Islamic University-Gaza

Deanship of Graduate Studies

Biological Sciences Master Program

Epidemiology of Septicemia at Neonatal Intensive Care

Units in Gaza City Hospitals.

Submitted in Partial Fulfillment for the Master Degree of Science in Biological

Sciences/Microbiology

BY

Yasser A. Elbayoumi

Supervisor

Dr. Abdelraouf A. Elmanama

Ph. D Microbiology

September 2011

Abstract
Epidemiology of septicemia at neonatal intensive care units in Gaza city hospitals
Background: The prevalence of healthcare-associated neonatal bloodstream
infections is increasing and results in significant morbidity, mortality, and economic
cost. The continuous emerging of bacterial resistance to antibiotics worsens the
situation and complicates the challenges. The epidemiology of these infections is well
studied in developed countries, but the picture is not that clear in developing
countries. The neonatal septicemia is reported in Gaza and connected to mortality, but
the epidemiology of neonatal septicemia was never studied.
Objectives: The research aimed to study the epidemiology of neonatal septicemia by
defining the main etiological bacterial agents of it in the neonatal intensive care units,
the potential predisposing factors for acquiring septicemia, the potential pathogenic
bacteria existed in the environment of the units, and the antibiotic resistance patterns
of isolated bacteria.
Methodology: A three-month descriptive cross-sectional study in two intensive care
units in Gaza city (Al-Shifa and Al-Nasser hospitals). The study consists of a
checklist to evaluate environmental and working conditions, a questionnaire to survey
the healthcare workers' knowledge and perspective, scanning patient's records for
potential risk factors, blood cultures for patients, sampling the environment and the
workers for potential pathogens and testing isolated microorganisms for antibiotic
susceptibility.
Results: A total of 622 cases, more than half of them from Al-Nasser hospital
(56.6%, n=346). The incidence rate of septicemia was 10.4% (24.2/1000 patient day)
in Al-Nasser unit (n=36), and 9.1% (14.4/1000 patient day) in Al-Shifa's (n=25). The
causative

bacteria

were:

coagulase-negative

Staphylococcus

(39%,

n=24),

Staphylococcus aureus (23%, n=14), Streptococcus spp.(12%, n=7), Enterobacter

cloacae and Pseudomonas spp. (8%, n=5 each), and Escherichia coli and Klebsiella
pneumoniae (5%, n=3 each).

ii

Lack of institutional commitment and worker's interest in preventive measures,

shortage of environment disinfection and unfacilitated handwashing are the main
negative observations. The environment and the healthcare workers are harbored with
potential pathogens.
Ampicillin, Gentamicin and Cefotaxime (claforan) are extensively used in the units as
a prophylactic medicines. Klebsiella

pneumoniae has shown the highest rate of

antibiotic resistance (53%), while Enterobacter cloacae has shown

the least

resistance(27%).
Conclusions: Neonatal sepsis is not a risk factor for mortality. Apgar score <7,
birthweight less than 2.5 kg, preterm, inherited disorders and cesarean section
delivery are the risk factors.
Potential intrinsic risk factors for septicemia are: preterm, low birth weight and
gender (male). Maternal fever and meconium staining of amniotic fluid could be
predictive factors for septicemia in newborns.
Extended beta-lactamase producing gram negative bacteria may be associated to
resistance to quinolones. Resistance of Staphylococcus spp. to Meropenem is a
serious finding.
Adherence of healthcare workers to hand hygiene and personal protective procedures
beside appropriate disinfection of the environment are key factors to reduce the
acquisition of neonatal septicemia and other infections. This may be achieved by
promotion, role modeling and continuous monitoring. Besides that, the availability
and accessibility of alcoholic hand-rub solutions will make the difference.
Keywords: epidemiology, neonatal sepsis, Gaza, Palestine, infection control,
nosocomial.

iii



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Declaration
"I hereby declare that this submission is my own work and that, to the best of
my knowledge and belief, it contains no material previously published or
written by another person nor material which to a substantial extent has been
accepted for the award of any other degree of the university or other institute,
except where due acknowledgment has been made in the text".

Yasser A. Elbayoumi

Copyright by
Yasser A. Elbayoumi
2011

Copyright.
All Right Reserved: No part of this work can be copied, translated or stored in
retrieval system, without prior permission of the author.

vi

DEDICATION

To the first teacher of all nations, prophet

MOHAMMED (peace be upon him), I dedicate this
modest humble work. Hoping its acceptance by almighty
ALLAH , the ultimate source of every knowledge.
To the benign spirits of my amiable parents, who put all
their stakes on my horse, and left before the end of the race.
If there is a pride of winning, its theirs.
To all those who believe in the power of knowledge and that
being the best is not impossible, this work is also dedicated.

vii

List of contents
Declaration ...........
Dedication .................
List of contents
List of figures..
List of tables ...........
List of annexes
List of abbreviations...
Acknowledgments ......

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CHAPTER I: INTRODUCTION
1.1 Overview ........................
1.2 Objectives .......................
1.3 Significance .........

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CHAPTER II; LITERATURE REVIEW

2.1 Introduction .
2.2 Bloodstream infections (BSI) in neonates .
2.2.1 Laboratory-confirmed bloodstream infection (LCBI) ...................
2.2.2 Clinical sepsis (CSEP) ...
2.3 Etiology and rates of infection ..
2.3.1 Etiological agents ...
2.3.1.1 Gram positive bacteria ...
Group B Streptococcus (GBS) ....
Staphylococcus aureus ....
Coagulase-negative staphylococci ..
Enterococcus species ..
Group A, C, D, and G Streptococcus species .
Listeria monocytogenes ..
2.3.1.2 Gram-Negative Organisms
Escherichia coli ..
Enterobacter, Klebsiella, and Serratia species ..
Citrobacter species .
Pseudomonas ..
Acinetobacter species .
Haemoplilus influenzae ..
2.3.1.3 Anaerobic Bacteremia ...
2.3.1.4 Fungal sepsis ..
2.3.2 Infection rates
2.3.3 Mortality rates
2.4 Acquisition of Infection .
2.4.1 Colonization of the Newborn .
2.4.2 Modes of Transmission ..
2.4.2.1 Direct contact transmission
2.4.2.2 Indirect contact transmission
2.5 Risk Factors for Infection ...
viii

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2.5.1 Intrinsic risk factors (The Newborn)

2.5.2 Extrinsic risk factors (Invasive Procedures) ..
2.5.3 Environment (infrastructure-related) risk factors .
2.6 Monitoring, prevention and control
2.6.1 Surveillance ...
2.6.2 NICUs Outbreak Control ...
2.6.3 The role of the microbiology laboratory
2.6.4 Environmental monitoring .
2.6.5 Patient-Care Items categorization concept ..
Critical Items ..
Semicritical Items ....
Noncritical Items ....
2.7 Antimicrobial therapy
2.7.1 Prophylactic use of antibiotics ..
2.7.2 Antimicrobial resistance of neonatal pathogens and hospital
microbiota . .
2.7.3 Regional differences .....
2.7.4 Antimicrobial resistance control
CHAPTER III: MATERIALS AND METHODS
3.1 Materials

3.1.1 Apparatus ...

3.1.2 Equipment and disposables ..
3.1.3 Reagents and stains
3.1.4 Culture media
3.1.5 Antibiotic discs .
3.2 Methodology ...
3.2.1 Permission and ethical consideration
3.2.2 Environmental and working conditions
3.2.3 Hospital records (epidemiological aspect)
3.2.4 Microbiological methods ...
3.2.4.1 Samples description ..
3.2.4.2 Sampling duration and sample size ...
3.2.4.3 Sampling methodology and primary processing ..
a- Neonate blood Culture ...
b- Environmental samples .
c- Nasal samples ...
d- Hand samples
e- Air samples
3.2.4.4 Bacterial isolates identification .
3.2.4.5 Antimicrobial susceptibility (The Kirby-Bauer method) ..
3.3 Knowledge and perspective questionnaire .
3.4 Statistical analysis ...

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CHAPTER IV Results

4.1 Environmental and working conditions .

4.1.1 Work and treatment areas .
4.1.2 The working staff ..
4.1.3 Antimicrobial therapy protocols
4.1.4 Infection control team
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4.1.5 Personal protection equipment (PPE) ..

4.1.6 Handling and disposal of tools ...
4.1.7 Intravascular access devices (catheters) ..
4.1.8 Cleaning processes .
4.2 Hospital records ..
4.2.1 Mortality
4.2.2 Clinical sepsis (CSEP) and Laboratory-confirmed bloodstream
infections (LCBI)
4.2.3 Risk factors for mortality and septicemia ......
4.2.4 Antibiotic administration ...
4.3 Questionnaire analysis
4.3.1 Respondents ..
4.3.2 Working experience ..
4.3.3 Staff knowledge and perspective of infection control practices
4.4 Bacterial isolates
4.4.1 Blood isolates
4.4.2 Hand isolates .
4.4.3 Nasal isolates .
4.4.4 Environment isolates .
4.4.5 Air microbial load .
4.5 Antibiotic susceptibility .

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CHAPTER V: Discussion

5.1 Incidence and prevalence of neonatal septicemia ...

5.2 Occupational and infrastructural risk factors ..
5.2.1 Working staff .....
5.2.2 Environmental conditions ..
5.2.3 Intravascular devices .
5.2.4 Handwashing .
5.3 Potential sources of HAI pathogens ...
5.3.1 Environmental surfaces. ....
5.3.2 Air microbial load ..
5.3.3 Health care workers ..
5.3.4 Bacterial isolates
5.4 Risk factors for neonatal septicemia ..
5.5 Antimicrobial Use and Resistance ...

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CHAPTER VI: Conclusions and Recommendations

6.1 Conclusions
6.2 Recommendations .
6.3 Research recommendations. ..
REFERENCES ..
ANNEXES ..

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List of figures
Fig 2.1: Timing of bacterial and fungal sepsis in VLBW infants .
Fig 3.1: Sampling of nasal swab ...
Fig 3.2: Sampling of hand swab
Fig 3.3: Sampl'air: Air sampler for microbiological samples ...
Fig 4.1: Photographs of Handwashing facilities in NICUs ..
Fig 5.1: The role of workers in directing towards personal hygiene practices
PHP as evaluated by health care workers (questionnaire results) .
Fig 5.2: Isolated bacteria from Environment and healthcare workers and blood
cultures
Fig 5.3: Use and resistance patterns of frequently administered antibiotics in the
two NICUs ...

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List of tables
Table (3.1): Microbiological samples from the two NICUs
Table (4.1): Distribution of Al-Shifa cases according to gender and mode of
delivery
Table (4.2): Relation between mortality rate and maternal and neonatal factors
(calculated for both NICUs cases) ...
Table (4.3): Symptoms classification according to nursery care level .
Table (4.4): Neonatal and maternal factors in neonates with clinical sepsis (AlNasser hospital) ...
Table (4.5): Neonatal and maternal factors in neonates with septicemia (positive
blood culture)
Table (4.6): Antibiotic administration in Al-Nasser and Al-Shifa NICUs
according to hospitals records ...
Table (4.7): Distribution of the questionnaire respondents according to
profession and gender .
Table (4.8) Isolated bacteria from different sources in the two NICUs
Table (4.9): Sources of tested bacterial isolates for antibiotic susceptibility
Table (4.10): Antibiotic susceptibility patterns (%) for bacteria isolated from
different sources from Al-Nasser and Al-Shifa NICUs .. ..

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List of annexes
Annex 1: Environmental and working conditions checklist .
Annex 2: Al-Nasser NICU environmental swabs .
Annex 3a: Al-Shifa NICU environmental swabs (ground floor) .....
Annex 3b: Al-Shifa NICU environmental swabs (first floor) .........
Annex 4: Perception Survey for Health-Care Workers ......................................
Annex 5: Perception Survey for Health-Care Workers (in Arabic) ...................
Annex 6: Environmental and working conditions checklist results ..
Annex 7: Results of the perception survey ...
Annex 8: Results of air samples of NICU of Al-Nasser and Al-Shifa hospitals ..
Annex 9: Antibiotic sensitivity for selected Gram negative bacteria isolated
from blood culture, environment, hand and nasal swabs ...
Annex 10 : Antibiotic sensitivity of staphylococcus aureus isolates ....
Annex 11: Antibiotic sensitivity of Al-Shifa NICU Coagulase negative
Staphylococcus (CoNS) .......
Annex 12: Antibiotic sensitivity of Al-Nasser NICU Coagulase negative
Staphylococcus(CoNS) .....
xi

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List of abbreviations
AAP
ASPs
BHIB
BSI
CAH
CDC
CHNRI
CLABSIs
CLSI
CMV
CNS
CoNS
CRP
CSEP
DRBC
ELBW
EMRO
EONI
EONS
ESBL
GBS
HAI
HAV
HBV
HCV
HCW
HIV
HSV
HTLV-I
ICPs
ICU
IFI
LCBI
LONS
MMWR
MRSA
MSAF
NEC
NI
NICHD
NICU
NNIS
PCBS
PHP
PNR
SIRS
SPSS
VLBW
VLONS
VRE
WHO

The American Academy of Pediatrics

Antimicrobial stewardship programs
Brain heart infusion broth
Bloodstream infection
The Department of Child and Adolescent Health and Development (WHO)
The Centers for Disease Control and Prevention (USA)
Child Health and Nutrition Research Initiative (USA)
Central lineassociated bloodstream infections
The Clinical and Laboratory Standards Institute (USA)
Cytomegalovirus
Central nervous system
Coagulase-negative Staphylococci
C-reactive protein
Clinical sepsis
Dichloran Rose Bengal Chloramphenicol (agar)
Extremely low birth weight
East Mediterranean Regional Office (WHO)
Early onset neonatal infection
Early-onset neonatal sepsis
Extended-spectrum -lactamase
Group B hemolytic streptococci
Health-care associated infection
Hepatitis A virus
Hepatitis B virus
Hepatitis C virus
Healthcare workers
Human immunodefiency virus
Herpes simplex virus
Human T-cell leukemia virus type I
infection control personnel
Intensive care unit
Invasive fungal infection
Laboratory-confirmed bloodstream infection
Late-onset sepsis
Morbidity and Mortality Weekly Report (USA)
Mithicillin resistant Staphylococcus aureus
Mecuonium staining of amniotic fluid
Necrotic entrocolitis
Nosocomial infection
National Institute of Child Health and Human Development (USA)
Neonatal Intensive Care Unit
National Nosocomial Infections Surveillance (USA)
Palestinian Central Bureau of Statistics
Personal Hygiene Practices
Patientnurse ratio
Systemic Inflammatory Response Syndrome
Statistical Package for Social Sciences
Very low birthweight
Very late-onset sepsis
Vancomycin-resistant enterococci
World Health Organization

xii

Acknowledgment
I would like to express my gratitude to all people who have contributed to this work.
In particular, I would like to thank:
Special thanks to my supervisor Dr. Abedelraouf Elmanama, for his
professionalism, encouragement and enthusiastic. He is a true researcher driven by
curiosity and with never ending energy. Without his stimulating, critical discussions,
comments, and great help, this work would not have been completed.
To the professors, Dr. Yousef Abu-Safieh and Dr. Basim Ayesh for their precious
advises. Their contributions have strengthened and enriched the content of this work.
To my colleagues in the public health lab. for their support, help and encouragement
in all stages of this work. Among them, Mohammed Seada, Hashim Arafa, Asaad
El Falit, Mohammed El Khatib and Saleh El Tawil were of great help.
Special thanks to my dear colleagues Ms. Ohoud Sarsour and Mr. Nahedh
Abdullatif for their kind and appreciable help.
To the workers of the microbiology laboratory and the archives at Al-Shifa and AlNasser hospitals for their significant help, without it, this work would have never been
accomplished. Also the workers of the NICUs in the two hospitals, where their
cooperation had an effective role in facilitating this work.
I would like also to thank all my friends and colleagues, for all of their support and
guidance and encouragement.
Finally, special thanks and apologies to my family: beloved wife, dear brothers and
sisters, and my sweet children . Without their guidance, help and patience, I would
have never been able to accomplish this work.

xiii

CHAPTER I
Introduction
1.1 Overview
At any point of time, over 1.4 million people worldwide are suffering from infections
acquired at hospitals. Between 5% and 10% of patients admitted to modern hospitals
in the developed world acquire one or more infections. The risk in developing
countries is 2 to 20 times higher [1]. In some developing countries, the proportion can
exceed 25% [2]. Infections are an important cause of neonatal morbidity and mortality
worldwide. Neonatal infections among low-birth-weight infants are associated with
significant risk of neurologic abnormalities, developmental and functional delays [3]
Although most neonatal infections are of maternal or community origin, an increasing
proportion are acquired in the nursery. Advances in newborn intensive care have
permitted the survival of low-birth-weight and sick infants and have simultaneously
created risks for neonatal infections, which are themselves a significant cause of
mortality in these infants [4]. Reported infection rates in the neonatal intensive care
unit (NICU) vary from 3.2 to 30 per 100 admissions or discharges, illustrating the
wide variability among centers. NICUs that admit surgery patients may have higher
rates [5]. Nosocomial bloodstream infections (BSIs) are increasing in prevalence and
result in significant morbidity, mortality, and economic cost. From 1975 to 1996, the
proportion of nosocomial infections accounted for by BSIs increased from 5% to 14%
[6].
Traditionally, three different categories of risk factors associated with nosocomial
infection (NI) acquisition have been described; factors inherent to patient, to invasive
procedures and to hospital environment. The study of these factors can guide the
selection, implementation, and evaluation of control measures for this type of
infection [7]. However, extensive investigations often fail to yield specific sources,
and the clusters may spontaneously disappear. This suggests that environmental or
host factors that have yet to be identified also contribute to the acquisition of NIs [4].
The centers for disease control and prevention (CDC) replaced the generic term
"nosocomial" with Health-care associated infection (HAI). The CDC defines an HAI
as a localized or systemic condition resulting from an adverse reaction to the presence
1

of an infectious agent(s) or its toxin(s). There must be no evidence that the infection
was present or incubating at the time of admission to the acute care setting [8]. The
world health organization (WHO) is less conservative than CDC in terminology;
Nosocomial infections, known also as hospital-acquired infections, hospitalassociated infections, and hospital infections [9] are infections that are not present in
the patient at the time of admission to hospital but develop during the course of the
stay in hospital [10]. In the coming chapters the definition "health-care associated
infection (HAI)" will be used.
There are two forms of infections; Endogenous infection, (self-infection, or autoinfection), in which the causative agent of the infection is present in the patient at the
time of admission to hospital but there are no signs of infection. The infection
develops during the stay in hospital as a result of the patients altered immunity. The
other form is cross-contamination followed by cross-infection; during the stay in
hospital the patient comes into contact with new infective agents, becomes
contaminated, and subsequently develops an infection [10]. While there is no
clinically significant difference between the endogenous self-infection and the
exogenous cross-infection, the distinction is important from the standpoint of
epidemiology and prevention [9].
In recent years, the subject of the emergence and subsequent increase in the incidence
of resistance to antimicrobial agents has become a serious threat. Reports from all
around the world suggest that antibiotics are rapidly losing their effectiveness, with
some early reports going so far as to suggest that we are approaching a post-antibiotic
era [11]. Antimicrobial resistance is increasing for a variety of reasons, these include
suboptimal use of antimicrobials for prophylaxis and treatment of infection, prolonged
hospitalization, increased number and duration of intensive-care-unit stays, multiple
co-morbidities in hospitalized patients, increased use of invasive devices and
catheters, ineffective infection-control practices, noncompliance with infectioncontrol practices, transfer of colonized patients from hospital to hospital, grouping of
colonized patients in long-term-care facilities, antibiotic use in agriculture, and
increasing national and international travel [12]. The rate of antimicrobial resistance
among HAI pathogens is steadily increasing; a 2000s surveillance revealed increasing
rates of MRSA, VRE, and other patterns of resistance patterns [13].
2

Despite the lack of good documentation system concerning NI in Palestinian

hospitals which is related to long neglecting of the occupation and the present siege,
but many indicators show clearly the tragic situation. Environmental sterility tests for
hospital departments were being done regularly in Gaza hospitals up to the year 2006.
The infection control committee was established in 2001 but was not activated until
late 2009. A 2005 study revealed a ratio of 4.1% NIs in admitted patients in the
European hospital in Southern Gaza strip [14]. Some outbreaks have been
documented; an outbreak of Acinetobacter baumannii infection in the neonatal
intensive care unit in a governmental Gazan hospital (Al-Shifa) in 2004 [15]. Another
outbreak of Serratia marcescens was reported in 2005 [16]. A recent study focused on
the adherence of health workers (physicians and nurses) to infection protection and
control protocol in Gaza hospital's NICUs showed very poor hygiene practices in the
NICUs, which was largely related to the absence of training programs for these
workers, and the shortage of knowledge about the whole issue [17].
In Palestinian territories, newborns with low birth weight constitute 7.2% of all births,
infant mortality rate is 25/1000 live births [18]; In Gaza Strip, infant mortality was
mainly caused by premature births (36.2%), and congenital abnormalities (23.5%).
[19]. Living conditions have worsened since 2006, when the elected Palestinian
administration became politically and economically boycotted, resulting in
unprecedented levels of Palestinian unemployment, poverty, and internal conflict, and
increased restrictions to health-care access [20]. One of the most dangerous neonatal
septicemias is that of low birth weight infants, and the estimation of incidence rate of
NIs among this category is unclear in Palestine. This shows the importance of
identifying the etiologic agents and the contributing risk factors for neonatal
infections in NICUs.

1.2 Objectives
The overall objective is to study the epidemiology of neonatal septicemia at the
selected NICUs. The following specific objectives will be achieved:
1. To evaluate the environmental and working conditions in two different NICUs
and their potential role in causing HAI.
2.

To identify the main bacterial pathogens causing septicemia in these units

3.

To identify the potential bacterial pathogens in the environment and those carried
by the working staff of the units

4.

To determine the antimicrobial susceptibility profiles for the common isolates.

5.

To define risk factors for health care-associated neonatal septicemia in the

selected units.

1.3 Significance
Neonates are highly susceptible to NIs, due to their weak immune system. The
environmental and work conditions of the NICUs impose another risk factor, and can
be the major cause of infection.
The prevalence of many NIs in Al-Shifa NICU has been reported in the last decade,
few of them have been documented. The records of Al-Nasser pediatric hospital
showed that about one third of blood culture in a three-month period where from
NICU, and more than 20% of them were positive cultures, while less than 10% were
positive in other sections.
NIs extend the stay of neonates in the hospital, and raise the cost of treatment with
antibiotics. The results of this study may provide insight of the etiological agents of
septicemia and the associated risk factors. This would be of importance in planning
actions to reduce such infections.

CHAPTER II
Literature Review
2.1 Introduction
Infections are important cause of neonatal morbidity and mortality worldwide.
Although most neonatal infections are of maternal or community origin, an increasing
proportion are acquired in the nursery. Advances in newborn intensive care have
permitted the survival of low-birth-weight and sick infants and have simultaneously
created risks for HAI, which are themselves a significant cause of mortality in these
infants [4].
Prevention of infection in the premature infant who starts life in an intensive care unit
and whose immature defenses are further depleted by illness and invasive procedures
is a major challenge. The newborn may acquire infection from the mother in utero,
during delivery or postpartum from maternal, hospital, or community sources. Many
infections transmitted from mother to infant during delivery, such as group B
hemolytic streptococci (GBS), Listeria, hepatitis B virus (HBV), or herpes simplex
virus (HSV), have not traditionally been considered HAIs. On the other hand,
infections classified as HAIs are often caused by microorganisms acquired from the
mother that become part of the flora of the newborn and subsequently invade because
of immature or impaired defenses. Difficulty in distinguishing between maternal and
hospital sources makes identification of newborn HAIs imprecise. Because of this
difficulty, the Center for Disease Control and Prevention (CDC) has defined all
neonatal infections, whether acquired during delivery or during hospitalization, as
HAIs unless evidence indicates transplacental acquisition [21].
Most published reports of HAIs have included only those infections with onset within
a specified period after admission to the nursery, whereas some have attempted to
separately define infections from maternal and hospital sources. The need to
distinguish between maternal and hospital sources is more than semantic. Infection
control measures designed to prevent acquisition of microorganisms within the
nursery will not affect pathogens acquired prenatally, for which control measures
involve prevention, diagnosis, and treatment of infection in the pregnant woman;
5

intrapartum antibiotic prophylaxis; postpartum antibiotic or immune prophylaxis for

the infant; and prevention of obstetric complications known to be associated with
increased intrapartum transmission [5].

2.2 Bloodstream infections (BSI) in neonates

Sepsis is defined as a systemic inflammatory response syndrome (SIRS) associated
with infection on the basis of either microbiologic cultures or strong clinical evidence
of the presence of an infection. Severe sepsis is defined as sepsis plus evidence of
organ dysfunction defined around pediatric parameters [22].
The diagnosis of neonatal sepsis begins with clinical suspicion. The challenge for the
neonatal practitioner is to decide which babies need empiric antibiotic therapy and for
how long, a decision which is complicated by the common occurrence and
nonspecific nature of sepsis-like symptoms in preterm infants [23]. The prevalence
and predictive value of common signs and symptoms of sepsis were described in a
study by the National Institute of Child Health and Human Development (NICHD)
Neonatal Network. The most common presenting symptoms in very low birth weight
(VLBW) infants undergoing evaluation for suspected sepsis were increased apnea
(55%), gastrointestinal problems (46%), increased need for oxygen or ventilatory
support (36%), and lethargy/hypotonia (23%). The positive predictive value of these
signs was low for culture-proven septicemia, ranging from 14 to 20%. The strongest
predictor of septicemia in that study was hypotension, present in fewer than 5% of
infants, which had only a 31% positive predictive value [24]. Isolation of an organism
from a blood culture of a neonate with clinical symptoms of infection constitutes the
common definition of sepsis. Due to technical constraints, often only a single
peripheral blood culture is obtained from a septic-appearing neonate, and in most
studies the isolation of an organism from one blood culture is considered evidence of
sepsis. In the case of coagulase-negative Staphylococci (CoNS), which is both a
common cause of sepsis and a frequent blood culture contaminant, many recent
studies require either isolation from two blood cultures or a single positive blood
culture with other laboratory evidence of sepsis, such as an elevated serum C-reactive
protein level (CRP) [23].

Neonatal sepsis is classified as early- or late-onset (figure 2.1). Whereas early-onset

neonatal sepsis (EONS) is usually due to microorganisms that are acquired from the
mother antepartum or intrapartum. The pathogens causing late-onset sepsis (LONS)
are generally acquired from the postnatal environment. LONS is most important as a
nosocomially acquired infection in hospitalized babies. The timing of the transition
from EONS to LONS is not clear-cut and depends, to some extent, on the individual
pathogen. For example, infections with group B streptococci (GBS) presenting within
the first 7 days of life are usually regarded as early-onset (and, therefore, of maternal
origin), whereas infections with CoNS presenting at any age are likely to have been
hospital-acquired (23).

Figure 2.1: Timing of bacterial and fungal sepsis in VLBW infants. Percentages indicate the
approximate number of VLBW infants with septicemia. EONS usually occurs via ascent of organisms
from the birth canal to the amniotic fluid, with or without rupture of amniotic membranes. LONS
occurs with vertical and horizontal spread of organisms. While the vast majority of cases of sepsis in
VLBW infants occur in the first 30 days of life, VLBW infants requiring prolonged intensive care are
at risk for VLONS beyond 2 months of age (23).

From a diagnostic perspective, CDC has defined two types of BSI; Laboratoryconfirmed bloodstream infection (LCBI), which may be used to report BSI in all age
groups, and clinical sepsis (CSEP), which may be used only to report primary BSI in
neonates and infants, but not in adults and children [8].

2.2.1 Laboratory-confirmed bloodstream infection (LCBI)

LCBI in neonates must meet the following criterion: Patient 1 year of age has at
least 1 of the following signs or symptoms: fever (>38oC, rectal), hypothermia
(<37oC, rectal), apnea, or bradycardia and signs and symptoms and positive
laboratory results are not related to an infection at another site and common skin
contaminant (ie, diphtheroids [Corynebacterium spp], Bacillus [not B. anthracis] spp,
7

Propionibacterium spp, CoNS [including S. epidermidis], viridans group streptococci,

Aerococcus spp, Micrococcus spp) is cultured from 2 or more blood cultures drawn
on separate occasions [8].

2.2.2 Clinical sepsis (CSEP)

Clinical sepsis must meet the following criterion: Patient 1 year of age has at least
1 of the following clinical signs or symptoms with no other recognized cause: fever
(>38oC rectal), hypothermia (<37oC rectal), apnea, or bradycardia and blood culture
not done or no organisms detected in blood and no apparent infection at another site
and physician institutes treatment for sepsis [8].

2.3 Etiology and rates of infection

2.3.1 Etiologic agents
In developing countries, hospital-based studies suggest that most infections in the first
week of life are due to Gram-negative pathogens, and many may be environmentally
rather than maternally-acquired, owing to unhygienic delivery practices. Such
practices may also explain the predominance of Gram-negative infections among
home-born infants, although data from home settings are limited [25].
2.3.1.1 Gram positive bacteria

Group B Streptococcus (GBS): Streptococcus agalactiae, causes invasive

disease primarily in infants, pregnant or postpartum women, and older adults, with
the highest incidence among young infants. Infections in newborns occurring
within the first week of life are designated early-onset disease. Late-onset
infections occur in infants aged >1 week, with most infections evident during the
first 3 months of life [26]. The pathogenicity of GBS has been attributed to a
number of virulence factors, including lipoteichoic acid, a thick polysaccharide
capsule, capsular sialic acid, and the enzyme C5a-ase, which inhibits neutrophil
accumulation at the site of infection [23].

Staphylococcus aureus: A much less common cause of neonatal sepsis in recent

decades than at its peak incidence in the 1950s through the 1970s, however, it can
8

be a highly virulent pathogen in immunocompromised patients such as premature

neonates [23]. S. aureus is perhaps the pathogen of greatest concern because of its
intrinsic virulence, its ability to cause a diverse array of life threatening infections,
and its capacity to adapt to different environmental conditions. The mortality of S.
aureus bacteremia remains approximately 2040%, and it is now the leading
overall cause of NIs [27]. Infections with S. aureus are especially difficult to treat
because of evolved resistance to antimicrobial drugs. Resistance to penicillin and
newer

narrow-spectrum

-lactamaseresistant

antimicrobial

drugs

(e.g.,

methicillin, oxacillin) appeared soon after they were introduced into clinical
practice in the 1940s and 1960s, respectively [28].

Coagulase-negative staphylococci: CoNS are the etiologic agents of the majority

of NIs in premature neonates. Although CoNS are common commensals with little
pathogenicity in immunocompetent hosts, premature neonates are particularly
susceptible to invasive infection. The first step in the pathogenicity of CoNS
involves adherence of the bacteria to skin, mucosal surfaces, or indwelling
artificial devices, such as intravascular catheters and central nervous system
(CNS) shunts, which are commonly used in preterm infants. Adherence of CoNS
is facilitated by a capsular polysaccharide adhesin consisting of poly- N-succinyl
glucosamine [23]. Of the 31 species of CoNS and the 13 known to colonize
human skin, species reported to cause disease in infants include S. epidermidis, S.
haemolyticus, S. hominis, S. warneri, S. saprophyticus, S. cohnii, and S. capitis.
The major species involved in neonatal infection is S. epidermidis, which accounts
for approximately 50 to 80% of CoNS colonization [29].

Enterococcus species: Although accounting for only a small proportion of

neonatal sepsis, Enterococcus species deserve special attention because of the
increasing incidence of neonatal enterococcal sepsis in several studies and the
emergence of vancomycin resistance among enterococci. Both Enterococcus
fecalis and E. faecium cause sepsis in preterm neonates, with E. fecalis accounting
for over 80% of cases [23]. For reasons that are unclear at present, vancomycin
resistance among enterococci has not become a significant problem in most

NICUs, yet several studies have reported endemic or epidemic vancomycinresistant enterococci (VRE) among hospitalized neonates [30].

Group A, C, D, and G Streptococcus species: Species of streptococci other than

GBS are infrequent agents in early onset neonatal sepsis (EONS) in premature
neonates and even less common in late onset neonatal sepsis (LONS) [31]. Group
A Streptococcus, historically a major agent in puerperal sepsis, has only
infrequently been implicated in neonatal sepsis in the last decade. Cases of
neonatal sepsis caused by group C, D, and G streptococci are also occasionally
reported [23].

Listeria monocytogenes: Listeria monocytogenes, a gram-positive bacillus, is a

well-known and well-studied neonatal pathogen. Although neonates account for
approximately one-third of cases of invasive listeriosis, the organism accounts for
less than 5% of cases of EONS in preterm neonates in most studies [32]. The
incidence of L. monocytogenes sepsis in neonates is approximately 13 per
100,000 live births in the United States as well as in Europe. Listeria infection
during pregnancy may result in miscarriage, stillbirth, or chorioamnionitis, often
with placental abscesses. Listeria may infect the fetus through the ascending or
hematogenous route, often leading to signs of severe sepsis at delivery [23]. The
vast majority of cases represent perinatal transmission, although nosocomial
transmission has been reported [32].

2.3.1.2 Gram-Negative Organisms

While gram-negative organisms are responsible for a smaller fraction of neonatal
sepsis than are gram-positive organisms, they are associated with the highest
mortality. In NICHD surveys, gram-negative bacteria accounted for 61% of cases of
EONS and 18% of cases of LONS in VLBW infants, with respective mortality rates
of 41 and 36% [31].

Escherichia coli: Since E. coli is the most common cause of neonatal sepsis by
gram-negative bacteria, both organism and host response have been investigated.
A number of E. coli virulence factors have been identified and linked to neonatal
10

sepsis, including the K1 capsule, fimbriae, hemolysin, rough lipopolysaccharide,

invasion of brain endothelium proteins, and cytotoxic necrotizing factor 1. A
pathogenicity island, or cluster of genes present in pathogenic but not in avirulent
strains, was found in E. coli C5, a strain commonly implicated in neonatal
meningitis. Mutant strains lacking this pathogenicity island were less able to
induce high-level bacteremia in a neonatal-rat model [33]. In a comparative study,
E. coli isolates from term infants with sepsis were more likely to express multiple
virulence factors than were those from preterm infants with sepsis implying that
bacterial factors contribute to the infectivity of E. coli in term infants while host
factors contribute to disease susceptibility in preterm neonates [23].

Enterobacter, Klebsiella, and Serratia species: Gram-negative enteric organisms

of the Enterobacteriaceae family, notably Enterobacter, Klebsiella, and Serratia
species, are common inhabitants of the neonatal intestine which may cause
nosocomial sepsis. Like the other well-known member of the family, E. coli, these
organisms are surrounded by a capsule and fimbriae that contribute to their
virulence in neonates. This capsular polysaccharide prevents activation of the
alternative complement system protecting the bacteria from opsonization,
phagocytosis, and bacteriolysis [23].
In a 1999, a CDC-sponsored point prevalence survey of HAIs in 29 NICUs
(including both term and preterm neonates), E. cloacae, K. pneumoniae, and S.
marcescens each accounted for 5 to 6% of the total pathogens causing various
types of infection [34]. These three organisms together accounted for 5.1% of
bloodstream infections in this survey and 8.7% of LONS in the NICHD Neonatal
Network survey [31].

Citrobacter species: Another uncommon but notable gram-negative pathogen

found in VLBW neonates is Citrobacter. Invasive infections with Citrobacter
koseri, formerly C. diversus, are much more common in neonates than in other
patient groups, while C. freundii rarely causes disease in neonates. C. koseri is
responsible for less than 5% of cases of sepsis in preterm VLBW infants but is
well known because of its propensity for CNS invasion and its association with
11

epidemic outbreaks in both well-baby and intensive care nurseries. C. koseri is not
a normal inhabitant of the maternal urogenital tract, but it is occasionally present,
causing maternal UTI and chorioamnionitis. Vertical transmission may lead to a
neonate with severe sepsis at birth or in the first days of life [35]. Horizontal
transmission of C. koseri from patient to patient via the hands of infant caregivers
has been documented. In the early 1980s, a number of outbreaks of C. koseri
meningitis in well-baby nurseries were reported [36].

Pseudomonas aeruginosa: A non-fermentative, gram-negative rod, is responsible

for a wide variety of clinical syndromes in NICU patients, including sepsis,
pneumonia, meningitis, diarrhea, conjunctivitis and skin infections. Nevertheless,
if compared to other gram-negative bacteria, outbreaks by P. aeruginosa in NICU
settings have been much less reported and have been associated with both
environmental reservoirs and healthcare workers' carriage [37]. Due to ubiquitous
nature of P. aeruginosa, its high affinity to moist environments, and ability to
survive at various conditions, it remains as a common pathogenic agent in
neonatal intensive care units. Immunodeficiency status of newborn, invasive
characteristics of diagnostic and therapeutic procedures and indiscriminating use
of antimicrobials are predisposing factors with significant morbidity and mortality
rates in P. aeruginosa septicemia [38].

Acinetobacter species: Usually commensals, but they are emerging as important

opportunistic pathogens because they are rapidly evolving towards multidrug
resistance and are often involved in various NIs that can be severe, such as
bacteremia, meningitis, or pneumonia [39]. Acinetobacter baumannii is a gramnegative, nonmotile, obligate aerobic coccobacillus harboring a number of
effective virulence factors. These factors include the attachment to and persistence
on solid and dry surfaces, the ability to obtain essential nutrients such as iron, the
adhesion to and subsequent destroying of epithelial cells, and the ability in some
strains to produce gelatinases and proteinases that damage host tissues. A.
baumannii has the added ability to colonize the skin of patients or healthy
individuals without causing illness. The transmission of colonized bacteria to a
susceptible patient, however, can result in infection [40].
12

Haemoplilus influenza: H. influenzae represents a significant cause of antepartum

and post-partum sepsis, neonatal meningitis, fetal death in utero and premature
rupture of membranes [41]. The predominant serotypes involved in neonates
appear to be non-type b whereas in older infants type b is responsible for the great
majority of cases. Most cases of neonatal H. influenzae sepsis begin before or at
the time of delivery, as the disease is strongly associated with early postnatal
onset, prematurity, and a variety of maternal complications. The mortality rate is
55.5% overall but 90% among babies born at less than or equal to 30 weeks of
gestation [42].

2.3.1.3 Anaerobic Bacteremia

Anaerobes account for less than 5% of cases of neonatal bacteremia, with premature
infants representing a substantial proportion of these cases [31]. The role of anaerobic
bacteria in neonatal bacteremia has not been studied adequately [23]. The true
incidence of neonatal anaerobic bacteremia is difficult to ascertain since anaerobic
blood cultures were not employed in the major reported series of neonatal bacteremia
and still are not routinely performed in some medical centers. Furthermore, many
medical centers do not employ appropriate techniques for recovery of anaerobes [43].
In a review of 178 cases of neonatal anaerobic bacteremia, 73 isolates were
Bacteroides species (69 were B. fragilis), 57 were Clostridium species (mostly C.
perfringens), 35 were Peptostreptococcus species, 5 were Propionibacterium acnes, 3
were Veillonella species, 3 were Fusobacterium species, and 2 were Eubacterium
species [44]. Other reports have confirmed this predominance of B. fragilis and C.
perfringens among anaerobic isolates from cultures of neonatal blood samples [23].
The factors predisposing for anaerobic bacteremia are similar to predisposing factors
for aerobic bacteremia. Prolonged time after premature rupture of membranes and
maternal amnionitis are the most common associated obstetric factors [43]. It is
important to consider the possibility of anaerobic infection in preterm neonates with
necrotic entrocolitis (NEC), since the standard antibiotic regimens used for LONS
may not provide adequate coverage for anaerobes and these infections are associated
with high mortality. Due to these risk factors for anaerobic bacteremia, both aerobic
13

and anaerobic blood culture bottles should be considered in the evaluation of

suspected cases of EONS and when LONS has gastrointestinal pathology [23].
2.3.1.4 Fungal sepsis
Fungi are the third most frequent causal agent of LONS in preterm neonates, with an
estimated incidence of 2.6% to 3.1% in VLBW and 10% to 16% in ELBW neonates
in the NICU, with a crude mortality of 30% to 75% [45]. The incidence of fungal
sepsis among preterm infants has increased considerably over the last two decadesof
the 20th century. In a single-center study (1989 to 1998) of VLBW infants, the
incidence increased from 3.8% in 1989 to 6.8% in 1998 [46]. On the other hand, a
significant decrease was reported in the incidence of hospital-acquired candidemia
among VLBW neonates [47]. Candida spp. accounts for approximately 12% of
LONS in VLBW infants. The vast majority of fungal infections in preterm neonates
are due to Candida species, with a small number being due to other rare fungi [48].
Most factors associated with an increased risk of fungal colonization and infection are
closely related to the clinical and demographic characteristics of preterm neonates and
the long and invasive care they require through their lack of immunocompetence. It is
also clear that invasive fungal infection (IFI) is usually preceded by colonization by
the same species, and colonization itself is a major IFI risk factor [45].
2.3.2 Infection rates
While HAIs are an important health care concern worldwide, they are especially
troublesome in developing nations. Infection rates range from 1% in Northern Europe,
especially the Netherlands, which introduced extremely aggressive infection control
measures, to > 40% in some parts of Asia, South America, and sub-Saharan Africa
[49]. In another review of studies, rates of neonatal sepsis were as high as 170/1000
live births (clinically diagnosed) and 5.5/1000 live births (blood culture-confirmed)
[50].
There are significant regional differences in pathogens of importance in neonatal
sepsis, especially in the proportion of infections caused by Group B streptococci
(GBS), S. aureus, and Acinetobacter/Pseudomonas. GBS is an important pathogen in
some African countries (but absent in others), Middle-eastern countries, and the
Caribbean Islands, but is less important in South Asia. However, intra-country
14

differences also occur and isolated studies in India and Pakistan have reported GBS to
be an important cause of early-onset sepsis. S. aureus is the most common pathogen
in African countries and a peculiar trend of Acinetobacter/Pseudomonas infections
was noted in Asia Pacific [51].
There are few data on infection rates in normal nurseries, where the infant is healthy
and the hospital stay is short. Reported rates are low, from 0.3 to 1.7 per 100
newborns. Infection rates in infants of birth weights less than 1,500 g, 1,501 to 2,500
g, and more than 2,500 g were 63%, 8.2%, and 6%, respectively in a study from the
USA, and 74%, 28%, and 13%, respectively in a study from Brazil [5].
National nosocomial infections surveillance (NNIS) system of the CDC rates for all
newborn nurseries reporting in 1984 were 0.9 and 1.7 per 100 discharges for
nonteaching and large teaching hospitals, respectively [52]. Reported infection rates
in the NICU in the following decades vary from 3.2 to 30 per 100 admissions or
discharges, illustrating the wide variability among centers [53]. NICUs that admit
surgery patients may have higher rates. A rate of 58 per 100 admissions was reported
in one small series from a newborn surgery unit [5].
2.3.3 Mortality rates
Neonatal mortality is increasingly recognized as an important global public health
challenge that must be addressed to reduce child health disparities between rich and
poor countries. Most of the estimated 4 million neonatal deaths per year occur in low
and middle income countries [54], in another measurement 99% in developing
countries [55], yet most epidemiological and other research focuses on the 1% of
deaths in rich countries [56].
Three conditions: infection, birth asphyxia, and consequences of premature birth/low
birth weight, are responsible for majority of these deaths. More than one-third is
estimated to be due to severe infections, and a quarter is due to the clinical syndrome
of neonatal sepsis/pneumonia. Case fatality rates for neonatal infections remain high
among both hospitalized newborns and those in the community [57].

15

According to WHO regional classification; the highest infant mortality rate (deaths in
1000 live births) in the year 2008 was in African region (40), while the lowest was in
European region (7). The Eastern Mediterranean region came second (35), the region
includes Arab countries, Iran and Afghanistan (occupied Palestine, Gaza strip and the
west bank are not included) [58]. In the Palestinian territories the rate is 25/1000 live
births [18].
Differences in mortality rates inside developed countries are reported as well, in a
study on sepsis-related mortality among newborns in the US, it was concluded that
despite declines in the overall mortality among newborns, racial and regional gaps in
mortality persisted over the 16-year study period (i.e. blacks and infants born in the
South) [59].
Preventing deaths in newborn babies has not been a focus of child survival or safe
motherhood programs. While these challenges are neglected, 450 newborn children
die every hour, mainly from preventable causes, which is unconscionable in the 21st
century [56]. It is no longer possible to overlook the important contribution of
neonatal mortality to overall infant survival. To reduce neonatal mortality caused by
infections, a strong case must be made for investment in expanded surveillance
activities and in further research on diagnosis, etiology, and optimal management of
neonatal sepsis at all levels of the health system [60]. The Department of Child and
Adolescent Health and Development of the World Health Organization (WHO/CAH)
applied the Child Health and Nutrition Research Initiative (CHNRI) priority-setting
methodology to identify and stimulate research most likely to reduce global newborn
infection-related mortality by 2015 and concluded that the implementation of research
studies in developing countries on health systems and policy research are top priority
to accelerate reduction of neonatal deaths, particularly due to infections [61].
2.4 Acquisition of Infection
2.4.1 Colonization of the Newborn
The neonatal period is crucial for intestinal colonization, and the processes involved
in the establishment of microbial populations are complex and involve both microbial
succession as well as interactions between the infant and the microbes in the different
16

regions of the gut [40]. Facultative anaerobes appear first, consisting of

Enterobacteria, streptococcus and Staphylococcus. Bifidobacterium and Lactobacillus
species appear after the first weeks of life and the former constitute the predominant
bacterial species in the infant gut [62]. The predominant sources of microbes for the
initial colonization of the gastrointestinal tract (GIT) following birth are the maternal
microbiota, especially during vaginal delivery, and the infants diet (breast versus
formula feeding). Other factors that influence the composition of the enteric
microbiota of infants are the environment during birth, gestational age, hygiene
measures and antibiotic treatment [63].
Mode of delivery is a key factor that shapes the developing infant microbiota.
Vaginally born infants are initially colonized by fecal and vaginal bacteria from the
mother, whereas infants born via caesarean section are exposed initially to bacteria
originating from the hospital environment and health-care workers [64].
The developmental aspect of the intestinal bacterial colonization of preterm infants is
reported to differ from that of full-term infants. Colonization of beneficial bacteria
such as lactobacilli and bifidobacteria is often delayed in preterm infants and these are
only found in low numbers during the first few weeks of life, whereas colonization of
potentially pathogenic bacteria such as E. coli, clostridia and staphylococci occurs
such that these are found in high numbers [65]. The composition of the enteric
microbiota of infants is strongly influenced by diet. Several studies have reported that
bifidobacteria and lactobacilli dominate the microbiota of breast-fed infants, while
formula-feeding generally results in a more diverse microbial population, including
bifidobacteria, Bacteroides, clostridia and streptococci and higher numbers of
facultative

anaerobic

bacteria,

such

as

staphylococci,

streptococci

and

Enterobacteriaceae [66].
Antibiotic administration results in suppression of all anaerobic bacteria, with the
exception of clostridia, which remain at detectable levels, and increased numbers of
Klebsiella,

Enterobacter,

Citrobacter

and

Pseudomonas.

Lactobacilli

and

bifidobacteria are generally absent in the intestine of antibiotic-treated infants [67].

17

Moreover, nursing of preterm infants in closed incubators and reduced exposure to

maternal microbiota may affect the development and the diversity of their intestinal
microbiota [68].
Surface colonization has less concern in this matter. Gram-positive microorganisms
predominate in the pharynx, and CoNS predominate at the umbilicus [5]. Maternal
source is also essential, a significant correlation was found between maternal genital
bacteria and neonatal umbilical swab, ear swab, throat culture as well as gastric
aspirate [69].
2.4.2 Modes of Transmission
The usual mode of transmission of microbes in the nursery is by contact, either direct
physical contact with an infected or colonized person or, more often, transfer from
one infant to another on the hands of personnel. Hands have been implicated in
several nursery outbreaks with various gram-negative bacilli, S. aureus,
Enterococcus, and viruses. Usually, hands are transiently contaminated, and hand
washing removes the microorganisms and interrupts transmission. Artificial
fingernails have been associated with transmission of P. aeruginosa. [70]. Hand
washing may itself perpetuate outbreaks if hand-washing agents become
contaminated [5]. The most common mode of transmission, contact transmission is
divided into two subgroups: direct contact and indirect contact [71].
2.4.2.1 Direct contact transmission: occurs when microorganisms are transferred
from one infected person to another person without a contaminated intermediate
object or person. Opportunities for direct contact transmission between patients and
healthcare personnel have been summarized in the Guideline for Infection Control in
Healthcare Personnel [70] and include:

Blood or other blood-containing body fluids from a patient directly enters a

caregivers body through contact with a mucous membrane [72] or breaks (i.e.,
cuts, abrasions) in the skin [73].

Mites from a scabies-infested patient are transferred to the skin of a caregiver

while he/she is having direct ungloved contact with the patients skin [74].
18

A healthcare provider develops herpetic whitlow on a finger after contact with

HSV when providing oral care to a patient without using gloves or HSV is
transmitted to a patient from a herpetic whitlow on an ungloved hand of a
healthcare worker (HCW) [75].

2.4.2.2 Indirect contact transmission: involves the transfer of an infectious agent

through a contaminated intermediate object or person. In the absence of a pointsource outbreak, it is difficult to determine how indirect transmission occurs.
However, extensive evidence cited in the Guideline for Hand Hygiene in HealthCare Settings suggests that the contaminated hands of healthcare personnel are
important contributors to indirect contact transmission [71]. Examples of
opportunities for indirect contact transmission include:

Hands of healthcare personnel may transmit pathogens after touching an

infected or colonized body site on one patient or a contaminated inanimate
object, if hand hygiene is not performed before touching another patient [76].

Patient-care devices (e.g., tourniquets [77], stethoscopes [78], thermometers

[79], glucose monitoring devices [80], etc) may transmit pathogens if devices
contaminated with blood or body fluids are shared between patients without
cleaning and disinfecting between patients [81].

Shared toys are bacterial reservoirs [82], and may become a vehicle for
transmitting pathogenic bacteria such as Pseudomonas aeruginosa [83] or
respiratory viruses such as respiratory syncytial virus (RSV) [84] among
pediatric patients.

Instruments that are inadequately cleaned between patients before disinfection

or sterilization such as bronchoscopes [85], colonoscopies [86] or that have
manufacturing defects that interfere with the effectiveness of reprocessing
[87] may transmit bacterial and viral pathogens.

19

Clothing and uniforms such as white coats [88], isolation gowns [89], gloves
when contaminated [90] or leaked [91] when used as personal protective
equipment (PPE), may become contaminated with potential pathogens after
care of a patient colonized or infected with an infectious agent such as MRSA
[92], VRE [93], and C. difficile [94].

Many other vectors and reservoirs have been reported in the health care environment,
(e.g., computer hardware [95], rings [96], keyboards [97], doctors neckties [98],
mobile phones [99], soap dispensers [100] and wristwatches [101]). Water sources are
additional potential hazards in the NICU. Blood transfusions may be a source of
viruses such as cytomegalovirus (CMV), Hepatitis A, B and C viruses (HAV, HBV,
HCV). Breast milk is another source of blood-borne viruses. Approximately one third
of CMV-seropositive women excrete CMV in their breast milk, and two thirds of
these women were found to transmit CMV to their newborns by breast-feeding. HIV
is transmitted from mother to newborn by breast milk, and breast-feeding may be the
major means of acquisition of human T-cell leukemia virus type I (HTLV-I). Breast
milk may contain bacteria if the mother is bacteremic or has mastitis but is more
likely to be contaminated with bacteria during collection or handling. One study
reported growth of gram-negative bacilli in 36% of samples of unpasteurized human
milk. Formula feeds may also become contaminated during preparation or handling.
Contaminated blenders have been identified as a source of infection. Bacteremia and
meningitis have been associated with powdered infant formula intrinsically
contaminated with Enterobacter sakazakii [5].
2.5 Risk Factors for Infection
HAI rates on different neonatal units vary widely. There are several reasons for this
variation, including differences in the way that sepsis is defined, differences in the
types of babies treated and differences in standards of care. There is clear evidence
that the contributors to HAI are indeed multifactorial. Clusters of infection with
particular nosocomial pathogens inevitably occur on NICUs from time to time. An
understanding of risk factors for acquisition and/or infection with the outbreak strain
can inform infection control measures to terminate the outbreak [102].

20

The determination of risk factors for all-cause sepsis is the most useful approach,
where the aim of surveillance is to compare intra- or inter-unit infection rates, since
the predominant microbial flora in units varies. The only exception to this might be
CoNS, which account for the majority of blood culture isolates in NICUs. Infection
rates with these bacteria might, therefore, represent a reasonable proxy for overall
infection rates. However, such an approach might mask important differences in rates
of infection with less common, but more virulent, pathogens [103].
Risk factors for BSI fall into three main categories:
1. Intrinsic risk factors that cannot be influenced, and relate to the patients biological
status. Some such risk factors are static, for example, birth weight, gestational age and
condition at birth, whereas others, for example, postnatal age, vary daily.
2. Extrinsic risk factors that relate to treatment that the individual patient receives.
These risk factors may vary from day to day.
3. Risk factors that relate to infrastructural considerations, such as access to
handwashing and isolation facilities, environmental cleanliness and staffing numbers.
These consist of a mixture of static and variable elements [102].

2.5.1 Intrinsic risk factors (The Newborn)

The fetus and newborn face a complex set of immunological demands, including
protection against infection, avoidance of harmful inflammatory immune responses,
that can lead to pre-term delivery, and balancing the transition from a sterile intrauterine environment to a world that is rich in foreign antigens. These demands shape a
distinct neonatal innate immune system that is biased against the production of proinflammatory cytokines. This bias renders newborns at risk of infection and impairs
responses to many vaccines [104]. Premature newborns respond adequately to most
protein antigens, but response to polysaccharide antigens is poor in the first 2 years of
life. Opsonization activities of the alternate complement system and serum fibronectin
levels are deficient in the term infant. The newborn has a high total T-lymphocyte
count, but phenotypic surface markers differ from those in the older child. Cytotoxic
T-cell activity is decreased as is T-cell helper function. T-cell dependent antigen
specific response is delayed, and there is limited production of several cytokines.

21

Natural killer cell activity, important in control of herpes group viral infections, is
also decreased [105].
It is universally agreed that the incidence of late onset sepsis is inversely proportional
to birth weight and gestational age [102]. The incidence of preterm births (<37 weeks
gestation) is increasing in many countries around the world and has become a global
health concern. More than 70% of preterm infants are born between 34 and 36 weeks
gestation (late preterm). Most large series describing the epidemiology of neonatal
sepsis are limited to infants with very low gestational age (<33 weeks) or VLBW
(<1500 g birth weight) [106].
Maternal risk factors can be included in this category; maternal fever, pre-labour
rupture of membranes of >18 hours, premature onset of labour, chorioamnionitis,
urinary tract infections and group B streptococcus (GBS) colonization are the key
maternal risk factors [51]. The effect of gestational age on the risk of GBS disease for
example could be explained by the amount of maternal IgG antibodies received by the
infant, because susceptibility to invasive GBS disease has been correlated with
deficiency in levels of maternal type-specific serum IgG antibodies [107].
2.5.2 Extrinsic risk factors (Invasive Procedures)
Any procedure that disrupts the normal barriers to infection is likely to present a
higher risk of infection in the newborn than later in life. The normal newborn escapes
most invasive procedures but may be subjected to scalp electrodes or percutaneous
punctures for blood sampling. Scalp electrodes provide a portal of entry for maternal
genital microorganisms. Infectious complications occur in less than 1% of infants and
most are benign abscesses, but severe cellulitis, bacteremia, osteomyelitis, and
disseminated HSV infection have been reported. Premature and ill newborns often
require feeding by nasogastric tubes, which provide a portal of entry and potentiate
overgrowth of microbes in the upper gastrointestinal tract. Breast milk and formula
feeds administered by continuous infusion remain at room temperature for several
hours, allowing microbes to proliferate in the reservoir or tubing during infusion.
[108]. The most commonly reported causative pathogens of central lineassociated
bloodstream

infections

(CLABSIs)

remain
22

CoNS,

Staphylococcus

aureus,

enterococci, and Candida spp. Gram negative bacilli accounted for 19-21% of
CLABSIs reported to CDC [109].

2.5.3 Environment (infrastructure-related) risk factors

A small number of studies have examined the relationship between neonatal sepsis
and organizational and structural factors on the NICU [102]. Infection rates in the
NICU increase with overcrowding and understaffing [5]. Increasing rates of endemic
MRSA was linked to overcrowding and understaffing, with eradication of MRSA
when these conditions improved [110]. An outbreak of Enterobacter cloacae
infection was associated with understaffing and overcrowding in another report; a
decrease in percentage of HAIs from 5.8 to 1.8 was observed after a move to a new
NICU with more nurses and space per infant, more accessible sinks, and improved
ventilation [111]. One of the most important predictors of patient well-being is the
amount of direct nursing care patients receive per day, the measure of nursing
provision used is the patientnurse ratio (PNR); this is the average number of
registered nurses (calculated over a 24 h period of shifts, including partial nurse
shifts) and occupancy in terms of NICU census of midnight the previous day [111].
Evidence-based guidelines for healthcare workers' hand hygiene practices exist, but
compliance with these is internationally low [113]. The hand-hygiene compliance
observed among HCW by many researchers doesn't exceed 50% [114-117]. Many
factors have contributed to poor handwashing compliance among healthcare workers,
including a lack of knowledge among personnel about the importance of hand hygiene
in reducing the spread of infection and how hands become contaminated, lack of
understanding of correct hand hygiene technique, understaffing and overcrowding,
poor access to handwashing facilities, irritant contact dermatitis associated with
frequent exposure to soap and water, and lack of institutional commitment to good
hand hygiene [118]. In order to be effective, efforts to improve compliance with
handwashing guidelines must be multifaceted. Alcohol hand rubs (with emollients)
need to be provided at each patient's bedside. Issues surrounding healthcare workers'
skin irritation need to be addressed urgently [113].

23

2.6 Monitoring, prevention and control

Today's preventive strategies for health-care associated sepsis focus on augmenting
the immunologic and functional immaturities of premature infants and ameliorating
the risks of extrinsic factors by the use of prophylactic antibiotics and best clinical
practices [119].
2.6.1 Surveillance
The HAI rate is an indicator of quality and safety of care. The development of a
surveillance process to monitor this rate is an essential first step to identify local problems
and priorities and evaluate the effectiveness of infection control activity [10].

Surveillance of HAIs provides data useful for identifying infected patients,

determining the site of infection, and identifying the factors that contribute to HAIs.
When infection problems are recognized, surveillance data allow the hospital to
institute appropriate intervention measures and evaluate their efficacy. In addition,
one can follow the trends of infections that are increasing in incidence, such as
bloodstream infections [120]. Infection surveillance on NICUs presents a number of
unique challenges, including defining infections, the preponderance of CoNS as both
pathogens and commensals, and allowing for the influence of important risk factors
[103]. Where resources are limited, the use of surveillance as an infection monitoring
tool generally should be restricted to investigating outbreaks or exposures. When
considering initiating other types of surveillance activities, the objectives should be
reasonable in terms of the resources and time available, and the projected use for the
data should be clearly defined before routine collection of data is established [121].
An HAI surveillance system may be sentinel event based, population based, or both.
A sentinel infection is one that clearly indicates a failure in the hospital's efforts to
prevent infections and, in theory, requires individual investigation. Population-based
surveillance, that is, surveillance of patients with similar risks, requires both a
numerator (the infection) and denominator (number of patients or days of exposure to
the risk) [122]. Rather than relying on point prevalence, a reasonable alternative
would be to base prospective surveillance on the concentrated scrutiny of microbial
cultures. This method of surveillance has been described as laboratory-based
24

surveillance. All culture positive patients in hospital are evaluated for a possible HAI
or a community acquired infection. The cut-off of a two to three day interval between
hospitalization and a positive bacterial culture is used to identify HAI. Every
suspected case of HAI is reviewed for confirmation. The HAI rate is computed
monthly as episodes per 100 hospital admissions. Nevertheless, the limited approach
of laboratory culture-based surveillance could be realistic, with negligible financial
burden on the hospital management [123].
Logically, surveillance should begin only after all recommended steps for preventing
HAIs have been taken. For hospitals in most countries, rigorously employing the
evidence-based infection prevention practices should be the primary strategy for
preventing NIs and avoiding bad outcomes in hospitalized patients. Then the use of
measures proven to reduce infection risk at specific sites or from invasive procedures
should be checked. Only after successfully implementing and monitoring these
recommendations should the use of surveillance be considered [121].

2.6.2 NICUs Outbreak Control

A significant change over background rate in infections at a certain site or with a
particular microbe should be considered an outbreak. Increased infection rates
involving a number of different microbes or strains of the same microbe are likely to
be related to: breakdown in infection control procedures such as occurs with
crowding, understaffing, or other major disruption of the routine functioning of the
unit; defective sterilization or disinfection technique; or a change in the use of
invasive procedures [124]. Outbreaks of health care-associated infections in neonatal
intensive care units (NICUs) are frequent and have received more attention in medical
literature than outbreaks from other types of intensive care units (ICUs).
Enterobacteriaceae were significantly more often responsible for NICU outbreaks,
whereas nonfermenting bacteria are more frequently identified in other ICU types
[125].
Recommended infection control and prevention strategies are: hand washing
promotion, decreased use of invasive procedures, limited antibiotic exposure, and
environmental hygiene. In this context infection surveillance is the first step to
25

recognize and analyze problems, to effectively target infection control measures and
feedback. Any suspicion of an outbreak should lead to a review of general infection
control procedures to prevent the spread of the pathogens as quickly as possible. A
multidisciplinary approach can be an effective means of developing a plan of action to
apply prolonged and strict adherence to isolation precautions, to detect potential
reservoirs or source of infections, to educate every member of the patient care team
and to review NICU protocols [126].
2.6.3 The role of the microbiology laboratory
The microbiology laboratory has become an integral part of a hospital epidemiology
and infection control program. The constantly changing spectrum of nosocomial
pathogens and their susceptibilities and the availability of newer technologies require
constant communication, cooperation, and collaboration between microbiology
personnel and infection control personnel (ICPs). In the twenty-first century, this
relationship is more critical than at any time in the past [127]. The clinical
microbiology laboratory contributes to preventing transmission of infectious diseases
in healthcare settings by promptly detecting and reporting epidemiologically
important organisms, identifying emerging patterns of antimicrobial resistance, and
assisting in assessment of the effectiveness of recommended precautions to limit
transmission during outbreaks, outbreaks of infections may be recognized first by
laboratorians [128]. Today, however, the work done by the microbiology laboratory is
increasingly complex and demanding. Much of this has direct implications on hospital
epidemiology and infection control. Microbiology laboratories now must be able to
detect, identify, and characterize an expanded array of microbes, including newly
emerging pathogens [127].
2.6.4 Environmental monitoring
Microbiologic sampling of air, water, and inanimate surfaces (i.e., environmental
sampling) is an expensive and time-consuming process that is complicated by many
variables in protocol, analysis, and interpretation. It is therefore indicated for only
four situations [129]:

The first is to support an investigation of an outbreak of disease or infections

when environmental reservoirs or fomites are implicated epidemiologically in
26

disease transmission [130]. It is important that such culturing be supported by

epidemiologic data. Environmental sampling, as with all laboratory testing,
should not be conducted if there is no plan for interpreting and acting on the
results obtained [131]. Linking microorganisms from environmental samples
with clinical isolates by molecular epidemiology is crucial whenever it is
possible to do so [132].

The second situation for which environmental sampling may be warranted is

in research. Well-designed and controlled experimental methods and
approaches can provide new information about the spread of health-care
associated diseases [133]. A classic example is the study of environmental
microbial contamination that compared health-careassociated infection rates
in an old hospital and a new facility before and shortly after occupancy [134].

The third indication for sampling is to monitor a potentially hazardous

environmental condition, confirm the presence of a hazardous chemical or
biological agent, and validate the successful abatement of the hazard. This
type of sampling can be used to: a) detect bio-aerosols released from the
operation of health-care equipment and determine the success of repairs in
containing the hazard, b) detect the release of an agent of bioterrorism in an
indoor environmental setting and determine its successful removal or
inactivation, and c) sample for industrial hygiene or safety purposes (e.g.,
monitoring a sick building) [132].

The fourth indication is for quality assurance to evaluate the effects of a

change in infection-control practice or to ensure that equipment or systems
perform according to specifications and expected outcomes. Any sampling for
quality-assurance purposes must follow sound sampling protocols and address
confounding factors through the use of properly selected controls. Results
from a single environmental sample are difficult to interpret in the absence of
a frame of reference or perspective. Evaluations of a change in infectioncontrol practice are based on the assumption that the effect will be measured
over a finite period, usually of short duration. Conducting quality-assurance
sampling on an extended basis, especially in the absence of an adverse
27

outcome, is usually unjustified. A possible exception might be the use of air

sampling during major construction periods to qualitatively detect breaks in
environmental infection-control measures [132].
2.6.5 Patient-Care Items categorization concept
Earle H. Spaulding devised a rational approach to disinfection and sterilization of
patient-care items and equipment [135]. Spaulding believed the nature of disinfection
could be understood readily if instruments and items for patient care were categorized
as critical, semicritical, and noncritical according to the degree of risk for infection
involved in use of the items [136].

Critical Items: Critical items confer a high risk for infection if they are
contaminated with any microorganism. Thus, objects that enter sterile tissue or
the vascular system must be sterile because any microbial contamination could
transmit disease. This category includes surgical instruments, cardiac and
urinary catheters, implants, and ultrasound probes used in sterile body cavities.
Most of the items in this category should be purchased as sterile or be
sterilized with steam if possible. Heat-sensitive objects can be treated with
ethylene oxide, hydrogen peroxide gas plasma; or if other methods are
unsuitable, by liquid chemical sterilants [136].

Semicritical Items: Semicritical items contact mucous membranes or

nonintact skin. This category includes respiratory therapy and anesthesia
equipment, some endoscopes, laryngoscope blades [137], esophageal
manometry probes, cystoscopes [138], anorectal manometry catheters, and
diaphragm fitting rings. These medical devices should be free from all
microorganisms; however, small numbers of bacterial spores are permissible.
Intact mucous membranes, such as those of the lungs and the gastrointestinal
tract, generally are resistant to infection by common bacterial spores but
susceptible to other organisms, such as bacteria, mycobacteria, and viruses.
Semicritical items minimally require high-level disinfection using chemical
disinfectants [136].

28

Noncritical Items: Noncritical items are those that come in contact with intact
skin but not mucous membranes. Intact skin acts as an effective barrier to most
microorganisms; therefore, the sterility of items coming in contact with intact
skin is "not critical". Noncritical items are divided into noncritical patient care
items and noncritical environmental surfaces [139]. Examples of noncritical
patient-care items are bedpans, blood pressure cuffs, crutches and computers
[97]. In contrast to critical and some semicritical items, most noncritical
reusable items may be decontaminated where they are used and do not need to
be transported to a central processing area. Virtually no risk has been
documented for transmission of infectious agents to patients through
noncritical items [136]. Noncritcal environmental surfaces include bed rails,
some food utensils, bedside tables, patient furniture and floors. Noncritical
environmental surfaces frequently touched by hand (e.g., bedside tables, bed
rails) potentially could contribute to secondary transmission by contaminating
hands of health-care workers or by contacting medical equipment that
subsequently contacts patients [140]. Mops and reusable cleaning cloths are
regularly used to achieve low-level disinfection on environmental surfaces.
However, they often are not adequately cleaned and disinfected, and if the
water-disinfectant mixture is not changed regularly (e.g., after every three to
four rooms, at no longer than 60-minute intervals), the mopping procedure
actually can spread heavy microbial contamination throughout the health-care
facility [141]. Frequent laundering of mops (e.g., daily), therefore, is
recommended. Single-use disposable towels impregnated with a disinfectant
also can be used for low-level disinfection when spot-cleaning of noncritical
surfaces is needed [136].

2.7 Antimicrobial therapy

Owing to several physiological peculiarities, the pharmacokinetics of antibiotics of
neonates is different from those in older children. Pre-term neonates have additional
limitations due to organ system immaturity. In particular, gastro-intestinal absorption
of oral antibiotics is reduced and varies considerably among neonates. Selection of
empiric antibiotic therapy is dependent upon target organisms and their antibiotic
susceptibility, spectrum of antibiotic activity, association with emergence of
resistance, drug distribution, therapeutic index, cost of therapy and ease of use [51].
29

2.7.1 Prophylactic use of antibiotics

Antibiotics are used to manage asymptomatic newborns when the mother has risk
factors for infection or has a confirmed infection. Maternal fever, pre-labour rupture
of membranes of >18 hours, premature onset of labour, chorioamnionitis, urinary tract
infections and group B streptococcus (GBS) colonization are the key maternal risk
factors. Attack rates of sepsis among newborns with maternal GBS colonization,
premature onset of labour, prolonged rupture of membranes (or chorioamnionitis) and
maternal post-partum bacteremia are 12%, 15%, 11% and 10%, respectively.
Maternal carriage rates of GBS in developing countries of Middle East/North Africa,
Asia/Pacific, Sub- Saharan Africa, India/Pakistan and Americas are 22%, 19%, 19%,
12% and 14%, respectively [10].
Early onset neonatal infection (EONI) must be promptly identified at birth and
antibiotics started immediately, because delaying the antibiotic therapy increases the
risk of mortality and long-term disability. Presumptive antibiotic therapy for EONI is
often based on nonspecific clinical and laboratory findings. This strategy results in
much over-treatment [142]. Different protocols recommend giving intrapartum
chemoprophylaxis to all GBS carriers or to only those with additional obstetric risk
factors. Emergence of antibiotic resistance is a real danger of intrapartum
chemoprophylaxis. If the mother receives chemoprophylaxis and the neonate has
signs of infection, he should be investigated for sepsis and treated [10]. The antibiotic
combination prescribed in most units is penicillin (Benzylpenicillin, Ampicillin, or
Cloxacillin) together with an aminoglycoside, most commonly Gentamicin [143]. A
systematic review looking at empirical treatment for febrile neutropaenia in cancer
patients found no significant difference between using -lactam monotherapy or lactam and aminoglycoside combination, although there was a slight advantage in
using third generation cephalosporins [144].
2.7.2 Antimicrobial resistance of neonatal pathogens and hospital microbiota
Hospitals are dangerous places to be, especially if you are sick, but even if not [145].
Resistance is not a new phenomenon; it was recognized early as a scientific curiosity
and then as a threat to effective treatment outcome. However, the development of new
families of antimicrobials throughout the 1950s and 1960s and of modifications of
30

these molecules through the 1970s and 1980s allowed us to believe that we could
always remain ahead of the pathogens. By the turn of the century this complacency
had come to haunt us. The pipeline of new drugs is running dry and the incentives to
develop new antimicrobials to address the global problems of drug resistance are
weak. Antimicrobial use is the key driver of resistance. Paradoxically this selective
pressure comes from a combination of overuse in many parts of the world,
particularly for minor infections, misuse due to lack of access to appropriate treatment
and underuse due to lack of financial support to complete treatment courses [146].
A drug-resistant organism may be introduced into a health care facility with the
admission of a patient who is infected with or who has been colonized by such a
strain. Alternatively, antimicrobial resistance may emerge in bacteria as a response to
selective antibiotic pressure, or a resistant organism may spread from person to
person. Often, a combination of these factors may be involved in the emergence and
transmission of antimicrobial resistance within a health care facility [147].
The role of antibiotic exposure on the acquisition of antibiotic resistant bacteria in the
intensive care nursery is difficult to calculate given the covariance of such exposure to
other markers of severe disease. Experience has demonstrated, however, that use of
the aminoglycosides is infrequently associated with emergence of resistance in the
newborn, whereas the use of higher-generation cephalosporins may be associated with
the rapid appearance of bacilli resistant to -lactamses [148]. The extraordinary
genetic capacities of microbes have benefitted from man's overuse of antibiotics to
exploit every source of resistance genes and every means of horizontal gene
transmission to develop multiple mechanisms of resistance for each and every
antibiotic introduced into practice clinically, agriculturally, or otherwise [149].
Selective antibiotic pressure enhances the risk of transmission by increasing a
patients' bacterial load (through selection of preexistent resistant flora), with a
subsequent risk of hand contamination in health care workers, and by creating new
ecological niches for resistant flora after eradication of susceptible flora in other
patients [150].
Hospital-based data show alarming rates of resistance to Ampicillin and Gentamicin
among common pathogens causing neonatal sepsis (71% of Klebsiella and 50% of
Escherichia coli are reportedly resistant to Gentamicin), suggesting that the WHO
31

recommended Ampicillin and Gentamicin combination for treatment of neonatal

sepsis may no longer be effective in treating many newborns with sepsis [54].
Aminoglycosides may be associated with important adverse effects and they require
frequent monitoring of blood levels. Preterm infants have immature organs and
therefore may not tolerate some antibiotics as well as term infants. Further to these
significant disadvantages, the majority of treated babies do not have proven sepsis.
Moreover, the use of broad spectrum antibiotics in neonates may alter gut flora and
may also increase antibiotic resistance in the unit. Alteration of intestinal flora or
sterilization of the gut with these antibiotics may increase the risk of developing NEC
after stopping treatment [151].
Among Gram-positive organisms, the most important resistant pathogens are
methicillin- (oxacillin-) resistant S. aureus, -lactam-resistant and multidrug-resistant
pneumococci, and vancomycin-resistant enterococci. Important causes of Gramnegative resistance include extended-spectrum -lactamases (ESBLs) in K.
pneumoniae, E. coli, and P. mirabilis, high-level third-generation cephalosporin lactamase resistance among Enterobacter species and C. freundii, and multidrugresistance observed in P. aeruginosa, Acinetobacter, and Stenotrophomonas
maltophilia [152].
2.7.3 Regional differences
It is difficult to compare antibiotic resistance between countries because the
epidemiology of neonatal sepsis is extremely variable [143]. For years neonatologists
in industrialized countries in North America, Europe, and Australia have been
reporting problems with multi-resistant bacteria such as MRSA and Gram negative
bacilli that produce extended spectrum lactamase. Similar reports are now appearing
from developing countries with alarming rates of antibiotic resistance [153].
There is insufficient information on antimicrobial resistance patterns in community
settings on the three most common pathogens (E. coli, Klebsiella species, and S.
aureus) causing EONS. Available data indicate that India and Pakistan may have
significant antimicrobial resistance among E. coli, Klebsiella species, and S. aureus
which, if confirmed by future studies, will make devising inexpensive but effective
empiric regimens for treatment of neonatal sepsis difficult. Resistance among these
32

three pathogens appears to be less common in Africa, but data are insufficient. There
are important regional differences in susceptibility patterns of Haemophilus
influenzae and pneumococci in Africa, with some countries (South Africa, Malawi)
reporting high resistance rates to penicillin, chloramphenicol and cotrimoxazole; other
African countries have intermediate (Kenya, Senegal), or low resistance rates
(Gambia, Central African Republic, Ghana). There is a substantial resistance among
respiratory pathogens to cotrimoxazole in South Asia [51].
2.7.4 Antimicrobial resistance control
Information regarding antimicrobial resistance among infections-causing bacteria in
communities is essential for developing appropriate management strategies. In
addition, the sustainability of community-based management strategies depends on
monitoring changes in the etiology as well as resistance patterns of serious infections
over time. Unfortunately, there is a paucity of information on resistance patterns of
community-acquired infections in neonates and young infants in developing countries,
owing to lack of appropriate laboratory and susceptibility testing facilities and
challenges of conducting studies of etiology of serious infections in community
settings [154]
In the present battle against the rising tide of resistance, several interventions have
been proposed to help control the situation. One of these is a process of planned
antibiotic restriction, introduced through cycling drug selection based on local
surveillance. Although such antibiotic cycling has been the subject of much
discussion, there are relatively few data available to assess its worth [155]. Cycling or
rotation is the scheduled substitution of a class of antibiotics (or a specific member of
a class) with a different class (or a specific member of that class) that exhibits a
comparable spectrum of activity. This substitution may be followed after a fixed
interval by a third, fourth or, indeed, any number of substitutions, but the cycle must
be repeated, with re-introduction of the original class/drug [156]. A dilemma may
exist in regard to replacing an antibiotic that is losing effectiveness due to resistance
with a new drug within the same class. Such replacement may enhance treatment
success in the short term but promote the spread of highly resistant strains [157]. A
one year study on 1062 infants found no detectable effect of antibiotic cycling in
decreasing the reservoir of resistant Gram-negative bacilli in a tertiary-care NICU
33

[158]. Moreover, it's believed that cycling is unlikely to be effective and may even
hinder resistance control. Alternative drug-use strategies are suggested such as
mixing, in which each treated patient receives one of several drug classes used
simultaneously in the hospital [159].
Antimicrobial stewardship programs (ASPs) promote the appropriate use of
antimicrobials by selecting the appropriate dose, duration, and route of administration.
The appropriate use of antimicrobials has the potential to improve efficacy, reduce
treatment-related costs, minimize drug-related adverse events, and limit the potential
for emergence of antimicrobial resistance [160]. At this time, data from wellcontrolled studies examining the effect of ASPs on emergence of resistance are
limited, but available data suggests that good ASP reduces rates of C. difficile
associated diarrhea, resistant gram-negative bacilli, and vancomycin-resistant
enterococci [161].
In addition, using pharmacokinetics and pharmacodynamics principles to guide
antimicrobial dosing regimens may have a role in controlling development of
resistance. Enforcing rigorous infection control practices can reduce the transmission
of problematic pathogens within the healthcare setting [162]. Nevertheless, a strategy
whereby multiple or all classes of antibiotics are available for use (i.e., antibiotic
heterogeneity) can be part of a broader effort aimed at curtailing antibiotic resistance
within ICUs. Such efforts should be routine, given the limited availability of new
antibiotic drug classes for the foreseeable future [163].
Strategies should also be adopted to reduce antibiotic consumption in NICUs, a
randomized controlled trial found no evidence that routine antibiotic use has a
protective effect in low risk preterm neonates [164]. On the other hand, there is also
clear evidence that in the management of patients with severe infection, not only must
the chosen antibiotic regimen be appropriate, but its administration must be promptly
initiated [165]. The importance of early initiation of appropriate antibiotic therapy
was confirmed in an analysis of patients with sterile-site MRSA infections. In this
retrospective analysis of 549 patients treated over a 3-year period through the end of
2004, appropriate antibiotic therapy initiated within the first 24 h after collection of a
culture-positive specimen was correlated with a significantly higher survival rate
34

(33.4% vs. 22.0% among those who did not receive appropriate antibiotics; P = .015)
[166]. Rapid laboratory tests such as Interleukin-8 (IL-8) and/or C-Reactive Protein
(CRP) can reduce unnecessary antibiotic therapy and is cost-effective [167].
To achieve complete restitution of therapeutic applications of antibiotics, there is a
need for more information on the role of environmental microbiomes in the rise of
antibiotic resistance. In particular, creative approaches to the discovery of novel
antibiotics and their expedited and controlled introduction to therapy are obligatory
[149].
In conclusion, the frequencies of resistant bacteria in hospitals can be reduced by (i)
reducing antibiotic use, (ii) controlling the spread of bacteria, (iii) using antibiotics for
which there is no resistance, (iv) increasing the rate of turnover of patients, and (v)
restricting the input of patients and health-care workers carrying resistant nosocomial
pathogens [145]. The design of antimicrobial management programs should be based
on the best current understanding of the relationship between antimicrobial use and
resistance. Such programs should be administered by multidisciplinary teams
composed

of

infectious

diseases

physicians,

clinical

pharmacists,

clinical

microbiologists, and infection control practitioners and should be actively supported

by hospital administrators. Strategies for changing antimicrobial prescribing behavior
include education of prescribers regarding proper antimicrobial usage, creation of an
antimicrobial formulary with restricted prescribing of targeted agents, and review of
antimicrobial prescribing with feedback to prescribers. Clinical computer systems can
aid in the implementation of each of these strategies, especially as expert systems able
to provide patient-specific data and suggestions at the point of care. Antibiotic
rotation strategies control the prescribing process by scheduled changes of
antimicrobial classes used for empirical therapy. When instituting an antimicrobial
stewardship program, a hospital should tailor its choice of strategies to its needs and
available resources [168].

35

Chapter III
Materials and Methods
3.1 Materials
3.1.1 Apparatus

Manufacturer (Country)

Air sampler

AES CHEMUNEX (France)

Autoclave

Tuttnauer (USA)

Colony counter

Anderman (UK)

Deep freezer

Kirsch (Germany)

Digital camera

NOKIA N95 (Finland)

Incubator

Carbolite (France)

Optical microscope

Zeiss (Germany)

Refrigerator

Sanyo (Italy))

Water bath

Fried Electric (Israel)

3.1.2 Equipment and disposables

Cotton
Inoculating plastic loops
Magnetic stirrer
Wide mouth plastic cups (50ml, sterile)
Culture swabs
Tissue paper
Ice box
Microscope glass slides
Antibiotic diameter scalar ruler
Glassware
Plastic Petri plates
Alcohol handrub
Forceps

36

3.1.3 Reagents and stains

API- 20E (BioMrieux- France)
Barium chloride BaCl2
Hydrogen peroxide (3% H2O2)
Glycerol
Gram stain kit (HiMedia- India)
Human serum
Oxidase discs (HiMedia- India)
3.1.4 Culture media (Manufacturer- Country)
Blood agar (HiMedia- India)
Blood culture bottles (HiMedia- India)
Brain heart infusion broth (BHIB) (HiMedia- India)
Dichloran Rose Bengal Chloramphenicol (DRBC) agar (Oxoide- UK)
MacConkey agar (HiMedia- India)
Muller Hinton agar (HiMedia- India)
Nutrient agar (HiMedia- India)
3.1.5 Antibiotic discs
Antibiotic
Penicillin G
Ampicillin
Piperacillin
Cephalexin
Cefixime
Ceftriaxone
Gentamicin
Amikacin
Imipinem
Meropenem
Trimethoprim
Vancomycin
Ciprofloxacin
Nalidixic acid
Chloramphenicol
Tetracycline
Erythromycin

Potency
10 units
10 g
100 g
30 g
5 g
30 g
10 g
30g
10 g
10 g
5 g
30 g
5 g
30 g
30 g
30 g
15 g

Abbreviation
P
Am
PIP
Cn
Cfm
Cro
GM
Ak
I
MEM
TR
Va
Cp
Na
C
Te
E

Manufacturer- Country
HiMedia- India
HiMedia- India
HiMedia- India
Oxoide-UK
Oxoide-UK
Difco- USA
Difco- USA
HiMedia- India
HiMedia- India
HiMedia- India
Oxoide-UK
Oxoide-UK
Difco- USA
Oxoide-UK
HiMedia- India
HiMedia- India
Difco- USA

37

3.2 Methodology
A cross-sectional descriptive study consists of a checklist to evaluate environmental
and working conditions, a questionnaire to evaluate the healthcare workers'
knowledge and perspective, scanning patient's records for potential risk factors, blood
cultures for patients, sampling the environment and the workers for potential
pathogens and testing isolated microorganisms for antibiotic susceptibility.
3.2.1 Permission and ethical consideration
Permissions were obtained from the general administration of hospitals, hospitals
administration and heads of the selected NICUs (annex 13).
3.2.2 Environmental and working conditions
A checklist was designed to evaluate the environmental and working conditions of the
NICUs included in this study (Al-shifa and Al-Nasser) (annex 1). The 1st part is an
overview of the unit describing the work and treatment areas, the working staff, the
environmental conditions, the infrastructure maintenance and monitoring beside the
antimicrobial therapy regimen. The 2nd part describes formation, role and activities of
the infection control team. The 3rd part covers the handwashing and personal hygiene
which describes handwashing basins, personal protection equipment, handling and
disposal of sharps beside the intravascular access devices (catheters). The 4th part
covers the cleaning processes describing the routine environmental cleaning, the
management of clinical wastes, the management of blood and body spills beside the
use and cleaning of trolleys.
3.2.3 Hospital records
Data of admitted cases were obtained from the hospitals archives which are noncomputerized; each case has a separate file with a serial number. The file includes:
name of the newborn, date of birth, date of admission, birth weight, mode of delivery,
Apgar score, primary diagnosis, date and state of departure, administered medications,
prognosis of the case, laboratory test results, maternal age and parity, physicians notes
and nurses diaries. Data were collected for all admitted cases in a three-month period
(April - June 2010)

38

3.2.4 Microbiological methods

3.2.4.1 Samples description
Different samples were collected from the NICUs; Blood samples for blood culture
from neonates admitted to the unit, hand and nasal swabs from the working staff,
indoor air and environmental samples from the NICU environment.
1. Blood culture bottles were used to culture two blood samples from each neonate
admitted in the NICU during the study period (done by the HCW).
2. Sterile swabs were used to collect environmental samples from incubators,
resuscitation beds, phototherapy units, sinks, air conditions, scrubbings, trolleys,
trays, baby balances, counters, ambu bags, fridges, cupboards, and pumps.
3. Sterile swabs were used to collect nasal samples, and sterile containers for hand
samples of the staff.
4. Air sampler was used to collect bacterial and fungal samples from the units air.
3.2.4.2 Sampling duration and sample size
Blood samples were collected over a period of three months (April - June 2010). A
total of 61 positive blood cultures were obtained from hospital laboratories. A total of
40 environmental samples were collected from Al-Nasser NICU, and 70 from AlShifa NICU. Eighteen nasal and 18 hand samples were taken from Al-Nasser NICU
staff and 19 nasal and 19 hand samples from Al-Shifa NICU. Seven air samples for
bacterial culture and 7 for fungal culture were collected from Al-Nasser NICU (4
samples from the main ward, 2 from reception and 1 from resuscitation ward),
thirteen air samples for bacterial culture and 13 for fungal culture were collected from
Al-Shifa NICU (4 samples from each main ward, 2 from each ground floor ward and
1 from resuscitation ward). Samples are summarized in table (3.1)
Table 3.1: Microbiological samples from the two NICUs
NICU
Blood cultures
Hand samples
Nasal samples
Environment swabs
Air samples
Total

AlShifa
25
19
19
70
26
159

AlNasser
36
18
18
40
14
126

Total
61
37
37
110
40
285

39

3.2.4.3 Sampling methodology and primary processing

a- Neonate blood Culture
Blood cultures were collected, transported and tested according to CLSI standard
[169]. Two blood samples per patient were drawn at least 30 min apart from each
other. Blood culture bottles were incubated for seven days at 37o C and visually
inspected daily to detect positive growth. Positive bottles (turbid) were subcultered on
Blood agar and MacConkey agar and incubated overnight at 37o C.

b- Environmental samples
Sterile swabs filled with 3 ml of BHIB were used to swab approximately 10 cm2 [170]
of each environmental spot (tested spots are detailed in annexes 2, 3). Swabs were
then incubated overnight at 37o C and tested for turbidity. Positive samples (turbid)
were subcultered on Blood and MacConkey agars and incubated overnight at 37o C.
c- Nasal samples
Sterile swabs were used to collect nasal
samples by inserting the swab in one side of
participant nose and rolling it gently (figure
3.1) [171]. 3 ml of BHIB were added to the
swab tube to cover the sample. Swabs were
then incubated over night at 37o C and tested

Figure 3.1: Sampling of nasal swab

for turbidity. Positive samples (turbid) were subcultered

on Blood agar and MacConkey agar and incubated
overnight at 37o.
d- Hand samples
Participants were asked to rub their fingers of one of
their hands in a Petri plate containing about 30 ml of
BHIB (figure 3.2) [171]. The contents of the plate were
then transferred to a sterile screw-cap plastic cup,
transferred to the laboratory in an ice box and incubated

40

Figure 3.2: Sampling of hand swab

overnight at 37o C. Positive samples (turbid) were subcultered on Blood agar and
MacConkey agar and incubated overnight at 37o C.
e- Air samples
An

air

sampler

(Sampl'air-

AES

CHEMUNEX, France) (figure 3.3) was used

to collect air samples. The apparatus is
designed to pump 50 liters of air through the
target media plate in one minute.
Nutrient agar plates were used to collect
samples for bacterial count, transferred to the
laboratory in ice box, incubated for 48 hours
at 37o C.
DRBC agar was used to collect samples for
fungal count, transferred to the laboratory in

Figure 3.3: Sampl'air: Air sampler for microbiological

samples

ice box and incubated for 5 days at 25o C

before counting the grown colonies. No further analysis was done.
3.2.4.4 Bacterial isolates identification
Positive cultures grown on both plates (Blood and MacConkey agars) were submitted
to biochemical identification (API 20E), cultures grown only on Blood agar were
gram stained. Gram positive cocci isolates were submitted to slide Catalase test (3%
H2O2 solution). Catalase positive isolates were submitted to tube method Coagulase
test [172].
3.2.4.5 Antimicrobial susceptibility (The Kirby-Bauer method)
Small filter paper disks (6 mm) impregnated with a standard amount of antibiotic
(commercially available) were placed onto a Muller Hinton agar plates to which test
bacteria have been swabbed. The plates were incubated overnight at 37o C, and the
zone of inhibition of bacterial growth was used as a measure of susceptibility.
Interpretation of results was done as suggested by CLSI. [173].

41

3.3 Knowledge and perspective questionnaire

A self administered questionnaire was made to evaluate knowledge and personal
perspectives of the health care workers (annexs 4, 5), it was divided into 4 parts, the
first part in the form of "yes/no questions" consists of 7 questions, the second part in
the form of "percent free estimation" consists of 3 questions, the third part in the form
of "directed estimation questions" consists of 6 questions to chose from 1 (very low)
up to 5 (very high), and the fourth part consists of 1 question, free multiple choice
question where more than one answer can be chosen beside the option of free
suggestions. The questionnaire was answered by all workers who agreed to submitt
hand and nasal swabs.
3.7 Statistical analysis
Data generated from this work was tabulated, entered into Microsoft excel sheets and
uploaded to SPSS (Statistical Package for Social Sciences version 14.0) software.
Performed tests were frequencies, Chi square and Odds Ratio.

42

CHAPTER IV
Results
4.1 Environmental and working conditions
A predefined checklist was used to evaluate the environmental and work condition of
the NICUs included in this study. The findings of the checklist are summarized in
annex (6). The findings of the checklist showed that the two hospitals lack defined
documentation systems in nearly all fields. The importance of documentation is not
stressed in the managerial systems of the hospitals.
4.1.1 Work and treatment areas
The location of the NICUs differs in the two hospitals; at Al-Shifa hospital, although
the unit is physically connected to the delivery section, it is well isolated from other
sections. At Al-Nasser hospital, the unit lacks this advantage, besides that, the traffic
flow is more facilitated in Al-Shifa NICU.
Infant space in both units is less than 2 m2, with a maximum distance of about or less
than 1 m between incubators. Handwashing sinks are less than 1 m far from the
closest incubator. No measures are taken to prevent water splashing or retaining
(figure 4.1). The use of sinks is not clearly defined, mixed use in Al-Nasser NICU,
and no clear signs to restrict them for handwashing only. No air filtration or
ventilation is provided in the two NICUs, but temperature is controlled using air
conditioning system. The dining area is physically separated in Al-Shifa NICU, while
the dining table is located exactly in the middle of the main ward in Al-Nasser NICU.

43

Figure 4.1: Photographs of Handwashing facilities in NICUs; left: Al-Shifa , right: Al-Nasser

4.1.2 The working staff

Considering the total number of nurses, an average of 2 nurses per incubator at AlNasser NICU, while less than 1 in Al-Shifa NICU (in the different shifts the average
number is one nurse per two incubators). HCW are immunized only against Hepatitis
B, and no health screening is done to evaluate their health status. No planned
programs are designed to educate and train HCW about the importance and best
methods for infection control.
4.1.3 Antimicrobial therapy protocols
No written or revised protocols are available for physicians. The regimens are verbal
as stated by physicians.
4.1.4 Infection control team
No engineers or epidemiologists are assigned to any of the two teams, but the team of
Al-Shifa hospital has a permanent location in the hospital which is not the case with
Al-Nasser team. No infection control manuals are easily accessible if present at all.
The main activity of the teams is monthly environmental sterility testing of different
44

locations in the hospital. Dealing with outbreaks seems to be the main cause for the
formation of the teams, microbiologists play crucial role in this field.
4.1.5 Personal protection equipment (PPE)
Gloves, masks, gowns, aprons and protective footwear are available in different
kinds, but not used or not properly used at all times.
4.1.6 Handling and disposal of tools
No written instructions are available, sharps are passed between HCW by hand in AlNasser NICU, but claimed to be passed by sharp trays at Al-Shifa NICU. Sterile
equipment are stored in a clean dry environment and well protected. Sharp disposal
containers are labeled and puncture proof. Thermometers are cleaned and disinfected
each use.

4.1.7 Intravascular access devices (catheters)

No written instructions are available, and no special precautions (hand washing or
sterile gloves) are taken when changing/maintaining solution containers, lines or
dressing. The same can be said about catheters insertion. No monitoring or
surveillance of catheter induced infections.
4.1.8 Cleaning processes
Environmental cleaning process is assigned to a private company, which employs
nonqualified cleaners. No written instructions for routine cleaning, management of
clinical wastes or management of blood and body spills. All equipment are easily
removable; no inaccessible areas to interrupt the cleaning process. Floors are cleaned
before and after each shift and when visibly soiled. Blood or other body fluids spills
method of cleaning depends on the experience of the cleaner.
4.2 Hospital records
Many cases were not properly documented, resulting in many missing data. The total
number of cases was 622, (56.6%) from Al-Nasser hospital (n=346), the other cases
were from Al-Shifa hospital. Cases of Al-Nasser NICU came from different hospitals
45

both governmental and private, while Al-Shifa NICU cases came exclusively from the
delivery department at the same hospital, which is physically connected to the NICU,
so it was important to compare numbers of admitted cases to the total delivery cases
at the hospital. The distribution of the total number of cases according to gender and
mode of delivery is shown in table (4.1), which clearly illustrate that male and
Caesarean section delivered neonates are more likely to develop morbidities.
Table (4.1): Distribution of Al-Shifa cases according to gender and mode of delivery
Gender
Male
Female
2151
1865
Total
170
106
NICU cases
(7.9%)
(5.7%)
(%)
P=0.003**
Statistical
OR=0.70
significance
NICU= Neonatal Intensive Care Unit

Mode of delivery
Vaginal
C. section
3085
931
141
135
(4.6%)
(14.5%)
P= <0.0001**
OR=3.5
** p =0.01

Total
4016
276
(6.9%)

4.2.1 Mortality
The total number of deaths at Al-Shifa NICU was 72 cases distributed according to
primary diagnosis as follows: Respiratory distress (n=55, 76.4%), Preterm (n=39,
54.2%,), Abortion (n=5, 6.9%), Polycystic kidney (n=3, 4.1%), (Hydrocephalus,
Asphyxia, Pulmonary hypertension) (n=2 each, 2.8%), (Spina bifida, Sepsis,
Osteogenesis
Hepatomegaly,

imperfecta,

Hernia,

Meningomyelocele,

Gastrochiasis,
Esophageal

Pulmonary

atresia,

hemorrhage,

Thalassemia,

Potter

syndrome)(n=1 each, 1.4%). At Al-Nasser hospital, 8 deaths distributed as follows:

Sepsis (n=5, 62.5%), Respiratory distress (N=5, 62.5%), (Preterm, Heart disorder)
(N=1 each, 12.5%). It's worth mentioning that many cases were admitted to the NICU
with more than one diagnosis.
A statistically significant difference between mortality rates in the two hospitals was
found (p=0.0001, OR=14.83), 27.2% in Al-Shifa NICU (72/265) and 2.5% in AlNasser NICU (8/326). Cases that were transferred to other hospitals were excluded.
The risk factors that probably affected mortality rate were calculated from the total
records (table 4.2).

46

Table (4.2): Relation between mortality rate and maternal and neonatal factors (calculated for both
NICUs cases).
Statistical significance
Parameter
Variables
Total Deaths (%)
P value
Odds Ratio
377
48 (12.7)
Male
0.262
0.83
Gender
Female
214
32 (15.0)
369
19 (5.1)
Term
0.0001**
0.14
Gestation age
Preterm
215
60 (27.9)
221
45 (20.4)
3 days
0.021*
1.68
Hospitalization period
>3 days
289
35 (12.1)
409
45 (11.0)
Vaginal
0.006**
0.52
Mode of delivery
C. section
177
34 (19.2)
199
62 (32.6)
Normal
0.0001**
10.71
Birth weight
Low
370
15 (4.1)
66
48 (72.7)
<7
0.0001**
240.9
Apgar score
7
274
3 (1.1)
554
67 (12.1)
No
0.0001**
0.23
Inherited disorder
Yes
35
13 (37.1)
534
71 (13.3)
Positive
Septicemia (blood
0.361
0.81
Negative
57
9 (15.8)
culture)
186
3 (1.6)
Yes
0.22
0.45
Sepsis
No
140
5 (3.6)
62
7 (11.3)
< 20 years
0.54
1.03
Maternal age
20 years
437
48 (11)
154
16 (10.4)
Multi
0.54
1.03
Parity
premier
292
30 (10.3)
* p < 0.05 , ** p <0.01

Apgar score, birth weight, gestation age and inherited disorders showed a very high
effect on mortality rate, followed by mode of delivery and hospitalization period.
Sepsis (clinically diagnosed) seems to have an effect (OR=0.45) but the p value was >
0.05. Maternal factors (age and parity) have no effect.
4.2.2 Clinical sepsis (CSEP) and Laboratory-confirmed infection (LCBI)
Relation between CSEP and LCBI was assessed for Al-Nasser cases only, since it was
almost absent as a primary diagnosis in Al-Shifa records (4/276, 1.45%). The
correlation was highly significant (p=0.001, OR=3.4); 16.7% of sepsis cases were
positive for blood culture (25/150), while only 5.6% of other cases were positive
(11/196).
4.2.3 Risk factors for mortality and septicemia
The level of nursery care for admitted cases depends on the primary diagnosis. Higher
care levels usually include more invasive procedures (central lines, mechanical
ventilation, etc) which may impose another risk factor for HAI. This factor was
studied in order to evaluate the effect of invasive procedures which were not well
47

documented in the records. After consulting pediatricians at the NICUs, the cases
were divided into 2 categories as shown in table (4.3)
Table (4.3): Symptoms classification according to nursery care level
Care
Symptoms
level
Preterm

(>28 weeks), MMC (meningomyelocele), Hydrocephalus, Jaundice, small for

gestational age (SGA), Transient tachypnea of the newborn (TTN), Fever, Dehydration,
Average

Hypoglycemia, Vomiting, Diabetic Mother (IDM), HB mother, Mecon staining, Sepsis, Cyanosis,
Wet lung, ABO incompatibility Hepatomegaly, Polycystic kidney, Down syndrome, Hematoma,
Anemia, Thalassemia, Bleeding, Pallor, Skin infection, Hypocalcaemia, Lower limb edema,
Bronchitis, URTI, Omphalitis, Convulsion, seizure
Preterm ( 28 weeks), Family history of Pompe, Spina bifida (post op.), Cloacal exstrophy (post
op.), Hernia (post op.), Esophageal Artesia (post op.), Pyloric stenosis (post op.) Respiratory
distress syndrome, Asphyxia, Intestinal obstruction, Low birth weight, Encephalopathy, Abortion,

High

Multiple cong., Osteogenesis imperfecta (Lobstein syndrome), Pulmonary hypertension

Gastrochiasis, Pulmonary hemorrhage, Potter syndrome, Hypoxic-ischemic

encephalopathy

(HIE), Septic shock, Meningitis, Congenital Heart Disease (CHD), Pneumonia, Transposition of
the Great Arteries (TGA), Inborn error of metabolism.
Post op. = post operation

Risk factors for CSEP were measured only from the records of Al-Nasser NICU
(CSEP is absent from Al-Shifa records) (table 4.4), while risk factors for LCBI for
each unit are summarized in table (4.5)
Table (4.4): Neonatal and maternal factors in neonates with clinical sepsis (Al-Nasser hospital)
Parameter

Variables

Male
Gender
Female
Term1
Gestation age
Preterm2
3 days
Hospitalization
>3 days
period
Vaginal
Mode of delivery
C- section
Normal
Birth weight
Low
<7
Apgar score
7
< 20 years
Maternal age
20 years
Multi
Parity
Premier
1
1
>37 weeks, 2 37 weeks

Suspected
sepsis (%)

Total
cases

Statistical significance

P value
Odds Ratio
222
0.346
1.12
124
291
0.042*
0.54
48
224
0.0001**
2.3
122
283
0.332
0.84
56
272
1.95
0.032*
47
10
0.565
0.90
177
43
0.559
0.99
279
211
0.049*
1.56
98
* p < 0.05 , ** p <0.01

94 (42.3)
56 (45.2)
133(45.7)
15(31.3)
81(36.2)
69(56.6)
124(43.8)
23(41.2)
126(46.3)
14(29.8)
5(50)
84(47.5)
19(44.2)
123(44.1)
98(46.4)
35(35.2)

48

The highest effect on sepsis was for hospitalization period, followed by birth weight,
gestation age and maternal parity. No effects were found for gender, mode of
delivery, Apgar score and maternal age.
Table (4.5): Neonatal and maternal factors in neonates with septicemia (positive blood culture)
Hospital NICU
Al-shifa
Al-Nasser
Variables
Parameter
+ve1 Total Stat. sigin.2
+ve1 Total Stat. sigin.2
22
170
P=0.003**
26
222
P=0.186
Male
Gender
Female
3
106
OR=0.2
10
124
OR=0.66
5
122
P=0.008**
19
224
P=0.082
0-3 days
Hospitalization
>3 days
20
153
OR=3.52
17
122
OR=1.74
period
5
104
P=0.066
33
291
P=0.215
Term3
Gestation age
Preterm4
20
178
OR=2.35
3
48
OR=0.52
11
141
P=0.297
31
283
P=0.400
Vaginal
Mode of delivery
C- section
14
135
OR=1.37
5
56
OR=0.77
21
166
P=0.008**
2
47
Normal
P=0.100
Birth weight
Low
4
109
OR=0.26
32
272
OR=2.93
7
60
P=0.438
2
10
P=0.312
<7
Apgar score
7
11
113
OR=0.82
19
177
OR=0.48
4
61
P=0.313
28
276
P=0.419
Average
Care level
High
21
215
OR=1.54
8
68
OR=1.18
1
20
P=0.485
5
43
P=0.544
< 20
Maternal age
20
16
184
OR=1.81
31
279
OR=0.95
4
64
P=0.367
12
98
P=0.494
Multi
Maternal parity
premier
9
99
OR=1.50
22
211
OR=0.83
1
Positive, 2Statistical significance, 3>37 weeks, 4 37 weeks
** p <0.01 OR= Odds Ratio

Based on chi square tests, only gender, hospitalization period and birth weight have
affected the incidence of septicemia in Al-Shifa cases and no such risk factors in AlNasser cases. Odds Ratios change the view; gestation age can be added as approved
risk factor beside maternal age to some extent. In Al-Nasser cases birth weight and
Apgar score are approved factors beside gestation age to some extent.
Other risk factors can be discussed; maternal fever and mecuonium staining of
amniotic fluid (MSAF) are not highly documented in the records, but out of 7
documented cases of maternal fever, only one was submitted to blood culture and it
was positive, and out of four documented cases of MSAF, only one case was
submitted to blood culture and it was positive.
4.2.4 Antibiotic administration rates
The primary option of antibiotic prophylaxis is Ampicillin followed by Gentamicin or
a combination of both given to the most of admitted neonates. The other antibiotics

49

administration depended largely on laboratory results. The antibiotic administration is

summarized in table (4.6)
Table (4.6): Antibiotic administration in Al-Nasser and Al-Shifa NICUs according to hospitals
records.
NICU
Al-Nasser
Al-Shifa
Antibiotic
Treated1
%2
Doses3
Mean4
Treated1
%2
Doses3
269
77.7
935
2.70
238
86.2
959
Ampicillin
187
54
487
1.40
213
77.2
666
Gentamicin
102
32.4
432
1.24
95
34.4
464
Cefotaxime
19
5.5
107
0.30
54
18.2
258
Amikacin
5
1.4
28
0.08
13
4.7
78
Meropenem
6
1.8
29
0.08
2
0.7
17
Vancomycin
1= Number of treated cases
2= Percent of treated cases to the total cases
3= Total administered doses
4= Administered doses/ total cases

Mean4
3.47
2.41
1.68
0.93
0.28
0.06

The antibiotic administration rate is higher in Al-Shifa NICU than Al-Nasser's.

Ampicillin, Gentamicin and Cefotaxime (claforan) are extensively used in both units
but significantly more in Al-Shifa's.
4.3 Questionnaire analysis
4.3.1 Respondents
Table (4.7): Distribution of the questionnaire respondents according to profession and gender.
NICU
Gender
Physicians
Nurses
Total

Al-Shifa
F Total
3
2
5
7
6
13

10

18

Al-Nasser
Total
F
5
0
5
9
5
14

8
16

2
11

Total
10
27

14

24

13

37

19

Total

4.3.2 Working experience

Working experience varied among respondents, 18.2% of them have about or less
than 1 year (n=6), more than half of them (54.5%) have less than 5 years of
experience (n=18), 21.6% have over 10 years of experience (n=8), no statistically
significant difference between the two NICUs (p=0.800).
4.3.3

Staff knowledge and perspective of infection control practices

Responses for the seventeen questions are summarized in annex (7). Less than half of
the respondents (48.6%) have received recent training about personal hygiene and
50

infection control (n=17), with no statistically significant relation to profession

(p=0.457), gender (p=0.459), or working experience (p=0.066).
Most of the respondents (70.3%) claimed using alcoholic hand-rub solutions, despite
the absence of any hand-rub solution, with no statistically significant relation to
profession (p= 0.919), gender (p=0.653), or working experience (p=0.543).
Only 10.8% of the respondents think that wearing gloves is a good replacement for
handwashing (n=4), although all of them are males, still no statistically significant
relation to profession (p=0.306), gender (p=0.150), or working experience (p=0.152).
Most of workers (73.0%) agree that the patient or his companion has the right to ask
him/her to wash his/her hands before treating the patient (n=27), while 18.9%
disagree (n=7), and 8.1% don't know (n=3), with no statistically significant relation to
profession (p= 0.434), gender (p=0.358), or working experience (p=0.505).
Most of workers (75.7%) knew that they are potential sources of infection to the
patients (n=28), 18.9% refused that fact (n=7), 5.4% didnt know (n=2), with no
statistically significant relation to profession (p=0.054), gender (p=0.529), or working
experience (p=0.922).
The vast majority of the workers (91.9%) believed that this research work will
contribute to infection control in the hospital (n=34), 2.7% disagreed (n=1) and 5.4%
didnt know (n=2), with no statistically significant relation to profession (p= 0.544),
gender (p=0. 566), or working experience (p=0.829).
The vast majority of the respondents (97.3%) were interested in getting the results of
their samples (hand and nasal swabs) (n=36).
Most of the respondents (78.8%) admitted not knowing the relative percentage of
patients acquiring infections in hospitals (n=29), the other workers gave estimates
from 10% up to 100%, with no statistically significant relation to profession (p=
0.370), gender (p=0.780), or working experience (p=0.157).

51

About half of the respondents (52.8%) couldnt evaluate the commitment of their
colleagues to personal hygiene practices (PHP) (19/36), the others gave estimates
from 30% to 90% with an average of 66.8%.
About one third of the respondents (35.1%) couldnt evaluate their own commitment
to PHP (13/37). The others gave estimates from 30% to 100%, with an average of
67.8%.
More than half of the respondents (54.1%) described the role of infection control
committee as low or very low (n=20), 32.4% described its role as moderate (n=12),
13.5% described its role as important (n=5) and none of them described its role as
very important, with no statistically significant relation to profession (p=0.367) or
working experience (p=0.920), but it was apparently unpopular among females
(p=0.025).
It was important to compare respondents evaluation of the committees in the two
hospitals. In Al-Nasser NICU, 57.9%, described its role as low or very low (n=11),
the others 42.1% (n=8) described it as moderate, none described it as high or very
high. In al-Shifa NICU, the infection control committee has relatively more respect,
27.8% described its role as high (n=5), the others varied from moderate (22.2%, n=4),
low or very low (50%, n=9). The difference between hospitals was statistically
significant (p=0.039)
About half of the respondents (51.5%, n=19) believed that HAI negatively affects the
patient prognosis, 32.4% believed the effect is moderate (n=12), the others believed
the effect is low (16.2%, n=6), with no statistically significant relation to profession
(p=0.205), gender (p=0.211), or working experience (p=0.058).
The vast majority of respondents (86.5%) believed that handwashing is highly
effective in preventing HAI (N=32), only 13.5% didn't agree (n=5), with no
statistically significant relation to profession (p=0.123), gender (p=0.668), or working
experience (p=0.123).

52

In the evaluation of direct managers role in directing workers to PHP, 36.2% of the
respondents evaluated it as low or very low (n=13), the same number evaluated it as
high or very high, 27.8% of them evaluated it as moderate (n=10), with no statistically
significant relation to profession (p= 0.551), gender (p=0. 823), or working
experience (p=0.351).
In the evaluation of colleagues role in directing workers to PHP, 35.1% of the
respondents evaluated it as low or very low (n=13), the same number evaluated it as
moderate, 29.7% of them evaluated it as high or very high (n=11), with no statistically
significant relation to profession (p= 0.519), gender (p=0. 875), or working
experience (p=0.180).
In the evaluation of workers role in directing residents (patients and companions) to
PHP, 32.4% of the respondents evaluated it as low or very low (n=12), 37.8% of them
evaluated it as moderate (n=14), 29.7% of them evaluated it as high or very high
(n=11), with no statistically significant relation to profession (p= 0.492), gender (p=0.
376), or working experience (p=0.484).
In the evaluation of residents (patients and companions) role in directing workers to
PHP, 62.2% of the respondents evaluated it as low or very low (n=23), 27% of them
evaluated it as moderate (n=10), only 10.8% of them evaluated it as high (n=4), with
no statistically significant relation to profession (p= 0.543), gender (p=0. 480), or
working experience (p=0.595). It is worth mentioning that a significant difference
(p=0.014) was found between hospitals.
With regard to the best way to make workers commit to PHP, respondents gave 53
answers (the possibility of picking more than one answer raised the number).
Promotion was the first option (54.8%, n=29), role model came second (20.4, n=11),
while enforcement came last (17%, n=9), four of the respondents gave other
suggestions, the first one was punishment of non-complying workers, the second
suggestion was "conscious", the third was the continuous education of workers, the
last one was the continuous monitoring.

53

4.4 Bacterial isolates

A total of 273 isolates were collected from different sources in the two NICUs. Less
than half (126) from Al-Nasser NICU, and 147 from Al-Shifa NICU. Isolates from all
sources are summarized in table (4.8).
4.4.1 Blood isolates
A total of 61 isolates were collected from blood cultures, 36 from Al-Nasser NICU
(10.4%), and 25 from Al-Shifa NICU (9.1%). Percentages were calculated per the
total number of hospitalized cases, although not all of them were submitted to blood
culture. In Al-Shifa NICU only 58 (21%) samples were collected from the 276
neonates during the three months period of the study, while 213 (62%) samples were
collected from the 346 neonates in Al-Nasser NICU at the same period.
4.4.2 Hand isolates
None of Al-Nasser hand swabs was negative. One of Al-Shifa hand swabs was
negative; A total of 34 bacterial isolates were collected from the two units: Bacillus
spp. (26%, n=9), CoNS (18%, n=6), K. pneumoniae (11%, n=4), S. aureus,
Pseudomonas spp. and Pantoea spp. (9%, n=3 each), Enterobacter spp., C. freundii
and Acinetobacter spp. (6%, n=2 each).
4.4.3 Nasal isolates
One of Al-Nasser nasal swabs was negative. None of Al-Shifa nasal swabs was
negative; A total of 34 isolates were collected from the two units: S. aureus and CoNS
(26%, n=9 each), Pseudomonas spp. (18%, n=6), Enterobacter spp., C. freundii,
Serratia rubidaeae and Acinetobacter spp. (6%, n=2 each), Bacillus sp. and E.coli
(3%, n=1 each).
4.4.4 Environment isolates
Two of Al-Nasser swabs were negative; some swabs gave two isolates (annex 2).
Three of Al-Shifa swabs were negative, some swabs gave two isolates (annex 3); a
total of 112 isolates were collected from the two units: Enterobacter spp. (28%,
n=31), Acinetobater spp. (12%, n=13), CoNS (11%, n=12), Bacillus spp. (9%, n=10),
K. pneumoniae (8%, n=9), Pseudomonas spp. (7%, n=8), Aerumonas spp. (6%, n=7),
54

Pantoea spp. (5%, n=6), E. coli, and S. rubidaea (2%, n=2 each), P. mirabilis and
Errwinia sp. (1%, n=1 each).
4.4.5 Air microbial load
Bacterial and fungal counts are summarized in annex (8). The bacterial count mean in
Al-Nasser NICU was about 1740 cfu/m3, in Al-Shifa NICU, it was about 1680 cfu/m3.
The fungal count mean in Al-Nasser NICU was about 480 cfu/m3, while in Al-Shifa
NICU it was about 520 cfu/m3. Some of the dominant bacterial colonies in the plates
were identified; main isolates were: CoNS, Bacillus spp., Pseudomonas spp.,
Aeromonas sp. and Actinomycetes.
Table (4.8) Isolated bacteria from different sources in the two NICUs.
Hospital NICU
Isolate source

Al-Nasser
A
B
E
H
N
T
CoNS
4 17 8
3
2
34
Staphylococcus aureus
0 10 0
3
4
17
Streptococcus sp.
0
5
0
0
0
5
Bacillus sp.
5
0
3
5
1
14
Klebsiella pneumonia
0
0
2
2
0
4
Escherichia coli
0
0
0
0
1
1
Enterobacter aerogenes
0
0
1
0
0
1
Enterobacter cloacae
0
2
4
0
0
6
Enterobacter sakazakii
0
0
3
0
0
3
Pantoea sp.
0
0
4
1
0
5
Citrobacter freundii
0
0
4
0
1
5
Proteus mirabilis
0
0
0
0
0
0
Serratia rubidaeae
0
0
1
0
1
2
Acinetobacter sp.
0
0
2
0
0
2
Pseudomonas sp.
4
2
6
3
6
21
Aeromonas sp.
0
0
3
0
0
3
Erwinia sp.
0
0
1
0
0
1
Actinomycetes
2
0
0
0
0
2
Total
15 36 42 17 16 126
A=air, B=blood, E= environment, H= hand, N=nasal, T=total

A
6
0
0
5
0
0
0
0
0
0
0
0
0
0
2
1
0
3
17

B
7
4
2
0
3
3
0
3
0
0
0
0
0
0
3
0
0
0
25

Al-Shifa
E
H
N
4
3
7
0
0
5
0
0
0
7
4
0
7
2
0
2
0
0
9
0
0
7
1
0
7
1
2
2
2
0
6
2
1
1
0
0
1
0
1
11
2
2
2
0
0
4
0
0
0
0
0
0
0
0
70 17 18

T
27
9
2
16
12
5
9
11
10
4
9
1
2
15
7
5
0
3
147

4.5 Antibiotic susceptibility

Antibiotic susceptibility tests were performed for 120 bacterial isolates. The
distribution of tested isolates according to sources is summarized in table (4.9).
Selection of these organisms as representatives of gram positive and gram negative
bacteria was based on their high prevalence among isolates and their representation of
most sources beside their clinical importance.

55

T
61
26
7
30
16
6
10
17
13
9
14
1
4
17
28
8
1
5
273

Table (4.9): Sources of tested bacterial isolates for antibiotic susceptibility

Al-Nasser NICU
Isolate source
A
B
E
H
N
T
CoNS
4
7
8
4
2
25
Staphylococcus aureus
15
3
4
22
Klebsiella pneumonia
3
7
2
12
Enterobacter cloacae
1
4
5
Escherichia coli
Total
4
26 19
9
6
64
A=air, B=blood, E= environment, H= hand, N=nasal, T=total

A
6
6

Al-Shifa NICU
B
E
H
N
7
4
3
7
5
5
2
1
1
2
7
1
2
2
1
16 15
5
14

T
27
10
4
10
5
56

T
52
32
16
15
5
120

The results of antibiotic susceptibility is detailed in annexes (9-12). The patterns of

bacterial susceptibility to antibiotic is summarized in table (4.10)
Table (4.10): Antibiotic susceptibility patterns (%) for bacteria isolated from different
sources from Al-Nasser and Al-Shifa neonatal intensive care units.
Gram positive

S. aureus

K. pneumoniae

E.cloacae

E. coli

Penicillin G
Ampicillin
Piperacillin
Cephalexin
Cefixime
Ceftriaxone
Gentamicin
Amikacin
Imipinem
Meropenem
Trimethoprim
Vancomycin
Chloramphenicol
Tetracycline
Erythromycin
Ciprofloxacin
Nalidixic acid
Average
NT=not tested

CoNS

Isolate \
Antibiotic

Gram negative

Average

(n=52)
0
6
100
65
33
48
77
81
100
17
53
100
92
85
19
87
NT
62

(n=32)
0
3
100
44
6
50
31
81
100
44
41
100
78
75
80
84
NT
57

(n=16)
NT
0
6
0
13
44
31
94
100
100
25
NT
69
50
NT
75
57
47

(n=15)
NT
7
80
7
54
80
80
87
100
100
60
NT
87
87
NT
100
87
73

(n=5)
NT
20
40
20
20
20
40
100
100
100
20
NT
100
60
NT
40
40
51

(n=120)
00
13
66
33
26
49
51
93
100
73
39
100
85
71
50
77
61
58

The highest resistance is for K. pneumoniae (53%), and the lowest is for E. cloacae
(27%) (resistance is calculated by subtracting the suscibtibility percentage from 100).
High resistance against penicillins is found for both gram positive and gram negative
bacteria, Piperacillin is the exception where it was highly active against gram positive
bacteria and E. cloacae, but not K.pneumoniae or E.coli. The three generations of
cephalosporins shown relative weak activity against all tested bacteria, the second
56

generation was the weakest. Considerable preponderance of Amikacin activity over

Gentamicins' (aminoglycosides) against S. aureus, K. pneumoniae, and E.coli, but not
CoNS or Enterobacter cloacae. Carbapenems are very active against both gram
positive and gram negative bacteria, the important exception is the high resistance of
gram positive bacteria to meropenem. No Vancomycin resistance is found among
gram positive cocci. CoNS is much more resistant to Erythromycin than S. aureus .

57

CHAPTER V
Discussion
The aim of this research was to study the epidemiology of neonatal septicemia in local
hospitals in order to define the best ways to interrupt the cycle of infection. An
environmental checklist and perspective questionnaire were introduced to define
environmental and human role in the cycle. In addition, the environment and working
staff were sampled to compare the microbial flora of the healthcare environment with
the etiologic agents of neonatal septicemia. The patient's hospital records were
scanned to define potential neonatal and maternal risk factors. Antimicrobial
susceptibility of some of the isolated bacteria from different sources was tested to
evaluate the role of antibiotic prophylaxis and treatment in the dynamics of the
problem.
5.1 Incidence and prevalence of neonatal septicemia
The limitations of the diagnosis of bloodstream infections among neonates motivated
the CDC to introduce the term clinical sepsis (CSEP) to be used for neonatal
septicemia beside the all-age term laboratory confirmed bloodstream infection (LCBI)
[8, 21]. To assess the efficacy of diagnosis in the studied units, the relation between
CSEP and LCBI was measured. The CSEP diagnosis was almost absent from AlShifa records which may be due to misdiagnosis or to records deficiency, while in ANasser it was well documented as "septicemia" or "sepsis" as a primary diagnosis.
About half of the cases (n=150, 44%) were primarily diagnosed as sepsis. Although a
high significance was calculated for Al-Nasser unit (p=0.001, OR=3.4), this finding
can be misleading because only 16.7% of suspected sepsis was laboratory approved.
The fact that clinical signs and laboratory data have not been perceived as sensitive or
specific for early stages of sepsis [174] could explain this finding. At Al-Shifa unit,
out of the four suspected sepsis cases, three produced positive blood culture, but the
fourth case wasnt subjected to the test. This emphasizes the importance of restoring
"all-case blood culture" strategy.
Calculated from the total deliveries at Al-Shifa hospital, sepsis rate is 6.23/1000 live
birth, which is lower than the rate in Gaza in 2004 (12.8/1000) [175], and higher than
the rate in southern occupied Palestine (3.2/1000) [176], and close to the rate in all
58

occupied Palestine (6.13/1000) [177] and USA (5.16/1,000) [178], and to the lower
limit in Asia (7.1-38/1000), Africa (6.5-23/1000) and to the mean rate in south
America and the Caribbean (3.5-8.9/1000) [143]. The current study reveals a
considerable decrease in neonatal sepsis from 2004 to 2010 in Gaza which may be
due to the efforts done after repeated outbreaks in 2004 [15,16]. The coincidence of
repeated outbreaks during the study of El Jadba and El Yazji could be a bias factor
when considering another study at the same period [14] where 4.1% rate was found
for HAI in general.
LCBI rate in Al-shifa unit was 9.1% (14.4/1000 patient day), and 10.4% (24.2/1000
patient day) in Al-Nasser's. The difference between the two units could be due to the
restricted blood culture strategy in Al-Shifa unit and the less controlled environmental
conditions in Al-Nasser unit compared to Al-Shifa's (an outbreak of K. pneumoniae
took place in Al-Nasser unit immediately after completion of sampling for the current
study). Unlike incidence rate, the use of patient day denominator elaborates the
difference between the two units, this finding support the suggestion of Chen et al.,
[179] to use this denominator in reporting the incidence of occupational exposures in
the healthcare facilities.
CoNS incidence, although decreased since 2004 (57%) [175], is still dominant among
etiological agents of LCBI (39%), K. pneumoniae and Pseudomonas spp. retained the
same incidence with a decrease in E. coli. The outbreak bacteria (Serratia and
Acinetobacter) have disappeared. These results are not far from other reported results
in the occupied Palestine [180]. CoNS was not always as dominant as the current
period in our region, Enterococuus was reported to be the main gram positive causing
neonatal bacteremia in an earlier report in occupied Palestine [181]. This fact reflects
the importance of continuous surveillance.
5.2 Occupational and infrastructural risk factors
Understaffing, overcrowding and poor hygiene practices are key factors in HAI
[111,182-191].

59

5.2.1 Working staff

The American Academy of Pediatrics AAP Guidelines for perinatal care suggests a
minimum staffing of one registered nurse for every two to three patients in
intermediate care and one nurse for every one to two patients in intensive neonatal
care [192]. The average PNR is 1.8/1 in Al-Nasser's and 3.2/1 in Al-Shifa's. In this
study, although PNR is calculated per the number of incubators regardless of being
empty or occupied, the criterion of AAP is fulfilled in Al-Nasser unit and not far from
Al-Shifa's. Many health issues have been linked to PNR; oxygen-related outcomes
[193], daily weight gain [112], infection related to medical devices [194], urinary tract
infection, upper gastrointestinal bleeding, hospital-acquired pneumonia, shock and
cardiac arrest, failure to rescue and length of stay for medical patients [195] and
mortality [196,197].
Personnel are more likely to comply with an infection control program if they
understand its rationale. Thus, personnel education is a cardinal element of an
effective infection control program [70]. The absence of programmed education
system with regard to infection control (annex 6) which was confirmed by workers
themselves (annex 7-Q1) resulted in lack of knowledge and attention; about 24% of
them didnt know that they are potential sources of infection and most of them didnt
give a close estimate of HAI rate (annex 7- Q5&Q8). Along with the absence of
health screening and immunization programs (with one exception of Hepatitis B)
(annex6) explain the lack of adherence to infection control measures revealed by
Awad [17]. Although the pre-mentioned PNR is acceptable in the two units, its not
enough to evaluate the healthcare in the units. Surveillance and education have been
approved to be of important role in changing behavior among HCW [198]. Thus, it
can be concluded that the PNR alone has less importance in the evaluation of heath
care in NICUs, which was concluded by other researches [199,200]. It can only be
used among other factors.
Evaluation of HCW adherence to infection control measures by HCW themselves
may not be the best approach, however, questions 9 & 10 of the questionnaire were
introduced to evaluate the objectivity of the respondents by measuring the difference
between their evaluation of

themselves and of their colleagues with regard to

compliance with infection control measures. Objectivity was assured; estimates were
60

about 68% and 67% for the two questions respectively. Additionally, these findings
reflects tendency among HCW to admit their incompliance with infection control
measures contrary to Boyce who concluded that self-reporting of compliance is not
sufficiently reliable to be useful [118]. This tendency may be a good baseline for a
productive approach to enhance compliance; passive deviance (PD) is based on the
observation that in every community there are certain individuals or groups whose
uncommon behaviors and strategies enable them to find better solutions to problems
than their peers, while having access to the same resources and facing similar or
worse challenges [201]. This approach was used recently to improve compliance
among HCW to PHP at a private tertiary care hospital in Brazil, and resulted in
measurable increase in handwashing and decrease in the incidence of HAIs [202],
sustainability in improvement in hand hygiene was also confirmed in another report
for the same authors [203].
Communication in this field is important; creating a culture where reminding each
other about hand hygiene and use of gloves is encouraged makes compliance the
social norm. Figure (5.1) represents the evaluation of HCW of the role of
communication in the units: from managers to staff (Q14), from staff to their
colleagues (Q15), and from staff to residents (patients and/or companions) (Q16)
(annex 7).

61

Fig 5.1: The role of workers in directing towards personal hygiene practices (PHP) as evaluated by
health care workers (questionnaire results)
Q14- The role of managers in directing workers to PHP
Q15- The role of colleagues in directing workers to PHP
Q16- The role of workers in directing residents to PHP

The equal distribution of the opinions from low to high and the low numbers of
determined opinions (very low and very high) represents the lack of a consensus
among HCW, which may be resulting from lack of interest. The absence of
institutional commitment to hand hygiene may be derived from these findings. The
absence of planned training programs, and monitoring (annex 6) supports this
conclusion. Institutional commitment to hand hygiene practice is an important factor
in the continuous effort for enhancing workers' commitment [118].

Differences

between hospitals in regard to compliance to handwashing were related to variations

in organizational support and hospital culture [204].
Encouraging HCW to adhere to infection control measures can be achieved through
promotion, role modeling, and enforcement as the last option as suggested by HCW
themselves (annex7, Q18). Staff involvement in planning to increase hand hygiene
compliance appears to have an effect [205]. The role modeling has been approved to
be of important value in raising the interest among HCW [206].
An assigned nurse in the unit, qualified in infection control measures and precautions
can be of utmost importance. He/she can be the connection link with infection control
personnel, and can do the role of monitoring and surveillance. The cost of continuous
training and education can be reduced by focusing on one person in each section who
62

can transfer the knowledge to others in the section, and the presence of such person in
the section will be a continuous motivation for others.
Infection control teams should support ICU personnel in their efforts to upgrade
facilities and help ensure that this is a priority when resources are limited [207]. This
cannot be achieved unless a good relation is established between infection control
personnel and HCW. According to HCW (annex 7, Q11), infection control teams are
not doing a good job, this may be due to poor communication and lack of facilities.
Infection control strategies should be centrally directed, and each team should
implement tailored programs based on central strategies of the health administration.
The statistically significant difference in the evaluation of Al-Shifa team over AlNasser's (p=0.039) (annex 7, Q11) gives the impression that the strategies are locally
designed and remote hospitals are far from administration follow up and monitoring.
The evaluation of HCW of the teams can be confirmed by the findings of the checklist
(annex 6); Al-Shifa`s team is more organized, includes more professions, and have a
separate headquarter in the hospital. In fact, both teams are newly assigned and
enough time should be given before final evaluation.
It is becoming clear that patients must be part of any meaningful solution to the
challenges facing health care [208]. Continuous quality improvement focuses on the
customer and, therefore, requires attention to customers feedback as a vital input
[209]. The role of patients and companions in directing HCW towards personal
hygiene was underscored by the HCW themselves (annex7-Q17), 27% of them even
denies the right of the patients to interfere (annex7-Q4). The relation between HCW
and healthcare receivers should be evaluated and patients role should be strengthened
in directing HCW towards the adherence to infection control measures. Public
performance reports, particularly those that highlight high and low performers, push
hospitals to improve [210]. Patient opinion websites [211] are now of important value
in this direction. Although it is complicated by conflicting attitudes, intentions, and
behaviors of patients and health care professionals toward engagement in safety issues
[212], patient participation has become increasingly recognized and advocated as the
key component in the redesigning of health care processes to enhance patient safety

63

[213]. Public awareness of their role is the best way to enforce these practices, and
their role, to my mind, should be enforced by law.
5.2.2 Environmental conditions
Environmental cleaning in the studied NICUs (annex 6) is done in a routine manner
for floors, walls, windows and curtains as mentioned by senior cleaners, but
disinfection of the environment is not receiving enough attention. The absence of
written instructions for environmental cleaning, management of spills and
management of clinical wastes indicates low attention and makes it very hard to
monitor and to evaluate the process. This could be the direct reason for the absence of
monitoring of environmental conditions (annex 6). Lack of ventilation and air
filtration in the units are additional risks contributing to environmental contamination
(annex 6).
Appropriate cleaning and disinfection programs are essential to render the ICU
relatively pathogen free and compliance with handwashing is imperative in
minimizing infection in this high-risk area [207]. There is an increasing body of
evidence that cleaning or disinfection of the environment can reduce transmission of
healthcare-associated pathogens [214].

On the other hand, standard cleaning

procedures have been proved to be not enough for full eradication of HAI pathogens
[215-217], hence, improved methods of disinfecting the hospital environment are
needed [214]. Moreover, cleanliness is not enough to assure effective removal of
pathogens and visual assessment is not a reliable indicator of surface cleanliness or of
cleaning efficacy [215,218].
Dining area in Al-Shifa NICU is separated from the wards, but in Al-Nasser NICU,
the table is located in the center of the main ward and is used for dining beside other
uses (e.g. reports filling), which contradicts with the basic rules of infection control.
Workflow differs significantly between the two units. All five wards in Al-Shifa unit
are well separated from each other, while in Al-Nasser's, the three wards open into
each other (the only way to the main ward passes through reception and then
resuscitation room).

64

5.2.3 Intravascular devices

The absence of written instructions for sharps disposal, catheters insertion and
maintenance (annex 6) affects the understanding and practices among HCW and
makes it hard to monitor. The differences in using the words "always and often" when
describing the observing of the proper precautions of catheter insertion may be a
direct result, which reflects lack of unified strategies.
Percutaneous injuries represent the greatest risk of transmission of blood borne
pathogens to health care personnel [70]. After a needlestick exposure to an infected
patient, a health care worker's risk of infection depends on the pathogen involved, the
immune status of the worker, the severity of the needle-stick injury, and the
availability and use of appropriate post-exposure prophylaxis [219]. Although sharps
disposal containers are available in the two units, the absence of written instructions
and injury records prevents good evaluation of the situation (annex 6). Moreover,
invasive procedures are overlooked in the unit, they are almost absent from patient
records, which prevented direct studying of their role in HAI.
5.2.4 Handwashing
Despite considerable evidence that appropriate hand hygiene is the leading measure to
prevent HAI, compliance with infection control recommendations remains low among
healthcare workers [220-222]. International institutes, i.e., WHO [223,224], and CDC
[225-227] keep on stressing on the great importance of handwashing in health-care
facilities.
Adherence to infection control measures was found to be very weak in the studied
units among other units in Gaza governmental hospitals [17]. Lack of knowledge
doesnt bear the whole burden as concluded by Awad; there is a considerable amount
of knowledge among HCW (annex 7, Q3-7). The absence of monitoring of hand
hygiene practices along with the absence of alcoholic hand-rub solutions in the units
are important factors (annex 6), considering the fact that soap is not enough to set the
hands pathogen-free [228-231].

65

Changing the situation, although difficult, is still possible, even in developing

countries with limited resources [230], the use of hand-rub solutions is the key factor
beside the monitoring of handwashing practices [232-234].
5.3 Potential sources of HAI pathogens
Health care settings is an environment where both infected persons and persons at
increased risk of infection congregate. Patients with infections or carriers of
pathogenic microorganisms admitted to hospitals are potential sources of infection for
patients and staff [10]. Most gram positive bacteria and many gram negative bacteria
survive for months on dry surfaces [235]. The role of environmental contamination in
contributing to patient-to-patient transmission is a hotly disputed topic because of the
large number of confounding variables and rare-event nature of the outcome [236]. It
is frequently difficult to differentiate environmental acquisition from that associated
with health care workers. Despite that, environmental contamination has been proved
to be predictive of colonizing with different HAI pathogens [237,238], with some
disagreement where the role of environment was questioned [216]. Health care
workers are also important reservoirs of HAI pathogens. In fact they are the strongest
link in the infection chain [239], besides being approved victims [240,241], with
higher risk [242].
In order to define potential HAI pathogens and their distribution in the environment of
the selected NICUs, environmental samples (surfaces and air) were collected, beside
hands and nasal samples from HCW. Results are summarized in table (4.8) along with
isolates from blood cultures.
5.3.1 Environmental surfaces.
Unlike routine environmental swabbing done by the Ministry of Health (MOH)
laboratories in Gaza (MOH records, unpublished data), in the current study, almost
all of surface swabs were positive (95%); this may be due to pre-enrichment of swabs
in brain heart infusion broth (BHIB), which confirms the importance of preenrichment for recovery of environmental contaminants mentioned by other studies
[243,244]. This finding favors the preenrichment method over the direct culture on

66

solid agars to avoid overlooking potential pathogens which exist in low numbers but
still impose risk.
5.3.2 Air microbial load
The availability of an air microbial sampler was the incentive for choosing this
method over the air sedimentation method which is more frequently used [245-249].
There are no standardized methods for bacterial air sampling or its frequency. Most of
the industrialized countries set their own standards, usually modifying the American
Federal Standard 209E to their local needs [250]; The American Federal Standard
adopted particulate count for evaluation purposes and didnt mention the microbial
count [251]. The only standard (after extensive online research) was from Hong
Kong [252]; according to Hong Kong indoor air quality management group [253], the
total bacterial count and fungal count in indoor environment of offices and public
places shouldnt exceed 500 cfu/m3. In healthcare facilities, the limits should be more
restricted; In well ventilated operating theaters, bacterial count shouldnt exceed 50150 cfu/m3 [250]. In the studied units of the current study, bacterial counts range
(1260-2160 cfu/m3) is far above standards for public spaces, not to mention the
hospital environment. The fungal counts are not far from the standards (360-600
cfu/m3). Nevertheless, the results demonstrated relative excellence for Al-Shifa unit
over Al-Nasser's. lack of ventilation or air filtration in both units may be the reason
for high microbial numbers.
5.3.3 Health care workers
Methods for the isolation of bacteria from the skin and particularly the hands have
included stripping with cellophane tape [254], swabbing small areas within glass
cylinders [255], imprinting fingertips on agar plates [256], rubbing with glass beads
within plastic bags or test tubes [257,258], scrubbing hands in basins [259], and
washing or rinsing methods [260] including glove-juice method [261]. Electric
toothbrushes were also used [262].
According to the European standard, only the fingertips are sampled, as they have a
higher density of bacteria than all other parts of the hand [263], whereas according to
the U.S. standard, the whole hand is sampled [264]. Campf et al. found no difference
67

between the two test methods for the efficacy on the resident hand flora [265]. Rotter
et al. proved that the European method is effective and reproducible [266].
Choosing the European test method for this study was based on cost effectiveness and
ease, since fingers rubbing in a Petri dish is more acceptable for workers than glove
juice method, which is also time and materials consuming.
The advantages of using a swab in the nares compared to nasopharyngeal aspirate are
for the patient less discomfort, more rapid sampling procedure and lower cost [267].
5.3.4 Bacterial isolates
Figure 5.2 shows the relation between bacteria isolated from the environment and
HCW, and from the neonatal blood cultures.

Fig 5.2: Isolated bacteria from Environment and healthcare workers (dark), and blood cultures (light)

The figure reflects considerable similarities between bacteria isolated from the
environment and HCW (potential sources) and from blood cultures. This finding may
be a strong indicator for the role of environment and HCW as potential sources of
septicemia in neonates. Solid based evidence for this correlation should be based on
molecular typing, which is beyond the resources of the current work.
Three exceptions to this finding should be mentioned from the figure: Streptococcus
spp. K. pneumoniae, and Pseudomonas spp.
Streptococcus spp. is commonly maternally originated [26], and is not commonly
isolated from environments of healthcare facilities [268,269]. K. pneumoniae
68

extensive isolation was predictive for an outbreak occurred immediately after

completion of sampling for this study. The outbreak took place in Al-Nasser unit,
where the majority of K. pneumoniae were isolated. This finding could be an alert for
pseudomonal outbreaks yet to come in both units.
Most of other bacteria isolated from the environment are well known as human
pathogens, but some of them dont have the same popularity:
Bacillus spp. was isolated from the environment and the staff (table 4.9), it's not a
common cause of septicemia, but was reported in a series of neonatal sepsis in
occupied Palestine [270]. Pantoea spp., isolated from different environmental swabs,
and hand swabs in the two units, is well known as plant pathogen [271], but was
reported in an outbreak of neonatal septicemia in a NICU in Malaysia [272]. The
aquatic pathogen, Aeromonas sp. was isolated from some environmental swabs in the
two units. Aeromonas septicemia is an uncommon but severe infection which occurs
predominantly in compromised hosts like infants and children [273]. Erwinia sp.,
although a common plant pathogen [274], but it was responsible for inpatient
infections including septicemia [275,276].
Most of isolated bacteria from the two NICUs are potential etiologic agents of
septicemia and other infections, this may be of importance for risk assessment and
should be taken into consideration by healthcare planners.
5.4 Risk factors for neonatal septicemia
Healthcare is an information-intensive industry. Information management is integral
to clinical practice and little occurs in the complex matrix of healthcare that does not
involve information management [277-280]. It has been estimated that as many as 22
different people need access to a hospital patient's medical record at any given time.
Physicians spend an estimated 38% and nurses an estimated 50% of their time
documenting in the patient's medical record. Despite that, 70% of hospital patients'
paper medical records are incomplete [281]. As more physicians and other providers
begin to participate in disease management, which requires increased data collection
and monitoring, tools that enable providers to cope with the volume of data at the
point of care are increasingly valuable and should be accessible via computerized
system [282].
69

Patient's file computerizing, although partially implemented in governmental hospitals

in Gaza, is yet to fulfill the research or health providers requirements. In Al-Nasser
Hospital, only the file index of patient records is computerized with limited data,
while in Al-Shifa hospital, NICU files are on the waiting list for index filing. Missing
data is a general phenomenon in all files.
From data in the patient records, possible risk factors were assessed for mortality
(table 4.3), CSEP (table 4.4) and LCBI (table 4.5).
Gender is found to be a considerable risk factor for morbidity (p=0.003, OR=0.7)
(table 4.1), especially LCBI (p=0.003, OR=0.2) (table 4.5), but not CSEP (table 4.4).
it had no effect on mortality (table 4.2). it's already known that both humoral and cell
mediated immunity are more active in females than in males [283-286].
Hospitalization period or the time spent in the unit is a dialectic factor, the higher the
severity of the illness is predictive for longer period, and the longer period on the
other hand is predictive for health complications. The findings of the current study
can go in both directions; a considerable relation with mortality (p=0.021, OR=1.68),
a very high relation with CSEP (p=0.0001 , OR=2.3) and CLBI (p=0.008. OR=3.52).
The length of stay has been the focus of many research work, not only from the
morbidity point of view [287-289], but also from the cost point of view [290-292].
The cut-off point to differentiate late from early onset has been varied among authors
from 24 hours to 7 days [143,293]. Three days cut-off point has been chosen for the
current study depending on a wide resourceful review article [23]. Early onset is more
likely to be of maternal origin, while late onset is more likely to be of hospital origin
(HAI) [23,294]. The results of the current study reveals a high preponderance of late
over early onset in both CSEP and LCBI, which agrees with the results in southern
occupied Palestine [176], but contradicts with El jadba and El Yazji study [175],
where early onset was higher in Al-Shifa unit. The cut-off point in their study was 48
hours, which may be the reason for this difference, another explanation may be the
enhancement of mother care and delivery environment in Al-Shifa hospital; an
unstudied factor to the moment.
A highly statistically significant correlation was found between preterm labor and
mortality (p=0.0001, OR=0.14), agreeing with the fact that preterm is the leading
cause of worldwide neonatal mortality [55,56]. On the other hand, relation to CSEP
70

(p=0.042, OR=0.52) and LCBI (p=0.066, OR=2.35 for Al-shifa, and p=0.215,
OR=0.52 for Al-Nasser) doesnt have the same strength in regard to chi square test.
For chi square test to give significance, numbers in the four fields should be above 5,
thats why Odds Ratio was used and gave important significance. In Al-Nasser unit,
preterm labor seems to be a protective factor for CSEP and LCBI. The nature of the
admitted neonates could be the reason for this finding where most of preterm infants
in the unit belong to late preterm category (34-37 weeks) and only 4 cases belong to
early preterm category (<34 weeks). Putting in mind that most large series describing
the epidemiology of neonatal sepsis are limited to infants with very low gestational
age [106] supports this explanation.
Normal birthweigh (2.5kg) was predictive for mortality (p=0.0001, OR=10.91),
CSEP (p=0.032, OR=1.95) and LCBI in Al-Shifa unit (p=0.008, OR=0.26). Only in
Al-Nasser unit low birthweight (<2.5kg) was predictive for LCBI (p=0.100,
OR=2.93). Most low birthweight cases in the current study dont belong to the very
low birth weight (VLBW) (<1.5kg) or extremely low birthweight (ELBW) (<1kg),
which are more predictive for mortality and morbidity [295,296]. Hospital level
where newborns are delivered may affect mortality and morbidity of low birthweight
newborns [296] which may explain the relation between LCBI and low birth weight
in Al-Nasser unit where infants are coming from lower level hospitals than Al-Shifa;
every preterm newborn in Al-Shifa hospital is transferred immediately to NICU.
Cesarean section delivery was found to be predictive of morbidity (table 4.1) and
mortality (table 4.2), but neither to CSEP (table 4.4) nor to LCBI (table 4.5). Many
researchers related cesarean section to some morbidities and to mortality [297-299],
while others demonstrated its protective effect [300]. Only repeated cesarean section
was connected to sepsis [301,302], a factor which is not well documented in the
studied records.
The cut-off point of 7 for Apgar score was used because no significant deference
between 0-3 and 4-6 groups [303]. Score < 7 was found to be extremely predictive
for mortality (p=0.0001, OR=240.9), but had no relation to CSEP (p=0.565,
OR=0.90) or to LCBI in Al-Shifa unit (p=0.313, OR=1.54) and some significance in
Al-Nasser unit (p=0.312, OR=0.48). The absence of significant relation between
LCBI and mortality (table 4.2) may confirm these findings. Low Apgar score is
71

proven predictive of mortality and morbidity [303-305]. Our findings contradict the
finding of Soman et al., [306] and Shah et al., [307], but both of them studied early
onset sepsis, while most of sepsis cases in the current study are late onset sepsis.
Absence of maternal factors effect on sepsis (tables 4.4, 4.5) could be explained by
the preponderance of late onset over early onset sepsis. Maternal fever and meconium
staining of amniotic fluid (MSAF) although under-documented seem to be exceptions.
Absence of invasive procedures from patient records lead to the use of care level as a
potential factor where high care level would be accompanied with more invasive
procedures. The significance of average care level to CSEP (table 4.4) is not useful,
since sepsis belongs to average care level category, LCBI was not connected to care
level (table 4.5) although invasive procedures are globally agreed to be of significant
prediction of LCBI.
5.5 Antimicrobial Use and Resistance
The use of antibiotic in the studied units is summarized in Table (4.6), and the results
of antibiotic sensitivity are summarized in table (4.10), and detailed in annexes (9-12)
Ampicillin, Gentamicin and Cefotaxime (claforan) and Amikacin to some extent are
more frequently used in the two units (table 4.6). Although complying with WHO
recommendations for antibiotic prophylaxis [51,308], the resistance among tested
bacteria seems to be a direct outcome of this compliance (fig 5.3).

Figure 5.3: Use and resistance patterns of frequently administered antibiotics in the two NICUs

72

Proportional relation is easily observed between antibiotic use and resistance

elevation among tested bacteria. The second generation cephalosporin is surpassing
others; community use of cephalosporins may be the reason: Gentamicin and
Amikacin are restricted to healthcare facilities due to administration mode, while
Ampicillin is not very popular in the community. second generation cephalosporins
are relatively cheap and considered first choice over the counter antibiotics, hence,
community overuse of cephalosporins may be important input for its elevated
resistance in the current work.
Comparing between the current study and El Jadba and El Yazji study [175], a
significant decrease is noticed in the activity of Ampicillin, Gentamicin and
cephalosporins from 2004 to 2010 but not Amikacin which is less administered in the
unit (table 4.6, fig 5.3). these findings support the hypothesis that extensive use of
these antibiotics in the studied NICUs may be a direct cause for elevated resistance
among studied bacteria.
Carbapenems (Meropenem, and Imipenem) shown different potency on tested gram
positive bacteria (table 4.10). The fact that Imipenem is more active than Meropenem
on gram positive bacteria [309,310] may explain the detected difference between the
two carbapenems, but may not be enough to explain the decreased activity of
Meropenem; Contrary to our results, a recent study in France has shown a 100%
effectiveness of Meropenem on gram positives, and some extent of resistance on gram
negatives [311]. Failure of Meropenem to treat an MRSA infection was recently
reported in Japan [312]. In vitro discrepancy in testing for carbapenem activity has
been demonstrated [313,314] even with automated systems [315]. This may explan
these uncommon results. More work on this issue may be of important value.
K. pneumoniae and E. coli, were found to be highly resistant to cephalosporins and
completely sensitive to imipenem (table 4.10): this is a typical characteristic of
extended-spectrum beta-lactamases (ESBLs) [316]. ESBLs were first described soon
after the introduction of third-generation cephalosporins in the early 1980s. Infections
caused by ESBL-producing Enterobacteriaceae are increasing in frequency and are
associated with high mortality rates [317]. E. cloacae has shown less extent of this
pattern (table 4.9), which confirms its lower existence in Enterobacter spp. [318].
73

New ESBL enzymes families are rising which presents great therapeutic challenges
for the 21st century [319].
ESBL is not uncommon in the Middle East and North Africa , it was reported in
southern occupied Palestine at the beginning of this century [320], and earlier in Saudi
Arabia [321], Tunisia [322] and Morocco [323], and later in Gaza strip [324].
Antibiotic choice is particularly important in seriously ill patients with infections due
to ESBL-producing K. pneumoniae. The use of a carbapenem (primarily imipenem)
was associated with a significantly lower mortality than was the use of other
antibiotics active in vitro [325]. Ertapenem is another good choice [326] and
tigecycline could be an option [327].
ESBL is indeed a serious threat; plasmids carrying ESBL genes frequently carry
aminoglycoside, tetracycline, sulfonamide or fluoroquinolone resistance genes [328].
Even the resistance to the strong combination piperacillin-tazobactam is thought to be
connected [329].
Quinolones (ciprofloxacin and nalidixic acid) are not frequently used in the two units
(table 4.6). Despite that, some resistance against ciprofloxacin and nalidixic acid is
found for K. pneumoniae and E. coli (table 4.10). The coexistence of quinolones
resistance

and

ESBL was reported in late nineties of the 20th century for K.

pneumoniae [330] and E. coli [331]. The two resistance mechanisms are thought to be
transferred on the same plasmid [332]. Putting in mind that ciprofloxacin resistance is
class effect, affecting all fluoroquinolones [333], makes the problem of greater
importance. Ciprofloxacin resistance was reported in Gaza in urinary tract infections
[334], but was not correlated to ESBL. This correlation should be confirmed through
molecular techniques.
Monitoring multidrug-resistant organisms and the infections they cause in a
healthcare setting is important to detect newly emerging antimicrobial resistance
profiles, to identify vulnerable patient populations, and to assess the need for and
effectiveness of interventions [335]. The current study could be an input in this
direction, and emphasize the importance of good monitoring of drugs.

74

CHAPTER VI
Conclusions and Recommendations
6.1 Conclusions
Neonatal septicemia is a very concerning health problem, healthcare environment has
a very important role in developing septicemia among neonates. Congregating sources
and susceptible targets for infections in the same area makes it very important to
understand the infection cycle and to define all direct and indirect contributing
factors. This is the only way to design appropriate measures to break the infection
cycle and to prevent (or to decrease) unwanted outcomes. One of the most annoying
obstacles in this issue is the continuous emerging of resistant microorganisms, which
raises the challenge for healthcare designers, providers and receivers.
The current study is a modest trial to contribute to this noble target. Two of neonatal
intensive care units in Gaza hospitals were extensively studied to define extrinsic and
intrinsic factors for neonatal septicemia.
The following conclusions were drawn from the study:

Potential risk factors for mortality include: Apgar score, birthweight of less
than 2.5 kg, preterm, inherited disorders (congenital diseases), and cesarean
section delivery.

The most reported symptom for admitted neonates is respiratory distress.

Incidence rate of neonatal septicemia differs significantly between the studied

units: 9.1% (14.4/1000 patient day) in Al-Shifa NICU, and 10.4% (24.2/1000
patient day) in Al-Nasser's

Main bacterial causative agent to neonatal septicemia is CoNS (39%),

followed by S. aureus (23%), Streptococcus sp. (12%), E. cloacae and
Pseudomonas spp. (8% each) and E. coli and K. pneumoniae (5% each).

Septicemia is not a major cause of mortality unless outbreaks of multidrug

resistant pathogens take place.

Healthcare environment has a high prevalence of pathogenic or potentially

pathogenic bacteria.

Many healthcare workers were shown to harbor potential pathogens and thus
may be a likely source of infections.

75

Similar bacteria were isolated from the blood culture of the neonates and from
the units environment on the level of genus and species.

Important environmental differences related to workflow design between Alshifa and Al-Nasser NICUs raise the need for more attention and monitoring
of remote hospitals.

Hospitalization for more than 3 days was found to be predictive for morbidity
(including septicemia).

Occupational and environmental potential risk factors can be summarized in:

1- Lack of interest among HCW.
2- Lack of monitoring.
3- Weak documentation obstructs monitoring possibilities.
4- Weak communication between infection control personnel and HCW.
5- The weak managers and seniors role and absence of care-receivers role
in monitoring of infection control measures.
6- Low level of disinfection for the healthcare environment.
7- Low level of handwashing facilities.
8- Shortage or sometimes the absence of alcoholic hand-rubs solutions

Potential intrinsic risk factors for septicemia are: preterm, low birth weight
and gender (male).

Maternal fever and meconium staining of amniotic fluid could be predictive

factors for septicemia in newborns.

Among tested bacteria for antibiotic resistance, K. pneumoniae has shown the
highest rate of resistance, while E. cloacae has shown the least resistance;
despite that, alarming levels of resistance are detected.

Antibiotic regimen may be a direct reason of resistance emergence among

neonatal pathogens.

Resistance of Staphylococcus spp. to Meropenemis is very alarming, thus,

extensive study should be done before declaring this serious finding.

Extended spectrum beta-lactamase producing gram negative bacteria is a

serious resistance pattern detected in the unit, it may be causing other patterns
of resistance, such as resistance to fluoroquinolones.

76

6.2 Recommendations
In light of the results of this study, and the above-mentioned conclusions, the
following recommendations may be valuable in reducing the risks for septicemia and
other infections in the NICU:
1. Active and continuous surveillance program for infections in these hospitals
should be employed.
2. Infection control measures should be centrally designed, and should be
monitored and enforced among HCW.
3. More attention should be paid to disinfecting environmental surfaces and
monitoring the efficacy of the process.
4. Handwashing facilities should be monitored, maintained and supplied with
appropriate disinfectant soaps
5. Hand-rub alcoholic solutions should be available for all workers.
6. Periodical screening for environments (sterility testing) should include HCW,
and should be used for surveillance for prevalence of pathogens in the
environment and trends of antibiotic resistance profiles.
7. Separating dining areas from working areas.
8. Reviewing antimicrobial prophylaxis and treatment regimens based on local
antibiotic resistance patterns.
6.3 Research recommendations.
The findings of the current work raised some questions; the answers for these
questions may be the aims of future research work:
1. Correlation of bacteria isolated from the environment to those isolated
from infections using molecular techniques.
2. The prevalence of ESBL producing gram negative bacteria in the
environment and among infectious pathogens.
3. The incidence of Meropenem resistance among gram positive bacteria.

77

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Annexes
Annex 1: Environmental and working conditions checklist
Hospital:..
Part I
Work and Treatment areas
Wards : .
Space between incubators: ...m

Area: m2
incubators:
Walls :
Ceramic

Regular painting

Notes: ..

Windows:

Blinds

curtains

Notes:

Floors:
Dining
areas:

Carpeted

Nonslip coverings

Notes:

Separate

Designated

Notes:

The staff
Main shift
Evening shift
Night shift
Total
Education and
training:

Physicians
..
..
..
..

Nurses
..
..
..
..

others
..
..
..
..

On employment

Health screening:

Annually

Immunization system:

Periodically

Upon
availability

Each .... years

None

documented

not documented

None

none

Environmental conditions
Ventilation:

Mechanical

Air filtration:

Natural

Present

None

Absent

Notes: ..,,,,,,
Notes: ..

Air-conditioning:

Present
Absent
Notes: ..
Monitoring,:
Documented
Not documented
None
Notes: .

Infrastructure maintenance and monitoring

Maintenance and mentoring:

Scheduled

Not Scheduled

None

Preventive maintenance plan:

Scheduled

Not Scheduled

None

manufacturers instructions
available to:
Equipment injuries:

Staff

Seniors

Documented

Head of dept

Not available

Not documented

Notes: .....

Antimicrobial therapy protocols

Accessibility the
protocols:
Review of protocols:

Always

On request

Availability of
antibiotics

Frequency of review

None
Local microbial
resistance data

None

Annually
Semiannually
Other
Notes: ..
..

104

Part II
Infection control team
Formation:

Physicians: .

Nurses:

Microbiologists:

Engineers:

Involvement in renovations and

new building works:
Role:

Meetings:

Formal

Monthly

Seniors

Activities:

Further testing
of the isolates:

Informal

Weekly
Always

On request

Sometimes

105

None

On compliance

On complaint
Biweekly

None

Availability of
resources

Planned

Planned

None

Not on regular bases

Staff

Planned programs

Monitoring of staff compliance with

infection control measures:

The frequency of
sterility testing:

Others: ...

Each

Availability of infection
control manuals:
Education and training of
HCW:

Monitoring of health
status of the staff:

Epidemiologists: ...

None

None

Monthly
On suspicion

On complaint
None

Part III
Hand washing and personal hygiene
Hand washing basins
Washstands: ..
Sinks: .........
Notes: ....
Sinks Use:
Designated
General ....................
Hot and cold water

Paper towels

Antisplash devices

Disposal's sink

Hard soap
Liquid soup
Antiseptic products (formulated for use without water)
If liquid soap:
Refillable containers
Disposable cartridges
Personal protective equipment (PPE)
Gloves
Sterile gloves
Nonsterile gloves
General purpose utility gloves
Protective
Optically clear
Antifog
distortion free
Close fitting
eyewear
regular masks

Personal respiratory
protection devices
Gowns

Surgical masks

Particulate filter personal respiratory protection devices

Disposable (one use)

Reusable

Plastic aprons

Disposable (one use)

Reusable

Footwear

Disposable (one use)

Reusable

Handling and disposal of sharps

Instructions

Written

Verbal

Passing sterile sharp instruments

None

By hand

between workers:

Sharps trays

Sharp disposal container:

Clearly labeled
Storage of sterile
Clean, dry environment
equipment:

Puncture-proof

None

Protection from sharp objects

Cleaning Thermometers:

Each use

Each shift

Daily

Never

Disinfecting Thermometers:

Each use

Each shift

Daily

Never

Intravascular access devices (catheters)

Insertion and
maintenance protocol:

Written

Verbal

none
Observational notes:
..
..
..
..
..
..

Handwashing with antimicrobial solution

Precautions
while
inserting
catheters

The use of sterile gloves

Cleaning the insertion site with antiseptic
Drying the cleaned area
Changing the catheter for each attempt
Handwashing with
antimicrobial solution

Precautions when changing

/maintaining solution containers,
lines or dressings

No special procedures

The use of sterile gloves

The atheter dressings:

Clean

Sterile

The available

The stabilizing tape:

Clean

Sterile

The available

In the patients progress notes

In the patient file
Notes:
....
On the
None
...
dressing
Monitoring and surveillance of catheter
Regular
On suspicion
Never
induced infections:
Testing of catheter
Regular
Occasionally
On suspicion
Never
after use:
The date and time
of insertion is
documented:

106

Part IV
Routine environmental cleaning
Written cleaning protocols:
Protocols include:
Inaccessible
areas (hard to
clean):
Routine floor
cleaning:

Written

Verbal

Methods and frequency

Many

Few

Before each
session

None

Standard precautions
Notes:

None
After each
session

When visibly
soiled

Walls cleaning:

Daily

weekly

When visibly soiled

none

Windows cleaning:

Daily

weekly

When visibly soiled

none

Curtains cleaning:

Daily

weekly

When visibly soiled

none

Curtains changing:

Daily

weekly

When visibly worn-out

none

Cleaning and
reprocessing areas

Defined areas for cleaned and

contaminated items

Non-defined areas

Management of clinical waste

Written

Protocols for clinical waste disposal:

Segregation of wastes:

At the point of generation

Medical waste containers

Color-coded

Handling medical waste:

Gloves

Clinical waste are

placed in:

Verbal

Trolleys for transport of infectious

or hazardous waste:

Later

Labeled

Leak-resistant bags
or containers

None
None

Neither

protective clothing

neither

Normal bags or
containers

Depending on
availability

Labeled

Not labeled

Waste transport. only

Multiple use

Cleaning equipment are

cleaned:

After each shift

Cleaning equipment are

changed:

After each shift

Daily

Weekly

Following the cleaning of spills

Daily

Weekly

Following the cleaning of spills

Management of blood and body spills

Procedural manuals:

written

If present, it contains:

Personal
precautions

verbal

none

Contained
cleaning

Aerosol
prevention

Trolleys
The use of trolleys:
Cleaning of trolleys:

Dedicated to one purpose

Daily

Weekly

107

Different uses
When visibly soiled

Annex 2: Al-Nasser NICU environmental swabs:

Code
NE1
NE2
NE3
NE4
NE5
NE6
NE7
NE8
NE9
NE10
NE11
NE12
NE13
NE14
NE15
NE16
NE17
NE18
NE19
NE20
NE21
NE22
NE23
NE24
NE25
NE26
NE27
NE28
NE29
NE30
NE31
NE32
NE33
NE34
NE35
NE36
NE37
NE38
NE39
NE40

Source
External washstand
External medications trolley
External baby balance (Detecto)
External baby balance (shekel)
Reception washstand
Reception incubator
Internal baby balance (Detecto)
Emergency trolley
Internal reception counter
Water Bailer holder
Incubator 1 (empty)
Incubator 2
Incubator3
Incubator 4 (empty)
Incubator 5 (empty)
Incubator 6
Incubator 7
Incubator 8
Incubator 9
Incubator 10
Resuscitation unit 1
Phototherapy unit 1 (west)
Phototherapy unit 2(east)
Air condition (west) off
Air condition (northeast) on
Air condition (north east) off
Wooden table (ward center)
Internal washstand
Scrubbing 1
Scrubbing 2
Medication prep. trolley
Ambo bag (resuscitation)
Ambo bag (incubator 3)
Ambo bag (incubator 6)
Ambo bag (incubator 9)
Internal fridge
External fridge (milk)
External counter
Disposables cupboard 1
Disposables cupboard 2

Result
Enterobacter aerugenes
CoNS
Erwinia sp.
Enterobacter cloacae
Pantoea sp.
Pseudomonas sp. + CoNS
CoNS
Enterobacter sakazakii
Pantoea sp.
Pantoea sp.
CoNS
Negative
Pseudomonas sp.
Bacillus sp.
Citrobacter freundii
Pantoea sp.
Enterobacter cloacae
Pseudomonas sp.
Citrobacter freundii
Klebsiella pneumoniae
Enterobacter sakazakii
Pseudomonas sp.
Klebsiella pneumoniae
Acinitobacter sp.
Negative
Pseudomonas sp.
Pseudomonas sp. + CoNS
Serratia rupidaea
Enterobacter sakazakii
CoNS+ Bacillus sp.
Aeromonas sp.
Enterobacter cloacae + CoNS
Pseudomonas sp.
Citrobacter freundii
Aeromonas sp. + CoNS
Aeromonas sp.
Citrobacter freundii
Enterobacter cloacae
Bacillus sp.
Acinitobacter sp.

108

Annex 3a: Al-Shifa NICU environmental swabs:

1- Ground floor
No

Result

Ground floor
Ward 2

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41

Steel wash stand

Citrobacter freundii
Ceramic baby sink
Proteus mirabilis
Incubator 6
Aeromonas sp.
Incubator 5
Klebsiella pneumoniae
Incubator 4
Enterobacter cloacaee
Incubator 2
Citrobacter freundii
Incubator 1
Pseudomonas sp.
Nurse counter
Aeromonas sp.
Solutions pump incubator 6
Acinetobacter sp.
Solutions pump incubator4
Bacillus sp.
syringe pump incubator 2
Klebsiella pneumoniae
infusion pump incubator 1
Acinetobacter sp. + Bacillus sp.
Water cooler
Escherichia coli
Thermometers container
Negative
Thermometers and alcohol swab tray
Pantoea sp.
Baby balance
Citrobacter freundii
Air conditioner (south)
Enterobacter aerugenes
Air conditioner (west)
Aeromonas sp,
Ward 1
Steel wash stand
Bacillus sp.
Ceramic baby sink
Citrobacter freundii
Incubator 1
Pantoea sp.
Incubator 2
Enterobacter aerugenes
Incubator 5
Enterobacter cloacae
Incubator 6
Klebsiella pneumoniae
Nurse counter
Acinetobacter sp.
Telephone
Acinetobacter sp.
infusion pump incubator 1
Enterobacter aerugenes
infusion pump incubator 2
Enterobacter sakazakii
infusion pump incubator 6
Enterobacter sakazakii
Oxygen pump moisturizer incubator 5
CoNS
Sucking tube incubator 5
Escherichia coli
Baby balance
Enterobacter aerugenes
Medicine prep. Trolley
Klebsiella pneumoniae
Medicine prep tray
Acinetobacter sp.
Air conditioner (east)
Citrobacter freundii
Sucking tube incubator 1
Enterobacter sakazakii
Resuscitation room
Steel wash stand
Enterobacter sakazakii
resuscitation bed 25
Enterobacter aerugenes
resuscitation bed 26
Acinetobacter sp.
Medicine prep. Trolley
Citrobacter freundii
Laryngoscope
Enterobacter aerugenes

109

Annex 3b: Al-Shifa NICU environmental swabs:

2- First floor
No

Result

First floor
ward 1

42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70

Steel wash stand

Incubator 1
Incubator 2
Incubator 3
Incubator 4
Incubator 5
Incubator 6
Incubator 7
Resuscitation bed
Medicine prep. Trolley
Medicine prep tray
Nurse counter
Telephone
Sucking tube incubator 4
Baby balance
Oxygen pump moisturizer incubator 1
infusion pump incubator 1
Ward 2
Incubator 1
Incubator 4
Incubator 7
Incubator 8
Steel wash stand (north)
Baby balance
Medicine prep. Trolley
Resuscitation bed
Steel wash stand (south)
infusion pump incubator 9
Nurse counter
Sucking tube (resuscitation bed)

Enterobacter aerugenes
Enterobacter sakazakii
Klebsiella pneumoniae
CoNS
Acinetobacter sp.
K. pneumonia
Enterobacter sakazakii
Acinetobacter sp.
Enterobacter cloacae
Enterobacter aerugenes
Negative
Enterobacter cloacae
Bacillus sp
Serratia rubidaea
CoNS + Klebsiella pneumonia
Enterobacter aerugenes
CoNS
Enterobacter sakazakii
Enterobacter cloacae
Enterobacter cloacae
Bacillus sp
Acinetobacter
Enterobacter cloacae + Bacillus sp.
Negative
Aerumonas sp.
Pseudomonas sp
Bacillus sp.
Acinetobacter sp.
Acinetobacter sp.

110

Annex 4 Perception Survey for Health-Care Workers

Serial:

Dear health worker: You are in direct contact with patients on a daily basis and this is why we are
interested in your opinion on health care-associated infections and hand hygiene. Your participation in
this research work will have important impact on the improvement of health care and the protection of
patients and health care workers from these infections.
Gender:

Male

12-

DOB:

/ /19

Years

Working experience:

Assistant nurse
Trainer.
Others: ..
Did you receive format training in hand hygiene in the last three years?
Yes No
Do you routinely use an alcohol-based handrub for hand hygiene?
Yes No

Profession:

Female

Physician

Nurse

3- Do you think wearing gloves replaces handwashing or

handrub?

Yes

6- Are you interested in the results of your samples?

Yes

Yes

9- In what percentage of situations requiring hand hygiene

do health care workers actually perform it?
10- In what percentage of situations requiring hand hygiene
do yu actually perform it?

..........%

develop a health care-associated infection (between 0 and 100%)?

No

No

7- Do you think this research will contribute to infection control in the hospital?
8- What is the average percentage of hospitalised patients who will

Dont know

Yes
No

4- Do the patient have the right to demand you clean hands before working?
5- Do you think you are a potential source of infection?

No

Yes

No

Dont know

............%

Dont know

..........%

Can't tell

11- What do you think about the role of infection control committee in the hospital;?

Very low

Low

Moderate

High

Very high

12- What is the impact of a health care-associated infection on patient's clinical outcome?

Very low

Low

Moderate

High

Very high

13- What is the effectiveness of hand hygiene in preventing health care-associated infection?

Very low

Low

Moderate

High

Very high

High

Very high

High

Very high

Very high

14- Seniors and managers direct workers towards personal hygiene

Very low

Low

Moderate

15- Workers direct their colleagues towards personal hygiene

Very low

Low

Moderate

16- Patients and/or their companions direct workers towards personal hygiene

Very low

Low

Moderate

High

17- The best way to make health workers comply with health conditions? (mark all that apply)

Enforcement

Promotion

Role model

Thank you for cooperation

Sorry for interruption

111

Other:.............................

Annex 5
:

, : ,
.

. ,
. ,
.
)(........ :
:
:

..............:
:
-1
-2
-3
-4
-5
-6
-7

19 / / :
..............: ............ :

%...........

-8

%...........

-9

%...........

16-10 5-1 =1 =2 ,=3 ,=4 ,=5 ,

-10
4 3 2 1
-11 ,
4 3 2 1

-12
4 3 2 1
-13
4 3 2 1

-14
4 3 2 1
-15
4 3 2 1

-16
4 3 2 1

-17 ) (
.................................. :

112

5
5
5
5
5
5
5

Annex 6: Environmental and working conditions checklist results

Part I

Work and
treatment areas

No. of Wards +
Resuscitation areas
Total area
No. of incubators +
resuscitation units
Space between
incubators (m)
Equipment injuries
Wall covering
Floors covering
External electrical
connections
Drinking and eating
areas
Ventilation
Filtration

Environmental
conditions

Infrastructure
maintenance &
monitoring

The staff

Antimicrobial
therapy regimen

Air condition
Monitoring of
environmental
conditions
Maintenance and
mentoring
Preventive
maintenance plan
Equip. manufactures'
instructions
Physicians/Nurses
Main shift (morning
shift)
Other shifts (evening
and night)
Education and
training

Al-Nasser NICU

Al-Shifa NICU

2+0

4+1
2

about 56 m

About 140 m2

9+2

28 + 4

0.6-1

0.6-1

Eased work flow

Not reported
Regular painting over
cement covering
Many visible scratches

Not reported
Regular painting over
cement covering
Many visible scratches

Regular granite slabs

Regular granite slabs

Many

Many

No documentation
No ceramic
More scratches in
Nasser NICU
No carpets or
nonslip covering
Most of them are
external

At the center of the

ward
None
Assumed by air
condition

Separated room
(designated)
None
Assumed by air
condition

3 in the main ward, 1 in

the reception room

2 (ground floor), 8
(upper floor)

Claimed to be done
(No documentation)

Not done

claimed to be
scheduled

Not scheduled

None

None

Not available in the

unit
8/22
6-8 physicians, 13-14
nurses
1-2 physicians, 6
nurses

Not available in the

unit
16/31

Upon availability

Health screening

None

Immunization
Availability of
protocols

Hepatitis B only

Reviewing the
protocols

Notes

Verbal (claimed)
None

113

No separate air
filters
Some are defected
(no regular
maintenance)

No documentation

kept with the

engineer

4 physician, 6 nurses
1 physician, 4 nurses
Upon employment/
periodically
On employment (No
documentation)
Hepatitis B only
Verbal (WHO under
accreditation)
Semiannually (local
microbial resistance
data)

No documentation

No documentation
No documentation
No documentation

Annex 6 Part II

Formation

Infection control teams

Physicians
Nurses
Microbiologist
Epidemiologist
Engineer

Al-Nasser NICU
1 (head of the team)
2
1
0
0

Role

Al-Shifa NICU
3 (different specialties)
3
1
0 (1 for 1meeting)
0
Pharmacist, radiologist and
an administrative

Notes

Not documented

Activities

Otters

none

Renovations and new

building work
Meetings
infection control manuals
Education and training of
workers
Monitoring of staff
compliance with infection
control measures
Monitoring of health status
of the workers
Sterility testing 2

Informal, not obligatory 1

Formal , but not obligatory 1

Monthly
Available only for the team

Monthly
Under preparation

Claimed to be scheduled

Claimed to be scheduled

Not documented

In coordination with the

heads of the staff

Claimed to be scheduled

Not documented

Only on complaints

scheduled for hepatitis

Not documented

Monthly
Monthly
-Identifying and disinfecting -Identifying and disinfecting
the infected areas
the infected areas
Testing results are used in:
-Designing and updating
-Designing and updating
infection control policies
infection control policies
1- Consolatory in both teams but more frequent in Al-Shifa team
2- Swabbing environmental spots in the section testing for contamination

No documentation

Annex 6 Part III

Hand washing and personal hygiene

Al-Nasser NICU

Al-Shifa NICU

Hand washing basins

Personal protection
equipment

The reception : 1/1

The main ward: 1/2

Each ward: 2/2

Hand washing and for

tools cleaning (baby
feeders, etc),
Available
Hard soap and liquid
soap
Refillable style
Paper towels

Hand washing is
separated from other
uses (No signs)
Available
Hard soap and liquid
soap
Refillable style
Paper towels

Available in all different

kinds

Available in all different

kinds

Not needed
Regular masks are
available but not
regularly used

Not needed
Regular masks are
available but not
regularly used

disposable gowns and plastic

aprons

For operations only

For operations only

Footwear

Available but not used

Available but not used

Washstand(s)/ sink(s)
Designated use
Water mixer tap
Soap
Liquid soap containers
Towels
Gloves
Protective eyewear
Masks

114

Notes

Manual filling
Non-sterile,
sterile and
general purpose
utility

The staff use

special wear
Direct
observations

Annex 6 Part III continue

Al-Nasser NICU

Al-Shifa NICU

Handling and disposal

of sharps

notes
No written
material
Trays are
available

Intravascular access devices (catheters)

Instructions

Verbal

Verbal

passing sharps between

workers

By hand

Sharp trays (claimed)

Puncture proof labeled

sharps disposal container
Clean dry environment
protected from sharps
Cleaned and disinfected
each use

Puncture proof labeled sharps

disposal container
Clean dry environment
protected from sharps
Cleaned and disinfected each
use

Instructions

Verbal

Verbal

Precautions while
inserting catheters

Handwashing with
antiseptic solution is
always done.
No use of sterile gloves.
The insertion site is
cleaned with antiseptic.
The insertion site is often
dried.
The catheter is changed for
each attempt.

Handwashing with antiseptic

solution is often done.
No use of sterile gloves.
The insertion site is cleaned
with antiseptic.
The insertion site is often
dried
The catheter is changed for
each attempt.

No special procedures
(hand washing or using
sterile gloves)

No special procedures(hand
washing or using sterile
gloves)

Always clean and sterile

Always clean and sterile

Always clean but not

necessarily sterile
On the dressing (always).
In the patient file
(sometimes)
In the patient progress
notes(sometimes)

Always clean but not

necessarily sterile
On the dressing (always).
In the patient file(always).
In the progress notes
(sometimes)

Direct
observations

only on suspicion

only on suspicion

Not documented

only on suspicion

Only on suspicion

Not documented

Needles disposal
Storage of sterile
equipments
Thermometers

Changing or
maintaining solution
containers, lines or
dressings
The dressing covering
the catheter
The stabilizing tape
The time and date of
insertion
Monitoring and
surveillance of
Catheter induced
infections
Testing of catheters
after use.

115

No direct
observation
No written
protocols

The information
is given by
nurses, no direct
observations

No direct
observation
No direct
observation

Annex 6 Part IV
Al-Nasser NICU

Cleaning processes

Al-Shifa NICU

notes

Routine environmental cleaning

No written
protocols
All
equipments
are easily
removable
No rough
surfaces to
interrupt the
cleaning
process
Claims

Cleaning instructions

Verbal

Verbal

Inaccessible areas for

cleaners

Very few

Very few

No carpets or nonslip
coverage.
Cleaned before and after
each shift and when visibly
soiled
Cleaned daily
Covered with regular
curtains
Cleaned only when visible
soil is reported, and changed
only when visibly worn-out
Defined for cleaned and
contaminated items
separately

No carpets or nonslip
coverage.
Cleaned before and after
each shift and when visibly
soiled
Cleaned daily
Covered with regular
curtains
Cleaned only when visible
soil is reported, and changed
only when visibly worn-out
Defined for cleaned and
contaminated items
separately

Verbal

Verbal

No written
protocols

At the point of generation

At the point of generation

Claims

Color-coded and labeled

Color-coded and labeled

Handling medical
wastes

Gloves and protective

clothes are claimed to be
worn and then placed in
regular bags or containers

Gloves and protective

clothes are claimed to be
worn and then placed in
regular bags or containers

Transport of infectious
or hazardous wastes

Trolleys labeled and used

only for waste transport

Trolleys labeled and used

only for waste transport

Cleaning of Cleaning
equipments
Changing of Cleaning
equipments

Only after the cleaning of the

spills
After each shift or after the
cleaning of the spills

Only after the cleaning of the

spills
After each shift or after the
cleaning of the spills

Procedural manuals

Not available

Not available

Verbal
instructions

As claimed
by senior
cleaners

The floors
The walls
The windows
The curtains
Cleaning and
reprocessing areas
Cleaning instructions

Management of clinical wastes

Segregation of medical
wastes from regular
wastes
Medical waste
containers

Management of
blood and body
spills

Instructions include

Use
Trolleys
Cleaning

Personal precautions
Contained cleaning
Aerosol prevention

Dedicated for one purpose

only
Daily and when visibly
soiled

116

Personal precautions
Contained cleaning
Aerosol prevention

Dedicated for one purpose

only
Daily and when visibly
soiled

No direct
observations

Bags and
containers
are not leakresistant
Claimed to be
(no signs are
noticed)

No signs
No direct
observations

Annex 7: Results of the perception survey

Part I
Yes

No

Dk

Total

1- Recent formal training in hand hygiene and infection control

17

18

35

2- Routine use of alcohol-based handrub for hand hygiene

3- Gloves wearing can replace handwashing
4- Patient and companions right to direct workers to handwashing
before working
5- The health worker is a potential source of infection to the patient
6- The current research work will contribute to infection control in the
hospital
7- Interested to get the results of his/her hand and nasal swabs
Dk= Dont know
Na= Not applicable

26
4

11
33

27

37
37
37

28

34

36

Question content

37
37
37

Part II
Question content
8- Average percentage of HAI
9- Colleagues commitment to PHP
10- Respondent's commitment to PHP
HAI= health care-Associated infection
Dk= dont know or dont remember

Dk
<30%
30-50%
>50%
29
2
4
2
19
0
6
11
13
0
3
21
PHP= Personal Hygiene Practices

Total
37
36
37

Part III
Question content

11- The role of infection control committee

12- The negative effect of HAI on patient prognosis
13- The effectiveness of PHP in preventing HAI
14- The role of managers in directing workers to PHP
15- The role of colleagues in directing workers to PHP
16- The role of workers in directing residents to PHP
17- The role of residents in directing workers to PHP
HAI= health care-Associated
PHP= Personal Hygiene
infection
Practices

total

2
18
12
5
0
1
5
12
14
5
0
1
4
14
18
2
11
10
11
2
3
10
13
10
1
3
9
14
8
3
4
18
10
4
0
1= very low, 2= low, 3= moderate,
4= high, 5= very high

37
37
37
36
37
35
36

Part VI
Question content

17- The best way to make health workers comply with health conditions
9
29
11
41-4
A= Enforcement
B= Promotion
C= Role model
D= Further suggestions
1
Punishment and criticism, 2conscious, 3continuous education of the workers about the importance of the
compliance to the patient and to himself and 4periodical examining of workers and the punishment for
those who dont comply

117

Annex 8: Results of air samples of NICU of Al-Nasser and Al-Shifa hospitals

NICU

Ward

Al-Nasser

Main
Resuscitation
Reception

Ground
floor

West
Resuscitation

First floor

Al-Shifa
1.
2.
3.

East

East

West

Bacteria 1,2
Count
Mean
67
63
91
124
110
63
115
108
100
90
85
81
85
90
95
77
89
99
82
56
83
79
81
79
84
71

Fungi1.3
Count
mean
21
17
18
10
25
30
25
25
25
16
25
33
29
26
23
26
21
22
21
22
18
19
17
19
21
19

CFU/50Litres
2 days incubation on nutrient agar
5 days incubation on Dichloran Rose Bengal Chloramphenicol Agar (DRBC Agar)

118

Annex 9: Antibiotic sensitivity for selected Gram negative bacteria isolated from
blood culture, environment, hand and nasal swabs.
Na

Cp

119

Te

Enterobacter cloacae

I
R
S
S
S
R
I
S
R
R
R
S
S
S
R
I
S
R
I
R
S
S
S
R
S
S
R
R
R
R
S
S
R
R
R
S
R
I
S
S
S
R
R
R
R
R
R
S
S
S
R
R
R
S
R
R
S
S
S
R
R
R
R
R
S
S
S
R
R
R
S
R
R
S
S
S
R
R
R
S
I
R
R
S
S
S
R
R
R
S
R
S
S
S
R
R
R
S
R
R
S
S
S
R
R
R
S
S
R
S
S
S
S
R
I
S
S
R
S
S
S
S
R
S
S
I
S
S
S
S
S
R
S
S
S
R
S
S
S
S
R
S
S
I
I
S
S
S
R
R
R
S
S
R
R
S
S
S
R
R
R
S
I
R
S
S
S
R
R
R
S
R
S
S
S
S
R
R
R
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
R
S
S
S
S
S
S
S
S
R
S
S
S
S
S
S
S
S
R
R
S
S
R
R
S
S
S
R
R
R
R
S
S
S
S
S
R
S
S
S
S
S
S
S
R
S
S
S
I
S
S
S
S
S
R
S
S
S
S
S
S
S
R
S
S
S
I
R
R
S
S
R
R
R
S
R
S
S
S
S
R
S
S
S
S
S
S
S
S
S
R
S
S
I
S
S
S
S
S
S
S
S
S
S
S
S
S
R
S
S
S
S
R
R
S
S
R
R
R
R
R
S
S
S
S
R
S
S
S
S
Am=ampicillin, PIP=piperacillin, GM=gentamicin,
Ak=amikacin, MEM=meropenem, I=imipinem, Cn=
Cephalexin, Cfm= cefixime, CRO=ceftriaxone,
C=chloramphenicol, TR=trimethoprim, Te=tetracycline,
Na=nalidixic acid, Cp= ciprofloxacin

TR

Cro

Cfm

Cn

MEM

Eschericiha
coli

ShE33
ShE44
ShE47
ShE56
ShH17
ShH18
NsE20
NsE23
NsH02
NsN11
ShB21
ShB22
ShE13
ShE31
ShN14
ShB07
ShB20
ShE05
ShE23
ShE50
ShE53
ShE60
ShE61
ShE64
ShH04
NsB24
NsE04
NsE17
NsE32
NsE38
Sh=Al-Shifa NICU,
Ns=Al-Nasser NICU,
B=blood, H=hand,
N=nasal,
E=environmental

Ak

R
R
R
R
R
R
R
R
R
R
R
R
R
R
I
R
S
R
R
R
S
R
R
R
R
R
R
R
R
R
R
R
S
R
R
S

GM

ShB01
ShB02
ShB09
ShE04
ShE11
ShE24

PIP

Klebsiella pneumoniae

Source

Am

Bacteria

Antibiotic sensitivity

R
R
R
R
R
R
R
R
R
R
R
R
S
S
S
S
R
R
S
R
R
S
R
S
R
I
S
R
S
R
S
S
S
S
R
S

I
S
S
S
R
S
I
R
S
S

S
I
S
S
S
I
I
R
I
S

S
S
S
S
S
I
I
R
S
S

S
I
S
S
I
S
S
S
R
R
S
S
R
S
S
I
S
S
S
R
R
S
R
R
I
S
S
S
R
R
R
S
S
S
S
S
S
S
S
S
S
S
I
I
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
R
S
S
S
S
S
S
S
S
S
R
S
S
S
S
S Sensitive
I Intermediate
R Resistant

Annex 10: Antibiotic sensitivity of staphylococcus aureus isolates

Antibiotic sensitivity
Code

Am

PIP

Cn

Cfm

Cro

GM

Ak

MEM

TR

Va

Cp

Tet

01

SB03

02

SB08

03

SB10

04

SB23

05

SB24

06

SN01

07

SN02

08

SN03

09

SN08

10

11

SN10
NB02

12

NB04

13

NB05

14

NB08

15

NB09

16

NB10

17

NB12

18

NB13

19

NB14

20

NB16

21

NB17

22

NB18

23

NB21

24

NB23

25

NB25

26

NH04

27

NH15

28

NH07

29

NN04

30

NN05

31

NN06

32

NN09

R
Sh=Al-Shifa NICU,
Ns=Al-Nasser NICU,
B=blood,
H=hand,
N=nasal,
E=environmental,
A=air

S S R S S S S S S S S S S S
P=penicillin, Am=ampicillin,
S Sensitive
I Intermediate
PIP=piperacillin, Cn= Cephalexin , Cfm=
R Resistant
cefixime, CRO=ceftriaxone,
GM=gentamicin, Ak=amikacin,
I=imipinem, MEM=meropenem,
TR=trimethoprim, Va=vancomycin, Cp=
ciprofloxacin C=chloramphenicol,
Te=tetracycline, E=erythromicin

120

Annex 11: Antibiotic sensitivity of Al-Shifa NICU Coagulase negative

Staphylococcus (CoNS).
P

Am

PIP

Cn

Cfm

Cro

GM

Ak

Tm

Va

Cp

Tet

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27

Code
SA02
SA09
SA13
SA19
SA21
SA25
SB04
SB04
SB11
SB12
SB16
SB18
SB25
SE30
SE45
SE56
SE58
SH10
SH12
SH15
SN04
SN06
SN07
SN09
SN12
SN13
SN17

R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R

R
R
R
R
S
S
R
R
R
R
R
R
R
S
R
S
R
S
R
R
R
R
S
R
R
S
R

S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S

S
S
S
S
S
S
I
I
R
R
R
S
S
S
R
S
I
R
R
R
S
S
S
S
S
S
S

R
R
R
R
R
R
R
R
R
R
R
R
S
R
R
R
R
R
R
R
R
R
R
R
R
R
R

S
S
S
I
S
S
I
I
I
R
I
I
S
S
S
S
S
R
R
S
S
S
I
R
S
S
S

S
R
S
R
S
S
S
S
S
R
R
S
S
S
S
S
S
R
S
S
S
S
S
I
S
S
S

S
S
S
S
S
S
R
R
I
R
R
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S

S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S

I
R
I
I
S
S
R
R
R
R
R
R
I
I
S
S
R
R
R
R
S
R
R
R
R
S
R

S
R
S
S
S
I
R
R
R
R
S
R
R
S
R
R
R
S
R
R
S
S
S
S
S
S
S

S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S

S
S
S
S
S
S
S
S
I
R
R
S
S
S
S
S
S
S
S
S
S
S
S
S
R
S
S

S
S
S
S
S
S
S
S
S
S
S
R
S
S
S
S
S
R
S
S
S
S
S
S
S
S
S

I
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
I
S
R
S
S
S
S
R
S
S
S

R
R
R
R
I
R
R
R
R
R
R
R
I
S
S
S
I
R
R
I
I
I
S
R
R
I
R

B=blood,
H=hand,
N=nasal,
E=environmental,
A=air

P=penicillin, Am=ampicillin, PIP=piperacillin, Cn=

Cephalexin , Cfm= cefixime, CRO=ceftriaxone,
GM=gentamicin, Ak=amikacin, I=imipinem,
MEM=meropenem, TR=trimethoprim, Va=vancomycin,
Cp= ciprofloxacin C=chloramphenicol, Te=tetracycline,
E=erythromicin

121

S Sensitive
I Intermediate
R Resistant

Annex 12: Antibiotic sensitivity of Al-Nasser NICU Coagulase negative

Staphylococcus (CoNS).
P

Am

PIP

Cn

Cfm

Cro

GM

Ak

Tm

Va

Cp

Tet

01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Code
NA02
NA08
NA09
NA13
NB03
NB06
NB07
NB11
NB19
NB20
NB22
NE02
NE06
NE07
NE11
NE27
NE30
NE32
NE35
NH03
NH05
NH09
NH17
NN02
NN16

R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R

R
S
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
S
S
S
R
R
R
R

S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S

S
S
S
S
R
R
R
R
R
R
R
S
S
S
S
S
S
S
S
S
S
R
S
S
S

S
S
S
S
R
R
R
R
R
R
R
S
S
S
S
S
S
S
S
S
S
R
S
S
S

I
S
S
S
I
I
I
I
R
R
R
S
S
S
S
S
S
S
S
I
S
R
S
S
S

R
S
R
S
S
S
S
S
I
I
R
S
S
S
S
S
S
S
S
S
S
S
I
S
S

R
S
S
S
S
S
S
S
R
R
R
S
S
S
S
S
S
S
S
S
S
S
I
S
S

S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S

R
R
R
I
R
R
R
R
R
S
S
R
R
R
R
R
R
R
R
R
S
R
R
R
R

R
I
R
S
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
S
R
R
S
R
R

S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S

S
S
S
S
S
S
S
S
R
R
R
S
S
S
S
S
S
S
S
S
S
S
S
S
S

S
S
S
S
S
S
S
S
R
S
S
S
S
S
S
S
R
S
S
S
S
S
S
S
S

R
S
S
S
S
S
S
S
R
S
S
S
I
S
S
S
S
S
S
I
S
R
S
S
S

R
I
R
R
S
I
I
I
R
R
R
R
I
R
I
R
R
R
R
S
I
S
S
S
S

B=blood,
H=hand,
N=nasal,
E=environmental,
A=air

P=penicillin, Am=ampicillin, PIP=piperacillin, Cn= Cephalexin ,

Cfm= cefixime, CRO=ceftriaxone, GM=gentamicin, Ak=amikacin,
I=imipinem, MEM=meropenem, TR=trimethoprim,
Va=vancomycin, Cp= ciprofloxacin C=chloramphenicol,
Te=tetracycline, E=erythromicin

122

S Sensitive
I Intermediate
R Resistant

123