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1.1 General introduction
The term nosocomial infection or hospital-acquired infection is applied to any clinical infection that was neither present nor was in its incubation period when the patient entered the hospital. Nosocomial infections may also make their appearance after discharge from the hospital, if the patient was in the incubation period at the time of discharge. Hospital infections are more frequent and generally, more severe in newborn infants than in older children or adults. The peculiar characteristics of this period of life allow for greater susceptibility to infections. In addition, another factor responsible for infections being more severe in these patients is the increased survival of premature newborn infants, following prolonged neonatal ICU stay, use of invasive procedures and of wide spectrum antimicrobials. Infections are the most common complication affecting hospital patients. The prevention and control of neonatal bacterial infections represent a challenge for all professionals involved in hospital care of newborns. Infection outbreaks in nurseries and that result in deaths have been widely reported by the Brazilian press. In other countries, hospital infections are associated with 7 to 73% of neonatal mortality (Stoll et al., 1997) .Neonatal hospital infections, in addition to being the cause of a significant number of perinatal, neonatal, and postnatal deaths, are also associated with increased health care costs. This is because hospitalization of infected children is up to threefold longer than that of non infected children. It is our objective to review the main aspects of this broad theme.The presence of normal flora and of mildly virulent microorganisms protects the neonate from potentially pathogenic microorganisms, such as gram negative bacillus.That is because the microorganisms in the normal flora spread to different sites and compete with pathogenic organisms, but rarely causing disease.Infections, which are the invasion by a microorganism that multiplies and causes lesions, usually occur as a direct extension of the sites of colonization or of bloodstream infection with the resulting dissemination of the infection. Infections also depend on the virulence of the microorganism, of the inoculums, and of the pathogen-host interaction. In most cases, the pathogens invade the newborn through the conjunctive, the respiratory and gastrointestinal tracts, and the skin.The decreased production and function of local and systemic defense (of both innate and specific responses) depend on the antigen and contribute to greater susceptibility to infection during the neonatal period ( Wilson et al., 1999). That is the reason for local natural barriers against bacterial infections being compromised in newborn infants.
The skin, and especially that of preterm newborn infants, is immature and has increased permeability, which is partially caused by the production of free fatty acids and alkaline pH. Moreover, skin integrity can be affected by environmental aggressions. The umbilical chord can be another source of infection due to is proximity to the bloodstream, to the increased permeability, and to the potential colonization by pathogens (Wilson et al.,1986).Also, the production of secretory immunoglobin A is absent during the first days of life; thus, the respiratory and gastrointestinal epithelium are more vulnerable (Quie et al.,1990). The lack of innate immune response (granulocytes, mononuclear phagocytes, and humoral factors such as the complement, fibronectin, and colectin), which is activated in the first hours or days of contact with microbes, plays a critical role in the susceptibility to infection by pyogenic bacteria and fungi. The antigen-specific response, in turn, does not develop until 5 to 7 days after the initial exposure to microorganisms. In general, in newborn infants, the ability to accelerate production of neutrophils as a response to infection is restricted, the chemotaxy of neutrophils is decreased as a response to a variety of stimuli, and these cells are less adherent, deformable, and survive less (Carr et al.,2000). As to what concerns the mononuclear phagocytes, despite the delayed and attenuated inflow of these cells to the site of inflammation, some studies have suggested that newborns present microbicidal activity against certain bacteria that is similar to that of adults.
The immature innate response of newborns is partially compensated by transplacental transfer of immunoglobin G from the mother. The specific antibodies acquired from the mother, in this sense, can promote more efficient opsonization and phagocytosis. However, the absence of type-specific antibodies acquired from the mother can be a predisposing factor to infection by certain agents independently of the production of antibodies by the newborn infant (Christensen et al.,1985).The ability to respond to specific antigens develops chronologically and in a distinct manner provided that the response occurs independently of the help of T lymphocytes, or that this help is necessary. With the exception of polysaccharide antigens, the response to most specific antigens is dependent on T cells. In newborn infants, the production of antibodies by the lymphocytes B and thymus dependent antigens is similar to that of adults (Tucci et al., 1991). Considering that many pyogenic bacteria are capsulated and, consequently, the response is thymus-independent, the production of antibodies by newborns will be limited and contribute to greater susceptibility.
1.2 Definition of Nosocomial infection
Nosocomial infection was considered to be present if onset of infection was beyond 48 h of life with either (a) culture of sterile body fluids (blood, CSF, urine) yielding a recognized bacterial pathogen; (b) a tracheal aspirate culture yielding a pure growth of known bacterial pathogen in a neonate on ventilatory support with respiratory deterioration and radiographic pneumonia, or (c) clinical examination revealing a soft tissue infection.
Neonates who had clinical features suggestive of infection appearing after 48 h of birth but not yielding bacterial pathogens on culture of body fluids or tracheal aspirate were defined as having nosocomial infection if they had a positive sepsis screen. All neonates suspected to have sepsis were screened by total leukocyte count (abnormal- <5000/cumm or >20,000/cumm), immature/total polymorphs (abnormal- >0.2), micro- ESR (abnormal >10 mm 1st h) and C-Reactive Protein (CRP).
1.3 Sourses of infection
The source of the infecting organism may be exogenous - from another patient or a member of the hospital staff, or from the inanimate environment in the hospital; or it may be endogenous from the patients own flora which at the time of infection may include organisms brought into the hospital at admission and certain others acquired subsequently. In either case, the infecting organisms may spontaneously invade the tissues of the patient or may be introduced into them by surgical procedures, instrumental manipulation or nursing procedures. The inanimate environment of the hospital that acts as an important source comprises of:
(a) Contaminated air, water, food and medicaments
(b) Used equipments and instruments
(c) Soiled linen
(d) Hospital waste (Biomedical waste)
For an infection to occur in the hospital the prerequisites are:
- A susceptible host.
- A microbe capable of producing an infection.
- An environment that is congenial for the multiplication of the microbe.
It is the delicate interplay of these 3 components that ultimately culminates in the occurrence of an infection.
Also, various combinations of four main factors influence the nature and frequency of infections. These are:
(a) Low resistance of the patients
(b) Contact with infectious persons
(c) Contaminated environmental sites
(d) Drug resistance of endemic organisms
1.4 Acquiring microorganisms and the predisposing factors for infection
The main pathways for acquiring microorganisms that can cause infections are airborne transmission; direct contact. (direct physical transmission from an infected or colonized person to a host by the hands or secretions) ( Guenthner et al.,1987).Indirect contact (physical transmission from inanimate objects such as transducers, thermometers, stethoscopes, manometers, suction catheters, and water); ( Vanden et al.,2000) common conveyors (contaminated fluids, IV solutions, milk, blood, and derivatives) and by vectors (flies and cockroaches).The exposure to these sources will contribute to the establishing of an endogenous flora of the newborn; in other words, bacterial colonization of the skin, the mucosa, and the gastrointestinal and respiratory tracts that, in turn, are also frequently the source of microorganisms that cause infection. Infections originated by the patient’s own reservoirs are classified as of endogenous transmission.The main risk factors for infection of newborns can be divided into intrinsic and extrinsic factors. The intrinsic factors include characteristics such as gestational age, sex, birth weight, severity of the disease, and immunologic development ( Gaynes et al.,1996). The extrinsic factors include hospital stay; use of invasive procedures, such as arterial and venous catheters, tracheal cannulas, gastric or gastric-duodenal probe, ventriculo-peritoneal shunt, chest drains, and so on;( Stoll et al.,1996) exposure to hospital environment and staff, such as nurse: patient ratio and physical space (overcrowding and understaffing), staff training, hygiene and hospital infection control techniques.( Harbarth et al.,1999) and use of antimicrobials. In general, newborn infants presenting good clinical status have a short hospital stay and are not submitted to invasive procedures. In this sense, the exposure to hospital staff is the most important risk factor for these patients (Parvez et al.,1999). Conversely, newborn infants admitted to neonatal ICUs have prolonged hospital stay, and frequent exposure to invasive procedures and to a great number of people responsible for the care of the baby. The care of these newborns involves frequent use of the hands. In general, low weight at birth is the most influential factor for hospital infections. The predisposition to infection in these neonates is due to a combination of several risk factors as a consequence of immature immune defenses and of the use of life support systems, in the sense that the latter promotes breakdown of the normal defense barriers. These systems submit the newborn to use of endotracheal cannulas andmechanical ventilators, which interfere on local pulmonary defenses; to use of catheters that allow for spreading of microorganisms from the cutaneous flora into the bloodstream to the use of mechanisms that reduce gastric acidity, such as H2 blockers, parenteral hyperalimentation and to prolonged and frequent use of
1.5 Colonization, infection, and mechanisms of defense in newborn
Colonization is the presence of a microorganism in or on a host, with growth and multiplication but without any overt clinical expression or detected immune response in the host at the time it is isolated (Jarvis et al.,1996). A developing fetus is protected from the microbial flora of the genital tract of the mother. Normal colonization in newborns and of the placenta begins during the birth process, after rupture of the amniotic membrane and through subsequent contacts with the inanimate or animate environments until a delicately balanced normal flora is established; subsequently, the precise components of a neonatal endogenous flora evolve. Many factors can influence the acquisition of neonatal flora: maternal genital flora; type of nutrition of the newborn ;( Yoshioka et al.,1883) hospital staff and people in direct contact with the newborn; and environment, including the flora of objects and other newborns.(Goldman et al.,1988) In general, newborns that remain in contact with the mother and are naturally breastfed can be colonized on the skin and mucous surfaces (nasopharynx, oropharynx, conjunctive, umbilical chord, external genitalia) several days after birth. The main microorganisms, in this sense, are alpha hemolytic Streptococcus, negative-coagulase Staphylococcus (skin, upper respiratory mucosa, umbilical stump), lactobacillus, other anaerobic microorganisms, and E. Coli (gastrointestinal tract). Other common bacteria are Candida albicans (gastrointestinal tract, vagina, perineal area) and Staphylococcus aureus (skin and mucous surface).
1.6 Etiology
The microorganisms that cause hospital infections include bacteria, fungi, and virus; it is also possible to include all commensal pathogens and organisms of humans. In normal nurseries, the Staphylococcus aureus, the enteropathogens and the respiratory virus are the main infection agents. At high-risk nurseries, there is a broad spectrum of infection agents that includes microorganisms normally nonpathogenic for term newborns, such as negative-coagulase staphylococci and Candida.(Gayners et al.,1996). In the assessment of the etiology of neonatal hospital infections it is important to consider that it also depends on birth weight; on characteristics of the unit; on use of invasive procedures; on maternal or nonmaternal origin of the infection; and on temporal evolution of etiological agents in the unit. It is fundamental that each institution register the microbiological ecology of its units through epidemiological surveillance.
Gram positive bacteria
The Staphylococcus is the main gram-positive infection agent of hospital infections of the newborn; the most important being negative-coagulase Staphylococci such as Staphylococcus epidermidis, which frequently affects low birth weight newborns with prolonged hospital stay, venous catheter, and administration of parenteral lipids. Bloodstream is the most frequent pathway of infection, presenting nonspecific and difficult to diagnose signs. This type of infection can, also, cause focal infections.( Hall et al.,1991). Considering that the referred agents are a part of the normal cutaneous flora, they can also contaminate hemocultures. Thus, the diagnosis after isolation of the agents becomes more difficult. Confirmed diagnosis of bloodstream infection follows criteria of resistance to at least six antimicrobial agents, since most strains are resistant to oxacillin ( Hwerwaldt et al.,1996). The Staphylococcus aureus is also a concern for most nurseries around the world. The Enterococcus spp can be acquired by the mother, but it is turning into a prevalent agent in nosocomial infections. The most common source of infection is the gastrointestinal tract of the newborn. There is also possibility of colonization of the mouth, respiratory tract, cutaneous lesions, and of contamination by objects and surfaces of the environment.( Boyce et al.,1997).These infections can be severe and include: necrotizing enterocolitis, sepsis, pneumonia, meningitis, and endocarditis.
Gram negative bacteria
Gram-negative bacteria are the cause of approximately 19% of cases of nosocomial sepsis, and of over 30% of pneumonias.These infections are severe and present high lethality rates (40 to 90%). Nonmaternal strains of Escherichia Coli (other patients or environment) can cause invasive diseases.(Dekema et al.,1997) The main reservoir of Klebsiela and Enterobacter are the gastrointestinal tract of the patient, invasive procedures, and catheters. Several gram-negative bacillus have been associated with outbreaks of hospital infections at neonatal units, especially those associated with environmental contamination, such as: Pseudomonas aeruginosa,(Muyldermans et al.,1998). Serratia marcencens,(Berthelet et al.,1999), Acinetobacter spp,( Mcdonald et al.,1998), Stenotrophomonas maltophilia( Verweij et al .,1998) among others.
Fungi
Similarly to infections by gram-negative bacteria, those by fungi are increasingly prevalent in neonatal units. These infections are associated with prolonged exposure to antibiotics, with parenteral hyperalimentation, with tracheal intubation, and with IV infusion of lipids.( Saiman et al.,2000). Different Candida strains (albicans, tropicalis, and parapsilosis) account for most hospital infections. The most common presentation is fungemia. However, the fungi can spread and cause meningitis, spleen or kidney abscess, endophtalmitis, Osteomyelitis or invasive dermatitis with mortality rates as high as 25 to 50% (Saxen et al.,1995).
Virus
Despite the fact that they are usually not identified, viral nosocomial infections are very common. Hospital staff, family members, and other infected patients represent the main conveyors of viral infections in neonatal units. The most frequent viral nosocomial infections are caused by respiratory syncytial virus and by rotavirus. Nosocomial transmission of respiratory syncytial virus can result in increased morbidity and mortality for all infected newborns, but especially for premature newborns, with congenital cardiac disease or associated pulmonary conditions, and for post surgical patients.( Langley et al.,1997).
1.7 Infection site
Infections of term newborns and at normal nurseries are primarily cutaneous and of soft tissues, including omphalitis, pocks, abscess, and bullous impetigo. Outbreaks of conjunctivitis and bacterial or viral gastroenteritis can spread very rapidly in these nurseries.(Maguire et al.,1981) In the case of neonatal ICUs, bacteremia and sepsis are the most frequent infections and account for 30 to 50% of hospital infections; these infections are followed by pneumonia; eye, ear, nose, and throat infections; skin and soft tissue infections; and gastrointestinal and surgical site infections. There are variations in these sites of infection according to weight at birth and to the characteristics of the Unit.
1.7.1 Urinary infection
This is the most common nosocomial infection; 80% of infections are associated with the use of an indwelling bladder catheter.Urinary infections are associated with less morbidity than other nosocomial infections, but can occasionally lead to bacteraemia and death. Infections are usually defined by microbiological criteria: positive quantitative urine culture (≥105 microorganisms/ml, with a maximum of 2 isolated microbial species). The bacteria responsible arise from the gut flora, either normal (Escherichia coli) or acquired in hospital (multiresistant Klebsiella).
1.7.2 Surgical site infections
Surgical site infections are also frequent: the incidence varies from 0.5 to 15% depending on the type of operation and underlying patient status .The impact on hospital costs and postoperative length of stay (between 3 and 20 additional days) is considerable. The definition is mainly clinical: purulent discharge around the wound or the insertion site of the drain, or spreading cellulitis from the wound. Infections of the surgical wound (whether above or below the aponeurosis), and deep infections of organs or immunocompromised patients, Legionella spp. And Aspergillus pneumonia may occur. In countries with a high prevalence of tuberculosis, particularly multiresistant strains, transmission in health care settings may be an important problem.
1.7.3 Nosocomial pneumonia
Nosocomial pneumonia occurs in several different patient groups. The most important are patients on ventilators in intensive care units, where the rate of pneumonia is 3% per day. Microorganisms colonize the stomach, upper airway and bronchi, and cause infection in the lungs (pneumonia): they are often endogenous (digestive system or nose and throat), but may be exogenous, often from contaminated respiratory equipment. The definition of pneumonia may be based on clinical and radiological criteria which are readily available but non-specific: recent and progressive radiological opacities of the pulmonary parenchyma, purulent sputum, and recent onset of fever.Apart from ventilator-associated pneumonia, patients with seizures or decreased level of consciousness are at risk for nosocomial infection, even if not intubated. Viral bronchiolitis (respiratory syncytial virus, RSV) is common in children’s units.
1.7.4 Other nosocomial infections
These are the four most frequent and important nosocomial infections, but there are many other potential sites of infection. For example:
- Skin and soft tissue infections: open sores (ulcers,burns and bedsores) encourage bacterial colonizationand may lead to systemic infection.
- Gastroenteritis is the most common nosocomial infection in children, where rotavirus is a chief pathogen: Clostridium difficile is the major cause of nosocomial gastroenteritis in adults in developed countries.
- Sinusitis and other enteric infections, infections of the eye and conjunctiva.
- Endometritis and other infections of the reproductive organs following childbirth.
1.8 Significance of the study
Neonatal nosocomial infection is now a very common infection among neonate .If it is not properly treated and managed it will turn a dangerous way. Those are neonate today will be the future generation and take the responsibility of our country ,they will be the asset of our country .Lack of proper knowledge of health personnel specially staff nurse’s to prevent and control neonatal nosocomial infection makes the neonatal morbidity and mortality rate so high. Without proper knowledge they can not managed the neonate properly .Every patient have the right to get quality nursing care. If we can know the knowledge level of the staff nurse then we can arrange proper training and many other things which will improve their knowledge level and also improve our profession. The aim of this study to assess the knowledge and practice of staff nurse’s about how to prevent and control neonatal nosocomial infection and to ensure quality care. The result of this study can help to identify the lack of knowledge and practice among staff nurse’s, that might help the authority or Government to take effective step for improving the quality of care to protect our future asset(neonate) from unwanted harm as well as to ensure the quality care and prevent and control this neonatal nosocomial infection.
1.9 Objectives of the study
1.9.1 General objectives
This study will be carried out with a view to assess the nurse’s knowledge and observe their practice to prevent and control neonatal nosocomial infection in maternal and neonatal unit at Rajshahi Medical College Hospital.
1.9.2 Specific objectives
a) To assess the nurse’s knowledge and observe their practice regarding neonatal nosocomial infection.
b) To identify their knowledge level about spread of neonatal nosocomial infection.
c) To find out nurse’s knowledge about risk factor of neonatal nosocomial infection.
d) To investigate the nurse’s knowledge in relation to current international and national policies regarding neonatal nosocomial infection.
e) To examine the nurse’s knowledge about prevention and control of neonatal nosocomial infection
1.10 Research Question
Are the nurse’s knowledgeable and practicable to prevent and control of neonatal nosocomial infection?
1.11 Variables
1.11.1 Independent variables
- Age
- Gender
- Marital status
- Religion
- Academic qualification
- Professional qualification
- Specialization course
- Length of service
1.11.2 Dependent variables
- Prevention and control of neonatal nosocomial infection.
- Attitudes towards neonates care (sincerity, sympathy, co-operation)
1.12 Operational definitions
1.12.1 Nurse
A nurse is a highly skilled health care professional who combines the art of caring with scientific knowledge and skills developed through their education and career.
1.12.2 Knowledge
Information and skills acquired through experience or education; the theoretical or practical understanding of a subject.
1.12.3 Practice
The actual application or use of an idea, belief, or method as opposed to theories about such application or use.
1.12.4 Prevention
Prevention is creating condition that promotes good health and it is achieved by reducing those factors that are known to cause illness and problem behaviors (risk factors) and encouraging those factors that buffer individuals and promote good health ( protective factors) .
1.12.5 Control
The power to influence or direct people's behavior or the course of events.
1.12.6 Neonate
An infant less than four weeks
1.12.7 Nosocomial infection
An infection acquired in hospital by a patient who was admitted for a reason other than that infection.
CONTENTS
Abstract
Chapter 1
1. INTRODUCTION
1.1 General Introduction
1.2 Definition of nosocomial infection
1.3 Sources of infection
1.4 Acquiring microorganisms and the predisposing factors for infection
1.5 Colonization, infection and mechanism of defense in newborns
1.6 Etiology
1.7 Infection site
1.8 Significance of the study
1.9 Objectives of the study
1.10 Research question
1.11 Variables
1.12 Operational definition
Chapter 2
2. REVIEW OF LITERATURE
Chapter 3
3. MATERIALS AND METHODS
3.1 Design of the study
3.2 Study population
3.3 Study place
3.4 Sample size, sampling and duration
3.5 Research instrument for data collection
3.6 Data collection Procedure
3.6 Data analysis
Chapter 4
4. RESULTS
Chapter 5
5. DISCUSSION
Chapter 6
6. CONCLUSION
Chapter 7
7. REFERENCES
Chapter 8
8. APPENDICES
List of Tables
Table 1: Demographic information of the participated nurses in the Rajshahi Medical College Hospital
Table 2: Information regarding knowledge of the participated nurses regarding prevention and control of neonatal nosocomial infection
Table 3: Demographic information of the neonates and attending parents
Table 4: Practice of the participated nurses in the Rajshahi Medical College Hospital
List of Figure
Figure 1: Distribution of the neonates age
Figure 2: Distribution of the respondent by their religion
Figure 3: Distribution of the respondent according to their knowledge level by yes/no question
Figure 4: Distribution of the respondent according to their knowledge level
Figure 5: Percentage of the level of practice in the ward by the Nurse
Thesis, Nurses, Knowledge, Practice, Prevent, Control, Neonatal, Nosocomial, Infection, Maternal, Neonatal, Units, Rajshahi, Medical, Nursing, College, Hospital
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