ORIGINAL

Niger J Paed 2014; 41 (1):54 - 58

Osinupebi OA

Ogunlesi TA

Fetuga MB

Pattern of nosocomial infections in

the special care baby unit of the

Olabisi Onabanjo University

Teaching Hospital, Sagamu, Nigeria

DOI:http://dx.doi.org/10.4314/njp.v41i1,10

Accepted: 27th September 2013

Abstract Background: Sepsis

contributes significantly to new-

born deaths in Nigeria. A signifi-

cant proportion of severe infec-

tions in the newborn may be

health care-related.

Objective: To determine the

prevalence, types and risk factors

for nosocomial infections in the

Special Care Baby Unit of a Nige-

rian Tertiary Hospital.

Method: A cross-sectional survey

of consecutively admitted infants

aged 0 to 28 days with signs of

infections or who developed signs

of infection following admission.

Infants with or without nosoco-

mial infections were compared for

the clinical and laboratory details.

Results: Out of 356 infants, 32

A significantly higher proportion

of babies with nosocomial infec-

tions were inborn (p < 0.000) and

stayed longer than 7 days on ad-

mission (p = 0.034). Bacteraemia

was significantly more frequent

among babies with nosocomial

infections (p = 0.014) while super-

ficial skin and mucosal infections

occurred to similar extents in both

groups. Klebsiella and Proteus

species were the leading isolates

among babies with nosocomial

infections. Nasogastric intubation

was significantly more frequently

performed among babies with

nosocomial infections (p = 0.045).

Conclusion: The present study

revealed that hospital acquired

infection is an important cause of

morbidity in the newborn unit.

(

)

Ogunlesi TA

Fetuga MB

Department of Paediatrics,

Osinupebi OA

Department of Medical Microbiology

and Parasitology,

College of Health Sciences,

Olabisi Onabanjo University,

P.M.B 2022, Sagamu-121001,

Ogun State,

Nigeria.

Email: tinuade_ogunlesi@yahoo.co.uk

(

8.9%) had between 1 and 3 noso-

comial infections while 48

13.5%) had community-acquired

(

Keywords: Bacteraemia; Hospital

-acquired infections; invasive pro-

cedures; newborns

infections. Half of babies with

nosocomial infections were pre-

term and weighed less than 2kg.

Introduction

newborn may also be associated with severe morbidities

such as shock, necrotizing enterocolitis and meningitis

which might leave severe sequelae in the survivors.

Therefore, every measure required for the reduction of

the burden of sepsis in the newborn needs to be put in

place.

Neonates are particularly susceptible to infection

because of their immature immune system in addition to

several invasive diagnostic and therapeutic procedur₁e_-s₃

and interventions required for their management.

Studies from developed countries have reported that

nosocomial infection is an important cause of morbidity

and mortality among ne₄o_-₆nates despite advances in

neonatal intensive care.

The overall contribution of nosocomial infections to

cases of newborn sepsis varies in centres from different

parts of the world, depending on the level of newborn

care in practice. Although, referred infants are mostly

9

A recent national epidemiological survey of newborn

deaths in Nigeria suggested that severe infections were

resp₇onsible for 22% of all newborn deaths in the coun-

try. This is very similar to 24.8% reported from a re-

view of newborn deaths recorded at the Olabisi Ona-

banjo University Teaching Hospit₈al (OOUTH), Sagamu,

Nigeria between 1996 and 2005. It is also important to

add that sepsis-related case fatality rate at the same cen-

tre in₉a study conducted between 2006 and 2008, was

affected by severe infections, inborn babies may also be

infected vertically or horizontally. The former com-

monly presents as Early-Onset sepsis while the latter

common₁₀ly presents as Late-Onset sepsis or Nosocomial

Sepsis.

Surveillance reports between 1999 and 2001 at OOUTH,

Sagamu, Nigeria revealed that the neonatal unit recorded

all the cases of hospital-acq₁₁uired infection in the pediat-

ric service of the hospital. The Special Care Baby Unit

3

2%. In addition to deaths, severe infections in the

5

(

SCBU) of the hospital, with 20 cot and incubator

Others included the type of infection, clinical findings,

procedures, interventions and device use, as well as the

results of bacteriologic examination of specimens. Cases

of nosocomial infections were determined using modi-

spaces, was established as a sub-unit of paediatric ser-

vice in 1989. The unit offers basic care for acutely-ill

newborn infants while facilities for intensive care such

as mechanical ventilation, blood gas analysis and par-

enteral nutrition are not available. The unit receives high

1

4

fied CDC definitions. Inborn infants were the babies

delivered in OOUTH while the out-born infants were

referred babies. Data were analyzed using SPSS 17.0

statistical package. Babies with nosocomial infections

were statistically compared with babies with community

acquired infections using clinical characteristics, pattern

of infections and spectrum of isolates. Proportions and

mean values were compared using the Chi-Squared test

and Student’s t-test respectively. P-values less than 0.05

defined statistical significance.

-risk infants delivered in the maternity unit of the hospi-

tal as well as infants referred from the lower levels of

health care located within and outside Sagamu commu-

nity. Thus, the unit is compartmentalized with inborn

infants separated from referred infants to prevent cross-

infections. A recent study conducted at the same centre

between 2006 and 2008 showed that referred babies and

inborn babies constituted 54.5% and 45.5%₁₂respectively

of the cases of Late-Onset sepsis in the unit.

The role of surveillance as an important tool in the

prevention of₁₀hospital- acquired infection has been

emphasized. This study is a step in that direction as it

was designed to evaluate the prevalence, types and some

of the factors related to health care associated infections

in the SCBU of OOUTH, Sagamu, Nigeria.

Result

During the study period, 356 infants were admitted into

the unit of whom 80 (22.5%) had infections. They con-

sisted of 50 male and 30 female infants with male-to-

female ratio of 1.7:1. The 80 infants with infections had

a mean EGA of 35.9 ± 3.9 weeks and a mean weight of

3

.3 ± 0.9kg.

Method

The general characteristics of these 80 infants are de-

picted in Table 1. Most of the infants were males

(62.5%), term (60.0%), single ton (87.5%), out-born

(72.5%), weighed > 2.0kg (58.8%) and were hospital-

ized for > 14 days (52.5%). The frequency of obvious

infections in this population varied between one and

three with a mean of 1.6 ± 0.6.

Forty-eight babies (60.0%) had community-acquired

infections while 32 (40.0%) had nosocomial infections.

The infants with nosocomial infections constituted 8.9%

(32/356) of the total admissions while infants with com-

munity acquired infections constituted 13.5% (48/356)

of the total admissions. The babies with community-

acquired infections had higher EGA compared with

those who acquired infection in the hospital. This differ-

ence lacked statistical significance (36.6 ± 3.3 weeks Vs

34.9 ± 4.5 weeks; t = 1.95, p = 0.055). Similarly, the

mean weight of babies admitted with infections was

similar to that of babies with nosocomial infections (3.4

± 0.8kg Vs 3.2 ± 0.9kg; t = 1.04, p = 0.301).

This cross-sectional survey was conducted in the Special

Care Baby Unit (SCBU) of OOUTH, Sagamu, Nigeria

between January and September, 2008. As mentioned

above, this unit only provides basic care for high-risk

infants with medical disorders such as preterm birth, low

birth weight and the associated problems, intrapartum-

related injuries, jaundice, infections and minor surgical

conditions. The unit is managed by at least two Consult-

ants, resident doctors, medical interns and nurses, most

of whom are specialized in paediatric care. The scope of

care available for infants with sep₉sis had been described

in detail in another publication. In addition, first-line

antibiotics employed in the treatment of newborn sepsis

in the unit include cefuroxime and gentami₁c₃in based on

previous reports of antibiogram in the unit. The choice

of antibiotics is usually tailored to the pattern of antibi-

otic susceptibility reported by the laboratory. Microbio-

logic services available in the hospital include routine

bacteriologic analysis of specimens; facilities for an-

aerobic bacterial, fungal or viral cultures are not rou-

tinely available.

Table 1: Clinical characteristics of 80 babies with infections

Characteristics

Type of birth

Frequency (%)

The study population consisted of consecutive infants

aged 0 to 28 days admitted with signs of infection or

who developed features of infection whilst on admis-

sion. The latter group was in turn, sub-divided into those

who developed signs of infection within or after the first

Singleton

Multiple

Inborn

Out-born

Female

Male

70 (87.5)

10 (12.5)

22 (27.5)

58 (72.5)

30 (37.5)

50 (62.5)

5 (6.2)

13 (16.3)

14 (17.5)

48 (60.0)

2 (2.5)

Place of birth

Gender

4

8 hours of admission. Informed consent was obtained

from the primary care givers available at the point of

recruitment into the study.

Gestational Age (weeks)

< 28

2

3

9 – 32

3 – 36

>

37

Demographic and clinical data were obtained from all

the infants admitted into the study. These data included

age and body weight on admission, gender, estimated

gestational age (EGA), place and type of delivery

Birth weight (kg)

0.5 – 1

1

.1 – 1.5

.6 – 2.0

16 (20.0)

15 (18.8)

47 (58.9)

>

2.0

5

6

Comparison of the babies admitted with and without

obvious infections

Table 3: Comparison of pattern of infections among babies

admitted with infections and babies with nosocomial infections

Infections

Babies admitted

with infections

Babies with p-

nosocomial values

infections

Table 2 depicts the comparison of the clinical details of

babies admitted with infections and babies with

nosocomial infections. A significantly higher proportion

of babies admitted with infections were out-born

(n = 48)

(

n = 32)

Ophthalmia

13 (27.1)

8 (25.0)

0.836

(

p = 0.000) and stayed for 7 days or less on admission

p = 0.034). Higher proportions of babies hospitalized

Omphalitis

Phlebitis

Superficial skin

infections

11 (22.9)

6 (12.5)

4 (12.5)

5 (15.6)

3 (9.4)

0.242

0.424

0.665

with obvious infections also had records of prolonged

rupture of membrane, prolonged labour and history

suggestive of asphyxia but without statistical signifi-

cance. Preterm birth, weight on admission < 2kg, multi-

ple gestation, abdominal delivery and requirement for

intubation at birth had no statistical association with

development of nosocomial infections.

Bacteraemia

2 (4.2)

7 (21.9)

0.014

Septicaemia

Respiratory infec-

tions

Urinary tract infec- 1 (2.1)

tions

27 (56.3)

3 (6.3)

15 (46.9)

2 (6.3)

0.411

1.000

0 (0.0)

3 (9.4)

0.310

0.490

Gastrointestinal

infections

7 (14.6)

Table 2: Comparison of babies with and without obvious

Infections

Parameters

Babies admit-

Babies with P-

ted with infec- nosocomial values

Table 4: Comparison of bacterial isolate types among babies

tions (n = 48)

infections

n =32)

with and without nosocomial infections

(

Isolates

Babies admitted

with infections

(n = 48)

Babies with p-

nosocomial values

infections

Male sex

Preterm birth

29 (60.4)

16 (33.3)

17 (35.4)

6 (12.5)

42 (87.5)

10 (20.8)

15 (31.2)

3 (6.3)

21 (65.6)

16 (50.0)

4 (12.5)

16 (50.0)

10 (31.3)

6 (18.8)

3 (9.4)

0.637

0.136

0.194

1.000

0.000

0.292

0.213

0.603

0.512

0.034

Weight < 2kg

Multiple births

Out-born

Caesarean Section

PROM*

Intubation at birth

Prolonged labour

Presence of asphyxia

Duration of hospi-

talization < 7 days

(n = 32)

Atypical coliforms

3 (6.3)

2 (6.3)

1.000

E.coli

2 (4.2)

8 (16.7)

2 (4.2)

3 (6.3)

2 (6.3)

0.675

0.126

0.076

0.530

Klebsiella spp.

Proteus spp.

Pseudomonas spp.

10 (31.3)

5 (15.6)

1 (3.1)

12 (25.0)

20 (41.7)

14 (29.2)

6 (18.8)

11 (34.4)

3 (9.4)

Staph. Aureus

8 (16.7)

4 (12.5)

0.609

Comparison of the possible factors predisposing babies

to nosocomial infections

*Pr olonged Rupture of Membranes

Table 5 shows that nasogastric intubation was more

frequently performed among babies with nosocomial

infections with statistical significance (p = 0.045).

Although intravenous infusion was more frequently

carried out among babies admitted with obvious infec-

tions, the difference did not reach level of significance.

Intravenous cannulation, airway suctioning, assisted

ventilation and clinical procedures like minor surgeries

and blood transfusions were performed at similar rates

in both groups of babies.

Pattern of infections among babies admitted with or

without obvious infections

Bacteraemia was significantly more frequent among

babies with obvious nosocomial infections (p = 0.014)

as shown in Table 3. The prevalence of ophthalmia, om-

phalitis, phlebitis, superficial skin infections and gastro-

intestinal tract infections were similar in both groups.

However, respiratory tract and urinary tract infection

was remarkably rare in both groups.

Table 5: Comparison of the procedures which may predispose

to nosocomial infections

Comparison of the pattern of clinical isolates among

babies with obvious infections

Procedures

Babies admitted Babies with p-

with infections

nosocomial values

infections

(n = 48)

In Table 4, Gram-negative bacilli, particularly Klebsiella

species, were the leading isolates among babies in both

groups. Staphylococcus aureus and Klebsiella species

were the leading isolates among babies admitted with

infections whereas Klebsiella and Proteus species were

the leading isolates among babies with nosocomial

infections. None of the comparisons of isolates reached

the level of statistical significance.

(

n = 32)

Nasogastric Intuba-

tion

IV Cannulation

Blood transfusion

Phototherapy

Intranasal oxygen

Suctioning

Assisted ventilation

Minor surgery

19 (39.6)

20 (62.5)

0.045

29 (60.4)

16 (33.4)

18 (37.5)

21 (43.8)

20 (41.7)

17 (35.4)

1 (2.1)

21 (65.6)

14 (43.8)

17 (53.1)

11 (34.4)

13 (40.6)

8 (25.0)

1 (3.1)

0.637

0.346

0.168

0.402

0.926

0.325

0.770

0.118

Intravenous infusion 11 (22.9)

3 (9.4)

5

7

Discussion

prevalence of Late-Onset sepsis was higher among

infants delivered at E₁₂GA less than 32 weeks and weigh-

ing less than 1.5kg. Ordinarily, such small babies tend

to have greater degree of immune immaturity and are

more likely to require invasive procedures and stay

longer on admission. Although, previous studies have

suggested associations betwee₁n₅_,₁m₆ echanical ventilation

that observation was

not made in the present study. We speculate that the

observation in the present study might be related to the

small number of infants studied.

The prevalence of nosocomial infections in the present

study was 8.9%. This is comparable to 7.8% report₁e₅d in

a neonatal intensive care unit (NICU) in Singapore but

remarkably lower than 19.2% and 21.4% reporte₁d₆_,₁i₇n a

Saudi NICU and an Egyptian NICU respectively.

In

addition, the prevalence of hospital-acquired infections

in different settings in Europe and North Am₁₄_,e₁r₈ica has

and intravenous cannulation,

been reported to vary between 7% and 24%.

There-

fore, the relatively lower prevalence of 8.9% in the pre-

sent study might reflect the non-NICU setting of the

study. It is important to add that the present study was

conducted in a SCBU rather than NICU where nosoco-

mial infections are expectedly more common. The dif-

ference lies in the tendency to use more invasive proce-

dures such as endotracheal intubation, mechanical venti-

lation an₁d₀ total parenteral nutrition in NICU rather than

The significant association between nasogastric intuba-

tion and nosocomial infection in the present study may

be borne out of the fact that this population of infants

are often too small or too ill to feed by direct sucking.

Therefore, tube feeding becomes a ready vehicle for

nosocomial sepsis particularly when the tube is left in-

situ for a long time just as total parenteral nutrition has

been reported t₁o₆ be associated with nosocomial sepsis in

other settings. For resource-poor settings where short-

age of nursing personnel might militate against the in-

sertion of a tube prior to every episode of feeding, fre-

quent replacement of in-situ nasogastric tubes may be

effective in the prevention of tube feeding-related sepsis.

SCBU.

In addition, infection control practices have

been institutionalized in our hospital since 1999 when

the Infection Control Unit was established. This unit

oversees the teaching and adoption of measures relevant

to the prevention of nosocomial infections by all cadres

of health workforce.

A large number of the infections in the present study

were blood stream infections. This is consistent with the

1

8

findings in other studies in Nor₁t₅h_-₁₇America and Europe

and few developing countries. Blood stream infec-

Conclusion

tions are frequently reported in noso₉comial neonatal

1

infections in the intensive care unit. This is closely

In conclusion, the present study revealed that hospital

acquired infection is an important cause of morbidity in

the newborn unit. The prevalence and types of nosoco-

mial infections in a Nigerian Special Care Baby Unit are

comparable to what had been reported in Neonatal

Intensive Care Units in many parts of the world. This

suggests that even in the absence of major invasive

procedures, the morbidities associated with nosocomial

infections in a Special Care Baby remains significant. It

is important that every newborn unit has a written policy

on guidelines for the control of hospital care-related

infections. This may include training of all cadres of

staff, environmental and equipment cleanliness, strin-

gent control of antibiotic use, stringent hand hygiene

practices and minimal use of invasive procedures. It is

important that the existing infection control programmes

should be strengthened.

related to the use of intravenous catheters both periph-

eral and central. The prominent role of superficial infec-

tions like ophthalmia, phlebitis and omphalitis in the

developin₁₀g world setting has been extensively de-

scribed. Cost-effective interventions such as stringent

hand washing techniques, liberal use of disinfectants and

prevention of ov₁e₀r_,c₂r₀o_,₂w₁ ding are useful in the control of

these infections.

Most of the pathogens isolated from both groups of neo-

nates were Gram negative bacilli. This finding is consis-

tent with other reports that Gram negative bacilli are the

m₁₉_,a₂i₂n_,₂₃pathogens in neonatal hospital acquired infections.

Unlike other studies which reported the predomi-

n₁₅a_,n₁₆ce of Coagulase Negative Staphylococcus (CONS)

there was no isolation of CONS in the present

study. This is difficult to explain since another study

from the same c₂entre had earlier reported the role of

1

CONS in LOS. The major challenge poised by these

Author’s Contributions

pathogens lies in the high incidence of multi-drug resis-

tance resulting in limited₉ therapeutic options and high

morbidity and mortality. This calls for judicious use of

antibiotics in newborn units to minimize the emergence

of resistant strains of pathogens. Therefore, neonatal

units need to have evidence-based protocols on the use

of antibiotics.

OOA and FMB conceived and designed the study.

OTA analyzed and interpreted the data. All the authors

drafted and edited the manuscript. All the authors made

substantial contributions to the intellectual content of the

manuscript.

Conflict of Interest: None

Funding: None

In the present study, the risk of nosocomial infection

was not significantly higher among preterm babies an₁d₅

babies weighing less than 2kg unlike previous reports.

A previous study at the same centre suggested that the

5

8

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