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LETTER Open Access
What is the risk of acquiring bacteria from
prior intensive care unit bed occupants?
Vincenzo Russotto1* , Andrea Cortegiani1, Santi Maurizio Raineri1, Pasquale Iozzo2, Cesare Gregoretti1
and Antonino Giarratano1
Keywords: Bacterial contamination, Multi-drug resistant bacteria, Infection, Sepsis
Contamination of inanimate surfaces and equipment
may play a role in cross-transmission of bacteria in the
intensive care unit (ICU), despite current standards of
terminal cleaning [1–3]. This is particularly relevant due
to the high prevalence of multidrug-resistant (MDR)
colonization of critically ill patients and the virulence
and invasiveness of bacteria, which frequently present
multidrug resistance to antimicrobials (e.g. Staphylococ-
cus aureus, Acinetobacter baumanii, Klebsiella pneumo-
niae). Moreover, colonization has been identified as a
risk factor for subsequent infections in critically ill
patients [4, 5].
We searched Medline, Scopus, and CINHAL data-
bases for either prospective or retrospective studies
reporting data on ICU-acquired bacterial species and
carriage status of the same species by the prior bed
occupant. An exclusion criterion was the non-ICU
setting due to differences in terminal cleaning proce-
dures and the hospital environment of the patients.
We applied no language restrictions and did not con-
sider gray literature. We performed a random-effect
meta-analysis (Mantel-Haenszel method) of included
studies and calculated the odds ratio (OR) for acquir-
ing specific microorganisms as well as from the
pooled data (Fig. 1). We assessed the heterogeneity
among studies by the I2 statistic.
The full search strategy can be found as Additional file 1.
Our search strategy found a total of 2264 articles from
inception to 1 January 2017 (1247 Medline, 654 Scopus,
363 CINHAL). Two authors (VR and AC) independently
performed the search and extracted the data. In case of
disagreement, it was solved by consensus with another
author (SMR). We used Review Manager 5.3.
We selected six studies for inclusion (two prospective
cohort study, one post-hoc analysis of a prospective
interventional cross-over study, and three retrospective
studies) for a total of 33,494 patients. The list of
included studies and references is available as Additional
file 2. Among 3838 patients admitted to ICU beds with
prior infected/colonized occupants, 230 acquired bac-
teria compared to 954 among 29,656 in the control
group. The overall pooled OR of acquiring a bacterial
pathogen from prior ICU bed occupants was 2.13 (95%
confidence interval 1.62–2.81). We observed a substan-
tial heterogeneity among included studies (I2 = 61%, P =
0.01). Figure 1 shows the forest plot of meta-analysis of
studies with subgroup analyses according to microorgan-
isms and pooled data.
Patients admitted to ICU beds of prior occupants
who were carrying bacterial pathogens should be con-
sidered at increased risk of ICU-acquisition compared
to other ICU patients. It should be highlighted that
these results refer to acquisition of bacteria and not to
infection. However, it may be argued that acquiring
bacteria may lead to colonization and nosocomial infec-
tions during the ICU stay due to disruption of natural
barriers for invasive procedures (e.g., insertion of
central venous catheters, arterial lines), use of broad-
spectrum antibiotics, and impaired immunological
function. A possible explanation for these results is that
bacteria frequently encountered in the ICU, especially
MDR, may have the ability to survive standard terminal* Correspondence: vinrussotto@gmail.com1Department of Biopathology and Medical Biotechnologies (DIBIMED),
Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico
Paolo Giaccone, University of Palermo, Via del Vespro 129, 90127 Palermo,
Italy
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Russotto et al. Critical Care  (2017) 21:55 
DOI 10.1186/s13054-017-1652-y
cleaning procedures in the environment close to the
patients after discharge. Further research should evalu-
ate the role of bacteria acquisition from prior ICU bed
occupants in terms of patient-related outcomes and the
impact of new strategies for terminal cleaning to reduce
hospital-acquired infection.
Additional files
Additional file 1: Search strategy. Search strategy adopted for the
systematic review. (PDF 34 kb)
Additional file 2: List of included studies. Table reporting the studies
included in the meta-analysis. (PDF 62 kb)
Abbreviations
CI: Confidence interval; HAI: Hospital-acquired infections; ICU: Intensive care
unit; MDR: Multidrug resistant; OR: Odds ratio
Acknowledgement
None
Funding
The authors did not receive any funding for this article.
Availability of data and materials
Not applicable.
Authors’ contributions
VR, AC, PI, SMR, CG, and AG conceived the content of the letter. AC, VR, PI, and
SMR performed the systematic review and meta-analysis. VR and AC wrote the
text. All authors read and approved the final version of the manuscript.
Fig. 1 Forest plot of studies evaluating the risk of acquiring bacteria from prior ICU bed occupants. CI confidence interval, M-H Mantel-Haenszel,
MRSA methicillin-resistant Staphylococcus aureus, VRE vancomycin-resistant enterococci
Russotto et al. Critical Care  (2017) 21:55 Page 2 of 3
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Not applicable.
Author details
1Department of Biopathology and Medical Biotechnologies (DIBIMED),
Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico
Paolo Giaccone, University of Palermo, Via del Vespro 129, 90127 Palermo,
Italy. 2Intensive Care Unit, Policlinico Paolo Giaccone, University of Palermo,
Via del Vespro 129, 90127 Palermo, Italy.
Received: 7 February 2017 Accepted: 28 February 2017
References
1. Russotto V, Cortegiani A, Raineri SM, Giarratano A. Bacterial contamination
of inanimate surfaces and equipment in the intensive care unit. J Intensive Care.
2015;3:54.
2. Russotto V, Cortegiani A, Gregoretti C, Raineri SM, Giarratano A. ICU-acquired
infections: it is not only about the number of patients per room.
J Crit Care. 2016;34:30.
3. Blazejewski C, Guerry M-J, Preau S, Durocher A, Nseir S. New methods to
clean ICU rooms. Infect Disord Drug Targets. 2011;11(4):365–75.
4. Karam G, Chastre J, Wilcox MH, Vincent J-L. Antibiotic strategies in the era
of multidrug resistance. Crit Care. 2016;20(1):136.
5. Russotto V, Cortegiani A, Graziano G, Saporito L, Raineri SM, Mammina C,
et al. Bloodstream infections in intensive care unit patients: distribution and
antibiotic resistance of bacteria. Infect Drug Resist. 2015;8:287–96.
Russotto et al. Critical Care  (2017) 21:55 Page 3 of 3


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