Presentación de los datos

Research needs. When the guidelines provided by CDC/HICPAC or other professional

societies cannot recommend solutions for HAI problems secondary to insufficient knowledge or evidence, hospitals must determine their own policy/intervention based on their unique

characteristics, such as acute care setting or long-term care facility status. In particular, MRSA active surveillance screening remains a controversial topic that has conflicting guidelines from the Society for Healthcare Epidemiology of America (SHEA) and HICPAC (Jackson, Jarvis, & Scheckler, 2004). Thus, further study is needed to compare the costs and outcomes among different MRSA surveillance screening strategies and to provide evidence regarding the most cost-effective MRSA screening policy on patient admission to academic hospitals that have distinctive characteristics (e.g., acute care facilities with more severely ill patients and frequent transfer-ins from other facilities).

Aim. This study aimed to evaluate the cost-effectiveness of three alternative active screening strategies for MRSA in an academic hospital setting (from the hospital perspective) to detect MRSA-colonized patients who should be isolated with contact precautions upon hospital

24

admission. The screening strategies were universal surveillance screening (USS) for all hospital admissions, targeted surveillance screening (TSS) for ICU admissions, and no surveillance screening (NSS). From the academic hospital perspective, a cost-effectiveness analysis was conducted using a decision-tree model to determine the most cost-effective active surveillance screening strategy for MRSA.

Area 3. Implementing policy (Chapter 4: Survey of North Carolina Hospital Policies

Regarding Visitor Use of Personal Protective Equipment for Entering the Rooms of Patients on Isolation Precautions)

Research needs. Every human has many endogenous microorganisms within his or her

own body and can be either a susceptible host or an intermediate transmission route of infectious agents. HCP are required to adhere to isolation precautions during their daily interactions with infected/colonized patients. However, there are no clear recommendations for hospital visitors, who could acquire healthcare-associated pathogens as susceptible hosts or could transmit these pathogens as reservoirs during their visit. Thus, a study on current hospital visitor policies is needed to suggest appropriate hospital policies related to isolation precautions.

Aim. This study explored the range of hospital policies for visitor use of personal protective equipment when entering the rooms of patients on isolation precautions. Using an online survey of hospitals in North Carolina, this study examined current hospital visitor policies related to isolation precautions and, based on lessons from infection preventionists (IPs)’

experience, suggested appropriate future policy directions, including difficulties with such policies and ideas for improving them.

25

REFERENCES

American Hospital Association. (2012, January 3, 2012). Fast facts on US hospitals. Retrieved from http://www.aha.org/research/rc/stat-studies/fast-facts.shtml

Anderson, D. J., Kirkland, K. B., Kaye, K. S., Thacker, P. A., 2nd, Kanafani, Z. A., Auten, G., & Sexton, D. J. (2007). Underresourced hospital infection control and prevention programs: Penny wise, pound foolish? Infect Control Hosp Epidemiol, 28(7), 767-773. doi:

ICHE2006358 [pii] 10.1086/518518

Archibald, L. K. (2012). Principles of infectious diseases epidemiology. In C. G. Mayhall (Ed.), Hospital epidemiology and infection control (4th ed., pp. 1-19). Philadelphia, PA: Lippincott Williams & Wilkins.

Aziz, A. M., & Murphy, P. (2009). C. difficile infection - a tool for improving practice and reducing rates. Br J Nurs, 18(11), 659-660, 662-654.

Bartley, J. (2009). Accrediting and regulatory agencies. In APIC (Ed.), APIC text of infection control and epidemiology (3rd ed.): APIC.

Burke, J. P. (2003). Infection control - a problem for patient safety. N Engl J Med, 348(7), 651- 656. doi: 10.1056/NEJMhpr020557348/7/651 [pii]

Carlet, J., Fabry, J., Amalberti, R., & Degos, L. (2009). The "zero risk" concept for hospital- acquired infections: A risky business! Clin Infect Dis, 49(5), 747-749. doi:

10.1086/604720

CDC. (2003). Guidelines for environmental infection control in health-care facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR, 52(RR10), 1-42.

CDC. (2009a). Healthcare-associated infections: Recovery act. Retrieved from http://www.cdc.gov/HAI/recoveryact/index.html

CDC. (2009b). Press release: CDC to distribute $40 million in recovery act funding to help states fight healthcare-associated infections. Retrieved from

http://www.cdc.gov/media/pressrel/2009/r090901.htm

CDC. (2010). Healthcare-associated infections: Recovery act. Retrieved from http://www.cdc.gov/HAI/recoveryact/top10.html

CDC. (2012, August 20, 2012). Hospital utilization (in non-Federal short-stay hospitals). Retrieved from http://www.cdc.gov/nchs/fastats/hospital.htm

26

Clock, S. A., Cohen, B., Behta, M., Ross, B., & Larson, E. L. (2010). Contact precautions for multidrug-resistant organisms: Current recommendations and actual practice. Am J Infect Control, 38(2), 105-111. doi: 10.1016/j.ajic.2009.08.008

CMS. (2011, October 2011). Hospital-acquired conditions (HAC) in acute inpatient prospective payment system (IPPS) hospitals: Fact sheet. Retrieved from

https://www.cms.gov/hospitalacqcond/downloads/hacfactsheet.pdf

Committee to Reduce Infection Deaths. (2011, October 2011). State legislation & initiatives on healthcare-associated infections. Retrieved from

http://www.hospitalinfection.org/legislation.shtml

Consumers Union. (2006). Consumers union model hospital infections disclosure act December 2006. Retrieved from

http://www.consumersunion.org/pub/campaignstophospitalinfections/000875.html DHHS. (2009). HHS action plan to prevent healthcare-associated infections: Appendices. Retrieved from http://www.hhs.gov/ash/initiatives/hai/appendices.html#appendix_g DHHS Press Office. (2009). Secretary Sebelius highlights two new reports on health care quality,

says improving quality is key component of health reform. Retrieved from http://www.ahrq.gov/news/press/pr2009/qrdr08pr.htm

Diekema, D. J., & Climo, M. (2008). Preventing MRSA infections: Finding it is not enough. JAMA, 299(10), 1190-1192. doi: 10.1001/jama.299.10.1190

Edmond, M. (2007). Public reporting of healthcare-associated infection rates. In W. R. Jarvis (Ed.), Bennett & Brachman's Hospital Infections (5th ed., pp. 801-811). Philadelphia: Lippincott.

Edmond, M., & Eickhoff, T. C. (2008). Who is steering the ship? External influences on infection control programs. Clin Infect Dis, 46(11), 1746-1750. doi: 10.1086/587987 Fauerbach, L. (2002). Risk factors for infection transmission. In APIC (Ed.), APIC text of

infection control and epidemiology (Revised edition 2002 ed., pp. 4:1-4:9). Washington, DC: APIC.

Garner, J. S., Jarvis, W. R., Emori, T. G., Horan, T. C., & Hughes, J. M. (1996). CDC definitions for nosocomial infections. In R. N. Olmsted (Ed.), APIC infection control and applied epidemiology: Principles and practices (pp. A1-A20). St.Louis: Mosby.

Goldrick, B. A. (2005). The practice of infection control and applied epidemiology: A historical perspective. Am J Infect Control, 33(9), 493-500. doi: S0196-6553(05)00738-8 [pii] 10.1016/j.ajic.2005.04.250

27

Gorwitz, R. J., Kruszon-Moran, D., McAllister, S. K., McQuillan, G., McDougal, L. K., Fosheim, G. E., . . . Kuehnert, M. J. (2008). Changes in the prevalence of nasal colonization with Staphylococcus aureus in the United States, 2001-2004. J Infect Dis, 197(9), 1226-1234. doi: 10.1086/533494

Graves, N., & McGowan, J. E., Jr. (2008). Nosocomial infection, the deficit reduction act, and incentives for hospitals. JAMA, 300(13), 1577-1579. doi: 300/13/1577 [pii]

10.1001/jama.300.13.1577

Haley, R. W., Culver, D. H., White, J. W., Morgan, W. M., Emori, T. G., Munn, V. P., & Hooton, T. M. (1985). The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol, 121(2), 182-205.

Henderson, D. K. (2006). Managing methicillin-resistant staphylococci: A paradigm for preventing nosocomial transmission of resistant organisms. Am J Med, 119(6 Suppl 1), S45-52; discussion S62-70. doi: 10.1016/j.amjmed.2006.04.002

Hidron, A. I., Edwards, J. R., Patel, J., Horan, T. C., Sievert, D. M., Pollock, D. A., & Fridkin, S. K. (2008). NHSN annual update: Antimicrobial-resistant pathogens associated with healthcare-associated infections: Annual summary of data reported to the National

Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infect Control Hosp Epidemiol, 29(11), 996-1011. doi: 10.1086/591861

IOM. (2000). To error is human: Building a safer health system. Washington, D.C.: National Academy Press.

Jackson, M., Jarvis, W. R., & Scheckler, W. E. (2004). HICPAC/SHEA--conflicting guidelines: What is the standard of care? Am J Infect Control, 32(8), 504-511. doi:

S0196655304005450 [pii] 10.1016/S0196655304005450

JCAHO. (2006). Raising the bar with bundles: Treating patients with an all-or-nothing standard. Joint Commission Perspective on Patient Safety, 6(4), 5-6.

Jones, M., & Woeltje, K. F. (2007). The development of infection control surveillance and control programs. In W. R. Jarvis (Ed.), Bennett & Brachman's Hospital Infections (5th ed., pp. 65-71). Philadelphia, PA: Lippincott Williams & Wilkins.

Klevens, R. M., Edwards, J. R., Richards, C. L., Jr., Horan, T. C., Gaynes, R. P., Pollock, D. A., & Cardo, D. M. (2007). Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep, 122(2), 160-166.

Koppaka, V. R., & Ridzon, R. (2003). Prevention and control of the nosocomial transmission of Mycobacterium tuberculosis. In R. P. Wenzel (Ed.), Prevention and control of

nosocomial infections (4th ed.). Philadelphia, PA: Lippincott williams & wilkins. Last, J. M. (2001). A dictionary of epidemiology (4th ed.). New York: Oxford University Press.

28

Lin, M., Weinstein, R. A., & Hayden, M. K. (2007). Multiply drug-resistant pathogens: Epidemiology and control. In W. R. Jarvis (Ed.), Bennett & Brachman's hospital infections (5th ed., pp. 193-222). Philadelphia, PA: Lippincott Williams & Wilkins. Lo Vecchio, A., & Zacur, G. M. (2012). Clostridium difficile infection: An update on

epidemiology, risk factors, and therapeutic options. Curr Opin Gastroenterol, 28(1), 1-9. doi: 10.1097/MOG.0b013e32834bc9a9

Mascola, L., Kainer, M. A., & Pollock, D. A. (2010). Council of State and Territorial

Epidemiologists – Centers for Disease Control and Prevention (CSTE-CDC) process for setting national standards for healthcare-associated infections case criteria and data requirements. Retrieved from http://www.cste.org/ps2010/10-ID-28.pdf

McCannon, C. J., Hackbarth, A. D., & Griffin, F. A. (2007). Miles to go: An introduction to the 5 Million Lives Campaign. Jt Comm J Qual Patient Saf, 33(8), 477-484.

Murphy, D. M., Alvarado, C. J., & Fawal, H. (2002). The business of infection control and epidemiology. Am J Infect Control, 30(2), 75-76. doi: S0196655302477814 [pii]

Nettleman, M. D., Roach, R. L., & Wenzel, R. P. (2012). Principles of healthcare epidemiology. In C. G. Mayhall (Ed.), Hospital epidemiology and infection control (4th ed., pp. 82-86). Philadelphia, PA: Lippincott Williams & Wilkins.

NNIS. (1998). National Nosocomial Infections Surveillance (NNIS) System report, data summary from October 1986-April 1998, issued June 1998. Am J Infect Control, 26(5), 522-533. doi: S019665539800100X [pii]

O'Boyle, C., Jackson, M., & Henly, S. J. (2002). Staffing requirements for infection control programs in US health care facilities: Delphi project. Am J Infect Control, 30(6), 321-333. doi: S0196655302000111 [pii]

O'Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., . . . (HICPAC), T. H. I. C. P. A. C. (2011, April 1, 2011). Guidelines for the prevention of intravascular catheter-related infections, 2011. Retrieved from

http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

O’Malley, Emily M. M., Ii, R. D. S. P., Gayle, J. M. P. H., Dekutoski, J. M. D., Foltzer, M. M. D., Lundstrom, Tammy S. M. D., . . . Panlilio, Adelisa L. M. D. (2007). Costs of management of occupational exposures to blood and body fluids. Infection Control and Hospital Epidemiology, 28(7), 774-782.

Ostrowsky, B. (2007). Epidemiology of healthcare-associated infections. In W. R. Jarvis (Ed.), Bennett & Brachman's Hospital infections (5th ed., pp. 3-23). Philadelphia, PA:

29

Patterson, J. E. (2004). Isolation of patients with communicable diseases. In C. G. Mayhall (Ed.), Hospital epidemiology and infection control (3rd ed., pp. 1703-1725). Philadelphia, PA: Lippincott Williams & Wilkins.

Pittet, D., & Donaldson, L. (2006). Challenging the world: Patient safety and health care- associated infection. Int J Qual Health Care, 18(1), 4-8. doi: mzi093 [pii]

10.1093/intqhc/mzi093

Rutala, W. A., Weber, D. J., & HICPAC. (2008). Guideline for disinfection and sterilization in healthcare facilities, 2008. Retrieved from

http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf

Salgado, C. D., & Farr, B. M. (2006). What proportion of hospital patients colonized with methicillin-resistant Staphylococcus aureus are identified by clinical microbiological cultures? Infect Control Hosp Epidemiol, 27(2), 116-121. doi: 10.1086/500624 Scott, R. D., II. . (2009). The direct medical costs of healthcare-associated infections in U.S.

hospitals and the benefits of prevention (CS200891-A). Atlanta, GA. Retrieved from http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf

Siegel, J. D., Rhinehart, E., Jackson, M., & Chiarello, L. (2007a). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in health care settings. Am J Infect Control, 35(10 Suppl 2), S65-164. doi: 10.1016/j.ajic.2007.10.007

Siegel, J. D., Rhinehart, E., Jackson, M., & Chiarello, L. (2007b). Management of multidrug- resistant organisms in health care settings, 2006. Am J Infect Control, 35(10 Suppl 2), S165-193. doi: 10.1016/j.ajic.2007.10.006

Sprague, L. (2009, March 13, 2009). Health care-associated infections: Is there an end in sight?, Retrieved from http://www.nhpf.org/library/issue-briefs/IB830_HAI_03-13-09.pdf Stone, P. W. (2009). Changes in Medicare reimbursement for hospital-acquired conditions

including infections. Am J Infect Control, 37(9), A17-18. doi: S0196-6553(09)00656-7 [pii] 10.1016/j.ajic.2009.07.001

Umsheid, C. A., Agarwal, R. K., Brennan, P. A., & HICPAC. (2009). Updating the guideline methodology of the Healthcare Infection Control Practices Advisory Committee (HICPAC). Retrieved from http://www.cdc.gov/hicpac/pdf/guidelines/2009-10- 29HICPAC_GuidelineMethodsFINAL.pdf

United States Government Accountability Office. (2008). Health-care-associated infections in hospitals: Leadership needed from HHS to prioritize prevention practices and improve data on these infections (GAO-08-673T). Washington, D.C.

Van den broek, P. J. (2003). Historical perspectives for the new millennium. In R. P. Wenzel (Ed.), Prevention and control of nosocomial infection (4th ed., pp. 3-13). Philadelphia: Lippincott Williams and Wilkins.

30

Wachter, R. M., Foster, N. E., & Dudley, R. A. (2008). Medicare's decision to withhold payment for hospital errors: The devil is in the details. Jt Comm J Qual Patient Saf, 34(2), 116-123. Weber, D. J., Rutala, W. A., Samsa, G. P., Wilson, M. B., & Hoffmann, K. K. (1992). Relative

frequency of nosocomial pathogens at a university hospital during the decade 1980 to 1989. Am J Infect Control, 20(4), 192-197. doi: 10.1016/S0196-6553(05)80145-2 Weber, D. J., Sickbert-Bennett, E. E., Brown, V., & Rutala, W. A. (2007). Comparison of

hospitalwide surveillance and targeted intensive care unit surveillance of healthcare- associated infections. Infect Control Hosp Epidemiol, 28(12), 1361-1366. doi: ICHE2007184 [pii] 10.1086/523868

Weinstein, R. A. (1998). Nosocomial infection update. Emerg Infect Dis, 4(3), 416-420. doi: 10.3201/eid0403.980320

Wright, S. B., Ostrowsky, B., Fishman, N., Deloney, V. M., Mermel, L., & Perl, T. M. (2010). Expanding roles of healthcare epidemiology and infection control in spite of limited resources and compensation. Infect Control Hosp Epidemiol, 31(2), 127-132. doi: 10.1086/650199

CHAPTER 2

THE CHANGES IN THE INCIDENCE OF HEALTHCARE-ASSOCIATED INFECTIONS BY PATHOGEN AT A UNIVERSITY HOSPITAL FROM 2005 TO 2011

Background

Surveillance for incidence of healthcare-associated infections

Monitoring the changes in the HAI incidence rate through surveillance is essential to planning, implementing, and evaluating infection control measures to prevent HAIs in hospital settings. According to a dictionary of epidemiology, “incidence” refers to the new cases of a disease in a defined population for a specific time period, and incidence density refers to the incidence rate per person-time (Last, 2001). Healthcare-associated infection (HAI) surveillance is the systematic, ongoing collection, analysis, and dissemination of HAI data (Allen-Bridson, Morrell, & Horan, 2012). Its goals are reducing the overall HAI incidence, establishing endemic rates, detecting outbreaks, convincing administrators and healthcare personnel to take measures against HAIs, evaluating control measures, satisfying accrediting and regulatory requirements, defending the institution against lawsuits, and comparing HAI rates within or between hospitals (Andrus, Horan, & Gaynes, 2007; Perl & Chaiwarith, 2010). To compare the incidence rate of HAIs in a hospital (across units or hospitals) over time, the incidence rate must be adjusted using the incidence-density approach for variations in the distribution of denominators (population at risk), such as length of hospital stay and device use (Allen-Bridson et al., 2012; Tokars, 2012). In this dissertation, incidence is used interchangeably with incidence density.

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Healthcare-associated pathogens

Information about pathogens isolated from patients’ HAIs has implications for both treatment and the implementation of infection control and prevention strategies (Henderson, 2006). However, in contrast to the increasing focus on antimicrobial-resistant pathogens, there are few reports on HAI pathogens (McDonald, 2006). In addition, data on HAIs occurring outside of intensive care units (ICU) are scarce since targeted (priority-based) surveillance emerged as a cost-effective method, leading to the discontinuation of hospital-wide surveillance in the Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance System (NNIS) in 1986 (NNIS, 1998). However, according to a recent study comparing the number of HAIs included in targeted surveillance (the National Healthcare Safety Network [NHSN] surveillance) and hospital-wide surveillance, targeted surveillance found only 77.7% of the bloodstream infections (BSIs), 74.5% of the surgical site infections (SSIs), 62.3% of the urinary tract infections (UTIs), and 18.6% of the respiratory tract infections (including 100% of the ventilator-associated pneumonia [VAP] cases) that were identified with hospital-wide

surveillance(Weber, Sickbert-Bennett, Brown, & Rutala, 2012). Therefore, comprehensive data on healthcare-associated pathogens based on hospital-wide surveillance data is currently lacking in most hospitals using targeted surveillance.

A healthcare-associated pathogen is an organism that causes healthcare-associated

infections (HAIs) within a healthcare setting, thus serving as the infectious agent in the “Chain of HAIs” model (see Chapter 1, Figure 1.1). Healthcare-associated pathogens include bacteria, fungi, and viruses (Ostrowsky, 2007). The NHSN report from 2006 to 2007 named the 10 most common infectious agents, which were isolated from 84% of the reported HAIs. They were coagulase-negative staphylococci (CoNS; 15.3%), Staphylococcus aureus (14.5%),

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Enterococcus species (12.1%), Candida species (6.8%), Escherichia coli (9.6%), Pseudomonas aeruginosa (7.9%), Klebsiella pneumonia (5.8%), Enterobacter species (4.8%), Acinetobacter baumannii (2.7%), and Klebsiella oxytoca (1.1%; Hidron et al., 2008). According to a study that examined the relative frequency of healthcare-associated pathogens at one university hospital from 1980 to 2008, 18 groups of HAI agents were found through hospital-wide surveillance: in order of decreasing frequency, the agents were S. aureus, E. coli, CoNS, “Candida and other yeast”, Enterococcus species, Pseudomonas aeruginosa, Klebsiella species, Enterobacter species, other streptococci, “Clostridium difficile and other anaerobes”, Proteus species, Serratia species, Acinetobacter species, Haemophilus species, Bacteroids species, Citrobacter species, Group B streptococci, and others (Kang, Sickbert-Bennett, Brown, Weber, & Rutala, 2012b).

The characteristics of the main healthcare-associated pathogens

Staphylococcus aureus. S. aureus has been the predominant healthcare-associated pathogen in hospital settings since the 1950s. It is a common community pathogen that causes soft tissue infections and furuncles (John & Shukla, 2012). S. aureus is commonly part of the normal flora of the human body. It is not an environmental pathogen, but it can persist on hospital surfaces for hours to days (John & Shukla, 2012; Salgado & Calfee, 2012).

Asymptomatic colonization of S. aureus has been reported in one-third of the human population, and hospitalization itself is a risk factor for S. aureus colonization (John & Shukla, 2012;

Salgado & Calfee, 2012). S. aureus may cause bacteremia, endocarditis, SSI, pneumonia, burn wound infections, hemodialysis shunt infections, meningitis, prosthetic device infections, urinary tract infection (UTI), osteomyelitis, septic arthritis, and toxic shock syndrome (John & Shukla, 2012). Methicillin-resistant S. aureus (MRSA) is a S. aureus strain that is resistant to

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beta-lactam antibiotics, such as cephalosporins (except ceftaroline which is a new cephalosporin that has activity against MRSA) and carbapenems (Salgado & Calfee, 2012). Since the first report of MRSA in 1961, it has become a common, endemic HAI problem in hospital settings throughout much of the world except Netherlands (Salgado & Calfee, 2012).

Coagulase-negative staphylococci. CoNS are low-pathogenic bacteria that reside on

human skin and mucosa. They are a rare source of disease in healthy individuals outside the hospital setting (Ziebuhr & Flückiger, 2012). Staphylococcus epidermidis is the most common HAI pathogen among the CoNS, which also include S. capitis, S. haemolyticus, S. hominis, S. lugdunensis, S. saprophyticus, S. schleiferii, and S. swarneri (Ziebuhr & Flückiger, 2012). In recent decades, CoNS have emerged as common HAI pathogens among patients who are critically ill, immunocompromised, have central venous access devices, and experiencing long- term hospitalization. CoNS infection has been linked to the use of foreign materials, such as indwelling medical devices (Ziebuhr & Flückiger, 2012). CoNS may cause BSI associated with central-line catheters, prosthetic valve endocarditis related to pacemakers or implantable

defibrillators, sternum osteomyelitis after cardiac surgery, prosthetic joint infections after joint replacement, meningitis/encephalitis associated with cerebrospinal fluid shunt implantation, and other device-related infections (Ziebuhr & Flückiger, 2012).

Enterococcus species. Enterococci are normally found in the human intestinal flora, but they may be found on hospitalized patients’ skin and wounds (e.g., pressure ulcers) and in the hospital environment, including the surfaces of medical equipment (Shuman & Chenoweth, 2012). E. faecalis, E. faecium, and E. gallinarum are the major healthcare-associated pathogen groups among the 33 species of Enterococcus, and they cause UTI, BSI, endocarditis, intra- abdominal/pelvic infections, and skin/soft tissue infections (Shuman & Chenoweth, 2012). Most

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enterococci have inherent antimicrobial resistance to many antibiotics. In the past 10-20 years, vancomycin-resistant enterococci (VRE) have become increasingly challenging to treat with the small number of options (e.g., linezolid, daptomycin, and tigecycline), and infection control is difficult because of heavy environmental contamination (Shuman & Chenoweth, 2012).

Gram-negative bacilli. The reservoirs for Gram-negative bacilli (e.g., P. aeruginosa, Acinetobacter species) are water, soil, human body (e.g., the pharyngeal, genitourinary and