American Journal of Infection Control 44 (2016) 465-9

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g

Major article

Recovery of resistant bacteria from mattresses of patients under

contact precautions
Roberta El Hariri Viana MSN a, Simone G. dos Santos PhD b, Adriana C. Oliveira PhD, RN c,*
a Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
b Department of Microbiology, Institute of Biological Sciences, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
c Department of Basic Nursing, School of Nursing, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil

Key Words: Background: Microorganisms may contaminate hospital mattresses even after terminal cleaning. We in-
Patient safety vestigated the recovery of resistant bacteria from the mattresses of patients under contact precautions
Disinfection at a university hospital.
Antibiotic-resistant bacteria
Methods: We conducted a cross-sectional study. Samples were obtained from the surface of mat-
Hospital infection
tresses, spread on replicate organism detection and counting plates, and cultivated at 37°C for 48 hours.
After collecting samples, we identified microorganisms and tested for antimicrobial susceptibility using
the Vitek 2 (bioMérieux SA, Marcy-l’Etoile, France) automation system.
Results: We evaluated 51 mattresses. A total of 26 had resistant bacteria on the surface; the predomi-
nant species were Acinetobacter baumannii (69.2%), Klebsiella pneumoniae (11.5%), and Pseudomonas aeruginosa
(11.5%). The median length of hospital stay was 41 days; the bed occupancy for patients under contact
precautions and the time at which the patient was diagnosed as a carrier of resistant bacteria was 18
days.
Conclusions: The phenotypic similarity of A baumannii in inpatient units (mattresses) suggests circula-
tion of the same strain. These results highlight the importance of controlling the potential spread of
microorganisms through hospital mattresses.
© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.

INTRODUCTION
Health care-associated infection (HAI) is an infection that pa-
tients acquire while receiving treatment for other conditions within
a health care setting.1 HAIs are a worldwide health problem that
result in long periods of hospitalization, increased hospital costs,
increased use of antimicrobial agents, and high mortality rates. Above
all, they adversely affect the productivity and quality of life of pa-
tients and their families.1,2
The World Health Organization estimates that 5%-10% of pa-
tients admitted to hospitals acquire 1 or more infections.1 In 2002,
1.7 million patients were diagnosed with HAIs and in 2004 HAIs had
an economic impact of $6.5 billion in the United States. Brazil does
not have systematic data on the incidence of HAIs, but the Minis-
* Address correspondence to Adriana C. Oliveira, PhD, RN, Department of Basic
Nursing, School of Nursing, Universidade Federal de Minas Gerais, Rua Aimorés, 2162,
apto 1601, 30140072 Belo Horizonte, Minas Gerais, Brazil.
E-mail address: adrianacoliveira@gmail.com (A.C. Oliveira).
Conflicts of interest: None to report.
try of Health has reported that the overall incidence is 9%-15%, with
14% mortality.1,3,4
Pathogens responsible for HAIs often spread by cross-
contamination; the main sources are colonized patients, patients
with infectious diseases, and the hands of health professionals.
However, several studies point to possible environment sources in
the maintenance and spread of pathogens that increase the likeli-
hood that hospitalized patients will acquire HAIs.1,2,5-8
Although the role of the environment in the acquisition of patho-
gens is unclear, epidemiologically relevant microorganisms have been
isolated in different hospital settings. Evidence exists that environ-
ments occupied by patients infected with resistant bacteria may
also become contaminated and contribute to the spread of
pathogens.6,7,9-11
Hospital bed mattresses, which are prone to contamination, are
a potential reservoir of pathogens. The surfaces of mattresses may
be contaminated by microorganisms that colonize a patient’s skin,
by body fluids such as urine and wound exudates, or by feces. Mat-
tresses with a high microbial load may contribute to the horizontal
transmission of microorganisms between patients and other
surfaces.12,13

0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2015.10.027
466 R. El Hariri Viana et al. / American Journal of Infection Control 44 (2016) 465-9

A better understanding of the role of environment surfaces in
the chain of pathogen transmission, especially surfaces in direct
contact with patients and frequently touched by health profession-
als, such as mattresses, is critically important. Such understanding
would help health care professionals to establish new strategies to
control the spread of microorganisms that may influence the oc-
currence of HAIs and antimicrobial-resistant bacteria. We investigated
the recovery of resistant bacteria from the mattresses of patients
under contact precautions at a university hospital.
2014.15 Antimicrobial drugs were selected based on microbial char-
acteristics and clinical relevance.
We characterized the previous occupants of mattresses by search-
ing the microbiology records of the institution to determine when
the patients had been diagnosed as beingresistant bacteria carriers.
We tabulated and processed data using Stata version 12.0 (Stata
Corp, College Station, TX), carried out univariate and multivariate
analysis using Poisson regression, and calculated coefficients with
95% confidence intervals.

MATERIALS AND METHODS Ethical procedures

Trial design and characteristics of the evaluated service In accordance with Resolution 466/2012 of the National Health
Council, we conducted this study with approval from the Re-
We carried out a cross-sectional study in 9 inpatient units of a search Ethics Committee of the Federal University of Minas Gerais
547-bed public general university hospital in Belo Horizonte, Minas (CAAE-0386.0.203.000-11).
Gerais, Brazil. Two of the 9 inpatient units were intensive care units
(ICUs)—the adult intensive care and the coronary care unit; 7 were RESULTS
clinical units.
We analyzed 51 mattresses used by patients colonized or in-
Data collection fected by resistant bacteria. The median length of hospital stay was
We analyzed all beds occupied by patients colonized or in- 41 days; the bed occupancy for patients under contact precaution
fected by resistant bacteria between May 2014 and July 2014. We and the time at which the patient was diagnosed as a carrier of re-
collected 3 samples from each mattress, the first in the upper area sistant bacteria was 18 days.
(near the head of the mattress), the second in the middle, and the Specimens were collected in the mornings before bed-bath and
third in the bottom area (near the foot). We collected samples from environment cleaning. We obtained 306 samples, and bacteria were
the face of the mattress; that is, the surface on which a patient lies. cultured from 61.4% (188 out of 306) (Table 1).
All mattresses were analyzed in the early morning before the We obtained 473 isolates from the 188 positive samples; 275
patient’s bed bath and environment cleaning. were gram positive (58.1%) and 198 (41.9%) were gram negative. Plate
counts of colony forming units indicated that most mattresses (31
Laboratory procedures: Microbiologic evaluation of mattress out of 51) had an uncountable microbial load (Table 2).
Twenty-six (51.0%) of the 51 mattresses analyzed had resistant
We carried out microbiologic evaluation of mattress surfaces bacteria on their surface, predominantly Acinetobacter baumannii,
using BBL replicate organism detection (BBL, Biomérieux, Marcy- Klebsiella pneumoniae, and Pseudomonas aeruginosa (Fig 1).
l’Étoile, France) and counting (RODAC) plates to identify the genus All resistant microorganisms recovered from the mattresses had
and species of bacteria present in samples; antimicrobial suscep- a profile of resistance in accordance with the resistance marker pro-
tibility profiles were established using the disk diffusion in agar posed by CLSI.16 Staphylococcus aureus was resistant to methicillin,
method. Enterococcus faecium was resistant to all antibiotics tested, and En-
RODAC plates containing brain heart infusion broth and terococcus faecalis was resistant to vancomycin.
MacConkey culture media were seeded with mattress samples and The A baumannii strains were all resistant to ciprofloxacin,
incubated in the laboratory at 37°C for 48 hours in a bacteriologic ceftriaxone, and imipenem, and many were resistant to ceftazidime.
incubator. For each culture medium used, we registered the char- All P aeruginosa strains were resistant to imipenem, and some were
acteristics of the colonies and performed a semiquantitative resistant to ciprofloxacin or ceftazidime.
assessment of bacterial growth. We estimated the microbial load
present on the surface of each mattress from the number of colony-
Table 1
forming units identified on plates. With respect to total microbial Bacterial growth under culture medium
load, we categorized mattresses that had RODAC plates with bac-
Culture media
terial growth up to 300 CFU as countable; those with plates showing
growth of >300 CFU were categorized as uncountable. Brain heart MacConkey
Bacterial growth infusion broth agar Total
We identified microorganisms on the basis of morphology and
Gram’s staining pattern. Biochemical, physiologic, or enzymatic char- Positive 148 (78.7) 40 (21.3) 188 (61.4)
acteristics were determined with use of the Vitek 2 system Negative 05 (4.2) 113 (95.8) 118 (38.6)
Total 153 153 306
(bioMérieux SA, Marcy-l’Etoile, France), gram-negative bacteria and
gram-positive bacteria. To test antibiotic susceptibility, we per- NOTE. Values are presented as n (%).
formed the disk diffusion method for isolated bacteria according to
guidelines from the Clinical and Laboratory Standards Institute Table 2
Resistant bacteria of epidemiologic relevance recovered according to the total mi-
(CLSI).14 Bacterium inoculates were prepared by direct colony sus-
crobial load identified in the mattresses of patients under contact precautions
pension in saline solution to obtain a density equivalent to a 0.5
McFarland standard (about 8.0 log CFU/mL). The inoculum suspen- Recovery of resistant
bacteria of epidemiologic
sion was spread in 3 directions on a Mueller Hinton agar (Difco PR (95%
relevance
Laboratories, Detroit, MI) plate surface with a sterile swab and in- Total microbial Confidence
load Yes No interval) P value
cubated at 35°C ± 2°C aerobiosis for 16-18 hours. After incubation,
we measured the diameter of inhibition zones using an electronic Countable 8 (40.0) 12 (60.0) 1 .239
digital caliper (Series 727, Starrett, Athol, MA). We interpreted the Uncountable 18 (58.1) 13 (41.9) 1.45 (0.78-2.70)

results according to the critical points recommended by CLSI in NOTE. Values are presented as n (%). PR, poison regression.
 R. El Hariri Viana et al. / American Journal of Infection Control 44 (2016) 465-9 467

20 73.1%

18

16

14

Number of Matress
12

10

4 11.5% 11.5%
7.7% 7.7% 7.7%
2

0
Acinetobacter Klebisiella VRE Pseudomonas Escherichia MRSA
baumannii pneumoniae aeruginosa coli
Antimicrobial resistant bacterial isolate

Fig 1. Distribution of resistant bacteria recovered from mattresses of patients under contact precautions.

10
9
8
Number of mattresses

7 Acinetobacter baumannii
6 Klebisiella pneumoniae
5 Pseudomonas aeruginosa
4 MRSA
3 Escherichia coli
2
Enterococcus faecium
1
Enterococcus faecallis
0
AICU 7 East* 8 East* 3 South* CCU 8 South* 10 South*
Inpatient units (*Clinical units)

Fig 2. Distribution of resistant bacteria recovered from mattresses according to the inpatient unit. AICU, adult intensive care unit; CCU, coronary care unit.

All K pneumonia strains were resistant to at least 2 antibiotic
agents, usually ampicillin, imipenem, or ceftriaxone. All Escheri-
chia coli strains were resistant to ampicillin, ceftriaxone, and
imipenem.
We observed that 80.7% (21 out of 26) of the analyzed mat-
tresses were contaminated by only 1 of the identified antimicrobial-
resistant bacteria, but 19.2% (5 out of 26) were contaminated
by >1 bacterium. The area of mattresses from which bacteria were
most often recovered was the lower region (73.1%), followed by the
upper region (50%), and the middle (42.3%).
A baumannii strains were present in most contaminated mat-
tresses (19 out of 26) (Fig 2) and 77.7% (7 out of 9) of inpatient units
in the study.
In 13 of 26 beds (50.0%) from which resistant bacteria were re-
covered, the phenotype was the same as that registered for the
patient occupying the bed at the time the mattress samples were
taken, especially A baumannii in 92% of the isolates.
In cases in which the isolated microorganism on the mattress
was different from that associated with the bed’s current occu-
pant, 54% (7 out of 13) of the microorganisms phenotypically
resembled those associated with the bed’s previous occupant,
according to the microbiology records of the institution. The species
were especially K pneumoniae, P aeruginosa, and methicillin-
resistant Staphylococcus aureus (MRSA). In other words, mattresses
previously occupied by patients with K pneumoniae, P aeruginosa,
and MRSA remained contaminated even after terminal cleaning.
For antimicrobial therapy, vancomycin was the antibiotic most
often used (75.5%) in patients under contact precautions in this study,
followed by meropenem (73.4%), polymyxin (51%), cefepime (36.7%),
and others. Data of duration in days for antimicrobial therapy for
patients under contact precautions are presented in Table 3.
DISCUSSION
Evidence of microbial growth was present in all evaluated mat-
tresses and, in most cases, the identified species involved resistant
bacteria. The detection of microorganisms on mattress surfaces re-
inforces the fact that the surroundings of colonized or infected
patients can become contaminated with bacteria and confirms that
mattresses are a potential reservoir of pathogens in health
facilities.11,12,15-17
468 R. El Hariri Viana et al. / American Journal of Infection Control 44 (2016) 465-9
Table 3
Average length of antimicrobial therapy in patients under contact precautions
Average time of
Antimicrobial agent antimicrobial use, d
Clarithromycin 10.0
Metronidazole 10.4
Daptomycin 12.5
Ceftriaxone 13.1
Amikacin 13.7
Vancomycin 13.8
Moxifloxacin 14.0
Polymyxin 15.4
Ceftazidime 16.0
Meropenem 18.5
Trimethoprim-sulfamethoxazole 19.2
Cefazolin 21.0
Ampicillin 24.7
Oxacillin 27.0
The predominant microorganisms recovered from mattresses in
the study sample were resistant A baumannii strains, which can
survive in different environments and on dry surfaces from 3 days-
11 months.18 They can also form biofilm owing to various virulence
factors and versatile metabolic capacity, which increases the chances
of outbreaks.
The varied strains of A baumannii were recovered especially from
the lower regions of the mattress surface. This finding corrobo-
rates similar research and correlates to how mattresses are typically
cleaned, from the upper region toward the lower region, which may
move microorganisms but not eliminate them.15,19
The protocol of the hospital involved in the study recommends
cleaning the frame, undercarriage, mattress, and base of the bed.
Beds should be decontaminated after each patient leaves (ie, ter-
minal cleaning) and once per week when the bed is occupied by
same patient. This cleaning schedule aims to prevent dust accu-
mulation and the harboring of microorganisms. During terminal
cleaning, lockers, bed tables, nurse call systems, bed controls, patient
chairs, oxygen and suction canisters, and other items need to be de-
contaminated. Environment surfaces that the patient contacts
frequently (eg, bedside table, bed rails, and mattress) can be con-
taminated with epidemiologically relevant microbes. Hospital
protocol recommends the use of Glucoprotamin as an effective,
rapidly acting bactericidal and fungicidal cleaning agent. Among
other institutions in Brazil, the local committee of hospital infec-
tion control may have other recommendations about which
disinfectant to use for cleaning the patient unit.20
When the bacteria recovered from the mattress were pheno-
typically different from the bacteria associated with the bed’s current
occupant, we sought to identify if the bed’s previous occupant had
been a carrier of a resistant microorganism. In those cases, micro-
biology laboratory records of the institution pointed out that
especially the strains of K pneumoniae, P aeruginosa, and MRSA iso-
lated from the mattresses were phenotypically similar to the
microorganism carried by the bed’s previous occupant. This result
aligns with studies that refer to a small but significant increase in
the risk of acquiring MRSA if patients are admitted into rooms pre-
viously occupied by carrier patients21 and reinforces flaws in terminal
cleaning procedures. Other studies also reinforce the premise that
2.4%-64.3% of mattresses previously occupied by patients colo-
nized or infected with resistant bacteria remain contaminated even
after terminal cleaning.9,15,18,19
The results should prompt health care facilities to consider their
cleaning procedures. Surfaces are usually cleaned mechanically with
disinfecting, germicidal agents, but such cleaning procedures and
their duration may be insufficient to act against microorganisms and
reduce microbial contamination to safe levels.22
In this study, the rate of contamination of mattresses with re-
sistant bacteria was highest in ICUs. Several studies around the world
have provided evidence of environment contamination in ICUs; the
high prevalence of resistant microorganisms in ICUs may be attrib-
uted to factors such as the severity of patients’ illnesses, extended
periods of hospitalization, use of invasive procedures, low-quality
cleaning and disinfection, physical structures of ICUs, and low ad-
herence to hand hygiene.4,10
The bacteria most often associated with cases of colonization were
vancomycin-resistant enterococci. The high frequency of coloniza-
tion of patients with this bacteria can be attributed to the significant
increase in the presence of vancomycin-resistant enterococci in hos-
pitals since 1990, when it was first isolated in the United States. The
use of antibiotics is an important risk factor for colonization by re-
sistant pathogens; in this study the antibiotic most frequently
administered to patients was vancomycin (75.5%).23,24
The widespread use of antimicrobial agents reported in this study
reinforces concerns about the continuing emergence of resistant mi-
croorganisms in health institutions and even in the community.2,25
The emergence of resistance among microorganisms is a con-
stant challenge to researchers and to the pharmaceutical industry.
Such resistance reduces the effectiveness of medicines, increases
duration of hospital stays, increases cost of treatment, and contrib-
utes to increased morbidity and mortality associated with
infections.25
Bacterial resistance to antimicrobial agents may result from either
novel mutation or transfer of genes causing resistance and
environment-related stresses. Adaptation may occur naturally
because of the presence of genes that confer resistance to certain
antimicrobial agents in various ways, and deserve special atten-
tion in health care facilities.10
The lag between the time at which an individual is diagnosed
as a carrier of resistant bacteria and the recovery of epidemiologi-
cally relevant numbers of bacteria from a mattress is probably
because of the time required for microbial growth.
Knowledge of the factors associated with the recovery of resis-
tant bacteria from mattresses can contribute to the development
of improved cleaning procedures and changes in the behavior of
health professionals who treat patients under contact precautions.
This study supports the idea that the environment is a poten-
tial source of transmission of microorganisms, especially when
terminal cleaning is not efficient. In addition, the findings show that
greater attention should be given to units occupied by patients with
resistant microorganisms where the chance of survival of these mi-
croorganisms is increased.
One limitation of the study was the use of a convenience sample;
cultures were not taken after terminal cleaning. The collection of
samples after terminal cleaning (ie, cleaning that occurs upon a
patient’s departure) was beyond the scope of the study. Patients
could depart at any time of day, and we were not able to collect
samples at all times within a 24-hour period. In addition, the high
rate of patient turnover meant that beds needed to be prepared
quickly for other patients, which left little time to collect samples
before environment cleaning occurred. However, the study was not
intended to evaluate the immediate effectiveness of terminal clean-
ing but rather to examine the potential for resistant microorganisms
to be transmitted through the mattresses of patients under contact
precautions.
CONCLUSIONS
We recovered resistant bacteria from the majority of analyzed
mattresses, most often from the lower region of the surface. Patho-
gens phenotypically similar to the microorganisms associated with
 R. El Hariri Viana et al. / American Journal of Infection Control 44 (2016) 465-9
the patient currently occupying the mattress, and other species not
associated with the current occupant, were present in mattresses.
About half of the mattresses we investigated were contami-
nated with resistant bacterial species associated with the current
patient. The majority of microorganisms unrelated to the current
patient were phenotypically similar to those associated with the pre-
vious patient.
We found similar antimicrobial resistance phenotypes in A
baumannii strains from inpatient units, which may suggest that the
strain was circulating among units included in the study.
These results provide further evidence of the importance of
paying attention to surfaces, such as mattresses, when establish-
ing hygiene and cleaning protocols for health care institutions. They
also suggest that institutions should review cleaning protocols with
the aim of reducing the potential spread of microorganisms and the
contamination of patients and health care professionals, which is
a key component of HAI prevention strategies.
References
1. World Health Organization. World alliance for patient safety. WHO guidelines
on hand hygiene in health care. First global patient safety challenge clean care
is safer care. Geneva (Switzerland): WHO Press; 2009. Available from: http://
apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf. Accessed
November 28, 2015.
2. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 guideline for isolation
precautions: preventing transmission of infectious agents in healthcare settings.
Am J Infect Control 2007;35(10, Suppl 2):S65-164.
3. World Health Organization. Report on the burden of endemic health care-
associated infection worldwide. Geneva (Switzerland): WHO Press; 2011.
4. Santos AAM, Lopes FFP, Cardoso MRA, Serufo JC. Diagnóstico do controle da
infecção hospitalar no Brasil. Brasilia (DF): Agência Nacional de Vigilância
Sanitária; 2005.
5. Dancer SJ. The role of environmental cleaning in the control of hospital-acquired
infection. J Hosp Infect 2009;73:378-85.
6. Boyce JM. Environmental contamination makes an important contribution to
hospital infection. J Hosp Infect 2007;65(Suppl 2):50-4.
7. Perugini MR, Nomi SM, Lopes GK, Belei RA, van der Heijden IM, Mostachio AK,
et al. Impact of the reduction of environmental and equipment contamination
on vancomycin-resistant Enterococcus rates. Infection 2011;39:587-93.
8. Sehulster LM, Chinn RYW, Arduino MJ, Carpenter J, Donlan R, Ashford D, et al.
Guidelines for environmental infection control in health-care facilities.
Recommendations of CDC and the healthcare infection control practices advisory
committee (HICPAC). Chicago (IL): American Society for Healthcare Engineering/
American Hospital Association; 2004.
469
9. Datta R, Platt R, Yokoe DS, Huang SS. Environmental cleaning intervention and
risk of acquiring multidrug-resistant organisms from prior room occupants. Arch
Intern Med 2011;171:491-4.
10. Oliveira AC, Damasceno QS, Piscoya M, Nicoli JR. Epidemiologic characteristics
of resistant microorganisms present in reserves from an intensive care unit. Am
J Infect Control 2012;40:186-7.
11. Sexton T, Clarke P, O’Neill E, Dillane T, Humphreys H. Environmental reservoirs
of methicillin-resistant Staphylococcus aureus in isolation rooms: Correlation with
patient isolates and implications for hospital hygiene. J Hosp Infect 2006;62:187-
94.
12. Carreiro MA, Figueiredo NMA, Brandao MAG. Cuidados de enfermagem com o
colchão hospitalar—segurança do cliente no ambiente terapêutico. Rev Enf
Profissional 2014;1:165-84.
13. Creamer E, Humphreys H. The contribution of beds to healthcare-associated
infection: The importance of adequate decontamination. J Hosp Infect 2008;69:8-
23.
14. Clinical and Laboratory Standards Institute. Performance standards for
antimicrobial susceptibility testing; twenty-fourth informational supplement.
CLSI document M100 S24. Wayne (PA): Clinical and Laboratory Standards
Institute; 2014.
15. Andrade D, Angerami ELS, Padovani CR. Condição microbiológica dos
leitos hospitalares antes e depois de sua limpeza. Rev Saúde Pública
[Internet] 2000;34:163-9. Available from: http://www.scielo.br/pdf/rsp/v34n2/
1952.pdf. Accessed December 15, 2015.
16. Manian FA, Griesenauer S, Senkel D, Setzer JM, Doll SA, Perry AM, et al. Isolation
of Acinetobacter baumannii complex and methicillin-resistant Staphylococcus
aureus from hospital rooms following terminal cleaning and disinfection: can
we do better? Infect Control Hosp Epidemiol 2011;32:667-72.
17. Kempf M, Rolain J. Emergence of resistance to carbapenems in Acinetobacter
baumannii in Europe: clinical impact and therapeutic options. Int J Antimicrob
Agents 2012;39:105-14.
18. Sattar SA, Maillard JY. The crucial role of wiping in decontamination of high-touch
environmental surfaces: review of current status and directions for the future.
Am J Infect Control 2013;41(Suppl 5):S97-104.
19. Silvia NO, Ferraz PC, Silva ALT, Malvezzi CK, Poveda VB. Avaliação da técnica de
desinfecção dos colchões de uma unidade de atendimento a saúde. Rev Min
Enferm 2011;15:242-7.
20. Brasil. Ministério da Saúde. Agência Nacional de Vigilância Sanitária (ANVISA).
Segurança do paciente em serviços de saúde: limpeza e desinfecção de
superfícies. Brasília (DF): 120p. 2010.
21. Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from
prior room occupants. Arch Intern Med 2006;166:1945.
22. Andrade D, Leopoldo VC, Haas VJ. Ocorrência de bactérias multirresistentes em
um centro de terapia intensiva de hospital brasileiro de emergências. Rev Bras
Ter Intensiva 2006;18:27-33.
23. Brasil. Agência Nacional de Vigilância Sanitária (ANVISA). Medidas de prevenção
de infecção relacionada à assistência a saúde. Brasília (DF):92p. 2013.
24. Oliveira AC, Silva RS. Desafios do cuidar em saúde frente à resistência bacteriana:
uma revisão. Rev Eletrônica Enferm 2008;10:189-97.
25. Pai S, Gouliouris T, Kappeler ARM, Gillham MI. Disinfection of dynamic
mattresses: Highlighting an infection control issue. J Hosp Infect 2015;90:172-3.