Multicomponent Approaches to Reduce Multidrug-Resistant Organisms in Critical Care: Determining the Ideal Strategy

Abstract

Although there is ample proof of the advantages of infection prevention and Control (IPC) in acute-care hospitals, there is still some questions about the efficacy of IPC interventions for multidrug-resistant organisms (MDROs), and there is a need for the development of evidence-based practices. No healthcare facility has found a single effective technique to reduce MDRO. However, a multicomponent intervention that included improved barrier protection, chlorhexidine bathing, microbiological monitoring, and staff involvement significantly decreased the likelihood of infection in the patient surroundings with multidrug-resistant organisms. A practical strategy suited to reducing the burden of MDROs and their transmission potential in the critical care unit must be established in light of the global development of AMR. In this review, we summarize key findings of a multicomponent approaches to reduce MDROs in critical care units.

Introduction

The rise of multidrug-resistant organisms (MDRO) in the twenty-first century is a significant public health problem [1]. It has a major disadvantage by reducing the number of diseases that can be effectively treated with antimicrobials and raises global morbidity, mortality, and healthcare expenditures [2–4].

While developing novel antibiotics is one of the most effective ways to attack MDROs directly, the process may need to be improved by financial and technological advancements and to overcome obstacles such as long clinical trials and low profitability yields [5]. Evidence points to a strong correlation between antibiotic consumption rates and the prevalence of antibiotic resistance, both individually and collectively [6, 7]. As a result, the current antimicrobial resistance (AMR) crisis cannot be solved effectively by employing antibiotics alone.

A different and valuable approach to reducing MDRO colonization and avoiding suffering from MDRO infections is infection prevention and Control (IPC). This strategy uses both horizontal and vertical interventions. While vertical solutions aim to curb the spread of a single illness by active screening and decontamination, horizontal interventions simultaneously aim to curb the spread of many diseases through best practices [8].

The incidence of MDROSs in intensive care units (ICUs) is rising. These include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Acinetobacter baumannii, Enterobacteriaceae that produce extended-spectrum beta-lactamases and carbapenemases (ESBLs and CREs), and carbapenem-resistant Enterobacterium. Infections caused by resistant pathogens are notoriously challenging to treat and have been related to more significant expenses, morbidity, and death [9, 10].

Antimicrobial resistance is associated with high death rates and high medical expenditures. AMR global burden was assed and evaluated as per recent Lancet Study, through obtained data from systematic literature reviews, hospital systems, surveillance systems, and other sources, covering 471 million individual records or isolates and 7585 study-location-years [11]. There were an estimated 4·95 million (3·62–6·57) deaths associated with bacterial AMR in 2019, including 1·27 million (95% UI 0·911–1·71) deaths attributable to bacterial AMR. At the regional level, we estimated the all-age death rate attributable to resistance to be highest in western sub-Saharan Africa, at 27·3 deaths per 100 000 (20·9–35·3), and lowest in Australasia, at 6·5 deaths (4·3–9·4) per 100 000. Lower respiratory infections accounted for more than 1·5 million deaths associated with resistance in 2019, making it the most burdensome infectious syndrome [11]. Disease prevention is hindered by the rise in the prevalence of MDROs. Because of this, the patient’s infection will persist for longer, and less medication will be effective. Also elevated costs with increase resistance associated with related consequences with use of specialized equipment, longer hospital stay and isolation procedures for the patients. Societal costs include death and loss of productivity [12].

MDROs of Concern and Risk Factors for Resistant Infections

Epidemiologically, MDROs are defined as microorganisms, predominantly bacteria, resistant to one key drug or more antimicrobial agents from several drugs classes [13]. Although the names of certain MDROs describe resistance to only one agent such as methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant Enterococci (VRE), these pathogens are frequently resistant to most available antimicrobial agents. This extended resistance was also observed with clinically significant Gram negative MDROs: Carbapenem-resistant Enterobacteriaceae (CRE), multidrug-resistant Acinetobacter, multidrug-resistant Pseudomonas aeruginosa and most significant fungal MDRO pathogen Candida auris [14]. Figure 1 shows the timeline of emergence MDROs of concern.

Fig. 1.

Timeline of the emergence of major MDROs

Specific factors increase the likelihood of infections with multidrug-resistant pathogens in ICUs by increasing the selection pressure (which results in the development of these organisms) and colonization pressure (which results in inadequate containment of these organisms) [15–17]. Mainly, the following are risk factors for resistant infections reported from ICUs [18–20]: higher age, reduced intellect and a lack of functional independence, underlying comorbid diseases (such as diabetes, renal failure, cancers, and immunosuppression) and more significant acute illness severity indices, having spent a long time in the hospital before being admitted to the ICU, including being transferred between institutions (particularly from nursing homes), interactions with healthcare settings regularly (e.g., hemodialysis units, ambulatory daycare clinics), frequent interaction with medical staff who are simultaneously caring for several patients, since their hands might function as a conduit for the spread of germs from one patient to another. Infections in the ICU may also be acquired via the use of shared equipment and contaminated settings as reservoirs and vectors, the use of indwelling medical equipment, such as urine catheters, endotracheal tubes, and central venous catheters, which work to circumvent the host’s natural defenses and act as entrance points for germs, Recent surgery or other invasive operations, followed by the administration of antibiotics before ICU admission, produces a selection pressure that encourages the growth of multidrug-resistant bacteria [21, 22].

Several research and approaches have shown the correlation between the past use of antibiotics and infection with drug-resistant organisms. Antibiotic exposure has repeatedly been linked to the formation of resistance to the same or a different class of antimicrobial agent in case-control studies [23]. For instance, the rise of P. aeruginosa, resistant to piperacillin, has been associated with fluoroquinolones [24]. In a study of patients with ventilator-associated pneumonia, those with piperacillin-resistant P. aeruginosa strains had a higher likelihood of taking fluoroquinolones before developing pneumonia (OR 4.6, 95% CI 1.7–12.7). In a different investigation, exposure to antibiotics was shown to be the most effective single predictor for infection with highly drug-resistant gram-negative bacteria [23].

Prevention Multi-components and Strategies

Preventive multi-components and strategies consist of two main arms (A) Antimicrobial stewardship and (B) Infection Control measures with its subcategories (Fig). 2.

Fig. 2.

Figure Multicomponent Approach to Reduce Multidrug-Resistant

A) Antibiotic Stewardship Programs — The objective of antibiotic stewardship programs (ASP) is lowering infections caused by resistant bacterial strains and may be fully addressed by incorporating ASP into hospital initiatives. The programs support antimicrobial agents’ efficient and wise use, assess and direct formulary choices, and execute educational initiatives to enhance antimicrobial use [25].

Antimicrobial stewardship programs in the ICU have been impactful and associated with decreased drug-resistant bacteria. As an example, in a study of two ICUs in the United States that implemented a comprehensive antimicrobial stewardship program, the proportion of hospital-acquired infections (HAI) caused by certain multidrug-resistant gram-negative bacilli, including P. aeruginosa, A. baumannii, and extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae decreased from 37.4 per cent in 2001 to 8.5 per cent in 2008 [23]. Similarly, in a study of an ICU in Melbourne, Australia, which implemented an antimicrobial stewardship program, 2838 gram-negative bacilli were isolated from clinical cultures over seven years, and, over this time, there were significant increases in susceptibility of P. aeruginosa to imipenem (18.3 per cent/year, p = 0.009) and gentamicin (11.6 per cent/year, p = 0.02) compared with trends recorded before the stewardship program [26]. Improvements in the rates of gentamicin and ciprofloxacin susceptibility were also noted among Enterobacter spp.

There may be concerns that antibiotic stewardship may delay the initiation of appropriate antimicrobial therapy, which has been associated with poor clinical outcomes with infections caused by multi- and extensively drug-resistant infections [27]. However, a meta-analysis of five studies found that implementation of antimicrobial stewardship programs in ICUs was not associated with increased mortality (pooled relative risk 1.03, 95% CI 0.93–1.14), thus providing some reassurance that there is no clear evidence of unintended harmful effects of stewardship programs on mortality in the ICU setting [28].

Antimicrobial use and the possibility of infection or colonization with resistant bacteria may be reduced by preventing infections and shortening patients’ lengths of stay in the hospital. Limiting unnecessary use of a central venous catheter, bladder catheter, and endotracheal intubation decreases infection rates, decreases antibiotic use, and decreases selective antibiotic pressure on resident bacteria. Clinicians should assess daily the need to keep each invasive device in place [29].

B) Infection Control Measures — Infection control methods are the main multidrug-resistant organism prevention strategies that do not modify how antimicrobials are used. Resistant organism outbreaks have been controlled by paying close attention to these activities [27]. Methicillin-resistant S. aureus (MRSA) may be selectively reduced with intranasal mupirocin [30]. Patients with resistant infections or colonization wound drainage that dressings cannot control and experiencing diarrhea all call for contact precautions. Identification and management of the epidemic and endemic resistance rates depend on the surveillance of drug-resistant organisms. A further proven strategy to stop the spread of multidrug-resistant pathogens in the ICU is to improve environmental cleaning, monitoring, and procedures [31].

1) Hand Hygiene - The great majority of analyzed papers by WHO systemic literature review [32] offer convincing evidence that improved hand hygiene practices lead to a reduction of HAIs and/or transmission or colonization by MDROs. Hand hygiene was the main intervention in most of these studies indicate that it remains the cornerstone in prevention of infection transmission but it needed to be multimodal and sustained over time which always consider the main drawback and need frequent and continuous monitoring for healthcare worker’s compliance.

According to Widmer, 2000, alcohol gel/foam is not appropriate for hands that are visibly soiled or for health care personnel caring for patients with C. difficile infection (or other spores-forming organisms) since the foam does not inactivate C. difficile toxins and does not kill the spores themselves. There must be strict adherence to hand-washing protocols. Alcohol-based hand hygiene is more effective than ordinary antiseptic soap and water at eliminating germs from the hands, and it may be done anywhere without a sink or towels [33].

2) Contact Precautions, Cohorting, and Dedicated Staff – Wright, 2004 outlines that reducing the spread of MRSA, vancomycin-resistant enterococci (VRE), carbapenem-resistant and extended-spectrum beta-lactamase (ESBL) producing gram-negative organisms, and other superbugs by wearing a gown and gloves when entering a patient room and removing them before or shortly after exiting is very essential as prevention for contact, cohorting and dedicated staff decline.(but still adjacent to the patient’s immediate environment) [34].

Whether to use universal contact precautions for every patient in the ICU, regardless of colonization history, is a matter of ongoing debate. Although this may be reasonable practice in outbreak settings or institutions with a high rate of colonization or infection with drug-resistant bacteria, routine use of universal contact precautions still needs to be supported by strong scientific evidence. Some observational studies have suggested a decrease in transmission rates of drug-resistant organisms with universal contact precautions [34]. However, a sizeable cluster-randomized trial failed to demonstrate a statistically significant benefit of the universal use of contact precaution measures in reducing MRSA acquisition in the ICU [35].

In another multicenter trial, contact isolation practices were observed among healthcare workers; as the proportion of patients in contact isolation increased, compliance with contact isolation precautions decreased [36].

Another potential control measure is geographically cohorting carriers of the same multidrug-resistant organism (MDRO) and assigning dedicated nursing staff to such patients. In one outbreak of carbapenem-resistant Enterobacteriaceae, the outbreak was contained only after the implementation of dedicated cohorting [37]. However, a single unit for the care of patients with multiple different types of MDROs should be avoided since genes conferring resistance can cross between species [38].

Decolonization/Patient Bathing

Daily bathing with chlorhexidine gluconate (CHG), an antiseptic agent with broad-spectrum activity against many organisms, effectively decreases hospital-acquired infections like bloodstream infections, urinary tract infections, surgical site infections, and ventilator-associated pneumonia among intensive care unit (ICU) patients. In cases when methicillin-resistant Staphylococcus aureus (MRSA) infection is of great concern, intranasal mupirocin may also be administered.

Chlorhexidine-impregnated cloths or chlorhexidine-soaked washcloths should be firmly massaged on overall patient body surfaces and skin folds below the jawline with exclusion of the face. Most extensive trials evaluating chlorhexidine bathing used this approach with impregnated cloths and it did show significant reduction in acquiring MDROs and developing HAI [32].

Studies on chlorhexidine bathing are mainly favorable, not with standing some minor discrepancies. Daily chlorhexidine bathing was linked to a lower risk of healthcare-associated bloodstream infections than soap and water or no bathing in a meta-analysis of two controlled trials and ten observational studies of ICU patients (odds ratio [OR] 0.44, 95% CI 0.33–0.59) [39]. Similarly, there was a 28% decrease in hospital-acquired bloodstream infections in a second study, including more than 7000 patients in ICUs and bone marrow transplant units (4.8 vs. 6.6 instances per 1000 patient days, respectively) [40].

Despite one study finding that daily chlorhexidine bathing did not show a decreased incidence of healthcare-associated infections, one cluster-randomized, crossover study with 9340 adults in ICUs was underpowered to detect such differences due to the rarity of events, which limits the generalizability of the findings [41].

Universal decolonization with chlorhexidine bathing and twice-daily mupirocin nasal cream is a strategy that can be used to decrease MRSA bloodstream infections in the intensive care unit. In a large, multicenter trial that involved over 74,000 patients, universal decolonization with chlorhexidine and twice daily intranasal mupirocin reduced both MRSA-positive clinical cultures and bloodstream infections due to any pathogen (hazard ratios [HRs] 0.63 and 0.56 compared with baseline rates) to a greater extent than screening and isolation (HRs 0.92 and 0.99) or targeted decolonization of carriers (HRs 0.75 and 0.78) [32]. The number of patients requiring decolonization to prevent one MRSA infection or one bloodstream infection was 181 or 54, respectively. However, since chlorhexidine and mupirocin were used for decolonization, the clinical effect in this study cannot be reliably attributed to chlorhexidine alone.

However, the emergence of resistance to chlorhexidine is an important consideration [42] In a study including two 15-bed intensive care units over four years, introducing a chlorhexidine-based surface antiseptic protocol was associated with a 70 per cent reduction in MRSA transmission. However, the transmission of strains carrying the plasmid-born qacA/B gene (which codes for multidrug efflux pumps and can lead to chlorhexidine resistance) was not reduced [43]. Resistance to triclosan, an ingredient in some antimicrobial soaps, has also emerged among dermal, intestinal, and environmental microorganisms, including S. aureus [44].

The acquisition rate grows non-linearly as the fraction of patients getting antibiotics increases. The qualities of the antibiotic agent and the frequency of antibiotic usage determine how antibiotics affect the spread of resistance [45]. The influence of antibiotics on the dissemination rises as the bacterial strain is more contagious and falls as resistance prevalence grows. For individuals receiving antibiotic treatment and those who do not, the risk of developing ARB rises in lockstep with antibiotic density. The use of antibiotics in the hospital context significantly impacts how quickly resistance spreads.

Digestive and Oropharyngeal Decontamination

Decontamination of the digestive and oropharyngeal tracts has been proposed to reduce infection in critically ill patients by reducing microorganism colonization at these sites.

In the Netherlands, a region with low baseline antimicrobial resistance, moderate mortality benefits have been demonstrated among ICU patients treated with selective oropharyngeal decontamination (SOD) and selective digestive decontamination (SDD). In addition, there has been uncertainty regarding the long-term effects of SOD and SDD on the emergence of antimicrobial resistance [46].

A cluster-randomized trial of mechanically ventilated ICU patients in the Netherlands, in which SOD was performed with topical tobramycin, colistin, and amphotericin B, and SDD was performed with four days of intravenous cefotaxime in addition to tobramycin, colistin, and amphotericin B administered topically and through a nasogastric tube [47]. These techniques were associated with lower mortality odds than standard care in adjusted analyses. In a subsequent trial analysis, SOD and SDD were associated with decreased bacteremia rates and respiratory tract colonization with highly resistant bacteria [46].

Active Surveillance Culture

Surveillance cultures can be either passive or active. The former is usually done as part of the diagnostic evaluation of an active infection guided by the patient’s clinical presentation. Typically, passive surveillance cultures are not done periodically and only focus on sites of evident infection (e.g., urine, blood, etc.). Active surveillance cultures (ASCs), on the other, are done periodically regardless of the presence or absence of infection, aim to identify asymptomatic carriers (colonization), and typically include external sites with no apparent infection (for example, nasal and rectal swabs).

Earlier studies of ASCs have focused on screening for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) [47–52]. Several studies in this regard have shown the benefit of ASCs with early identification of infected and asymptomatic carriers coupled with isolation/cohorting of these patients. Most of these studies included targeted patients for ASCs in acute care, but the universal screening was also reported [53, 54]. The duration of applying ASCs reported in these studies varied from months in the majority to several years in some. More recently, studies evaluated the implementation of ASCs to curbside hospital and community outbreaks of gram-negative multidrug-resistant organisms (MDROs) with emphasis on carbapenem-resistant Enterobacteriaceae (CRE), carbapenem-resistant A. baumannii (CRAB), and, to a lesser extent, Carbapenem-resistant P. aeruginosa. [55–59].

Furthermore, several studies have assessed other potential additional benefits when applying ASCs, whether ASCs were the only intervention or part of a multi-interventional program. In this context, ASCs are effective in controlling outbreaks, identifying asymptomatic carriers, especially during outbreaks, providing accurate data on the prevalence of MDROs in hospitals and communities, guiding empirical antimicrobial therapy in sick patients, decreasing rates of hospital-associated infections, focusing infection prevention efforts wherever needed, inform local and national policies and guidelines, and identify emerging or novel pathogens and resistance mechanisms in any given population [49, 60–73].

Studies that have evaluated implementing ASCs were either done with ASCs as the primary intervention, usually coupled with isolation/cohorting of identified patients [74], or were included in a multimodal intervention; the latter included some or all of the following additional infection control measures: hand hygiene, isolation of infected/colonized patients, intensifying environmental cleaning and disinfection, implementing chlorhexidine-based daily baths, incorporating decolonization interventions whenever available, and launching antimicrobial stewardship program. Although several studies have reported benefits from the sole implementation of ASCs alone, the effectiveness of ASCs when incorporated in a multimodal approach was more profound and sustained over time [73]–[74].

ASCs, as part of multi-level interventions to control outbreaks of MDROs, have been endorsed in the most recent guidelines of the U.S. Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) and the European Centers for Disease Control and Prevention (EUCDC) [73–75]. Nonetheless, when establishing ASCs in a hospital or at a broader scale, several factors have to be considered: (1) pathogen(s) of concern, (2) epidemiological setting (endemic or epidemic) in the population, (3) targeted versus universal screening, (4) screening methods (conventional versus molecular), (5) sites of screening cultures based on anticipated colonization sites, (6) frequency and duration of ASCs, (7) measures to be implemented for colonized patients identified in the ASC (e.g. isolation/cohorting, decolonization, etc.), and (8) cost-effectiveness of the ASCs.

To have a successful program, we recommend implementing targeted ASCs for patients in critical care units and other high-risk areas, screening for pathogens of epidemiological significance, extending the ASCs for one or more years, and including a cost-benefit analysis.

Device-Specific Strategies

In addition, as many of the multidrug-resistant infections in the ICU are associated with indwelling devices, specific strategies for placement and care of such devices, as well as additional adjunctive measures, are effective in reducing the risk of catheter-associated urinary tract infections (CAUTI), ventilator-associated pneumonia (VAP), and central line-associated blood stream infection (CLABSI).

To prevent the spread of MDROs, device-specific strategies are implemented for urinary catheters, ventilators, and central lines. For urinary catheters, it involves using aseptic technique during insertion, utilizing infection prevention features, implementing catheter care bundles, minimizing unnecessary use, and monitoring for catheter-associated urinary tract infections (CAUTIs). For ventilators, strategies include following hand hygiene and aseptic technique, regular cleaning and disinfection, proper circuit management, maintenance, monitoring, and following guidelines for ventilator-associated pneumonia (VAP) prevention. Central line strategies involve adhering to aseptic technique, using evidence-based bundles, assessing necessity and promoting removal, utilizing specialized dressings or catheters, implementing CLABSI prevention programs, and ensuring surveillance and education. Customizing these strategies to facility guidelines, providing staff education, training, and monitoring compliance are important components in halting MDRO spread.

It’s important to note that these strategies should be tailored to the specific policies and guidelines of each healthcare facility, as recommendations may vary. Regular staff education, proper training, and ongoing monitoring of compliance are critical components of stopping the spread of MDROs with these devices.

Environmental Cleaning

In the critical care unit and the rest of the hospital environment, environmental cleaning, disinfection, and sterilization are crucial procedures to prevent or decrease infections. Hydrogen-peroxide vapor decontamination tools and ultraviolet light sterilization lamps are two novels but unproven methods for cleaning the environment that may aid future efforts to lessen colonization pressure. However, these new technologies will not replace the need for adequate manual “terminal” cleaning that every ICU should set in a documented policy, and adherence to the protocol must be frequently checked [76].

Due to their simplicity, safety, and microbiologic effectiveness, the following three novel technologies seem promising: The final cleaning process uses (1) hydrogen peroxide vapor and (2) UV light decontamination [77]. Even in places that are difficult to reach, these methods work. (3) Daily cleaning may be done using ultra-microfibers and a copper-based biocide basis [76]. Other approaches, including ozone, steam, or high-efficiency particle air filtration, need to be more practical to be taken seriously as candidates for raising the standard of the hospital environment. The prevalence and incidence of HAP and HAI have not yet been shown to be reduced as a result of these novel technologies. Until further studies can validate these new techniques’ efficacy in treating HAI, it is still challenging to justify the additional expense involved [78].

The number and kind of research that have been published that address the primary categories of cleaning and disinfection treatments. Including 47 studies of surface cleaning/disinfection modalities, 12 studies of strategies for monitoring cleanliness, and 17 studies addressing implementation of best practices. Many surface disinfection techniques were evaluated, including well-established products such as quaternary ammonium and bleach, recently emerging technologies such as UV-C light, hydrogen peroxide vapor, and copper coatings, and less frequently used approaches, including sporicidal wipes and microfiber cleaning instruments. These studies did show positive outcomes in achieving improvement in cleaning and disinfection practice [79].

Multiple studies assessed several different monitoring techniques, including ATP, UV light, microbiologic colony counts, and visual inspection. It found that these modalities may demonstrate better diagnostic than visual inspection.

Antibacterial Curtains Used in Open Area Designation

Privacy curtains are among the environmental elements identified as important sites of bacterial contamination in hospitals [80, 81]. One study carried out in intensive care units and medical wards revealed that 95% of the examined curtains were contaminated with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) [58]. Evidence suggests that bacteria from privacy curtains can be transferred to healthcare workers’ hands and gloves, for example, in a recent study from a Canadian hospital emergency department [77]. Studies have indicated that integrated antibacterial, sporicidal privacy curtains with antimicrobial properties may be cost-effective in removing bioburden from the patient environment [60].

A prospective, open-labeled, multicenter study with a follow-up duration of 6 months. This study included 12 rooms of patients with multidrug-resistant organisms (MDROs) Culture samples were collected from curtain surfaces twice a week for 2 weeks, followed by weekly intervals. Antimicrobial curtain was highly effective in reducing the bioburden (colony forming units /100 cm, 1 vs. 57; P < 0.001) compared with the standard curtain, included MRSA and CRAB. Moreover, the median time to first contamination by MDROs was 27.6 times longer for antimicrobial curtains than for standard curtains [83].

In one research, the efficiency of preventing pathogenic contamination was compared between calamine-impregnated curtains and calamine-impregnated curtains with a hypochlorite spray [82] Halamines are organic hindered-amine polymers that are attached to the surface of fabric fibers. This amine polymer transforms into calamine by coming into contact with a hypochlorite solution. When exposed to bacteria, the chlorine permanently bonds to the amine and is released as a Cl + ion [83]. You may “recharge” the calamine by exposing it to more hypochlorite solution. Products based on hypochlorite efficiently lower the risk of infection, as shown by their usage as disinfectants in healthcare facilities for more than a century [14]. Wide-ranging antibacterial efficacy, excellent stability, and quick killing action, notably against C. difficile spores, are all characteristics of hypochlorites. For three weeks, samples were taken twice weekly to evaluate the presence of harmful microorganisms.

Comparing Calamine antimicrobial curtains to Control, pathogenic contamination was not substantially reduced. In the healthcare context, antimicrobial curtains could help to reduce environmental pollution. Further research should be conducted to ascertain the long-term impacts of employing antimicrobial curtains in healthcare.

In conclusion, this review article discussed that a multi-pronged infection prevention strategy, including enhanced barrier precautions for high-risk patients, chlorhexidine bathing, hand hygiene promotion, staff education, and outcome feedback, significantly decreased the prevalence of MDRO overall as well as the amount of contamination of the room environment with any MDRO and VRE.

Author Contributions

Authors contribution to the manuscript as per following: S.B. wrote the main manuscripts. M.S. worked on the section of infection control measures. Z.M. prepared the figures. All authors reviewed and finalized the manuscripts.

Funding

No funding.

Data Availability

Available as per request.

Declarations

Competing Interests

The authors declare no competing interests.

Ethical Approval

No ethical approval required for review article.