The hospital environment as an ecological driver of multidrug-resistant organisms: evidence from intensive isolation and operating rooms
Abstract
Purpose: Multidrug-resistant organisms (MDROs) present a significant challenge for hospital infection control, with environmental surfaces acting as key reservoirs. This study sought to identify MDRO species, evaluate their biofilm-forming capacity, and quantify microbial bioburden in intensive care isolation and operating rooms.
Methods: Environmental sampling was conducted in 16 rooms. Air and surface samples, including floors, walls, and bedside monitors, were collected using a microbiological air sampler and sterile swabs. Samples were cultured to determine total bioburden and detect MDROs, with bacterial identification performed using VITEK 2. Antimicrobial resistance was assessed using the Kirby-Bauer disc diffusion test, and bioburden levels were compared to national standards.
Results: Forty-nine MDRO isolates were identified: 3 methicillin-resistant Staphylococcus aureus (MRSA, 6.12%), 19 methicillin-resistant coagulase-negative staphylococci (MRCONS, 38.78%), 24 carbapenem-resistant Acinetobacter spp. (CRA, 48.98%), and 3 extended-spectrum β-lactamase (ESBL)-producing Enterobacterales (6.12%). Mean microbial bioburden remained within acceptable limits for air (57.44 CFU/m³), walls (70.63 CFU/100 cm²), and bedside monitors (22.63 CFU/100 cm²), but exceeded thresholds on floors (753.75 CFU/100 cm²). Biofilm-forming capacity varied: MRCONS (26.32% strong biofilm), CRA (8.33% strong biofilm), and ESBL-producing Enterobacterales (66.67% weak biofilm).
Conclusion: MDROs were detected in all sampled rooms, with CRA as the predominant species. Floors exhibited microbial loads above acceptable standards, highlighting the necessity for improved cleaning protocols. Enhanced environmental infection control strategies are essential to reduce MDRO transmission in healthcare settings.
References
Allegranzi B, Bagheri Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L, et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. The Lancet. 2011;3377(9761):228–41.
Rosenthal VD, Maki DG, Salomao R, Moreno CA, Mehta Y, Higuera F, et al. Device-associated nosocomial infections in 55 intensive care units of 8 developing countries. Annals of Internal Medicine. 2006;145(8):582–91.
Goh LPW, Marbawi H, Goh SM, Bin Abdul Asis AK, Gansau JA. The prevalence of hospital-acquired infections in Southeast Asia (1990-2022). Journal of Infection in Developing Countries. 2023;17(2): 139–46.
Suleyman G, Alangaden G, Bardossy AC. The role of environmental contamination in the transmission of nosocomial pathogens and healthcare-associated Infections. Current Infectious Disease Report. 2018; 20(6):12.
Dancer SJ. Controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination. Clinical Microbiology Reviews. 2014;27(4):665–90.
Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Archives of Internal Medicine. 2006; 166(18):1945–51.
Mody L, Washer LL, Kaye KS, Gibson K, Saint S, Reyes K, et al. Multidrug-resistant Organisms in Hospitals: What is on patient hands and in their rooms?. Clinical Infectious Diseases. 2019;69(11): 1837–44.
Nuryastuti T. Current in vitro assay to determine bacterial biofilm formation of clinical isolates. Journal of the Medical Sciences. 2014;46(3):142–52.
Christianson CD, Baylis JB, Komisar V, Brinkerhoff J. Quantifying ventilation design, room layout, and occupant activity parameters during aerosol-generating medical procedures in hospitals. Indoor Air. 2023;2023(1).
Sánchez-Barroso G, García Sanz-Calcedo J. Evaluation of HVAC design parameters in high-performance hospital operating theatres. Sustainability. 2019;11(5):1493.
Sabuco-Tébar EA, Arense-Gonzalo JJ, Campayo-Rojas FJ. Biocontamination of surfaces in controlled environment rooms: The influence of environmental parameters and the design of the air conditioning system. Indoor and Built Environment. 2021;30(8):1244–51.
Fu Shaw L, Chen IH, Chen CS, Wu HH, Lai LS, Chen YY, et al. Factors influencing microbial colonies in the air of operating rooms. BMC Infectious Diseases. 2018;18(1):4.
Aziz MH, Tjampakasari CR, Aditianingsih D, Wahid M. Surveillance of fungal airborne contamination in hospital wards in Indonesia 2020-2021: Impact of HEPA filters and occupancy. Infection, Epidemiology and Microbiology. 2024;10(1):43–50.
Hiwar W, King MF, Shuweihdi F, Fletcher LA, Dancer SJ, Noakes CJ. What is the relationship between indoor air quality parameters and airborne microorganisms in hospital environments? A systematic review and meta‐analysis. Indoor Air. 2021;31(5):1308–22.
Andriana Y, Widodo ADW, Endraswari PD. A Correlation between the number of airborne bacteria and fungi using the settle plate method with temperature and relative humidity at the clinical microbiology laboratory of Dr. Soetomo Regional General Hospital Surabaya, Indonesia. Journal of Pure and Applied Microbiology. 2023; 17(2):942–50.
Murrell LJ, Hamilton EK, Johnson HB, Spencer M. Influence of a visible-light continuous environmental disinfection system on microbial contamination and surgical site infections in an orthopedic operating room. American Journal of Infection Control. 2019;47(7):804–10.
Sehulster LM, Chinn RYW, Arduino MJ, Carpenter J, Donlan R, Ashford D, et al. Guidelines for environmental infection control in health-care facilities. Recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Chicago, IL: American Society for Healthcare Engineering/American Hospital Association; 2004. Available from: [Website]
Ling ML, Apisarnthanarak A, Thu LTA, Villanueva V, Pandjaitan C, Yusof MY. APSIC guidelines for environmental cleaning and decontamination. Antimicrobial Resistance and Infection Control. 2015;4(1):58.
Sbarra AN, Harris AD, Johnson JK, Madger LS, O’Hara LM, Jackson SS, et al. Guidance on frequency and location of environmental sampling for Acinetobacter baumannii. Infection Control and Hospital Epidemiology. 2018;39(3):339–42.
Tajeddin E, Rashidan M, Razaghi M, Javadi SSS, Sherafat SJ, Alebouyeh M, et al. The role of the intensive care unit environment and health-care workers in the transmission of bacteria associated with hospital acquired infections. Journal of Infection and Public Health. 2016;9(1):13–23.
Nseir S, Blazejewski C, Lubret R, Wallet F, Courcol R, Durocher A. Risk of acquiring multidrug-resistant Gram-negative bacilli from prior room occupants in the intensive care unit. Clinical Microbiology and Infection. 2011;17(8):1201–8.
Ajao AO, Johnson JK, Harris AD, Zhan M, McGregor JC, Thom KA, et al. Risk of acquiring extended-spectrum β-lactamase– producing Klebsiella species and Escherichia coli from prior room occupants in the intensive care unit. Infection Control & Hospital Epidemiology. 2013;34(5):453–8.
Genet C, Kibru G, Tsegaye W. Indoor air bacterial load and antibiotic susceptibility pattern of isolates in operating rooms and surgical wards at Jimma University Specialized Hospital, Southwest Ethiopia. Ethiopian Journal of Health Sciences. 2011;21(1): 9–17.
Ahmed EH, Hassan AM, El-Sherbiny NM, Soliman AMA. Bacteriological monitoring of inanimate surfaces and equipment in some referral hospitals in Assiut City, Egypt. International Journal of Microbiology. 2019;2019:5907507.
Yimer RM, Alemu MK. Bacterial contamination level of indoor air and surface of equipment in the operation room in Dil-Chora Referral Hospital, Dire Dawa, Eastern Ethiopia. Infection and Drug Resistance. 2022;15:5085–97.
Ribeiro LF, Lopes EM, Kishi LT, Ribeiro LFC, Menegueti MG, Gaspar GG, et al. Microbial community profiling in intensive care units expose limitations in current sanitary standards. Frontiers in Public Health. 2019;7:240.
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