Open Access is an initiative that aims to make scientific research freely available to all. To date our community has made over 100 million downloads. It’s based on principles of collaboration, unobstructed discovery, and, most importantly, scientific progression. As PhD students, we found it difficult to access the research we needed, so we decided to create a new Open Access publisher that levels the playing field for scientists across the world. How? By making research easy to access, and puts the academic needs of the researchers before the business interests of publishers.
We are a community of more than 103,000 authors and editors from 3,291 institutions spanning 160 countries, including Nobel Prize winners and some of the world’s most-cited researchers. Publishing on IntechOpen allows authors to earn citations and find new collaborators, meaning more people see your work not only from your own field of study, but from other related fields too.
Multidrug-resistant (MDR) pathogens are a formidable challenge in hospital settings, with far-reaching implications for patient outcomes, healthcare resources, and public health. Combating their spread requires a combination of microbiological surveillance, stringent infection prevention and control measures, responsible antibiotic use, and continuous innovation. A sustainable approach to infection control must also prioritize environmental stewardship, workforce training, and policy integration at the local, national, and global levels. This chapter explores these components by considering best practices and emerging strategies for effective and sustainable infection management in the era of antimicrobial resistance. The impact of MDR pathogens spans the clinical, economic, social, and policy domains. Their ability to evade treatment and spread rapidly in healthcare settings demands a multifaceted response that includes robust surveillance, strict infection control, responsible antibiotic use, and global cooperation. As MDR organisms continue to evolve, failure to act swiftly and comprehensively could jeopardize the safety and effectiveness of modern healthcare systems.
Department of Biological Sciences, College of Science, University of Jeddah, Jeddah, Saudi Arabia
*Address all correspondence to: aaaljudaibi@uj.edu.sa
1. Introduction
The emergence and global spread of multidrug-resistant (MDR) pathogens is among the pressing public health challenges of the twenty-first century. In hospital environments, where vulnerable patient populations are exposed to invasive procedures, immunosuppressive therapies, and prolonged antibiotic use, the risk of healthcare-associated infections (HAIs) caused by MDR organisms is high. These infections are difficult to treat because of the limited therapeutic options and, accordingly, contribute to increased morbidity, mortality, and healthcare costs. The World Health Organization (WHO) has repeatedly emphasized the urgent need to address antimicrobial resistance (AMR) through integrated surveillance, prudent antibiotic use, and strengthened infection prevention and control (IPC) strategies [1–3].
Microbiological surveillance plays a pivotal role in identifying, monitoring, and responding to trends in MDR pathogens in healthcare settings. Surveillance systems facilitate the early detection of outbreaks, track resistance patterns over time, and provide critical data for guiding empirical therapy and informing antimicrobial stewardship programs (ASPs) [4, 5]. These systems rely on robust laboratory capacity, standardized reporting frameworks, and the timely sharing of data among microbiologists, infection control teams, and clinical practitioners [6]. With the increasing availability of rapid diagnostics and whole-genome sequencing, microbiological surveillance is evolving into a precise and proactive tool for combating MDR infections [7].
Effective control of MDR pathogens in hospitals requires a multi-layered approach that integrates microbiological surveillance with evidence-based IPC measures [8]. Standard precautions, such as hand hygiene, environmental cleaning, and the use of personal protective equipment (PPE), must be rigorously implemented and audited [9]. In addition, contact precautions and cohorting strategies may be necessary in high-risk wards, such as intensive care units (ICUs) [10]. Antibiotic stewardship is equally critical, as optimizing the selection, dosage, and duration of antimicrobial therapy can significantly reduce the selective pressure that drives resistance [4].
The sustainability of infection management strategies hinges on their adaptability, resource efficiency, and alignment with broader public health goals. In recent years, hospitals have been encouraged to adopt green infection control practices, such as the use of eco-friendly disinfectants and decreased reliance on single-use plastics, without compromising patient safety [11]. Furthermore, digital health innovations, including electronic surveillance dashboards, tele-infectious disease consultations, and mobile health applications, offer promising avenues for real-time monitoring and decision support [12, 13].
In alignment with the United Nations sustainable development goals (SDGs), this chapter contributes, in particular, to SDG Target 3.3 (ending epidemics of communicable diseases) and SDG Target 3.d (strengthening global health preparedness and addressing antimicrobial resistance) [14]. These global targets emphasize the urgent need to prevent, detect, and control infectious diseases through coordinated international action, improved surveillance systems, and strengthened laboratory capacity. Antimicrobial resistance represents one of the most critical challenges threatening the achievement of these goals, as resistant pathogens compromise the effectiveness of standard treatments, prolong hospital stays, increase healthcare costs, and elevate mortality rates [15].
In the wake of the COVID-19 pandemic, global awareness of infection prevention and microbial threats has reached unprecedented levels. The pandemic has underscored the need for resilient healthcare systems capable of responding to both viral outbreaks and the insidious threat of AMR. It has also catalyzed investment in diagnostic infrastructure and IPC protocols that can often be leveraged to strengthen ongoing efforts against MDR pathogens [16, 17].
By addressing the mechanisms of multidrug resistance, infection control strategies, and molecular surveillance tools, this chapter aligns with the global agenda for sustainable health systems and contributes to building resilience against both endemic and emerging infectious threats. Integrating SDG perspectives into microbial surveillance and hospital infection management highlights the importance of a “One Health” approach, recognizing the interconnectedness of human, animal, and environmental health in mitigating the spread of antimicrobial resistance worldwide.
The aim of this chapter is to provide a comprehensive overview of microbiological surveillance and control strategies for MDR pathogens in hospital settings, with a special focus on sustainability. Through an exploration of current practices, technological advances, and future directions, the chapter highlights integrated approaches that can enhance infection management while preserving antimicrobial efficacy for future generations.
2. Multidrug-resistant pathogens
Multidrug-resistant pathogens pose a grave and escalating threat to global health, particularly in hospital environments. The resistance that these pathogens have developed to multiple classes of antimicrobial agents renders standard treatments ineffective and significantly complicates the management of infections [18]. The evolution and dissemination of MDR organisms are driven by a complex interplay of factors, including antibiotic misuse, insufficient infection control practices, lack of effective surveillance, and environmental pressures in clinical settings [19, 20]. The WHO classifies AMR as one of the top 10 global public health threats and emphasizes the urgent need for coordinated and sustainable interventions [2].
In hospital settings, MDR pathogens are frequently associated with HAIs, which disproportionately affect critically ill, immunocompromised, and surgical patients [21]. The most notorious MDR pathogens, often referred to by the acronym ESKAPE, are Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species [22–24]. These organisms are known for their ability to “escape” the effects of commonly used antibiotics and are a leading cause of bloodstream infections, pneumonia, urinary tract infections, and surgical site infections [25].
Mechanisms of AMR in MDR organisms vary widely and include the enzymatic degradation of antibiotics, such as β-lactamases, efflux pumps that expel drugs from bacterial cells, the modification of drug targets, and biofilm formation [26]. These adaptations often emerge through spontaneous genetic mutations or horizontal gene transfer facilitated by plasmids, transposons, and integrons [27]. In hospital environments, high antibiotic selection pressure and close patient contact provide ideal conditions for the rapid spread of these resistant traits [28, 29].
Multidrug resistance in pathogenic bacteria is driven by a complex network of molecular mechanisms that collectively enhance bacterial survival against diverse classes of antimicrobial agents. Among these molecular mechanisms, efflux pumps play a pivotal role by actively expelling antibiotics and toxic compounds from the bacterial cytoplasm, thereby maintaining sub-inhibitory intracellular drug concentrations [30, 31]. The major efflux systems include the resistance-nodulation-division (RND) family, which is predominant in Gram-negative bacteria (e.g., the AcrAB–TolC system in E. coli), the major facilitator superfamily (MFS), and the small multidrug resistance (SMR) family [32, 33]. These systems contribute not only to intrinsic resistance but also to adaptive responses triggered by antibiotic exposure and environmental stress.
Another key mechanism involves enzymatic drug inactivation, such as β-lactamases (e.g., blaNDM, KPC, OXA), aminoglycoside-modifying enzymes, and chloramphenicol acetyltransferases, which chemically modify or degrade antibiotics, thereby rendering them ineffective [34]. Target modification also plays a central role, for genetic mutations can alter antibiotic-binding sites on bacterial ribosomes, DNA gyrase, or RNA polymerase, leading to resistance to macrolides, fluoroquinolones, or rifamycins, respectively [35]. Furthermore, the reduced membrane permeability that often occurs because of the loss or modification of outer membrane porins restricts antibiotic entry, particularly in Gram-negative bacteria [36]. This mechanism often acts synergistically with efflux pumps to confer high-level resistance.
An equally significant contributor to the rapid dissemination of resistance traits is horizontal gene transfer (HGT). Through transformation (the uptake of naked DNA), transduction (phage-mediated gene transfer), and conjugation (plasmid exchange between bacteria), HGT enables the spread of resistance determinants across species and genera, including between commensal and pathogenic bacteria [37, 38]. Mobile genetic elements, such as plasmids, transposons, integrons, and insertion sequences, further facilitate the accumulation and mobilization of multiple resistance genes within a single bacterial cell, giving rise to multidrug- or even pan-drug-resistant strains [39].
Collectively, these mechanisms create a robust and dynamic resistance network that challenges current therapeutic strategies and complicates infection management in hospital environments. Understanding these molecular pathways provides insights essential for developing targeted interventions, novel antimicrobial agents, and strategies to curb the spread of MDR pathogens in healthcare settings.
Multidrug-resistant gram-negative bacteria present a particularly formidable challenge. Klebsiella pneumoniae produces extended-spectrum β-lactamases (ESBLs) and carbapenemases such as KPC and NDM, which have been implicated in major hospital outbreaks [22, 34]. Likewise, A. baumannii is notorious for its environmental persistence and ability to acquire resistance genes and, thus, is a significant concern in ICUs. Gram-positive MDR pathogens, such as methicillin-resistant S. aureus (MRSA) and vancomycin-resistant Enterococcus (VRE), also continue to be leading causes of hospital-acquired infections worldwide [32, 40].
The burden of MDR pathogens is especially high in low- and middle-income countries (LMICs), where diagnostic capabilities, antimicrobial stewardship programs, and infection prevention infrastructure may be limited [24, 41]. The fact that surveillance data from these regions often remain scarce or fragmented hinders the development of targeted interventions. In Saudi Arabia and across the Gulf Cooperation Council (GCC) countries, recent studies have reported alarming rates of resistance among hospital isolates, particularly in Gram-negative bacilli [42, 43]. These findings underscore the critical need for robust national surveillance systems and harmonized antimicrobial policies across the region.
Addressing the threat of MDR pathogens, then, requires an integrated, multidisciplinary strategy. IPC measures, including standard precautions such as hand hygiene, appropriate use of PPE, and environmental disinfection, form the first line of defense [44]. In outbreak situations and high-risk wards, contact precautions, patient cohorting, and staff training are essential to limit transmission [45].
Antimicrobial stewardship programs play a crucial role in curbing resistance by ensuring the rational use of antibiotics (Figure 1). These programs promote the selection of the appropriate antimicrobial agent, as well as the appropriate dose, route, and duration of therapy based on microbiological data and clinical guidelines [46]. ASPs rely on close collaboration among infectious disease physicians, clinical microbiologists, pharmacists, and hospital administrators [47]. Recent innovations in rapid diagnostics, such as multiplex polymerase chain reaction (PCR), matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) spectrometry, and point-of-care tests, have significantly enhanced the ability to detect resistance markers early and guide targeted therapy [48, 49].
Figure 1.
Preventing the transmission of infectious agents within healthcare environments: standard, contact, and airborne precautions.
Global and regional initiatives, including the WHO’s Global Antimicrobial Resistance Surveillance System (GLASS) and the GCC Center for Infection Control (GCC-CIC), have been instrumental in promoting data sharing and developing action plans to tackle AMR. Participation in these initiatives helps standardize surveillance methods, promote laboratory capacity building, and facilitate the implementation of evidence-based guidelines [50].
The COVID-19 pandemic has both complicated and advanced the fight against MDR pathogens. On the one hand, the increased use of broad-spectrum antibiotics during the pandemic may have exacerbated resistance rates. On the other hand, the crisis has catalyzed investments in diagnostic laboratories, IPC infrastructure, and digital health systems that can be leveraged to enhance AMR surveillance and response.
3. The impacts of MDR pathogens
Multidrug-resistant pathogens have emerged as a critical threat to global health, with profound implications for clinical care, public health systems, and healthcare economics. These pathogens, defined by their resistance to at least one agent in three or more antimicrobial categories, have rendered many first-line and even last-resort antibiotics ineffective [51]. The burden they impose is particularly significant in hospital settings, where vulnerable patient populations are at high risk and infection control is complex.
3.1 Impact on patient outcomes
The most direct and devastating impact of MDR pathogens is on patient morbidity and mortality. Infections caused by resistant bacteria tend to be more severe, persist longer, and are more difficult to treat than those caused by susceptible strains. The treatment options are limited, often requiring the use of toxic or less effective alternatives [52]. For example, infections with carbapenem-resistant K. pneumoniae or colistin-resistant A. baumannii are associated with mortality rates exceeding 50% in critically ill patients [53]. This impact is especially concerning in ICUs, neonatal wards, and post-operative settings, where patients are already immunocompromised or recovering from invasive procedures [54].
The delay in administering the appropriate empiric antibiotic therapy, often due to a lack of rapid diagnostics or local antibiogram data, also contributes to poor outcomes. Even when susceptibility testing is available, the resistant nature of these organisms is such that treatment options may be suboptimal [55, 56]. Recurrent infections, an increased risk of complications such as sepsis, and prolonged recovery periods are common in MDR-related cases [57].
3.2 Impact on healthcare resources
In addition to health-related consequences, MDR pathogens exert a substantial economic toll on healthcare systems. Patients with MDR infections often require longer hospital stays, additional diagnostic testing, repeated or prolonged antimicrobial courses, and sometimes intensive care support [58, 59]. These factors significantly increase healthcare costs. For example, it is estimated that an MDR infection can be up to six times more expensive to treat than an infection caused by a drug-susceptible pathogen.
Furthermore, hospital outbreaks involving MDR organisms may lead to the temporary closure of wards, the diversion of resources to contact tracing and environmental decontamination, and increased workloads for IPC teams [60, 61]. The costs associated with managing such outbreaks include staff training, patient isolation, and repeated laboratory testing, and can be overwhelming, particularly for low-resource healthcare settings [62].
3.3 Impact on public health and infection control
Beyond the burdens on individual patients and institutions, MDR pathogens pose a broader public health challenge. The transmission of resistant organisms within and among hospitals, and even into the community, undermines infection prevention efforts and complicates disease surveillance. Resistant strains of E. coli, S. aureus, and Mycobacterium tuberculosis are now reported globally in both developed and developing nations [63].
Hospital settings serve as amplifiers of resistance, as the high antibiotic pressure, invasive procedures, and high patient turnover provide ideal conditions for MDR organisms to thrive and spread [64]. When standard infection control measures, such as hand hygiene, sterilization, and antimicrobial stewardship, are insufficient or inconsistently applied, MDR pathogens gain a significant foothold [44, 45]. The results include endemic transmission patterns, persistent reservoirs of infection, and increased difficulty in eradicating colonization in patients.
The spread of MDR bacteria also has implications for surgical procedures, cancer therapies, organ transplantation, and other life-saving interventions that rely on effective antimicrobial prophylaxis [65]. Thus, the rise of untreatable infections could reverse decades of progress in modern medicine.
3.4 Psychosocial and societal impacts
Multidrug-resistant infections can have profound psychosocial consequences for patients and healthcare workers alike. For patients, the burden includes prolonged isolation, psychological stress, and diminished quality of life. For example, the fear of contracting or transmitting MDR infections may influence patients’ willingness to seek care, especially for elective procedures [66]. Healthcare workers, on the other hand, may experience anxiety related to the risks of occupational exposure, ethical dilemmas regarding the treatment of incurable infections, and emotional fatigue when managing recurrent or fatal cases [44, 67]. Additionally, public fear and misinformation about “superbugs” can fuel distrust in healthcare institutions.
3.5 Impact on antimicrobial development
The growing prevalence of MDR pathogens has intensified the need for new antimicrobial agents. However, the development of antibiotics has stagnated because of high costs, low profitability, and scientific challenges. The limited investment in new antibiotics by the pharmaceutical industry has created a pipeline crisis, leaving clinicians with diminishing options to combat MDR infections [68].
In response, governments and international organizations have launched initiatives to incentivize antibiotic research and development, as well as promote alternative strategies such as bacteriophage therapy, monoclonal antibodies, and microbiome-based treatments. However, these approaches remain in the early stages and cannot yet replace broad-spectrum antibiotics in acute clinical scenarios [69, 70].
4. Surveillance strategies in hospital settings
Microbiological surveillance forms the foundation of IPC programs, particularly in the management of MDR pathogens. Timely and accurate detection of resistant organisms not only enables effective containment and clinical management but also guides hospital-wide antimicrobial policies and stewardship interventions. In hospital environments, where the transmission of pathogens can occur rapidly and silently, surveillance systems serve as early warning mechanisms to prevent outbreaks and minimize risks to patients and healthcare workers.
4.1 Microbiological surveillance: Active compared with passive
Hospital-based surveillance strategies generally fall into two categories: passive and active. Passive surveillance relies on routine laboratory results and clinical case reports. It is cost-effective and easy to implement but may fail to detect asymptomatic colonization or underreported infections. While useful for trend analysis over time, passive systems depend on clinicians’ diagnostic accuracy and reporting compliance [71, 72].
Active surveillance, by contrast, involves proactive data collection and targeted screening of high-risk patient populations, healthcare workers, and even the hospital environment. This screening includes routine cultures on admission, especially in ICUs, transplant wards, and during outbreaks. Active surveillance is more resource-intensive but enables early detection of colonization by MDR organisms such as MRSA, VRE, and carbapenem-resistant Enterobacteriaceae (CRE), thereby allowing for timely isolation and intervention [73, 74].
The choice between active and passive methods depends on hospital capacity, the prevalence of resistant organisms, and the available laboratory infrastructure. In most tertiary hospitals, both systems operate in parallel, with active surveillance focused on high-risk areas and passive data providing longitudinal trends.
4.2 Screening and culturing techniques
Comprehensive microbiological surveillance involves standardized sampling methods and diagnostic tools. The following techniques are widely used:
Nasal and rectal swabs are commonly used for MRSA and VRE screening, particularly upon ICU admission and prior to surgery. Swabs are cultured on selective chromogenic media or analyzed using rapid molecular assays in accordance with the Clinical and Laboratory Standards Institute (CLSI) M41 guidelines [75].
Wound and catheter site cultures are especially indicated in patients with prior hospitalization or known colonization, in accordance with the CLSI M56 recommendations [76].
Blood, urine, and respiratory cultures remain essential for diagnosing active infections and monitoring resistance trends in accordance with the CLSI M47 and M100 standards [77, 78].
Environmental cultures are taken from high-touch surfaces (e.g., bed rails, infusion pumps, and ventilators), particularly during outbreaks and routine audits, in accordance with the CLSI M29 recommendations [76].
Standardization of the collection, transport, and processing of samples is essential to ensure the quality of the data. Institutions often develop sampling protocols in coordination with microbiologists and infection control teams to optimize resource use and clinical utility.
4.3 Antibiograms and tracking of resistance patterns
Hospital antibiograms play a vital role in monitoring local resistance trends and guiding empirical therapy.
Cumulative antibiograms are typically compiled annually using the CLSI guidelines to provide a summary of susceptibility profiles across common pathogens [75–78].
These data help physicians select appropriate empirical therapies and antimicrobial stewardship programs to tailor formulary restrictions and treatment protocols.
Unit-specific antibiograms, particularly for ICUs and transplant wards, provide more targeted insights.
During outbreaks and changes in pathogen prevalence, real-time resistance dashboards and automated alert systems can support rapid decision-making.
Linking antibiogram data with electronic medical records (EMRs) and pharmacy systems is an increasingly common approach that facilitates the dynamic adjustment of antibiotic usage policies [79].
4.4 Molecular tools in surveillance
Traditional culture-based methods are increasingly supplemented by molecular diagnostics, which offer rapid and high-throughput capabilities.
PCR detects specific resistance genes (e.g., mecA for MRSA, vanA/B for VRE, and blaNDM/KPC/OXA for carbapenemases). Rapid PCR panels can yield results in hours rather than days [80, 81].
MALDI-TOF mass spectrometry enables the precise and rapid identification of bacterial species, thereby reducing turnaround time and improving diagnostic accuracy [48].
Whole genome sequencing provides detailed insights into resistance mechanisms, clonal relationships, and outbreak tracking. Though costly, it is increasingly used in research and high-resource hospital settings for comprehensive surveillance [82].
Multiplex syndromic panels enable the simultaneous detection of multiple pathogens and resistance genes in clinical specimens (e.g., respiratory, gastrointestinal, and blood panels). Recent advances in molecular diagnostics have further revolutionized microbial surveillance in hospital environments. Building on conventional PCR-based methods, advanced techniques such as 16S rRNA gene sequencing and next-generation sequencing (NGS) now provide high-resolution information for microbial identification, phylogenetic classification, and the profiling of resistance genes [83].
These sequencing-based platforms enable the simultaneous detection of diverse bacterial taxa and resistance determinants and thus offer deep insights into hospital microbiomes and transmission dynamics. In addition, loop-mediated isothermal amplification (LAMP) has emerged as a rapid and cost-effective alternative for pathogen detection that requires minimal equipment, produces results within minutes, and thus is advantageous for field or resource-limited settings.
Collectively, these molecular platforms enhance diagnostic precision, accelerate infection control responses, and strengthen AMR surveillance systems. Their integration into clinical microbiology laboratories contributes to more evidence-based infection prevention policies and supports timely decision-making during outbreaks of high-risk MDR pathogens.
The integration of molecular tools enhances the accuracy of surveillance and supports timely infection control decisions, especially during outbreaks of high-risk MDR pathogens.
4.4.1 Sustainable development goal alignment and global relevance
The integration of molecular tools in microbial surveillance not only advances diagnostic accuracy but also aligns with global public health priorities outlined in the SDGs [84].
Specifically, these approaches contribute to SDG Target 3.3, which aims to end epidemics of communicable diseases through improved detection, prevention, and control measures, and to SDG Target 3.d, which emphasizes strengthening global health preparedness and the capacity to manage emerging health risks, including AMR [14, 15].
By enhancing early warning systems, facilitating rapid pathogen identification, and guiding evidence-based infection control, molecular surveillance represents a cornerstone in achieving sustainable and resilient healthcare systems worldwide.
4.5 Infection surveillance in Saudi Arabia
Saudi Arabia has significantly expanded its national infrastructure for AMR surveillance and infection control in recent years. The following institutions and initiatives play key roles.
4.5.1 Role of the Saudi Ministry of Health
The Saudi Ministry of Health (MOH) oversees the strategic planning and implementation of AMR surveillance at the national level and supports hospitals in establishing local surveillance systems, reporting, and aligning national priorities with international guidelines, such as those set by the WHO [85].
4.5.2 National surveillance initiatives
The Health Electronic Surveillance Network (HESN) is Saudi Arabia’s primary digital platform for tracking infectious diseases, including AMR data. This platform allows for real-time data entry, centralized analysis, and the early detection of emerging resistance patterns [86, 87].
The National AMR Surveillance Program, launched by the Saudi Center for Disease Prevention and Control (SCDC), standardizes laboratory diagnostics and reporting across healthcare institutions. The program contributes data to the WHO’s GLASS [88].
4.5.3 Examples from tertiary care centers
Major hospitals in Saudi Arabia, such as King Faisal Specialist Hospital, King Saud Medical City, and National Guard Health Affairs, have implemented comprehensive surveillance systems using electronic dashboards, unit-specific antibiograms, and rapid diagnostics [89]. These institutions serve as models for national rollout and have contributed valuable epidemiological data on the prevalence of ESBLs, CRE, MRSA, and VRE in Saudi settings [90]. Selected findings from recent studies of MDR pathogen isolates from Saudi tertiary care hospitals, including genomic investigations, are shown in Table 1.
MDR pathogen isolates reported by Saudi tertiary hospitals.
4.5.4 Accreditation and auditing standards
Accreditation and auditing are central to sustaining high-quality IPC and AMR surveillance in Saudi hospitals. In practice, accreditation translates national policy into day-to-day behaviors by standardizing how hospitals collect AMR data, run stewardship programs, and investigate outbreaks.
National frameworks include Saudi Arabia’s Central Board for Accreditation of Healthcare Institutions (CBAHI), which makes accreditation mandatory and classifies standards based on structure, process, and outcome measures. These measures explicitly include outcome indicators related to HAIs, specifically central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs), and require the availability of IPC resources and staff, which is a prerequisite for robust AMR surveillance and the control of MDR organisms [99]. In parallel, the MOH issues a comprehensive National Guide for Auditors in Infection Control, the most recent edition of which operationalizes audits across domains such as hand hygiene, isolation, outbreak management, HAI surveillance, antimicrobial stewardship/antibiograms, and MDR organism prevention bundles, thereby linking audit findings to corrective action plans and follow-up checks [100].
Empirical evidence of the impact on Saudi hospitals
Health accreditation and auditing of hospitals are essential elements for ensuring they are free of antibiotic-resistant microorganisms and have sustainable high-quality infection control, which has been reflected positively in patient safety indicators and prevention of nosocomial infections. A study encompassing several hospitals in Medina demonstrated a decrease in hospital-acquired infections following accreditation. Medication errors and post-discharge mortality rates were also decreased, indicating the positive impact of implementing a patient safety assessment system on safety outcomes [95, 96].
Another study, a pre- and post-accreditation evaluation at a university hospital, showed that the national accreditation program significantly improved several aspects of patient safety culture (teamwork, feedback, and error communication) and safety outcomes. These results suggest that the accreditation mechanism, which promotes adherence to infection control standards and reporting practices, benefits patients’ health and well-being [97].
Furthermore, evidence from Saudi hospitals accredited by the Joint Commission International (JCI) indicates positive changes resulting from accreditation and measurement and improvement processes, reflecting the impact of international accreditation in strengthening infection control systems and local governance [99].
Mechanisms by which accreditation enhances AMR control
Governance and resourcing: The CBAHI mandates dedicated IPC departments and committees, leadership support, and continuous training – conditions that enable sustained surveillance and rapid response to outbreaks of MDR organisms [82, 84].
Standardized measurement: Routine audits against national checklists ensure that hospitals maintain unit-specific antibiograms, track MDR organisms, and apply patient-care bundles for CLABSI, CAUTI, ventilator-associated events, and surgical site infections, which reduce HAIs and, by extension, antimicrobial exposure and resistance selection [100, 101].
Feedback loops and accountability: Accreditation ties the results of audits to corrective action plans and reassessment, creating a cycle of improvement that has been associated with lower nosocomial infection trends following accreditation in MOH facilities [102].
Culture and compliance: By elevating reporting, teamwork, and communication about errors, accreditation improves patient-safety culture, which correlates with adherence to hand hygiene, isolation, and antimicrobial stewardship protocols [103, 104].
Illustrative example (Saudi tertiary care)
Hospitals preparing for (or renewing) CBAHI or JCI status commonly implement electronic IPC dashboards that integrate laboratory alerts for CRE, MRSA, and VRE, real-time isolation flags, and stewardship prompts. These tools align with the MOH’s audit domains for HAI surveillance, antimicrobial stewardship, and antibiograms, and are the same operational levers documented in national guidance and accreditation narratives [86, 87].
5. Infection control measures
Infection control measures are critical for limiting the spread of HAIs, especially those caused by MDR organisms. In hospital settings, these measures protect patients, healthcare workers, and visitors, and ensure operational safety and quality. Successful infection control relies on a combination of standardized protocols, consistent compliance, multidisciplinary leadership, and continuous monitoring [105, 106].
5.1 Isolation precautions: Standard, contact, and airborne
Isolation precautions are central to preventing the transmission of infectious agents within healthcare environments. These precautions are divided into three categories (Figure 2):
Standard precautions are applied to the care of all patients, regardless of their infection status. Key elements include hand hygiene before and after every patient contact, the use of PPE such as gloves, gowns, and masks based on anticipated exposure, respiratory hygiene and cough etiquette, the safe handling of sharps and contaminated materials, and disinfection of reusable medical equipment [6, 107].
Contact precautions are necessary for patients infected or colonized with organisms such as MRSA, VRE, or CRE. Protocols include wearing gloves and gowns when entering such patients’ rooms, dedicating non-critical equipment to individual patients, placing patients in single rooms, and cohorting with others infected with the same organism [9, 11].
Droplet precautions are used for pathogens transmitted by respiratory droplets (e.g., influenza and pertussis). Surgical masks must be worn within one meter of patients, and eye protection may be required for procedures likely to generate secretions [108, 109].
Airborne precautions are applied for diseases such as tuberculosis, measles, and varicella. These precautions involve placement in airborne infection isolation rooms with negative pressure ventilation and the use of fit-tested N95 respirators or higher-level protection [110, 111].
Figure 2.
Principles of antimicrobial stewardship programs in healthcare settings and their main components.
The appropriate application of isolation precautions helps reduce transmission risks in hospitals, especially in emergency departments, ICUs, and during outbreaks.
5.2 Role of infection control committees
The infection control committees (ICCs) play a leadership and oversight role in coordinating hospital-wide infection-prevention activities. A well-structured ICC typically includes infectious disease physicians, clinical microbiologists, infection preventionists and nurses, quality assurance and occupational health representatives, and hospital administrators.
The responsibilities of the ICC include developing and updating infection-prevention policies, overseeing surveillance data and outbreak management, reviewing hand hygiene compliance and environmental hygiene data, supporting antimicrobial stewardship efforts, conducting risk assessments, and preparing mitigation plans [28, 112].
In Saudi Arabia, ICCs are mandatory components of CBAHI and JCI accreditation programs, reflecting their critical importance to hospital safety culture [113].
5.3 Staff education and compliance monitoring
Education and training are essential for the successful implementation of ICPs. Programs should be comprehensive, covering hand hygiene, PPE use, isolation protocols, waste management, and outbreak responses, and tailored to the roles and responsibilities of various staff categories, such as nurses, physicians, and housekeepers. Programs should also include continuous, regular refreshers and updates based on new guidelines or identified gaps, and be interactive in terms of the use of simulations, case studies, and role-playing to improve engagement and knowledge retention [9, 18].
Compliance monitoring is equally important and includes the following:
Data from these activities inform quality improvement initiatives and are often reported to the ICC.
5.4 Audits and feedback mechanisms
Auditing provides measurable insight into the effectiveness of infection control interventions. Common types of audits include the following:
hand hygiene audits using the WHO’s Five Moments for Hand Hygiene;
environmental cleaning audits using visual inspection or quantitative methods; and
isolation compliance audits (e.g., signage, PPE use, and room setup) [115].
Feedback mechanisms include the following:
real-time or periodic reports to units;
“Scorecards” for departments comparing infection rates and compliance; and
recognizing high-performing units and addressing underperformance with targeted training [116].
6. Antimicrobial stewardship programs
With the focus on post-COVID-19 progress, ASPs have emerged as a cornerstone of the global effort to combat AMR. The aims of these programs are the optimization of the use of antimicrobials to improve patient outcomes, the minimization of the development of resistance, and the reduction of unnecessary healthcare costs (Figure 2). In hospital settings, ASPs work in tandem with IPC programs to provide a comprehensive framework for the safe and effective use of antibiotics [117, 118].
6.1 Core principles and goals of ASPs
The primary goal of ASPs is to ensure that the right antibiotic is given to the right patient, at the right dose, for the right duration, and through the right route. By doing so, ASPs seek to:
improve clinical outcomes and reduce treatment failures;
minimize adverse effects, including those of Clostridioides difficile infections;
curtail the emergence and spread of resistant organisms;
reduce inappropriate or unnecessary antibiotic use; and
reduce direct and indirect healthcare costs [119, 120].
The key interventions of ASPs include the following:
prospective auditing and feedback;
formulary restrictions and pre-authorization policies;
the development of local antimicrobial guidelines based on antibiograms;
the de-escalation of therapy based on culture results;
intravenous-to-oral switch policies; and
dose optimization for pharmacokinetic and pharmacodynamic targets.
6.2 Role of multidisciplinary teams
Effective ASPs depend on collaboration among various healthcare professionals. A multidisciplinary team typically includes the following personnel:
Infectious disease physicians, who provide clinical oversight, ensure evidence-based prescribing and manage complex infection cases.
Clinical pharmacists with infectious disease training, who lead antibiotic audits, educate prescribers, and implement interventions in real time.
Clinical microbiologists interpret susceptibility data, identify resistance trends, and advise on appropriate testing and diagnostics.
Infection control specialists who integrate stewardship with surveillance and IPC efforts.
Hospital administration and IT professionals who support data collection, reporting, and policy enforcement [121, 122].
6.3 Post-COVID-19 improvements in ASPs
The COVID-19 pandemic, as a global health crisis, served as a catalyst for the transformation of ASPs. Hospitals were forced to rapidly adapt their infection control and antimicrobial use strategies, leading to several long-term improvements [123–126].
Improved awareness of microbial resistance
The initial overuse of antibiotics in COVID-19 patients, despite the viral etiology, heightened awareness of inappropriate prescribing.
Surveillance reports revealed a sharp increase in resistance rates during the early phases of the pandemic, prompting calls for stronger stewardship controls.
Hospitals began integrating AMR messaging into COVID-19 clinical training and public health campaigns.
Increased adoption of rapid diagnostics
Rapid molecular assays (e.g., multiplex PCR and antigen-based point-of-care testing) were widely adopted to distinguish viral infections from bacterial infections.
Biomarkers, such as procalcitonin, were increasingly used to guide decisions about initiating and discontinuing antibiotics.
This expansion of diagnostics allowed for more targeted therapies and minimized empirical broad-spectrum antibiotic use.
Shift toward digital monitoring and tele-infectious diseases
Remote consultation systems emerged during lockdowns, enabling infectious disease specialists to advise on cases remotely.
Many hospitals developed or expanded electronic stewardship dashboards linked to laboratory and pharmacy data.
Tele-stewardship models were piloted in rural and understaffed hospitals to increase their reach and efficiency.
Policy changes supporting ASPs in Saudi Arabia
The MOH and the SCDC updated stewardship guidelines to include pandemic-related considerations.
National policies emphasized diagnostic stewardship, early de-escalation, and stewardship roles in outbreak management.
Increased integration of ASPs into accreditation (e.g., in the CBAHI standards) and quality improvement initiatives followed.
6.4 Examples of ASPs in Saudi hospitals
Saudi Arabia has taken significant steps in implementing ASPs at both the national level and the institutional level. Several leading hospitals serve as benchmarks for stewardship excellence.
Ministry of National Guard-Health Affairs. ASPs are embedded in this system’s infectious disease units and pharmacy services. The program includes formulary restrictions, prospective auditing and feedback, and unit-specific antibiograms. Pharmacists trained in infectious diseases round daily with clinical teams, reviewing antimicrobial prescriptions [127].
King Faisal Specialist Hospital and Research Centre (KFSHRC). The ASP team integrates clinical microbiology, pharmacy, and infection prevention to optimize antimicrobial usage across multiple campuses. The hospital leverages EMRs to flag inappropriate prescriptions and automate alerts [128, 129].
King Saud Medical City, a model for MOH-affiliated institutions, runs a full-time ASP with dedicated infectious disease specialists and stewardship pharmacists, participates in national AMR reporting, and hosts regional training workshops for the implementation of ASPs [129–131].
7. Novel and sustainable approaches to infection management
The increasing threat of AMR necessitates complementary strategies that extend beyond conventional surveillance, infection prevention, and antimicrobial stewardship. Integrating technological innovation, ecological responsibility, and systems-level design supports a resilient, sustainable framework for managing MDR pathogens in hospitals. The following discussion highlights emerging tools and practices that enhance early detection, optimize interventions, and reduce the ecological footprint of infection control.
7.1 Emerging technologies: Artificial intelligence, biosensors, and mobile applications
Artificial intelligence (AI) and machine learning. AI-driven analytics leverage large datasets, EMRs, microbiological results, pharmacy dispensing logs, and bed movement data to model transmission dynamics and forecast outbreaks before clinical escalation. Predictive algorithms can (1) flag atypical resistance patterns suggesting clonal spread, (2) support empiric therapy selection by integrating current antibiogram trends with patient-specific risk factors, and (3) prioritize isolation or screening based on probabilistic colonization scores. Natural language processing applied to clinical notes can improve the detection of under-coded infections and reduce lags in passive surveillance. The integration into clinical decision-support systems enables real-time prompts for de-escalation, dose optimization, or intravenous-to-oral conversion, further reinforcing the goals of stewardship.
7.1.1 Biosensors and real-time environmental monitoring
Next-generation electrochemical and optical sensors, such as surface plasmon resonance systems, together with advanced microfluidic platforms, are being increasingly applied to facilitate rapid and near-patient detection of pathogens, as well as molecular resistance determinants, including carbapenemase genes. Continuous or periodic surface monitoring (e.g., smart sensor patches on high-touch zones) can provide quantitative bioburden metrics to guide targeted cleaning rather than fixed-schedule disinfection. Air quality biosensors, coupled with particle-counting and microbial-capture technologies, help assess the performance of ventilation systems in isolation units and procedure rooms [132, 133].
On the other hand, mobile platforms support point-of-care decision-making. Examples include antibiogram lookup tools, isolation precaution checklists, and PPE competency modules. Secure applications can deliver push alerts for new resistance clusters, pending culture results requiring therapy adjustments, and lapsed isolation orders. The integration of bedside barcodes and radio-frequency identification with mobile apps reduces device-associated infection risks by tracking catheter dwell times and prompting timely removal. Staff engagement tools gamify hand hygiene and appropriate prescribing to enhance adherence and sustainability through feedback dashboards [134, 135].
7.2 Phage therapy and microbiome restoration
Bacteriophages offer a pathogen-specific modality capable of targeting MDR organisms such as P. aeruginosa and A. baumannii while sparing commensal flora, thereby potentially reducing the collateral ecological damage commonly associated with broad-spectrum antibiotics [136]. Advances include engineered phages and phage cocktails that broaden the host range and overcome resistance. Their incorporation into compassionate-use pathways and clinical trials in tertiary centers enables salvage therapy in refractory infections such as prosthetic joint infections, ventilator-associated pneumonia, and complex wound colonization [137]. Stewardship-aligned frameworks are necessary to ensure that phage use remains evidence-based and that resistance, such as phage receptor alteration, is monitored through genomic surveillance [46].
The preservation of host microbiota mitigates colonization by opportunistic MDR pathogens. The strategies for preservation include the following:
Probiotics and prebiotics: selected strains may reduce the recurrence of C. difficile and limit gut colonization by ESBL-producers, though clinical efficacy varies by strain and indication [138].
Symbiotics and post-biotics: combined substrate-microbe strategies and metabolite supplementation can stabilize dysbiotic ecosystems [139].
Fecal microbiota transplantation: Post-antibiotic or recurrent C. difficile cases benefit from the restoration of diversity, which indirectly reduces the selective pressure that favors MDR colonization. Standardization, rigorous donor screening, and emerging defined microbial consortia improve safety and reproducibility [140].
Selective digestive and oral decontamination: The efficacy of these approaches is still debated, and risk–benefit assessments must consider potential shifts in resistance and local epidemiology [141].
7.3 Ventilator-associated pneumonia (VAP)
Ventilator-associated pneumonia (VAP) is one of the most important healthcare-associated infections encountered in ICUs, and it remains a major contributor to morbidity, mortality, and healthcare costs worldwide [142, 143]. VAP typically develops after 48 hours or more of mechanical ventilation, during which normal airway defenses are impaired, and micro-aspiration of contaminated secretions commonly occurs as a result of endotracheal intubation [142, 144]. These factors create an environment highly conducive to colonization and subsequent infection by hospital-associated pathogens, particularly those exhibiting MDR.
The pathogens most frequently implicated in VAP include P. aeruginosa, A. baumannii, K. pneumoniae, and MRSA. These organisms are well-adapted to survive in the ICU environment and commonly harbor multiple resistance determinants, such as β-lactamases, carbapenemases (KPC, NDM, and OXA types), efflux pumps, porin loss, and robust biofilm formation that protect them from exposure to antibiotics and the host’s immune system [145–147]. The involvement of MDR pathogens is particularly concerning because it limits therapeutic options, delays the initiation of effective targeted therapy, and increases the likelihood of adverse outcomes [143, 146].
Clinically, VAP is associated with prolonged mechanical ventilation, increased ICU length of stay, septic complications, and mortality rates that are markedly higher when MDR Gram-negative organisms are involved [146]. Early diagnosis is essential but often challenging because of clinical features that overlap with other ICU conditions. For this reason, rapid diagnostic approaches, including syndromic PCR panels, multiplex molecular assays, and next-generation sequencing, are increasingly used to accelerate pathogen identification and resistance profiling, thereby guiding early and appropriate antimicrobial therapy [145, 147].
Prevention remains a cornerstone of VAP management. Evidence-based ventilator bundles that include elevation of the head of the bed, daily sedation interruption and spontaneous breathing trials, subglottic secretion drainage, and optimized oral care have shown significant reductions in VAP incidence when applied consistently [148, 149]. Additionally, strict adherence to hand hygiene, minimization of ventilator duration, and the use of closed suction systems further reduce risk. Integrated ICU surveillance systems help detect emergent MDR trends, monitor outbreaks, and inform antimicrobial stewardship interventions that target the inappropriate use of broad-spectrum antibiotics [147, 150].
Given its strong association with MDR pathogens, high clinical burden, and preventability, VAP represents a critical focal point in hospital-acquired infection control programs. Strengthening diagnostic capabilities, improving prevention protocols, and enhancing real-time ICU surveillance are essential strategies for mitigating its impact and improving patient outcomes in critical care settings.
7.4 Hospital architecture and airflow systems
Modern hospital design leverages computational fluid dynamics to optimize air exchange, directional flow, and pressure differentials. Negative pressure isolation rooms, anteroom buffering, and HEPA (high-efficiency particulate air) filtration reduce airborne transmission of not only tuberculosis and measles but also aerosolizable MDR organisms during certain procedures. Demand-controlled ventilation, paired with sensor-triggered modulation, can maintain air quality while reducing the energy footprint [151].
Furthermore, the clear demarcation of “clean,” “transition,” and “contaminated” zones minimizes inadvertent cross-traffic. Similarly, decentralized nurse stations adjacent to isolation rooms reduce unnecessary corridor movement. The placement of hand hygiene stations in room entry sightlines increases compliance (an example of behavioral “nudge” design). The selection of materials such as seamless flooring, non-porous high-touch surfaces, and antimicrobial copper alloys constrains environmental persistence without over-reliance on chemical disinfectants [152]. Furthermore, the use of automated doors, sensor-activated faucets, UV disinfection for cabinet handles, and voice-activated chart access terminals reduces fomite-mediated transfer. Integration with occupancy and movement analytics can trigger adaptive cleaning schedules for high-use zones [153].
7.5 Sustainable infection control practices (green approaches)
Transitioning from high-residual chemical agents to accelerated hydrogen peroxide, enhanced citric acid, or hypochlorous acid formulations can reduce the emission of volatile organic compounds and staff exposure while maintaining microbicidal efficacy. Lifecycle assessments guide selection by balancing efficacy against MDR organisms with environmental impact [154].
Currently, the proliferation of single-use devices contributes significantly to the amount of regulated medical waste. Strategies for reducing waste include the following:
The use of reprocessable or modular PPE components, when approved with validated decontamination cycles (e.g., vaporized hydrogen peroxide for certain respirators);
The rationalization of instrument sets (lean trays) to decrease unnecessary sterilization; and
The establishment of segregated recycling streams for packaging materials and sharps containers made of recyclable polymers [155].
Modern washer-disinfectors and steam sterilizers incorporate heat recovery and intelligent load cycling to reduce energy and water consumption. Similarly, real-time sensor telemetry can benchmark resource usage per surgical case to support the achievement of quality improvement and sustainability goals [156].
Reducing unnecessary antibiotic use not only limits resistance but also decreases pharmaceutical waste and downstream ecological dissemination, such as active metabolites in wastewater. Hospital wastewater monitoring, as a form of wastewater-based epidemiology, can provide early warnings about resistance gene flux and inform upstream stewardship interventions [4, 107].
Generally, the embedding of sustainability metrics in infection control dashboards, which include disinfectant usage per occupied bed-day and PPE waste per isolation day, is consistent with environmental stewardship and key patient-safety performance indicators, and recognition programs reinforce staff engagement.
7.6 Integrative impact
The convergence of digital surveillance, ecological design, and precision biologics, including phages, microbiome therapeutics, and green operational practices, forms a systems-based model for sustainable infection management. Unlike isolated interventions, layered strategies produce such synergistic benefits as earlier detection (e.g., through the use of AI and biosensors) and targeted control (e.g., isolation and precision therapy), while sustainable materials and workflows reduce environmental reservoirs and operational burdens. This integrated paradigm enhances resilience against MDR threats and aligns with broader institutional goals of quality, safety, and environmental responsibility [157].
8. Challenges and future directions
Despite substantial advances in antimicrobial stewardship, infection control, and microbiological surveillance, the global healthcare community continues to face critical challenges in the management of MDR pathogens. These challenges are particularly pronounced in LMICs, where resource limitations intersect with growing healthcare demands. Addressing these gaps requires a strategic vision that embraces international collaboration, digital innovation, and long-term investment in human capital and infrastructure.
8.1 Continued threat of AMR in LMICs
While AMR is a global issue, its impact is disproportionately strong in LMICs. Several interrelated factors contribute to this burden.
Inadequate access to diagnostics. Many healthcare facilities in LMICs lack basic laboratory capabilities for culture and sensitivity testing. This lack often leads to empirical treatment with broad-spectrum antibiotics, thereby accelerating resistance selection.
Unregulated antimicrobial use, over-the-counter access to antibiotics, self-medication with them, and their unmonitored use in agriculture remain prevalent. The lack of regulatory frameworks and enforcement exacerbates the problem of inappropriate antibiotic use.
Gaps in infection-prevention infrastructure, inadequate water, sanitation, and hygiene facilities in hospitals, combined with overcrowding and insufficient PPE, create an environment conducive to the spread of MDR organisms.
Limited surveillance systems, fragmented data collection, inconsistent reporting standards, and the absence of electronic infrastructure hinder effective monitoring and response.
The fact that these systemic weaknesses not only affect local healthcare outcomes but also contribute to global AMR reservoirs emphasizes the need for equitable international support and resource mobilization [4, 158].
8.2 Need for global coordination and regional alignment
The transboundary nature of AMR demands a globally harmonized response. Pathogens do not recognize borders, and resistance genes can spread rapidly through trade, travel, and the environment.
Global initiatives
The WHO’s GLASS provides a standardized platform for participating countries to collect, analyze, and share AMR data. This system promotes transparency, benchmarking, and the development of targeted interventions based on global trends.
The Tripartite One Health Approach, which is led by the WHO, the Food and Agriculture Organization, and the Office International des Epizooties (now the World Organization for Animal Health), integrates human, animal, and environmental health strategies to tackle AMR across sectors [2, 159].
Regional collaboration
The GCC-CIC fosters collaborative research, the harmonization of guidelines, and joint AMR surveillance efforts among GCC member states, including Saudi Arabia. The center plays a vital role in coordinating infection control policies, outbreak response mechanisms, and workforce training programs across the Gulf region.
The Arab Board for Health Specializations and GCC surveillance networks have recently intensified efforts to develop unified standards and expand laboratory capacity regionally [49, 118].
Multilateral collaboration ensures not only the efficient sharing of knowledge and resources but also strengthens preparedness and responsiveness across health systems with varying capacities.
8.3 Data integration and big data analytics
The proliferation of electronic health records, laboratory information systems, and digital monitoring platforms has created an unprecedented opportunity to harness big data for infection control and AMR containment.
Data integration: Linking surveillance data, such as culture results and antibiograms,with pharmacy records, patient outcomes, and device use enables real-time tracking of resistance trends, detection of outbreaks, and monitoring of antibiotic consumption [160].
Predictive analytics: Machine learning algorithms can identify high-risk patients, forecast AMR hotspots, and guide resource allocation. These tools also support early warning systems and preemptive isolation strategies [161].
Dashboards and decision-support systems: The integration of data into clinician-friendly interfaces enhances situational awareness and improves compliance with antimicrobial stewardship protocols [154].
Privacy and interoperability: While powerful, such systems must be designed to comply with data governance standards and ensure compatibility across diverse healthcare environments [162].
In Saudi Arabia, national initiatives such as the HESN and the use of institutional dashboards in tertiary hospitals have begun to operationalize these digital solutions. However, scaling such systems across facility levels remains an ongoing challenge.
8.4 Capacity building and workforce training
The sustainability of AMR containment strategies hinges on a skilled and adequately resourced workforce. However, gaps in human capacity persist across several domains.
Microbiology and diagnostics. There is a global shortage of trained clinical microbiologists, particularly in LMICs. Therefore, expanding microbiology residency programs, mentorship schemes, and regional laboratory networks is critical [163].
Infectious disease specialists and stewardship pharmacists. Many hospitals, especially those located outside major cities, lack access to dedicated infectious disease physicians and trained pharmacists to lead ASPs [46, 113].
Infection control practitioners: The pandemic highlighted the need for continuous training in IPC principles, outbreak management, and biosafety procedures [61, 99].
Training platforms, e-learning modules, mobile-based training apps, and simulation-based education can overcome geographical barriers and provide scalable solutions for capacity development [164].
Accreditation requirements, such as those of the CBAHI and JCI, increasingly mandate demonstrated competency in IPC and stewardship. The embedding of AMR and IPC training in medical, nursing, and allied health curricula ensures foundational knowledge across the healthcare workforce.
9. Conclusions
MDR pathogens present a formidable challenge to modern healthcare systems worldwide, threatening the efficacy of current treatment regimens and undermining the safety of clinical procedures ranging from routine surgeries to organ transplantation. The increasing prevalence of AMR, particularly in hospital settings, necessitates a comprehensive, integrated, and sustainable approach to infection management.
This chapter has outlined the critical role of microbiological surveillance, infection control, and ASPs in addressing the threat of MDR organisms. Through both passive and active surveillance methods, hospitals can detect and track resistance trends in order to enable timely interventions and inform local antibiotic policies. Isolation precautions, environmental hygiene, the use of PPE, and the education of staff members are essential components of a robust infection control infrastructure, while audits and feedback ensure accountability and continuous improvement.
The evolution of ASPs, especially in the aftermath of the COVID-19 pandemic, has highlighted the importance of multidisciplinary collaboration, rapid diagnostics, digital health tools, and remote consultation systems. In Saudi Arabia, national initiatives such as the HESN, policy reforms, and exemplary programs in leading tertiary hospitals reflect commendable progress and offer scalable models for the region.
Beyond conventional strategies, novel approaches such as phage therapy, microbiome restoration, AI-driven analytics, and sustainable hospital design are expanding the frontiers of infection management. These innovations, when combined with global collaboration, digital integration, and capacity building, create a resilient framework capable of adapting to emerging threats.
As the burden of AMR continues to increase, particularly in LMICs, international coordination and equitable investment will be vital. Empowering the healthcare workforce, fostering cross-sector partnerships, and embedding infection prevention principles into all levels of care are essential to long-term success.
References
1.World Health Organization. Global action plan on antimicrobial resistance. Geneva: WHO; 2015. Available from: https://www.who.int/publications/i/item/9789241509763 [Accessed: 2025-July-22]
2.World Health Organization. GLASS Report: Early implementation 2020. Geneva: WHO; 2020. Available from: https://www.who.int/publications/i/item/9789240005587 [Accessed: 2025-July-22]
3.TacconelliE, CarraraE, SavoldiA, HarbarthS, MendelsonM, MonnetDL, PulciniC, KahlmeterG, KluytmansJ, CarmeliY, OuelletteM, OuttersonK, PatelJ, CavaleriM, CoxEM, HouchensCR, GraysonML, HansenP, SinghN, TheuretzbacherU, MagriniN, WHO Pathogens Priority List Working Group. Discovery, research, and development of new antibiotics: The WHO priority list of antibiotic-resistant bacteria and tuberculosis. The Lancet Infectious Diseases. 2018;18:318–327. DOI: 10.1016/S1473-3099(17)30753-3
4.ChindelevitchL, JauneikaiteE, WheelerNE, AllelK, Ansiri-AsafoakaaBY, AwuahWA, BauerDC, BeiskenS, FanK, GrantG, GrazM. Applying data technologies to combat AMR: Current status, challenges, and opportunities on the way forward. arXiv Preprint. 2022;arXiv:2208.04683. DOI: 10.48550/arXiv.2208.04683
6.SerapideF, PalloneR, QuirinoA, MarascioN, BarrecaGS, DavoliC, LionelloR, MateraG, RussoA. Impact of multiplex PCR on diagnosis of bacterial and fungal infections and choice of appropriate antimicrobial therapy. Diagnostics. 2025;15(8):1044. DOI: 10.3390/diagnostics15081044
7.WeissfeldAS, BaselskiV, CornishNE, KraftCS, LaRoccoMT, McNultP, NachamkinI, ParrottJS, RichterSS, RubinsteinM, SaubolleMA. The American Society for Microbiology collaboration with the CDC Laboratory Medicine Best Practices initiative for evidence-based laboratory medicine. Clinical Microbiology Reviews. 2024;37(4):e00065–18. DOI: 10.1128/cmr.00065-18
8.BianconiI, AschbacherR, PaganiE. Current uses and future perspectives of genomic technologies in clinical microbiology. Antibiotics. 2023;12(11):1580. DOI: 10.3390/antibiotics12111580
9.YuanX, WangP, LiuJ. A novel intelligent approach for infection protection using a multidisciplinary collaboration in regional general hospitals. Scientific Reports. 2025;15:22639. DOI: 10.1038/s41598-025-06329-7
10.GlowiczJB, LandonE, Sickbert-BennettEE, AielloAE, DekayK, HoffmannKK, MaragakisL, OlmstedRN, PolgreenPM, TrexlerPA, VanAmringeMA. SHEA/IDSA/APIC practice recommendation: Strategies to prevent healthcare-associated infections through hand hygiene: 2022 update. Infection Control & Hospital Epidemiology. 2023;44(3):355–376. DOI: 10.1017/ice.2022.304
11.LiR, ZhangZ, WangZ, QianK. Containment of a carbapenem-resistant Klebsiella pneumoniae in an intensive care unit during the COVID-19 pandemic. Frontiers in Public Health. 2025;13:1557068. DOI: 10.3389/fpubh.2025.1557068
12.ValléeA. Green hospitals face to climate change: Between sobriety and resilience. Heliyon. 2024;10(2):e24769. DOI: 10.1016/j.heliyon.2024.e24769
13.MateoM, ÁlvarezR, CoboC, PallasJR, LópezAM, GaiteL. Telemedicine: Contributions, difficulties and key factors for implementation in the prison setting. Revista Española de Sanidad Penitenciaria. 2019;21(2):95. DOI: 10.4321/S1575-06202019000200005
14.United Nations. Sustainable development goal 3: Ensure healthy lives and promote well-being for all at all ages. Available from: https://sdgs.un.org/goals/goal3 [Accessed: 2025-July-25]
16.BearM, AungstT, HerrenJ, MosaffaS, LiuS, RileyS. Optimizing antibiotic use in older adults through digital health initiatives. Current Infectious Disease Reports. 2025;27(1):7. DOI: 10.1007/s11908-025-00858-y
17.RawsonTM, MooreLSP, Castro-SanchezE, CharaniE, DaviesF, SattaG, EllingtonMJ, HolmesAH. COVID-19 and the potential long-term impact on antimicrobial resistance. Journal of Antimicrobial Chemotherapy. 2020;75(7):1681–1684. DOI: 10.1093/jac/dkaa194
18.MathewD, APM, SimonB, JosephA. Strengthening the health system of the communities in the battle against infectious diseases. In KanchiS, BathinapatlaA, VargheseA, MdluliPS, editors. Nano‐Biosensor Technologies for Diagnosis of Infectious Diseases. Chichester: Wiley; 2025. p. 469–483
19.Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2019. Atlanta, GA: CDC; 2019. Available from: https://www.cdc.gov/antimicrobial-resistance/media/pdfs/2019-ar-threats-report-508.pdf [Accessed: 2025-July-22]
20.VentolaCL. The antibiotic resistance crisis: Part 1: Causes and threats. P & T: A Peer-Reviewed Journal for Formulary Management. 2015;40(4):277–283. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4378521/
21.AbalkhailA, AlslamahT. Institutional factors associated with infection prevention and control practices globally during the infectious pandemics in resource-limited settings. Vaccines. 2022;10(11):1811. DOI: 10.3390/vaccines10111811
22.NoelD, BrooksA, DebraA. Impact of healthcare-associated infections on length of stay and cost in cardiac and oncology units: A meta review. 2025. Available from: https://www.researchgate.net/publication/393871137_Impact_of_Healthcare-Associated_Infections_on_Length_of_Stay_and_Cost_in_Cardiac_and_Oncology_Units_A_Meta-_Review [Accessed: 2025-July-25]
23.LarssonDJ, FlachCF. Antibiotic resistance in the environment. Nature Reviews Microbiology. 2022;20(5):257–269. DOI: 10.1038/s41579-021-00649-x
24.AgyemanWY, BishtA, GopinathA, CheemaAH, ChaludiyaK, KhalidM, NwosuM, KonkaS, KhanS. A systematic review of antibiotic resistance trends and treatment options for hospital-acquired multidrug-resistant infections. Cureus. 2022;14(10):e29956. DOI: 10.7759/cureus.29956
26.BharadwajA, RastogiA, PandeyS, GuptaS, SohalJS. Multidrug‐resistant bacteria: Their mechanism of action and prophylaxis. BioMed Research International. 2022;2022(1):5419874. DOI: 10.1155/2022/5419874
27.Rodríguez-BeltránJ, DelaFuenteJ, Leon-SampedroR, MacLeanRC, San MillanA. Beyond horizontal gene transfer: The role of plasmids in bacterial evolution. Nature Reviews Microbiology. 2021;19(6):347–359. DOI: 10.1038/s41579-020-00497-1
28.ZackKM, SorensonT, JoshiSG.Types and Mechanisms of Efflux Pump Systems and the Potential of Efflux Pump Inhibitors in the Restoration of Antimicrobial Susceptibility, with a Special Reference to Acinetobacter baumannii. Pathogens. 2024;13:197. DOI: 10.3390/pathogens13030197
29.PereiraAL, de OliveiraPM, Faria-JuniorC, AlvesEG, de CastroE, Caldo LimaGR, da Costa LamounierTA, HaddadR, de AraújoWN. Environmental spreading of clinically relevant carbapenem-resistant gram-negative bacilli: The occurrence of bla KPC-or-NDM strains relates to local hospital activities. BMC Microbiology. 2022;22(1):6. DOI: 10.1186/s12866-021-02400-1
30.GauravA, BakhtP, SainiM, Pandey S, Pathania R. Role of bacterial efflux pumps in antibiotic resistance, virulence, and strategies to discover novel efflux pump inhibitors. Microbiology. 2023:169(5):001333. DOI: 10.1099/mic.0.001333
31.NovelliM, BollaJM. RND efflux pump induction: A crucial network unveiling adaptive antibiotic resistance mechanisms of gram-negative bacteria. Antibiotics. 2024;13(6):501
32.LiD, GeY, WangN, ShiY, GuoG, ZouQ, LiuQ. Identification and characterization of a novel Major Facilitator Superfamily (MFS) efflux pump SA09310 mediating tetracycline resistance in Staphylococcus aureus. bioRxiv. 2023;10:2023–01
33.AlenazyR. Drug efflux pump inhibitors: A promising approach to counter multidrug resistance in gram-negative pathogens by targeting AcrB protein from AcrAB-TolC multidrug efflux pump from Escherichia coli. Biology. 2022;11(9):1328
34.GajicI, TomicN, LukovicB, JovicevicM, KekicD, PetrovicM, JankovicM, TrudicA, Mitic CulaficD, MilenkovicM, OpavskiN. A comprehensive overview of antibacterial agents for combating Multidrug-Resistant bacteria: The current landscape, development, future opportunities, and challenges. Antibiotics. 2025;14(3):221
35.GalganoM, PellegriniF, CatalanoE, CapozziL, Del SambroL, SposatoA, LucenteMS, VasiniotiVI, CatellaC, OdigieAE, TempestaM. Acquired bacterial resistance to antibiotics and resistance genes: from past to future. Antibiotics. 2025;14(3):222. DOI: 10.3390/antibiotics14030222
36.SaxenaD, MaitraR, BormonR, CzekanskaM, MeiersJ, TitzA, VermaS, ChopraS.Tackling the outer membrane: Facilitating compound entry into Gram-negative bacterial pathogens. Npj Antimicrobials and Resistance. 2023;1(1):17
38.PetrovG, DymovaM, RichterV. Bacteriophage-mediated cancer gene therapy. International Journal of Molecular Sciences. 2022;23(22):14245
39.BelayWY, GetachewM, TegegneBA, TefferaZH, DagneA, ZelekeTK, AbebeRB, GedifAA, FentaA, YirdawG, TilahunA. Mechanism of antibacterial resistance, strategies and next-generation antimicrobials to contain antimicrobial resistance: A review. Frontiers in Pharmacology. 2024;15:1444781
40.MarinoA, ManiaciA, LentiniM, RonsivalleS, NunnariG, CocuzzaS, ParisiFM, CacopardoB, LavalleS, La ViaL. The global burden of multidrug-resistant bacteria. Epidemiologia. 2025;6(2):21. DOI: 10.3390/epidemiologia6020021
41.IskandarK, MolinierL, HallitS, SartelliM, HardcastleTC, HaqueM, LugovaH, DhingraS, SharmaP, IslamS, MohammedI, MohamedIN, HannaPA, SaidEH, JamaluddinNAH, SalamehP, RoquesC. Surveillance of antimicrobial resistance in low-and middle-income countries: A scattered picture. Antimicrobial Resistance and Infection Control. 2021;10(1):63. DOI: 10.1186/s13756-021-00931-w
42.BorgioJF, RasdanAS, SonbolB, AlhamidG, AlmandilNB, AbdulAzeezS. Emerging status of multidrug-resistant bacteria and fungi in the Arabian Peninsula. Biology. 2021;10(11):1144. DOI: 10.3390/epidemiologia6020021
43.Al-OrphalyM, HadiHA, EltayebFK, Al-HailH, SamuelBG, SultanAA, SkariahS. Epidemiology of multidrug-resistant Pseudomonas aeruginosa in the Middle East and North Africa Region. Msphere. 2021;6(3):e00202–21. DOI: 10.1128/mSphere.00202-21
44.AlhumaidS, Al MutairA, Al AlawiZ, AlsulimanM, AhmedGY, RabaanAA, Al-TawfiqJA, Al-OmariA. Knowledge of infection prevention and control among healthcare workers and factors influencing compliance: A systematic review. Antimicrobial Resistance and Infection Control. 2021;10(1):86. DOI: 10.1186/s13756-021-00957-0
45.AbbasM, Robalo NunesT, MartischangR, ZinggW, ItenA, PittetD, HarbarthS. Nosocomial transmission and outbreaks of coronavirus disease 2019: The need to protect both patients and healthcare workers. Antimicrobial Resistance and Infection Control. 2021;10(1):7. DOI: 10.1186/s13756-020-00875-7
46.RahmanMM, Alam TumpaMA, ZehraviM, SarkerMT, YaminMD, IslamMR, Harun-Or-RashidM, AhmedM, RamproshadS, MondalB, DeyA. An overview of antimicrobial stewardship optimization: The use of antibiotics in humans and animals to prevent resistance. Antibiotics. 2022;11(5):667. DOI: 10.3390/antibiotics13040353
47.SalahA, El-HousseinyG, ElleboudyN, YassienM. Antimicrobial stewardship programs: A review. Archives of Pharmaceutical Sciences Ain Shams University. 2021;5(1):143–157. DOI: 10.21608/APS.2021.76105.1059
48.YoonEJ, JeongSH. MALDI-TOF mass spectrometry technology as a tool for the rapid diagnosis of antimicrobial resistance in bacteria. Antibiotics. 2021;10(8):982. DOI: 10.3390/antibiotics10080982
49.YaminD, UskokovićV, WakilAM, GoniMD, ShamsuddinSH, MustafaFH, AlfouzanWA, AlissaM, AlshengetiA, AlmaghrabiRH, FaresMAA. Current and future technologies for the detection of antibiotic-resistant bacteria. Diagnostics. 2023;13(20):3246. DOI: 10.3390/diagnostics13203246
50.HadiHA, Al-HailH, AboidrisLE, Al-OrphalyM, AhmedMAS, SamuelBG, MohamedHA, SultanAA, SkariahS. Prevalence and genetic characterization of clinically relevant extended-spectrum β-lactamase-producing enterobacterales in the Gulf Cooperation Council countries. Frontiers in Antibiotics. 2023;2:1177954. DOI: 10.3389/frabi.2023.1177954
51.BaciuAP, BaciuC, BaciuG, GurauG. The burden of antibiotic resistance of the main microorganisms causing infections in humans–Review of the literature. Journal of Medicine and Life. 2024;17(3):246. DOI: 10.25122/jml-2023-0404
52.Alaoui MdarhriH, BenmessaoudR, YacoubiH, SeffarL, Guennouni AssimiH, HamamM, BoussettineR, Filali-AnsariN, LahlouFA, DiawaraI, EnnajiMM. Alternative therapeutic approaches to conventional antibiotics: Advantages, limitations and potential application in medicine. Antibiotics. 2022;11(12):1826. DOI: 10.3390/antibiotics11121826
53.BartalC, RolstonKV, NesherL. Carbapenem-resistant Acinetobacter baumannii: Colonization, infection and current treatment options. Infectious Diseases and Therapy. 2022;11(2):683–694. DOI: 10.1007/s40121-022-00597-w
54.DendirG, AwokeN, AlemuA, SintayhuA, EangaS, TeshomeM, ZerfuM, TilaM, DessuBK, EfaAG, GashawA. Factors associated with the outcome of a pediatric patients admitted to intensive care unit in resource-limited setup: Cross-sectional study. Pediatric Health, Medicine and Therapeutics. 2023;14:71–79. DOI: 10.2147/PHMT.S389404
55.GajicI, KabicJ, KekicD, JovicevicM, MilenkovicM, Mitic CulaficD, TrudicA, RaninL, OpavskiN. Antimicrobial susceptibility testing: A comprehensive review of currently used methods. Antibiotics. 2022;11(4):427. DOI: 10.3390/antibiotics11040427
56.GiovagnorioF, De VitoA, MadedduG, ParisiSG, GeremiaN. Resistance in Pseudomonas aeruginosa: A narrative review of antibiogram interpretation and emerging treatments. Antibiotics. 2023;12(11):1621. DOI: 10.3390/antibiotics12111621
57.MaZ, LaiC, ZhangJ, HanY, XinM, WangJ, WuZ, LuoY. High mortality associated with inappropriate initial antibiotic therapy in hematological malignancies with Klebsiella pneumoniae bloodstream infections. Scientific Reports. 2024;14(1):13041. DOI: 10.1038/s41598-024-63864-5
58.MarinoA, AugelloE, BellancaCM, CosentinoF, StracquadanioS, La ViaL, ManiaciA, SpampinatoS, FaddaP, CantarellaG, BernardiniR, CacopardoB, NunnariG. Antibiotic therapy duration for multidrug-resistant gram-negative bacterial infections: An evidence-based review. International Journal of Molecular Sciences. 2025;26(14):6905. DOI: 10.3390/ijms26146905
59.BassettiM, KanjSS, KiratisinP, RodriguesC, Van DuinD, VillegasMV, YuY. Early appropriate diagnostics and treatment of MDR Gram-negative infections. JAC-Antimicrobial Resistance. 2022;4(5):dlac089. DOI: 10.1093/jacamr/dlac089
60.KongY, LiuT, ZhangY, WangH, LinH. Investigation of an outbreak of carbapenem resistant Acinetobacter baumannii in an intensive care unit during the COVID-19 epidemic. Antimicrobial Resistance and Infection Control. 2025;14(1):30. DOI: 10.1186/s13756-025-01547-0
61.SchinasG, PolyzouE, SpernovasilisN, GogosC, DimopoulosG, AkinosoglouK. Preventing multidrug-resistant bacterial transmission in the intensive care unit with a comprehensive approach: A policymaking manual. Antibiotics. 2023;12(8):1255. DOI: 10.3390/antibiotics12081255
62.WardhaniP. International Conference on Prevention and Infection Control 2023. Antimicrobial Resistance and Infection Control. 2023;12(1):81. DOI: 10.1186/s13756-023-01276-2
63.YekC, PachecoAR, VanaerschotM, BohlJA, FahsbenderE, Aranda-DíazA, LayS, CheaS, OumMH, LonC, TatoCM, ManningJE. Metagenomic pathogen sequencing in resource-scarce settings: Lessons learned and the road ahead. Frontiers in Epidemiology. 2022;2:926695. DOI: 10.3389/fepid.2022.926695
64.OuZJ, YuDF, LiangYH, HeWQ, LiYZ, MengYX, XiongHS, ZhangMY, HeH, GaoYH, WuF, ChenQ. Trends in burden of multidrug-resistant tuberculosis in countries, regions, and worldwide from 1990 to 2017: Results from the Global Burden of Disease Study. Infectious Diseases of Poverty. 2021;10(1):24. DOI: 10.1186/s40249-021-00803-w
65.NadăşGC, ManchonAM, BouariCM, FițNI. Veterinary clinics as reservoirs for Pseudomonas aeruginosa: A neglected pathway in one health surveillance. Antibiotics. 2025;14(7):720. DOI: 10.3390/antibiotics14070720
66.TerreniM, TaccaniM, PregnolatoM. New antibiotics for multidrug-resistant bacterial strains: Latest research developments and future perspectives. Molecules. 2021;26(9):2671. DOI: 10.3390/molecules26092671
67.BaronR, EilersR, HaverkateMR, FeenstraSG, TimenA. A qualitative study examining the impact of multidrug-resistant organism (MDRO) carriage on the daily lives of carriers and parents of carriers with experiences of hospital precautionary measures. Antimicrobial Resistance and Infection Control. 2022;11(1):103. DOI: 10.1186/s13756-022-01141-8
68.BaligaMS, LasradoS, KrishnaA, GeorgeT, MadathilLP, D’souzaRF, PalattyPL. Social, ethical and treatment related problems faced by healthcare workers in the care of head and neck cancer patients: A narrative review from the bioethics consortium from India. Indian Journal of Otolaryngology and Head & Neck Surgery. 2023;75(4):4137–4147. DOI: 10.1007/s12070-023-03738-w
69.BrüssowH. The antibiotic resistance crisis and the development of new antibiotics. Microbial Biotechnology. 2024;17(7):e14510. DOI: 10.1111/1751-7915.14510
70.AlaraJA, ORA. An overview of the global alarming increase of multiple drug resistant: A major challenge in clinical diagnosis. Infectious Disorders - Drug Targets. 2024;24(3):26–42. DOI: 10.2174/1871526523666230725103902
71.CookMA, WrightGD. The past, present, and future of antibiotics. Science Translational Medicine. 2022;14(657):eabo7793. DOI: 10.1126/scitranslmed.abo7793
72.MusaK, OkoliegbeI, AbdalazizT, AboushadyAT, StellingJ, GouldIM. Laboratory surveillance, quality management, and its role in addressing antimicrobial resistance in Africa: A narrative review. Antibiotics. 2023;12(8):1313. DOI: 10.3390/antibiotics12081313
73.MeckawyR, StucklerD, MehtaA, Al-AhdalT, DoebbelingBN. Effectiveness of early warning systems in the detection of infectious diseases outbreaks: A systematic review. BMC Public Health. 2022;22(1):2216. DOI: 10.1186/s12889-022-14625-4
74.DaowdRAA, AlgarniAM, AlmograbiMA, SaabSM, AlrashedNM, HarthiMM, QuilapioAFP, AlnajjarIN, MumtazSA, AlbusayyisRF, AljumaiahDA, AlsafamahY, AlmulhimHI. A retrospective longitudinal study on venous thromboembolisms: The impact of active monitoring on the venous thromboembolism management practices of healthcare providers to improve patient outcomes. Journal of Mind and Medical Sciences. 2025;12(1):12. DOI: 10.3390/jmms12010012
75.CollectionCLSI. Transport, and Processing of Clinical Specimens; Approved Guideline – M41. 2nd ed. Wayne, PA, USA: Clinical and Laboratory Standards Institute; 2014
76.CLSI. Protection of Laboratory Workers from Occupationally Acquired Infections – M29. 4th ed. Wayne, PA, USA: Clinical and Laboratory Standards Institute; 2014
77.CLSI. Principles and Procedures for Blood Cultures; Approved Guideline – M47. 2nd ed. Wayne, PA, USA: Clinical and Laboratory Standards Institute; 2017
78.CLSI. Performance Standards for Antimicrobial Susceptibility Testing – M100. 34th ed. Wayne, PA, USA: Clinical and Laboratory Standards Institute; 2024
79.MoradigaravandD, SenokA, Al-DabalL, KhansahebHH, HabousM, AlsuwaidiH, Alsheikh-AliA. Unveiling the dynamics of antimicrobial utilization and resistance in a large hospital network over five years: Insights from health record data analysis. PLOS Digital Health. 2023;2(12):e0000424. DOI: 10.1371/journal.pdig.0000424
80.BanerjeeR, PatelR. Molecular diagnostics for genotypic detection of antibiotic resistance: Current landscape and future directions. JAC-Antimicrobial Resistance. 2023;5(1):dlad018. DOI: 10.1093/jacamr/dlad018
81.ZerroukiH, RebiahiSA, HadjadjL, RolainJM, DieneSM. Real-time PCR assay for rapid and simultaneous detection of vanA and vanB genes in clinical strains. Diagnostics. 2021;11(11):2081. DOI: 10.3390/diagnostics11112081
82.SherryNL, GorrieCL, KwongJC, HiggsC, StuartRL, MarshallC, BallardSA, SaitM, KormanTM, SlavinMA, LeeRS. Multi-site implementation of whole genome sequencing for hospital infection control: A prospective genomic epidemiological analysis. The Lancet Regional Health - Western Pacific. 2022;23:100446. DOI: 10.1016/j.lanwpc.2022.100446
83.SunZ, LiuW, ZhangJ, WangS, YangF, FangY, JiangW, DingL, ZhaoH, ZhangY. The direct semi-quantitative detection of 18 pathogens and simultaneous screening for nine resistance genes in clinical urine samples by a high-throughput multiplex genetic detection system. Frontiers in Cellular and Infection Microbiology. 2021;11:660461. DOI: 10.3389/fcimb.2021.660461
84.StruelensMJ, LuddenC, WernerG, SintchenkoV, JokelainenP, IpM. Real-time genomic surveillance for enhanced control of infectious diseases and antimicrobial resistance. Frontiers in Science. 2024;2:1298248
85.UkuhorHO. The interrelationships between antimicrobial resistance, COVID-19, past, and future pandemics. Journal of Infection and Public Health. 2021;14(1):53–60
86.Saudi Ministry of Health. Health Electronic Surveillance Network. Available from: https://www.moh.gov.sa [Accessed: 2025-July-15]
87.Saudi Center for Disease Prevention and Control (SCDC). National Antimicrobial Resistance Surveillance Program. Available from: https://cdc.gov.sa [Accessed: 2025-July-15]
88.Al YousefSA. Surveillance of antibiotic-resistant bacteria in king khalid hospital, Hafr Al-Batin, Saudi Arabia, during 2013. Jundishapur Journal of Microbiology. 2016;9(9):e19552
89.BrekT, AlghamdiAK, AbujamelTS, YasirM, AlattasEM, HazaziMS, Al-ZahraniIA. Prevalence and molecular determinants of carbapenemase-producing Klebsiella pneumoniae isolated from Jazan, Saudi Arabia. Journal of Infection in Developing Countries. 2023;17(10):1420–1429. DOI: 10.3855/jidc.17662
90.TahaR, MowalladA, MuftiA, AlthaqafiA, Jiman-FataniAA, El-HossaryD, OssenkoppJ, AlhajHusseinB, KaakiM, JawiN, HassanienA, AlsaediA. Prevalence of carbapenem-resistant Enterobacteriaceae in Western Saudi Arabia and increasing trends in the antimicrobial resistance of Enterobacteriaceae. Cureus. 2023;15(2):e35050. DOI: 10.7759/cureus.35050
91.JalalNA, AlharbiM, AlotaibiF, et al.Prevalence and antibiogram pattern of Klebsiella pneumoniae in a tertiary care hospital in Makkah, Saudi Arabia: An 11-year experience. Antibiotics (Basel). 2023;12(1):164. DOI: 10.3390/antibiotics12010164
92.KharabaA, HusseinMA, Al-HameedFM, MandourahY, AlmekhlafiGA, AlgethamyH, HamdanA, AzeMA, FataniJ, Al BeshabsheA, AminY, DorsiH, Al HazmiA, AlMA, AlshaahranI, ArabiYM; The Saudi Critical Care Trial Group. Acinetobacter baumannii in Saudi Arabia: The new growing threat. Saudi Critical Care Journal. 2019;3(1):54–57. DOI: 10.4103/2543-1854.259469
93.Al-SultanAA. Prevalence of high-risk antibiotic-resistant Acinetobacter baumannii in the Holy Cities of Makkah and Al-Madinah. The Open Microbiology Journal. 2021;15:145–157. DOI: 10.2174/1874285802115010145
94.AlsaediA, SikeriS, YacobNM, AlmazroeaA. Impact of the accreditation program of the Saudi Central Board for Accreditation of Healthcare Institutions on the Safety Dimension of the Institute of Medicine Quality. Journal of Multidisciplinary Healthcare. 2023;16:1583–1596. DOI: 10.2147/JMDH.S410925
95.Ministry of Health (Saudi Arabia). National Guide for Auditors in Infection ControlAuditing Strategies for Healthcare Facilities, Version 6 (2025) [Accessed: 2025-July-22]
96.CBAHI.CBAHI Standards (overview page). Explains mandatory accreditation and the structure/process/outcome standard model with HAI outcome indicators [Accessed: 2025-July-22]
97.Al-SurimiK, NajjarS, Al QuidaihiA, MasuadiE. The impact of a national accreditation program on patient safety culture in a tertiary hospital: Pre- and post-evaluation study. Global Journal on Quality and Safety in Healthcare. 2021;5(4):18–26. DOI: 10.36401/JQSH-20-30
98.AlghamdiM, Al-JudaibiE, Al-RashedeM, Al-JudaibiA. comparative de novo and pan-genome analysis of MDR nosocomial bacteria isolated from hospitals in Jeddah, Saudi Arabia. Microorganisms. 2023;11(10):2432. DOI: 10.3390/microorganisms11102432
99.Al MansourA, MerryAF, JowseyT, WellerJM. Hospital accreditation processes in Saudi Arabia: Perceptions of managers in JCI-accredited hospitals. BMJ Open Quality. 2022;11:e001652. DOI: 10.1136/bmjoq-2021-001652
100.HartKM, StapletonF, CarntN, ArundelL, LianKY. Optometry Australia’s infection control guidelines 2020. Clinical and Experimental Optometry. 2021;104(3):267–284. DOI: 10.1080/08164622.2021.1887704
101.PetersA, SchmidMN, ParneixP, LebowitzD, de KrakerM, SauserJ, ZinggW, PittetD. Impact of environmental hygiene interventions on healthcare-associated infections and patient colonization: A systematic review. Antimicrobial Resistance and Infection Control. 2022;11(1):38. DOI: 10.1186/s13756-022-01075-1
102.DrossinosY, WeberTP, StilianakisNI. Droplets and aerosols: An artificial dichotomy in respiratory virus transmission. Health Science Reports. 2021;4(2):e275. DOI: 10.1002/hsr2.275
103.GaoCX, LiY, WeiJ, CottonS, HamiltonM, WangL, CowlingBJ. Multi-route respiratory infection: When a transmission route may dominate. Science of the Total Environment. 2020;752:141856. DOI: 10.1016/j.scitotenv.2020.141856
104.CarlsonE, ShayD, PontiacIL. Attachment# 2: Public comment submitted in writing. National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion. 2023;22:39
105.AbdurabuhA, HamidMD, Che HassanCR, FataniMI. Evaluating the impact of hospital accreditation on patient safety culture in Saudi Arabia healthcare facilities. Journal of Multidisciplinary Healthcare. 2024;17:5021–5033. DOI: 10.2147/JMDH.S480496
106.GastaldiS, FestaMG, NiedduA, ZavagnoG, CauE, BarbieriC, BeccariaE, D’AnconaF. Identification of essential contents and a standard framework for the development of an infection prevention and control manual for healthcare facilities: A scoping review. American Journal of Infection Control. 2024;52(3):358–364. DOI: 10.1016/j.ajic.2023.08.021
107.BaleTL, RamukumbaTS, MudauLS. Evaluation of compliance to the World Health Organization’s five moments of hand hygiene: Cross-sectional observation of healthcare professionals. Southern African Journal of Infectious Diseases. 2021;36(1):255. DOI: 10.4102/sajid.v36i1.255
108.CalzadaTR, VilaIR, BenitoCC. Suitability of referenced models for designing balanced scorecards in healthcare organizations. Journal of Industrial Engineering and Management. 2025;18(1):33–47. DOI: 10.3926/jiem.6793
109.DellitTH, OwensRC, McGowanJE, GerdingDN, WeinsteinRA, BurkeJP, HuskinsWC, PatersonDL, FishmanNO, CarpenterCF, BrennanPJ, BilleterM, HootonTM, Infectious Diseases Society of America, Society for Healthcare Epidemiology of America. IDSA and SHEA guidelines for developing an institutional program to enhance antimicrobial stewardship. Clinical Infectious Diseases. 2007;44(2):159–177. DOI: 10.1086/510393
110.OkeahialamCA, RabaanAA, BolhuisA. An evaluation of toxigenic Clostridioides difficile positivity as a patient outcome metric of antimicrobial stewardship in Saudi Arabia. Journal of Infection Prevention. 2021;22(5):231–236
111.WeberDJ, AndersonDJ, DJS, RutalaWA. Role of the environment in the transmission of Clostridium difficile in health care facilities. American Journal of Infection Control. 2013;41(5 Suppl):S105–S110. DOI: 10.1016/j.ajic.2012.12.009
112.DyarOJ, HuttnerB, SchoutenJ, PulciniC; ESCMID Study Group For Antimicrobial Stewardship. What is antimicrobial stewardship?Clinical Microbiology and Infection. 2017;23(11):793–798. DOI: 10.1016/j.cmi.2017.08.026
113.Morency-PotvinP, SchwartzDN, WeinsteinRA. Antimicrobial stewardship: How the microbiology laboratory can help clinicians. Clinical Microbiology Reviews. 2017;30(2):381–407. DOI: 10.1128/CMR.00066-16
114.DivechaCA, TulluMS, KarandeS. Challenges in implementing an antimicrobial stewardship program (ASP) in developing countries. Journal of Postgraduate Medicine. 2024;70(4):185–190. DOI: 10.4103/jpgm.jpgm_228_24
115.PradelliL, RisoliC, SummerE, BelliniG, MozzarelliF, AndersonG, GuasconiM, ArtioliG, BonacaroA, SarliL. Healthcare professional perspective on barriers and facilitators of multidisciplinary team working in acute care setting: A systematic review and meta-synthesis. BMJ Open. 2025;15(3):e087268. DOI: 10.1136/bmjopen-2024-087268
116.GoffDA, GauthierTP, LangfordBJ, PrusakovP, Ubaka ChukwuemkaM, NwomehBC, YunisKA, SaadT, van den BerghD, VillegasMV, MartinezN. Global resilience and new strategies needed for antimicrobial stewardship during the COVID‐19 pandemic and beyond. JACCP: Journal of the American College of Clinical Pharmacy. 2022;5(7):707–715. DOI: 10.1002/jac5.1622
117.DavisB, Bankhead-KendallBK, DumasRP. A review of COVID-19’s impact on modern medical systems from a health organization management perspective. Health and Technology. 2022;12(4):815–824. DOI: 10.1007/s12553-022-00660-z
118.Asante AntwiH, ZhouL, XuX, MustafaT. Beyond COVID-19 pandemic: An integrative review of global health crisis influencing the evolution and practice of corporate social responsibility. Healthcare. 2021;9(4):453. DOI: 10.3390/healthcare9040453
119.AlfouzanW, Al-BalushiZ, Al-MaslamaniM, Al-RashedA, Al-SabahS, Al-SalmanJ, BaguneidM, KhamisF, HabashyN, KurdiA, EckmannC. Antimicrobial management of complicated skin and soft tissue infections in an era of emerging multi-drug resistance: Perspectives from 5 gulf countries. Journal of Acute Care Surgery. 2021;11(3):89–101
120.AlsowaidaYS, ThabitAK, AlmangourTA, SalehKB, MahrousA, AlmutairiMS, AlshehailB, AljefriD, MohzariY, AlfahadW, AlmohaizeieA, EljaalyK. Infectious diseases pharmacy practice, education, and research in Saudi Arabia: A review and future perspectives by the Infectious Diseases Pharmacy Specialty Network at the Saudi Society of Clinical Pharmacy. Saudi Pharmaceutical Journal. 2022;30(12):1836–1843. DOI: 10.1016/j.jsps.2022.10.014
121.King Faisal Specialist Hospital & Research Centre. Available from: https://www.kfshrc.edu.sa/en [Accessed: 2025-July-22]
122.Abu EsbaLC, AlmodaimeghH, Ahmed KhanM, YousefCC, Al-AbdulkarimH, Al AklabiAA, AlHM. A formulary management group consensus. Global Journal on Quality and Safety in Healthcare. 2024;7(2):88–94. DOI: 10.36401/JQSH-23-26
123.King Saud Medical City. Available from: https://www.ksmc.med.sa/Portal/ [Accessed: 2025-July-22]
124.MüllerL, SrinivasanA, AbelesSR, RajagopalA, TorrianiFJ, Aronoff-SpencerE. A risk-based clinical decision support system for patient-specific antimicrobial therapy (iBiogram): Design and retrospective analysis. Journal of Medical Internet Research. 2021;23(12):e23571. DOI: 10.2196/23571
125.KaveriP. Aptamer Beacon-based Single-step Fluorescence Method for Rapid Detection of Bacteria and Antimicrobial Resistance. [thesis]. Loughborough: Loughborough University; 2021
126.KostGJ. Public health education should include point-of-care testing: Lessons learned from the Covid-19 pandemic. Ejifcc. 2021;32(3):311. Available from: https://pubmed.ncbi.nlm.nih.gov/34819821/ [Accessed: 2025-July-26]
127.ChuVH, editor. Advances in the Prevention and Management of Device-Associated Infections, an Issue of Infectious Disease Clinics of North America: Device-associated Infections, an Issue of Infectious Disease Clinics of North America. Amsterdam: Elsevier Health Sciences; 2024
128.BiswasSK, SumonMMH, AhmedS, RumaRA, ParvinA, PaulDK, RoyAK, TangSS. Beyond antibiotics: Exploring the potential of bacteriophages and phage therapy. PHAGE. 2024;5(4):186–202. DOI: 10.1089/phage.2024.0005
129.GholizadehO, GhalehHEG, TatM, RanjbarR, DorostkarR. The potential use of bacteriophages as antibacterial agents against Klebsiella pneumoniae. Virology Journal. 2024;21(1):191. DOI: 10.1186/s12985-024-02450-7
130.VernonJJ. Modulation of the human microbiome: Probiotics, prebiotics, and microbial transplants. In N.D-T, DengD, TD, editors. Oral Microbiome: Symbiosis, Dysbiosis and Microbiome Interventions for Maintaining Oral and Systemic Health. Cham: Springer; 2025. p. 277–294. DOI: 10.1007/978-3-031-79146-8_17
131.ZhouP, ChenC, PatilS, DongS. Unveiling the therapeutic symphony of probiotics, prebiotics, and postbiotics in gut-immune harmony. Frontiers in Nutrition. 2024;11:1355542. DOI: 10.3389/fnut.2024.1355542
133.IkpeAE, EkanemII, UdohVE. The role of mechanical ventilation systems and their applications in contemporary engineering practices. Optimality. 2024;1(2):262–275. DOI: 10.22105/opt.vi.58
134.ObeidatB, YounisMB, Al-ShloolEA. Investigations into the impact of nursing unit layout on critical care nurses. Heliyon. 2022;8(2):e08929. DOI: 10.1016/j.heliyon.2022.e08929
135.ScottR, JoshiLT, McGinnC. Hospital surface disinfection using ultraviolet germicidal irradiation technology: A review. Healthcare Technology Letters. 2022;9(3):25–33. DOI: 10.1049/htl2.12032
136.JahnLG, TangM, BlomdahlD, BhattacharyyaN, AbueP, NovoselacA, RuizLH, MisztalPK. Volatile organic compound (VOC) emissions from the usage of benzalkonium chloride and other disinfectants based on quaternary ammonium compounds. Environmental Science: Atmospheres. 2023;3(2):363–373. DOI: 10.1039/D2EA00054G
137.PatrickR, ForresterM, ThanekarU, GunasiriH, AnanthapavanJ, NaebeM, NaebeM, AllenderS. Reducing personal protective equipment waste in the emergency department of a large regional hospital: Codesign informed by system science. BMJ Public Health. 2024;2(2). DOI: 10.1136/bmjph-2023-000741
138.AljashamSA, AlrashedNS, HattanRAE, AlhejailiSM, AlhejailiSMH, EMA, AlabasAYA, AlshaiSY. Advanced smart sterilization systems integrating medical sterilization, sterilization technicians, and biomedical innovations for sustainable and safe healthcare solutions. Journal of International Crisis and Risk Communication Research. 2024;7(S4):1. DOI: 10.63278/jicrcr.vi.2466
139.AkanoOA, HansonE, NwakileC, EsiriAE. Integrating sustainability and safety in high-risk industries: A framework for balancing operational efficiency and environmental responsibility. Global Journal of Research in Multidisciplinary Studies. 2024;2(2):027–037. DOI: 10.58175/gjrms.2024.2.2.0052
140.WalshTR, GalesAC, LaxminarayanR, DoddPC. Antimicrobial resistance: Addressing a global threat to humanity. PLoS Medicine. 2023;20(7):e1004264. DOI: 10.1371/journal.pmed.1004264
141.LevML, BacharierLB, BatemanE, BouletLP, BrightlingC, BuhlR, BrusselleG, CruzAA, DrazenJM, DuijtsL, FlemingL. Key recommendations for primary care from the 2022 Global Initiative for Asthma (GINA) update. NPJ Primary Care Respiratory Medicine. 2023;33(1):7. DOI: 10.1038/s41533-023-00330-1
142.TorresA, NiedermanMS, KonOM. Infectious respiratory disease in the intensive care unit. The Lancet Respiratory Medicine. 2024;12(1):54–72
143.Martin-LoechesI, TorresA. Ventilator-associated pneumonia: Updated epidemiology and management strategies. Critical Care (London, England). 2023;27:120
144.KalilAC, MeterskyML, KlompasM, MuscedereJ, SweeneyDA, PalmerLB, NapolitanoLM, O’GradyNP, BartlettGJ, CarratalàJ, El SolhAA. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clinical Infectious Diseases. 2016;63(5)
145.RussellCD, GouldingJ, KermackLM, et al.Rapid molecular diagnostics for respiratory infections in critical care. Critical Care Medicine. 2023;51:521–533
146.De PascaleG, MontiniL, PennisiMA, et al.Multidrug-resistant Gram-negative infections in the ICU: Focus on ventilator-associated pneumonia. Journal of Antimicrobial Chemotherapy. 2024;79:432–446
147.BabaeiF, HemmatiF, ShokoohiM, et al.Carbapenem-resistant Acinetobacter baumannii causing ventilator-associated pneumonia: Clinical outcomes and resistance mechanisms. Microbial Drug Resistance. 2023;29:512–520
148.KlompasM. Prevention of ventilator-associated pneumonia and ventilator-associated events: An updated review. Clinics in Chest Medicine. 2023;44(3):455–472
149.PapazianL, CalfeeCS, ChastreJ, et al.Strategies for preventing ventilator-associated pneumonia in critical care. Intensive Care Medicine. 2023;49:987–1002
150.RodríguezAH, LisboaT, BarriosM, et al.Clinical utility of syndromic diagnostic panels for pneumonia in critically ill patients. Diagnostic Microbiology and Infectious Disease. 2024;108:115972
151.GiacobbeDR, BassettiM, De RosaFG, et al.Surveillance of multidrug-resistant pathogens in the ICU: Implications for ventilator-associated pneumonia management. Clinical Microbiology Reviews. 2022;35:e00014–22
152.TjandraKC, Ram-MohanN, AbeR, HashemiMM, LeeJH, ChinSM, RoshardtMA, LiaoJC, WongPK, YangS. Diagnosis of bloodstream infections: An evolution of technologies towards accurate and rapid identification and antibiotic susceptibility testing. Antibiotics. 2022;11(4):511. DOI: 10.3390/antibiotics11040511
153.ArdilaCM, González-ArroyaveD, TobónS. Machine learning for predicting antimicrobial resistance in critical and high-priority pathogens: A systematic review considering antimicrobial susceptibility tests in real-world healthcare settings. PLOS One. 2025;20(2):e0319460. DOI: 10.1371/journal.pone.0319460
154.LeivaditisV, ManiatopoulosAA, LausbergH, MulitaF, PapatriantafyllouA, LiolisE, BeltsiosE, AdamouA, KontodimopoulosN, DahmM. Artificial intelligence in thoracic surgery: A review bridging innovation and clinical practice for the next generation of surgical care. Journal of Clinical Medicine. 2025;14(8):2729
155.WinterJS, DavidsonE. Harmonizing regulatory regimes for the governance of patient-generated health data. Telecommunications Policy. 2022;46(5):102285. DOI: 10.1016/j.telpol.2021.10228
156.QuirósR, AraujoJS, MacchiA, Di LiberoE, TeruelM, de LimaACB, ZurawskiA, MeraJ. Strengthening Antimicrobial Stewardship Programs in Latin America through Telementoring: Results from the TEACH PROA-ECHO Initiative. 2025. p. 14. DOI: 10.2139/ssrn.5383897
157.ThangavelS, SharmilaK, SufinaK. Revolutionizing education through augmented reality (AR) and virtual reality (VR): Innovations, challenges and future prospects. challenges and future prospects. Asian Journal of Interdisciplinary Research. 2025;8(1). DOI: 10.54392/ajir2511
158.AslamB, AsgharR, MuzammilS, ShafiqueM, SiddiqueAB, KhurshidM, IjazM, RasoolMH, ChaudhryTH, AamirA, BalochZ. AMR and sustainable development goals: At a crossroads. Globalization and Health. 2024;20(1):73
159.FiguiéM, BatieC, MacuamuleC, CuinhaneC, GoutardF. AMR as a global and one health issue: The challenge to adapt a global strategy in two low‐and middle‐income countries, Mozambique and Vietnam. EuroChoices. 2024;23(2):72–77
160.AlatawiAD, HettaHF, AliMA, RamadanYN, AlaqyliAB, AlansariWK, AldhaheriNH, Bin SelimTA, MerdadSA, AlharbiMO, AlatawiWA. Diagnostic innovations to combat antibiotic resistance in critical care: Tools for targeted therapy and Stewardship. Diagnostics. 2025;15(17):2244
161.PennisiF, PintoA, RicciardiGE, SignorelliC, GianfrediV. The role of artificial intelligence and machine learning models in antimicrobial stewardship in public health: A narrative review. Antibiotics. 2025;14(2):134
162.AhmedA, ShahzadA, NaseemA, AliS, AhmadI. Evaluating the effectiveness of data governance frameworks in ensuring security and privacy of healthcare data: A quantitative analysis of ISO standards, GDPR, and HIPAA in blockchain technology. PLoS One. 2025;20(5):e0324285
163.MarutaT. Training of medical laboratory professionals in Africa region: A perspective of the practicing laboratory professionals. Texila International Journal of Academic Research. 2025;12(2)
164.JueraLC. Digitalizing skills development using simulation-based mobile (SiM) learning application. Journal of Computers in Education. 2024;11(1):29–50
Written By
Awatif A. Al-Judaibi
Submitted: 10 September 2025Reviewed: 09 December 2025Published: 04 March 2026
Open access peer-reviewed chapter - ONLINE FIRST
