# Exposure and Health Effects of Bacteria in Healthcare Units: An Overview
## 4 Discussion
Osteoarthicular infections can occur by the direct inoculation of microorganisms into tissues due to penetrating or open trauma [69]. In limited settings, infections complicate as many as 44% of open fractures [69]. Trauma-related osteoarthicular infections among patients with punctures wounds seeking medical care varied from 2-60% depending on the type of the injury [70; 71; 72]. _S. aureus_ was also prevalent in the studies by [PERSON] et al. [38] and [PERSON] et al. [73], being detected on door handles, which could be considered a possible source of nosocomial infection [38]. Additionally, _Staphylococcus epidermidis_, as well as _Microoccus luteus_ and _Bacillus subtilis_, were common in the studies by [PERSON] et al. [50],[PERSON] et al. [74], and [PERSON] et al. [39]. The reason for these results could be related to the presence of these bacteria in the skin, mucous membranes, hair of human beings and animals [75; 76; 77; 78]. Considering health effects, the identification of _Clostridium difficile_, a Gram-positive, anaerobic, spore-forming bacillus, must be considered, as it is the principal agent of pseudomenbanous colitis in humans [79]. In the hospital setting, _C. difficile_ infection is the main cause of healthcare-associated diarrhea [80]. Symptoms arise when _C. difficile_ spores germinate in the intestine, and the bacteria start to produce toxins, Toxin A (TcdA) and Toxin B (TcdB), causing the inflammation of the large intestine [81]. The clinical presentation can range from mild diarrhea to lethal toxic megacolon [81]. Nonetheless, the ingestion of _C. difficile_ spores does not always lead to the development of symptomatic disease, since this bacterium can be silently present in the intestine without manifesting any symptoms, denominated as asymptomatic _C. difficile_ colonization [82]. However, the patients with this condition act as a reservoir for further transmissions [83; 84], and they can progress to the infection themselves, especially if they are affected by an underlying illness [85]. The infection is transmitted by spores that are environmentally resistant [86]. Another microorganism of interest is _H. pylori_, which is associated with occupational exposure among endoscopy personnel [87]. The study by [PERSON] et al. [40] aimed to determine if different staff groups of healthcare workers, either with or without direct patient contact, were at equal risk of acquiring _H. pylori_ infection. The authors concluded that direct contact with patients is an important factor for becoming infected, as opposed to simply working in the endoscopy unit. Another study highlighted [87] that 24% (9 out of 37) of gastrointestinal endoscopy personnel, and 47% (33 out of 70) of workers in a hospital who care for disabled individuals, tested positive for _H. pylori_. In this case, direct contact with patients and working in a hospital where disabled individuals reside was associated with _H. pylori_ infections, but the exposure to gastrointestinal secretions of the patients was not [87]. This study supports the previous study's idea that direct contact with patients is a factor to take into consideration. Among Gram-negative bacteria, the most frequently identified pathogens are _Escherichia coli_, _Klebsiella pneumoniae_, _Pseudomonas aeruginosa_, and _Actinobacter baumaniii_. _E.coli_ was described to be prevalent in operating beds due to fecal contamination and the lack of efficiency in the cleaning process [88; 89]. _Pseudomonas_ spp., one of the most significant genera of nosocomial pathogens, was the most prevalent bacteria in all operating theatres in the [PERSON] et al. study [38], and was identified in other studies [73; 90] that referred to antiseptic solutions as a possible source of this contamination [56; 57; 91; 92]. Other bacteria, _Bacillus_ spp., can be related to dusty environments, the type commonly found in Uganda [38]. This contamination might occur in indoor areas if the windows are open for natural ventilation and could then be transferred to the operating theatres [73]. Furthermore, _A.