Hospital Infection Prevention Principles & Practices

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Foreword

I have had the privilege of reviewing “The Principles and Practices of

Infection Prevention” edited by Dr. Nancy Khardori and Dr. Chand Wattal.
This monograph has been carefully edited to provide a balanced view of
important topics covered by various authors including the editors themselves.
It provides an easy read for both veterans in infectious diseases and those get-
ting introduced to this specialty as beginners. Editors note that this mono-
graph focuses on “nonglamorous” field of infection prevention. While it may
be a design to make the reading less threatening, it is no exaggeration that
infection prevention is one of the most important functions of any healthcare
facility particularly when there is a reflexive tendency to use antibiotics on
slightest pretext.
Both editors have decades of cumulative experience to share with readers.
Dr. Khardori has experience of nearly two decades serving as the Medical
Director at University level besides also serving as the Medical Director for
Infection Control for the state of Illinois. Dr. Khardori is a trained microbi-
ologist as well as an internist with subspecialty training in infectious disease.
She is board certified by the American Board of Internal Medicine in the
subspecialty of infectious disease. Additionally she is qualified by the
American Board of Microbiology.
Dr. Wattal is a physician and a trained microbiologist overseeing the
department of microbiology at Sir Ganga Ram Hospital in New Delhi (India).
He has been successful in creating a unique bench to bedside collaboration in
his institution which makes the microbiology laboratory results very relevant
to patient care. He has been overseeing and upgrading the infection control
service at his institution and providing direction to a number of other institu-
tions around the country. His efforts in infection control won his hospital the
Hospital Management Asia award.
This monograph begins with an overview of microbial world focusing on
various modes of transmission covering organisms such as bacteria, viruses,
mycobacteria, fungi, protozoa, and worms. An entire chapter has been
devoted to vaccination – the most important modality of infection prevention.
This focus often gets a short shrift in many monographs devoted to infection
control. Additionally this monograph provides review of hospital infection
control programs and the associated processes highlighting role of hospital
infection control committee, and its functionaries (epidemiologist, microbi-
ologist, pharmacist, clinicians, and the all important – nursing staff). Given

v
vi Foreword

the editors’ background in microbiology, it is not surprising to see a prominent

section addressing the role of microbiology laboratory in infection preven-
tion. A chapter has been devoted to “antimicrobial stewardship” which is
critical to preventing/reducing emergence of antimicrobial resistance. This
chapter addresses goals of antibiotic stewardship program including role of
interdisciplinary team focusing on formulating and implementing policies
and procedures in a very precise manner. A brief four-step process has been
described.
Issues pertaining to housekeeping, disinfection, and waste management
have been addressed in a very clear and user-friendly manner. Often this
focus is wanting in many monographs of this kind. Processes of decontami-
nation and sterilization have been discussed in appropriate detail. This sec-
tion also covers the controversial issue of reuse of “single-use” medical
devices providing much needed guidance in this area. Focus and emphasis on
the importance of “hand hygiene” in infection prevention have been given its
deserved place.
This text covers individual high-risk areas within the hospital that deserve
special emphasis such as ICUs, dialysis units, operating suits, maternity suits,
and burn units. There is a very effective section dealing with bloodstream
infections and urinary tract infections pertaining to “open ward.”
Overall, I believe the reader will find this monograph as an excellent
resource and update pertaining to infection control programs and practices for
both those entering the field of infection control and those already possessing
expertise in this area.

Eastern Virginia Medical School Edward C. Oldfield III

Sentara Norfolk General Hospital
Norfolk, VA, USA
Preface

“First do no harm” is the operating principle for physicians taking care of

patients in a healthcare setting. This book addresses a potential unintended
event that can occur while receiving healthcare and thus breach this funda-
mental trust. It is outrageous but commonplace to find a patient admitted for
an elective surgery developing urinary tract infection just because a urinary
catheter was placed to facilitate overall care. Unfortunately, the curriculum of
medical graduates or even postgraduates in most of the universities is not
adequate enough to impart knowledge on principles of infection prevention in
day-to-day practice of medicine. Instead, they are expected to memorize a set
of “Infection Control Guidelines.” The misconception in the front lines is that
these guidelines need to be adhered to simply to “stay out of trouble.”
Prevention of infection as the nonglamorous but an integral part of medical
care needs to be understood rather than practiced with automation in order to
get passion into the equation.
This monograph is aimed at blending principles and practices of infection
prevention primarily in hospital settings but also addresses an important area
of prevention, namely, using vaccines, usually ignored, has also been included
for comprehensive reading. It is a paradox that India being the biggest vac-
cine producer for the rest of the world utilizes the same the least for its own
population. The contributors to this monograph are directly involved in the
efforts to reduce morbidity and mortality from hospital-acquired infections.
The vast knowledge and hands-on experience in the principles and practices
of infection prevention for decades are shared in a very reader-friendly man-
ner. The introductory chapter “The Mighty World of Microbes” has tried to
impress as to how extensive the world of microorganisms existing around us
is and provides a rationale for understanding the principles behind practices
of infection prevention. The various practices of infection prevention have
already been laid down by various international bodies to allow an organized
and consistent approach to the complex problem of hospital-acquired infec-
tions. A hospital infection prevention program along with an understanding
of the role of medical microbiology laboratory and an active antibiotic stew-
ardship program can go a long way in making healthcare facilities much safer
than what they are in spite of major advances in managing serious illnesses.
It is essential for prevention of hospital-acquired infections to understand and
implement relevant policies with regard to disinfection and waste manage-
ment by the hospital administrators. The concept of segregation of waste at

vii
viii Preface

the point of its generation has resulted in a sea change in the management and
disposal of hospital waste. While this is being practiced by healthcare work-
ers, it is the moral responsibility of the administrators to provide appropriate
personal protective equipment and facilities especially for hand hygiene to
prevent the healthcare personnel contracting the very diseases that they help
their patients overcome. Often emphasis is laid on environmental monitoring,
whereas enough evidence exists in literature as to where routine environmen-
tal surveillance is not recommended unless there is an outbreak-like scenario.
This monograph has tried to address some of the controversial aspects of
disinfection and sterilization and has tried to take those issues to a logical
conclusion with evidence. It is essential to address in detail the disinfection
and sterilization concepts that need to be pursued with zest and zeal in the
high-risk areas and for procedures conducted on floor by the medical staff.
The training of medical staff should start at the very outset of their profes-
sional career so that routine infection prevention practices can become “habit
forming” if not addictive.
The creation and persistence of antibiotic-resistant bacteria has added a
particularly dangerous dimension to the short falls in infection prevention.
Since we are at the end of the road for search of newer antibiotics, it is the
responsibility of the medical fraternity to preserve such precious and lifesav-
ing reserves like antibiotics. Antibiotic stewardship practiced and accepted at
the institutional level is hallmark of appropriate and long-lasting use of anti-
biotics. This monograph could not have been possible without the participa-
tion of all of its contributors who took upon themselves to share their
experiences. Special thanks are owed to Dr. J. K. Oberoi for the time and
understanding she has contributed to the successful completion of the
first-of-its-kind monograph published in India.

New Delhi, India Chand Wattal

Virginia, USA Nancy Khardori
Contents

Part I The Mighty World of Microbes: An Overview

1 The Mighty World of Microbes:

An Overview .................................................................................. 3
Iass El Lakkis and Nancy Khardori

Part II Vaccinations and Infection Prevention

2 Vaccinations and Infection Prevention........................................ 33

Vivek Kak

Part III Current Practices for Infection Prevention

in the Hospital Settings

3 Current Practices for Infection Prevention

in the Hospital Settings ................................................................. 45
Alice Haynes and Nancy Khardori

Part IV Hospital Infection Prevention Program

4 Hospital Infection Prevention Program ...................................... 55

Pallab Ray and Lipika Singhal

Part V Infection Prevention

5 The Role of Microbiology Laboratory

in Infection Prevention ................................................................. 67
Erin Fortier and Nancy Khardori
6 Role of Antimicrobial Stewardship
in Infection Prevention ................................................................. 73
Thomas J. Lynch, Erin Fortier, Divya Trehan,
and Nancy Khardori

ix
x Contents

7 A Four-Step Approach to Antibiotic Stewardship

in India: Formulation of Antibiotic Policy .................................. 77
Chand Wattal and J.K. Oberoi

Part VI Role of Hospital Housekeeping

and Materials Management Including
Disinfection and Waste Management

8 Role of Hospital Housekeeping

and Materials Management Including Disinfection
and Waste Management ............................................................... 81
Purva Mathur

Part VII Hand Hygiene and Personal Protective Equipment

9 Hand Hygiene and Personal Protective Equipment .................. 93

Arti Kapil

Part VIII Decontamination and Sterilization Procedures

10 Decontamination and Sterilization Procedures .......................... 103

Chand Wattal and J.K. Oberoi

Part IX Monitoring of High-Risk Areas

11 Monitoring of High-Risk Areas: Intensive Care Units .............. 123

B.K. Rao
12 Monitoring of High-Risk Areas: Operating Suite ...................... 127
Jayashree Sood and Chand Sahai
13 Monitoring of High-Risk Areas: Maternity Wards.................... 133
Bhavna Anand and Kanwal Gujral
14 Monitoring of High-Risk Areas: Cancer Wards ........................ 137
Jeewan Garg and Anupam Sachdeva
15 Monitoring of High-Risk Areas: Dialysis Units.......................... 143
Ashwini Gupta
16 Monitoring of High-Risk Areas: Burn Units .............................. 159
Sarika Jain and Rajni Gaind

Part X Infection Prevention for Procedures in Wards

17 Infection Prevention for Procedures in Wards ........................... 169

Sushant Wattal and Neeraj Goel
 Part I
The Mighty World of Microbes:
An Overview
 The Mighty World of Microbes:
An Overview 1
Iass El Lakkis and Nancy Khardori

The Microbial World bial cells than the number of human cells in the
On and Around Us entire body. The understanding of the relation-
ship between microbes and humans is at best
The world of microbes on our planet is vast and rudimentary at this point in time. Similarly, the
diverse. This includes the normal bacterial flora relationship between humans and microbes in
present on the skin and mucous membranes of the environment and environmental surfaces is
humans. The human microbiome project (HMP) poorly understood except for a few pathogenic
was launched by NIH in 2007 as a part of a road microbes.
map for medical research. The HMP serves as a The most well-studied host-associated
template for researchers who are studying more microbes are those in the gastrointestinal tract.
than 1,000 microbial genomes with a focus on In the area of infectious diseases and infection
their role in health and disease. The study sam- control, we typically look at individual diseases
ples have been derived from five human body caused by single organisms. Conventionally
regions that are known to be inhabited by micro- microbes are thought of as bad actors because
bial flora. These include the gastrointestinal the emphasis is on disease rather than interaction
tract, female urogenital tract, mouth, nose, and between human and microbial cells. The protec-
skin. The techniques being used include finger tive role of a large number of bacterial species
printing, sequencing, dynamic range, and com- that exist on and around us has largely been
parison of multiple samples. It is now well minimized. In fact, these bacteria should be
accepted that there are more microbial cells than referred to as “Nature’s Bioshield.” Their associ-
human cells in the human body. Just the gastro- ation with the areas they were put in by nature is
intestinal tract harbors more than tenfold micro- strong and symbiotic. Since they are common to
healthy individuals, their transmission from
I. El Lakkis, M.D.
person to person is of no relevance. We know now
Division of Infectious Diseases, Department that the disruption of this bioshield by physical
of Internal Medicine, Eastern Virginia Medical School, injury and its alteration by the selection process
Norfolk, VA, USA from antibiotic use are the most significant risk
N. Khardori, M.D., Ph.D. (*) factors for developing infectious diseases includ-
Division of Infectious Diseases, Department ing those caused by multiple antibiotic-resistant
of Internal Medicine, Eastern Virginia Medical School,
Norfolk, VA, USA
bacteria and their transmission to others in the
health-care as well as community settings.
Department of Microbiology and Molecular Cell
Biology, Eastern Virginia Medical School,
The transmission from person to person was
Norfolk, VA, USA proven even before the germ theory of disease was
e-mail: nkhardori@gmail.com proven. For example, in 1841, Ignaz Semmelweis,

C. Wattal and N. Khardori (eds.), Hospital Infection Prevention: Principles & Practices, 3
DOI 10.1007/978-81-322-1608-7_1, © Springer India 2014
4 I. El Lakkis and N. Khardori

a Hungarian physician, attempted to mandate hand

washing and change of coats used in autopsy Box 1.1
rooms before examining patients or performing
Loeffler’s postulate Koch’s postulate
deliveries. He believed that invisible agents can be
1. The organisms must be 1. The same organism
transferred particularly from autopsy room to shown to be constantly must be present in
delivery room thus infecting mothers during present in characteristic every case of the
birthing. He built this belief from his observation form and arrangement in disease
that the death rates in the ward that was run by the disease tissue
physicians were 18 % more than that in the ward run 2. The organisms, which 2. The organism must
from their behavior be isolated from
by midwives. He contributed that to the fact that appear to be responsible the diseased host
physicians were working in autopsy rooms and the for the disease, must and grown in pure
midwives were not. Also one of his colleagues be isolated and culture
died after he cut himself during an autopsy on a cultivated in purity
3. The pure cultures 3. The isolate must
patient who had died from puerperal fever/sepsis.
must be shown to cause the disease,
His colleagues did not accept the concept despite include disease when inoculated
the fact that the death rate in the hospital dropped experimentally into a healthy,
by 66 % after applying the two interventions. It is susceptible animal
difficult to comprehend why Dr. Semmelweis 4. The organism must
be reisolated from
faced opposition despite the success of his the inoculated,
measures. The question was and remains today: diseased animal
Is it hard to apply these practices or are we not
able to meaningfully convey the principles?
Historically, the concept of cleaning and sani-
tizing was practiced long before the germ theory were being conceived also. Joseph Lister and
was conceived, it is all about cleaning. Even the John Snow contributed significantly to the accep-
theories developed in the middle ages about clean- tance of germ theory.
ing said that diseases were caused by the presence A century and quarter later, everybody seems
of “miasma” in the air. Miasma is a poisonous to agree with the importance of prevention and
vapor with a foul smell. This theory encouraged its application but the compliance is still an issue.
people to get rid of the foul smell by cleaning Perhaps this is because the consequences of
which helped decrease the rate of diseases by noncompliance are not obvious right away and it
getting rid of what later was named as germs. is hard to point to a single action that caused the
It was the effort of many scientists to develop incident. It is a fact that those we ask to comply
and prove the germ theory. The first step was with infection prevention practices do not have
taken by Antoni Van Leeuwenhoek who saw tiny a clear understanding of the microbial world
structures under the microscope in 1677 and at large and therefore the principles. This has made
called them “animalcules.” it difficult and at times impossible to have an
The germ theory of disease was well estab- optimal adherence with these practices. We believe
lished in the early 1880s based on Robert Koch’s that it is absolutely necessary to convey to
published work on tubercle bacillus. In 1882, one health-care providers of all levels the significance
of his assistants Friedrich Loeffler published the of the microbial flora on and around us, the
three postulates that need to be fulfilled to estab- factors that put them at risk for acquiring and
lish an association between a microbe and a dis- subsequently transmitting disease-causing patho-
ease process (Box 1.1). These postulates were gens to patients at high risk of developing infec-
formalized by Koch himself between 1884 and tious processes due to multiple factors including
1890. Concurrent with establishing the pathoge- age, immunocompromise, and comorbid condi-
nicity of the limited number of bacteria, the tions. With that in mind the rest of this chapter
transmission pathways and their interruption will provide an overview of bacteria, viruses,
1 The Mighty World of Microbes: An Overview 5

prions, fungi, and parasites with focus on In contrast, gram-negative bacteria have a thin
modes of transmission and therefore the modes layer of peptidoglycan, are decolorized after
of prevention of transmission. The details of the the initial staining by crystal violet, and take the
procedures to reduce transmission in the health- counter stain safranin. These bacteria acquire
care settings will be provided in the following pink in color and are classified as gram negative.
chapters. The bacteria of clinical relevance are further
classified based on their morphology that is
spherical or cocci or rod shaped or bacilli. The
Pathogenic Bacteria and Their cocci can be present in clusters such as staphylo-
Modes of Transmission cocci or in chains such as streptococci. The third
level of classification is based on the growth
Bacteria by definition lack membrane-enclosed under aerobic and anaerobic conditions. Most
nucleus and membrane-enclosed organelles like aerobic bacteria are able to also grow under
mitochondria and chloroplast. They have double- anaerobic condition and are facultative anaer-
stranded DNA and a cell wall made of peptido- obes. Obligate anaerobes, on the other hand,
glycan. Based on the amount of the peptidoglycan grow only in the absence of oxygen. Further
in the cell wall, bacteria will retain crystal violet identification to the genus and the species level
during the gram-staining process and not get is determined by biochemical reactions (pheno-
decolorized which gives them a purple color and typic characteristics) and/or molecular tech-
therefore are classified as gram-positive bacteria. niques (genotypic characteristics).

Gram-Positive Bacteria

Gram-positive Gram-positive Gram-positive Gram-positive

aerobic cocci anaerobic cocci aerobic bacilli anaerobic bacilli
Staphylococcus Peptostreptococcus Bacillus Clostridium
Streptococcus Peptococcus Corynebacterium Actinomycete
Enterococcus Listeria
Nocardia

Aerobic Gram-Positive Cocci are the skin and soft tissue; however, infection
Staphylococci are aerobic/facultatively anaerobic can become disseminated, causing bloodstream
gram-positive cocci that are not motile and do not infection and multiple organ involvement includ-
form spores. Of the 31 species recognized, ing endocarditis. The point of entry of S. aureus
Staphylococcus aureus and Staphylococcus maybe obvious such as folliculitis or maybe
intermedius produce the enzyme coagulase related to skin disruption which is not obvious.
which helps in their identification and is also a In addition, S. aureus can colonize devices
virulence factor. following transcutaneous insertion producing a
S. aureus colonizes the skin and mucous biofilm on the device with subsequent potential
membranes of 30–50 % of healthy adults and for bloodstream infection and dissemination.
children, most commonly in the anterior nares, The ingestion of food contaminated with
skin, vagina, and rectum [1]. In addition to coag- S. aureus can cause food poisoning due to the
ulase, S. aureus has a number of virulence factors presence of preformed enterotoxin.
including exotoxins such as enterotoxin, exfolia- Transmission of S. aureus occurs primarily
tive toxin, and toxic shock syndrome toxin 1. The by contact with the skin of colonized people
primary sites of infections caused by S. aureus and/or environmental surfaces which have been
6 I. El Lakkis and N. Khardori

contaminated by colonized people. Colonized S. pyogenes, group A (GAS), β-hemolytic, is a

personnel in the health-care setting serve as common cause of pharyngitis and impetigo.
reservoir for S. aureus transmission to patients S. pyogenes contains cell wall M protein which is
and to the surfaces. However, transmission is an important virulent factor and induces cross-
common even in the community setting. The reactive antibodies leading to nonsuppurative
best example is the recent significant increase in complications of rheumatic fever and glomerulo-
the community-associated skin and soft tissue nephritis. It can occasionally colonize the respi-
infections caused by S. aureus clone 300. Food ratory tract and the skin. It can be transmitted
contaminated by dietary personnel has been from person to person through respiratory drop-
implicated in staphylococcal food poisoning. lets to cause pharyngitis or through a break of the
Transmission of S. aureus can be reduced by skin after direct contact to an infected person,
hand hygiene and decontamination of environ- fomite, or arthropod vector to cause skin
mental surfaces. infection. Nosocomial transmission of GAS to or
Coagulase-negative staphylococci (CNS) are by personnel can be prevented by hand hygiene
present on the skin of all humans and are the and other practices including standard precau-
most abundant constituent of the normal flora at tions that should be used for every patient con-
this site [2]. If and when CNS enter the blood- tact. Other transmission-based precautions may
stream, e.g., through insertion of medical be needed under special circumstances and
devices, they can cause bloodstream infection, outbreak situations.
endocarditis in patients with prosthetic valves, S. agalactiae, group B (GAS), β-hemolytic,
infections of pacemakers and intravascular can cause urinary tract infection, postpartum
catheters, and other foreign bodies in place. endometritis, and bacteremia in pregnant women
Staphylococcus epidermidis accounts for about and sepsis and meningitis in neonates. Recently it
half of resident staphylococci and majority of has been recognized as an important cause of
the isolates in clinical blood specimens [3]. sepsis in nonpregnant adults especially those with
Other clinically significant species include diabetes mellitus [4]. It can be a part of the flora of
S. saprophyticus, which causes urinary tract the upper respiratory tract and genitourinary
infection in young sexually active women, and tract. The transmission of GBS from the mother’s
S. lugdunensis which cause endocarditis, osteo- vaginal flora to the newborn during delivery is
myelitis, and septicemia. S. hominis, S. haemo- clearly understood. This has lead to the practice of
lyticus, S. warneri, and S. simulans are rarely surveillance cultures for GBS in vaginal flora
isolated as pathogens. The most optimal way during antenatal care. There are clear guidelines
to prevent infections by CNS is hand hygiene, to manage GBS colonization in pregnant women
effective skin antisepsis, and barrier precautions prior to and during delivery in order to prevent its
during procedures outside the operating room. transmission to the newborn.
Streptococci are facultatively anaerobic Group C and group G (S. dysgalactiae) are
gram-positive cocci that form pairs or chains. β-hemolytic streptococci that can cause pharyn-
Different species cause different infections, so it gitis and cellulitis clinically indistinguishable
is important to know the classification. The clas- from GAS disease although they are more com-
sification does not depend on a single factor but monly opportunistic and nosocomial pathogens.
rather it depends on different factors including These similarities can be explained by the shar-
hemolytic reaction on blood agar, serologic ing of a number of virulence factors with GAS
specificity of cell wall (Lancefield classifica- like streptolysin and antigens similar to M pro-
tion), and biochemical characteristics. tein. They can be part of the normal human flora
The serological classification (Lancefield and the transmission is similar to that for GAS.
classification) depends on the carbohydrate anti- Viridans streptococci like S. mitis, S. sanguis,
gen in the cell wall based on which streptococci and S. salivarius are α-hemolytic and are members
are classified into (A, B, C, etc.). of the upper respiratory tract flora and can cause
1 The Mighty World of Microbes: An Overview 7

transient bacteremia which makes them the Aerobic Gram-Positive Bacilli

principal cause of endocarditis on abnormal heart Bacillus species are aerobic spore-forming
valves. S. mutans produces polysaccharide that gram-positive rods occurring in chains. They are
contributes to the genesis of dental caries. saprophytic organisms prevalent in soil, water,
S. pneumoniae is α- or nonhemolytic which can and air. The principle pathogens of this genus are
cause pneumonia, meningitis, endocarditis, and B. anthracis and B. cereus. B. anthracis causes
disseminated infection. These bacteria are ubiq- anthrax which occurs when the spores are
uitous. Most infections are caused by spread introduced cutaneously or through inhalation.
from colonized nasopharynx or oropharynx to dis- The inhalation form is more serious but both
tal sites (lung, blood, meninges). Person-to-person forms can be complicated by systemic disease
spread through respiratory droplets is rare. and meningitis. In 2001, 22 cases occurred due
S. bovis (formerly called nonenterococcal to bioterrorist attacks through contaminated
group D streptococci) are nonhemolytic and can envelopes which brought awareness to this old
cause endocarditis and are commonly isolated in pathogen since it was rarely seen in the United
blood in patients with colon cancer. It can colo- states from 1980 to 2000 [6]. B. cereus is known
nize the lower gastrointestinal tract and rarely the to cause food poisoning and occasionally can
upper gastrointestinal tract. cause bacteremia. This is a challenging diagnosis
Enterococci (formerly called group D strepto- as Bacillus species are common contaminants in
cocci) are gram-positive cocci of intestinal blood cultures and only 5–10 % present blood-
origin that usually form short chains. They are a stream infection [7].
part of the gastrointestinal flora which is the com- Corynebacterium: C. diphtheria is the most
monest source of infections caused by enterococci. important member of the group and can cause
Rarely person-to-person spread can occur. The respiratory and cutaneous disease. Asymptomatic
infections caused by enterococci include endo- carriers accounts for 5 % of the population and
carditis, urinary tract infection, wound infection, are important for the transmission of the disease
biliary tract infection, and bacteremia. E. faecalis [8]. It secretes a toxin that inhibits protein syn-
in the most common species and causes 85–90 % thesis and has necrotizing and neurotoxic effect.
of enterococcal infections, while E. faecium Treatment of the carriers and isolation of infected
causes 5–10 %. Some of enterococci, especially patients are important measures for the preven-
E. faecium, are vancomycin resistant. In the United tion of transmission, but the toxoid-based vacci-
States, 80 % of E. faecium and 6.9 % of E. faecalis nation is the key to the decrease in the incidence
were resistant to vancomycin between 2006 and of diphtheria.
2007 [5]. Vancomycin-resistant enterococci (VRE) Listeria species are facultative, motile, non-
are often multidrug-resistant bacteria, and contact spore-forming gram-positive rods. L. monocyto-
precaution is applied in the hospital settings for genes is the most common and can cause a wide
prevention of transmission. spectrum of diseases. It enters through gastroin-
testinal tract and can cause food-borne infections
Anaerobic Gram-Positive Cocci (1 % of cases of food-borne infections [9]).
Peptococci are obligate anaerobic gram-positive It can cause septicemia, meningitis, or encephali-
cocci. These bacteria are part of the flora of the tis especially in immunocompromised, pregnant
mouth, upper respiratory tract, and large intes- women, elderly, and neonates.
tine. They can cause soft tissue infection and Nocardia asteroides complex is the species
bacteremia. that is responsible for the majority of the cases of
Peptostreptococci are obligate anaerobic gram- nocardiosis. They are aerobic gram-positive rods
positive cocci that is α- or nonhemolytic. These but they are also weak acid-fast. Nocardia are
bacteria are part of the normal flora on the skin found in soil and water and are not transmitted
and mucous membranes. They can cause abscesses from person to person. Nocardiosis is an opportu-
mostly in association with other bacteria. nistic infection associated with impaired cellular
8 I. El Lakkis and N. Khardori

immunity. It causes chronic pneumonia which which can cause rapid and significant damage to
can mimic tuberculosis and can spread from lung the muscles and soft tissues which can rapidly
to brain and form abscesses. Disseminated form progress to shock and death. In the other hand,
can spread to skin, kidney, bone, and other ingesting secreted enterotoxin can cause self-
systems. limited diarrhea.
C. difficile causes pseudomembranous colitis in
Anaerobic Gram-Positive Bacilli patients with exposure to antibiotics. It secretes
Clostridium species are anaerobic spore-forming toxin A and toxin B which are responsible for the
large gram-positive rods which are also sapro- disease. Hand washing with soap and water is the
phytic organisms found in the soil and the intes- only effective way to prevent transmission from
tinal tract of animals and humans. Among the patient to patient in the hospital setting. Alcohol-
pathogens is C. botulinum that causes food poi- based hand hygiene products do not kill C. difficile
soning mostly from the canned foods that leads spores.
to flaccid paralysis due to the blocking effect of Actinomyces are non-spore-forming branching
the toxin on the acetylcholine release in the syn- anaerobic filamentous gram-positive bacilli that
apse of the neuromuscular junctions. C. tetani readily fragment into bacillary forms. They repro-
causes tetanus which is a tonic contraction of the duce by binary fission, a feature that differentiates
muscles as the toxin blocks the release of the them from fungi [10]. Most are saprophytes and
inhibitory mediators like gamma-aminobutyric live in soil, but members of this group are respon-
acid. Both pathogens act through their toxins and sible for actinomycosis.
are associated with high mortality. C. botulinum Actinomyces israelii is responsible for most of
spores are highly resistant to heat and 20 min of the cases of actinomycosis. It is a part of the
boiling is needed to destroy these spores. For human oral flora. It causes chronic disease char-
tetanus, the toxoid-based vaccination is the key acterized by abscess formation, draining sinus
for prevention. tracts, fistulae, and tissue fibrosis. Cervicofacial
C. perfringens can cause myonecrosis and form accounts for half of the cases and also can
gas gangrene when introduced into damaged tis- manifest as central nervous system, thoracic,
sue. The effect is through alpha and theta toxins abdominal, and pelvic infections [11].

Gram-Negative Bacteria

Gram-negative Gram-negative Gram-negative Gram-negative

aerobic cocci anaerobic cocci aerobic bacilli anaerobic bacilli
Neisseria Veillonella Enterobacteriaceae Bacteroides
Moraxella Pseudomonas
Haemophilus
Brucella
Bordetella
Legionella
Chlamydia
Mycoplasma
Rickettsia
1 The Mighty World of Microbes: An Overview 9

Aerobic Gram-Negative Cocci Moraxella catarrhalis is an aerobic gram-

Neisseria are aerobic or facultatively anaerobic negative diplococcus that is an exclusive human
gram-negative diplococci. N. meningitidis and pathogen involving the upper respiratory tract.
N. gonorrhoeae are pathogenic for humans which Most children have upper respiratory tract colo-
are the only host and typically are found associ- nization at some point in the first several years of
ated with or inside polymorphonuclear cells. life. Colonization is uncommon in healthy adults,
Other Neisseria species are normal inhabitants of occurring in approximately 1–5 % of individuals
the upper respiratory tract; they are extracellular [12]. It is a common cause of otitis media in
and rarely cause disease. children and acute exacerbations in adults with
N. meningitidis can be subdivided into sero- chronic obstructive pulmonary disease.
groups based on distinct capsular polysaccha-
rides. Eight serogroups most commonly cause Anaerobic Gram-Negative Cocci
infections in humans (A, B, C, X, Y, Z, W135, Veillonella are small anaerobic gram-negative cocci.
and L). The organism is considered a respiratory They are part of the normal flora of the mouth,
pathogen and spread by the aerosol route. It is nasopharynx, and the intestine. Though occasionally
clear that the high attack rates seen in the less isolated in polymicrobial anaerobic infections, they
developed countries are in part due to poverty are rarely the sole cause of infection.
and a consequence of crowding, poor sanitation,
and malnutrition. Infection can produce a variety Aerobic Gram-Negative Bacilli
of clinical manifestations, ranging from transient Enterobacteriaceae are aerobic (facultative
fever and bacteremia to meningitis and fulminant anaerobic) non-spore-forming gram-negative
disease with death ensuing within hours of the bacilli. Some enteric organisms like Escherichia
onset of clinical symptoms. coli are part of the normal flora and incidentally
CDC recommends two doses of MCV4 (the vac- cause disease, while others like Salmonellae and
cine that covers serotypes A,C,Y, and W135) for Shigellae are enteric pathogens for humans.
adolescents aging from 11 to 18 years, the first dose E. coli, Proteus, Enterobacter, Klebsiella,
at 11 years of age with a booster dose at age 16. Morganella, Providencia, Citrobacter, and Serratia
For chemoprophylaxis, CDC recommends for are members of the normal intestinal flora and
adults or children who within 7 days prior to the can be a part of the normal flora of the upper
onset of meningococcal disease lived or slept in respiratory and genital tracts. They can be recov-
the same household as the patient, have been con- ered from the gastrointestinal tract of cattle
tacts in the day care center, or directly exposed to and other mammals, soil, sewage, aquatic envi-
the patient’s oral secretions (e.g., through kiss- ronment, contaminated food, water, and medical
ing, mouth-to-mouth resuscitation, endotracheal environment. They can be transient residents
intubation, or endotracheal tube management). on the hands of health-care workers. They are
For health-care settings, patients infected with transmitted by “food, fingers, feces, and flies” from
N. meningitidis are rendered noninfectious by person to person, and health-care workers play a
24 h of effective therapy. Personnel who care for significant role in the hospital setting.
patients with suspected N. meningitidis infection They can cause hospital- and community-
can decrease their risk of infection by adhering to acquired infections, and some of them like Serratia
droplet precautions. Postexposure prophylaxis is and Enterobacter are considered opportunistic
advised for persons who have had intensive, pathogens. They cause urinary tract infection,
unprotected contact (i.e., without wearing a mask) pneumonia, bacteremia, wound infections, and
with infected patients, e.g., mouth-to-mouth meningitis. Some E. coli strains can cause diar-
resuscitation, endotracheal intubation, endotra- rheal diseases, e.g., enterotoxigenic E. coli that
cheal tube management, or close examination of causes traveler’s diarrhea due to exotoxins and
the oropharynx of patients. enterotoxins and enterohemorrhagic E. coli that
10 I. El Lakkis and N. Khardori

causes hemorrhagic diarrhea due to the shiga-like Salmonella: Although there are many types of
toxin, among which the serotype O157:H7 can be Salmonella, they can be divided into two broad
associated with hemorrhagic uremic syndrome. categories: those that cause typhoid and enteric
Association for Professionals in Infection fever and those that primarily cause gastroenteri-
Control and Epidemiology (APIC) recommends tis. The typhoidal Salmonella, such as S. typhi
hand washing, alcohol-based hand hygiene, bar- and S. paratyphi, have a high host specificity for
rier protection, proper maintenance of equip- humans. Infection virtually always implies con-
ment, and education as measures to prevent tact with an acutely infected individual, a chronic
transmission. carrier, or contaminated food and water. In the
CDC recommends personal hygiene including United States, typhoid fever has become less
hand washing, cooking meat thoroughly, avoid- prevalent and is now primarily a disease of travel-
ing consuming raw milk and unpasteurized dairy ers and immigrants. The much broader group of
products, and avoiding swallowing water during nontyphoidal Salmonella is a common cause of
swimming. food-borne gastroenteritis worldwide, particu-
In case of multiresistant bacteria contact, iso- larly in outbreak settings. Traditionally infection
lation should be performed to prevent transmis- has been associated with raw meat or poultry
sion from one patient to another by applying products and improperly handled food that has
hand hygiene and using gloves and gowns. been contaminated by animal or human fecal
Shigellae are limited to the intestinal tract of material or via the fecal-oral route, from other
humans and other primates. Infections are almost humans or farm or pet animals [15].
always limited to the gastrointestinal tract. The Enteric (typhoid) fever can be complicated
infective dose is low at 10–100 organisms, with intestinal bleeding and perforation due to
whereas it usually is 105–108 for Salmonella and the ileocecal lymphatic hyperplasia. It is usually
Vibrio [13]. They are also transmitted by “food, manifested by fever, bradycardia, abdominal
fingers, feces, and flies” from person to person. pain, and faint rash. Symptoms gradually resolve
Infections occurred most frequently among over weeks to month.
children in daycare centers. CDC, besides hand hygiene, recommends
Shigella causes diarrhea that is most of the times that people should avoid eating raw or under-
self-limited, and on recovery most persons shed the cooked eggs, poultry, or meat. People who have
bacteria for a short period but few remain chronic salmonellosis should not prepare food for oth-
intestinal carriers. S. sonnei commonly causes mild ers until their diarrhea has resolved. Many
disease which may be limited to watery diarrhea, health departments require that restaurant
while S. dysenteriae or S. flexneri causes dysenteric workers with Salmonella infection have a stool
symptoms (bloody diarrhea) [14]. test showing that they are no longer carrying
CDC recommends hand washing after going the Salmonella bacterium before they return
to the bathroom, after changing diapers, and to work. Reptiles and birds (especially baby
before preparing foods or beverages and super- chicks) are particularly likely to have Salmonella,
vising hand washing of toddlers and small chil- and it can contaminate their skin. Everyone
dren after they use the toilet. Keeping children should immediately wash their hands after
with diarrhea out of child care settings and not to touching them, and they are not appropriate
prepare food for others while ill with diarrhea are pets for small children and should not be in a
also recommended. house that has an infant.
It is important to report the cases of shigellosis Pseudomonas aeruginosa is a gram-negative
to the public health department. If many cases aerobic bacillus. The organism is common in
occur at the same time, it may mean that a the environment, especially in water, even con-
restaurant or food or water supply has a prob- taminating distilled water [16]. It is also the cause
lem that needs correction by the public health of infections associated with hot tubs and con-
department. taminated contact lens solutions. Considerable
1 The Mighty World of Microbes: An Overview 11

attention is paid to P. aeruginosa as a potential through f) and non-encapsulated forms (nontype-

pathogen in hospitals because reservoirs for able). The most important serotype is H. influenzae
infection can develop, especially in intensive care serotype b (Hib), which was a frequent cause of
units. The organism is an opportunistic pathogen bacteremia, meningitis, and other invasive infec-
for immunocompromised hosts. tions prior to the routine use of Hib conjugate
Historically, P. aeruginosa has been a major vaccines in children. Other capsular serotypes
burn wound pathogen, an agent of bacteremia in and unencapsulated H. influenzae strains can also
neutropenic patients and the most important cause disease, mainly mucosal infections (sinusitis,
pathogen in cystic fibrosis patients. It can infect otitis, bronchitis) but occasionally cause more
many organs; it is the second most common invasive infections.
cause of nosocomial pneumonia (17 %), the third Hib vaccine induces antibodies to the type b
most common cause of urinary tract infection capsular polysaccharide; it is highly protective
(7 %), the fourth most common cause of surgical and is recommended by CDC for all children
site infection (8 %), the seventh most frequently younger than 5 years old. It is usually given to
isolated pathogen from the bloodstream (2 %), infants starting at 2 months old.
and the fifth most common isolate (9 %) overall Chemoprophylaxis is recommended for
from all sites [17]. household contacts defined as persons residing
CDC recommends contact precaution in with the index patient or nonresidents who cumu-
addition to standard precaution if the organ is latively spent 4 or more hours with the index case
resistant to multiple antibiotic classes. for at least 5 of the 7 days prior to the day of
Multidrug-resistant Pseudomonas aeruginosa hospital admission and there is a member of the
and Acinetobacter baumannii are becoming contact’s household who is younger than 4 years
increasingly important nosocomial pathogens of age and is unimmunized or incompletely
worldwide. To study the evolution of non- immunized or is an immunocompromised child,
fermenters in a tertiary care hospital, a 10-year regardless of the child’s immunization status.
(1999–2008) retrospective trend analysis of anti- Brucella are small, gram-negative, nonmo-
microbial consumption and resistance in non- tile, facultative, intracellular aerobic rods.
fermenters causing bacteremia was undertaken. Brucellosis is a zoonotic infection transmitted
A significant increase in resistance in A. baumannii to humans by contact with fluids from infected
to fluoroquinolones (r2 = 0.63, P = 0.006), amino- animals (sheep, cattle, goats, pigs, or other ani-
glycosides (r2 = 0.63, P = 0.011), and carbapenems mals) or through food products such as unpas-
(r2 = 0.82, P = 0.013) and in P. aeruginosa to amino- teurized milk and cheese. It is one of the most
glycosides (r2 = 0.59, P = 0.01) was observed. widespread zoonosis worldwide [19]. Clinical
Carbapenem consumption was associated with manifestations of brucellosis include fever,
the development of resistance in A. baumannii night sweats, malaise, anorexia, arthralgias,
(r = 0.756, P = 0.049), whereas no such association fatigue, weight loss, and depression. It can
was observed for other antimicrobials among become chronic and is characterized by local-
non-fermenters [18]. ized infections like spondylitis, osteomyelitis,
Haemophilus is a facultative anaerobic pleo- tissue abscesses, and uveitis.
morphic gram-negative rod occurring in pairs or Bordetella pertussis causes pertussis, also
short chains. H. influenzae type b is an important known as “whooping cough” which is a highly
human pathogen. H. ducreyi, a sexually transmit- contagious, acute respiratory illness. In the pre-
ted pathogen, causes chancroid. Other species are vaccine era, the disease predominantly affected
among normal flora of mucous membranes and children less than 10 years of age and usually
only occasionally cause disease. Humans are the manifested as a prolonged cough illness with one
only known reservoir. or more of the classical symptoms, including inspi-
H. influenzae is transmitted by respiratory ratory whoop, paroxysmal cough, and post-tussive
droplet spread. It has encapsulated (serotypes a emesis [20]. Since the introduction of pertussis