|
 
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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 6
| Issue : 2 | Page : 45-52 |
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An overview evaluation of bacterial infection and bacterial contamination at the hospital environment and antibiogram for the isolated pathogens at Al Kufra Teaching Hospital, Libya
Ismaeel H Bozakouk1, Alabirsh N Hussein2, Iain R L. Kean3, Mohammed M Bumadian1, Abubaker S Toboli4
1 Department of Microbiology, Faculty of Science, Benghazi University, Benghazi, Libya
2 The Medical Services Office, Ministry of Health, Al Kufra, Libya
3 Department of Paediatrics, University of Cambridge, Box 116, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, Libya
4 Department of Microbiology, Faculty of Medicine, Benghazi University, Benghazi, Libya
| Date of Submission | 10-May-2022 |
| Date of Acceptance | 26-Oct-2022 |
| Date of Web Publication | 02-Jan-2023 |
Correspondence Address:
Dr. Ismaeel H Bozakouk
Department of Microbiology, Faculty of Science, Benghazi University, Benghazi
Libya
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ljms.ljms_25_22
Background/Aims: Infectious diseases are the major public health problem worldwide. The medical services into the Southern Libyan sub-Saharan hospitals do not receive much attention in knowing the infection rates of pathogenic bacteria coming to the hospital, as well as there is not much information available about the hospital infection control application system. This study was performed to evaluate the infectious disease received to Al Kufra teaching hospital and determination the hospital risk factors involved in hospital-acquired infection. Materials and Methods: The screening was performed to investigate the distribution of potential pathogens among 157 samples collected from the four hospital wards including intensive care unit, the pediatric ward, male and female surgical ward from the hospitalizes patients, medical staff and hospital workers, and across different hospital facilities. Results: The bedsores swabs and urine samples showed 100% of infection, followed by sputum, stool, surgical wounds, and cerebrospinal fluid (85.8%, 67%, 62.5%, and 42.9%), respectively. Most of the hospital facilities showed 100% of contamination. The results showed Staphylococcus aureus colonized 40 (77%) of the total nasal swabs, other samples detected Bacillus cereus, Streptococcus pneumoniae, Pseudomonas aeruginosa, Enterococcus faecalis, Escherichia coli 0157. The sensitivity of Gram-positive organisms to the antibiotics showed resistance to Penicillin G (90.1%) and Amoxicillin + Clavulanic acid (82.7%), Methicillin (65.5%) and Vancomycin (65.5%). For Gram-negative organisms, the isolates showed resistance to tetracycline and colistin (62.5%) for each. Conclusion: The bacterial outbreak in the clinical and environmental samples of Al Kufra Teaching Hospital was relatively high. To control bacterial infection and hospital contamination, several instructions need to be carried out to protect the hospital staff and patients from being infected.
Keywords: Al Kufra, bacterial infection, hospital environment, infectious diseases, Libya, Staphylococcus aureus
How to cite this article:
Bozakouk IH, Hussein AN, L. Kean IR, Bumadian MM, Toboli AS. An overview evaluation of bacterial infection and bacterial contamination at the hospital environment and antibiogram for the isolated pathogens at Al Kufra Teaching Hospital, Libya. Libyan J Med Sci 2022;6:45-52 |
How to cite this URL:
Bozakouk IH, Hussein AN, L. Kean IR, Bumadian MM, Toboli AS. An overview evaluation of bacterial infection and bacterial contamination at the hospital environment and antibiogram for the isolated pathogens at Al Kufra Teaching Hospital, Libya. Libyan J Med Sci [serial online] 2022 [cited 2023 Mar 29];6:45-52. Available from: https://www.ljmsonline.com/text.asp?2022/6/2/45/366077 |
| Introduction | |  |
Bacteria naturally present in the human body as a normal flora, some of which are found on the skin, respiratory system, genitourinary system, and gastrointestinal system; these bacteria may have a protective benefit for the host.[1] However, in special circumstances, some of these bacteria possess opportunistic pathogenic properties that may cause disease during their entry into the host's body. The flayer of the body's defences lead to infection development that may end up with a possible death.[2] The severity of bacterial infection depends on many aspects including the pathogenicity of bacteria causing the infection, health of the patient and factors that promote bacterial infection including the hospital environment that incubating the endemic pathogens and the applied strategies that control hospital-acquired infections.[3] The diversity of bacterial infectious diseases that come to the hospital depends on the body site of infection as well as on the type of infection. Patients accumulating microbial diseases who visit the hospital for treatment are representing the main source for increasing of bacterial diversity into the hospital environment, thus bacterial endemicity leading to a potential way of transmitting infection to other patients, taking into account the lack of health care services.[4],[5] Residency of the patients into the hospital for more than 72 h is considering the risk factor for potential hospital-acquired infection through contaminated hands of the medical care staff during normal clinical activities.[6],[7] The most frequent bacteria involved in the hospital environment contamination are including Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.[8],[9] The practical reports received regarding the microbial assessment of infectious diseases of patients attending to the Al Kufra Teaching hospital, as well as the assessment survey of microbes contaminating the hospital environment are very limited and unclear. This study was performed to educate bacterial infection investigation and to provide the better understanding of hospital-acquired management at Al Kufra Teaching hospital.
| Materials and Methods | | |
Sampling and the study area
This study was undertaken at the Libyan South Sahara general hospital named "The Maryr Al-Kasch Teaching Hospital Al Kufra" in Al Kufra city. The medical samples were collected after approval statement provided by the medical ethics using standard methods as instructed by the hospital infection control unit. The collection was targeted clinical samples randomly selected from patients who attended to the hospital with symptoms diagnosed with bacterial infections from different body sites including surgical wounds, pressure ulcers (bedsores), cerebrospinal fluid (CSF), sputum, urine, and stool samples. In order to determine the individual's carriers, the contamination in the hospital environment and consider it as a source of infection; the investigation was performed by collecting the nasal and hand swab samples from the admitted patients and from the medical care staff using the sterile cotton swabs. The investigation was also performed to collect the samples and from different locations into the hospital including air, floor, tables, and beds sheets, as well as from different equipment including stethoscopes, thermometers, and sphygmomanometers. The investigation was covered the four hospital wards including the intensive care unit (ICU), pediatric ward (PW), male surgical ward, and female surgical ward (FSW).
Microbiological investigation
]After samples collections, the clinical samples were screened by the microscope for evidence of microbial infection. The swab samples were enriched by inoculation into 10 ml of Thioglycolate Broth followed by immediate transportation to the hospital central laboratory for microbiological investigation and incubated aerobically at 37°C for overnight. Next day, the enrichment cultures were sub-cultured for single colonies using MacConkey agar, Blood agar, and Chocolate agar. For the isolation of stool pathogens, small portion of fresh stool samples was first inoculated into Selenite Broth and then incubated at 37°C for overnight, next day, the Broth cultures were sub-cultured on SS agar and on Sorbitol MacConkey agar plates. The urine samples were cultured on Blood and MacConkey agar followed by incubation aerobically at 37°C for overnight.
Identification of the isolated pathogens
The microbial cultures that showed more than one microbe, distinct colonies of each type were isolated by repeat culture on fresh selective agar. Pure cultures were used as microbial stocks for bacterial identification and performing antimicrobial-susceptibility testing. The microbial isolates were characterized morphologically for size, shape, color, hemolysis resection, and substrate utilization. Cellular morphology was observed on Gram-stained samples. The bacterial identification scheme was performed in the comparison between the morphological and biochemical characters according to Bergey's Manual of Systematic Bacteriology.[10] For bacterial isolation and identification, the selections of culture media were used including Triple sugar iron agar, Simmon's citrate agar, urease agar and Sulfur indole motility agar, DNase agar and Mannitol salt agar. Evaluation of the enzymatic reaction was performed using oxidase test, catalase test, and coagulase test. Isolates identification was confirmed using Automated Phoenix 100 System (BD), the microbial culture preparations and the identification method was performed according to the manufacturer's instructions.
Antibiograms profile of the isolated pathogen
Antimicrobial susceptibility testing of the isolated pathogens was performed using the Kirby–Bauer disc-diffusion method using Muller Hinton agar plates as described by the Clinical and Laboratory Standards Institute.[11],[12] Commercially prepared antimicrobial diffusion discs were purchased from Oxoid including streptomycin (5 mg), neomycin (5 mg), chloramphenicol (5 mg), gentamycin (5 mg), tetracycline (10 mg), ciprofloxacin (5 mg), nitrofurantoin (5 mg), amoxicillin-clavulanic acid (5 mg), trimethoprim-sulfamethoxazole (25 mg), amikacin (5 mg), ceftazidime (5 mg), colistin (5 mg), erythromycin (15 mg), bacitracin (5 mg), methicillin (5 mg), penicillin G (5 mg), vancomycin (5 mg), and clindamycin (5 mg) were placed onto the culture plates and then incubated aerobically at 37°C for overnight. The next day, the inhibition zones were determined in millimeters based on zone size interpretative and compared to zone size interpretative chart of Himedia Laboratories Pvt. Limited catalogue 2013–2014.
| Results | | |
Screening of bacterial infection and contamination into Al Kufra Teaching Hospital
The sample collection process was restricted to a limited period of time due to the conditions of the hospital was going through; therefore, the duration of samples collection was performed within 2 months, that represented total of samples was 157. During this period, a total of 35 clinical samples were collected, and the results showed that, the highest rate of infection from the potential pathogens was observed from the cultures of bedsores and urinary tract infection (UTI) samples (100%) of growth, followed by sputum, stool, surgical wounds, and CSF, demonstrated bacterial growth rates of (85.8%, 67%, 62.5%, and 42.9%), respectively. The results of the investigation from people who were considered carriers of pathogenic bacteria were included 52 nasal swab samples collected from resident patients and from medical care staff, whereas only 17 hand swab samples were collected from the medical care team. The rate of microbial colonizing was into 40 (77%) of the total nasal swab samples, whereas the hand hygiene investigation indicated 15 (88.2%) of the individuals who have been subjected to the screening as microbial carries. The investigation of the bacterial contamination into the different hospital facilities included 53 samples. The results obtained from stethoscopes, sphygmomanometer, floors, tables, bedssheets, and air showed (100%) of microbial contamination for each, however, thermometer showed less frequent of microbial contamination and no contamination was recorded from the hospital incubators, [Table 1]. | Table 1: Locations of bacterial isolate from patients and the hospital environment at Al Kufra hospital
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Total bacterial distribution according to the hospital wards (intensive care unit, paediatric ward, male surgical ward, and female surgical ward)
The bacterial diversity investigated different types of pathogens isolation from the clinical samples, hospitalized patients and from microbes have colonized the hospital environment at the different departments and wards. From 157 samples, 130 (82.80%) showed bacterial growth. Gram-positive bacteria represented 122 (194%) while only eight (6%) of Gram-negative bacteria were isolated. The diversity of bacterial isolates was included 76 (58.46%) of S. aureus followed by 19 (14.62%), Bacillus cereus, 15 (11.53%) Staphylococcus epidermidis 9 (6.92%), Streptococcus pneumoniae, four (3.07%) P. aeruginosa, four (3.07%), Escherichia coli 0157, and three (2.31%) Enterococcus faecalis, [Table 2].
Bacterial distribution according to the type of samples and hospital wards at Al Kufra teaching hospital
The infection investigation results for the clinical samples showed that, the sputum and CSF samples represented infection with S. pneumoniae (85.5% and 42.9%), respectively, the surgical samples showed infection with S. aureus (62.5%), bedsore samples showed infection with P. aeruginosa (100%) of the samples in the ICU area, the UTI samples showed infection with E. faecalis (100%) of the samples in the ICU area, the stool samples showed infection with E. coli 0157 (100%) of the samples in the PW area. The results of nasal and hand hygiene swabs showed that, S. aureus has represented the predominant pathogen that make colonized the individuals and represented 77% of the tested nasal samples, whereas the hands screening showed the samples mostly contaminated with S. epidermidis, followed by the contamination with B. cereus. The bacterial distribution that contaminates the hospital facilities showed contamination with S. aureus which considered the most predominant microbe isolated from the different hospital wards followed by B. cereus, [Table 3]. | Table 3: Distribution of pathogens according to type of sample and hospital ward
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Antimicrobial susceptibility testing
Antimicrobial resistance was performed based on the data supplied by the diffusion disc manufacturer.[11],[12] The rate of full antimicrobial resistance for each major isolate class aggregated for all samples taken across all hospital sites is listed in [Table 4]. The most frequently isolated bacteria S. aureus had high rates of resistance to Penicillin G or Amoxicillin + Clavulanic acid with 92.1% and 84.2% of isolates being resistant. High rates of resistance were also observed for Penicillin and Amoxicillin + Clavulanic acid in S. epidermidis, B. cereus, S. pneumoniae, and E. faecalis. The resistance rate of S. aureus to methicillin and Vancomycin was 53 (69.7%) for each, whereas the resistance to Erythromycin and Tetracycline was observed in over 50% of the isolates. Chloramphenicol was the most effective antimicrobial for the treatment of S. aureus isolates (19.7% resistance), followed by Nitrofurantoin (23% resistance) and Streptomycin (31.8% resistance). S. epidermidis isolates were highly resistant to Penicillin G (86.6% resistance), Amoxicillin + Clavulanic acid (86.6% resistance), and Vancomycin (80% resistance). Rates of resistance to Methicillin were lower for S. epidermidis than S. aureus, with only 53.3% of isolates exhibiting resistance. Isolated strains of S. epidermidis were most susceptible to chloramphenicol, ciprofloxacin, clindamycin, and gentamicin with 13.3% resistance for each antimicrobial. Antimicrobial testing of B. cereus showed that, the isolated pathogens were resistant to Penicillin G and Amoxicillin + Clavulanic acid (94.7% and 84.2%), respectively, followed by Bacitracin, Methicillin, and Streptomycin (68.4%, 52.6%, and 52.6%), respectively. Antimicrobial testing of S. pneumoniae showed that, the isolated pathogens were moderate resistant to tested antibiotics of Penicillin G, Amoxicillin + Clavulanic acid, methicillin, and nitrofurantoin, where they showed the rate of resistance of 66.6% for all of them. The antibiotics Bacitracin, Vancomycin, and Tetracycline showed the same effect and they were less frequently resistant (55.5%, 55.5%, and 55.5%), respectively. E. faecalis susceptibility to the antibiotics showed 100% of resistance to the following antibiotics Penicillin G, methicillin, clindamycin, ciprofloxacin vancomycin, and Trimethoprim-sulphamethoxazole. The tested pathogens were more susceptibility to the rest of the tested antibiotics. For Gram-negative bacteria (75%) of P. aeruginosa, isolates showed resistance to streptomycin, tetracycline, nitrofurantoin, and ceftazidime were the same effect of resistance, other antibiotics were more susceptibility. E. coli O157: H7 susceptibility to the antibiotics showed rate of resistance of 75% to streptomycin, tetracycline, trimethoprim-sulphamethoxazole, and colistin, followed by chloramphenicol, nitrofurantoin, and Amoxicillin + Clavulanic acid that showed the same effect and they were less frequently resistant (50%, 50%, and 62.5%), respectively, other antibiotics were more susceptibility. | Table 4: The antibiotic resistance profile according to the type of pathogen
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| Discussion | | |
Al Kufra city located far South East of Libya and considered one of the most important migration portals into the Libyan Desert located Northern Africa. It is the way for the transit of travelers to Europe, the city including one main hospital named "The Maryr Al-Kasch Teaching Hospital Al Kufra," the nearest official governmental hospital is far at least 800 km away, this gives importance as an investigation point for the extent of the microbial spread for infectious diseases and epidemics that cross the country and are capable of spreading among human communities. This study was the first prospective point incidence study to describe the prevalence of infection disease into the Southern East Sahara of Libya. The limitation of research work into the study area leads to the limitation of the information on the mortality rates caused by the infectious diseases. The application defect in the infection control system leads to increase the microbial diversity into the hospital environment, which in turn increases the chance of colonize and endemicity of pathogens; therefore, resulting in serious economic and public health problems.[13] This study has represented bacterial infection recorded for the patients at different body sites and revealed reservoir of opportunistic pathogens across different clinical wards, where 25 (71.4%) of the total clinical specimens showed bacterial infections including surgical wounds, bedsores, UTI, sputum, CSF, and stool samples. Increase the diversity of infectious diseases and poor sanitization surrounding the patients plus limitations of the educational knowledge associated with the health care management drive microorganisms colonizing the hospital environment leading to biofilm formation and that may increase the chance of the hospital-acquired infections. In addition, the investigation represented different points were the most frequent source of the contamination, the results showed 105 (86.1%) of the patients, physicians and workers, equipment, medical tools, floors, and air were contaminated with bacteria. Similar to other studies,[14],[15],[16],[17] S. aureus and S. epidermidis demonstrated the most abundant opportunistic pathogens on each screened ward and hospital environment. From the male and FSWs, the results have investigated S. pneumoniae infection collected from the sputum samples of admitted patients. Our finding was similar to another study,[18] where they showed the infection with has S. pneumoniae represented the highest rate of infection (48%) and the main causative agent for upper respiratory tract infection at a Tertiary Care Hospital, Libya. Here in our study, we isolated B. cereus from different hospital wards; B. cereus has represented the second most frequent hospital contaminant (14.62%), the presence of B. cereus considered was indicator for poor hygiene system into the hospital. Other studies also isolated B. cereus from the hospitals, it can be found into the soil, food, surfaces, human skin, medical devices, and hands of the staff and has a wide spread into the environment.[19],[20] It was principally considered as an environmental contaminant and causative agent of systematic infections.[21],[22] The study investigated a limited Gram-negative infection, only two types including E. coli O157: H7 and P. aeruginosa. The infection with P. aeruginosa was only isolated from the ICU from bed sore swabs, whereas E. coli 0157: H7 was only isolated from the PW from stool samples. Our results are in agreement with another study,[23] they showed that E. coli 0157: H7 and Pseudomonas sp. were the main pathogens isolated from patients and from the hospital environment. The finding in this study directly contradicted with another study,[14] that showed Proteus vulgaris was the most prevalent and ranked first Gram-negative bacteria isolated from the hospital environments, followed by P. aeruginosa, E. coli, Klebsiella spp., Salmonella spp., Shigella spp. and P. mirabilis. The results of this study differ from another study,[24] which reported K. pneumoniae was the most prevalent bacteria isolated from the hospital personnel hand of and hospital environment, followed by P. aeruginosa, Enterobacter sp., E. coli, and Proteus sp. Whereas similar study was performed,[2] they reported that K. pneumoniae and Acinetobacter baumanii were the most prevalent pathogens isolated from the trauma ICU in Libya. In addition, it is quite different from another work,[25] showed that Citrobacter sp. was the prevalent bacteria isolated from hospital staff apparel, followed by Enterobacter sp., E. coli, P. aeruginosa, Klebsiella sp., Salmonella sp., P. vulgaris, and Shigella dysenteriae. Our results involved antibiogram profiling to understand the antimicrobial-resistant characteristics of the isolated pathogens. All the tested antibiotics were directed by the hospital infection control unit as the potential drug development. The antimicrobial susceptibility results demonstrated a critical information, the effectiveness of the antibiotics showed that there were similar prevalence of bacterial strain isolated from animate objects and inanimate objects were resistant to most antibiotics. The tested Penicillin G was the most resistant antimicrobial agent (90.1%) against Gram-positive isolates followed by Amoxicillin-Clavulanic acid (82.7%), methicillin (65.5%), vancomycin (65.5%), erythromycin (50%), bacitracin (48.3%), tetracycline (45.9%), trimethoprim-sulfamethoxazole (42.6%), neomycin (40.1%), clindamycin (37.7%), gentamycin (33.6%), streptomycin (32.7%), ciprofloxacin (30.3%), nitrofurantoin (26.2%), and chloramphenicol (21.3%). The results have shown that S. aureus isolates were resistant to Penicillin G (86.6%) followed by Amoxicillin-Clavulanic acid (84.2%), Methicillin (69.7%) and Vancomycin (69.7%). There was a similar study on the incidence of antibiotic resistance was performed,[26] showed that there was high resistance (62.5%) to Methicillin. This study demonstrated that the incidence of Penicillin G resistance was also high among S. aureus, with (92.1%). The results shown that S. epidermidis was resistant to Penicillin G (87%), Amoxicillin-Clavulanic acid (87%), Vancomycin (80%), and Methicillin (54%). Interestingly, our finding was differ from the result of another study,[27] that showed the resistant of S. epidermidis was high with tetracycline (100%) and chloramphenicol was (95%), in contrast another study,[28] showed S. epidermidis was resistance to penicillin (95.65%), tetracycline (90.30%), and erythromycin (82.60%). [Table 4] shows the most antibacterial resistant to Gram-negative isolates was for Streptomycin by (75%) followed by tetracycline, colistin (62.5%), Ceftazidime (50%), the rest of tested antibiotics was more susceptible. Our results were contradicted with another study,[29] they have found that E. coli strains were resistant to Ceftazidime (33.2%) and low resistance to Amikacin (0.4%). The results also showed that P. aeruginosa isolates were resistant to ceftazidime (75%), amikacin (50%), gentamycin (25%), trimethoprim sulfamethoxazole (50%), ciprofloxacin (50%), and ceftazidime (75%). Similarly,[30] represented antimicrobial sensitivity; they have found that the resistance rates among isolated P. aeruginosa were ceftazidime (86.3%), amikacin (13.7%), and gentamycin (49%).
| Conclusion | | |
The bacterial outbreak in the clinical and environmental samples was relatively high and the proportion accounted for bacteria Gram-positive bulk of the outbreak in Al kufra hospital. The rate of outbreak in inanimate objects (floor, beds, tables, medical instruments, and air) in the hospital was in the high level of contamination, and the outbreak rate of the Gram-positive bacteria were higher than Gram-negative bacteria. In this study that S. aureus was the most predominant pathogen isolated from both of the animate and inanimate objects. The Gram-negative bacteria diversity isolated from the clinical specimens were very limited including P. aeruginosa and E. coli. The results also showed the resistance of the isolated pathogens to the tested antibiotics were relatively high.
Recommendations
The control of hospital contamination can be achieved by the implementation of a comprehensive infection control program and surveillance of infections in the hospital by an infection control committee, which includes representative staff from the different departments and service areas, headed by the hospital director and helped by the infection control team, which is the core of the committee and includes the microbiologist and the infection control nurses. To prevent microbial contamination and bacterial endemicity into the hospital, several instruction need to be carried out including education of hospital staff to protect themselves and protect patients from being infected by any pathogens. Frequent handwashing by antimicrobial agents to reduce the transmission of infection. Personal protection by gloves, masks, and gowns. Proper hygiene applications by applying the correct sterilization rules in operating rooms and the proper surgical technique etc. Monitoring of disinfection and sterilization of patient care equipment. Conservative antibiotic use and implementation of antibiotic policies and proper disposal of infectious hospital waste.[31],[32],[33]
Acknowledgments
We would like to express our thanks to the Al Kufra hospital infection control team and to Mr Hassan Abu Matari "Assistant director of the Martyr Attia Al-Kufra teaching Hospital."
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Davis CP. Normal flora. In: Baron S, editor. Medical Microbiology. 4 th ed. Galveston (TX): University of Texas Medical Branch at Galveston; 1996.  |
| 2. | Peterson JW. Bacterial Pathogenesis. In: Baron S, editor. Medical Microbiology. 4 th ed. Galveston (TX): University of Texas Medical Branch at Galveston; 1996. |
| 3. | Sanchez E, Doron S. Bacterial Infections: Overview. International Encyclopedia of Public Health, 2 nd edition 2017;1:273-81. |
| 4. | Drexler M. Institute of Medicine (US). What You Need to Know About Infectious Disease. Washington (DC): National Academies Press (US); 2019. [Last accessed on 2022 Nov 18]. |
| 5. | Otter JA, Yezli S, Salkeld JA, French GL. Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. Am J Infect Control 2013;41:S6-11. |
| 6. | Osme SF, Almeida AP, Lemes MF, Barbosa WO, Arantes A, Mendes-Rodrigues C, et al. Costs of healthcare-associated infections to the Brazilian public Unified Health System in a tertiary-care teaching hospital: A matched case-control study. J Hosp Infect 2020;106:303-10. |
| 7. | Sereia AF, Christoff AP, Cruz GN, da Cunha PA, da Cruz GC, Tartari DC, et al. Healthcare-associated infections-related bacteriome and antimicrobial resistance profiling: Assessing contamination hotspots in a developing country public hospital. Front Microbiol 2021;12:711471. |
| 8. | Sastry AS, Sandhya BK. Essentials of Medical Microbiology. 2 nd ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2018. p. 606. |
| 9. | Birru M, Mengistu M, Siraj M, Aklilu A, Boru K, Woldemariam M, et al. Magnitude, diversity, and antibiograms of bacteria isolated from patient-care equipment and inanimate objects of selected wards in Arba Minch General hospital, Southern Ethiopia. Res Rep Trop Med 2021;12:39-49. |
| 10. | Krieg NR, Staley JT, Brown DR, Hedlund BP, Paster BJ, Ward NL, et al. Bergey's Manual of Systematic Bacteriology, Vol. 4: The Bacteroidetes, Spirochaetes, Tenericutes (Mollicutes), Acidobacteria, Fibrobacteres, Fusobacteria, Dictyoglomi, Gemmatimonadetes, Lentisphaerae, Verrucomicrobia, Chlamydiae, and Planctomycetes. 2 nd ed. New York: Springer; 2010. |
| 11. | Clinical Laboratory Standards Institute. Performance Standards for Antimicrobial Disk Susceptibility Tests; Approved Standards. 9 th ed., Vol. 1. Wayne, PA: Document M2-A9 Clinical Laboratory Standards Institute; 2006. p. 26. |
| 12. | Clinical and Laboratory Standards Institute/NCCLS (CLSI). Performance Standards for Antimicrobial Susceptibility Testing; Fifteenth Informational Supplement. USA: CLSI/NCCLS Documents M100-S15; 2005. |
| 13. | Sun B. Nosocomial infection in China: Management status and solutions. Am J Infect Control 2016;44:851-2. |
| 14. | UmmuKulthum M, Alhaji MI, Aliyu ZM. Distribution of potential nosocomial pathogens isolated from environments of four selected hospital in Sokoto, North Western Nigeria. Sch Res Libr J Microbiol Biotech Res 2013;3:139-43. |
| 15. | Ijioma BC, Kalu IG, Nwachukwu CU. Provide legend report and negative Bacteria isolated in the hospital specimen. Rep Opin 2010;2:45-52. |
| 16. | Chikere CB, Omoni VT, Chikere BO. Distribution of potential nosocomial pathogens in a hospital environment. Afr J Biotechnol 2008;7:3535-9. |
| 17. | Swain B, Otta S. Bloodstream infections in a teaching hospital. Ann Biol Res 2012;3:1923-8. |
| 18. | Atia A, Abired A, Ammar A, Elyounsi N, Ashour A. Prevalence and types of bacterial infections of the upper respiratory tract at a tertiary care hospital in the city of Tripoli. Libyan Int Med Univ J 2022;3:54-8. |
| 19. | Auger S, Ramarao N, Faille C, Fouet A, Aymerich S, Gohar M. Biofilm formation and cell surface properties among pathogenic and nonpathogenic strains of the Bacillus cereus group. Appl Environ Microbiol 2009;75:6616-8. |
| 20. | Bottone EJ. Bacillus cereus, a volatile human pathogen. Clin Microbiol Rev 2010;23:382-98. |
| 21. | Gaur AH, Patrick CC, McCullers JA, Flynn PM, Pearson TA, Razzouk BI, et al. Bacillus cereus bacteremia and meningitis in immunocompromised children. Clin Infect Dis 2001;32:1456-62. |
| 22. | Veysseyre F, Fourcade C, Lavigne JP, Sotto A. Bacillus cereus infection: 57 case patients and a literature review. Med Mal Infect 2015;45:436-40. |
| 23. | Asghar AH, Faidah HS. Frequency and antimicrobial susceptibility of gram-negative bacteria isolated from 2 hospitals in Makkah, Saudi Arabia. Saudi Med J 2009;30:1017-23. |
| 24. | Ekrami A, Kayedani A, Jahangir M, Kalantar E, Jalali M. Isolation of common aerobic bacterial pathogens from the environment of seven hospitals, Ahvaz, Iran. Jundishapur J Microbiol 2011;4:75-82. |
| 25. | Orji MU, Mbata TI, Kalu OU. Isolation of pathogenic bacteria from hospital staff apparel in Nigeria. Malawi Med J 2005;17:128-30. |
| 26. | Pablito MP, Grace A, Laiño G, Gonzales LM. Nasal Carriage of Staphylococcus aureus among pediatric health care workers in a pediatric intensive care unit. PIDSP J 2012;13:44-50. |
| 27. | Akortha EE, Ikenebomeh MJ. Nasal colonization of symptomatic pneumonia patient University of Benin teaching Hospital, Benin City, Nigeria by multiple antibiotic resistant Staphylococcus aureus. Afr J Microbiol Res 2010;4:1071-5. |
| 28. | Chabi R, Momtaz H. Virulence factors and antibiotic resistance properties of the Staphylococcus epidermidis strains isolated from hospital infections in Ahvaz, Iran. Trop Med Health 2019;47:56. |
| 29. | Morfin-Otero R, Tinoco-Favila JC, Sader HS, Salcido-Gutierrez L, Perez-Gomez HR, Gonzalez-Diaz E, et al. Resistance trends in gram-negative Bacteria: Surveillance results from two Mexican hospitals, 2005-2010. BMC Res Notes 2012;5:277. |
| 30. | Nurain AM, Bilal NE, Ibrahim ME. The frequency and antimicrobial resistance patterns of nosocomial pathogens recovered from cancer patients and hospital environments. Asian Pac J Trop Biomed 2015;5:1055-9. |
| 31. | Mehta Y, Gupta A, Todi S, Myatra S, Samaddar DP, Patil V, et al. Guidelines for prevention of hospital acquired infections. Indian J Crit Care Med 2014;18:149-63. [ PUBMED] [Full text] |
| 32. | Resman F. Antimicrobial stewardship programs; A twopart narrative review of stepwise design and issues of controversy Part I: Stepwise design of an antimicrobial stewardship program. Ther Adv Infect Dis 2020;7:1-26. |
| 33. | |
[Table 1], [Table 2], [Table 3], [Table 4]
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