ICU and antimicrobial resistance: how to face an ever-increasing challenge?

Roismann, Hector; Vitoreti, Gabriel Mathias; Druszcz, Rafael Azevedo; Guimarães, Luiz Eduardo Latorre; Grein Neto, Homero; Gama Filho, Ozimo Pereira; Bernardo, Antonio; Roismann, Oscar

doi:10.55684/2026.84.pt.e00009

ABSTRACT

Introduction: Antimicrobial resistance in critical care units represents one of the main challenges of health care, associated with high morbidity and unfavorable prognostic impact.

Objective: To analyze the epidemiological dynamics, microbiological profile, risk factors, and prognostic impact of antimicrobial resistance in intensive care units, considering different patient profiles.

Method: This is an integrative literature review based on the analysis of 20 scientific articles that investigated healthcare-associated infections, pathogen prevalence, and bacterial resistance in different critical care settings.

Results: There was a predominance of gram-negative bacilli, especially microorganisms associated with high clinical severity, especially in ventilator-associated lung infections and bloodstream infections. Patients in specialized units, such as burns, pediatric, neonatal, and liver units, showed specific vulnerabilities. In addition, inadequacies in the nursing team sizing were associated with increased risk of microorganism dissemination.

Conclusion: The reduction of antimicrobial resistance in these contexts requires an integrated approach, including programs for the rational use of antimicrobials, incorporation of rapid diagnostic methods, strict adherence to preventive measures, and adequacy of the workload of health professionals.

KEYWORDS:
Nosocomial infection; Bacterial drug resistance; Critical Care; Sepsis

VISUAL ABSTRACT

RESUMO

Introdução: A resistência antimicrobiana em unidades de cuidados críticos representa um dos principais desafios da assistência à saúde, associando-se à elevada morbidade e impacto prognóstico desfavorável.

Objetivo: Analisar a dinâmica epidemiológica, o perfil microbiológico, os fatores de risco e o impacto prognóstico da resistência antimicrobiana em unidades de terapia intensiva, considerando diferentes perfis de pacientes.

Método: Trata-se de revisão integrativa da literatura baseada na análise de 20 artigos científicos que investigaram infecções relacionadas à assistência à saúde, prevalência de patógenos e resistência bacteriana em diferentes cenários de cuidados críticos.

Resultados: Observou-se predominância de bacilos Gram-negativos, com destaque para microrganismos associados à elevada gravidade clínica, especialmente em infecções pulmonares associadas à ventilação e infecções da corrente sanguínea. Pacientes em unidades especializadas, como as de queimados, pediátricas, neonatais e hepáticas, apresentaram vulnerabilidades específicas. Além disso, inadequações no dimensionamento da equipe de enfermagem mostraram-se associadas ao aumento do risco de disseminação de microrganismos.

Conclusão: A redução da resistência antimicrobiana nesses contextos requer abordagem integrada, incluindo programas de uso racional de antimicrobianos, incorporação de métodos diagnósticos rápidos, adesão rigorosa a medidas preventivas e adequação da carga de trabalho dos profissionais de saúde.

PALAVRAS-CHAVE:
Infecção hospitalar; Farmacorresistência bacteriana; Cuidados Críticos; Sepse

RESUMO VISUAL

INTRODUCTION

Nosocomial infections, also known as healthcare-associated infections, represent one of the greatest challenges in contemporary intensive care medicine. Intensive care units (ICUs) house patients who are in broad clinical severity, requiring therapeutic interventions that, paradoxically, compromise their natural defenses. The prolonged use of mechanical ventilation, central venous catheters, and bladder tubes, which creates direct entry points for opportunistic pathogens, results in infection rates significantly higher than those observed in general wards.¹^.²

In recent decades, the epidemiology of these infections has undergone critical transformation due to the emergence and global spread of multidrug-resistant bacterial strains. Multicenter studies have shown that gram-negative bacilli, notably Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae, have become endemic in many hospitals.²^-⁴ The production of inactivating enzymes, such as extended-spectrum beta-lactamases and carbapenemases, confers on these microorganisms the ability to resist the main classes of antibiotics available, drastically limiting empirical and definitive therapeutic options.⁵^-⁷

The impact of this resistance transcends isolated treatment failure. Infection by multidrug-resistant bacteria in critically ill patients is associated with a substantial increase in mortality, prolonged ICU stay, and exponential increase in hospital costs.²^,³^,⁸ Transmission dynamics are aggravated in highly susceptible subpopulations. In burn units, loss of the skin barrier and systemic immunosuppression facilitate fulminant infections by environmental pathogens.⁹^-¹¹ Similarly, pediatric patients, premature newborns in neonatal ICUs, and pre-transplant hepatopathic patients face disproportionate risks in the face of exposure to hospital strains.¹^,⁶^,¹²^,¹³

Despite advances in infection control policies, the literature points to systemic gaps that perpetuate the spread of resistance. Excessive and often inappropriate prescribing of broad-spectrum antimicrobials generates strong selective pressure on the patient’s microbiota and the environment.³^,⁵^,⁷ At the same time, structural factors, such as the work overload of nursing teams, have been increasingly recognized as determining variables in the breakdown of contact protocols and in the occurrence of outbreaks.¹⁴^,¹⁵ Understanding the intersection between the epidemiological profile of pathogens, host susceptibility, and the ICU environment is essential for the design of effective containment strategies.

METHOD

This is an integrative review, carried out in the PubMed database, whose formulation of the guiding question and eligibility criteria was based on the PICO strategy: P (Population) - patients hospitalized in Intensive Care Units (ICUs); I (Intervention/Exposure) - nosocomial infections by multidrug-resistant bacteria; C (Comparison) - not applicable / patients without infection or with susceptible infections; O (Outcomes) - associated risk factors, clinical impact, and mortality. As this is a literature review, the study is exempt from evaluation by the Institutional Research Ethics Committee.

The structured search used the combination of the following keywords (DeCS/MeSH) and their corresponding terms: “Cross Infection”, “Intensive Care Units”, “Drug Resistance, Multiple”, “Bacterial Infections” and “Risk Factors” (Risk Factors). The inclusion criteria included original articles (clinical trials, observational cohort studies, retrospective, and prospective) and review articles published from 2003 to March 2025, in Portuguese and English, available in full text. Articles that did not address the topic of multidrug-resistant bacterial infections in the context of intensive care, or that did not present specific data on prognosis, risk factors, or infection control strategies, were excluded. In total, 20 articles were selected to compose this review (Table).

Thumbnail

TABLE
Summary of the studies incorporated in this review¹^-²⁰

RESULTS

The consolidated analysis of the studies reveals that infections in ICUs are mostly driven by Gram-negative bacilli, which have supplanted Gram-positive cocci in prevalence and complexity of management in several regions.²^,⁴^,¹⁶^,¹⁷

Microbiological profile and resistance

The carbapenemase-producing Klebsiella pneumoniae and the multidrug-resistant Acinetobacter baumannii emerge as the most critical pathogens. In large university hospitals, the prevalence of extended-spectrum beta-lactamase-producing K. pneumoniae and Escherichia coli has shown a sustained annual increase, complicating the empirical approach to bloodstream infections.¹⁸ The scenario is aggravated by the identification of genetic determinants of extreme resistance, such as the blaNDM-1, mcr-1, and blaKPC-2 genes, which confer resistance even to last-line agents in outbreaks within neonatal units.⁶ In prolonged outbreaks, carbapenem-resistant strains of A. baumannii demonstrate a remarkable ability to persist in the abiotic ICU environment, requiring drastic infection control interventions for their eradication.¹⁵

Clinical and structural risk factors

The literature is unanimous in pointing to the use of invasive devices as the main catalyst for nosocomial infections. The risk of ventilator-associated pneumonia and central catheter-associated bloodstream infections increases proportionally to the patient’s exposure to these interventions.²^,¹⁷^,¹⁹ Prior use of broad-spectrum antimicrobials acts as a strong independent predictor for superinfection or subsequent colonization by multidrug-resistant pathogens.³^,⁷^,²⁰ It was evidenced that the increase in the workload of the nursing team and the undersizing of personnel are positively correlated with the increase in the rates of cross-colonization by multidrug-resistant bacteria, demonstrating that structural failures sabotage hygiene and contact precaution practices.¹⁴

Outcomes and mortality

Mortality associated with infections by multidrug-resistant microorganisms in ICUs is severe. Patients who develop resistant bacilli sepsis or nonsusceptible pathogen pneumonia have considerably lower survival rates than those infected with susceptible strains.²^,¹⁶^,²⁰ The prognosis is particularly bleak when initial empirical antimicrobial therapy is inadequate, which occurs with high frequency in the face of Gram-negative bacteria with complex resistance profiles.⁴^,⁵^,¹⁶

Specific scenarios and vulnerable populations

Epidemiology varies depending on the ICU profile. The Burn Units are characterized by rapid colonization of wounds by aggressive environmental bacteria, with the massive presence of P. aeruginosa and A. baumannii with extreme resistance, making grafting difficult and increasing mortality.⁹^-¹¹ In pediatric and neonatal ICUs, newborns and children admitted to adult ICUs are at higher risk of acquiring hospital strain infections than those allocated to strictly pediatric units.¹³ In these populations, immune immaturity transforms bloodstream infections into rapidly fatal events.¹^,⁶ For patients with liver disease in pre-liver transplant ICUs, the incidence of infections is driven by the inherent deficiency of the immune system resulting from liver failure, making secondary infections a critical barrier to transplant viability.¹²

DISCUSSION

The synthesis of evidence reaffirms that the ICU is not only the place of treatment for the most serious infections, but also the main cradle for the selection of bacterial resistance mechanisms. The convergence of data demonstrates that prolonged hospital stays and previous exposure to carbapenems are universal variables for the development of sepsis by multidrug-resistant strains, regardless of the geographic location of the study.²^,³^,⁷^,²⁰

A fundamental aspect raised by the literature is the distinction in the management of primary versus secondary infections. Patients who are admitted to the ICU already colonized by resistant bacteria have an exponentially higher risk of developing active systemic infections during hospitalization, which reinforces the need for surveillance cultures at admission.²⁰ The high mortality observed in cases of ventilator-associated pneumonia underlines the severity of lung inflammation triggered by pathogens such as A. baumannii, which often frustrates traditional therapeutic regimens.⁵^.¹⁹

The divergences found in the literature refer mainly to the dominant microbial etiology in specific niches. While general ICUs report growing concerns about enterobacteria that produce resistance.²^,⁴^,⁷^,¹⁷ burn units face a continuous challenge with non-fermenting pathogens, which persist in the environment due to protein-rich eschar and constant tissue manipulation.⁹^-¹¹ This indicates that prophylaxis and empirical treatment protocols cannot be universalized, and must be strictly guided by the local epidemiology of the unit.

To reverse the current scenario of escalating resistance, the analysis points to solutions that go beyond the simple discovery of new antibiotics. Human resource management emerges as a direct health intervention: adjusting the ratio of nurses per bed is vital to ensure that basic measures, such as hand hygiene and care with catheter insertions, are strictly complied with, interrupting the chain of cross-transmission.¹⁴ In addition, the implementation of preventive measures has proven to be a highly effective strategy, resulting in sustained declines in infection rates in hospitals in developing countries.² In the diagnostic and therapeutic realm, the future requires the integration of ultra-rapid microbial identification technologies with institutional antimicrobial stewardship programs. These initiatives allow for early de-escalation of the antibiotic by adjusting the therapy to the narrowest possible spectrum, which saves the life of the critically ill patient and simultaneously protects the ICU ecosystem from selective pressure.⁵ The implications of these findings reinforce the urgent need to implement antimicrobial stewardship protocols and strengthen contact precautionary measures, aiming to reduce morbidity and mortality rates and hospital costs associated with bacterial resistance.

The limitations of this study include the qualitative nature of the review and the temporal and idiomatic constraints in the selection of articles, which may have omitted specific regional epidemiological data from areas with a lower volume of indexed publications. Despite this, the study offers an updated overview that can guide clinical decisions and the development of infection control policies in critical care units.

CONCLUSION

Healthcare-associated infections caused by multidrug-resistant bacteria pose a threat to the survival of patients in ICUs. The literature review confirms that highly virulent and resistant Gram-negative pathogens are the main responsible for the increase in lethality rates, prolonged hospitalizations, and treatment failures, especially in the context of mechanical ventilation and central vascular accesses. Specific populations, such as large burns and neonates, are disproportionately affected by this phenomenon. In view of the imminent exhaustion of the classical therapeutic arsenal, the clinical implications of this study reinforce that the control of multidrug resistance requires action on multiple fronts. It is imperative that healthcare institutions invest in continuous epidemiological surveillance, the adoption of rapid molecular diagnostic technologies, and the structuring of effective antimicrobial stewardship programs. In addition, the literature demonstrates that the adequacy of nursing team sizing and the rigorous application of prevention packages are not only administrative measures, but vital and scientifically validated interventions to cut the chain of transmission and ensure the safety of critical patients.

References

¹ Carey AJ, Saiman L, Polin RA. Hospital-Acquired Infections in the NICU: Epidemiology for the New Millennium. Clin Perinatol. 2008;35(1):223-49. https://doi.org/10.1016/j.clp.2007.11.014
» https://doi.org/10.1016/j.clp.2007.11.014
² Al-Mousa HH, Omar AA, Rosenthal VD, Salama MF, Aly NY, Noweir ME, et al. Device-associated infection rates, bacterial resistance, length of stay, and mortality in Kuwait: International Nosocomial Infection Consortium findings. Am J Infect Control. 2016;44(4):444-9. https://doi.org/10.1016/j.ajic.2015.10.031
» https://doi.org/10.1016/j.ajic.2015.10.031
³ Yang J, Chen M, Li L, Zha Z, Cheng M, Yang X. Prognosis analysis and infection-related risk factors of multi-drug-resistant bacteria isolated from a general hospital in China, 2019-2023. J Hosp Infect. 2025;158:29-37. https://doi.org/10.1016/j.jhin.2025.02.003
» https://doi.org/10.1016/j.jhin.2025.02.003
⁴ Agaba P, Tumukunde J, Tindimwebwa JVB, Kwizera A. Nosocomial bacterial infections and their antimicrobial susceptibility patterns among patients in Ugandan intensive care units: a cross sectional study. BMC Res Notes. 2017;10(1):349. https://doi.org/10.1186/s13104-017-2695-5
» https://doi.org/10.1186/s13104-017-2695-5
⁵ Kollef MH, Burnham CAD. Ventilator-Associated Pneumonia: The Role of Emerging Diagnostic Technologies. Semin Respir Crit Care Med. 2017;38(3):253-63. https://doi.org/10.1055/s-0037-1599224
» https://doi.org/10.1055/s-0037-1599224
⁶ Zhou X, Wagh K, Lv G, Sharma D, Lei W. Genome drafting of nosocomial infection CRE Klebsiella pneumoniae confirming resistance to colistin and eravacycline, carrying blaNDM-1, mcr-1, and blaKPC-2 in neonatology from November to December 2023. Front Cell Infect Microbiol. 2025;14:1528017. https://doi.org/10.3389/fcimb.2024.1528017
» https://doi.org/10.3389/fcimb.2024.1528017
⁷ Wang Z, Qin RR, Huang L, Sun LY. Risk Factors for Carbapenem-resistant Klebsiella pneumoniae Infection and Mortality of Klebsiella pneumoniae Infection. Chin Med J (Engl). 2016;129(10):1135-9. https://doi.org/10.4103/0366-6999.221267
» https://doi.org/10.4103/0366-6999.221267
⁸ Bonnet V, Dupont H, Glorion S, Aupée M, Kipnis E, Gérard JL, et al. Influence of bacterial resistance on mortality in intensive care units: a registry study from 2000 to 2013 (IICU Study). J Hosp Infect. 2019;102(3):317-24. https://doi.org/10.1016/j.jhin.2019.01.011
» https://doi.org/10.1016/j.jhin.2019.01.011
⁹ Elmanama AA, Al Laham NA, Tayh GA. Antimicrobial susceptibility of bacterial isolates from burn units in Gaza. Burns. 2013;39(8):1612-8. https://doi.org/10.1016/j.burns.2013.04.011
» https://doi.org/10.1016/j.burns.2013.04.011
¹⁰ Öncül O, Öksüz S, Acar A, Ülkür E, Turhan V, Uygur F, et al. Nosocomial infection characteristics in a burn intensive care unit: Analysis of an eleven-year active surveillance. Burns. 2014;40(5):835-41. https://doi.org/10.1016/j.burns.2013.11.003
» https://doi.org/10.1016/j.burns.2013.11.003
¹¹ Santucci SG, Gobara S, Santos CR, Fontana C, Levin AS. Infections in a burn intensive care unit: experience of seven years. J Hosp Infect. 2003;53(1):6-13. https://doi.org/10.1053/jhin.2002.1340
» https://doi.org/10.1053/jhin.2002.1340
¹² Hassan EA, Elsherbiny NM, Abd El-Rehim AS, Soliman AMA, Ahmed AO. Health care-associated infections in pre-transplant liver intensive care unit: Perspectives and challenges. J Infect Public Health. 2018;11(3):398-404. https://doi.org/10.1016/j.jiph.2017.09.006
» https://doi.org/10.1016/j.jiph.2017.09.006
¹³ Kim B, Kim K, Yoon JS. Nosocomial Acinetobacter baumannii infection in children in adult versus pediatric intensive care units. Pediatr Int. 2020;62(4):451-58. https://doi.org/10.1111/ped.14133
» https://doi.org/10.1111/ped.14133
¹⁴ Aycan IO, Celen MK, Yilmaz A, Almaz MS, Dal T, Celik Y, et al. Bacterial colonization due to increased nurse workload in an intensive care unit. Rev Bras Anestesiol. 2015;65(3):180-5. https://doi.org/10.1016/j.bjane.2014.05.005
» https://doi.org/10.1016/j.bjane.2014.05.005
¹⁵ Enoch DA, Summers C, Brown NM, Moore L, Gillham MI, Burnstein RM, et al. Investigation and management of an outbreak of multidrug-carbapenem-resistant Acinetobacter baumannii in Cambridge, UK. J Hosp Infect. 2008;70(2):109-18. https://doi.org/10.1016/j.jhin.2008.05.015
» https://doi.org/10.1016/j.jhin.2008.05.015
¹⁶ Sligl WI, Dragan T, Smith SW. Nosocomial Gram-negative bacteremia in intensive care: epidemiology, antimicrobial susceptibilities, and outcomes. Int J Infect Dis. 2015;37:129-34. https://doi.org/10.1016/j.ijid.2015.06.024
» https://doi.org/10.1016/j.ijid.2015.06.024
¹⁷ Mitharwal SM, Yaddanapudi S, Bhardwaj N, Gautam V, Biswal M, Yaddanapudi L. Intensive care unit-acquired infections in a tertiary care hospital: An epidemiologic survey and influence on patient outcomes. Am J Infect Control. 2016;44(10):113-7. https://doi.org/10.1016/j.ajic.2016.01.021
» https://doi.org/10.1016/j.ajic.2016.01.021
¹⁸ Nagao M. A multicentre analysis of epidemiology of the nosocomial bloodstream infections in Japanese university hospitals. Clin Microbiol Infect. 2014;20(12):1002-10. https://doi.org/10.1111/1469-0691.12083
» https://doi.org/10.1111/1469-0691.12083
¹⁹ Karakuzu Z, Iscimen R, Akalin H, Girgin NK, Kahveci F, Sinirtas M. Prognostic Risk Factors in Ventilator-Associated Pneumonia. Med Sci Monit. 2018;24:1321-8. https://doi.org/10.12659/msm.905919
» https://doi.org/10.12659/msm.905919
²⁰ Xu M, Zeng J. Analysis of factors influencing the risk of secondary infection in patients colonized or infected with multidrug-resistant Gram-negative bacteria following hospitalization. Microb Pathog. 2024;190:106637. https://doi.org/10.1016/j.micpath.2024.106637
» https://doi.org/10.1016/j.micpath.2024.106637

Central Message
Antimicrobial resistance in Intensive Care Units is dominated by Gram-negative bacilli, such as Klebsiella pneumoniae and Acinetobacter baumannii, which have high mortality rates. The review highlights that long-term use of invasive devices and prior exposure to broad-spectrum antibiotics are the main triggers for these infections. In addition, structural factors, such as nursing staff overload, directly impact cross-bacterial spread. Effective control requires constant epidemiological surveillance and the adoption of rapid molecular diagnostic technologies.
Perspective
The findings reinforce that the mitigation of multidrug resistance in intensive care units depends on a multidisciplinary approach that transcends the prescription of new antibiotics. In clinical practice, the rigorous implementation of packages of preventive measures (bundles) and the rational management of antimicrobials (stewardship) are vital to stop the selective pressure on the hospital microbiota. The adequacy of the sizing of health teams emerges as an administrative intervention with a direct impact on patient safety, reducing fatal outcomes and optimizing the length of hospital stay in highly complex environments.
How to cite this article
Roismann H, Vitoreti GM, Druszcz RA, Guimarães LEL, Neto HG, Gama O, Bernardo A, Roismann O. UTIs e resistência antimicrobiana: como enfrentar um desafio cada vez maior? BioSCIENCE. 2026;84:e00009. https://doi.org/10.55684/2026.84.pt.e00009
Funding:
None
Data availability:
Data are available from the corresponding author upon reasonable request.

Edited by

Associate Editor:
Selma Maria Bezerra Jerônimo http://orcid.org/0000-0002-4784-9904

Data availability

Data are available from the corresponding author upon reasonable request.

Publication Dates

Publication in this collection
21 Aug 2026
Date of issue
2026

History

Received
27 Jan 2026
Accepted
12 Mar 2026
Published
03 Apr 2026

Este é um artigo publicado em acesso aberto sob uma licença Creative Commons

[1] ¹ Carey AJ, Saiman L, Polin RA. Hospital-Acquired Infections in the NICU: Epidemiology for the New Millennium. Clin Perinatol. 2008;35(1):223-49. https://doi.org/10.1016/j.clp.2007.11.014
» https://doi.org/10.1016/j.clp.2007.11.014

[2] ² Al-Mousa HH, Omar AA, Rosenthal VD, Salama MF, Aly NY, Noweir ME, et al. Device-associated infection rates, bacterial resistance, length of stay, and mortality in Kuwait: International Nosocomial Infection Consortium findings. Am J Infect Control. 2016;44(4):444-9. https://doi.org/10.1016/j.ajic.2015.10.031
» https://doi.org/10.1016/j.ajic.2015.10.031

[3] ³ Yang J, Chen M, Li L, Zha Z, Cheng M, Yang X. Prognosis analysis and infection-related risk factors of multi-drug-resistant bacteria isolated from a general hospital in China, 2019-2023. J Hosp Infect. 2025;158:29-37. https://doi.org/10.1016/j.jhin.2025.02.003
» https://doi.org/10.1016/j.jhin.2025.02.003

[4] ⁴ Agaba P, Tumukunde J, Tindimwebwa JVB, Kwizera A. Nosocomial bacterial infections and their antimicrobial susceptibility patterns among patients in Ugandan intensive care units: a cross sectional study. BMC Res Notes. 2017;10(1):349. https://doi.org/10.1186/s13104-017-2695-5
» https://doi.org/10.1186/s13104-017-2695-5

[5] ⁵ Kollef MH, Burnham CAD. Ventilator-Associated Pneumonia: The Role of Emerging Diagnostic Technologies. Semin Respir Crit Care Med. 2017;38(3):253-63. https://doi.org/10.1055/s-0037-1599224
» https://doi.org/10.1055/s-0037-1599224

[6] ⁶ Zhou X, Wagh K, Lv G, Sharma D, Lei W. Genome drafting of nosocomial infection CRE Klebsiella pneumoniae confirming resistance to colistin and eravacycline, carrying blaNDM-1, mcr-1, and blaKPC-2 in neonatology from November to December 2023. Front Cell Infect Microbiol. 2025;14:1528017. https://doi.org/10.3389/fcimb.2024.1528017
» https://doi.org/10.3389/fcimb.2024.1528017

[7] ⁷ Wang Z, Qin RR, Huang L, Sun LY. Risk Factors for Carbapenem-resistant Klebsiella pneumoniae Infection and Mortality of Klebsiella pneumoniae Infection. Chin Med J (Engl). 2016;129(10):1135-9. https://doi.org/10.4103/0366-6999.221267
» https://doi.org/10.4103/0366-6999.221267

[8] ⁸ Bonnet V, Dupont H, Glorion S, Aupée M, Kipnis E, Gérard JL, et al. Influence of bacterial resistance on mortality in intensive care units: a registry study from 2000 to 2013 (IICU Study). J Hosp Infect. 2019;102(3):317-24. https://doi.org/10.1016/j.jhin.2019.01.011
» https://doi.org/10.1016/j.jhin.2019.01.011

[9] ⁹ Elmanama AA, Al Laham NA, Tayh GA. Antimicrobial susceptibility of bacterial isolates from burn units in Gaza. Burns. 2013;39(8):1612-8. https://doi.org/10.1016/j.burns.2013.04.011
» https://doi.org/10.1016/j.burns.2013.04.011

[10] ¹⁰ Öncül O, Öksüz S, Acar A, Ülkür E, Turhan V, Uygur F, et al. Nosocomial infection characteristics in a burn intensive care unit: Analysis of an eleven-year active surveillance. Burns. 2014;40(5):835-41. https://doi.org/10.1016/j.burns.2013.11.003
» https://doi.org/10.1016/j.burns.2013.11.003

[11] ¹¹ Santucci SG, Gobara S, Santos CR, Fontana C, Levin AS. Infections in a burn intensive care unit: experience of seven years. J Hosp Infect. 2003;53(1):6-13. https://doi.org/10.1053/jhin.2002.1340
» https://doi.org/10.1053/jhin.2002.1340

[12] ¹² Hassan EA, Elsherbiny NM, Abd El-Rehim AS, Soliman AMA, Ahmed AO. Health care-associated infections in pre-transplant liver intensive care unit: Perspectives and challenges. J Infect Public Health. 2018;11(3):398-404. https://doi.org/10.1016/j.jiph.2017.09.006
» https://doi.org/10.1016/j.jiph.2017.09.006

[13] ¹³ Kim B, Kim K, Yoon JS. Nosocomial Acinetobacter baumannii infection in children in adult versus pediatric intensive care units. Pediatr Int. 2020;62(4):451-58. https://doi.org/10.1111/ped.14133
» https://doi.org/10.1111/ped.14133

[14] ¹⁴ Aycan IO, Celen MK, Yilmaz A, Almaz MS, Dal T, Celik Y, et al. Bacterial colonization due to increased nurse workload in an intensive care unit. Rev Bras Anestesiol. 2015;65(3):180-5. https://doi.org/10.1016/j.bjane.2014.05.005
» https://doi.org/10.1016/j.bjane.2014.05.005

[15] ¹⁵ Enoch DA, Summers C, Brown NM, Moore L, Gillham MI, Burnstein RM, et al. Investigation and management of an outbreak of multidrug-carbapenem-resistant Acinetobacter baumannii in Cambridge, UK. J Hosp Infect. 2008;70(2):109-18. https://doi.org/10.1016/j.jhin.2008.05.015
» https://doi.org/10.1016/j.jhin.2008.05.015

[16] ¹⁶ Sligl WI, Dragan T, Smith SW. Nosocomial Gram-negative bacteremia in intensive care: epidemiology, antimicrobial susceptibilities, and outcomes. Int J Infect Dis. 2015;37:129-34. https://doi.org/10.1016/j.ijid.2015.06.024
» https://doi.org/10.1016/j.ijid.2015.06.024

[17] ¹⁷ Mitharwal SM, Yaddanapudi S, Bhardwaj N, Gautam V, Biswal M, Yaddanapudi L. Intensive care unit-acquired infections in a tertiary care hospital: An epidemiologic survey and influence on patient outcomes. Am J Infect Control. 2016;44(10):113-7. https://doi.org/10.1016/j.ajic.2016.01.021
» https://doi.org/10.1016/j.ajic.2016.01.021

[18] ¹⁸ Nagao M. A multicentre analysis of epidemiology of the nosocomial bloodstream infections in Japanese university hospitals. Clin Microbiol Infect. 2014;20(12):1002-10. https://doi.org/10.1111/1469-0691.12083
» https://doi.org/10.1111/1469-0691.12083

[19] ¹⁹ Karakuzu Z, Iscimen R, Akalin H, Girgin NK, Kahveci F, Sinirtas M. Prognostic Risk Factors in Ventilator-Associated Pneumonia. Med Sci Monit. 2018;24:1321-8. https://doi.org/10.12659/msm.905919
» https://doi.org/10.12659/msm.905919

[20] ²⁰ Xu M, Zeng J. Analysis of factors influencing the risk of secondary infection in patients colonized or infected with multidrug-resistant Gram-negative bacteria following hospitalization. Microb Pathog. 2024;190:106637. https://doi.org/10.1016/j.micpath.2024.106637
» https://doi.org/10.1016/j.micpath.2024.106637

Author(s)	Title	Periodical	Objectives	Conclusion
Marin H. Kollef and Carey-Ann D. Burnham (2017)	Ventilator-Associated Pneumonia: The Role of Emerging Diagnostic Technologies	Semin Respir Crit Care Med	To assess the impact of antimicrobial resistance and the role of novel rapid diagnostic technologies in ventilator-associated pneumonia.	Integrating rapid diagnostic tests into protocols maximizes clinical benefits and minimizes bacterial resistance.
J. Yang et al. (2025)	Prognosis analysis and infection-related risk factors of multi-drug-resistant bacteria isolated from a general hospital in China, 2019-2023	Journal of Hospital Infection	To analyze detection trends, prognosis, and risk factors for nosocomial infections by multidrug-resistant bacteria.	The high lethality requires rigorous clinical attention in ICUs and better supervision of antimicrobial use.
Alison J. Carey et al. (2008)	Hospital-Acquired Infections in the NICU: Epidemiology for the New Millennium	Clinics in Perinatology	To describe the epidemiology and propose best practices for the prevention and diagnosis of nosocomial infections in neonatal ICUs.	Rigorous preventive strategies and the use of lumbar puncture are essential in the evaluation of neonatal sepsis.
Xinlong Zhou et al. (2025)	Genome drafting of nosocomial infection CRE Klebsiella pneumoniae confirming resistance to colistin...	Frontiers in Cellular and Infection Microbiology	To investigate the genome of carbapenem-resistant K. pneumoniae isolated during an outbreak in neonatal ICU.	The complexity of outbreaks requires continuous genomic surveillance and strict infection control to avoid therapeutic failures.
Haifaa Hassan Al-Mousa et al. (2016)	Device-associated infection rates, bacterial resistance, length of stay, and mortality in Kuwait: International Nosocomial Infection Consortium findings	American Journal of Infection Control	To report the rates of device-associated infection, bacterial resistance, and mortality in ICUs in Kuwait.	The high infection rates underscore the urgent need to strengthen rigorous infection control programs.
Ziyaettin Karakuzu et al. (2018)	Prognostic Risk Factors in Ventilator-Associated Pneumonia	Med Sci Monit	To analyze the clinical and laboratory factors that affect the prognosis of patients diagnosed with ventilator-associated pneumonia in the ICU.	The SOFA score was shown to be a strong predictor of mortality, and should be continuously monitored for prognostic evaluation.
Elham A. Hassan et al. (2018)	Health care-associated infections in pre-transplant liver intensive care unit: Perspectives and challenges	Journal of Infection and Public Health	To assess the incidence, risk factors, and infection-causing microorganisms in patients with end-stage liver disease.	The high prevalence of multidrug resistance requires effective surveillance, active control measures, and strict antibiotic use policies.
Wendy Irene Sligl et al. (2015)	Nosocomial Gram-negative bacteremia in intensive care: epidemiology, antimicrobial susceptibilities, and outcomes	International Journal of Infectious Diseases	To describe the epidemiology, susceptibility, and clinical outcomes of ICU-acquired Gram-negative bacteremia.	The high mortality of these bacteremias requires the adoption of appropriate empirical therapy and greater attention to the management of comorbidities.
Abdelraouf A. Elmanama et al. (2013)	Antimicrobial susceptibility of bacterial isolates from burn units in Gaza	Burns	To determine the susceptibility profile of bacteria isolated in clinical and environmental samples from burn units.	The prevalence of multidrug-resistant strains, especially MRSA, requires the immediate implementation of strict infection control measures.
Beomjoon, Kim et al. (2020)	Nosocomial Acinetobacter baumannii infection in children in adult versus pediatric intensive care units	Pediatrics International	To compare the incidence of A. baumannii infection in pediatric patients treated in adult ICUs versus pediatric ICUs.	Paediatric ICUs provide a safer care environment, significantly reducing the risk of nosocomial infections in children.
Oral, Öncül et al. (2014)	Nosocomial infection characteristics in a burn intensive care unit: Analysis of an eleven-year active surveillance	Burns	To describe the rates of nosocomial infection, risk factors, and the bacterial resistance profile in a burn ICU.	The increased risk associated with the burned area makes it vital to know the local microbiological profile to direct appropriate treatment.
Min Xu and Jing Zeng (2024)	Analysis of factors influencing the risk of secondary infection in patients colonized or infected with multidrug-resistant Gram-negative bacteria...	Microbial Pathogenesis	To investigate the factors that influence the emergence of secondary infections in patients with multidrug-resistant Gram-negative bacteria.	The adoption of infection control measures and the rational use of antibiotics are essential to minimize secondary risks.
Ilker Onguc Aycan et al. (2015)	Bacterial colonization due to increased nurse workload in an intensive care unit	Brazilian Journal of Anesthesiology	To evaluate the possible association between the high workload of the nursing team and the development of nosocomial infections in the ICU.	Excessive workload increase and undersizing of staff directly correlate with a higher risk of infection.
Peter Agaba et al. (2017)	Nosocomial bacterial infections and their antimicrobial susceptibility patterns among patients in Ugandan intensive care units: a cross sectional study	BMC Research Notes	To describe the common bacterial infections, resistance patterns, and factors associated with nosocomial infection in Ugandan ICUs.	The high bacterial multi-resistance in critical units reinforces the strict need for antibiotic surveillance and infection control.
D.A. Enoch et al. (2008)	Investigation and management of an outbreak of multidrug-carbapenem-resistant Acinetobacter baumannii in Cambridge, UK	Journal of Hospital Infection	To describe the investigational measures and practical management of an outbreak of multidrug-resistant A. baumannii occurring in intensive care units.	Successful control of the clinical outbreak required a multidisciplinary approach, rapid isolation of patients, and deep environmental cleansing.
V. Bonnet et al. (2019)	Influence of bacterial resistance on mortality in intensive care units: a registry study from 2000 to 2013 (IICU Study)	Journal of Hospital Infection	To assess the direct influence of antibiotic resistance on mortality in patients admitted to intensive care units.	Infections by resistant strains are independently and significantly associated with increased length of hospital stay and mortality.
S. G. Santucci et al. (2003)	Infections in a burn intensive care unit: experience of seven years	Journal of Hospital Infection	To analyze the epidemiological characteristics and record the rates of nosocomial infections in a burn ICU over seven years.	The high rate of infections in these patients highlights the need for continuous surveillance strongly focused on the use of invasive devices.
Sanwar M. Mitharwal et al. (2016)	Intensive care unit-acquired infections in a tertiary care hospital: An epidemiologic survey and influence on patient outcomes	American Journal of Infection Control	To study the epidemiological patterns of ICU-acquired infections and identify their direct impact on patients’ clinical outcomes.	The high incidence of infections caused by resistant pathogens is strongly associated with prolonged mechanical ventilation time.
M. Nagao (2013)	A multicentre analysis of epidemiology of the nosocomial bloodstream infections in Japanese university hospitals	Not informed in the article	To analyze current epidemiological trends and resistance profile in bloodstream infections in university hospitals.	Additional efforts are needed to promote serial blood culture collection and significantly improve the prognosis of these infections.
Zhe Wang et al. (2018)	Risk Factors for Carbapenem-resistant Klebsiella pneumoniae Infection and Mortality of Klebsiella pneumoniae Infection	Not informed in the article	To identify primary risk factors and predictors of mortality in infections caused by carbapenem-resistant K. pneumoniae.	The protection of patients’ immune function and the adoption of control measures are essential to reduce the risks and lethality of the condition.