotic.25 Overall, 19% are viruses or prions, 31% are
bacteria or rickettsia, 13% are fungi, 5% are protozoa, and 32% are
helminths. Thirty-five percent of zoonoses can be transmitted by
direct contact, 61% by indirect contact, 22% by vectors, and for 6%
the transmission route is unknown. Only 33% of zoonotic species
are known to be transmissible between humans and only 3% are
considered to have their main reservoir in human populations; the
main reservoir of the remainder is in animal populations. Zoonoses
are more likely to be transmitted by indirect contact or vectors and
are less likely to be transmitted by direct contact when compared
with all pathogens.
The list of zoonoses found in animals in the ICU is long, but
because some organisms are generally more prevalent, they have a
greater potential for transfer to humans and result in disease.25a The
enteric pathogens, such as Campylobacter, Salmonella, C. difficile, and
E. coli commonly are isolated from animals in the ICU, and all of
these organisms have been responsible for nosocomial outbreaks in
that setting.7,8,13 Campylobacter species can occur in large numbers as
commensals in companion animals, and there is a strong correlation
between diarrhea and the ability to recover C. jejuni from healthy
dogs. Salmonella spp., on the other hand, are not normal commensals
of dogs and cats, and the presence of Salmonella in feces likely indi-
cates infection. Enteropathogenic E. coli (EPEC) have been isolated
from dogs and cats with enteritis, and strains have emerged as impor-
tant causes of diarrhea in puppies. E. coli is also the most common
cause of urinary tract infections in dogs and cats in the ICU,
and many strains are now resistant to a wide spectrum of antimicro-
bial agents. Zoonotic transmission of resistant urinary isolates of
E. coli from companion animals to humans has been suggested.26
C. difficile and Enterococcus species are now considered emerging
zoonotic agents, and this is also true of some veterinary staphylo-
cocci, particularly methicillin-resistant S. pseudintermedius (MRSP)
and methicillin-resistant S. schleiferi (MRSS).27,28
Pathogenic Leptospira species have the potential to infect humans
and also cause nosocomial infections in animals housed with infected
or shedding animals (see Chapter 124). Leptospires often colonize
proximal convoluted kidney tubules and may be excreted in urine for
extended periods by dogs that show no clinical symptoms. The
carrier state may be as short as a few days or may extend throughout
the life of the animal. The primary routes of infection for dogs are
direct contact (oral, conjunctival), venereal and placental transfer,
bite wounds, and ingestion of contaminated water or meat.
The cutaneous mycoses of animals are caused primarily by
Microsporum and Trichophyton species and are well-recognized
zoonotic agents that cause ringworm in humans and can be acquired
from contact with infected animals or fomites. Dermatophyte spores
gain entry into the skin through minor trauma such as abrasions.
Uncommon, but perhaps emerging, zoonotic agents that may be
found in veterinary patients also include a variety of Mycobacterium
species, Malassezia pachydermatis, Candida albicans, Brucella canis,
and MDR strains of P. aeruginosa and Klebsiella pneumoniae.
Undoubtedly, as veterinary nosocomial infection surveillance systems
improve, a host of additional pathogenic or MDR organisms will be
reclassified as zoonotic.
EMERGING NOSOCOMIAL INFECTIONS
IN DOGS AND CATS
Consistent with a generalized increase in β-lactam resistance, several
reports in the veterinary literature have described an increase in the
prevalence of MRSA strains isolated from dogs and cats.29,30 In 1998
a Korean veterinary hospital representative reported three small
nosocomial clusters of MRSA infection in hospitalized dogs. Isolates
were obtained from 12 dogs and were recovered from the anterior
nares, catheters, conjunctiva, a postoperative wound, and a skin
lesion.31 A further description of MRSA infection in dogs from the
United Kingdom reported that in 8 of 11 dogs the infection likely
was contracted during surgical procedures, most commonly during
repair of traumatic fractures.32 Of the 11 dogs, three suffered from
chronic pyoderma that was not responsive to routine antimicrobial
management. The MRSA infection resolved or improved in nine of
those cases after appropriate antimicrobial therapy. Management of
individual MRSA cases must begin with review of the antibiotic
susceptibility profile of individual isolates, and selective antimicro-
bial therapy should be based upon those results.
In addition to MRSA, methicillin-resistant S. pseudintermedius
and S. schleiferi may present a more pressing threat to veterinary

patients. In a survey done at the Matthew J. Ryan Veterinary Hospital
of the University of Pennsylvania, the rates of methicillin resistance
in these three pathogens isolated between 2003 and 2004 was 32%,
17%, and 49%, respectively.33
C. difficile was implicated as the causative organism in an out-
break of diarrhea in dogs at a small animal veterinary teaching hos-
pital.13 No cases were identified in the ICU, and this was attributed
to stringent infection control measures. C. difficile–associated disease
(CDAD) occurs as a result of intestinal colonization and toxin pro-
duction by toxigenic strains. A diagnosis of CDAD is made after
detection of an enterotoxin, designated Toxin A, and a cytotoxin,
designated Toxin B, in fecal specimens. Some animals are known to
carry toxigenic strains of C. difficile without toxin production, so
demonstration of the organism in feces by anaerobic culture is not
confirmatory. Sources of nosocomial C. difficile include colonized or
infected animals, indirect contact via hospital personnel, or environ-
mental reservoirs of potentially pathogenic spores that are known to
be resistant to commonly used disinfectants. Management of CDAD
depends on a number of factors, especially if coinfection with addi-
tional enteric pathogens is suspected or confirmed. Metronidazole or
vancomycin is generally the antimicrobial of choice for uncompli-
cated CDAD.
Vancomycin-resistant Enterococcus faecium (VRE) has not been
implicated yet in nosocomial infections of dogs and cats. However,
VRE has been identified in a canine urinary tract infection, and
monitoring at veterinary teaching hospitals in the United States and
Europe has revealed VRE carriage in healthy dogs.34,35 Dogs treated
with antimicrobials for 2 to 9 days in a veterinary ICU were shown
to carry a large drug-resistant population of enterococci.36 Most
enterococci, (especially VRE) isolates are highly resistant to many
other antimicrobial classes, and the gene responsible for vancomycin
resistance is resident on a transposable element; the exchange of this
element has been demonstrated between human and canine E.
faecium. Therefore the use of vancomycin alone may not be a neces-
sary prerequisite for selection of VRE in small animals.34
Overall, the number of reports of infection or colonization in
animal species of pathogens that traditionally have been thought to
have a reservoir only in humans has increased since the earliest
reports of MRSA in the 1960s and 1970s. This trend can be consid-
ered a significant public health concern given the potential for direct
spread of MDR pathogens between humans and animals. A reason-
able assumption is that infected dogs and cats can serve as reservoirs
for these pathogenic organisms. However, the alternative hypothesis,
that humans also can be a reservoir for MDR infectious agents that
can be transmitted to dogs and cats, now seems equally feasible.
NOSOCOMIAL INFECTION PREVENTION
AND CONTROL
The reservoirs of nosocomial pathogens include people, animals,
fomites, air currents, water and food sources, insects, and rodents; it
has long been known that the spread of pathogens in hospitals occurs
primarily via the hands of personnel.1 Therefore frequent hand
washing is of the utmost importance and the use of gloves when
handling patients also may help to decrease the incidence of nosoco-
mial infections. In 1989 Murtaugh and Mason proposed that noso-
comial infection control committees be established in veterinary
hospitals, especially at the larger teaching and referral centers.37 Some
veterinary institutions were receptive to this proposal, but there are
still no national or international standards for veterinary hospital
infection control. A survey of veterinary teaching hospitals in the
United States indicated that only 42% of these hospitals required
personnel to complete a biosecurity training program, but 40% of
respondents indicated that they believed that their hospital ranked
CHAPTER 89  •  Nosocomial Infections and Zoonoses 465
38
among the top 10% in regard to rigor of infection control efforts.
Much of what is done is borrowed from human health care guide-
lines, and worldwide surveillance statistics of veterinary nosocomial
infection rates are not available.
The guidelines for prevention and control of nosocomial infec-
tion are simple and comprise three main strategies. First, methods
are needed to prevent cross-contamination and to control potential
sources of pathogenic microorganisms that can be transmitted from
patient to patient or from hospital personnel to patient. Second,
guidelines are needed to direct the appropriate use of prophylactic,
empiric, and therapeutic antimicrobial use. Finally, strategies to limit
the emergence or spread of MDR pathogens should be developed and
targeted against organisms known to be prevalent in individual insti-
tutions. Some of these approaches may at first seem to be restrictive,
but infection control guidelines are intended only to improve the
process of care. Infection control measures when instituted in human
health care settings have been unpopular, and compliance is difficult
to maintain. It has been suggested that noncompliance is connected
with many aspects of human behavior, including the yearning of
human beings for liberty, the false perception of an invisible risk, and
the underestimation of individual responsibility in the epidemiology
of the institution.1
CONCLUSION
In conclusion, the importance of nosocomial transmission of infec-
tious organisms, particularly in the ICU, cannot be overemphasized.
Although the intrinsic risk factors of individual animal patients for
the development of nosocomial infection are difficult to assess, the
risk of transmission of pathogenic and MDR organisms can and
should be reduced to a minimum whenever possible.
REFERENCES
1. Eggimann P, Pittet D: Infection control in the ICU, Chest 120(6):2059-
2093, 2001.
2. Morley PS: Biosecurity of veterinary practices, Vet Clin North Am Food
Anim Pract 18(1):133-155, 2002.
3. Weese JS: Barrier precautions, isolation protocols, and personal hygiene
in veterinary hospitals, Vet Clin North Am Equine Pract 20(3):543-549,
2004.
4. Portner JA, Johnson JA: Guidelines for reducing pathogens in veterinary
hospitals: disinfectant selection, cleaning protocols and hand hygiene,
Compend Contin Educ Vet 32:5, E1-E12, 2010.
5. Glickman LT: Veterinary nosocomial (hospital acquired) Klebsiella infec-
tions, J Am Vet Med Assoc 179(12):1389-1392, 1989.
6. Sanchez S, McCrackin Stevenson MA, Hudson CR, et al: Characterization
of multidrug-resistant Escherichia coli isolates associated with nosoco-
mial infections in dogs, J Clin Microbiol 40(10):3586-3595, 2002.
7. Cherry B, Burns A, Johnson GS, et al: Salmonella typhimurium outbreak
associated with a veterinary clinic, Emerg Infect Dis 10(12):2249-2251,
2004.
8. Wright JG, Tengelsen LA, Smith KE, et al: Multidrug-resistant Salmonella
typhimurium in four animal facilities, Emerg Infect Dis 11(8):1235-1241,
2005.
9. Fox JG, Beaucage CM, Folta CA, et al: Nosocomial transmission of Ser-
ratia marcescens in a veterinary hospital due to contamination by benzal-
konium chloride, J Clin Microbiol 14(2):157-160, 1981.
10. Uhaa IJ, Hird DW, Hirsch DC, et al: Case-control study of risk factors
associated with nosocomial Salmonella krefeld infection in dogs, Am J Vet
Res 49:1501-1505, 1988,
11. Kruth SA, Prescott JF, Welch MK, et al: Nosocomial diarrhea associated
with enterotoxigenic Clostridium perfringens infection in dogs, J Am Vet
Med Assoc 195(3):331-334, 1989.
12. Francey T, Gaschen F, Nicolet J, et al: The role of Acinetobacter baumannii
as a nosocomial pathogen for dogs and cats in an intensive care unit, J Vet
Intern Med 14:177-183, 2000.
13. Weese JS, Armstrong J: Outbreak of Clostridium difficile-associated disease
in a small animal veterinary teaching hospital, J Vet Intern Med 17:813-
816, 2003.
14. Grundmann H, Barwolf S, Tami A, et al: How many infections are caused
by patient to patient transmission in intensive care units? Crit Care Med
23(5):946-951, 2005.
15. Johnson JA: Nosocomial infections, Vet Clin North Am Small Anim Pract
32(5):1101-1126, 2002.
16. Nakamura RK, Tompkins E: Nosocomial infections, Compend Contin
Educ 34: 4, E1-E11, 2012.
17. Gibson JS, Morton JM, Cobbold RN, et al: Risk factors for dogs becoming
rectal carriers of multidrug-resistant Escherichia coli during hospitaliza-
tion, Epidemiol Infect 139:1511-1521, 2011.
18. Prescott JF, Brad Hanna WJ, Reid-Smith R, Drost K: Antimicrobial drug
use and resistance in dogs, Can Vet J 43:107-110, 2002.
19. Brooks MB, Morley PS, Dargatz DA, et al: Survey of antimicrobial suscep-
tibility testing practices of veterinary diagnostic laboratories in the United
States, J Am Vet Med Assoc 222(2):168-174, 2003.
20. Wieler LH, Ewers C, Guenther S, et al: Methicillin-resistant staphylococci
(MRS) and extended-spectrum beta-lactamases (ESBL)-producing
Enterobacteriaceae in companion animals: Nosocomial infections as one
reason for the rising prevalence of these potential zoonotic pathogens in
clinical samples, Int J Med Microbiol 301:635-641, 2011.
21. Normand EH, Gibson NR, Reid SWJ, et al: Antimicrobial-resistance
trends in bacterial isolates from companion-animal community practice
in the UK, Prev Vet Med 46:267-278, 2000.
22. Normand EH, Gibson SR, Taylor DJ, et al: Trends of antimicrobial resis-
tance in bacterial isolates from a small animal referral hospital, Vet Record
146:151-155, 2000.
23. Jones RN: Resistance patterns among nosocomial pathogens. Trends over
the past few years, Chest 119(2):397S-404S, 2001.
24. Shah AA, Hasan F, Ahmed S, et al: Characteristics, epidemiology and
clinical importance of emerging strains of Gram-negative bacilli produc-
ing extended-spectrum beta-lactamases, Res Microbiol 155:409-421,
2004.
25. Taylor LH, Latham SM, Woolhouse MEJ: Risk factors for human disease
emergence, Phil Trans R Soc Lond B 356:983-989, 2001.
25a.  Epp T, Waldner C: Occupational health hazards in veterinary medicine:
zoonoses and other biological hazards, Can Vet J 53(2):144-150, 2012.
26. Johnson JR, Stell AL, Delavari P, et al: Phylogenetic and Pathotypic Simi-
larities between Escherichia coli isolates from urinary tract infections in
dogs and extraintestinal infections in humans, J Infect Dis 183:897-906,
2001.
27. Morris DO, Boston RC, O’Shea K, et al: The prevalence of carriage of
methicillin-resistant staphylococci by veterinary dermatology practice
staff and their respective pets, Vet Dermatol 21:400-407, 2010.
28. Damborg P, Top J, Hendrickx APA, et al: Dogs are a reservoir of ampicillin
resistant Enterococcus faecium lineages associated with human infections,
Appl Env Microbiol 75:2360-2365, 2009.
29. Duquette RA, Nuttall TJ: Methicillin-resistant Staphylococcus aureus in
dogs and cats: an emerging problem? J Small Anim Pract 45:591-597,
2004.
30. Weese JS: Methicillin-resistant Staphylococcus aureus: an emerging
problem in small animals, J Am Anim Hosp Assoc 41:150-157, 2005.
31. Pak SI, Han HR, Shimizu A: Characterization of methicillin-resistant
Staphylococcus aureus isolated from dogs in Korea, J Vet Med Sci
61(9):1013-1018, 1999.
32. Tomlin J, Pead MJ, Lloyd DH, et al: Methicillin-resistant Staphylococcus
aureus infections in 11 dogs, Vet Record 1:60-64, 1999.
33. Morris DO, Rook KA, Shofer FS, et al: Screening of Staphylococcus aureus,
Staphylococcus intermedius, and Staphylococcus schleiferi isolates obtained
from small companion animals for antimicrobial resistance: a retrospec-
tive review of 749 isolates (2003-2004), Vet Dermatol 17:332-337, 2006.
34. Simjee S, White DG, McDermott PF, et al: Characterization of Tn1546 in
vancomycin-resistant Enterococcus faecium isolated from canine urinary
tract infections: evidence of gene exchange between human and animal
enterococci, J Clin Microbiol 40(12):4659-4665, 2002.
35. Pressel MA, Fox LE, Apley MD, et al: Vancomycin for multi-drug resistant
Enterococcus faecium cholangiohepatitis in a cat, J Feline Med Surg 7:317-
321, 2005.
36. Ghosh A, Dowd SE, Zurek L: Dogs leaving the ICU carry a very large
multi-drug resistant enterococcal population with capacity for biofilm
formation and horizontal gene transfer, PLoS ONE 6(7):e22451, 2011.
37. Murtaugh RJ, Mason GD: Antibiotic pressure and nosocomial disease, Vet
Clin North Am Small Anim Pract 19(6):1259-1274, 1989.
38. Benedict KM, Morley PS, Van Metre DC: Characteristics of biosecurity
and infection control programs at veterinary teaching hospitals, J Am Vet
Med Assoc 233:767-773, 2008.