Wild Iris Medical Education
COURSE PRICE: $10.00
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This course will expire or be updated on or before December 2, 2013.
ABOUT THIS COURSE
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.
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Wild Iris Medical Education, Inc. is a Continuing Competency Approval Agency recognized by the Physical Therapy Board of California.
Approval of physical therapy continuing education credit varies by state. Confirm approval with your state's licensing agency before you take the course for CE credit. See Physical Therapy CE Approval for more information.
Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. See our disclosures for more information.
Copyright © 2011 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to provide healthcare professionals with an overview of the most common multi-drug resistant organisms and recommendations for preventing their spread.
Upon completion of this course, you will be able to:
Multi-drug resistant organisms, or MDROs, are bacteria resistant to current antibiotic therapy and therefore difficult to treat. MDROs can cause serious local and systemic infections that can be severely debilitating and even life-threatening. In the past, MDROs were predominantly confined to healthcare facilities such as hospitals, long-term care facilities, and dialysis centers. However, in recent years, these organisms have been found in populations in a variety of community settings across the country, including schools, day-care centers, prisons, and other well-populated areas.
Although there are several MRDOs, the most common include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), tuberculosis (TB), Acinetobacter, and Clostridium difficile infections (C-diff).
According to the Centers for Disease Control and Prevention, the prevalence of infections caused by MDROs is on the rise. Therefore, healthcare providers must not only be able to accurately identify and care for patients suffering from these infections but also must take measures to prevent the transmission of MDROs.
DID YOU KNOW?
A recent study in a long-term care (LTC) setting found that 51% of residents were colonized with multi-drug resistant gram-negative bacteria (MDRGN), 28% were colonized with MRSA, and 4% were colonized with VRE. Advanced dementia and nonambulatory status were risk factors for the development of multidrug-resistant gram-negative bacteria (Pop-Vicas et al., 2008).
Methicillin-resistant Staphylococcus aureus (MRSA) is a type of staphylococcal organism resistant to traditional antibiotic therapy, including methicillin, oxacillin, amoxicillin, penicillin, and cephalosporins. In 2008, there were 89,785 reported cases and 15,249 reported deaths related to MRSA (CDC, 2008a).
Magnified 20,000X, this colorized scanning electron micrograph (SEM) depicts a grouping of methicillin-resistant Staphylococcus aureus (MRSA) bacteria. (Source: Janice Carr, Centers for Disease Control and Prevention, Public Health Image Library.)
Since MRSA infections can be spread in healthcare and community settings, everyone is at risk. However, people who live in crowded and/or unclean conditions or who have a poor immune system are more susceptible to infection by MRSA. When MRSA is acquired in a healthcare facility—such as a hospital, long-term care facility, or dialysis center—it is referred to as healthcare associated MRSA, or HA-MRSA. If MRSA is acquired in a community setting—such as a prison, homeless shelter, or day-care center—it is referred to as community-associated MRSA, or CA-MRSA.
Healthcare-associated MRSA is transmitted via personal contact with contaminated items such as dressings or other infected materials. It is also spread via healthcare providers’ hands and medical objects, such as stethoscopes. Community-associated MRSA is transmitted through close personal contact with infected individuals or by sharing personal items such as towels and razors.
MRSA is normally found in the nose and pharynx and may not cause illness in its host. However, if this organism enters open cuts, incisions, or wounds, severe infection throughout the body may result. MRSA initially affects the skin and soft tissue, but it can quickly cause sepsis and/or pneumonia that may lead to death. Patients often present to their healthcare providers with an area of skin that is:
Often the affected area has a furuncle (abscessed hair follicle or “boil”), carbuncle (coalesced mass of furuncles), or an abscess. The area may also resemble a spider bite.
A cutaneous abscess located on the back of a patient, caused by MRSA. (Source: Gregory Moran, MD, Centers for Disease Control and Prevention, Public Health Image Library.)
The primary method of treatment for MRSA infection includes incising and draining infected areas. However, treatment with empiric antibiotic therapy may also be necessary. Often, vancomycin is used. If initial methods to treat a MRSA infection are unsuccessful, it is imperative that healthcare providers consult infectious disease specialists.
Enterococci are a type of bacteria normally present in the gastrointestinal tract and genital tract of some women. Enterococci can cause infections in wounds, the blood stream, and the urinary tract. Some people carry the bacteria but are unaffected by it. These people are said to be “colonized”. When enterococcus does cause an infection, the infection is treated with the antibiotic vancomycin. In recent years, Enterococci have become resistant to vancomycin treatment, giving rise to vancomycin-resistant Enterococci, or VRE. The two organisms that are predominately responsible for VRE include Enterococcus faecalis and Enterococcus faecium.
Scanning electron micrograph (SEM) image of vancomycin-resistant gram-positive Enterococci sp. bacteria. (Source: Janice Haney Carr, Centers for Disease Control and Prevention, Public Health Image Library).
VRE most commonly occurs in hospital and long-term care settings. However, it has also been seen in community settings. In 2006 and 2007, Enterococci caused approximately 1 of every 8 infections in hospitals. However, only about 30% of these infections were caused by VRE (CDC, 2008b).
According to the CDC (2008b), people at-risk for acquiring VRE include:
VRE can be found in the blood, urine, and feces. Therefore, it is often transmitted on the hands of providers who cared for a patient with VRE and inadvertently pass the “bug” on to other patients. VRE can also be transferred from patient to patient. VRE can live for several weeks on surfaces such as countertops, bedrails, and door handles and can be transmitted via contact with these surfaces.
The clinical manifestations of VRE depend on the site of the infection. If the bacterium is located in the urine, symptoms of a urinary tract infection will be evident, including lower back pain, urinary urgency and frequency, and pain with urination. If the bacterium infects a wound, the area will typically exhibit swelling, redness, and other common signs of a wound infection. Patients with a VRE infection may also have fever, chills, and diarrhea, as well as other signs of an infection.
Once identified through laboratory testing, VRE can be treated with antibiotics, preferably penicillin G or ampicillin. However, newer drugs such as Linezolid, Dapto, or Tigecycline may be needed if the VRE strain is resistant to penicillin G or ampicillin. Infectious disease specialists should be consulted to determine the best plan of care for patients with VRE.
Patients with VRE infections are placed in private rooms or with other patients who have VRE. Healthcare providers should take extra precautions to prevent the spread of the bacteria to other hospitalized patients (CDC, 2008b).
Multi-drug resistant tuberculosis (MDR-TB) is caused by Mycobacterium tuberculosis that are resistant to isoniazid and rifampicin, which are used to treat traditional strains of TB. MDR-TB may be caused by either primary infection with resistant bacteria or may develop in the course of a patient’s treatment. Extensively drug-resistant TB (XDR-TB) is a form of TB caused by bacteria that are resistant to isoniazid and rifampicin (i.e., MDR-TB) as well as to any fluoroquinolone and any of the second-line anti-TB injectable drugs (amikacin, kanamycin, or capreomycin) (WHO, 2010).
Mycobacterium tuberculosis culture revealing this organism’s colonial morphology. (Source: George Kubica, Centers for Disease Control and Prevention, Public Health Image Library.)
According to the CDC (2010c), “among TB cases in the United States with initial drug-susceptibility testing results who did not have prior treatment, the percentage of primary MDR TB cases increased slightly from 1.0% (89 cases) in 2008 to 1.2% (94 cases) in 2009.” Between 2000–2006, there were seventeen cases of XDR-TB in the United States (CDC, 2007).
While anyone can acquire MDR or XDR-TB, the following individuals are at risk for developing these resistant infections:
MDR-TB and XDR-TB are spread in the same way that traditional strains of tuberculosis are spread. TB predominately affects the lungs and is transmitted through the air via respiratory droplets when a patient coughs, sneezes, laughs, talks, etc. TB droplets can live in the air for several hours and infect others who breathe in the droplets. TB is prevalent in closed or crowded areas, such as prisons, homeless shelters, long-term care facilities, and hospitals.
Patients with MDR-TB and XDR-TB exhibit clinical manifestations in the same manner as patients with traditional strains of TB. Clinical manifestations of pulmonary tuberculosis may include all or some of the following: night sweats, fever, chills, weight loss, coughing, hemoptysis, and chest pain. Although TB predominantly affects the pulmonary system, it may affect other parts of the body, such as the kidneys, meninges, bones, joints, and abdomen. Therefore, other clinical manifestations may be present in a patient with TB and will be dependent on the parts of the body affected by the Mycobacterium tuberculosis bacterium.
According to the World Health Organization (2010b), “while drug-resistant TB is generally treatable, it requires extensive chemotherapy (up to 2 years of treatment) with second-line anti-TB drugs, which are more costly than first-line drugs, and which produce adverse drug reactions that are more severe, though manageable.”
Patients with pulmonary tuberculosis may be treated in the home. If hospitalized, these patients should be placed in respiratory isolation in a private room with negative pressure. Patient rooms should also be labeled with a sign that indicates the need to adhere to the principles of airborne precautions. N-95 respirator masks should be worn by healthcare providers when providing care to all patients with TB, regardless of the strain of TB present.
DID YOU KNOW?
The CDC “has estimated the costs for hospitalization of one XDR-TB patient at approximately $483,000, whereas outpatient treatment costs, productivity losses, patient out-of-pocket expenses, and quality-of-life changes attributable to XDR TB are unknown” (LaBue et al., 2009).
Acinetobacter is a gram-negative bacterium that is often found in soil and water and on the skin of healthy people, particularly healthcare providers. Multi-drug resistant Acinetobacter strains are resistant to most antibiotics.
Clusters of Acinetobacter baumannii. (Source: Janice Haney Carr, Centers for Disease Control and Prevention, Public Health Image Library.)
Although there are several different types of Acinetobacter bacterium, according to the CDC (2010d), “Acinetobacter baumannii accounts for about 80% of reported infections.” Furthermore, “the proportion of Acinetobacter species associated with ICU pneumonia increased from 4% in 1986 to 7% in 2003” (Gaynes & Edward, 2005).
Acinetobacter bacterium is most often found in burn units, intensive care units, and other units that care for severely ill patients (Towner, 2009). Patients with weakened immune systems or chronic diseases such as diabetes mellitus are more susceptible to an Acinetobacter bacterium. Acinetobacter is also associated with intensive care unit (ICU)–acquired pneumonia. Recently, there has been an increase in infections caused by Acinetobacter baumannii among soldiers returning from the Iraqi and Afghanistan wars due to contaminated surfaces in field hospitals (Peleg et al., 2008).
The Acinetobacter bacterium is transmitted from person-to-person contact, contact with contaminated surfaces, or environmental exposure. Acinetobacter bacterium can last quite some time on the hands of healthcare providers and also in the environment on counters and other areas within healthcare settings. Healthcare providers who are colonized with Acinetobacter can spread the infection while not exhibiting clinical manifestations of infection.
Acinetobacter bacterium can cause a variety of infections, including blood and wound infections. Therefore, the clinical manifestations will depend on the site of infection. As previously mentioned, Acinetobacter can also cause pneumonia. Patients with pneumonia caused by the Acinetobacter bacterium will exhibit fever, chills, and/or cough.
Multi-drug resistant strains of Acinetobacter are sometimes susceptible only to polymyxins (colistin and polymyxin B), a class of antimicrobial drugs that has not been in widespread use for several decades and is more toxic than most currently used antimicrobial drugs (Sunenshine et al., 2007). However, treatment decisions for infections caused by the Acinetobacter bacterium should be made on a case-by-case basis.
Clostridium difficile (C-diff) is a gram-positive bacterium that causes severe diarrhea and in some cases, inflammation of the colon. In 2004, Clostridium difficile bacterium strains resistant to antibiotics such as fluoroquinolones were reported in several hospitals throughout the country. The CDC (2010a) reports that:
…increased fluoroquinolone resistance does not affect the management of infections caused by this strain. Fluoroquinolones have never been recommended for treatment of Clostridium difficile infection, and susceptibility testing is performed only as a part of an epidemiological investigation. However, resistance to fluoroquinolones may provide the epidemic strain with an advantage over susceptible strains to spread within healthcare facilities where these antibiotics are commonly used.
Clusters of Clostridium difficile bacterium from a stool sample culture. (Source: Janice Haney Carr, Centers for Disease Control and Prevention, Public Health Image Library.)
Eighty percent of C-diff cases are found in healthcare settings (CDC, 2010a). The C. difficile bacterium is responsible for 15–25% of all episodes of antibiotic-associated diarrhea (CDC, 2010a).
Patients at risk for the development of illness due to the Clostridium difficile bacterium predominately include the elderly. However, this bacterium has recently been reported in traditionally healthy people, such as peripartum women (CDC, 2010a). Other patients at risk for the development of illness due to C-diff include patients with any of the following:
The Clostridium difficile bacterium is spread in fecal matter and can be transmitted via surfaces such as countertops and toilets and equipment such as rectal thermometers. However, the bacterium is most commonly transmitted on the hands of healthcare providers (CDC, 2010a).
DID YOU KNOW?
A recent study found “that a daily cleaning regimen using germicidal bleach wipes reduced the incidence and time between cases of healthcare-acquired Clostridium difficile infections on two units that had been hard hit by the troublesome pathogen. …The overall incidence of healthcare-acquired C. diff infection (CDI) fell from 18.4 per 10,000 patient-days to 3.7 after the intervention. Moreover, the time between healthcare-acquired cases of CDI went from 13 days to 74 days” (Orenstein, 2010).
Patients affected by C-diff may exhibit watery diarrhea, fever, loss of appetite, nausea, and abdominal pain and tenderness. Clinical manifestations can range from mild diarrhea to death. Patients carrying the C. difficile bacterium can be colonized with the bacterium and not exhibit any clinical manifestations. However, patients may also present with symptoms of pseudomembranous colitis, toxic megacolon, perforation of the colon, and sepsis (CDC, 2010a).
Healthcare providers treating patients affected by resistant strains of the Clostridium difficile bacterium have the unique challenge of finding effective treatment for these patients.
The usual treatment for C. difficile infection includes, if possible, stopping antibiotics being given for other purposes and/or treatment with metronidazole or vancomycin. In order to reduce selective pressure for vancomycin resistance in Enterococci, current guidelines recommend the first-line use of metronidazole over vancomycin. However, recent reports suggest that the new strain may not respond as well to treatment with metronidazole despite the absence of laboratory evidence of metronidazole resistance. This may be due to increased virulence in the new strain. Depending upon the severity of the CDI, metronidazole is likely to be the appropriate first-line therapy for most cases. Regardless of what therapy is used, patients should be carefully monitored to be sure they are responding to therapy and that there is no deterioration in their condition (CDC, 2010a).
Patients should be cared for in private rooms or with other patients affected by the bacterium. These patients should also be placed on contact precautions while being treated.
DID YOU KNOW?
Because alcohol does not kill Clostridium difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs. However, early experimental data suggest that, even using soap and water, the removal of C-diff spores is more challenging than the removal or inactivation of other common pathogens (CDC, 2010a).
Preventing the spread of multi-drug resistant organisms is vital to the safety and well-being of patients who are hospitalized as well as individuals who are susceptible to infection due to unsanitary or crowded living conditions or a weakened immune system. It is the responsibility of all healthcare providers to not only aid in preventing the development of multi-drug resistant organisms but to teach patients and the public about the prevention and transmission of multi-drug resistant organisms.
The CDC (2007) categorized the interventions necessary to control or eradicate multi-drug resistant organisms. These categories include administrative support, education, judicious use of antimicrobial agents, MDRO surveillance, infection control precautions, environmental precautions, and decolonization.
In order to assist in controlling the transmission of multi-drug resistant organisms, administrators must be dedicated to offering the financial and human resources necessary to combat these organisms. Allocation of fiscal resources for antimicrobial agents, hand-washing sinks, personal protective equipment, alert systems, education, and infectious disease personnel are imperative. For example, a sufficient number and the correct placement of hand-washing sinks and sanitizer dispensers, along with the development of educational materials and guidelines for the enforcement of compliance policies, can help curtail this growing dilemma.
Administrators must also be willing to allocate personnel who can track and monitor the incidence of multi-drug resistant organisms and educate healthcare providers regarding prevention, identification, and treatment of these organisms. Personnel should also be available to work on regional, state, and federal initiatives to control the spread of multi-drug resistant organisms in healthcare facilities and in the community (CDC, 2008).
Education is one of the most important components of any program designed to decrease the transmission of multi-drug resistant organisms. According to the CDC (2008):
Educational campaigns to enhance adherence to hand-hygiene practices in conjunction with other control measures have been associated temporally with decreases in MDRO transmission in various healthcare settings. It is important for patients and healthcare providers to understand their role in the transmission of MDROs and the importance of hand hygiene.
Healthcare providers with prescribing privileges must be knowledgeable regarding the administration of antimicrobial agents to control the transmission of MDRO. The CDC’s Campaign to Prevent Antimicrobial Resistance, which was launched in 2002, recommends focusing on the following:
Healthcare providers without prescribing privileges are also an important component of this process and should be knowledgeable about the efforts to use antimicrobials judiciously and to educate their patients about these efforts.
One of the most essential components in the fight to control MDROs is the surveillance of MDROs. The study of epidemiological trends, emerging pathogens, and the effectiveness of interventions are all part of MDRO surveillance.
HEALTHCARE-ASSOCIATED INFECTIONS
In American hospitals alone, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. Of these infections:
Source: CDC, 2010a.
The implementation of Standard Precautions and Contact Precautions are necessary to aid in preventing the transmission of MDROs. Standard Precautions instruct healthcare providers to wash hands often and effectively and to use PPE (personal protective equipment) when coming into contact with blood or body fluids. Such precautions are necessary with all patients and effective in preventing transmission from potentially colonized patients (CDC, 2008).
Precautions used when caring for patients with MDROs vary based on the organism involved. However, Contact Precautions are often used with these patients and involve wearing PPE prior to entering the patient’s room and discarding that equipment prior to leaving the patient’s room. Additionally, dedicated equipment, such as stethoscopes, blood pressure cuffs and machines, etc., should be placed and used only in the patient’s room. These patients are often assigned to private rooms or semi-private rooms with other patients who are also under special precautions.
Many MDROs can survive for quite some time on environmental surfaces in healthcare facilities and in patient homes. Therefore, it is imperative that healthcare providers, environmental services personnel, and patients understand the importance of both meticulous hand washing and proper cleaning methods. The CDC (2006) reports that “the lack of adherence to facility procedures for cleaning and disinfection” is a commonly cited cause for environmental contamination in healthcare facilities. Therefore, the regular testing of environmental surfaces and subsequent education of all personnel is essential to help prevent the further spread of MDROs.
DID YOU KNOW?
“Frequently touched surfaces in rooms of patients with CDAD (Clostridium difficile associated diseases) or VRE (vancomycin-resistant enterococcus) colonization or infection were often contaminated with these pathogens after terminal cleaning by housekeeping staff. Simple educational interventions directed at housekeepers can result in improved environmental decontamination, but these interventions should include efforts to monitor cleaning practices and provide feedback to the housekeeping staff” (Eckstein et al., 2007).
Decolonization involves the treatment of patients colonized with a MDRO with the goal of destroying the offending organism, usually MRSA. Decolonization has not been particularly effective and is therefore only used in the presence of a MDRO outbreak. Patients who are colonized with a MDRO and are asymptomatic are generally not candidates for decolonization (CDC, 2006).
PREVENTING ANTIMICROBIAL RESISTANCE IN HEALTHCARE SETTINGS
Prevent Infection
Diagnose and Treat Infection Effectively
Use Antimicrobials Wisely
Prevent Transmission
Source: CDC, 2003.
With the constant need to protect patients from MDROs, healthcare providers must be willing and able to educate patients and their families regarding MDROs. Education for each patient should be tailored to the MDRO that caused the problem. However, there are a few general measures that healthcare providers can teach patients and their families to help prevent the transmission of MDROs.
When at a healthcare facility:
At home:
With the increased rate of infection caused by multi-drug resistant organisms, healthcare providers are charged with the responsibility of preventing and detecting MDROs as well as educating the public about these organisms. It is imperative that healthcare providers learn about and remain up-to-date on resistant organisms, prevention measures, and treatment options.
Association for Professionals in Infection Control and Epidemiology
http://www.apic.org
CDC Get Smart for Healthcare Program
http://www.cdc.gov/drugresistance/healthcare/default.htm
Discover Nursing: Infection Control Nursing
http://www.discovernursing.com/jnj-specialtyID_171-dsc-specialty_detail.aspx
Infectious Diseases Society of America
https://www.idsociety.org
Institute for Health Care Improvement
http://www.ihi.org/IHI/Topics/HealthcareAssociatedInfections
International Council of Nurses: TB/Multi-Drug Resistant Tuberculosis (MDR-TB)
http://www.icn.ch/projects/tb-mdr-tb/
Medline Plus: Infection Control
http://www.nlm.nih.gov/medlineplus/infectioncontrol.html
World Health Organization: Infectious Diseases
http://www.who.int/topics/infectious_diseases/en/
Centers for Disease Control and Prevention (CDC). (2010a). Clostridium difficile infection. Retrieved March 10, 2011, from http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html.
Centers for Disease Control and Prevention. (2010b). Fact sheet: Multidrug-resistant tuberculosis (MDR-TB). Retrieved June 7, 2010, from http://www.cdc.gov/tb/publications/factsheets/drtb/mdrtb.htm.
Centers for Disease Control and Prevention. (2010c). Trends in tuberculosis: 2009. Retrieved March 10, 2011, from http://www.cdc.gov/tb/publications/factsheets/statistics/TBTrends.htm.
Centers for Disease Control and Prevention. (2010d). Acinetobacter in healthcare settings. Retrieved March 11, 2011, from http://www.cdc.gov/HAI/organisms/acinetobacter.html.
Centers for Disease Control and Prevention. (2008a). Active Bacterial Core Surveillance Report, Emerging Infections Program Network, Methicillin-Resistant Staphylococcus Aureus, 2008. Retrieved March 11, 2011, from http://www.cdc.gov/abcs/reports-findings/survreports/mrsa08.pdf.
Centers for Disease Control and Prevention. (2008b). Vancomycin-resistant Enterococci in healthcare settings. Retrieved March 11, 2011, from http://www.cdc.gov/HAI/organisms/vre/vre.html.
Centers for Disease Control and Prevention. (2007). Extensively drug-resistant tuberculosis: United States, 1993–2006. Morbidity and Mortality Weekly Report, 6(11), 250–253.
Centers for Disease Control and Prevention. (2006). Management of multidrug-resistant organisms in healthcare settings, 2006. Retrieved March 11, 2011, from http://www.cdc.gov/ncidod/dhqp/pdf/ar/MDROGuideline2006.pdf.
Centers for Disease Control and Prevention. (2003). Campaign to prevent antimicrobial resistance in health care settings. Retrieved July 12, 2010, from http://www.cdc.gov/drugresistance/healthcare/ha/12steps_HA.htm.
Eckstein BC, Adams DA, Eckstein EC, Rao A, Sethi AK, Yadavalli GK, Donskey CJ. (2007). Reduction of Clostridium difficile and vancomycin-resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods. BMC Infectious Diseases, 7(61), 1–6.
Gaynes R & Edwards JR. (2005). Overview of nosocomial infections caused by gram-negative bacilli. Clinical Infectious Disease, 41(6), 848–54.
LaBue P, Sizemore C & Castro K. (2009). Plan to combat extensively drug-resistant tuberculosis: Recommendations of the Federal Tuberculosis Task Force. MMWR Recommendations & Reports, 58 (RR-3), 1–43.
Orenstein, R. (2010). Bleach wipe program vanquishes C. diff. Hospital Infection Control & Prevention, 37(6), 68–69.
Peleg AY, Seifert H & Paterson DL. (2008). Acinetobacter baumannii: Emergence of a successful pathogen. Clinical Microbiology Reviews, 21(3), 538–82.
Pop-Vicas A, Mitchell S, Kandel R, Schreiber R, & D'Agata E. (2008). Multidrug-resistant gram-negative bacteria in a long-term care facility: Prevalence and risk factors. Journal of the American Geriatrics Society, 56(7), 1276–1280.
Sunenshine RH, Wright M-O, Maragakis LL, Harris AD, Song X, Hebden J, et al. (2007). Multidrug-resistant Acinetobacter infection mortality rate and length of hospitalization. Emerging Infectious Diseases. Retrieved June 22, 2010, from http://www.cdc.gov/ncidod/EID/13/1/97.htm.
Towner KJ. (2009). Acintobacter: An old friend, but a new enemy. Journal of Hospital Infections, 73(4), 35–63.
World Health Organization. (2010a). Drug-resistant tuberculosis now at record levels. Retrieved June 7, 2010, from http://www.who.int/mediacentre/news/releases/2010/drug_resistant_tb_20100318/en/index.html.
World Health Organization. (2010b). Fact sheet: Tuberculosis. Retrieved June 7, 2010, from http://www.who.int/mediacentre/factsheets/fs104/en/index.html.
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