# Metagenomic Analysis of Bacterial Diversity on Reusable Tourniquets in Hospital Environments
## 4 Discussion
### Key Findings and Departmental Variability
aeruginosa_ accounted for 6.9% of infections in the intensive care unit, including 11.5% of urinary tract infections [13]. _Enterococcus_ spp. was also identified as a causative agent of surgical site infections in the study by [PERSON] and [PERSON], accounting for 5.4% of cases, primarily following hip prosthesis implantation procedures [15]. _P. aeruginosa_ was also identified in neurosurgical patients by [PERSON] and [PERSON] in 2022 [14]. It accounted for 4% of all cases in that study and was primarily associated with surgical site infections [14]. In the presented study, _Klebsiella_ was detected in 5 out of 12 tourniquets. In the research conducted by [PERSON] and [PERSON] (2021), _Klebsiella pneumoniae_ was responsible for 16.3% of reported healthcare-associated infections (HAIs), primarily associated with urinary tract infections (UTIs) [13]. In the study by [PERSON] and [PERSON], _Klebsiella pneumoniae_ caused 10.8% of infections [15]. Additionally, in the 2022 study by [PERSON] and [PERSON], _Klebsiella_ accounted for 12% of infections, mainly postoperative wound infections and UTIs [14]. _Staphylococcus aureus_ was detected on only one tourniquet, and it was associated with skin and soft tissue infections in 42.8% of cases in studies conducted in the Polish ICU [12]. Among neurosurgical patients in a study conducted by [PERSON] and [PERSON] (2022), _Staphylococcus aureus_ was responsible for 11.5% of infections, primarily bloodstream infections and surgical site infections [14]. The presence of pathogens associated with healthcare-associated infections on tourniquets represents a significant challenge in the treatment of patients in Polish hospitals. Infections caused by these bacteria have been documented across various hospital departments and patient populations. A total of 12 bacterial species potentially capable of antibiotic resistance were identified on the surface of reusable tourniquets. These pathogens pose a significant risk, as they are resistant to multiple classes of antibiotics, complicating the treatment of healthcare-associated infections. The identified potentially antibiotic-resistant species include _Acinetobacter baumanniiii_, _Pseudomonas aeruginosa_, _Klebsiella pneumoniae_, _Enterococcus faecalis_, _Stentrophomonas maltophilis_, _Enterobacter quasihormaecchi_, _Acinetobacter lwoffii_, _Klebsiella varicola_, _Shewanella algae_, _Serratia liquefaciens_, _Serratia fonicola_, and _Staphylococcus aureus_. Additionally, 16 bacterial species capable of forming biofilms were identified on tourniquet surfaces. Biofilm formation is a significant survival strategy that enhances bacterial persistence and resistance to antimicrobial treatments, including disinfectants. Among them, _Acinetobacter baumannii_ can exhibit resistance to carbapenems (e.g., impenem, meropenem), cephalosporporins (e.g., ceftrixone), aminoglycos (e.g., gentamicin), fluoroquinolones (e.g., ciprofloxacin), tetracyclines, and sometimes polymyxins, making it challenging to treat with conventional antibiotics. Additionally, _A. buumani_ forms robust biofilms on surfaces, which increase its resistance to disinfectants and its ability to survive on medical devices. It is also known to survive on dry surfaces, such as medical tourniquets, for extended periods [16]. _Pseudomonas aeruginosa_ is known for resistance to carbapenems (e.g., meropenem), aminoglycosides, cephalosporporins, fluoroquinolones, and occasionally polymyxins, due to its intrinsic and acquired resistance mechanisms. It forms biofilms, complicating removal through standard cleaning protocols, and can survive in both moist and dry environments, making it a persistent contaminant on medical equipment [17]. _Klebsiella pneumoniae_ produces extended-spectrum beta-lactamases (ESBLs) and carbapenemases, resulting in resistance to beta-lactam antibiotics, including cephalosporporins and carbapenems. Additionally, resistance to aminoglycosides may occur via other mechanisms, such as the presence of the _armA_ gene [18].