Hospital Acquired Infection Revisited: Route of Transmission

Lusia Sri Sunarti *

Department of Microbiology, Faculty of Medicine, Universitas Kristen Indonesia, Jakarta, Indonesia.

*Author to whom correspondence should be addressed.


Aims: to revisited hospital route of infection transmission in patients under medical care with its related problems and re-focus on some important MDR nosocomial infection agents route of transmission to vulnerable patients.

Discussion: Accidental infections acquired in hospitals or hospital acquired infection (HAI) is a global major health condition, and become a major obstacle in the present day era of hospitalization. Increased risk of morbidity with mortality, lengthened hospitalization, massive prescription of antibiotics, and socio-economically become a definite financial burden. Disinfection and sterilization in hospitals is of increasing concern. Besides that, the abuse of antibiotics has led to the prompt wide spread of multidrug-resistant drugs (MDR) microorganisms which is characterized by the ability to quickly adapt to an environment that previously does not support its growth commonly and able to initiate serious life-threatening HAI. The need to understand route of transmission and its associated obstacles will help combating MDR microorganisms.

Conclusion: The Global emergence of MDR microorganisms with its difficult route of infections has created a major obstacle to combat the bacterial pathogens, and need serious attention from all stakeholders, throughout the world.

Keywords: Long term wide spectrum antibiotics, multidrug-resistant drugs, healthcare, medical staff, gram negative bacteria, antibiotic stewardship, Hospital Acquired Infection (HAI)

How to Cite

Sunarti , Lusia Sri. 2024. “Hospital Acquired Infection Revisited: Route of Transmission”. International Journal of Pathogen Research 13 (3):24-35.


Download data is not yet available.


Sikora A, Zahra F. Nosocomial Infections. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Available:

Raoofi S, Pashazadeh Kan F, Rafiei S, Hosseinipalangi Z, Noorani Mejareh Z, Khani S, et al. Global prevalence of nosocomial infection: A systematic review and meta-analysis. PLoS One. 2023;18(1): e0274248. Available:

Stewart S, Robertson C, Pan J, Kennedy S, Haahr L, Manoukian S, Mason H, Kavanagh K, Graves N, Dancer SJ, Cook B, Reilly J. Impact of healthcare-associated infection on length of stay. J Hosp Infect. 2021;114:23-31. Available:

Tolera M, Marami D, Abate D, Dheresa M. Are Invasive Procedures and a Longer Hospital Stay Increasing the Risk of Healthcare-Associated Infections among the Admitted Patients at Hiwot Fana Specialized University Hospital, Eastern Ethiopia? Adv Prev Med. 2020; 2020:6875463.


Brown J, Doloresco F, Joseph M. Mylotte JM. “Never Events”: Not Every Hospital-Acquired Infection Is Preventable, Clinical Infectious Diseases. 2019;49(5): 743–46 Available:

Windle M, Lee HD, Cherng ST, Lesko CR, Hanrahan C, Jackson JW, et al. From Epidemiologic Knowledge to Improved Health: A Vision for Translational Epidemiology. Am J Epidemiol. 2019;188(12):2049-2060. Available:

World Health Organization. The burden of health care-associated infection worldwide. April 29th.; 2010. Available:

Chen YY, Chen IH, Chen CS, Sun SM. Incidence and mortality of healthcare-associated infections in hospitalized patients with moderate to severe burns. J Crit Care. 2019;54:185-190.


Pergam SA. Infection Prevention in Transplantation. Curr Infect Dis Rep. 2016;18(7) Available:

Sass L, Karlowicz MG. Healthcare-Associated Infections in the Neonate. Principles and Practice of Pediatric Infectious Diseases. 2018:560–566.e3. Available:

Blot S, Ruppé E, Harbarth S, Asehnoune K, Poulakou G, Luyt CE, et al. Healthcare-associated infections in adult intensive care unit patients: Changes in epidemiology, diagnosis, prevention and contributions of new technologies. Intensive Crit Care Nurs. 2022; 70: 103227 Available:

El-Beeli M, Al-Farsi Y, Balkhair A, Al-Muharrmi Z, Al-Jabri M, Al-Adawi S. Estimation of Prevalence of Hospital-Acquired Blood Infections among Patients Admitted at a Tertiary Hospital in Oman over a Period of Five Years: A Cross-Sectional Study. Interdiscip Perspect Infect Dis. 2023;2023:5853779.


World Health Organization. WHO launches first ever global report on infection prevention and control. May 6th 2022. Available:

Mordor Intelligence. Hospital Acquired Infection Control Market Size & Share Analysis - Growth Trends & Forecasts (2024 - 2029). Available:

Nelson RE, Jones M, Liu CF, Samore MH, Evans ME, Stevens VW, et al. The Impact of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Infections on Postdischarge Health Care Costs and Utilization across Multiple Health Care Systems. Health Serv Res. 2018;533(S3):5419-37.


Haque M, Sartelli M, McKimm J, Abu Bakar M. Health care-associated infections - an overview. Infect Drug Resist. 2018;11:2321-33. Available:

Fehlberg EA, Lucero RJ, Weaver MT, McDaniel AM, Chandler AM, Richey PA, Mion LC, Shorr RI. Impact of the CMS No-Pay Policy on Hospital-Acquired Fall Prevention Related Practice Patterns. Innov Aging. 2017;1(3): igx036. Available:

Waters TM, Daniels MJ, Bazzoli GJ, Perencevich E, Dunton N, Staggs VS, Potter C, Fareed N, Liu M, Shorr RI. Effect of Medicare's nonpayment for Hospital-Acquired Conditions: lessons for future policy. JAMA Intern Med. 2015;175(3):347-54. Available:

Cohen CC, Liu J, Cohen B, Larson EL, Glied S. Financial Incentives to Reduce Hospital-Acquired Infections Under Alternative Payment Arrangements. Infect Control Hosp Epidemiol. 2018;39 (5):509-515.


Vokes RA, Bearman G, Bazzoli GJ. Hospital-Acquired Infections Under Pay-for-Performance Systems: An Administrative Perspective on Management and Change. Curr Infect Dis Rep. 2018;20(9):35.


Brooks J. US Medicare will stop paying for preventable errors. CMAJ. 2007;177 (8):841-2. Available:

Brown JR, Sox HC, Goodman DC. Financial incentives to improve quality: skating to the puck or avoiding the penalty box? JAMA. 2014;311(10):1009-10 Available:

Sankaran R, Sukul D, Nuliyalu U, Gulseren B, Engler TA, Arntson E, Zlotnick H, Dimick JB, Ryan AM. Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study. BMJ. 2019; 366: l4109. Available:

Lee GM, Kleinman KP, Soumerai SB, Tse AC, Cole DV, Fridkin SK, et al. Effect of nonpayment for preventable infections in U.S. hospitals. The New England journal of medicine. 2012;367 (15):1428-37.


Wallan M. Hospital Infection Rates Unchanged by CMS Penalties No evidence of impact from nonpayment policy; 2012. Available:

Bastani H, Goh J, Bayati M. Evidence of Upcoding in Pay-for-Performance Programs. Stanford Graduate School of Business Research Paper Series; 2015.


Joiner KA, Lin J, Pantano J. Upcoding in medicare: where does it matter most? Health Econ Rev. 2024;14(1):1. Available:

Ho V, Tapaneeyakul S, Russell HV. Price Increases Versus Upcoding as Drivers of Emergency Department Spending Increases, 2012–19. Health Affairs. 2023;42:8:1119-1127 Available:

Drabiak K, Wolfson J. What Should Health Care Organizations Do to Reduce Billing Fraud and Abuse? AMA J Ethics. 2020;22(3):E221-231 Available:

Coustasse A, Layton W, Nelson L, Walker V. Upcoding Medicare: Is Healthcare Fraud and Abuse Increasing? Perspect Health Inf Manag. 2021;18 (4):1f.

Coustasse Cremeans K, Followay C, Oldaker J. Implications of Upcoding on Medicare Fraud. 2018;7.


Monegro AF, Muppidi V, Regunath H. Hospital-Acquired Infections. [Updated 2023 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Available:

Alshahrani KM, Alhuwaishel AZ, Alangari NM, Asiri MA, Al-Shahrani NA, Alasmari AA, Alzahrani OJ, Ayedh AY, Qitmah MM. Clinical Impacts and Risk Factors for Central Line-Associated Bloodstream Infection: A Systematic Review. Cureus. 2023;15(6):e40954. Available:

Seidelman JL, Mantyh CR, Anderson DJ. Surgical Site Infection Prevention: A Review. JAMA. 2023;329(3):244–252. Available:

Modi AR, Kovacs CS. Hospital-acquired and ventilator-associated pneumonia: Diagnosis, management, and prevention. Cleveland Clinic Journal of Medicine. 2020;87(10):633-9.


Kim BG, Kang M, Lim J, Lee J, Kang D, Kim M, et al. Comprehensive risk assessment for hospital-acquired pneumonia: sociodemographic, clinical, and hospital environmental factors associated with the incidence of hospital-acquired pneumonia. BMC Pulm Med. 2022;22(1):21. Available:

McLure A, Clements ACA, Kirk M, Glass K. Clostridium difficile classification overestimates hospital-acquired infections. J Hosp Infect. 2018;99(4): 453-460 Available:

Hughes R, Rapsomaniki E, Janson C, Keen C, Make BJ, Burgel PR, et al. Frequent productive cough: Symptom burden and future exacerbation risk among patients with asthma and/or COPD in the NOVELTY study. Respir Med. 2022;200:106921 Available:

Hall DP, Scott DHT. The risks of acquiring hospital-acquired infections from wet breathing systems, Expert Review of Anti-infective Therapy. 2010;8: 10:1071-3 Available:

Gebrie TA, Handiso TB, Hagisso SN. Management Outcome and Associated Factors of Surgically Treated Non Traumatic Acute Abdomen at Attat Hospital, Gurage Zone, Ethiopia. Int J Surg Res Pract. 2019;6:099. Available:

Hamilton DL. Rebound pain: distinct pain phenomenon or nonentity? Br J Anaesth. 2021;126(4):761-763. Available:

Penna AR, Sancken CL, Stone ND, Eure TR, Bamberg W, Barney G, et al. Documentation of acute change in mental status in nursing homes highlights opportunity to augment infection surveillance criteria. Infect Control Hosp Epidemiol. 2020;41(7):848-850. Available:

Nagaraj C. Hospital-Acquired Urinary Tract Infections [Internet]. Advances and Challenges in Urine Laboratory Analysis. IntechOpen; 2024. Available:

Isigi SS, Parsa AD, Alasqah I, Mahmud I, Kabir R. Predisposing Factors of Nosocomial Infections in Hospitalized Patients in the United Kingdom: Systematic Review. JMIR Public Health Surveill. 2023;9:e43743. DOI:

William ST. Dysuria. In: Haydock S, Whitehead D, Fritz Z, editors. Acute Medicine: A Symptom-Based Approach. Cambridge: Cambridge University Press. 2014;149–54.

Sikora A, Zahra F. Nosocomial Infections. [Updated 2023 Apr 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Available:

Azzouzi S, Stratton C, Muñoz-Velasco LP, Wang K, Fourtassi M, Hong BY, Cooper R, Balikuddembe JK, Palomba A, Peterson M, Pandiyan U, Krassioukov A, Tripathi DR, Tuakli-Wosornu YA, Hajjioui A. The Impact of the COVID-19 Pandemic on Healthy Lifestyle Behaviors and Perceived Mental and Physical Health of People Living with Non-Communicable Diseases: An International Cross-Sectional Survey. Int J Environ Res Public Health. 2022;19 (13):8023. Available:

Alzyood M, Jackson D, Aveyard H, Brooke J. COVID-19 reinforces the importance of handwashing. J Clin Nurs. 2020;29(15-16):2760-2761. DOI:

Gilbert GL, Kerridge I. What is needed to sustain improvements in hospital practices post-COVID-19? a qualitative study of interprofessional dissonance in hospital infection prevention and control. BMC Health Serv Res. 2022;22(1):504. Available:

Puro V, Coppola N, Frasca A, Gentile I, Luzzaro F, Peghetti A, Sganga G. Pillars for prevention and control of healthcare-associated infections: an Italian expert opinion statement. Antimicrob Resist Infect Control. 2022;11(1):87. DOI:

World Health Organization. Global report on infection prevention and control. 23 May 2022. Downloaded from Available:

Centers for Disease Control and Prevention. Healthcare Associated Infections (HAIs). 10 November 2021. Available:://

Menatti L, Bich L, Saborido C. Health and environment from adaptation to adaptivity: a situated relational account. Hist Philos Life Sci. 2022;44(3):38 Available:

Bonadonna L, Briancesco R, Coccia AM. Analysis of Microorganisms in Hospital Environments and Potential Risks. Indoor Air Quality in Healthcare Facilities. 2017;24:53–62. Available:

Cooper BS, Evans S, Jafari Y, Pham TM, Mo Y, Lim C, Pritchard MG, Pople D, Hall V, Stimson J, Eyre DW, Read JM, Donnelly CA, Horby P, Watson C, Funk S, Robotham JV, Knight GM. The burden and dynamics of hospital-acquired SARS-CoV-2 in England. Nature. 2023;623(7985):132-8.


Schmid H, Heininger U, Vuichard-Gysin D, Widmer A, Bielicki J. Preventive measures for accompanying caregivers of children in paediatric health care during the COVID-19 pandemic-walking an ethical tightrope. Clin Microbiol Infect. 2021;27(5):668–70. Available:

Maliqi B, Hinton R, Chowdury M, Roder-DeWan S, Eluwa A, Kassa M et al. Prepared health systems provide quality care at all times BMJ. 2023;380: e072698 Available:

Scott GY, Ezie KN, Dauda Z, Andigema AS, Amekpor F. Occupational Exposure to Infectious Diseases among Health Workers: Effects, Managements and Recommendations. J Infect Dis Epidemiol. 2023;9:295. Available:

Goldenhart AL, Nagy H. Assisting Patients with Personal Hygiene. [Updated 2022 Sep 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Available:

Georgiou MK, Merkouris A, Hadjibalassi M, Sarafis P. Contribution of Healthcare Professionals in Issues that Relate to Quality Management. Mater Sociomed. 2021;33(1):45-50. Available:

Shenoy ES, Branch-Elliman W. Automating surveillance for healthcare-associated infections: Rationale and current realities (Part I/III). Antimicrob Steward Healthc Epidemiol. 2023;3(1): e25.


Rawlinson S, Ciric L, Cloutman-Green E. How to carry out microbiological sampling of healthcare environment surfaces? A review of current evidence. J Hosp Infect. 2019;103(4):363-374.


Knobloch MJ, McKinley L, Keating J, Safdar N. Integrating antibiotic stewardship and infection prevention and control programs using a team science approach. Am J Infect Control. 2021;49 (8):1072-1074. Available:

Suleyman G, Alangaden G, Bardossy AC. The Role of Environmental Contamination in the Transmission of Nosocomial Pathogens and Healthcare-Associated Infections. Curr Infect Dis Rep. 2018;20(6):12. DOI:

Facciolà A, Pellicanò GF, Visalli G, Paolucci IA, Venanzi Rullo E, Ceccarelli M, D'Aleo F, Di Pietro A, Squeri R, Nunnari G, La Fauci V. The role of the hospital environment in healthcare-associated infections: a general review of the literature. Eur Rev Med Pharmacol Sci. 2019;23(3):1266-1278.


Olise CC. Fomites: Possible vehicle of nosocomial infections. Public Health Nutrition. 2018;1:11-6.


Beggs CB. The Airborne Transmission of Infection in Hospital Buildings: Fact or Fiction? Indoor and Built Environment. 2003;12:18-9. Available:

Squier C, Yu VL, Stout JE. Waterborne Nosocomial Infections. Curr Infect Dis Rep. 2000;2(6):490-496.


English KM, Langley JM, McGeer A, et al. Contact among healthcare workers in the hospital setting: developing the evidence base for innovative approaches to infection control. BMC Infectious Diseases. 2018;18(1):184. Available:

Mancuso G, Midiri A, Gerace E, Biondo C. Bacterial Antibiotic Resistance: The Most Critical Pathogens. Pathogens. 2021;10(10):1310. Available:

Huang L, Tang J, Tian G, Tao H, Li Z. Risk Factors, Outcomes, and Predictions of Extensively Drug-Resistant Acinetobacter baumannii Nosocomial Infections in Patients with Nervous System Diseases. Infect Drug Resist. 2023;16:7327-7337. Available:

Srinivasan S, Arora NC, Sahai K. Report on the newly emerging nosocomial Burkholderia cepacia in a tertiary hospital. Med J Armed Forces India. 2016;72(Suppl 1):S50-S53. Available:

Farzin A, Mizanur Rahman Md, Ara Mollika F. Pseudomonas aeruginosa: The Alarming Pathogen of Hospital Acquired Infection [Internet]. Pseudomonas aeruginosa - New Perspectives and Applications [Working Title]. IntechOpen; 2023. Available:

Ragusa R, Giorgianni G, Lupo L, Sciacca A, Rametta S, La Verde M, Mulè S, Marranzano M. Healthcare-associated Clostridium difficile infection: role of correct hand hygiene in cross-infection control. J Prev Med Hyg. 2018;59(2): E145-E152.

Tschudin-Sutter S, Lucet JC, Mutters NT, Tacconelli E, Zahar JR, Harbarth S. Contact Precautions for Preventing Nosocomial Transmission of Extended-Spectrum β Lactamase-Producing Escherichia coli: A Point/Counterpoint Review. Clin Infect Dis. 2017;65(2):342-7. Available:

Shibabaw A, Sahle Z, Metaferia Y, Atlaw A, Adenew B, Gedefie A, Tilahun M, Ebrahim E, Kassa Y, Debash H, Wang SH. Epidemiology and prevention of hospital-acquired carbapenem-resistant Enterobacterales infection in hospitalized patients, Northeast Ethiopia. IJID Reg. 2023;7:77-83. DOI:

Kampmeier S, Kossow A, Clausen LM, Knaack D, Ertmer C, Gottschalk A, Freise H, Mellmann A. Hospital acquired vancomycin resistant enterococci in surgical intensive care patients - a prospective longitudinal study. Antimicrob Resist Infect Control. 2018;7: 103. Available:

Samia NI, Robicsek A, Heesterbeek H, Peterson LR. Methicillin-resistant staphylococcus aureus nosocomial infection has a distinct epidemiological position and acts as a marker for overall hospital-acquired infection trends. Sci Rep. 2022;12(1):17007.


Unni S, Siddiqui TJ, Bidaisee S. Reduced Susceptibility and Resistance to Vancomycin of Staphylococcus aureus: A Review of Global Incidence Patterns and Related Genetic Mechanisms. Cureus. 2021;13(10): e18925. Available:

Selim S, Faried OA, Almuhayawi MS, Saleh FM, Sharaf M, El Nahhas N, Warrad M. Incidence of Vancomycin-Resistant Staphylococcus aureus Strains among Patients with Urinary Tract Infections. Antibiotics (Basel). 2022;11 (3):408. Available:

Xie Z, Zhou N, Chi Y, Huang G, Wang J, Gao H, Xie N, Ma Q, Yang N, Duan Z, Nie W, Sun Z, Chu N. Nosocomial tuberculosis transmission from 2006 to 2018 in Beijing Chest Hospital, China. Antimicrob Resist Infect Control. 2020; 9(1):165. Available:

Mehrad B, Clark NM, Zhanel GG, Lynch JP 3rd. Antimicrobial resistance in hospital-acquired gram-negative bacterial infections. Chest. 2015;147(5): 1413-1421 Available:

Sevin T, Daniau C, Alfandari S, Piednoir E, Dumartin C, Blanchard H, Simon L, Berger-Carbonne A, Le Vu S. Patterns of antibiotic use in hospital-acquired infections. J Hosp Infect. 2021;114:104-110.


Balasubramanian R, Van Boeckel TP, Carmeli Y, Cosgrove S, Laxminarayan R. Global incidence in hospital-associated infections resistant to antibiotics: An analysis of point prevalence surveys from 99 countries. PLoS Med. 2023;20(6): e1004178 Available:

Dadgostar P. Antimicrobial Resistance: Implications and Costs. Infect Drug Resist. 2019;12:3903-3910. Available:

Tacconelli E, Sifakis F, Harbarth S, Schrijver R, van Mourik M, Voss A, Sharland M, Rajendran NB, Rodríguez-Baño J; EPI-Net COMBACTE-MAGNET Group. Surveillance for control of antimicrobial resistance. Lancet Infect Dis. 2018;18(3):e99-e106. Available:

Centers for Disease Control and Prevention. CDC’s Antibiotic Resistance Threats in the United States, 2019. November 23, 2021. Available:

Gurjar M, Saigal S, Baronia AK, Rao BP, Azim A, Poddar B, Singh RK. Carbapenem-resistant Acinetobacter ventilator-associated pneumonia: Clinical characteristics and outcome. Indian J Crit Care Med. 2013;17(3):129-34. Available:

Katsaragakis S, Markogiannakis H, Toutouzas KG, Drimousis P, Larentzakis A, Theodoraki EM, Theodorou D. Acinetobacter baumannii infections in a surgical intensive care unit: predictors of multi-drug resistance. World J Surg. 2008;32(6):1194-202. Available:

Kinross P, Gagliotti C, Merk H, Plachouras D, Monnet DL, Högberg LD; EARS-Net Study Group; EARS-Net Study Group participants. Large increase in bloodstream infections with carbapenem-resistant Acinetobacter species during the first 2 years of the COVID-19 pandemic, EU/EEA, 2020 and 2021. Euro Surveill. 2022;27(46): 2200845. Available:

Taj Z, Rasool MH, Almatroudi A, Saqalein M, Khurshid M. Extensively Drug-resistant Acinetobacter baumannii Belonging to International Clone II from A Pet Cat with Urinary Tract Infection; The First Report from Pakistan. Pol J Microbiol. 2020;69(2):1-4 Available:

Otter JA, Yezli S, Salkeld JA, French GL. Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. Am J Infect Control. 2013;41(5 Suppl): S6-11 Available:

Yiek WK, Coenen O, Nillesen M, van Ingen J, Bowles E, Tostmann A. Outbreaks of healthcare-associated infections linked to water-containing hospital equipment: a literature review. Antimicrob Resist Infect Control. 2021;10 (1):77 Available:

Kanamori H, Rutala WA, Weber DJ. The Role of Patient Care Items as a Fomite in Healthcare-Associated Outbreaks and Infection Prevention. Clin Infect Dis. 2017;65(8):1412-1419. Available:

Repp KK, Hostetler TP, Keene WE. A norovirus outbreak related to contaminated surfaces. J Infect Dis. 2013;208(2):295-8. Available:

Gall E, Long A. Carbapenem-Resistant Enterobacteriaceae. In: Hall KK, Shoemaker-Hunt S, Hoffman L, et al. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020. Available:

Howard-Anderson J, Bower CW, Smith G, Elizabeth Sexton M, Satola SW, Farley MM, Jacob JT. 506. Urinary Catheters Are Associated with Progression from Bacteriuria to Invasive Infections in Patients with Carbapenem-Resistant Enterobacteriaceae, Metropolitan Atlanta, 2011–2017. Open Forum Infect Dis. 2019;6(Suppl 2):S245–6. Available:

Khawcharoenporn T, Laichuthai W. Subsequent carbapenem-resistant Enterobacteriaceae (CRE)-associated infections among hospitalized patients with CRE colonization: Impact of antibiotic use and other factors. Infect Control Hosp Epidemiol. 2020;41(9): 1084-1089. Available:

Ansari AS. Therapeutic Options for the Treatment of Carbapenem-resistant Enterobacteriaceae Infections: Hope in the Times of Hype and Despair. Indian J Crit Care Med. 2021;25(7):752-753. Available:

Mullish BH, Williams HR. Clostridium difficile infection and antibiotic-associated diarrhoea. Clin Med (Lond). 2018;18(3):237-241. Available:

McCusker ME, Harris AD, Perencevich E, Roghmann MC. Fluoroquinolone use and Clostridium difficile-associated diarrhea. Emerg Infect Dis. 2003;9(6): 730-3. Available:

Mizusawa M, Doron S, Gorbach S. Clostridium difficile Diarrhea in the Elderly: Current Issues and Management Options. Drugs Aging. 2015;32(8):639-47 Available: