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		  <p class="Type-of-Article" lang="en-GB"><span class="CharOverride-1">Review Article</span></p>
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		<div class="Basic-Text-Frame">
			<p class="title- ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="title- ParaOverride-1" lang="en-GB">Nosocomial Infections and their Surveillance in Veterinary Hospitals</p>
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			<p class="Authors ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Authors ParaOverride-1" lang="en-GB"><span class="CharOverride-3">Arockiasamy Arun Prince Milton</span><span class="CharOverride-4">1</span><span class="CharOverride-3">, Govindarajan Bhuvana Priya</span><span class="CharOverride-4">2</span><span class="CharOverride-3">, Manivasagam Aravind</span><span class="CharOverride-4">3</span><span class="CharOverride-3">, Swain Parthasarathy</span><span class="CharOverride-4">1</span><span class="CharOverride-3">, Mani Saminathan</span><span class="CharOverride-4">4</span><span class="CharOverride-3">, Karuppannan Jeeva</span><span class="CharOverride-4">5</span><span class="CharOverride-3">, Rajesh Kumar Agarwal</span><span class="CharOverride-4">2</span></p>
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			<p class="Affiliations ParaOverride-1" lang="en-GB"><span class="CharOverride-2">1</span>Division of Veterinary<span class="CharOverride-2"> </span>Public Health; <span class="CharOverride-2">2</span>Division of Bacteriology and Mycology; <span class="CharOverride-2">3</span>Division of Parasitology; <span class="CharOverride-2">4</span>Division of Pathology, Indian Veterinary Research Institute (IVRI), Izatnagar, Bareilly (UP)–243122, India; <span class="CharOverride-2">5</span>Department of Veterinary Parasitology, Madras Veterinary College, Chennai-600007, Tamilnadu, India.</p>
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			<p class="Abstract ParaOverride-1" lang="en-GB">&nbsp;</p>
	  <p class="Abstract ParaOverride-1" lang="en-GB"><span class="CharOverride-5">Abstract</span> | Nosocomial, or hospital-acquired, infections are well-thought-out to be the most common problem affecting hospitalized human patients as well as veterinary patients. These are of great consequence in veterinary medicine and can have considerable adverse effects on the individual patient as well as on the veterinary hospital as a whole. Different infectious agents like MRSA, <span class="CharOverride-6">Cl. difficile</span>, MDR <span class="CharOverride-6">E. coli</span>, <span class="CharOverride-6">Salmonell</span>a spp. and many more are of prodigious significance in causing NIs. A surveillance and control measure for these NIs in veterinary settings needs to be addressed in future. This review consolidates some Nosocomial infections and the strategy for its surveillance in veterinary practice.</p>
			<p class="Abstract ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Abstract ParaOverride-1" lang="en-GB"><span class="CharOverride-5">Keywords </span>| Nosocomial infections, Surveillance, Veterinary, Hospitals, MDR</p>
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			<p class="Editor----Citation" lang="en-GB">&nbsp;</p>
			<p class="Editor----Citation" lang="en-GB"><span class="CharOverride-8">Editor</span> | Ruchi Tiwari, College of Veterinary Sciences, Department of Veterinary Microbiology and Immunology Uttar Pradesh Pandit Deen Dayal Upadhayay Pashu Chikitsa, Vigyan Vishvidhyalaya Evum Go-Anusandhan Sansthan (DUVASU), Mathura (U.P.) – 281001, India.</p>
			<p class="Editor----Citation" lang="en-GB"><span class="CharOverride-8">Special Issue</span>| 2 (2015) “Reviews on Trends and Advances in Safeguarding Terrestrial /Aquatic Animal Health and Production”</p>
            
		  <p class="Editor----Citation" lang="en-GB"><span class="CharOverride-5">Received</span> | December 03, 2014; <span class="CharOverride-5">Revised</span> | December 15, 2014; <span class="CharOverride-5">Accepted</span> | December 16, 2014; <span class="CharOverride-5">Published</span> | December 29, 2014&#9;&#9;</p>
            
		  <p class="Editor----Citation" lang="en-GB"><span class="CharOverride-5">*Correspondence</span> | Arockiasamy Arun Prince Milton, Indian Veterinary Research Institute, Izatnagar, Bareilly, India; <span class="CharOverride-5">Email:</span> vetmilton@gmail.com</p>
			<p class="Editor----Citation" lang="en-GB"><span class="CharOverride-5">Citation</span> | Milton AAP, Priya GB, Aravind M, Parthasarathy S, Saminathan M, Jeeva K, Agarwal RK (2015). Nosocomial infections and their surveillance in veterinary hospitals. Adv. Anim. Vet. Sci. 3(2s): 1-24.  </p>
			<p class="Editor----Citation" lang="en-GB"><span class="CharOverride-8">DOI</span> | <a href"http://dx.doi.org/10.14737/journal.aavs/2015/3.2s.1.24">http://dx.doi.org/10.14737/journal.aavs/2015/3.2s.1.24</a></p>
			<p class="Editor----Citation" lang="en-GB"><span class="Editor---Citation CharOverride-5" lang="en-US">ISSN </span><span class="Editor---Citation CharOverride-5" lang="en-US">(</span><span class="Editor---Citation CharOverride-5" lang="en-US">Online</span><span class="Editor---Citation CharOverride-5" lang="en-US">)</span> | 2307-8316; <span class="Editor---Citation CharOverride-5" lang="en-US">ISSN </span><span class="Editor---Citation CharOverride-5" lang="en-US">(Print)  | </span>2309-3331</p>
			<p class="Editor----Citation" lang="en-GB"><span class="CharOverride-8">Copyright </span>© 2015 Milton et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</p>
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			<p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
			<p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
			<p class="Heading-1--Introduction----" lang="en-GB"><span class="Body-text">Introduction</span></p>
			<p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
			<p class="Caps-on-First-Para ParaOverride-1" lang="en-GB"><span class="_idGenDropcap-1">N</span><span class="Body-text">osocomial </span><span class="Body-text">infections are  hospital acquired infections which may be localized or systemic form acquired by the patient who was admitted for reasons other than infection, because of the existence of an infectious agent or its toxin which was not present or incubating at the time of hospital admittance (</span><a href="#Horan-TC--Andrus-M--Dudeck-MA--2008-."><span class="Hyperlink">Horan</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 2008</span></a><span class="Body-text">). Furthermore they are the high-flying reasons for the failure of advanced health treatment (</span><a href="#Mielke-M--2010-"><span class="Hyperlink">Mielke, 2010</span></a><span class="Body-text CharOverride-9">). Generally Nosocomial infections are frequent impediment encountered by the hospitalized human beings, and nosocomial bloodstream infections are the eighth leading cause of death in the United States (</span><a href="#Burke-JP--2003-"><span class="Hyperlink">Burke, 2003</span></a><span class="Body-text CharOverride-9">). About 5–10% of patients acquire infections from human hospitals and approximately 90,000 deaths per year due to nosocomial infections (</span><a href="#Burke-JP--2003-"><span class="Hyperlink">Burke, 2003</span></a><span class="Body-text CharOverride-9">). The risk factors in veterinary hospitals are comparable to those in human hospitals. Prevalence studies have shown that 4-9% patients endure from a nosocomial infection (</span><a href="#Mielke-M--2010-"><span class="Hyperlink">Mielke, 2010</span></a><span class="Body-text CharOverride-9">). The occurrence of nosocomial infections in veterinary hospitals has not been w</span><span class="Body-text">ell established and in nascent stage (</span><a href="#Boerlin-P--Eugster-S--Gaschen-F--Straub-R--Schwalder-P--2001-."><span class="Hyperlink">Boerlin et al., 2001</span></a><span class="Body-text">; </span><a href="#Johnson-JA--2002"><span class="Hyperlink">Johnson, 2002</span></a><span class="Body-text">; </span><a href="#Morley-PS--2004-."><span class="Hyperlink">Morley, 2004</span></a><span class="Body-text">; </span><a href="#Smith-BP--2004-."><span class="Hyperlink">Smith, 2004</span></a><span class="Body-text">; </span><a href="#Traub-Dargatz-JL--Dargatz-DA--Morley-PS--Dunowska-M--2004"><span class="Hyperlink">Traub-Dargatz et al., 2004</span></a><span class="Body-text">; </span><a href="#Morley-PS--Weese-JS--2008-."><span class="Hyperlink">Morley and Weese, 2008</span></a><span class="Body-text">), even though the nosocomial infections are of immense significance in the field of veterinary medicine since quite a lot of nosocomial outbreaks of different etiologies in veterinary hospitals has been documented (</span><a href="#Castor-ML--Wooley-RE--Shotts-EB--Brown-J--Payeur-JB--1989-."><span class="Hyperlink">Castor et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">1989</span></a><span class="Body-text">; </span><a href="#Madewell-BR--Tang-YJ--Jang-S--Madigan-JE--Hirsh-DC--Gumerlockm-PH--Silva-J--1995-."><span class="Hyperlink">Madewell et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">1995</span></a><span class="Body-text">; </span><a href="#Hartmann-FA--Callan-RJ--McGuirk-SM--West-SE--1996-."><span class="Hyperlink">Hartmann</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 1996</span></a><span class="Body-text">; </span><a href="#Konkle-DM--Nelson-KM--Lunn-DP--1997-"><span class="Hyperlink">Konkle et al</span><span class="Hyperlink CharOverride-6">.</span><span class="Hyperlink">, 1997</span></a><span class="Body-text">; </span><a href="#Tillotson-K--Savage-CJ--Salman-MD--Gentry-Weeks-C--Rice-D--Fedorka-Cray-PJ--Traub-Dargatz-JL--1997-"><span class="Hyperlink">Tillotson et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">1997</span></a><span class="Body-text">; </span><a href="#Seguin-JC--Walker-RD--Caron-JP--Kloos-WE--George-CG--Hollis-RJ--Pfaller-MA--1999"><span class="Hyperlink">Seguin et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">1999</span></a><span class="Body-text">; </span><a href="#Schott-HC--Ewart-SL--Walker-RD--Dwyer-RM--Dietrich-S--Eberhart-SW--Derksen-FJ--2001-."><span class="Hyperlink">Schott et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2001</span></a><span class="Body-text">; </span><a href="#Weese-JS-Armstrong-J--2003-"><span class="Hyperlink">Weese and Armstrong, 2003</span></a><span class="Body-text">; </span><a href="#Cherry-B--Burns-A--Johnson-GS--Pfeiffer-H--Dumas-N--Barrett-D--McDonough-PL--Eidson-M--2004-."><span class="Hyperlink">Cherry et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2004</span></a><span class="Body-text">; </span><a href="#Wright-JG--Tengelsen-LA--Smith-KE--Bender-JB--Frank-RK--Grendon-JH--Angulo-FJ--2005-."><span class="Hyperlink">Wright et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2005</span></a><span class="Body-text">; </span><a href="#Weese-JS--Caldwell-F--Willey-BM--Kreiswirth-BN--McGeer-A--Rousseau-J--Low-DE--2006a-"><span class="Hyperlink">Weese et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2006a</span></a><span class="Body-text">; </span><a href="#Dallap-Schaer-BL--Aceto-H--Rankin-SC--2010-."><span class="Hyperlink">Dallap et al., 2010</span></a><span class="Body-text">; </span><a href="#Goehring-LS--Landolt-GS--Morley-PS--2010-."><span class="Hyperlink">Goehring et al., 2010</span></a><span class="Body-text">; </span><a href="#Steneroden-KK--Van-Metre-DC--Jackson-C--Morle-PS--2010-."><span class="Hyperlink">Steneroden et al., 2010</span></a><span class="Body-text">). Six of those outbreaks had evidence of zoonotic infection (</span><a href="#Konkle-DM--Nelson-KM--Lunn-DP--1997-"><span class="Hyperlink">Konkle et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">1997</span></a><span class="Body-text">; </span><a href="#Seguin-JC--Walker-RD--Caron-JP--Kloos-WE--George-CG--Hollis-RJ--Pfaller-MA--1999"><span class="Hyperlink">Seguin et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">1999</span></a><span class="Body-text">; </span><a href="#Schott-HC--Ewart-SL--Walker-RD--Dwyer-RM--Dietrich-S--Eberhart-SW--Derksen-FJ--2001-."><span class="Hyperlink">Schott et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2001</span></a><span class="Body-text">; </span><a href="#Cherry-B--Burns-A--Johnson-GS--Pfeiffer-H--Dumas-N--Barrett-D--McDonough-PL--Eidson-M--2004-."><span class="Hyperlink">Cherry et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2004</span></a><span class="Body-text">; </span><a href="#Wright-JG--Tengelsen-LA--Smith-KE--Bender-JB--Frank-RK--Grendon-JH--Angulo-FJ--2005-."><span class="Hyperlink">Wright et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2005</span></a><span class="Body-text">; </span><a href="#Weese-JS--Caldwell-F--Willey-BM--Kreiswirth-BN--McGeer-A--Rousseau-J--Low-DE--2006a-"><span class="Hyperlink">Weese et al., 2006a</span></a><span class="Body-text">).</span></p>
			<p class="Caps-on-First-Para ParaOverride-1" lang="en-GB">&nbsp;</p>
		  <p class="Caps-on-First-Para ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-1--Introduction----" lang="en-GB"><span class="Body-text">History</span></p>
		  <p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="Body-text">In the middle ages, the hospitals were established to treat pitiable plague victims and to till date the hospitals and health care personnel are serving the society with great dedication and hospitals has become more obligatory in the healthy living of both human and animals. In 1869, Sir James Young Simpson did an initial signature in the field of hospital epidemiology by his study with more than 4000 amputees in Scotland and England where he found the mortality rate was higher in patients who remained in the hospital for post-operative care. He used the term “hospitalism” to express the risk linked to hospital care. After many years of dedicated works by people like Oliver Wendell Holmes, Ignaz Philipp Semmelweis, Louis Pasteur, Joseph Lister, and Robert Koch, to illuminate the risk factors connected with hospital-related infections (</span><a href="#Semmelweis-I--1848-"><span class="Hyperlink">Semmelweis, 1848</span></a><span class="Body-text">; </span><a href="#Major-RH--1954-"><span class="Hyperlink">Major, 1954</span></a><span class="Body-text">; </span><a href="#Eickhoff-TC--1981-."><span class="Hyperlink">Eickhoff, 1981</span></a><span class="Body-text">) and introduction of rectification guidelines like hand washing and sterilization of instruments used for surgery reduced the propagation of disease and death (</span><a href="#Major-RH--1954-"><span class="Hyperlink">Major, 1954</span></a><span class="Body-text">). The “tide of complacency” in the history of control of nosocomial infection is after the discovery of antibiotics, since the understanding and research of nosocomial infections was not highly developed in the time of world wars (</span><a href="#Eickhoff-TC--1981-."><span class="Hyperlink">Eickhoff, 1981</span></a><span class="Body-text">). In 19</span><span class="Body-text CharOverride-2">th</span><span class="Body-text"> century after the commencement of advanced research in medicine and surgery which revolutionised the healthcare facilities and interventions but also unearthed the unintended harm to patients i.e. Nosocomial infections through health care settings.</span></p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-1--Introduction----" lang="en-GB"><span class="Body-text">Epidemiology and Risk Factors</span></p>
		  <p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="Body-text">Nowadays, some of the important factors which have been often associated with the nosocomial infections in human health care centres like employing invasive devices (e.g., intravenous and urinary catheters), lengthened hospitalization of decisively ill patients, complex medical treatment  and surgical procedures, and the extensive exploitation of antibiotics (</span><a href="#Boerlin-P--Eugster-S--Gaschen-F--Straub-R--Schwalder-P--2001-."><span class="Hyperlink">Boerlin et al., 2001</span></a><span class="Body-text">; </span><a href="#Johnson-JA--2002"><span class="Hyperlink">Johnson, 2002</span></a><span class="Body-text">) are increasing in  veterinary hospitals. Intensive care Patients are at 5 to 10 times higher risk of developing a nosocomial infection than normal patients (</span><a href="#Weber-DJ--Raasch-R--Rutala-WA--1999"><span class="Hyperlink">Weber et al., 1999</span></a><span class="Body-text">). The threat of developing infection for hospitalized patients are due to extrinsic risk factors, such as the use of invasive devices and intrinsic risk factors, like underlying ailment during hospitalization (</span><a href="#National-Nosocomial-Infections-Surveillance--NNIS--System.--1991"><span class="Hyperlink">National Nosocomial Infections Surveillance System, 1991</span></a><span class="Body-text">; </span><a href="#Emori-TG--Gaynes-RP--1993"><span class="Hyperlink">Emori and Gaynes, 1993</span></a><span class="Body-text">). Nosocomial infections are either site specific (e.g., surgical site infection) or unit specific (e.g., intensive care unit). The possible source for nosocomial agents are the patient’s own flora, health personnel, instruments and equipment of hospital (</span><a href="#Hardy-KJ--Oppenheim-BA--Gossain-S--Gao-F--Hawkey-PM--2006-."><span class="Hyperlink">Hardy et al., 2006</span></a><span class="Body-text">; </span><a href="#Marshal-BM--Ochieng-DJ--Levy-SB--2009-."><span class="Hyperlink">Marshal et al., 2009</span></a><span class="Body-text">) (</span><a href="#Figure-1"><span class="Hyperlink">Figure 1</span></a><span class="Body-text">). The amplifying risks which favours the transmission of antibiotic resistant pathogens and other nosocomial infections in veterinary hospitals are lack of hygiene, employing invasive devices, prolonged treatment, longer visits by health care worker and caseloads (</span><a href="#D-Agata-EM--Horn-MA--Ruan-S--Webb-GF--Wares-JR--2012-."><span class="Hyperlink">D’Agata et al., 2012</span></a><span class="Body-text">), delayed and breaks in treatment (</span><a href="#D-Agata-EM--Dupont-Rouzeyrol-M--Magal-P--Olivier-D--Ruan-S--2008"><span class="Hyperlink">D’Agata et al., 2008</span></a><span class="Body-text">), lengthy hospital stay (</span><a href="#D-Agata-EM--Magal-P--Olivier-D--Ruan-S--Webb-GF--2007-."><span class="Hyperlink">D’Agata et al., 2007</span></a><span class="Body-text">) and dependence on antimicrobials (</span><a href="#Johnson-JA--2002"><span class="Hyperlink">Johnson, 2002</span></a><span class="Body-text">; </span><a href="#Morley-PS--Apley-MD--Besser-TE--Burney-DP--Fedorka-Cray-PJ--2005"><span class="Hyperlink">Morley et al., 2005</span></a><span class="Body-text">), administration of antiulcer drugs (</span><a href="#Ruple-Czerniak-A--Aceto-HW--Bender-JB--Paradis...2013"><span class="Hyperlink">Ruple-Czerniak et al., 2013</span></a><span class="Body-text">).</span></p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="Body-text">In one individual-based model study to scrutinize the effect of movement of dogs to various locations in a veterinary teaching hospitals, it was found out that nosocomial infection transmission is greater in diagnostic rooms, intensive care units and housing wards than operation theatre and lobby and it also revealed that transmission following the contact with healthcare personnel was more common (</span><a href="#Suthar-N--Roy-S--Call-DR--Besser-TE--Davis-MA--2014-."><span class="Hyperlink">Suthar et al., 2014</span></a><span class="Body-text">). Veterinary hospitals are the major source and accountable for increasing prevalence of a MDR&#160;E. coli&#160;</span><span class="Body-text">in horses&#160;(</span><a href="#Ahmed-MO--Williams-NJ--Clegg-PD--van-Velkinburgh-JC--Baptiste-KE--2012-"><span class="Hyperlink">Ahmed</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 2012</span></a><span class="Body-text">). Veterinary personnel and veterinary hospital environments are allegedly most important key factors in risk of gaining antibiotic resistant pathogens by hospitalized dogs (</span><a href="#Hamilton-E--Kruger-JM--Schall-W--Beal-M--Manning-SD--2013-"><span class="Hyperlink">Hamilton et al., 2013</span></a><span class="Body-text">; </span><a href="#Heller-J--Kelly-L--Reid-SW--Mellor-DJ--2010-."><span class="Hyperlink">Heller</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">et al., 2010</span></a><span class="Body-text">; </span><a href="#KuKanich-KS--Ghosh-A--Skarbek-JV--Lothamer-KM--Zurek-L--2012-"><span class="Hyperlink">KuKanich et al., 2012</span></a><span class="Body-text">).</span></p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
		  
          <div class="pt" > <a href="http://nexusacademicpublishers.com/uploads/figures/20150104220649.png" target="new"><img class="img_display" src="http://nexusacademicpublishers.com/uploads/figures/20150104220649.png" width="80" height="80"></a>
    <p class="Figure--and-Table-Heading ParaOverride-1" lang="en-GB"><span class="CharOverride-5"><a id="Figure-1"></a>Figure 1: </span>Spread of nosocomial infections in veterinary hospitals</p></div>
          
      
			<p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
			<p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
			<p class="Heading-1--Introduction----" lang="en-GB"><span class="Body-text">Impacts of Veterinary hospital associated infections</span></p>
			<p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="Body-text">Nosocomial infections are the growing cause of morbidity and mortality in both human and veterinary medicine&#160;(</span><a href="#Weese-JS--2008a"><span class="Hyperlink">Weese, 2008a</span></a><span class="Body-text">; </span><a href="#Weese-JS--2008b"><span class="Hyperlink">Weese, 2008b</span></a><span class="Body-text">; </span><a href="#Owens-CD--Stoessel-K--2008-"><span class="Hyperlink">Owens et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2008</span></a><span class="Body-text CharOverride-6">; </span><a href="#Faires-MC--Traverse-M--Tater-KC--Pearl-DL--Weese-JS--2010-"><span class="Hyperlink">Faires et al., 2010</span></a><span class="Body-text">). Implication of multiple drug resistant bacterias in nosocomial infections are the main concern because of high morbidity, high cost and duration of treatment and more challenging to eliminate (</span><a href="#Weese-JS--2008a"><span class="Hyperlink">Weese, 2008a</span></a><span class="Body-text">; </span><a href="#Owens-CD--Stoessel-K--2008-"><span class="Hyperlink">Owens et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2008</span></a><span class="Body-text">;</span><span class="Body-text CharOverride-6"> </span><a href="#Faires-MC--Traverse-M--Tater-KC--Pearl-DL--Weese-JS--2010-"><span class="Hyperlink">Faires et al., 2010</span></a><span class="Body-text">)</span><span class="Body-text"> and there is potential zoonotic risk (</span><a href="#Suthar-N--Roy-S--Call-DR--Besser-TE--Davis-MA--2014-."><span class="Hyperlink">Suthar </span></a><a href="#Suthar-N--Roy-S--Call-DR--Besser-TE--Davis-MA--2014-."><span class="Hyperlink">et al., 2014</span></a><span class="Body-text">). The food animals with resistant antimicrobial  bacteria pose a serious public health risk (</span><a href="#Howard-DH--Scott-RD--Packard-R--Jones-D--2003-."><span class="Hyperlink">Howard et al., 2003</span></a><span class="Body-text">), but the pet animals transmit the resistant bacteria directly to human population by acting as a reservoir (</span><a href="#Guardabassi-L--Schwarz-S--Lloyd-DH--2004-."><span class="Hyperlink">Guardabassi</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 2004</span></a><span class="Body-text">; </span><a href="#Lloyd-DH--2007-"><span class="Hyperlink">Lloyd, 2007</span></a><span class="Body-text">;  </span><a href="#Murphy-C--Reid-Smith-RJ--Prescott-JF--Bonnett-BN--Poppe-C--Boerlin-P--Weese-JS--Janecko-N--McEwen-SA"><span class="Hyperlink">Murphy et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2009</span></a><span class="Body-text">;&#160; </span><a href="#Song-SJ--Lauber-C--Costello-EK--Lozupone-CA--Humphrey-G--2013-."><span class="Hyperlink">Song et al., 2013</span></a><span class="Body-text">). MDR in companion animals encompass stern public health impacts (</span><a href="#Abraham-S--Wong-HS--Turnidge-J--Johnson-JR--Trott-DJ--2014-"><span class="Hyperlink">Abraham</span><span class="Hyperlink CharOverride-5">&#160;</span><span class="Hyperlink">et al., 2014</span></a><span class="Body-text">). Undue exploitation of antibiotics and horizontal gene transfer may lead to increased possession of antibiotic resistance, thereby escorting to longer period of antibiotic treatment and treatment failure (</span><a href="#Levin-BR--Rozen-DE--2006-"><span class="Hyperlink">Levin et al., 2006</span></a><span class="Body-text">; </span><a href="#Bootsma-MC--van-der-Horst-MA--Guryeva-T--ter-Kuile-BH--Diekmann-O--2012-."><span class="Hyperlink">Bootsma et al., 2012</span></a><span class="Body-text">). The occupational risk to the veterinary health personnel and staff are other concern (</span><a href="#Jordan-D--Simon-J--Fury-S--Moss-S--Giffard-P--Maiwald...2011"><span class="Hyperlink">Jordan</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 2011</span></a><span class="Body-text">). There will be huge economic loss due to this outbreaks and it may tarnish the reputation of the concerned veterinary hospital with reduced client confidence and increased panic.</span></p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
		  <p class="Heading-1--Introduction----" lang="en-GB"><span class="Body-text">MRSA&#9;</span></p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="Body-text">With all the evidence </span><span class="Body-text CharOverride-6">Staphylococcus aureus</span><span class="Body-text"> is an important pathogen of both human and animal causing meek skin infections to grave bacteraemia. Generally almost all </span><span class="Body-text CharOverride-6">S. aureus</span><span class="Body-text"> strains are resistant to beta-lactam antibiotics since it is producing pencillinases. Owing to this resistance, meticillin which is resistant to penicillinases were extensively used to treat </span><span class="Body-text CharOverride-6">S. aureus</span><span class="Body-text"> Infections. In late 1950s the meticillin use was initiated in human medicine to treat resistant </span><span class="Body-text CharOverride-6">S. aureus</span><span class="Body-text"> infections. Meticillin resistance was accounted in the early 1961 (</span><a href="#Jevons-MP--1961"><span class="Hyperlink">Jevons, 1961</span></a><span class="Body-text">) and the resistance development was demonstrated (</span><a href="#Barber---1961-."><span class="Hyperlink">Barber, 1961</span></a><span class="Body-text">). In 1970s MRSA emerged as a staid public health issue in US hospitals (</span><a href="#Panlilio-AL--Culver-DH--Gaynes-RP--Banerjee-S--Henderson-TS--Tolson-JS--Martone-WJ--1992-"><span class="Hyperlink">Panlilio et al., 1992</span></a><span class="Body-text">). In 1990s MRSA expanded itself as a solemn nosocomial infection throughout the world (</span><a href="#Ayliffe-GA--1997"><span class="Hyperlink">Ayliffe, 1997</span></a><span class="Body-text">). Eventhough MRSA was first emerged as a human pathogen, nowadays MRSA reports in animals are gradually increasing mainly in equine and companion animals. It is known that </span><span class="Body-text CharOverride-6">S.aureus</span><span class="Body-text"> is one of the chief cause for mastitis and the extensive use of intramammary antibiotics in cattle, so it is not unanticipated that, MRSA was isolated from milk of a mastitic animal, which is first among animals (</span><a href="#Devriese-LA--Vandamme-LR--Fameree-L--1972-."><span class="Hyperlink">Devriese</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 1972</span></a><span class="Body-text">). After this MRSA has been isolated from various species like dogs (</span><a href="#Pak-SI--Han-HR--Shimizu-A--1999-.-C"><span class="Hyperlink">Pak et al., 1999</span></a><span class="Body-text">), cats (</span><a href="#Scott-GM--Thomson-R--Malone-Lee-J--Ridgway-GL--1988-"><span class="Hyperlink">Scott et al., 1988</span></a><span class="Body-text">), sheep (</span><a href="#Goni-P--Vergara-Y--Ruiz-J--Albizu-I--Vila-J--Gomez-Lus-R--2004-."><span class="Hyperlink">Goni et al., 2004</span></a><span class="Body-text">), horses (</span><a href="#Seguin-JC--Walker-RD--Caron-JP--Kloos-WE--George-CG--Hollis-RJ--Pfaller-MA--1999"><span class="Hyperlink">Seguin et al., 1999</span></a><span class="Body-text">), pigs (</span><a href="#Voss-A--Loeffen-F--Bakker-J--Klaassen-C--Wulf-M--2005-."><span class="Hyperlink">Voss et al., 2005</span></a><span class="Body-text">) and chickens (</span><a href="#Lee-JH--2003-."><span class="Hyperlink">Lee, 2003</span></a><span class="Body-text">). Methicillin-resistant&#160;</span><span class="Body-text CharOverride-6">Staphylococcus aureus&#160;</span><span class="Body-text">(MRSA) is an important concern nowadays in pet animals for being a significant cause in nosocomial infections (</span><a href="#Weese-JS--2008b"><span class="Hyperlink">Weese, 2008b</span></a><span class="Body-text CharOverride-6">; </span><a href="#Faires-MC--Traverse-M--Tater-KC--Pearl-DL--Weese-JS--2010-"><span class="Hyperlink">Faires et al., 2010</span></a><span class="Body-text">; </span><a href="#Weese-JS--Finley-R--Reid-Smith-RR--Janecko-N--Rousseau-J--2010-."><span class="Hyperlink">Weese et al., 2010</span></a><span class="Body-text">) and also a threat of zoonoses to veterinary health care personnel&#160;(</span><a href="#Loeffler-A--Pfeiffer-DU--Lloyd-DH--Smith-H--Soares-Magalhaes-R--Lindsay-JA--2010"><span class="Hyperlink">Loeffler et al., 2010</span></a><span class="Body-text">; </span><a href="#Burstiner-LC--Faires-M--Weese-JS--2010-."><span class="Hyperlink">Burstiner</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">et al., 2010</span></a><span class="Body-text">) and horses may act as a reservoir of MRSA and serve as a source of infection to humans (</span><a href="#Weese-JS--Archambault-M--Willey-BM--Dick--2005a"><span class="Hyperlink">Weese et al., 2005</span></a><span class="Hyperlink">a</span><span class="Body-text">). Interestingly, various studies reported that MRSA isolated from companion animals like dogs and cats are found indistinguishable from MRSA isolated from human associated infections (</span><a href="#Baptiste-KE--Williams-K--Williams-NJ--Wattret...-2005"><span class="Hyperlink">Baptiste et al., 2005</span></a><span class="Body-text">, </span><a href="#Loeffler-A--Boag-AK--Sung-J--Lindsay-JA--Guardabassi-L--Dalsgaard-A--Lloyd-DH--2005-"><span class="Hyperlink">Loeffler et al., 2005</span></a><span class="Body-text">;  </span><a href="#O-Mahony-R--Abbott-Y--Leonard-FC--Markey-BK--Quinn-PJ--Pollock-PJ--Rossney-AS--2005-."><span class="Hyperlink">O’Mahony et al., 2005</span></a><span class="Body-text">; </span><a href="#Middleton-JR--Fales-WH--Luby-CD--Oaks-JL--Sanchez-S--Kinyon-JM--Hartmann-F--2005"><span class="Hyperlink">Middleton et al., 2005</span></a><span class="Body-text">;</span><span class="Body-text CharOverride-6"> </span><a href="#Rich-M--Roberts-L--Deighton-L--2005-"><span class="Hyperlink">Rich et al., 2005</span></a><span class="Body-text">; </span><a href="#Hanselman-B--Rousseau-J--Kruth-S--Weese-JS--2006-."><span class="Hyperlink">Hanselman et al., 2006</span></a><span class="Body-text">; </span><a href="#Malik-S--Peng-H--Barton-M--2006-"><span class="Hyperlink">Malik</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 2006</span></a><span class="Body-text">). The association was found out by various phenotypic typing and molecular typing methods like PFGE (</span><a href="#O-Mahony-R--Abbott-Y--Leonard-FC--Markey-BK--Quinn-PJ--Pollock-PJ--Rossney-AS--2005-."><span class="Hyperlink">O’Mahony et al., 2005</span></a><span class="Body-text">), SCCmec, MLST (</span><a href="#Enright-MC--Day-NP--Davies-CE--Peacock-SJ--Spratt-BG--2000-"><span class="Hyperlink">Enright et al., 2000</span></a><span class="Body-text">), spa typing (</span><a href="#Moodley-A--Stegger-M--Bagcigil-AF--Baptiste...-2006"><span class="Hyperlink">Moodley et al., 2006</span></a><span class="Body-text">). The data obtained through all these studies sturdily suggesting the bidirectional transmission of MRSA between companion animals and human (</span><a href="#Leonard-FC--Abbott-Y--Rossney-A--Quinn-PJ--O-Mahony-R--Markey-BK--2006-."><span class="Hyperlink">Leonard et al., 200</span></a><span class="Hyperlink">6</span><span class="Body-text">). Whereas with the assistance  of epidemiological typing it is proved that strains of MRSA isolated from horses and equine associated personnel are different (</span><a href="#Baptiste-KE--Williams-K--Williams-NJ--Wattret...-2005"><span class="Hyperlink">Baptiste et al., 2005</span></a><span class="Body-text">; </span><a href="#O-Mahony-R--Abbott-Y--Leonard-FC--Markey-BK--Quinn-PJ--Pollock-PJ--Rossney-AS--2005-."><span class="Hyperlink">O’Mahony et al., 2005</span></a><span class="Body-text">; </span><a href="#Weese-JS--Archambault-M--Willey-BM--Dick--2005a"><span class="Hyperlink">Weese et al., 2005a</span></a><span class="Body-text">; </span><a href="#Cuny-C--Kuemmerle-J--Stanek-C--Willey-B--Strommenger-B--Witte-W--2006-"><span class="Hyperlink">Cuny et al., 2006</span></a><span class="Body-text">). Outbreaks linking both horses and humans in veterinary hospitals were reported from the United States (</span><a href="#Seguin-JC--Walker-RD--Caron-JP--Kloos-WE--George-CG--Hollis-RJ--Pfaller-MA--1999"><span class="Hyperlink">Seguin et al., 1999</span></a><span class="Body-text">), Canada (</span><a href="#Weese-JS--Archambault-M--Willey-BM--Dick--2005a"><span class="Hyperlink">Weese et al., 2005</span></a><span class="Hyperlink">a</span><span class="Body-text">), Ireland (</span><a href="#O-Mahony-R--Abbott-Y--Leonard-FC--Markey-BK--Quinn-PJ--Pollock-PJ--Rossney-AS--2005-."><span class="Hyperlink">O’Mahony et al., 2005</span></a><span class="Body-text">), Austria (</span><a href="#Cuny-C--Kuemmerle-J--Stanek-C--Willey-B--Strommenger-B--Witte-W--2006-"><span class="Hyperlink">Cuny et al., 2006</span></a><span class="Body-text">, </span><a href="#Cuny-C--Strommenger-B--Witte-W--Stanek-C--2008"><span class="Hyperlink">2008</span></a><span class="Body-text">), the Netherlands (</span><a href="#van-Duijkeren-E--Moleman-M--Sloet-van-Oldruitenborgh-Oosterbaan-...-2010"><span class="Hyperlink">van Duijkeren et al., 2010</span></a><span class="Body-text">) Switzerland (</span><a href="#Sieber-S--Gerber-V--Jandova-V--Rossano-A--Evison-JM--Perreten-V--2011-"><span class="Hyperlink">Sieber et al., 2011</span></a><span class="Body-text">) and Israel (</span><a href="#Schwaber-MJ--Venezia-SN--Masarwa-S--Levy-...-2013"><span class="Hyperlink">Schwaber et al., 2013</span></a><span class="Body-text">). The typing studies revealed that the MRSA isolated from pigs (</span><a href="#Voss-A--Loeffen-F--Bakker-J--Klaassen-C--Wulf-M--2005-."><span class="Hyperlink">Voss et al., 2005</span></a><span class="Body-text">; </span><a href="#Van-Dijke-B--Koppen-H--Wannet-W--Huijsdens-X--de-Neeling-H--Voss-A--2006-."><span class="Hyperlink">Van Dijke</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 2006</span></a><span class="Body-text">) and cattle (</span><a href="#Kwon-NH--Park-KT--Moon-JS--Jung-WK--Kim-SH--Kim-JM--Hong-SK--Koo-HC--Joo-YS--Park-YH--2005"><span class="Hyperlink">Kwon</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 2005</span></a><span class="Body-text">) are distinct from MRSA of human lineage. Numerous studies have acknowledged the increasing MRSA infections in companion animals are coupled with  post-surgical infections and wounds (</span><a href="#Rich-M--Roberts-L--2004-."><span class="Hyperlink">Rich et al., 2004</span></a><span class="Body-text">; </span><a href="#Leonard-FC--Abbott-Y--Rossney-A--Quinn-PJ--O-Mahony-R--Markey-BK--2006-."><span class="Hyperlink">Leonard et al., 2006</span></a><span class="Body-text">) and indwelling devices and suture materials (</span><a href="#Leonard-FC--Abbott-Y--Rossney-A--Quinn-PJ--O-Mahony-R--Markey-BK--2006-."><span class="Hyperlink">Leonard et al., 2006</span></a><span class="Body-text">). </span><a href="#Smith-MM--Vasseur-PB--Saunders-HM--1989-."><span class="Hyperlink">Smith et al. (1989)</span></a><span class="Body-text"> accounted 38% isolation rate of bacteria in dogs from the orthopaedic implant fixation site soon after the removal following the union of the closed fracture (</span><a href="#Smith-MM--Vasseur-PB--Saunders-HM--1989-."><span class="Hyperlink">Smith et al., 1989</span></a><span class="Body-text">). The primary route of MRSA infection transmission in veterinary hospitals is through hands of healthcare personnel (</span><a href="#Leonard-FC--Abbott-Y--Rossney-A--Quinn-PJ--O-Mahony-R--Markey-BK--2006-."><span class="Hyperlink">Leonard et al., 200</span></a><span class="Hyperlink">6</span><span class="Body-text">). As far as public health is concerned many years ago likelihood of companion animals to act as the source for the zoonotic infections of </span><span class="Body-text CharOverride-6">Staphylococci</span><span class="Body-text">  is suggested (</span><a href="#Mann-P--1959-."><span class="Hyperlink">Mann, 1959</span></a><span class="Body-text">) and many reports have offered the suggestion that animals may act as reservoirs of MRSA infections to human. In one case a cat was involved as a MRSA source for nurses in geriatric care unit (</span><a href="#Scott-GM--Thomson-R--Malone-Lee-J--Ridgway-GL--1988-"><span class="Hyperlink">Scott et al., 1988</span></a><span class="Body-text">). In another case of two nurses, a dog was considered as a reservoir for the treatment failure for MRSA and reinfection (</span><a href="#Cefai-C--Ashurst-S--Owens-C--1994-.-H"><span class="Hyperlink">Cefai</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 1994</span></a><span class="Body-text">). Another interesting case of recurrent MRSA infection in a diabetic patient and his wife, the source was found out to be a dog after the sampling of dog’s nares which is colonized with identical PFGE type of MRSA from the couple and the infection was halted in the couple when the dog was treated completely for MRSA (</span><a href="#Manian-FA--2003"><span class="Hyperlink">Manian, 2003</span></a><span class="Body-text">). Some reports implies that swine farmers are at risk of </span><span class="Body-text CharOverride-6">S.aureus</span><span class="Body-text"> and MRSA colonization (</span><a href="#Armand-Lefevre-L--Ruimy-R--Andremont-A---2005-."><span class="Hyperlink">Armand-Lefevre et al., 2005</span></a><span class="Body-text">; </span><a href="#Voss-A--Loeffen-F--Bakker-J--Klaassen-C--Wulf-M--2005-."><span class="Hyperlink">Voss et al., 2005</span></a><span class="Body-text">). An attending pet surgeon who was an asymptomatic carrier of MRSA was found to be associated with postoperative wound infection of MRSA in five dogs (</span><a href="#Leonard-FC--Abbott-Y--Rossney-A--Quinn-PJ--O-Mahony-R--Markey-BK--2006-."><span class="Hyperlink">Leonard et al., 2006</span></a><span class="Body-text">). In a survey conducted in a referral hospital for small animals from the nasal and oral mucosae of hospital staff and animals, MRSA was isolated from four dogs and 14 staff (</span><a href="#Loeffler-A--Boag-AK--Sung-J--Lindsay-JA--Guardabassi-L--Dalsgaard-A--Lloyd-DH--2005-"><span class="Hyperlink">Loeffler et al., 2005</span></a><span class="Body-text">). The veterinary personnel working in veterinary hospitals are at greater risk of MRSA colonization and hence MRSA colonization is regarded as an occupational risk (</span><a href="#Hanselman-B--Rousseau-J--Kruth-S--Weese-JS--2006-."><span class="Hyperlink">Hanselman et al., 2006</span></a><span class="Body-text">; </span><a href="#Anderson-MEC--Lefebvre-SL--Weese-JS--2008-."><span class="Hyperlink">Anderson et al., 2008</span></a><span class="Body-text">; </span><a href="#van-Duijkeren-E--Moleman-M--Sloet-van-Oldruitenborgh-Oosterbaan-...-2010"><span class="Hyperlink">van Duijkeren et al., 2010</span></a><span class="Body-text">; </span><a href="#Jordan-D--Simon-J--Fury-S--Moss-S--Giffard-P--Maiwald...2011"><span class="Hyperlink">Jordan et al., 2011</span></a><span class="Body-text">). MRSA colonized personnel plays a vital task in the MRSA introduction and transmission in veterinary health care settings (</span><a href="#van-Duijkeren-E--Moleman-M--Sloet-van-Oldruitenborgh-Oosterbaan-...-2010"><span class="Hyperlink">van Duijkeren et al., 2010</span></a><span class="Body-text">; </span><a href="#Sieber-S--Gerber-V--Jandova-V--Rossano-A--Evison-JM--Perreten-V--2011-"><span class="Hyperlink">Sieber et al., 2011</span></a><span class="Body-text">) and besides this they spread the infection to other persons (</span><a href="#Anderson-MEC--Lefebvre-SL--Weese-JS--2008-."><span class="Hyperlink">Anderson et al., 2008</span></a><span class="Body-text">). An outbreak occurred at teaching veterinary hospital in Israel by an uncommon MRSA strain displayed the bidirectional spread between animal and humans (</span><a href="#Schwaber-MJ--Venezia-SN--Masarwa-S--Levy-...-2013"><span class="Hyperlink">Schwaber et al., 2013</span></a><span class="Body-text">). From animal health relevance methicillin-resistant&#160;</span><span class="Body-text CharOverride-6">Staphylococcus pseudintermedius</span><span class="Body-text"> (MRSP) is often associated with pyoderma</span><span class="Body-text"> and surgical site infections (</span><a href="#Weese-JS--2008"><span class="Hyperlink">Weese, 2008b</span></a><span class="Body-text">) has swiftly emerging as an opportunistic nosocomial infectious agent (</span><a href="#Laarhoven-LM--de-Heus-P--van-Luijn-J--Duim-B--Wagenaar-JA--van-Duijkeren-E--2011"><span class="Hyperlink">Laarhoven et al., 2011</span></a><span class="Body-text">). MRSP can be detected in apparently normal animals (</span><a href="#Murphy-C--Reid-Smith-RJ--Prescott-JF--Bonnett-BN--Poppe-C--Boerlin-P--Weese-JS--Janecko-N--McEwen-SA"><span class="Hyperlink">Murphy et al., 2009</span></a><span class="Body-text">) and in veterinary hospital environment (</span><a href="#Nienhoff-U--Kadlec-K--Chaberny-IF--Verspohl-J--Gerlach-GF--Kreienbrock-L--Schwarz-S--2011"><span class="Hyperlink">Nienhoff</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 2011</span></a><span class="Body-text">). A large outbreak was recorded in Finnish veterinary teaching hospital caused by MRSP (</span><a href="#Gronthal-T--Moodley-A--Nykasenoja-S--Junilla-J--Guardabassi-L--Thomson-K--Rantala-M--2014"><span class="Hyperlink">Gronthal et al., 2014</span></a><span class="Body-text">).</span></p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
		  <p class="Heading-1--Introduction----" lang="en-GB"><span class="Body-text CharOverride-15">Clostridium difficile</span></p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="Body-text">Following the discovery of </span><span class="Body-text CharOverride-6">C. difficile</span><span class="Body-text"> in 1935, it was thought to be the normal faecal flora of the newborns rather than pathogenic (</span><a href="#Hall-IC--O-Toole-E--1935"><span class="Hyperlink">Hall and O’Toole, 1935</span></a><span class="Body-text">).  But the preamble of broad spectrum antibiotics prompted the emergence of pseudomembranous colitis and it is now considered one of the serious cause of nosocomial infections since it is emerging in the human community and food animals (</span><a href="#Rupnik-M--Wilcox-MH--Gerding-DN--2009-."><span class="Hyperlink">Rupnik et al., 2009</span></a><span class="Body-text">). </span><span class="Body-text CharOverride-6">Clostridium difficile</span><span class="Body-text"> is a gram positive, spore forming anaerobic bacterium. </span><span class="Body-text CharOverride-6">C. difficile</span><span class="Body-text"> spores are comparatively resistant to common disinfectants making </span><span class="Body-text CharOverride-6">C. difficile </span><span class="Body-text">a lasting environmental contaminant. Many studies have reported a strong association between nosocomial </span><span class="Body-text CharOverride-6">C. difficile </span><span class="Body-text">infection and antibiotic therapy in horses (</span><a href="#Madewell-BR--Tang-YJ--Jang-S--Madigan-JE--Hirsh-DC--Gumerlockm-PH--Silva-J--1995-."><span class="Hyperlink">Madewell et al., 1995</span></a><span class="Body-text">; </span><a href="#Ruby-R--Magdesian-KG--Kass-PH--2009-"><span class="Hyperlink">Ruby et al., 2009</span></a><span class="Body-text">; </span><a href="#Barr-BS--Waldridge-BM--Morresey-PR--Reed-SM--...-2013"><span class="Hyperlink">Barr et al., 2013</span></a><span class="Body-text">). In a Prospective study conducted in horses pre-treated with penicillin followed by experimental infection resulted in increased isolation of </span><span class="Body-text CharOverride-6">C. difficile</span><span class="Body-text"> from faecal samples, revealing the role of antimicrobials as a risk factor (</span><a href="#Gustafsson-A--Ba--verud-V--Gunnarsson-A--Pringle-J--Franklin-A--2004-."><span class="Hyperlink">Gustafsson et al., 2004</span></a><span class="Body-text">). Prevalence and distribution of </span><span class="Body-text CharOverride-6">C. difficile</span><span class="Body-text"> was studied in dogs and cats visiting Veterinary Hospitals and animal shelters (</span><a href="#Clooten-J--Kruth-S--Arroyo-L--Weese-JS---2008-."><span class="Hyperlink">Clooten et al., 2008</span></a><span class="Body-text">; </span><a href="#Schneeberg-A--Rupnik-M--Neubauer-H--Seyboldt-C--2012"><span class="Hyperlink">Schneeberg et al., 2012</span></a><span class="Body-text">). A study conducted in an animal shelter in Germany, reported  </span><span class="Body-text CharOverride-6">C</span><span class="Body-text">. </span><span class="Body-text CharOverride-6">difficile</span><span class="Body-text"> prevalence rate of 5.5% and 3.5% in dogs and cats respectively further the study acknowledged that dogs and cats kept in animal shelters act as a reservoir for&#160;C.&#160;difficile PCR ribotypes that can infect human (</span><a href="#Schneeberg-A--Rupnik-M--Neubauer-H--Seyboldt-C--2012"><span class="Hyperlink">Schneeberg et al., 2012</span></a><span class="Body-text">).</span><span class="Body-text CharOverride-16">&#160;</span><span class="Body-text">An another prospective study conducted in a veterinary teaching hospital reported that </span><span class="Body-text CharOverride-6">C. difficile</span><span class="Body-text"> could be isolated from 18% from dogs and cats and the study concluded that antibiotic administration  prior to admission and administration of immunosuppressive drugs during hospitalization were risk factors for the nosocomial colonization (</span><a href="#Clooten-J--Kruth-S--Arroyo-L--Weese-JS---2008-."><span class="Hyperlink">Clooten et al., 2008</span></a><span class="Body-text">). </span><span class="Body-text CharOverride-6">C. difficile</span><span class="Body-text"> Ribotype 001, which is very common in hospitalized patients in Ontario was also frequently encountered among dogs in Ontario (</span><a href="#Weese-JS--Duijkeren-EV--2010"><span class="Hyperlink">Weese et al., 2010</span></a><span class="Body-text">). A high environmental load of </span><span class="Body-text CharOverride-6">C</span><span class="Body-text">. </span><span class="Body-text CharOverride-6">difficile</span><span class="Body-text"> is present in veterinary hospitals (</span><a href="#Weese-JS--Staempfli-HR--Prescott-JF--2000"><span class="Hyperlink">Weese et al., 2000</span></a><span class="Body-text">). An environmental survey conducted in a teaching veterinary hospital for the presence of </span><span class="Body-text CharOverride-6">C. difficile</span><span class="Body-text"> documented an isolation rate of 6.3%. The places where </span><span class="Body-text CharOverride-6">C. difficile</span><span class="Body-text"> was isolated are places of high animal traffic and rough floor (spores persist in cracks) with more likelihood of faecal contamination (</span><a href="#Weese-JS--Staempfli-HR--Prescott-JF--2000"><span class="Hyperlink">Weese et al., 2000</span></a><span class="Body-text">).</span><span class="Body-text CharOverride-5"> </span><span class="Body-text">Similar type of ribotype was reported from various species like in piglets (</span><a href="#Keessen-EC--Hensgens-MP--Spigaglia-P--Barbanti-F--Sanders-IM--Kuijper-EJ--Lipman-LJ--2013"><span class="Hyperlink">Keessen et al., 2013</span></a><span class="Body-text">), calves (</span><a href="#Costa-MC--Stampfli-HR--Arroyo-LG--Pearl-DL--Weese-JS--2011-."><span class="Hyperlink">Costa et al., 2011</span></a><span class="Body-text">), humans (</span><a href="#Debast-SB--van-Leengoed-LA--Goorhuis-A--Harmanus-C--Kuijper-EJ--Bergwerff-AA--2009-."><span class="Hyperlink">Debast et al., 2009</span></a><span class="Body-text">) and other food animals (</span><a href="#Indra-A--Lassnig-H--Baliko-N--Much-P--Fiedler-A--Huhulescu-S--Allerberger-F--2009"><span class="Hyperlink">Indra et al., 2009</span></a><span class="Body-text">) and also in meat implicated in outbreaks (</span><a href="#Rodriguez-Palacios-A--Reid-Smith-RJ--Staempfli...2009"><span class="Hyperlink">Rodriguez-Palacios et al., 2009</span></a><span class="Body-text">). This paved way for making an assumption that </span><span class="Body-text CharOverride-6">C. difficile</span><span class="Body-text"> transmission from animals to human is likely to occur. An Austrian study concluded that animal reservoirs can be a possible source for human CDI infection through the food animals (</span><a href="#Indra-A--Lassnig-H--Baliko-N--Much-P--Fiedler-A--Huhulescu-S--Allerberger-F--2009"><span class="Hyperlink">Indra et al., 2009</span></a><span class="Body-text">). However frank zoonosis was not established, owing to the ubiquitous nature of the organism it may act as common source for both animals and human beings.</span></p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
		  <p class="Heading-1--Introduction----" lang="en-GB"><span class="Body-text">Multidrug-Resistant </span><span class="Body-text CharOverride-15">Escherichia coi </span><span class="Body-text">and other</span><span class="Body-text CharOverride-15"> Enterobacteriaceae</span></p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="Body-text">Multidrug-resistant nosocomial infections is one of the big challenges in tertiary-care veterinary hospitals and have turned out to be endemic in the veterinary hospital environment (</span><a href="#Sanchez-S--Stevenson-MAM--Hudson-CR--Maier-M--Buffington-T--Dam-Q--Maurer-JJ--2002"><span class="Hyperlink">Sanchez et al., 2002</span></a><span class="Body-text">). Managing </span><span class="Body-text CharOverride-6">E. coli</span><span class="Body-text"> infections in veterinary hospitals has become more challenging task due to the emergence of multiple-antimicrobial-resistant </span><span class="Body-text CharOverride-6">E. coli </span><span class="Body-text">in food animals and pet animals (</span><a href="#Bischoff-KM--White-DG--McDermott-PF--Zhao-S--Gaines-S--Maurer-JJ--Nisbet-DJ--2001"><span class="Hyperlink">Bischoff</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 2001</span></a><span class="Body-text">; </span><a href="#Wagner-S--Gally-DL--Argyle-SA--2014-."><span class="Hyperlink">Wagner et al., 2014</span></a><span class="Body-text">; </span><a href="#Zhao-S--White-DG--McDermott-PF--Friedman-2001"><span class="Hyperlink">Zhao</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 2001</span></a><span class="Body-text">). The growing predominance of infections with organisms generating broad spectrum b-lactamses such as the ESBLs (mainly the CTX-M type), AmpC and carbapenemase enzymes are threatening the future of the b-lactam drug. Since b-lactams are inevitable to veterinary practice and the outlook of losing these drugs, warrants the necessity for defining the epidemiology of ESBL and carbapenemase producers in companion animals (</span><a href="#Rubin-JE--Pitout-JDD--2014-"><span class="Hyperlink">Rubin et al., 2014</span></a><span class="Body-text">). In the ICU of University of Georgia Veterinary Teaching Hospital, </span><span class="Body-text CharOverride-6">E.coli</span><span class="Body-text"> resistant to 12 antibiotics could be isolated from two dogs housed together, of which one dog died due to sudden septic shock. Followed by this incident 21 hospital-acquired </span><span class="Body-text CharOverride-6">E. coli </span><span class="Body-text">infections were reviewed and found out that the isolates had similar antibiotic resistance profiles (</span><a href="#Sanchez-S--Stevenson-MAM--Hudson-CR--Maier-M--Buffington-T--Dam-Q--Maurer-JJ--2002"><span class="Hyperlink">Sanchez et al., 2002</span></a><span class="Body-text">). Mostly </span><span class="Body-text CharOverride-6">E. coli</span><span class="Body-text"> isolates of nosocomial events were found to be resistant to cephalosporins, beta lactams and beta lactamase inhibitor clavlanic acid and this attributes to a common </span><span class="Body-text CharOverride-6">ampC </span><span class="Body-text">class of cephamycinases (</span><a href="#Oteo-J--Cercenado-E--Cuevas-O--Bautista-V--Delgado--...2010"><span class="Hyperlink">Oteo et al., 2010</span></a><span class="Body-text">). Especially, </span><span class="Body-text CharOverride-6">ampC</span><span class="Body-text">-like gene, </span><span class="Body-text CharOverride-6">bla</span><span class="Body-text">CMY2 was noticed in ceftriaxone-resistant </span><span class="Body-text CharOverride-6">E. coli </span><span class="Body-text">isolates of animal origin (</span><a href="#Zhao-S--White-DG--McDermott-PF--Friedman-2001"><span class="Hyperlink">Zhao et al., 2001</span></a><span class="Body-text">). Carriage of ESBL and AmpC-producing </span><span class="Body-text CharOverride-6">E. coli</span><span class="Body-text"> has been acknowledged in many species (</span><a href="#Bortolaia-V--Larsen-J--Damborg-P--Guardabassi-L--2011-"><span class="Hyperlink">Bortolaia et al., 2011</span></a><span class="Body-text">). ESBL </span><span class="Body-text CharOverride-6">E. coli</span><span class="Body-text"> (O’Keefe et al., 2010) and AmpC producing </span><span class="Body-text CharOverride-6">E. coli</span><span class="Body-text"> (</span><a href="#Oteo-J--Cercenado-E--Cuevas-O--Bautista-V--Delgado--...2010"><span class="Hyperlink">Oteo et al., 2010</span></a><span class="Body-text">) are the emerging problems. ESBL </span><span class="Body-text CharOverride-6">E. coli</span><span class="Body-text"> are linked to range of clinical diseases like urinary tract infections, neonatal septicaemia and wound infections (</span><a href="#Pitout-JDD--2010-"><span class="Hyperlink">Pitout, 2010</span></a><span class="Body-text">; </span><a href="#Ewers-C--Stamm-I--Pfeifer-Y--Wieler-LH---Kopp-PA---Sch-nning-K--2014-."><span class="Hyperlink">Ewers et al., 2014</span></a><span class="Body-text">) and reported from canine clinical isolates (</span><a href="#Sanchez-S--Stevenson-MAM--Hudson-CR--Maier-M--Buffington-T--Dam-Q--Maurer-JJ--2002"><span class="Hyperlink">Sanchez et al., 2002</span></a><span class="Body-text">; </span><a href="#Shaheen-BW--Nayak-R--Foley-SL--Kweon-O--Deck-J--Park-M--Rafii-F--Boothe-DM--2011-."><span class="Hyperlink">Shaheen et al., 2011</span></a><span class="Body-text">). ESBL-producing uropathogenic </span><span class="Body-text CharOverride-6">Escherichia coli</span><span class="Body-text"> (CTX-M-15) were isolated from 5% dogs and 3.3% cats in Switzerland (</span><a href="#Huber-H--Zweifel-C--Wittenbrink-MM--Stephan-R--2013"><span class="Hyperlink">Huber et al., 2013</span></a><span class="Body-text">). A survey carried out in Netherlands in companion animals and horses demonstrated a 2% prevalence of ESBL and AmpC-producing isolates. The same study identified, ESBL producing </span><span class="Body-text CharOverride-6">S. enterica, Proteus miriabilis</span><span class="Body-text"> and </span><span class="Body-text CharOverride-6">Enterobacter cloaceae</span><span class="Body-text"> from urinary, wound, respiratory, abdominal and bone infections (</span><a href="#Dierikx-CM--van-Duijkeren-E--Schoormans-AH--van-Essen-Zandbergen-...-2012"><span class="Hyperlink">Dierikx et al., 2012</span></a><span class="Body-text">). In Germany from six nosocomially infected dogs, OXA-48 type Carbopenamases  producing </span><span class="Body-text CharOverride-6">E. coli</span><span class="Body-text"> and </span><span class="Body-text CharOverride-6">K. pneumonia</span><span class="Body-text"> were isolated (</span><a href="#Stolle-I--Prenger-Berninghoff-E--Stamm-I--Scheufen...2013"><span class="Hyperlink">Stolle</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 2013</span></a><span class="Body-text">) and in France CTX-M-15 generating  </span><span class="Body-text CharOverride-6">K. pneumoniae</span><span class="Body-text"> have been detected from urinary tract infections of dogs and cats (</span><a href="#Haenni-M--Ponsin-C--Metayer-V--Medaille-C--Madec-JY--2012-"><span class="Hyperlink">Haenni et al., 2012</span></a><span class="Body-text">). Clinical samples from urinary, wound infections etc. from Germany and European countries were investigated for ESBL producing </span><span class="Body-text CharOverride-6">K. pneumoniae</span><span class="Body-text"> from horses and companion animals. MLST and PFGE were performed for comparing with human isolates. About 75.8% of the strains possess ST15-CTX-M-15, which is a clonal group that emerged in humans in recent times and this strain shared PFGE clusters with human isolates, signifying the dissemination of this clonal group between human and animal populations (</span><a href="#Ewers-C--Stamm-I--Pfeifer-Y--Wieler-LH---Kopp-PA---Sch-nning-K--2014-."><span class="Hyperlink">Ewers et al., 2014</span></a><span class="Body-text">).There are reports of ESBL in other </span><span class="Body-text CharOverride-6">Enterobacteriaceae</span><span class="Body-text"> members like </span><span class="Body-text CharOverride-6">Enterobacter</span><span class="Body-text"> sp., </span><span class="Body-text CharOverride-6">K. pneumoniae</span><span class="Body-text">, </span><span class="Body-text CharOverride-6">Citrobacter</span><span class="Body-text"> sp. and </span><span class="Body-text CharOverride-6">Salmonella enterica</span><span class="Body-text"> serovar Newport (</span><a href="#Haenni-M--Ponsin-C--Metayer-V--Medaille-C--Madec-JY--2012-"><span class="Hyperlink">Haenni et al., 2012</span></a><span class="Body-text">; </span><a href="#Ma-J--Zeng-Z--Chen-Z--Xu-X--Wang-X--Deng-Y--Lu-D--Huang-L--Zhang-Y--Liu-J--Wang-M--2009"><span class="Hyperlink">Ma et al., 2009</span></a><span class="Body-text">). A recent study conducted in Netherlands reported a high prevalence of faecal carriage of </span><span class="Body-text CharOverride-6">Enterobacteriaceae </span><span class="Body-text">resistant to third-generation cephalosporins in cats and dogs (</span><a href="#Hordijk-J--Schoormans-A--Kwakernaak-M--Duim-B--Broens-E--Dierikx-C--Mevius-D--Wagenaar-JA--2013"><span class="Hyperlink">Hordijk et al., 2013</span></a><span class="Body-text">). Various risk-based case control studies reported that hospitalization is a major risk associated with the dogs to become multi-drug resistant (MDR)&#160;</span><span class="Body-text">E. coli&#160;rectal carriers (</span><a href="#Gibson-JS--Morton-JM--Cobbold-RN--Filippich-LJ--Trott-DJ--2011-"><span class="Hyperlink">Gibson et al., 2011</span></a><span class="Body-text">; </span><a href="#Hamilton-E--Kruger-JM--Schall-W--Beal-M--Manning-SD--2013-"><span class="Hyperlink">Hamilton et al., 2013</span></a><span class="Body-text">). </span><span class="Body-text CharOverride-6">Enterobacter cloacae</span><span class="Body-text">, also a nosocomial agent and particularly the multidrug resistant strains, are concerning (</span><a href="#Wilberger-MS--Anthony-KE--Rose-S--McClain-M--Bermudez-LE--2012-"><span class="Hyperlink">Wilberger et al., 2012</span></a><span class="Body-text">). </span></p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-2--History-in-MM-" lang="en-GB"><span class="Body-text">Acinetobacter baumannii</span></p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="Body-text CharOverride-6">Acinetobacter</span><span class="Body-text"> spp. is environmental bacteria and normal flora of skin and mucous membrane in humans and animals and often associated with opportunistic infections in animals (</span><a href="#Clemetson-LL--Ward-AC--1990-."><span class="Hyperlink">Clemetson and Ward, 1990</span></a><span class="Body-text">). </span><span class="Body-text CharOverride-6">Acinetobacter baumannii</span><span class="Body-text"> has emerged over the last decade as a cause of nosocomial infections and the pathogenicity is mainly due to multidrug resistance and biofilm formation. Its ability to acquire the resistance easily making it as one of the ominous agent to the existing antibiotic era (</span><a href="#Kempf-M.--Rolain-J.M--2012-"><span class="Hyperlink">Kempf and Rolain, 2012</span></a><span class="Body-text">). Outbreaks have been recorded in hospitalized animals (</span><a href="#Francey-T--Gaschen-F--Nicolet-J--Burnens-AP--2000-."><span class="Hyperlink">Francey et al., 2000</span></a><span class="Body-text">) and associated with indwelling vascular catheter infection in horses (</span><a href="#Vaneechoutte-M--Devriese-LA--Dijkshoorn-L--2000-"><span class="Hyperlink">Vaneechoutte et al., 2000</span></a><span class="Body-text">). </span><span class="Body-text CharOverride-6">A. baumannii</span><span class="Body-text"> have been isolated from the clinical samples of companion animals (</span><a href="#Francey-T--Gaschen-F--Nicolet-J--Burnens-AP--2000-."><span class="Hyperlink">Francey et al., 2000</span></a><span class="Body-text">; </span><a href="#Zordan-S--Prenger-Berninghoff-E--Weiss-R--van-der-Reijden-T--van-den-Broek-P--Baljer-G--Dijkshoorn-L"><span class="Hyperlink">Zordan et al., 2011</span></a><span class="Body-text">). It is evident that companion animals can be reservoirs of antimicrobial resistant bacteria and the role of pets in the dissemination of antimicrobial resistance is well understood (</span><a href="#Guardabassi-L--Schwarz-S--Lloyd-DH--2004-."><span class="Hyperlink">Guardabassi et al., 2004</span></a><span class="Body-text">). The spread of multiresistant </span><span class="Body-text CharOverride-6">A. baumannii</span><span class="Body-text"> from a companion animal clinic to a horse clinic was recorded and the reason behind the transmission was believed to be the hands of staff personnel and students working simultaneously in both the clinics (</span><a href="#Boerlin-P--Eugster-S--Gaschen-F--Straub-R--Schwalder-P--2001-."><span class="Hyperlink">Boerlin et al., 2001</span></a><span class="Body-text">). Majority of the </span><span class="Body-text CharOverride-6">Acinetobacter baumannii</span><span class="Body-text"> isolates belong to ST25, where ST is an emergent clonal lineage which includes Carbapenemases including oxacillinases (OXA-58 and OXA-72), metallo-ß-lactamases (NDM-1) (</span><a href="#Zarrilli-R--Pournaras-S--Giannouli-M--Tsakris-A--2013-"><span class="Hyperlink">Zarrilli et al., 2013</span></a><span class="Body-text">) and recently for the first time OXA-23 mediated Carbapenem resistance in sequence type 2 multidrug-resistant </span><span class="Body-text CharOverride-6">Acinetobacter baumannii</span><span class="Body-text">&#160;was recorded from a cat with urinary tract infection. A recent study demonstrated increased resistance of </span><span class="Body-text CharOverride-6">A. baumannii</span><span class="Body-text"> towards dessication and its biofilm forming ability on abiotic surfaces which facilitates its persistence in hospital environment (</span><a href="#Giannouli-M--Antunes-LCS--Marchetti-V--Triassi-M--Visca-P--Zarrilli-R--2013-"><span class="Hyperlink">Giannouli et al. 2013</span></a><span class="Body-text">), one more study revealed the isolation of carbapenem-resistant </span><span class="Body-text CharOverride-6">A. baumannii</span><span class="Body-text"> from hospital sewges in Beijing (</span><a href="#Zhang-C--Qiu-S--Wang-Y--Qi-L--Hao-R--Liu-X--Shi-Y--Hu-X--An-D--Li-Z---2013"><span class="Hyperlink">Zhang et al., 2013</span></a><span class="Body-text">). A multicentre cross-sectional study conducted to detect the carriage of </span><span class="Body-text CharOverride-6">Acinetobacter baumannii</span><span class="Body-text"> in pets revealed a carriage prevalence of 6.5% and nine carriers were identified from four veterinary clinics. Hospitalization and recent antibiotic therapy was notably associated with the carriage of </span><span class="Body-text CharOverride-6">A. baumannii</span><span class="Body-text"> (</span><a href="#Belmonte-O---Pailhories-H--Kempf-M---Gaultier-MP--Lemarie..-2014"><span class="Hyperlink">Belmonte et al., 2014</span></a><span class="Body-text">).</span></p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-2--History-in-MM-" lang="en-GB"><span class="Body-text">Multidrug-Resistant </span><span class="Body-text CharOverride-15">Enterococci</span></p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="Body-text CharOverride-6">Enterococci</span><span class="Body-text"> are saprophytic, Gram-positive, facultative anaerobes inhabitating the intestinal tract of humans and animals as a commensal. But now </span><span class="Body-text CharOverride-6">Enterococci</span><span class="Body-text"> has been emerged as an important nosocomial agent , particularly multiple drug resistance species of </span><span class="Body-text CharOverride-6">Enterococci</span><span class="Body-text"> (</span><a href="#Poeta-P--Costa-D--Rodrigues-J--Torres-C.--2006-."><span class="Hyperlink">Poeta et al., 2006</span></a><span class="Body-text">) and the development of multiple drug resistance among </span><span class="Body-text CharOverride-6">Enterococci</span><span class="Body-text"> species rose as a significant public health issue due to abuse and over exploitation of antibiotics in human and veterinary practices. It can also thrive well in dry hospital surfaces, medical instruments and resistant to heat, alcohol and chlorine (</span><a href="#Fisher-K--Phillips-C--2009-"><span class="Hyperlink">Fisher et al., 2009</span></a><span class="Body-text">; </span><a href="#Giraffa-G--2002-"><span class="Hyperlink">Giraffa, 2002</span></a><span class="Body-text">). In Europe </span><span class="Body-text CharOverride-6">Enterococci</span><span class="Body-text"> are ranked second most hazardous pathogen among intensive care unit-acquired bloodstream infections (</span><a href="#Bohme-H--Konigsmark-C--Klare-I--Zischka-M--Werner-G--2012-."><span class="Hyperlink">Bohme et al., 2012</span></a><span class="Body-text">). In the USA around 12% of the nosocomial infections are due to </span><span class="Body-text CharOverride-6">Enterococcus</span><span class="Body-text"> species. </span><span class="Body-text CharOverride-6">E. faecalis</span><span class="Body-text"> is the predominant species responsible for clinical infection whereas </span><span class="Body-text CharOverride-6">E. faecium </span><span class="Body-text">claims the higher antibiotic resistance (</span><a href="#Giraffa-G--2002-"><span class="Hyperlink">Giraffa, 2002</span></a><span class="Body-text">). Globally multiresistant </span><span class="Body-text CharOverride-6">E. faecium</span><span class="Body-text"> causing increasing number of hospital associated infections (</span><a href="#Willems-RJ--Top-J--VanSchaik-W--Leavis-H--Bonten-M--Siren-J--2012-"><span class="Hyperlink">Willems et al., 2012</span></a><span class="Body-text">) and embodies upto to one third of Enterococcal infections (</span><a href="#Willems-RJ--VanSchaik-W--2009-."><span class="Hyperlink">Willems and VanSchaik, 2009</span></a><span class="Body-text">). In 1972, Vancomycin was first used and first vancomycin-resistant </span><span class="Body-text CharOverride-6">Enterococci</span><span class="Body-text"> (VRE) were documented   15 years later and  NNIS accounted increase of 7.6% in Vancomycin resistant </span><span class="Body-text CharOverride-6">Enterococci</span><span class="Body-text">  between 1989 and 1993 (</span><a href="#Metan-G--Zarakolu-P--Unal-S--2005-."><span class="Hyperlink">Metan et al., 2005</span></a><span class="Body-text">). In a study conducted in Korea to investigate the possibility of MDR </span><span class="Body-text CharOverride-6">Enterococcus </span><span class="Body-text">cross transmission, </span><span class="Body-text CharOverride-6">Enterococcus</span><span class="Body-text"> species was isolated from dogs, dog owners, veterinary personnel and five veterinary hospital environment  and the study demonstrated a high prevalence of 62.5% of MDR </span><span class="Body-text CharOverride-6">E. faecalis</span><span class="Body-text">  and 75% of MDR </span><span class="Body-text CharOverride-6">E. faecium</span><span class="Body-text"> (</span><a href="#Chung-YS--Kwon-KH--Shin-S--Kim-JH--Park-YH--Yoon-JW--2014-"><span class="Hyperlink">Chung  et al., 2014</span></a><span class="Body-text">). In a study conducted in veterinary teaching hospital in Switzerland, two multiresistant </span><span class="Body-text CharOverride-6">E. faecium</span><span class="Body-text"> isolates with similar antibiotic resistant and PFGE profiles was recovered from two different cats with less than one month interval suggesting the persistence in hospital environment and nosocomial transmission (</span><a href="#Boerlin-P--Eugster-S--Gaschen-F--Straub-R--Schwalder-P--2001-."><span class="Hyperlink">Boerlin et al., 2001</span></a><span class="Body-text">). In the early 1980’s the emergence of Hospital associated Ampicillin resistant </span><span class="Body-text CharOverride-6">Enterococci</span><span class="Body-text"> (ARE) in USA preceded rise of vancomycin resistance in </span><span class="Body-text CharOverride-6">enterococci,</span><span class="Body-text"> which happend in the 1990s, is the reason  why virtually all VRE of nosocomial infections in humans are also ampicillin resistant (</span><a href="#Grayson-ML--Eliopoulos-GM--Wennersten-CB--Ruoff-KL--De-Girolami-PC--Ferraro-MJ--1991-"><span class="Hyperlink">Grayson</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 1991</span></a><span class="Body-text">) but ARE associated with human infections remain vancomycin susceptible (</span><a href="#Tremblay-CL--Charlebois-A--Masson-L--Archambault-M--2013"><span class="Hyperlink">Tremblay et al., 2013</span></a><span class="Body-text">). The hospital associated </span>ARE have been recovered from dogs suffering from urinary tract infections in US (<a href="#Simjee-S--White-DG--McDermott-PF--Wagner-DD--Zervos-MJ--Donabedian-SM--2002-."><span class="Hyperlink">Simjee et al., 2002</span></a>), Denmark (<a href="#Damborg-P--Top-J--Hendrickx-AP--Dawson-S--Willems-RJ--Guardabassi-L--2009-."><span class="Hyperlink">Damborg et al., 2009</span></a>), Korea (<a href="#Kwon-KH--Moon-BY--Hwang-SY--Park-YH--2012"><span class="Hyperlink">Kwon et al., 2012</span></a>) and also from the faeces of dogs departing the intensive care unit of an American veterinary medicine teaching hospital (<a href="#Ghosh-A--Dowd-SE--Zurek-L--2011-."><span class="Hyperlink">Ghosh et al., 2011</span></a>). In a study conducted in veterinary teaching hospital of Canada with the objective of characterizing the ARE strains of dogs and human revealed the cross-transmission between humans and dogs and further supports the significance of antibiotic stewardship to avoid zoonotic spread of canine ARE (<a href="#Tremblay-CL--Charlebois-A--Masson-L--Archambault-M--2013"><span class="Hyperlink">Tremblay et al., 2013</span></a>).</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-2--History-in-MM-" lang="en-GB"><span class="CharOverride-15">Salmonella</span></p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="CharOverride-6">Salmonella enterica</span> was found out to be a most common agent associated with nosocomial outbreaks in veterinary teaching hospitals through a survey conducted by the biosecurity experts (<a href="#Benedict-KM--Morley-PS--Van-Metre-DC--2008-."><span class="Hyperlink">Benedict et al., 2008</span></a>). Many outbreaks of nosocomial salmonellosis have been reported from different large animal hospitals especially among horses (<a href="#Steneroden-KK--Van-Metre-DC--Jackson-C--Morle-PS--2010-."><span class="Hyperlink">Steneroden et al., 2010</span></a>; <a href="#Tillotson-K--Savage-CJ--Salman-MD--Gentry-Weeks-C--Rice-D--Fedorka-Cray-PJ--Traub-Dargatz-JL--1997-"><span class="Hyperlink">Tillotson et al., 1997</span></a>; <a href="#Dallap-Schaer-BL--Aceto-H--Rankin-SC--2010-."><span class="Hyperlink">Dallap et al., 2010</span></a>; <a href="#Schott-HC--Ewart-SL--Walker-RD--Dwyer-RM--Dietrich-S--Eberhart-SW--Derksen-FJ--2001-."><span class="Hyperlink">Schott et al., 20</span></a><span class="Hyperlink">01</span>). In horses <span class="CharOverride-6">Salmonella </span>spp. can cause enterocolitis but the organism also present in the absence of the disease making the horse, a transient, sub-clinical shedders of <span class="CharOverride-6">Salmonella</span> (<a href="#Jones-SL--2008-."><span class="Hyperlink">Jones, 2008</span></a>). Studies have reported 1% to 5% prevalence of the sub-clinical shedding of <span class="CharOverride-6">Salmonella </span>by horses entering veterinary clinics (<a href="#Roberts-MC--O-Boyle-DA--1981-.-T"><span class="Hyperlink">Roberts and O’Boyle, 1981</span></a>). Persistence of <span class="CharOverride-6">Salmonella </span>in the hospital environment has been often reported to be associated with nosocomial outbreaks (<a href="#Steneroden-KK--Van-Metre-DC--Jackson-C--Morle-PS--2010-."><span class="Hyperlink">Steneroden et al., 2010</span></a>; <a href="#Schott-HC--Ewart-SL--Walker-RD--Dwyer-RM--Dietrich-S--Eberhart-SW--Derksen-FJ--2001-."><span class="Hyperlink">Schott et al., 2001</span></a>) and environmental contamination with <span class="CharOverride-6">S. enterica </span>in veterinary hospitals are identified as a hazard related to the nosocomial infections (<a href="#Pandya-M--Wittum-T--Tadesse-DA--Gebreyes-W--Hoet-A--2009"><span class="Hyperlink">Pandya et al., 2009</span></a>; <a href="#Ewart-SL--Schott-HC--Robison-RL--Dwyer-RM--Eberhart-SW-Walker-RD--2001-."><span class="Hyperlink">Ewart et al., 2001</span></a>). In fact, many nosocomial outbreaks recorded in equine veterinary hospitals have been associated with multi drug resistant strains (<a href="#Table-1-"><span class="Hyperlink">Table 1</span></a>).</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Body-Text" lang="en-GB">MDR <span class="CharOverride-6">Salmonella</span> <span class="CharOverride-6">Typhimurium</span> have been reported from companion animals (<a href="#Cherry-B--Burns-A--Johnson-GS--Pfeiffer-H--Dumas-N--Barrett-D--McDonough-PL--Eidson-M--2004-."><span class="Hyperlink">Cherry et al., 2004</span></a>; <a href="#Low-JC--Tennant-B--Munro-D--1996-"><span class="Hyperlink">Low et al., 1996</span></a>; <a href="#Wall-PG--Threllfall-EJ--Ward-LR--Rowe-B--1996-"><span class="Hyperlink">Wall et al., 1996</span></a>). In an outbreak occurred in a small animal hospital of US, two cats, one dog,  3 pet owners and two technicians were affected from a same strain of <span class="CharOverride-6">Salmonella enterica </span>serovar <span class="CharOverride-6">Typhi-</span><span class="Body-Text ParaOverride-1"><span class="CharOverride-6">murium</span> (<a href="#Cherry-B--Burns-A--Johnson-GS--Pfeiffer-H--Dumas-N--Barrett-D--McDonough-PL--Eidson-M--2004-."><span class="Hyperlink">Cherry et al., 2004</span></a>). A report documented multi-drug resistant <span class="CharOverride-6">Salmonella</span> <span class="CharOverride-6">Typhimurium</span> in four veterinary health care centres described that Pet care centres can act as a foci of <span class="CharOverride-6">Salmonella</span> transmission between animals and humans, if necessary precautions are not followed (<a href="#Wright-JG--Tengelsen-LA--Smith-KE--Bender-JB--Frank-RK--Grendon-JH--Angulo-FJ--2005-."><span class="Hyperlink">Wright et al., 2005</span></a>).</span></p>
		  <p class="Body-Text" lang="en-GB">&nbsp;</p>
			<p class="Figure--and-Table-Heading" lang="en-GB"><span class="CharOverride-5"><a id="Table-1-"></a>Table 1: </span>MDR <span class="CharOverride-6">Salmonella </span>strains of nosocomial outbreaks in horses</p>
			<table width="657" height="278" class="Table-Style-1" id="table-1">
				<colgroup>
					<col class="_idGenTableRowColumn-1" />
					<col class="_idGenTableRowColumn-2" />
					<col class="_idGenTableRowColumn-3" />
				</colgroup>
				<tbody>
					<tr class="_idGenTableRowColumn-4">
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB"><span class="CharOverride-5">Serial no.</span></p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB"><span class="CharOverride-5">MDR </span><span class="CharOverride-15">Salmonella</span><span class="CharOverride-5"> strains of nosocomial outbreaks - Horses</span></p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB"><span class="CharOverride-5">References</span></p>
						</td>
					</tr>
					<tr class="_idGenTableRowColumn-5">
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">1</p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB"><span class="CharOverride-6">S. Infantis</span></p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">Tillotson et al., 1997; Dunowska et al., 2007</p>
						</td>
					</tr>
					<tr class="_idGenTableRowColumn-6">
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">2</p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB"><span class="CharOverride-6">S. Anatum</span></p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-1" lang="en-GB">Hartmann, 1995; Hartmann et al., 1996; Castor et al., 1989</p>
						</td>
					</tr>
					<tr class="_idGenTableRowColumn-5">
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">3</p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB"><span class="CharOverride-6">S</span><span class="CharOverride-6">. Heidelberg</span></p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">Amavisit et al., 2001</p>
						</td>
					</tr>
					<tr class="_idGenTableRowColumn-7">
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">4</p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB"><span class="CharOverride-6">S Agona</span></p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">Donahue et al., 1986; Castor et al., 1989</p>
						</td>
					</tr>
					<tr class="_idGenTableRowColumn-5">
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">5</p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB"><span class="CharOverride-6">S Krefeld</span></p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">Ikeda et al., 1985</p>
						</td>
					</tr>
					<tr class="_idGenTableRowColumn-7">
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">6</p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB"><span class="CharOverride-6">S Saintpaul</span></p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">Ikeda et al., 1985; Hird et al., 1986</p>
						</td>
					</tr>
					<tr class="_idGenTableRowColumn-5">
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">7</p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB"><span class="CharOverride-6">S Newport</span></p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">Castor et al., 1989; Dallap et al., 2010</p>
						</td>
					</tr>
					<tr class="_idGenTableRowColumn-7">
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">8</p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB"><span class="CharOverride-6">S. Oranienburg</span></p>
						</td>
						<td>
							<p class="Body-Text ParaOverride-2" lang="en-GB">Kevin et al., 2014</p>
						</td>
					</tr>
				</tbody>
			</table>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-1--Introduction----" lang="en-GB">Others</p>
		  <p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">Nosocomial transmission of <span class="CharOverride-6">Cryptosporidium</span> was documented in a veterinary hospital through an outbreak involving multiple species, which originated from an infected dairy calf (<a href="#Konkle-DM--Nelson-KM--Lunn-DP--1997-"><span class="Hyperlink">Konkle et al., 1997</span></a>). Biofilms are group of adherent microorganisms encased in a self-produced extracellular polymeric substance or slime, formed in both biotic and abiotic surfaces. They are often associated with a number of persistent infections that poorly respond to antibiotics (<a href="#Hall-IC--O-Toole-E--1935"><span class="Hyperlink">Hall-Stoodley, 2004</span></a>). Nosocomial spread of <span class="CharOverride-6">Mycobacterium bovis</span> between cats was recorded in a veterinary clinic in Ireland (<a href="#Murray-A--Dineen-A--Kelly-P--McGoey-K--Madigan-G--Nighallchoir-E--Gunn-Moore-DA--2014-."><span class="Hyperlink">Murray et al., 2014</span></a>). In Hospital settings biofilm formation in indwelling medical devices like i.v catheter can harbour numerous potentially infectious pathogens resulting in elevated morbidity, mortality and propagation of antimicrobial resistance. The main pathogen for i.v catheter, urethral catheter and endotracheal tubes are coagulase negative <span class="CharOverride-6">Staphylococci</span>, <span class="CharOverride-6">E. coli</span> and enteric gram negative bacilli respectively. The other common pathogens forming biofilms are <span class="CharOverride-6">S. aureus</span>, <span class="CharOverride-6">K. pneumonia, P. mirabilis, E. faecalis, P. aeruginosa, Streptococcus </span>spp,<span class="CharOverride-6"> Candida </span>spp (<a href="#Lynch-AS--Robertson-GT--2008-"><span class="Hyperlink">Lynch and Robertson, 2008</span></a>). The nosocomial outbreak of canine parainfluenza infection was recorded in a veterinary referral hospital among dogs (<a href="#Weese-JS--Stull-J--2013-"><span class="Hyperlink">Weese and Stull, 2013</span></a>).</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-2--History-in-MM-" lang="en-GB">Surveillance in veterinary hospitals			</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">Even though loads of recommendations for prevention and control of nosocomial infection is available out of the lesson learnt from previous experiences (<a href="#Hartmann-FA--Callan-RJ--McGuirk-SM--West-SE--1996-."><span class="Hyperlink">Hartmann et al</span><span class="Hyperlink CharOverride-6">.</span><span class="Hyperlink">, 1996</span></a>; <a href="#Schott-HC--Ewart-SL--Walker-RD--Dwyer-RM--Dietrich-S--Eberhart-SW--Derksen-FJ--2001-."><span class="Hyperlink">Schott et al</span><span class="Hyperlink CharOverride-6">., </span><span class="Hyperlink">2001</span></a>; <a href="#Wright-JG--Tengelsen-LA--Smith-KE--Bender-JB--Frank-RK--Grendon-JH--Angulo-FJ--2005-."><span class="Hyperlink">Wright et al., 2005</span></a>; <a href="#Dallap-Schaer-BL--Aceto-H--Rankin-SC--2010-."><span class="Hyperlink">Dallap et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2010</span></a>; <a href="#Goehring-LS--Landolt-GS--Morley-PS--2010-."><span class="Hyperlink">Goehring et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2010</span></a>; <a href="#Steneroden-KK--Van-Metre-DC--Jackson-C--Morle-PS--2010-."><span class="Hyperlink">Steneroden et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2010</span></a>). Presently there is no recognized or  published principles or standards for surveillance and control of infection in veterinary hospitals, which makes the system weak to determine rates and fraction of nosocomial and preventable infections respectively (<a href="#Morley-PS--2002"><span class="Hyperlink">Morley, 2002</span></a>, <a href="#Morley-PS--2004-."><span class="Hyperlink">2004</span></a>; <a href="#Benedict-KM--Morley-PS--Van-Metre-DC--2008-."><span class="Hyperlink">Benedict et al., 2008</span></a>; <a href="#Morley-PS--Weese-JS--2008-."><span class="Hyperlink">Morley and Weese, 2008</span></a>).</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">The surveillance is broadly classified into Hospital wide surveillance and Targeted surveillance. The Hospital wide surveillance are very expensive, time consuming, laborious and tend to detect more infections which cannot be prevented (<a href="#Pottinger--JM--Herwaldt-LA--Perl-TM--1997-."><span class="Hyperlink">Pottinger et al., 1997</span></a>).<span class="CharOverride-5"> </span>A study conducted for understanding the trends in nosocomial infections in University of Virginia Hospital for the period of eight years revealed that nosocomial infection rates are 4 times greater in intensive care units than in general wards (<a href="#Landry-SL--Donowitz-LG--Wenzel-RP--1982-."><span class="Hyperlink">Landry et al., 1982</span></a>)<span class="CharOverride-6">,</span> and during the study period there were seven infectious disease outbreaks and interestingly all the seven were in critical care units. One more study conducted on the same hospital exposed that the competence of surveillance systems for spotting nosocomial infection was maximum when it is focused in intensive care units rather than hospital wide surveillance (<a href="#Wenzel-RP--Osterman-CA--Donowitz-LG--Hoyt-JW--Sande-MA--Martone-WJ--Miller-GB--1981-"><span class="Hyperlink">Wenzel</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 1981</span></a>). An additional study performed in German hospital exclusively in an intensive care unit revealed that only a minimum difference in the sensitivity and specificity when there is a targeted approach when compared to entire hospital wide surveillance (<a href="#Dettenkofer-M--Ebner-W--Els-T--Babikir-R--L-cking-C--Pelz-K--Daschner-F--2001-.-S"><span class="Hyperlink">Dettenkofer et al., 2001</span></a>). By another study researcher found that narrowing the population under surveillance, like targeting the hospitalized patients with increased risk of developing nosocomial infections may increase the sensitivity and reduce the labour, money and time consumption (<a href="#Brusaferro-S--Regattin-L--Faruzzo-A--Grasso-A--Basile-M--Calligaris-L--Scudeller-L--Viale-P--2006-."><span class="Hyperlink">Brusaferro et al., 2006</span></a>).<span class="CharOverride-5"> </span>Targeted surveillance is efficient and less time, money and labour consuming than hospital wide surveillance which requires more cost and effort for data collection (<a href="#Morley-PS--2004-."><span class="Hyperlink">Morley, 2004</span></a>).<span class="CharOverride-5"> </span>The only drawback of this approach is missing out of nosocomial infections in general ward and other area patients.</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-2--History-in-MM-" lang="en-GB">Different methods of Targeted surveillance</p>
			<p class="Heading-2--History-in-MM-" lang="en-GB">&nbsp;</p>
			
			  <li class="Body-Text ParaOverride-3" lang="en-GB">Device associated infection surveillance</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Specific etiological agent surveillance</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Syndromie based  surveillance </li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Environmental based surveillance</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Laboratory based surveillance</li>
			
			<p class="Heading-2--History-in-MM-" lang="en-GB">&nbsp;</p>
			<p class="Heading-2--History-in-MM-" lang="en-GB">Device associated infection surveillance			</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">Most of the device associated infections that had been published are restricted to dogs with urinary catheter (<a href="#Wise-LA--Jones-RL--Reif-JS--1990-."><span class="Hyperlink">Wise et al., 1990</span></a>). A prospective study done with 18 male cats to evaluate the incidence of catheter-associated urinary tract infections by collecting urine samples three times, i.e. straight away after catheterization, 24 hours after and before removal. The bacterial culture of the urine samples detected that six cats (33.3%) developed bacteriuria, 5 cats with <span class="Emphasis">Escherichia coli, Staphylococcus</span><span class="apple-converted-space CharOverride-17">&#160;</span>species, one cat with <span class="Emphasis">Streptococcus bovis</span><span class="apple-converted-space CharOverride-17"> and one more cat developed </span>fungal infection (<a href="#Hugonnard-M--Chalvet-Monfray-K--Dernis-J--Pouzot-Nevoret-C--Barth-l-my-A--Vialard-J--Goy-Thollot-I--"><span class="Hyperlink">Hugonnard et al., 2013</span></a>). A prospective study conducted by <a href="#Smarick-SD--Haskins-SC.--Aldrich-J--Foley-JE--Kass-PH--Fudge-M--Ling-GV--2004-."><span class="Hyperlink">Smarick</span></a> and others in <a href="#Smarick-SD--Haskins-SC.--Aldrich-J--Foley-JE--Kass-PH--Fudge-M--Ling-GV--2004-."><span class="Hyperlink">2004</span></a> reported 10.3% of healthy catheterized dogs of both sex developed urinary tract infection. Furthermore this study revealed that female dogs are more susceptible to develop the urinary tract infection (<a href="#Smarick-SD--Haskins-SC.--Aldrich-J--Foley-JE--Kass-PH--Fudge-M--Ling-GV--2004-."><span class="Hyperlink">Smarick et al., 2004</span></a>).<span class="CharOverride-5"> </span>A randomized clinical trial was performed with dogs underwent intervertebral disk correction surgery. Based on sex, the dogs were stratified and assigned randomly with three different urinary bladder managing methods, <span class="CharOverride-6">viz.</span> manual expulsion, intermittent catheterization or catheter insitu. The proportion of urinary tract infection was higher in dogs with indwelling catheter and 32% showed noticeable growth of minimum one bacterial species (<a href="#Bubenik-L--Hosgood-G--2008-."><span class="Hyperlink">Bubenik and Hosgood, 2008</span></a>). The other device always associated with nosocomial infection in animal is intravenous catheter (<a href="#Marsh-Ng-ML--Burney-DP--Garcia-J--2007-."><span class="Hyperlink">Marsh-Ng et al., 2007</span></a>) and it is due to the contamination of the catheter (<a href="#Johnson-JA--2002"><span class="Hyperlink">Johnson, 2002</span></a>). Number of studies have been conducted to estimate the prevalence of contamination of intravenous catheter in veterinary hospitals.<span class="CharOverride-5"> </span>In a study conducted for one year period at intensive care unit Ontario Veterinary College, they collected all the intravenous catheters from dogs and cats and cultured and found out the bacterial contamination rate of 10.7% (<a href="#Mathews-KA--Brooks-MJ--Valliant-AE--1996-."><span class="Hyperlink">Mathews et al., 1996</span></a>). With another study the bacterial contamination rate of intravenous catheter from 100 dogs was found out to be 22% and the bacteria isolated were often found to be of gastrointestinal and environmental origin (<a href="#Lobetti-RG--Joubert-KE--Picard-J--Carstens-J--Pretorius-E--2002-."><span class="Hyperlink">Lobetti et al., 2002</span></a>). Other studies reported 24.5% (<a href="#Marsh-Ng-ML--Burney-DP--Garcia-J--2007-."><span class="Hyperlink">Marsh-Ng et al., 2007</span></a>) and 23.2% (<a href="#Jones-ID--Case-AM--Stevens-KB--Boag-A--Rycroft-AN--2009"><span class="Hyperlink">Jones et al., 2009</span></a>) of bacterial contamination rates due to intravenous catheters in dogs and cats.</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-2--History-in-MM-" lang="en-GB">Specific etiological agent surveillance			</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">Some hospitals are performing surveillance based on specific etiological agents which are associated with nosocomial infections. In 2008, <a href="#Benedict-KM--Morley-PS--Van-Metre-DC--2008-."><span class="Hyperlink">Benedict et al. (2008)</span></a><span class="CharOverride-6"> </span>conducted a study in US veterinary teaching hospitals and reported that 53% of hospitals are collecting samples for detecting the specific pathogen and it is their one of the element of infection control practices. One of the specific contagious pathogen often encountered in veterinary nosocomial outbreaks and also incorporated in hospital surveillance is <span class="CharOverride-6">Salmonella </span>(<a href="#Schott-HC--Ewart-SL--Walker-RD--Dwyer-RM--Dietrich-S--Eberhart-SW--Derksen-FJ--2001-."><span class="Hyperlink">Schott et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2001</span></a>; <a href="#Cherry-B--Burns-A--Johnson-GS--Pfeiffer-H--Dumas-N--Barrett-D--McDonough-PL--Eidson-M--2004-."><span class="Hyperlink">Cherry et al., 2004</span></a>; <a href="#Benedict-KM--Morley-PS--Van-Metre-DC--2008-."><span class="Hyperlink">Benedict et al., 2008</span></a>; <a href="#Steneroden-KK--Van-Metre-DC--Jackson-C--Morle-PS--2010-."><span class="Hyperlink">Steneroden et al., 2010</span></a>). Patient who are under greater risk of shedding <span class="CharOverride-6">Salmonella</span> are included in the surveillance (<a href="#Morley-PS--2002"><span class="Hyperlink">Morley, 2002</span></a>, <a href="#Morley-PS--2004-."><span class="Hyperlink">2004</span></a>; <a href="#Morley-PS--Weese-JS--2008-."><span class="Hyperlink">Morley and Weese, 2008</span></a>; <a href="#Ekiri-AB--Morton-AJ--Long-MT--MacKay-RJ--Hernandez-JA--2010-."><span class="Hyperlink">Ekiri et al., 2010</span></a>). The sampling plan includes faecal sampling at the time of admittance and then at regular intervals during the hospital stay (<a href="#Morley-PS--2002"><span class="Hyperlink">Morley, 2002</span></a>; <a href="#Ekiri-AB--Morton-AJ--Long-MT--MacKay-RJ--Hernandez-JA--2010-."><span class="Hyperlink">Ekiri et al., 2010</span></a>). If <span class="CharOverride-6">Salmonella</span> was not present at the time of admittance and detected during subsequent sampling, which of similar serotype and antibiogram pattern as other isolates in the patients, then the Salmonellosis is considered to be of nosocomial origin (<a href="#Ekiri-AB--Morton-AJ--Long-MT--MacKay-RJ--Hernandez-JA--2010-."><span class="Hyperlink">Ekiri et al., 2010</span></a>). A study conducted for<span class="CharOverride-6"> Salmonella </span>surveillance in 246 hospitalized colic horses reported positive result in 9% of the faecal sample (<a href="#Kim-LM--Morley-PS--Traub-Dargatz-JL--Salman-MD--Gentry-Weeks-C--2001-"><span class="Hyperlink">Kim et al., 2001</span></a>). In Human medicine one of the most significant nosocomial pathogen is Methicillin-resistant <span class="CharOverride-6">Staphylococcus aureus </span>(MRSA) and in all probability it is one of the emerging multiple drug resistant bacteria in veterinary health settings (<a href="#Beard-LA--2010-.-M"><span class="Hyperlink">Beard, 2010</span></a>). In a survey conducted in seven teaching veterinary hospitals in the United States regarding the <span class="CharOverride-6">S.aureus </span>isolated from hospitalized patients revealed that 14% of animals were infected with Methicillin-resistant <span class="CharOverride-6">Staphylococcus aureus </span>and the highest prevalence was estimated in horses and dogs (<a href="#Middleton-JR--Fales-WH--Luby-CD--Oaks-JL--Sanchez-S--Kinyon-JM--Hartmann-F--2005"><span class="Hyperlink">Middleton et al., 2005</span></a>). In an attempt to determine the prevalence rate of MRSA, an emerging equine pathogen, a screening program was organized, in which nasal swab was collected from all horses during admission, hospitalization and discharge. MRSA was isolated from 5.3% of horses and the incidence rate of overall nosocomial MRSA was found to be 23/1000 admissions (<a href="#Weese-JS--Rousseau-J--Willey-BM--Archambault-M--McGeer-A--Low-DE--2006b"><span class="Hyperlink">Weese et al., 2006b</span></a>). A study conducted in a small animal hospital revealed MRSA prevalence of 9% in dogs (<a href="#Loeffler-A--Boag-AK--Sung-J--Lindsay-JA--Guardabassi-L--Dalsgaard-A--Lloyd-DH--2005-"><span class="Hyperlink">Loeffler et al., 2005</span></a>). Various studies have also documented clear rise in the MRSA infections on surgical sites of companion animals (<a href="#Boag-A--Loeffler-A--Lloyd-DH--2004-.-M"><span class="Hyperlink">Boag et al., 2004</span></a>; <a href="#O-Mahony-R--Abbott-Y--Leonard-FC--Markey-BK--Quinn-PJ--Pollock-PJ--Rossney-AS--2005-."><span class="Hyperlink">O’Mahony et al., 2005</span></a>). A retrospective study with the faecal culture data conducted in a teaching veterinary hospital following an outbreak of salmonellosis with high percentage of cases within 24 hours of admission revealed the etiological agent was <span class="CharOverride-6">Salmonella enterica</span><span class="apple-converted-space CharOverride-17">&#160;</span>serovar Oranienburg. Severe scrutiny of their medical records exposed the concealed epidemiological association to the veterinary hospital following the index case (<a href="#Cummings-KJ--Rodriguez-Rivera-LD--Katharyn-JM--Karin-H--Martin...-2014"><span class="Hyperlink">Cummings</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 2014</span></a>).</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-2--History-in-MM-" lang="en-GB">Syndrome based surveillance			</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">Syndrome based surveillance means detecting simple adverse conditions (pyrexia of unknown origin) in hospitalized patients or distinct signs and symptoms of any infection (<a href="#Mostashari-F--Hartman-J--2003-."><span class="Hyperlink">Mostashari and Hartman, 2003</span></a>). This system can be used based on the monitoring of clinical datas (flu-like symptoms) and nonclinical datas (sale of over-the-counter drugs or school absenteeism) (<a href="#Lombardo-J--Burkom-H--Elbert-E--Magruder-S--Lewis-SH--Loschen-W--Pavlin-J--2003"><span class="Hyperlink">Lombardo et al., 2003</span></a>; <a href="#Mostashari-F--Hartman-J--2003-."><span class="Hyperlink">Mostashari and Hartman, 2003</span></a>). On an added advantage, to make an evidence-based veterinary practices, the Syndromic surveillance in veterinary hospitals can be used concurrently to collect information about prevalene, incidence and various risk factors prevailing in the animal population (<a href="#Stone-AB--Hautala-JA--2008-"><span class="Hyperlink">Stone and Hautala, 2008</span></a>). Various studies has been conducted with syndromic surveillance in veterinary hospitals (<a href="#Nicholson-M--Beal-M--Shofer-F--Brown-DC--2002-"><span class="Hyperlink">Nicholson et al., 2002</span></a>; <a href="#Eugster-S--Schawalder-P--Gaschen-F--Boerlin-P--2004-."><span class="Hyperlink">Eugster et al., 2004</span></a>; <a href="#Ahern-BJ--Richardson-DW--Boston-RC--Schaer-TP--2010-"><span class="Hyperlink">Ahern et al., 2010</span></a>; <a href="#Ruple-Czerniak-AA--Aceto-HW--Bender-JB--Paradis-...-2014"><span class="Hyperlink">Ruple-Czerniak et al., 2014</span></a>). A syndromic surveillance for evaluating the occurrence of healthcare-associated infections in Critical Care Units of Small Animal Referral Hospitals reported that 16.3% of dogs and 12% of cats had ≥1 nosocomial syndrome during hospitalization (<a href="#Ruple-Czerniak-A--Aceto-HW--Bender-JB--Paradis...2013"><span class="Hyperlink">Ruple-Czerniak et al., 2013</span></a>). Another Syndromic surveillance used to estimate the rate of nosocomial infections in   equine hospitals reported that  19.7% of the study population had at least one nosocomial event during hospital stay and the most commonly observed nosocomial syndromes were surgical site inflammation and intra-venous catheter site inflammation (<a href="#Ruple-Czerniak-AA--Aceto-HW--Bender-JB--Paradis-...-2014"><span class="Hyperlink">Ruple-Czerniak et al., 2014</span></a>). Though the specificity of this system is low in outbreak surveillance, the sensitivity is high by guaranteeing the pertinent markers of disease (<a href="#Van-Metre-DC--Barkey-DQ--Salman-MD--Morley-PS--2009"><span class="Hyperlink">Van Metre et al., 2009</span></a>). Some of the relevant markers used in the surveillance are:</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="CharOverride-5">Acute respiratory tract disorders:</span> evidence of coughing, abnormal lung sounds, dyspnoea or tachypnea, sneezing, nasal discharges. </p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="CharOverride-5">Acute infectious gastrointestinal disorders:</span> diarrhoea, vomiting, abdominal pain or discomfort.</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="CharOverride-5">Pyrexia of unknown origin:</span> temperature more than 102.0ºF in horses or more than 102.5ºF in dogs and cats. </p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="CharOverride-5">Septicemia:</span> clinical or microbiological confirmation of septicemia</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB"><span class="CharOverride-5">Surgical wound analysis:</span> inflammation, infection or discharges.		  </p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-2--History-in-MM-" lang="en-GB">Environmental based surveillance			</p>
			<p class="Body-Text" lang="en-GB">In Environment based surveillance the hospital should submit the hospital environment sample for routine culture. Many studies has been published stating that hospital equipment and fomites harbouring potential nosocomial infectious agents and act as a reservoir such as sponge pots with benzalkonium chloride (<a href="#Fox-JG--Beaucage-CM--Folta-CA--Thornton-GW--1981-"><span class="Hyperlink">Fox et al., 1981</span></a>), stethoscopes (<a href="#Fujita-H--Hansen-B--Hanel-R--2013-."><span class="Hyperlink">Fujita et al., 2013</span></a>), thermometers (<a href="#Van-den-Berg-RWA--Claahsen-HL--Niessen-M--Muytjens-HL--Liem-K--Voss-A--2000"><span class="Hyperlink">Van den Berg et al., 2000</span></a>; <a href="#Weese-JS--Staempfli-HR--Prescott-JF--2000"><span class="Hyperlink">Weese et al., 2000</span></a>), Faucet handles and computer keyboards (<a href="#Bures-S--Fishbain-JT--Uyehara-CFT--Parker-JM--Berg-BW--2000-."><span class="Hyperlink">Bures et al., 2000</span></a>), endoscopes (<a href="#Schelenz-S--French-G--2000-"><span class="Hyperlink">Schelenz and French, 2000</span></a>; <a href="#Cowen-AE--2001-"><span class="Hyperlink">Cowen, 2001</span></a>), multiple-dose vials (<a href="#Sabino-CV--Weese-JS--2006-"><span class="Hyperlink">Sabino and Weese, 2006</span></a>), Cellular phones (<a href="#Brady-RR--Fraser-SF--Dunlop-MG--Brown-SP--Gibb-AP--2007-."><span class="Hyperlink">Brady et al., 2007</span></a>; <a href="#Julian-T--Singh-A--Rousseau-J--Weese-JS--2012-."><span class="Hyperlink">Julian et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">2012</span></a>), white coats and surgical scrubs (<a href="#Singh-A--Walker-M--Rousseau-J--Monteith-GJ--Weese-JS--2013-"><span class="Hyperlink">Singh et al., 2013</span></a>). Examination tables, floors and doors (<a href="#Van-den-Berg-RWA--Claahsen-HL--Niessen-M--Muytjens-HL--Liem-K--Voss-A--2000"><span class="Hyperlink">van Balen et al., 2013</span></a>). In <a href="#Burgess-BA--Morley-PS--Hyatt-DR--2004-."><span class="Hyperlink">2004, Burgess et al.,</span></a> reported that the nosocomial infectious agents are often encountered in the environment whenever the nosocomial rates are increased (<a href="#Burgess-BA--Morley-PS--Hyatt-DR--2004-."><span class="Hyperlink">Burgess et al., 2004</span></a>). And it has been reported that contamination of veter<span class="Body-Text ParaOverride-1">inary hospital environment was responsible for many nosocomial infection outbreaks (<a href="#Castor-ML--Wooley-RE--Shotts-EB--Brown-J--Payeur-JB--1989-."><span class="Hyperlink">Castor et al., 1989</span></a>; <a href="#Hartmann-FA--Callan-RJ--McGuirk-SM--West-SE--1996-."><span class="Hyperlink">Hartmann et al., 1996</span></a>; <a href="#Tillotson-K--Savage-CJ--Salman-MD--Gentry-Weeks-C--Rice-D--Fedorka-Cray-PJ--Traub-Dargatz-JL--1997-"><span class="Hyperlink">Tillotson et al., 1997</span></a>; <a href="#Schott-HC--Ewart-SL--Walker-RD--Dwyer-RM--Dietrich-S--Eberhart-SW--Derksen-FJ--2001-."><span class="Hyperlink">Schott et al., 2001</span></a>; <a href="#Weese-JS-Armstrong-J--2003-"><span class="Hyperlink">Weese and Armstrong, 2003</span></a>; <a href="#Wright-JG--Tengelsen-LA--Smith-KE--Bender-JB--Frank-RK--Grendon-JH--Angulo-FJ--2005-."><span class="Hyperlink">Wright et al., 2005</span></a>; <a href="#Dallap-Schaer-BL--Aceto-H--Rankin-SC--2010-."><span class="Hyperlink">Dallap et al., 2010</span></a>; <a href="#Steneroden-KK--Van-Metre-DC--Jackson-C--Morle-PS--2010-."><span class="Hyperlink">Steneroden et al., 2010</span></a>).  The percentage recovery of nosocomial agents in environmental survey of hospitals is depicted in <a href="#Table-2--P"><span class="Hyperlink">table 2</span></a>.</span></p>
		  <p class="Body-Text" lang="en-GB">&nbsp;</p>
			<p class="Figure--and-Table-Heading" lang="en-GB"><span class="CharOverride-5"><a id="Table-2--P"></a>Table 2: </span>Percentage recovery of nosocomial agents in environmental survey of hospitals</p>
			<table width="557" height="180" class="Table-Style-1" id="table-2">
				<colgroup>
					<col class="_idGenTableRowColumn-8" />
					<col class="_idGenTableRowColumn-9" />
					<col class="_idGenTableRowColumn-10" />
					<col class="_idGenTableRowColumn-11" />
				</colgroup>
				<tbody>
					<tr class="_idGenTableRowColumn-12">
						<td class="CellOverride-1">
							<p class="Default ParaOverride-1"><span class="CharOverride-18" lang="en-GB">S.no</span></p>
						</td>
						<td class="CellOverride-1">
							<p class="Default ParaOverride-1"><span class="CharOverride-18" lang="en-GB">Nosocomial agent</span></p>
						</td>
						<td class="CellOverride-1">
							<p class="Default"><span class="CharOverride-18" lang="en-GB">Percentage  recovery in environmental survey of hospitals</span></p>
						</td>
						<td class="CellOverride-1">
							<p class="Default ParaOverride-1"><span class="CharOverride-18" lang="en-GB">Reference</span></p>
						</td>
					</tr>
					<tr class="_idGenTableRowColumn-13">
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">1</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-19" lang="en-GB">Salmonella </span><span class="CharOverride-17" lang="en-GB">spp</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">2.1%</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">(Alinovi et al., 2003)</span></p>
						</td>
					</tr>
					<tr class="_idGenTableRowColumn-14">
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">2</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-19" lang="en-GB">Salmonella </span><span class="CharOverride-17" lang="en-GB">spp</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">11.9%</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">(Burgess et al., 2004)</span></p>
						</td>
					</tr>
					<tr class="_idGenTableRowColumn-13">
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">3</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-19" lang="en-GB">Clostridium difficile</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">6.3%</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">(Weese et al., 2000)</span></p>
						</td>
					</tr>
					<tr class="_idGenTableRowColumn-14">
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">4</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">MRSA</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">9.6%</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">(Weese et al., 2004)</span></p>
						</td>
					</tr>
					<tr class="_idGenTableRowColumn-15">
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">5</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-19" lang="en-GB">Staphylococci</span><span class="CharOverride-17" lang="en-GB"> count</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">55.9% of sample contain ≥2.5 cfu/cm2</span></p>
						</td>
						<td class="CellOverride-2">
							<p class="Default ParaOverride-1"><span class="CharOverride-17" lang="en-GB">(Aksoy et al., 2010).</span></p>
						</td>
					</tr>
				</tbody>
			</table>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-2--History-in-MM-" lang="en-GB">Laboratory based surveillance			</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">The Surveillance system used in human health care centres includes laboratory diagnosis (<a href="#Emori-TG--Gaynes-RP--1993"><span class="Hyperlink">Emori and Gaynes, 1993</span></a>; <a href="#Brossette-SE--Hacek-DM--Gavin-PJ--Kamdar-MA--Gadbois-KD--Fisher-AG--Peterson-LR--2006-"><span class="Hyperlink">Brossette et al., 2006</span></a>). Many researchers in veterinary nosocomial infections also included laboratory diagnosis for confirmation (<a href="#Biertuempfel--P.-H.--Ling--G.-V.--and-Ling--G.-A.--1981-."><span class="Hyperlink">Biertuempfel et al., 1981</span></a>; <a href="#Mathews-KA--Brooks-MJ--Valliant-AE--1996-."><span class="Hyperlink">Mathews et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">1996</span></a>; <a href="#Lobetti-RG--Joubert-KE--Picard-J--Carstens-J--Pretorius-E--2002-."><span class="Hyperlink">Lobetti</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 2002</span></a>; <a href="#Smarick-SD--Haskins-SC.--Aldrich-J--Foley-JE--Kass-PH--Fudge-M--Ling-GV--2004-."><span class="Hyperlink">Smarick et al., 2004</span></a>; <a href="#Marsh-Ng-ML--Burney-DP--Garcia-J--2007-."><span class="Hyperlink">Marsh-Ng et al., 2007</span></a>; <a href="#Bubenik-L--Hosgood-G--2008-."><span class="Hyperlink">Bubenik and Hosgood, 2008</span></a>; <a href="#Jones-ID--Case-AM--Stevens-KB--Boag-A--Rycroft-AN--2009"><span class="Hyperlink">Jones et al., 2009</span></a>) and some researchers have not included laboratory confirmation (<a href="#Johnson-JA--2002"><span class="Hyperlink">Nicholson, 2002</span></a>; <a href="#Eugster-S--Schawalder-P--Gaschen-F--Boerlin-P--2004-."><span class="Hyperlink">Eugster et al., 2004</span></a>; <a href="#Ahern-BJ--Richardson-DW--Boston-RC--Schaer-TP--2010-"><span class="Hyperlink">Ahern et al., 2010</span></a>). Committing laboratory confirmation is not cost effective and also more time consuming which prevents immediate action during outbreaks. In other way laboratory diagnosis can be used as a passive surveillance in regular basis. Passive surveillance means collecting data for other purposes, like samples which are regularly collected from patients can be tested for nosocomial infectious agents and Active surveillance means data collection for the specific purpose, and these are the types based on data collection (<a href="#Morley-PS--2004-."><span class="Hyperlink">Morley, 2004</span></a>). But the sensitivity of active surveillance is greater than the passive surveillance (<a href="#Brachman-PS--1993-."><span class="Hyperlink">Brachman, 1993</span></a>). </p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-2--History-in-MM-" lang="en-GB">Methods in Data Collection and Comparsion			</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">The data collection may be either Prospective or Retrospective. Data collection by monitoring the patient during hospitalization is Prospective and data collection by reviewing the hospital records after the patient has been discharged is Retrospective (<a href="#Abrutyn-E--Talbot--GH--1987-."><span class="Hyperlink">Abrutyn and Talbot, 1987</span></a>). Eventhough the Prospective data collection is gold standard there is a possibility of missing out of nosocomial infections after the patient is discharged (<a href="#Freeman-J--McGowan-JE--1981-."><span class="Hyperlink">Freeman and McGowan, 1981</span></a>) however it is wise to follow prospective surveillance during outbreaks of nosocomial infections (<a href="#Wenzel-RP--Osterman-CA--Hunting-KJ--Gwaltney-JM--1976-."><span class="Hyperlink">Wenzel</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 1976</span></a>). But retrospective method is used in hospital readmissions for infections (<a href="#Pottinger--JM--Herwaldt-LA--Perl-TM--1997-."><span class="Hyperlink">Pottinger et al., 1997</span></a>). Lot of studies has been conducted to illustrate the magnitude of nosocomial infections occurring after discharge from hospitals especially post-surgical infections (<a href="#Brown-RB--Bradley-S--Opitz-E--Cipriani-D--Pieczarka-R--Sands-M--1987-."><span class="Hyperlink">Brown et al.,</span><span class="Hyperlink CharOverride-6"> </span><span class="Hyperlink">1987</span></a>; <a href="#Delgado-Rodriguez-M--G-mez-Ortega-A--Sillero-Arenas-M--Llorca-J--2001-."><span class="Hyperlink">Delgado-Rodriguez et al., 2001</span></a>; <a href="#Eugster-S--Schawalder-P--Gaschen-F--Boerlin-P--2004-."><span class="Hyperlink">Eugster et al., 2004</span></a>). There are two methods in prospective data collection i.e patient-based collection methods by nurse or physician while attending the patient (<a href="#Abrutyn-E--Talbot--GH--1987-."><span class="Hyperlink">Abrutyn and Talbot, 1987</span></a>; <a href="#Pottinger--JM--Herwaldt-LA--Perl-TM--1997-."><span class="Hyperlink">Pottinger et al., 1997</span></a>) and diagnostic laboratory-based data collection which is time consuming, lacking in clinical data and with more false positive and false nagatives (<a href="#Abrutyn-E--Talbot--GH--1987-."><span class="Hyperlink">Abrutyn and Talbot, 1987</span></a>).</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">Inter-hospital comparison of data of nosocomial infections will facilitate the effective surveillance and for this nosocomial infection rates should be determined in each hospital (<a href="#Gaynes-RP--1997-."><span class="Hyperlink">Gaynes, 1997</span></a>). But the crude rates cannot be compared since it varies with the patient number, hospital size, facilities, case load, underlying illness and severity of disease (<a href="#Pottinger--JM--Herwaldt-LA--Perl-TM--1997-."><span class="Hyperlink">Pottinger et al., 1997</span></a>; <a href="#Sax-H--Pittet-D--and-the-Swiss-NOSO-network--2002-"><span class="Hyperlink">Sax et al., 2002</span></a>). For effective comparison it must be standardized like, which risk factors should be taken into account like length of hospital stay, exposure to invasive devices and intrinsic factors of patient (<a href="#Pottinger--JM--Herwaldt-LA--Perl-TM--1997-."><span class="Hyperlink">Pottinger et al., 1997</span></a>).</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-1--Introduction----" lang="en-GB">Prevention and control of Nosocomial Infections: Best to be proactive rather than reactive</p>
		  <p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
			
			  <li class="Body-Text ParaOverride-3" lang="en-GB">Hand hygiene is the easiest, cost effective and most underused measure (<a href="#Sax-H--Uckay-I--Richet-H--Allegranzi-B--Pittet-D--2007-."><span class="Hyperlink">Sax et al., 2007</span></a>). Hand washing with plain soaps failed to remove pathogens (<a href="#Ehrenkranz-NJ--Alfonso-BC--1991-.-F"><span class="Hyperlink">Ehrenkranz et al., 1991</span></a>) and also there are ironical reports stating that hand washing with plain soaps increases the bacterial counts on the skin (<a href="#Larson-EL--Leyden-JJ--McGinley-KJ--Grove-GL--Talbot-GH--1986"><span class="Hyperlink">Larson et al., 1986</span></a>; <a href="#Winnefeld-M--Richard-MA--Drancourt-M--Grubb-JJ--2000-."><span class="Hyperlink">Winnefeld et al., 2000</span></a>). Proper hand hygiene (<a href="#Sax-H--Uckay-I--Richet-H--Allegranzi-B--Pittet-D--2007-."><span class="Hyperlink">Sax et al., 2007</span></a>) and 70% alcohol gel based hand sanitizers should be placed throughout the hospitals (<a href="#Kampf-G--Rudolf-M--Labadie-JC--Barrett-SP--2002-."><span class="Hyperlink">Kampf et al., 2002</span></a>; <a href="#Leonard-FC--Markey-BK--2008-."><span class="Hyperlink">Leonard et al., 2008</span></a>). The alcohol based hand sanitizers have increased antimicrobial activity and reduces the cross contamination from taps and paper towel dispensers (<a href="#Harrison-WA--Grifith-CJ--Ayers-T--Michaels-B--2003-"><span class="Hyperlink">Harrison et al., 2003</span></a>). Hand washing should be done– i) before and after contact with a patient, ii) before and after contact with objects in the animals environment, iii) after contact with potentially infective biological specimen or discharges and iv) before and after wearing gloves is necessary (<a href="#CCAR.-Infection-preven"><span class="Hyperlink">CCAR, 2008</span></a>).</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Preliminary screening of all patients for signs of contagious disease before admission to the hospital and separate isolation facility for the contagious disease infected animals (<a href="#Traub-Dargatz-JL--Dargatz-DA--Morley-PS--Dunowska-M--2004"><span class="Hyperlink">Traub-Dargatz et al., 2004</span></a>).</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">If environmental contamination is suspected, regular monitoring and intervention is required with periodic spot checks of environment (<a href="#Traub-Dargatz-JL--Dargatz-DA--Morley-PS--Dunowska-M--2004"><span class="Hyperlink">Traub-Dargatz et al., 2004</span></a>).</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Veterinary health care personnel should take necessary occupational health measures like personal protective equipment, vaccination while handling infected materials like discharges, blood and sharps (<a href="#Mielke-M--2010-"><span class="Hyperlink">Mielke, 2010</span></a>).</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">The outerwear should be changed frequently since gross contamination does not need for pathogen to be present and attached laundry services may be provided.</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Cover skin lesions and open wounds. Strict asepsis in surgery with autoclaved surgical instruments and thoroughly cleaned endotracheal tubes (<a href="#CCAR.-Infection-preven"><span class="Hyperlink">CCAR, 2008</span></a>).</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Removal of implants and appropriate antibiotic treatment based on antibiogram (<a href="#Leonard-FC--Abbott-Y--Rossney-A--Quinn-PJ--O-Mahony-R--Markey-BK--2006-."><span class="Hyperlink">Leonard et al., 2006</span></a>).</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Animals with suspected clinical signs of any infectious diseases should not be admitted for any elective procedures (<a href="#CCAR.-Infection-preven"><span class="Hyperlink">CCAR, 2008</span></a>).</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Animals belonging to hospital workers should be screened (<a href="#Leonard-FC--Markey-BK--2008-."><span class="Hyperlink">Leonard et al., 2008</span></a>)</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Animals with multi-drug resistant infections should be handled with great precautions since the body sites like nose, rectum could be colonized with those pathogens (<a href="#CCAR.-Infection-preven"><span class="Hyperlink">CCAR, 2008</span></a>).</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Ensure appropriate handling of sterile medical devices particularly indwelling devices like urinary catheter and drugs for parental administration. Invasive procedures should only be performed if mandatory.</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Regular collection of Laboratory samples as a part of comprehensive monitoring programme. For example, Faeces can be collected for culture to detect salmonella from all the animals admitted for colic. If a particular nosocomial agent has been a problem in the past, there should be a readymade programmed action plan (<a href="#Traub-Dargatz-JL--Dargatz-DA--Morley-PS--Dunowska-M--2004"><span class="Hyperlink">Traub-Dargatz et al, 2004</span></a>).</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Special precautions on re-dispensation of medical products by proper disinfection and sterilization and disinfection of hand touch surfaces. Touching clean items like telephone or microscope while handling potential infectious material like swabs should be avoided.</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Ensure healthy patient environment and waste disposal (<a href="#Mielke-M--2010-"><span class="Hyperlink">Mielke, 2010</span></a>).</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Monitoring of antibiotic drugs consumption and development of resistance. Ensure antibiotic stewardship.</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">Adequate education and training for staff on infection control and occupational health supervision and Education of veterinary graduates and personnel about nosocomial infections and the significance of infection control measures (<a href="#Schwaber-MJ--Venezia-SN--Masarwa-S--Levy-...-2013"><span class="Hyperlink">Schwaber</span><span class="Hyperlink CharOverride-5"> </span><span class="Hyperlink">et al., 2013</span></a>). </li>
		  <li class="Body-Text ParaOverride-3" lang="en-GB">Client education particularly about zoonosis if the veterinarian has a reasonable suspicion of any zoonotic infectious disease.</li>
				<li class="Body-Text ParaOverride-3" lang="en-GB">The surveillance of nosocomial infections should be accomplished by creating nationwide reference data which will facilitate the quick reporting about infection clusters, outbreak and thereby makes evidence based preventive and control measures (<a href="#Mielke-M--2010-"><span class="Hyperlink">Mielke, 2010</span></a>).</li>
                <p>&nbsp;</p>
          <p>&nbsp;</p>
			
			<p class="Heading-1--Introduction----" lang="en-GB">Conclusions</p>
		  <p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">Nosocomial infections are preventable yet it is more neglected area of veterinary practice since it warrants some added tasks which do not fetch money. Unfortunately it will influence the success of the treatment and care provided so it cannot be ignored any longer. The mandate elements for providing patient safety and to prevent nosocomial infections are clean hospital environment, clean equipment and clean procedures or practices. Further in broader sense proactive policies, health worker education, safe use of medicines and surveillance system can strengthen patient safety, curtail dissemination of antibiotic resistance and zoonotic diseases. </p>
			<p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
		  <p class="Body-Text ParaOverride-1" lang="en-GB">&nbsp;</p>
			<p class="Heading-1--Introduction----" lang="en-GB">Reference</p>
			<p class="Heading-1--Introduction----" lang="en-GB">&nbsp;</p>
			
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