No soc omi al strai n s o f m i cr o org an i sns

No so comi al i nfect i o ns ar e also k no wn as hosp i tal ac qui r e d /asso -

cia ted i nfe c t io ns . N ati o nal Heal th c are Safety Netw o r k alo ng w ith
Ce nters for D i sease Co ntr ol for sur vei l l anc e has c l assi fi e d n o so comi a l
i nfe c ti on si te s i nto 13 types wi th 50 i nfe c ti on si tes , whi c h ar e sp ec i fic
o n th e basi s o f bio lo gi c al an d c l ini cal c r i t er ai . Th e age n ts th at
ar e usual l y i nvolved ni hospi tal - ac qui re d i nfe c t i o ns i nc l ude Stre p -
t oc occ us spp . , A c i n e to bac t er spp . , e nter o c occ i , P seud om o nas
aerug in o sa , coag ulase -n eg ati ve staphyl oc occi , Sta phyl ococ cus aur e us ,
Bac i l l u s c ere us , Leg i one l l a a nd Ente r obacte r i ace ae fami l y me mbers,
namel y , Pro teus mi r abl is , K l e bsi el l a pne umo n i a , Esc he r ic hia c ol i , Se rr ati a
marc e scens . N o so c om ai l path og e n s c an be transmi tt ed t h r o ug h person
to person , e n vir onm e n t or c o n t am inated wate r and food , i nfec te d
i n divi du al s , c ontami nated h e al th c ar e pe rson ne l 's ski n or c o ntac t v i a
shar e d i tems and surface s . Mai nl y , m u lti - dr ug - r esi stan t nosoc o mial
o rg ansi ms i ncl ude meth i ci l l ni -ressi tant Staphyl oc occu s aur e us , vanco myc in -
r esi stant e nter o co c ci , P seu d o mo n as aerugi no sa and K l e bsi el l a pne-
um o ni a , wh ere as Clo str i d iu m diffic i l e shows nat ural resi stanc e .
E xc e ssiv e an d i m proper u se o f br o ad -spec t r u m anti bi o t ic s ,
espe c i all y i n h eal th car e se tti ng s , i s ele v ati ng nosoc om i al i n fe c ti o n s ,
w hic h no t o n l y be co me s a bi g he al th care pr o bl em but al so c auses
g r eat e c o n o m i c an d pr oduc ti o n l oss ni the c o mmuni ty . No so c o mi al
i n fe cti o ns c an be c o n tr o l l ed by m e asuri ng an d c ompari ng the i nfecti on
r ates withi n h ealthcare se tti ng s and sti c k i ng to th e best h e althc are
p r ac ti ces . Ce n t er s for Di se ase Contr ol and Pr evention p r ovi de s the
methodol o g y for surve i l l ance of n o soc o mial i n fec ti on s al o ng w i th
i nvesti gati on o f maj or o utbr eak s . B y means of t h si sur v ei l l ance ,
ho spitals can de v i se a strat e g y c o mp r i si ng of ni fec ti on co ntro l
pr ac tic es .
A si an P acfi i c Journal o f T r o pi c al B i ome di c i ne
Vo l u me 5 , Issue 7 , July 20 15 , Pages 509 - 514
Revi e w ar ti c l e
N oso c omi al i nfe ctio ns and th ei r c o n t rol strate g i es
 Auth or l i nks open o v er l ay pan el Hassan Ahm e dK h an1Ri ffatM ehb oob 34a
Sh o w mor e
O ut l i n e
Shar e
Cite
https : / / doi . or g / 1 0 . 1016 / j . apj tb. 2015 .05 . 00 1 Get righ t s and c on ten t
Un de r a Creat i ve Co mmo ns l i ce n se
o p en ac c e ss
A bstr ac t
N osoc omi al i nfe c t i ons ar e al so kn o w n as h ospi tal -ac qui re d / assoc i at e d
i nfec ti o ns . N ati onal H ealth c ar e S a fety Ne twor k along wi th Cente rs
for Di se ase Co n tr o l fo r surve i ll anc e has c l assi fi ed no so co mi al
i n fe c ti on si te s i nto 13 t yp e s wi th 50 infe c ti on si te s , w h i c h are sp e c i fic
on the basi s o f bio l ogical and c l i ni c al cr it er i a . The ag e nts that are
usual l y inv ol v e d ni h o spi tal -ac quir ed i nfec ti o n s i n c l ud e Strep tococ cu s
spp . , Ac i ne tobac ter spp . , ente ro c oc c i , P se udom o nas aer ugi n osa ,
c o agulase - ne gatvi e stap h yl o cocc i , Stap h yl o coc cu s aure u s , B ac i l lus c e -
r eus , Le g i one lla and Ente r obac t e r i ac eae fam i l y me mbe r s , name ly ,
P r oteus mi r abli s , Kle bsi el l a pn e umoni a , Esc her i c h i a c o l i , Ser r ati a
m ar ce sc en s . Noso c omi a l path og e ns c an be tra n smi tte d t hr o ugh p er son
to p e r so n , e n v ir o nme nt o r c ontami nate d water and foo d , i nfec ted
i nd i vi duals , co ntami nate d heal thc are pe r so nn el ' s ski n or c on t ac t v i a
shar ed i te ms and sur fac e s . Mai nl y , mul ti- dr u g -ressi tant nosocomial
or ganisms i ncl ud e m eth i ci l li n - r esistant Staphyl o c o c c u s aur e us ,
vanc om yc i n -r e si stan t e nter o c o c ci , P seud o m onas aer ug i nosa and
Kl e bsiel l a pne umoni a , w her e as Cl ost r i dium dfi fi ci l e sho ws n atural
re ssi t a nc e . Exc essi v e and i mpro p er u se o f br o ad - spe ctr u m ant i bioti c s,
esp e c i al ly i n heal thcar e se t tni gs , i s el e vati n g n o so c omi al i nfec ti o ns ,
whi ch no t o n l y be c o me s a big h ealth c ar e probl e m bu t al so
c auses g re at eco nomi c and pr od u c toi n l o ss i n th e c o mmu ni ty .
N osoc omi al i nfecti on s can be c on tr ol l e d by measu r i n g an d
c omp ar i ng the i nfe c toi n r ate s wi t h i n he al thcar e setting s and sti ck i ng
to th e be st heal thc ar e pr acti ce s . Ce nters fo r D ise ase Cont r ol and
 Pre v e nti o n pr o vi d es the m eth o d ol og y fo r su rv ei l lanc e of noso com ial
i n fecti o ns alo ng wi th i n v e sti g ati o n of m aj or ou tbreaks . B y me ans o f th i s
surve i l l an c e , ho spi t al s c an d e v i se a strateg y com p ri si ng of i n fe c tio n
c o ntr o l pr ac ti c e s .
Pr evi o us
Ne xt
Ke yw o rds
Ho spi tal - ac q u i r e d i nfe cti on
A nti bio ti cs
Con tr ol str ate g ies
Su r ve i l l anc e
1 . In troduc tion
“Noso co m ial ” t e r m i s u sed for an y di se ase ac quri e d by pat i en t under
m e d i c al car e [1 ] . It i s an i nfe cti o n ac q uir e d by pati en t duri ng
hosp i tal stay . Re c e ntl y , a new ter m , “ heal th c ar e asso ci ated i nfe c ti ons ”
is used for t he t yp e of i nfe c ti ons c ause d by pr o l o ng e d h osp i tal stay
and i t acc ou nts for a m ajo r r i sk fac tor fo r se riou s h e al th i ssu e s
l e adi ng to d ea t h [2 ]. A bo u t 75 % of the burd en of these i nfe c t i o n s
i s pr e sen t in dev el o pi ng c o u n t ri e s [3 ] . Asympto matic p ati ents may be
c o nsi de r e d i nfe cted i f these p ath oge ns are fo und i n t h e bo dy fl uids
or at a ste r i l e bod y si te , suc h as blo od o r c e r e br osp in al fl ui d [4 ] .
Infec ti o ns t hat ar e ac q uri ed by h ospi tal staff , vi si tor s o r other h eal thc are
p e r sonne l may al so be c onsi d ere d as n osoc omi al [5 ] .
T h e si tu ati on s i n whi ch i nfec ti ons are no t bel ie v e d as n osoc o mi al
are : ( 1) T he i n fecti ons t h at we r e p r esent at the ti m e o f ad missio n
an d be c o me c o mpl i cate d , ne v erthel e ss path oge n s or symptoms
ch ange r e su lti ng to a new i nfe ct oi n ; ( 2 ) The i nfe c ti o ns t h at are
acqui r ed t r ans - pl ac en tall y due to so me di seases l i ke toxo plasm o si s ,
r ube l la , syp h ili s or c yt ome g al ovir us a nd appear 4 8 h after bi r th [6 ] .
Hospi tal - ac qu i r ed i nfe c ti on s appear e d be for e th e or i g inati on o f ho spi tal s
and be c ame a he al th p r o bl e m dur i n g th e m i r ac u l o us ant i bi oti c
e ra . D ue to th ese i nfe c t i ons , no t onl y the c ost s but al so t he
use o f anti bi o ti c s i n c r eased with an exte n ded ho sp i tal i zati o n . Th i s
r esul t ed i n el e vated mo r bidi ty and mortal ti y . S t u d i e s co nd ucted i n d if -
fe r ent
 pa rts of the wor l d sh o w th at in N or th Ame r i c a and Euro pe 5 % –10 %
of al l ho sp i t al i zatio n s r esul t i n nosoc omial i nfe cti o n s , whi l e Lati n
A me ri c a , S ub -S ah ar an A fri c a and A si a sh o w m or e th an 4 0 %
ho spi tal i zati ons w i th noso c omai l infec ti ons [ 7 ] .
N oso comi al i n fe ct i ons can be caused by any o rg ani sms bu t fe w or -
gani sms ar e par ti c ul arly r e sp o nsi ble for h osp i tal - ac qui r ed ni fe c ti ons . I n
thi s r ev i ew ar tic l e , a br i e f ov erv ei w o n di ffer ent aspec t s of
nosoc o m i al ni fe ctions , particul arl y si tes of i n fe ctions , co m mon
n osoc o mi al bact e r i al ag e nts , sel ec t ed an ti bi oti c -ressi tan t path o g e n s
al o ng w i th th e i r m od e s o f tran smi ssio n an d c o ntrol measure s wi l l be
di sc ussed .
2 . Types o f no soc omi al i nfectoi n s
Na ti o n al He al th c ar e Safet y N etwo rk wi th Cente r for Disease Con tr ol
(CDC ) for su rve i l l anc e has c l assi fi e d nosocomial i nfec ti on si te s i nt o 13
type s , wi t h 50 ni fec ti on si te s , wh i c h are sp e c fi i c on th e basi s o f
bi o lo gical a nd c l i ni c al cri t er i a . T he si tes whi c h ar e c ommo n
i nc l u d e uri nar y t ract i n fe ctoi ns ( UT I ) , surg i c al and soft ti ssue i n fection s,
gastro e nte r i ti s , me ni ng i ti s and respirator y i nfecti ons [8 ] . A c h ang e
r e g ar di ng no so co m i al i n fect i on si te s can be e asi ly det ecte d wi th
t i me d u e to th e e l e v at ed use o f c anc e r ch e mo th e rapy , ad van -
c e me nt in o r gan tr ansp lant atoi n , m i munot h er apy and i nvasi ve
t e ch ni q ue s for d i ag nost i c and ther apeu ti c pur p ose s . Th e pe r fect
exam pl e of thi s c an be se en i n the c ase of pne um oni a as pr eva -
l e n ce o f n oso co mi al p n e umo ni a i ncrease d from 17 % to 3 0 %
d ur ni g fi ve years [9 ] .
3 . Age nts of no so c o mi al i nfe c ti o ns
N oso c omi al i nfe cti ons are c aused by many mci r obes and e ac h o ne
can cause i n fe c ti o n i n heal th car e se tti ngs . B act eri a are
r e sponsibl e fo r about nin et y p e r c e nt i nfe ct oi ns , wh e r eas pro to z oans ,
fu ngi , vir uses an d mycobac ter ai are less c ontr i butni g compar ed to
bac te r i al infe cti o ns [10 ] . The agent s that ar e u suall y i nvol ve d i n
ho spi tal - acqui re d i n fe c ti ons i nc l ude S t r e pto co cc us spp . , A c ni e tobac te r
sp p . , enter o coc c i , P se u domonas aer ugi nosa ( P . ae rug i nosa) , c o agu l ase -
n e g ati v e staph yl oc occ i , S taphyl o co cc us aur eus (S . aur eus ) , B ac il l us
 cer e u s ( B . c ere u s ) , L egi one l l a and Ent ero bac ter i ac e a e fami l y
mem be rs i nc l udi ng P r oteus mi r abl i s , Kl e bsi el l a pn eu mo n i a ( K . p n e umo n i a ) ,
Esc her i c hi a coli ( E . c o l i ) , Ser rati a marcesc ens . Out o f the se enter ococc i ,
P . aeru g i n osa , S . au reu s and E . c ol i h av e a major ro l e [1 1 ] .
UT I usual l y c ont ai n E . c o li , w hi le i t is un c o m mon ni oth e r i n fe c ti on
si te s . Contr ari l y , S . aur eus i s fr e quent at o the r bo dy si te s an d r ar ely
ca u se s U TI . I n bl oo d - bor n e i nfec ti o n s , c oag ul ase -neg ative S . au r eus
i s the mai n c ausatvi e a g en t . Su rgi cal -site i nfe ct i o ns con tai n
Entero c o ccus sp p . wh i c h is l e ss p re val en t at re spi rato ry tract . One
tenth o f al l in fec ti o ns ar e c aused by P . ae r ugi no sa , whi c h is
eve nl y d i str bi u t ed to th e e nti r e bod y si tes [4 ] .
Exce ssi ve and improper use of br o ad - spec trum antbi oi tci s , especi al l y i n
h eal thc are se tti ngs , ar e el evati n g noso c omial ni fecti o n s . Peni c li l in - ressi tant
p n e umoc o cc i , mul ti -d rug - r esi stant tu ber c ul o sis , met hici l l in - r esi stant S .
aureu s ( MRSA ) , v anc omycin -r e si stan t S . au r e u s ar e co m mo n
examp l e s of dr ug -resi stant bac ter ai . T he di str i butoi n of bac te r i a i n
no so c om i al i nfec ti ons si ch angi n g ov e r ti me . For e xampl e , P r o teus sp p . ,
Kl e bsi el l a sp p . and Escheri c h i a spp. we r e r esp onsbi le for no so c omi a l
i nfec ti ons i n th e 196 0s, bu t fr om 19 7 5 to 1 980s , A ci netobac te r spp .
wi th P . ae rugi no sa cr eat ed cl inic al diffi c ul ti es [12 ] . Du ri ng the
re ce nt ye ar s , str e ptoc oc c i al o ng wi th c o ag ul ase - n eg ati v e staphyloco c c i
and co ag u l ase -posi tive staph yl o co c c i r ee merg e d and i nci d enc e l eve l
o f K . pne umo ni a and E . c o li d ec li n e d fr o m 7 % to 5 % a nd
2 3 % –16 % , re spe c ti ve l y [1 3 ] .
4 . B ac ter iol og y of c o m m o n l y i so l ate d nosoco m ial p at ho g ens
A mul ti ce nte r stu dy was c o nduc te d i n Japan to i sol ate bac teria from
surg ic al i nfec tio n s duri ng 2 011 –2 012 . A bout 785 st r ai n s i nc l u di n g 3 1
o f Can d i da spp . w er e si o l at e d fr om 204 out o f 259 surgi c al patie nts.
About 523 str ai ns we re i so l ate d fr om pr i m ar y i nfec ti on s and 2 31 fr o m
su r gi c al si te infec ti o n . F r om pr i mar y i nfe c toi ns , a nae robi c
G r am -n egatvi e bac ter ai wer e pr e val e nt . En ter o cocc us spp . w as the
hig he st among G ram -po si tive aer obi c bacter i a fol l o w e d by St r e p t o c o c c us
an d S taph yl oco c c us spp . E . c o l i was th e p r e domi nant fo r m
amo n g the G r am -n egati ve aero bi c bacte r i a fol l o wed by K .
 p ne u moni a , P. ae rugi n o sa and Enterobac ter c l o acae [14 ] .
4 . 1 . S. aur eus
O ut o f m any speci e s o f S tap hyl oco ccu s g en u s , S . aur eus i s
c onsi dere d o ne o f the m ost i m port ant p atho g e ns , re spo nsi bl e fo r
no so c omi al i n fe c ti ons . It i s Gram - p o si ti v e c o c c i , no n - spo re fo r min g ,
cat al ase - and coag u l ase -p o si tiv e , i mmo t i l e , fac u l tat i v e l y anae robe [15 ] .
It i s no t o n ly a d ise ase -c ausi n g or g ani sm bu t al so pl ays i ts r o l e
as com mensal . It m ai nly c o l o ni zes i n n asal p assage s . About 20 %
i nd iv id u a ls h a ve pe r si ste nt c ol o ni z ati o n of S . aur e u s , whe reas 30%
are i n t e r m ti tent . H ospitali z e d p atie nts wi th de c rea se d i m m uni ty and
i mmu nocom pe t ent pe o ple in co m mu ni ty are m or e pr one to S .
aure us i nfecti o n s . S . aureu s infects n ot onl y the super fi ci al bu t al so
th e de ep ti ssu e s and l ocal absc ess le si o n . To x i n - me d ai ted d i se ase s
o f S . aure us i n c l ud e fo o d po i soni ng , d ue to i nge sti on of enter o -
tox ni s , whi l e to xci sh o ck syn d r ome t ox ni 1 i s respo nsibl e for toxi c sh ock
synd ro me [ 16 ] an d e xfol i ati ve t o xi ns c ause stap hyloc o cc al scal d ed
sk i n synd r o me . Vi rule nc e mech a ni sm s of S . au r e u s i ncl ud e toxi ns ,
en zym e s and i m mu ne mod ul ator s [15 ] .
4 . 2 . E . co l i
E . c ol i i s an e m e r g i ng n o so c o mi a l pat h og en causi ng pr o bl em s in
h e al th c ar e setti n g s [17 ] . E . c o l i i s G r am - ne g at i v e and
o xi da se-n e gat i v e fac ul tati v e anaer obe bacte r i a . It c an c ol oni z e i n
gastr ointesti nal tract of h u man bei ngs and o th er animal s . E . col i i s
r esp o nsi bl e fo r a number of disease s i ncl udi ng U TI , se pti cemi a , p ne -
umo ni a , ne onatal meni ng i tis , perit o ni tsi and g astr o enteri t i s . Vi rule nc e
fac tor s me an t fo r i ts p ath og enic ity ar e end oto xi ns , c apsule , ad hesoi n s
and t ype 3 se creti o n systems [18 ] . Specai l i ze d v ir ul e n ce fac to rs
ar e se en i n case o f U T I an d g astr o e n t eri t i s .
4 .3 . Vancom yc ni -re sistan t en terococ c i
Ente r o coc c i si th e second leadi ng c ause of ho spi t al ac q ui r ed
ni fe cti ons worl d wi d e an d the mai n l ead ni g cau se i n Uni ted S tat e s
c o ntr i bu ti ng 20 % –3 0 % o f i nfe c toi ns. These ar e fac ul tatvi e anaero bi c
Gram -p osi ti v e en ter ic m i c r o bes [ 1 9 ] . T h ey ar e a part o f nor m al
mi cr obi ota i n fe mal e g eni tal t r ac t an d g astro i ntestinal tr ac t as w el l .
 Ente roc o c ci ar e i n volv e d i n the bl oo d -bo rn e i nfecti o ns ; U T I an d
w o u nd i nfecti o ns c on sor t to sur g i c al pr o c e dur e s [2 0 ] . Vi r ul e nc e
fac to r s i nc l ude extr acellular sur fac e pr ot ei ns , c yto l ysi n , adhesi on s ,
h emol ysi ns , g e l ati nase , e xt r ace l l ular su pero xi de an d aggregat i o n subs -
t ance s [21 ] .
4 . 4 . K . p neu m oni a
Three to se v en pe rc en t of ho sp i t al -ac qui r e d bact erial i nfe cti ons ar e
r e la ted t o K . pne um o n i a , wh i ch is t h e e i g h t h si g ni fi c ant p ath og en i n
h eal thcare setti ngs . It i s a Gram -p osi ti ve baci l l u s and an oppo r tu ni sti c
bac teri um , wh ic h i s a par t of Enter o bac teri ac e ae fam i l y . It usual l y
co l o ni ze s gastr oi nte stinal t r ac t, p h ar ynx an d ski n . It ge ts i nv ol v ed
i n d i se ases su ch as n e o natal se p ti c ae mi a , pne u m o ni a , wo und i nfe c -
ti o ns and septic e mi a . I ts virul ence fac tor s i nc l u de en d otoxi n s , c e l l wal l
r e c eptor s and c apsul ar pol ysacc h ar i de [22 ] .
4 .5 . P . aer ug in osa
P . aer u g i n osa con tri butes to 1 1 % of al l noso co mi al i nfe c ti on s , whic h
resul t i n hi g h mo r t al i ty an d mo rbi di ty r ates . It i s non -fe r me n te r
G ram -n e gati ve or g ani sm c ausin g d i se ases espe c i al l y am ong i mm une -
c ompr omi se d pe o pl e . Th e sites o f c ol o n i z ati on ar e k i d ne y , u ri nar y
tr ac t and u ppe r r e spi r ato ry tr act . It i s a cause o f surg i cal and
wo u n d i nfe c ti o ns , U T I , pneumonia , c ysti c fi br o ssi an d bac t er e m i a .
S ome of i mpor t an t v i r ul en c e fac t o r s ar e ad hesi o ns , h emo l ysi ns ,
e xot o xi ns , pr ote ases and si d er ophores [23 ] .
4 . 6 . Cl ostri di um di ffi cil e ( C . d iffi ci l e)
C . di ffi ci l e is an imp o rt ant nosoc om i a l pat hogen whi c h mai nly
c au se s di ar rh e a . Se v er al cases of C . d iffi ci l e are repor ted i n
Eur ope, U . S . and Canad a . It i s a G r am - posi tive baci l l us . It i s
an ae r o bi c and spo r e - fo rmi ng bacter i a . It u sual l y c olon i zes in in testi nal
trac t an d se r ve s as par t o f n o r m al mi c ro bi ota [24 ]. Di sease s c au se d
by to xi ns p r o duced by C . di ffi c i l e ar e col i ti s and it i s re spo n sbi l e fo r
15 % – 2 5 % c ases o f di a r r hea . M aj o r v i r ul e nce fac tor s fo r C .
di ffi cil e ar e tox i ns , fi mbr i ae , c ap sul e and hydr o l yti c enzymes [25 ] .
5 . M od e s of tr an smissio n
5 .1 . S . aur e u s
 T r an smissi on o f S . aur e us si thr o ug h ni fe c ted i ndivi d uals’ sk i n or
c o ntact v i a shar ed item s and surfac e s l i ke doo r h and l es , be nc he s ,
to wel s and taps .
5 .2 . E . co li
E . c ol i can be transmi tted th ro ugh pe r son to p e rso n , e nv i r on me nt o r
c o ntami nated water and fo o d [17 ] .
5 .3 . Vancomyci n - r e si st ant en ter o coc c i
Pati ent s with di a r rhea ar e commo n m eans o f tr ansmi ssi o n . Th e i r
r o o m i te ms suc h as sur fac e s and e q ui pme nts ac t as re serv oirs . T hi s
bac te ri um c an sur v i v e on these s surface s fo r d ays o r wee k s an d
bec om e a so urce o f c ontami n a ti o n fo r h e althc are i nd vi i d ual s and
oth e r patei nts [ 21 ] .
5 . 4 . K . pne u moni a
I n hospi tal setti n g s , K . pneumo nai c an be tr ansmitt e d by per sonto -
per son c ontact an d esp eci al l y when h e al t hc ar e pro fe ssi o nal s do no t
wash o r c l ean h and s afte r ch e cki ng a contami nate d p ati ent .
Resp ri ato ry m ac hi n es , c athe ter s o r expose d wo und s c an be the sou rce
of i ts t ransm i ssi o n . K . pne um oni ae i s repor t e d to be tr ansm i tte d
th ro u g h st o o l (7 7 % ) , pati e nts ’ h and s ( 4 2 % ) and p h arynx ( 1 9 % )
[2 2 ].
5 . 5 . P . aer ugi nosa
Co mmo n r e se r v oi rs for i ts c o ntaminatio n i n c l u de br ea st pumps ,
i n cu bators [ 2 6 ] , si n ks and han d s of ho sp i tal staff an d han d soaps
[27] .
5 . 6 . C . d i ffi c i le
Spo r e s of C . d iffi c i l e c an h o l d fo r mo n th s and beco m e a pro bl e m
for disi nfe c tants and c l ean i ng ag e nts . Inani mat e o bje cts and i n -
fec te d i nt est i n al p at ien ts ar e maj or si te s ac t ed as rese rv o i r s .
H o spi tal staff al ong w i th h o sp i tal se ttni gs are al so pl ayi ng th eir p art to a
g re ate r e xt ent [2 8 ] .
6 . Se l ec te d anti bi o ti c -r e si stant no so comi al path oge ns
M u l t i -dr ug - r e si stant nosoc omi al or g ansi ms i ncl ud e MRS A,
vancom yc i n - r e sistant e nter oco c c i , P . aeru g ni osa and K . p n e umoni a ,
whe r e as C . d i ffic i l e sho ws natur al resistance . In t he 1940s , the
 p r obl em o f drug re sistanc e c ame i nto l i g h t an d i n the past fe w
ye ars , a rap i d ni cr e ase of mul t i - d rug - re ssi tant patho g ens w as
se e n .
F ifty to si x ty per c e nt of h ospi tal -acqu i re d infe c tio n s ar e c aused by r e -
si st ant p athog e ns i n the U ni t e d States . Imp r o per u se of anti bi oti c s i s
tho u gh t to be the m ajo r cause of thi s dru g r e sistance .
6 .1 . M RS A
β - L act amase an ti biotic s ni cl u di n g p eni ci l l i n al on g wi th o ther
anti mi c robi al s bec ame re sist an t i n the 194 0s . Re si stan c e of p eni c i l l i n
sl ow l y pr e v ai l s fr om ho spti al s to communi ty d ue to i ts m i prope r u se .
T his r esistanc e r esu l ts ar e due to the Staph yloc occ al sp eci es h av i ng
p e ni cli l i nase enzym e whi ch was l ate r sol v e d by th e i n trod ucti on of
p en i c i l l in ase - r essi tan t anti bi oti cs , cep h al osp or i n s . I n th e 19 6 0 s ,
me th i cil l i n -resista nt speci es of S . aur e u s we r e re porte d . T h i s
r e ssi tance was d ue to th e mo d i ficati o n of pe n ci i ll i n -bni di ng prote i n s .
Th is mo di fi c ati o n m ade al l β - l act am anti biot i cs al ong wi th thei r d e rivatvi e s
i n e ffec tiv e . A mi no g l yc o sid e s r esi stance was ano th er addi t i on to
me th i c il l in r e si stanc e [2 9 ] .
6 . 2 . Vanc o myc i n - r esi stant e nt e ro coc c i
V a nc omyc i n r esistan c e is se en i n th e e n teroc o c c al sp e c ie s du e to
th e van A an d v anB g e n es . Th ese g e ne s are a par t o f plasm i d
a n d wo u l d sp r e ad r e si st a nc e to oth er micr o bes as we ll . E n te rococ c i
a re re si stan t to di ffe re nt c l asses o f anti bi o ti c s wh i ch i nclude p eni c i l li n ,
am pi ci l l i n , amni o g l yco si de s , t e tr acycl in es , c ar bape nems ,
fl u o roqui n o l one s and mac r ol id es [30 ] .
6 .3 . P . aer u g i nosa
P . ae r ug i no sa i s be c o mi ng resistant d u e to di ffere n t mec h ani sm s
wo r ki n g ag ai nst antibi o ti c s . T h e se me chanisms i n c l ude th e r estr ci te d
u p tak e of d rug , d r u g m odi fi cat i on and al te r e d tar g ets for
anti bi o ti c s . Due to th i s i n cr easi ng r esi stan c e , c o m pli c ati o n s are se en
i n the tr e atmen t o f P . ae r ugni o sa in fe cti o ns . The d r ug s that ar e
no w i n effe c tvi e du e to i n c re asi ng ressi t anc e i ncl ud e ce ph al o spo r i ns ,
t r i me thopr m i , mac r ol i d es, chlor am p h e n i c ol , te tr ac yc l ines and
fl uo r oqu i nol o ne s [ 2 3 ] .
 6 . 4 . K . pn e umo ni a
Re si stanc e to β -l actam antbi oi t ci s i s a majo r c ause o f
c omp l i cati ons i n n oso c o mi al i n fec ti ons . K . pn eum oni a i s one of th e
m i cr o bes e xp eri enci ng resi st ance of β - l ac tamase antibi oti cs al o n g wit h
E . co l i . Cephal osp or i ns of thi r d an d fo ur t h g e n er ati o n sho w r e si stan ce
fo r K . pne um o n i a [2 2 ] .
6 . 5 . C . diffi ci l e
In c re ase d use of broad -spe ctrum ant ibi o ti cs agai nst C . di ffi c i l e - assocai ted
di se ases makes it r e si stant . Ce ph al ospo r ins , fl uor o q u i n ol ones , c l i n -
damyc i ns and ampi c i l li ns are tho se anti m i c robi al s tha t a r e u su al l y
empl o ye d for C . d i ffic il e - asso c i ated d i se ases . Re c e nt stud ie s
r e po rted th at th e m i p r oper an ti bioti c use was the c ause o f i ncr e asi ng
i nfe ct i o ns of C . di ffi ci l e [2 8 ] .
7. Con tr o l o f n o so comi al i nfe c ti ons
T h er e i s a l ac k of act ual st at i sti c s r egar d i ng the c ause s and
an t imci robai l susc e pti bil i ty i n deve l o ping cou nt ri es . P ath oge ns wti h
r esi stant organ i sms ma k e i t e x tre mel y di ffci ul t t o d e v i se a pr o per
p l an and i ts i m pl em e ntati o n for c o ntr o l [3 ] .
7 .1 . Me asu r e me nt and co m par i son of i n fecti on r at e s
I t i s d i ffi c u l t to m easu r e the ni fe c ti o n r ate s i n d i ffe rent he al th c ar e
setti ngs . For the measuremen t o f i nfe cti o n r ates , i t is i m p ortan t to kn ow
t h e typ es o f mi c r o org ani sm i nvo l v e d and its c or rec t l o c ati o n i nsi de
th e body o f i nd i v i dual . In fe c ti ous or gan isms ar e he t e r o g en eo u s i n
natur e , whi c h makes th e m di ffe rent from o n e ano ther . It i s possi bl e
t h at i n a ho spi tal , t he r ates of i nfec ti o n show sim il ar i ty w h i l e
th e l oc ati o n and h e te r o g eneity of o r g ani sm s gr eatl y di ffer .
To c om p ar e t h e i nfec tio n rate s , one m u st k n o w the typ e of
heal th car e setti n g s , whi c h may be publ i c or pr i v ate , be c ause the
infe ctoi n r ates v ary in both typ e s o f h osp i tal s . In addi ti on , i n these
ho spi tals , th e man ag e me nt o f ni fe c ti on s di ffe r s gre atl y . T h e type s o f
se r vi ce s th at a h o spi tal p ro v i d e s to pati e n ts mu st be tak e n i nto ac -
c o un t