ABSTRACT
Bacterial contamination of the labour and delivery room is of clinical concern because it is one of the major risk factors of sepsis in neonates and most life threatening nosocomial infections for mothers after undergoing childbirth procedures. Three hundred (300) consecutive samples were collected from fomites and anterior nares of the health care workers from six (6) different Primary Health Centres (PHCs). These were screened for the presence of bacterial pathogens. Preliminary identification of bacteria isolates were performed based on gram stain reactions, colony characteristics of the organisms like hemolysis on blood agar, changes in physical appearance in differential media and enzyme activities of the organisms. Antibiotic susceptibility testing was done by using Kirby-Bauer disc diffusion technique. The isolates of clinical importance observed were Staphylococcus aureus (35.1%), Bacillus spp.(15.5%) Streptococcus spp. (14.8%), E. coli (10.1%), Coagulase Negative Staphylococcus (CONS) spp. (8.1%), Proteus spp. (7.4%), Pseudomonas aeruginosa (5.4%), ,Klebsiella spp.(1.3%). Eight (8) antibiotics used against S.aureus which was the most prevalent isolate showed below 50% sensitivity and almost the same with E.coli. High level resistance to commonly prescribed and administered antibiotics such as amoxicillin clavulanate, penicillin, amoxicillin, ampicllin, cefalexin and cotrimoxazole was observed. The percentage of Extended Spectrum Beta-lactamase (ESBL) among E coli isolates was 64.2%, and the least was Pseudomonas aeruginosa (14.2%). Percentages of biofilm forming organisms are S aureus(39.3%), and the least was klebsiella spp(1.0%).The plasmid profile of 15 resistant isolates was studied and the study revealed that 3 isolates had plasmids. The types of bacteria most frequently isolated were consistent with the isolates which could cause nosocomial infections. Constant disinfection of surfaces and items under a strict infection control policy will check the transmission of infectious agents from these fomites.
TABLE OF CONTENTS
Cover
Page
Title
Page i
Declaration ii
Certification iii
Dedication iv
Acknowledgements
v
Table
of Contents vi
List
of Table ix
List
of Figure x
Abstract
xi
CHAPTER
I: INTRODUCTION 1
1.1. Why do These Deaths
Occur 4
1.2. Statement of the Problem 11
1.3. Aims and Objectives
of the Study 12
CHAPTER
2: LITERATURE
REWIEW 14
2.1. Nigerian Maternity
Wards and Infections 14
2.2.
Nosocomial Infections 17
2.3.
Epidemiology of Nosocomial Infections 18
2.3.1.
Endogenous infection, self-infection, or auto-infection. 22
2.3.2. Cross-contamination followed by
cross-infection. 22
2.3.3.
The transition from contamination to infection. 23
2.4.
The Sources of Infection 24
2.5.
The Routes of Transmission 25
2.6.
Sepsis in the Maternity Setting
26
2.7.
Some Hospital Pathogens related with Hospital Environment 28
CHAPTER
3: MATERIALS AND METHODS 36
3.1.
Study Design
36
3.2.
Study Area and Health Facility Selection 36
3.3. Sample Collection 37
3.4.
Specimen Processing 37
3.5.
Media Preparation 38
3.6.
Gram staining Technique 38
3.7.
Total viable count 39
3.8.
Isolation and Identification of Bacteria 39
3.9.
Biochemical Tests 39
3.9.1.
Catalase test 40
3.9.2.
Coagulase test 40
3.9.3.
Oxidase test 40
3.9.4. Indole test 41
3.9.5.
Citrate utilization 41
3.9.6.
Motility test 41
3.9.7.
Sugar fermentation 42
3.10. Antibiotic
Susceptibility Test 42
3.11. Determination of
Multiple Antibiotic Resistance (MARI) Index 42
3.12.
Biofilm Production 43
3.13.
Extended Spectrum Beta-Lactamase (ESBL) Producers Screening and
Confirmation 43
3.14. Plasmid Extraction
(Alkaline lysis Method) 44
3.15.
Plasmid Analysis 45
3.16. Plasmid Curing 45
CHAPTER
4: RESULTS AND DISCUSSION 46
4.1. Results 46
4.2. Discussion 67
CHAPTER
5: CONCLUSION AND RECOMMENDATIONS 71
5.1. Conclusion 71
5.2. Recommendations 72
REFERENCES
LIST OF TABLES
4.1: Percentage and types
of Bacterial Isolates from the study 50
4.2: Frequency and Types of Bacterial Isolates from
Fomites in PHC 51
4.3: Frequency and Types of Bacterial Isolates from
Fomites in PHC 2 52
4.4: Frequency and Types of Bacterial Isolates from
Fomites in PHC 3 53
4.5: Frequency and Types
of Bacterial Isolates from Fomites in PHC 4
54
4.6: Frequency and Types
of Bacterial Isolates from Fomites in PHC 5
55
4.7: Frequency and Types
of Bacterial Isolates from Fomites in PHC 6
56
4.8: Total Distribution
Pattern of The Bacterial Isolates from Fomites
57
4.9: Isolates with Biofilm
Production potential 58
4.10: Bacteria Isolates
from the Anterior Nares of Health care Workers 59
4.11a: Antibiogram for
Gram Positive Isolates
60
4.11b: Antibiogram for
Gram Negative Isolates 61
4.12 Multiple Antibiotics
Resistance Index (MARI) of Bacterial Isolates
from the six PHCs 62
4.13: Extended Spectrum
Beta-Lactamase Producers 63
4.14: Plasmid Profiles of
the Isolated Pathogens 64
4.15:
Distribution of Cured Plasmids 65
LIST OF FIGURES
4.1: Plasmid profile of bacterial isolates from
the study 66
CHAPTER I
INTRODUCTION
In Nigeria, the most populous country in Africa, 45,000 women die in
childbirth every year, (UNICEF 2004, UNFPA 2011, and WHO 2004). This represents
the third highest estimated number of women that die through childbirth
globally. India and Ethiopia have maternal deaths, of 110,000 and 46,000
respectively (WHO, 2004).
More than 8 million infants die before birth or in the
first few weeks of life; the majority of these infants’ mortality occur in
developing countries. A great number of
this infant mortality is due to transmittable diseases, complications related
to the pregnancy, and complications that came up during delivery (WHO, 2015).
To minimize this form of maternal and infants deaths, interventions which are
priority should be taken before birth, all through the process of childbirth,
and also without delay after birth, this is because, the first week after
childbirth has been seen as the most susceptible period for both mother and
child (WHO, 2009).
The dissemination of health-care associated infections (HAI) often originates from cross contamination. The
most common means of pathogen transference occurs between the hands of health professionals and patients (UNFPA,
2011). However, the hospital environment may contribute with the dissemination of pathogens. Environments occupied
by colonized and/or infected patients generally can
become contaminated (UNICEF, 2004). The presence of bacteria
is common in inanimate surfaces and equipment (WHO, 2004).
The dissemination of nosocomial infection is complex
and has multifactor causes. In this sense, addressing the environment in
bacteria dissemination aims at achieving a better understanding of HAI control,
defining policies for control and building awareness about the subject among
health professionals (UNFPA, 2011).
The single most successful and helpful approach of reducing mothers’
deaths during childbirth is by providing skilled care during and after
childbirth, (Family Care International, 2008). This means that the skilled
attendant — example, a trained midwife, nurse, or doctor, should have the
necessary skills and should be supported by a primary health centre and a
hospital with adequate supplies and equipment, and also a better and easy means
of communication with referral and transport. An experienced healthcare worker should have
the knowledge on how to provide certain healthcare needs and also should be
able to recognize difficulties in childbirth so as to be able to calm the woman
condition if need arises, before referring her to another facility that can
have emergency obstetric care (EOC). This includes administering drugs, caring
for abortion complications, stopping bleeding, managing prolonged labour,
providing blood transfusions, and performing Caesarean section operations
(Singh, 2002)
"Maternal mortality is responsible for a few major health problems
for which medical intervention is the key to the solution," (Peju, 2008).The
provision of adequate urgent obstetric care and infection free environment is
an important way of reducing maternal mortality drastically.
Some
factors have the potentials to contribute to the contaminations of environmental
surfaces in the spread of pathogens which are healthcare associated, these factors depend on the following: the tendency
of that very pathogen to continue to remain alive on various environmental
surfaces that are dry, the rate by which the surface is being contaminated by
both the patients and healthcare providers; example, by touching and most importantly, if the contamination level is adequately high enough
to cause the spread of the pathogens in a patients (Weber et al., 2010).
Before
now, it was believed that environmental surfaces do not play an important part in the spread of endemic
pathogens that are healthcare associated, but recent data however have shown
that surfaces that are contaminated aid in
the endemicity and epidemic spread of some pathogens that are responsible for nosocomial
infections (Otter et al., 2011).
Prevention
and controlling of diseases which may bring more harm to the patients, patient’s
relations and health-care personnel within the hospital environment is the duty
of all the health personnel within that hospital environment. Studies carried
out globally have proven that a good percentage of pathogenic aerobic bacteria
do stick on surfaces within the hospital environment (Weber et al, 2010), and this poses a serious
health issues for the healthcare personnel, patients and even patients relatives.
Contamination of hospital surfaces by pathogens that persist on the surfaces
and the cross contamination of these surfaces by these persistent organism
could increase the danger by which healthcare associated infection would be
acquired (Otter et al., 2011), which could
then result to high treatment cost, considerable
morbidity, lengthened stay in the hospital,
failure of treatment and occasionally
death.
1.1. WHY DO
THESE DEATHS OCCUR
Hospital environment is a reservoir of wide
varieties of microorganisms. Several strains of pathogenic bacteria have been
frequently reported colonizing medical equipments (like Stethoscopes) (Otter
et al., 2011). These pathogens
include superbugs like Vancomycin Resistant Enterococcus spp., Methicillin
Resistant and Sensitive Staphylococcus species and Multidrug
resistant, P. aeruginosa, E. coli, Klebsiella spp.
and Streptococcus spp.(Youngster et al., 2008).
Health care-associated infections (HAI)
remain a major cause of patient morbidity and mortality. An estimated 20% to
40% of HAI have been attributed to cross infection via the hands of health care
personnel. This contamination has been via direct contact with the patient or indirectly
by touching contaminated environmental surfaces. Prolonged periods in the hospital
stay terms of hospital infection have been associated with frequent surface
contamination in hospital rooms and health care workers’ hands. In some cases,
the extent of patient-to-patient transmission has been found to be directly
proportional to the level of environmental contamination (Al-Maani et al., 2014).
Medical equipments used in the non-critical care
setting are less likely to have standard disinfection and cleaning protocols
than equipments in the critical care setting. Thus medical care equipments are
more likely to carry considerable number of pathogenic microorganisms (Youngster
et al., 2008). The contamination of
stethoscope particularly the diaphragm is reported mainly due to lack of
regular disinfection (before and after examining each patient). A study from
India reported that, 45% of general practitioners disinfect their stethoscope
once a year or never and 35% disinfect their stethoscope monthly (Weber
et al., 2010).
Infection prevention protocols are effective in
reducing the health care associated infections (Alothman et al., 2009). The use of 70% propyl alcohol has been found to be
effective in reducing contamination of stethoscopes and other medical
equipments than other agents like detergents (Nelson et al., 2006). However, a study conducted by Hayden and his
colleagues shows that, the implementation of such programs were hindered by
poor compliance of Physicians, Nurses and other health care workers (Hayden et al., 2006). Inconvenience, time
pressures, and skin damage from frequent washing of hands are some of the
reasons quoted by the health care personnel that made them not to adhere to
infection prevention protocols in that particular study (Fauci et al., 2008). A routine disinfection of
stethoscope is hardly undertaken in most of the health care institutions
worldwide (Nelson et al., 2006).
During auscultation stethoscope contamination is
common; if the same stethoscope is used for the next patient without
disinfection, it might bring risk of infection to the patient and may
continuously impose the risk serially to all patients (Whittington et al., 2009). Draping of stethoscopes
around the neck is still a commonly seen practice, resulting in the risk of
recontamination of the diaphragm of the stethoscope from the unclean earpieces,
with normal flora and pathogenic bacterial strains harbouring in the ears of
the healthcare workers (HCWs). The universal and unavoidable use of the
stethoscope and its direct contact with multiple patients makes it an important
potential factor in the dissemination of microorganisms from one patient to another
(Bdareen, 2009).
Exposure of the already susceptible hospitalized
patient to resident flora (in most cases are multidrug resistant pathogens
unless proved) of the hospital environment may worsen the clinical condition of
the patient. Periodic surveillance of medical equipments and hospital
environments may help in identifying potential bacterial pathogens and
associated factors (WHO, 2009).
The hospital environment is contaminated
by a variety of pathogenic and non-pathogenic microorganisms that can persist
on surfaces for prolonged periods. Numerous studies have demonstrated that the
hands and gloves of healthcare workers readily acquire pathogens after contact
with contaminated hospital surfaces and can transfer these organisms to
subsequently touched patients and inanimate surfaces. The acquisition of
nosocomial pathogens by a patient and the resultant development of infection
depend on a multifaceted interplay between the environment, a pathogen and a susceptible
host. However, there is good evidence that infection transmission via hospital
surfaces and medical equipment can occur. For these reasons, hospitals must
implement evidence-based infection prevention measures that will reduce the
risk of transmission of pathogens via contaminated hospital surfaces and
medical equipment and hold personnel accountable for adhering to these measures
(Bdareen, 2009).
Environmental
surfaces act as a reservoir for bacterial and viral gathering and proliferation.
These organisms can be expelled from an infected or colonized patient either
through direct contact, aerosol droplets, or feces. Clostridium difficile has
been shown to last 5 months on hospital floors (Amazian et al., 2010).It has also been found on shoes and stethoscopes of
healthcare workers (Belghiti Alaoui et al.,
2015). Methicillin-resistant Staphylococcus aureus (MRSA) can live
on plastic laminate surfaces for 2 days and can spread rapidly through contact
[Arias, 2010]. Vancomycin-resistant enterococci (VRE) can survive on gowns of health
care workers as well as medical equipment, bed rails, counters, bedside tables
and sheets (Nelson et al.,
2006). One study showed that VRE could live for
up to 58 days on countertops. Acinetobacter baurmannii survival can last
for up to 33 days on plastic laminate surfaces (Arias, 2010). As cell phone use
becomes more widespread in the hospital setting, they are considered as a
possible source for cross contamination (Nelson et al., 2006). Noroviruses
can also contaminate the environment, persist after drying and may even become
re-aerosolized during floor sweeping.
The advent of molecular epidemiology is helping with a better
understanding of the role of the environment in nosocomial infection by
confirming that environmental isolates are the same as patient isolates (Belghiti
Alaoui et al., 2015).
Environmental
surfaces and semi-critical items have been implicated in the transmission of
infections. Relatively speaking, the intensive care unit (ICU) patient will be
more susceptible to infection because of possible breaks in their skin due to
trauma or surgery, indwelling medical devices, or general immune suppression
due to disease state or chemotherapy. For these patients, a lower inoculum of microbes
can cause an infection and microbes that are normally not pathogenic to healthy
individuals can cause an infection. Hence the contaminated item in the ICU
could play a more significant role in the transmission of infection to this
population (Nelson et al.,
2006).
Predominant
evidence suggests that the airborne microflora of indoor environments remain
major causes of hospital infections (Li and Hou, 2003; Hota, 2004; Saka et al., 2016). Many infections are spread
by the direct contact, because healthcare workers do not wash their hands
effectively before attending the patients (Arias, 2010). It has been estimated
that the airborne route of transmission accounts for between 10 to 20% of
endemic nosocomial infections (Li and Hou, 2003). Most airborne microorganisms found
in hospitals are disseminated within the building by the staff, patients and
visitors. Only a minority of these microorganisms is seen in the air and there
are usually fungal spores which were infiltrate from outside. Generally, the
higher the occupancy level the greater the microbial burden in the air. Consequently,
the air bioburden within hospitals tends to be very transient and can fluctuate
widely, depending on occupancy levels and the tasks being performed (Arias,
2010). Activities, such as bed making, release huge number of microorganisms
into the atmosphere. According to study the total viable count in a patient
room exceeded 6 X 103 colony forming units per cubic meter of air
during vigorous bed making (Greene et al., 1960). Bacterial spores can
remain viable for years and are very resistant to environmental stresses such as
heat, cold and UV radiation (Nevalainen et al., 1993).
Many
species appear to lower their metabolic rate and reduce in size under
conditions of nutrient starvation (Roszak and Colwell, 1987) and has also been
observed by a number of investigators (Butkeviczi, 1988; Greene et al.,
1960; Novitsky and Morita, 1977). The predominant mechanism that makes the
pathogens airborne is the production of aerosol droplets by sneezing or
coughing and their subsequent loss of water, which allows them to float in the
air over considerable distances and for a longtime (Emmerson, 1995).
Blessing-Moore et al., (1979) recovered Pseudomonas aeruginosa from
settle plates located near patients with cystic fibrosis and airborne Pseudomonas
spp. were linked with an outbreak of nosocomial bacteraemia at a hospital
in the USA (Grieble et al., 1974).
Inanimate
objects which become contaminated with pathogenic bacteria and then spread
infection to others are often referred to as fomites. Most outbreaks of
infection associated with inanimate objects are caused by items that should be
sterile but have been contaminated (Roszak and Colwell, 1987).
The hypothesis that environmental microorganism cause human
diseases arises from two facts, firstly, our interaction with the inanimate
environment is constant and close, secondly environmental objects are usually
contaminated often with important human pathogens. Unfortunately, though it is
fairly easy to assess the prevalence of microorganism in the environment, it is
relatively difficult to establish the role the organisms in the environment
play in causing human disease (Nevalainen et
al., 1993).
There are no systematic studies of the relative importance of
various environmental factors in ensuring a safe delivery room environment;
however it is known that contaminated fluid or equipment in the delivery room
may result in contaminations and lead to outbreaks of infections (Arias, 2010).
Management
of health-care waste is an integral part of hospital hygiene and infection
control. Health-care waste should be considered as a reservoir of pathogenic
microorganisms, which can cause contamination and give rise to infection. If
waste is inadequately managed, these microorganisms can be transmitted by
direct contact, in the air, or by a variety of vectors. Infectious waste
contributes in this way to the risk of nosocomial infections, putting the
health of hospital personnel, and patients, at risk (Hota, 2004).
Mothers
and neonates are vulnerable to get infections from the surrounding environment
of the Hospital. The chances of infection increases, if the precautions are not
taken appropriately, especially by nursing staff who is the prime person,
responsible for taking care of neonates in the Hospital. Infection control is a
more substantial area of concern in Labor and delivery room because these
neonates do not adapt to their surroundings immediately after they come out of
the womb of mothers. In addition to this, mothers might be exposed to infection
due to multiple examinations by health care providers during the process of
labor. Moreover, in lower middle income countries, neonatal deaths are due to
infections acquired at home or in the hospital and around 36% of the neonatal
deaths occur due to infection (WHO, 2004). Healthcare professionals always aim
to preserve the maternal and newborn health, but sometimes little negligence
can put their health at risk which should not be overlooked. Multiple factors
can cause infection in the labour room, therefore it is important to assess
various factors of maternal and neonatal infection (WHO, 2009).
1.2. STATEMENT OF THE
PROBLEM
Today
the increasing number of antenatal deliveries and the effect of the hospital
environment on women’s birth experience have become critical issues. The transition
of childbirth from home to hospital and thus the trend of defining birth as a
pathological event have created hospital settings that regard medical safety
first.
At
birth, newborns, especially premature and low birth weight neonates are devoid
of efficient structural barriers, of a protective endogenous microbial flora
and of a mature immune system. The newborn represents one of the most
vulnerable populations among the pediatric group, especially neonates delivered
in a contaminated primary health care (PHC) facilities, where the
large-scale use of medical devices and lack of maturation of a child’s immune
system increase the chances of acquiring nosocomial infections which the
causative organisms may be bacterial, viral, or fungal in origin (Nevalainen et
al., 1993). Nevertheless,
nosocomial infections remain a major cause of preventable morbidity and mortality
in developing countries where infection rates are relatively high with poor infection
control practices, lack of supervision and inappropriate use of limited
resources. The major pathogens of neonatal infections differ not only from
country to country and from nursery to nursery, but also change within years in
the same nursery (Belghiti et al.,
2009).
Healthcare
workers not only contaminate their hands after direct patient contact but also
after touching inanimate surfaces and equipment in the labour ward zone (the
patient and her immediate surroundings). Inadequate hand hygiene before and
after entering a labour zone may result in cross-transmission of pathogens and
patient colonization or infection. A number of equipment items and commonly
used objects in labour wards carry bacteria which, in most cases, show the same
antibiotic susceptibility profiles of those isolated from patients. This study
is to provide updated evidence about contamination of inanimate surfaces and
equipment in labour wards in light of the concept of labour zone and the
possible implications for bacterial pathogen cross-transmission to mother and
child during childbirth.
For
these reasons, effective surveillance was very important to evaluate the
epidemiology, associated risk factors, causative organisms and outcomes based
on understanding the epidemiology of nosocomial infection in our locality.
Therefore, this study was conducted to determine the types and prevalence of bacterial
pathogens associated with labour ward environments and antibiotic
susceptibility pattern of these isolates from six different primary health
centers (PHCs) within Umuahia metropolis.
1.3. AIMS AND OBJECTIVES OF THE STUDY
General objective;
The aim of this study is to
investigate the Bacterial contamination that is associated with labour ward
environment from selected primary health care (PHC) setting in Umuahia
metropolis.
Specific
objective;
1.
Evaluation of
overall bacterial spectrum associated with labour ward environment from selected PHC settings in the study.
2.
Evaluation of
the distribution of the bacterial strains isolated from tools and sections of labour and delivery wards
such as delivery coach, delivery forceps,
mucus extractor, scissors,
cord clamp,etc.
3.
To evaulate the
antibiotic susceptibility pattern of the bacteria isolated
4.
To determine
resistant factors associated with such isolates.
5.
To determine the
plasmid profile of some resistant bacteria.
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