Nosocomial infections remain a major cause of mortality and morbidity worldwide. Despite the highly specialized interventions and policies, the rate of infection is still high due to the emergence of antimicrobial-resistant bacteria. This study described the prevalence of bacterial nosocomial infections and antimicrobial susceptibility pattern of isolates among patients admitted at Hiwot Fana Specialized University Hospital, Eastern Ethiopia. A hospital-based cross-sectional study was conducted among 394 nosocomial infection-suspected patients from March 2017 to July 2017. Data were collected using a structured questionnaire. Specimens from the respective site of infections were collected and examined for the presence of pathogenic bacteria and their antimicrobial susceptibility using standard culture and serological tests. Data were summarized using descriptive statistics. The prevalence of culture-confirmed bacterial nosocomial infection was 6.9% (95% CI: 4.3–7.9).
A nosocomial infection (NI) (also known as hospital-acquired infection) is a localized or a systemic infection resulting from an adverse reaction to infectious agents or its toxins that develops in 48 hours or more after admission and was not incubating on admission [
The emergence of antimicrobial-resistant bacteria has become a public health problem, creating a new burden on modern medical care in hospitals [
Knowledge of proper antimicrobial prescription policy of a particular setting is crucial to optimize the management and reduction of the rate of NIs; however, the investigation of causative agents and their antimicrobial susceptibility profile are an essential prerequisite [
A cross-sectional quantitative study involving bacteriological analysis was conducted at Hiwot Fana Specialized University Hospital, Harar, Eastern Ethiopia from March 2017 to July 2017. Harar is the political and administrative town of the Harari Regional State and is located at 525 km from Addis Ababa, Ethiopia. There are six hospitals and eight health centers in this region. Hiwot Fana Specialized University Hospital provides health care services and serve as a referral hospital for eastern parts of our country. It has the largest client load with an average bed occupancy rate of 83% (sources: Hiwot Fana Specialized University Hospital Annual Report of 2016). The hospital consists of six major wards: Medical, Surgical, Obstetrics, Gynecology, Malnutrition, and Pediatric wards.
Patients admitted to the Medical, Surgical, Obstetrics, Gynecology, Malnutrition, and Pediatric wards for more than 48 hours and who had a clinical evidence of NIs were included in this study.
A single population proportion formula was used to calculate a sample size, assuming 95% confidence level, 3% margin of error, 10% predicted nonresponse rate, and 10.3% prevalence of NIs [
Patients admitted in Medical, Surgical, Obstetrics, Gynecology, Malnutrition, and Pediatric wards were followed prospectively for the development of NIs by the clinicians. The patients were assessed for SSIs, UTIs, respiratory infections, and BSIs as per the Center for Disease Control and Prevention (CDC) criteria [
Clinical specimens such as a clean-catch midstream urine, blood, wound swab, throat swab, nasal swab, and other body fluids were collected by trained laboratory technologists using standard procedures as described by Horan et al. [
In vitro phenotypic characterization of bacteria was carried out using standard culture and biochemical tests as described by Cheesbrough [
A modified Kirby Bauer disk diffusion method was used to test each isolate for in vitro antimicrobial susceptibility based on the Clinical and Laboratory Standards Institute criteria [
The questionnaire was initially prepared in English and translated into local languages (
Data were entered into the EpiData software (v. 2; Odense, Denmark) and analyzed using the Statistical Package for Social Sciences software (v. 22; SPSS, Inc, Illinois, USA). The prevalence of NIs was presented in percentage along with the 95% confidence interval (CI). Two or more bacteria isolated from one patient were categorized as one bacterium for summarizing the prevalence but were analyzed separately for the antimicrobial susceptibility profile. Each bacterium was tested in triplicate for a single antimicrobial, and the mean value was taken to determine its antimicrobial susceptibility pattern. Intermediate results were included in the resistant category for analysis.
The study was reviewed and ethically approved by the Institutional Health Research Ethics Review Committee of the College of Health and Medical Sciences, Haramaya University. Informed, voluntary, written, and signed consent/assent was obtained from each parent/caretaker or participant. Positive finding was communicated to attending clinician for appropriate treatment.
A total of 394 clinically suspected patients for NIs were included in this study. The majority of study participants were females, 223 (56.6%), with a male-to-female ratio of 0.8 : 1. The mean age of participants was 23.9 years (±18.3 standard deviation). A large number of participants were admitted to Obstetrics/Gynecology (26.1%) followed by Medical ward (25.9%). The majority (86.3%) of patients had no previous history of admission. The length of stay of the patients on the admission was 4–7 days (37.3%) (Table
Characteristics of NI-suspected patients at Hiwot Fana Specialized University Hospital, Eastern Ethiopia, March 2017 to July 2017.
Characteristics | Total (%) |
---|---|
Sex | |
Male | 171 (43.4) |
Female | 223 (56.6) |
|
|
Age group (in years) | |
Less than 10 | 123 (31.2) |
10–19 | 39 (9.9) |
20–29 | 89 (22.6) |
30–39 | 68 (17.3) |
40–49 | 37 (9.4) |
More than 49 | 37 (9.4) |
|
|
Admission wards | |
Medical | 102 (25.9) |
Obstetrics/Gynecology | 103 (26.1) |
Pediatric | 90 (22.9) |
Surgical | 99 (25.1) |
|
|
Previous history of admission | |
Yes | 54 (13.7) |
No | 340 (86.3) |
|
|
Length of hospital stay | |
<4 days | 142 (36) |
4 to 7 days | 147 (37.3) |
>7 days | 105 (26.7) |
The overall prevalence of culture-confirmed NIs was 6.9% (95% CI: 4.3–7.9). A total of 54 bacterial pathogens were recovered. Of these, 30 (55.6%) were Gram-positive bacteria. The most common bacteria were
Distribution of bacterial agents isolated from patients with NIs admitted at wards of Hiwot Fana Specialized University Hospital, Eastern Ethiopia, March 2017 to July 2017.
Bacterial isolates | Surgical site no. (%) | Urinary tract no. (%) | Respiratory tract no. (%) | Bloodstream no. (%) | Total (%) |
---|---|---|---|---|---|
|
2 (11.8) | 4 (36.3) | 0 (0) | 3 (21.4) | 9 (16.7) |
|
0 (0) | 1 (9.1) | 3 (25) | 0 (0) | 4 (7.4) |
|
2 (11.8) | 1 (9.1) | 0 (0) | 0 (0) | 3 (5.5) |
|
3 (17.6) | 0 (0) | 2 (16.7) | 1 (7.1) | 6 (11.1) |
|
0 (0) | 2 (18.2) | 0 (0) | 0 (0) | 2 (3.7) |
|
5 (29.4) | 1 (9.1) | 0 (0) | 4 (28.6) | 10 (18.5) |
CoNS | 3 (17.6) | 0 (0) | 0 (0) | 2 (14.3) | 5 (9.3) |
|
0 (0) | 0 (0) | 5 (41.6) | 3 (21.4) | 8 (14.8) |
|
0 (0) | 0 (0) | 2 (16.7) | 0 (0) | 2 (3.7) |
|
2 (11.8) | 2 (18.2) | 0 (0) | 1 (7.1) | 5 (9.3) |
Total | 17 (31.5) | 11 (20.4) | 12 (22.2) | 14 (25.9) | 54 (100) |
Of the total Gram-positive bacteria, 73.3% were resistant to tetracycline, 66.7% to erythromycin, and 53.3% to penicillin, while all other isolates showed sensitivity to antimicrobials in the testing panel. Of the Gram-positive bacteria
Antimicrobial susceptibility pattern of Gram-positive bacteria isolated from NI-suspected patients at Hiwot Fana Specialized University Hospital, Eastern Ethiopia, March 2017 to July 2017.
Bacterial species | Total isolates | Pattern | Antimicrobial susceptibility, |
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C | CIP | CL | E | CRO | GN |
|
TE | |||
|
10 | S | 2 (20) | 8 (80) | 3 (30) | 2 (20) | 5 (50) | 7 (70) | 4 (40) | 3 (30) |
R | 8 (80) | 2 (20) | 7 (70) | 8 (80) | 5 (50) | 3 (30) | 6 (60) | 7 (70) | ||
|
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CoNS | 5 | S | 3 (60) | 3 (60) | 4 (80) | 2 (40) | 5 (100) | 4 (80) | 4 (80) | 2 (40) |
R | 2 (40) | 2 (40) | 1 (20) | 3 (60) | 0 (0) | 1 (20) | 1 (20) | 3 (60) | ||
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|
8 | S | 7 (87.5) | 6 (75) | 5 (62.5) | 2 (25) | 5 (62.5) | 4 (50) | 3 (37.5) | 2 (25) |
R | 1 (12.5) | 2 (25) | 3 (37.5) | 6 (75) | 3 (37.5) | 4 (50) | 5 (62.5) | 6 (75) | ||
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|
2 | S | 2 (100) | 1 (50) | 0 (0) | 0 (0) | 2 (100) | 2 (100) | 2 (100) | 0 (0) |
R | 0 (0) | 1 (50) | 2 (100) | 2 (100) | 0 (0) | 0 (0) | 0 (0) | 2 (100) | ||
|
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|
5 | S | 3 (60) | 4 (80) | 3 (60) | 4 (80) | 3 (60) | 4 (80) | 1 (20) | 1 (20) |
R | 2 (40) | 1 (20) | 2 (40) | 1 (20) | 2 (40) | 1 (20) | 4 (80) | 4 (80) | ||
|
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Total | 30 | S | 17 (56.7) | 22 (73.3) | 15 (50) | 10 (32.3) | 18 (60) | 21 (70) | 14 (46.7) | 8 (26.7) |
R | 13 (43.3) | 8 (26.7) | 15 (50) | 20 (66.7) | 12 (40) | 9 (30) | 16 (53.3) | 22 (73.3) |
S: sensitive; R: resistance; C: chloramphenicol; CIP: ciprofloxacin; CL: cephalexin; E: erythromycin; CRO: ceftriaxone; GN: gentamycin; P: penicillin; TE: tetracycline.
All Gram-negative isolates were found to be resistant to ceftazidime (66.7%) and chloramphenicol (66.5%), while showed sensitivity to ciprofloxacin (78.5%), ceftriaxone (70.8%), gentamycin (66.7%), and cephalexin (54.2%). The most resistant to a number of antimicrobials was
Antimicrobial susceptibility pattern of Gram-negative bacteria isolated from NI-suspected patients at Hiwot Fana Specialized University Hospital, Eastern Ethiopia, March 2017 to July 2017.
Bacterial species | Total isolates | Pattern | Antimicrobial susceptibility, |
|||||
---|---|---|---|---|---|---|---|---|
C | CAZ | CIP | CL | CRO | GN | |||
|
9 | S | 3 (33.3) | 2 (22.2) | 9 (100) | 7 (77.8) | 7 (77.8) | 6 (66.7) |
R | 6 (66.7) | 7 (77.8) | 0 (0) | 2 (22.2) | 2 (22.2) | 3 (33.3) | ||
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|
4 | S | 2 (50) | 1 (25) | 4 (100) | 3 (75) | 3 (75) | 2 (50) |
R | 2 (50) | 3 (75) | 0 (0) | 1 (25) | 1 (25) | 2 (50) | ||
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|
3 | S | 1 (33.3) | 2 (66.7) | 2 (66.7) | 2 (66.7) | 2 (66.7) | 2 (66.7) |
R | 2 (66.7) | 1 (33.3) | 1 (33.3) | 1 (33.3) | 1 (33.3) | 1 (33.3) | ||
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|
6 | S | 2 (33.3) | 1 (16.3) | 4 (66.7) | 1 (16.3) | 3 (50) | 4 (66.7) |
R | 4 (66.7) | 5 (83.7) | 2 (33.3) | 5 (83.7) | 3 (50) | 2 (33.3) | ||
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|
2 | S | 1 (50) | 2 (100) | 2 (100) | 0 (0) | 2 (100) | 1 (50) |
R | 1 (50) | 0 (0) | 0 (0) | 2 (100) | 0 (0) | 1 (50) | ||
|
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Total | 24 | S | 9 (37.5) | 8 (33.3) | 21 (78.5) | 13 (54.2) | 17 (70.8) | 16 (66.7) |
R | 15 (66.5) | 16 (66.7) | 3 (12.5) | 11 (45.8) | 7 (29.2) | 8 (33.3) |
S: sensitive; R: resistance; C: chloramphenicol; CAZ: ceftazidime; CIP: ciprofloxacin; CL: cephalexin; CRO: ceftriaxone; GN: gentamycin.
The overall prevalence of multidrug resistance (MDR) bacteria was 42.6% (23/54). The predominant MDR bacteria were
Multidrug resistant bacteria isolated from NI-suspected patients at Hiwot Fana Specialized University Hospital, Eastern Ethiopia, March 2017 to July 2017.
Nosocomial infections are one of the major public health problems around the world that vary from one country to the other. The prevalence of culture-confirmed NIs in this study was 6.9% (95% CI: 4.3–7.9). This was lower compared with a previous study conducted in a Tertiary Care Hospital, Ethiopia (35.8%) [
The prevalence of SSIs (31.5%) in this study was higher compared with a study reported from Bahirdar, Ethiopia (10.9%) [
The prevalence of BSIs (25.9%) in this study was relatively comparable with the findings of a study conducted in Liaquat University Hospital, Hyderabad, Pakistan (22.7%) [
The most frequent bacteria causing NIs were
While most resistant Gram-negative and positive bacteria in this study were consistent with other findings [
The isolation of MDR bacteria (42.6%) in this study was lower compared to a study conducted in Zahedan, Iran (95%) [
This study has several limitations. First, it was a single hospital-based study. Second, patients were not followed after discharge due to difficulties in follow up and communication. Third, anaerobic bacterial NIs were not investigated due to limited laboratory facilities. These limitations are likely to underestimate the true prevalence of NIs, and hence, the results may not be applicable to other hospitals.
In conclusion, the prevalence of culture-confirmed bacterial NIs in this study was comparable with other similar study findings. The most common infections were surgical site and bloodstream.
The SPSS data used to support the findings of this study are available from the corresponding author upon request.
The authors declare that they have no conflicts of interest.
We gratefully appreciate Haramaya University for funding this research and the study participants for their meticulous information.