|Year : 2011 | Volume
| Issue : 4 | Page : 239-243
Hospital-acquired infections in a Nigerian tertiary health facility: An audit of surveillance reports
OK Ige, AA Adesanmi, MC Asuzu
Department of Community Medicine, University College Hospital, Ibadan, Nigeria
|Date of Web Publication||13-Mar-2012|
O K Ige
Department of Community Medicine, University College Hospital, Ibadan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Hitherto efforts to implement data driven prevention guidelines for hospital-acquired infections (HAI) in Nigeria have been limited by the inadequate knowledge of the risks of these infections. This study evaluated the occurrence of HAI in a foremost tertiary health facility over a 5-year period for the purpose of reinforcing control efforts. Materials and Methods: A retrospective survey of records from the infection control unit of the University College Hospital, Ibadan, Nigeria, was done for the years 2005-09. For the 5 years studied 22,941 in-patients were reviewed and the data of those who developed infections during admission were retrieved and analyzed. The prevalence, types, and causative organisms of HAI were determined. The chi-square test was used to evaluate associations. Results: The prevalence of HAI over the 5-year period was 2.6% (95% CI: 2.4-2.8). Surgical and medical wards had the most infections (48.3%) and (20.5%) respectively. Urinary tract infection (UTI) and surgical site infection (30.7%) were the most prevalent (43.9%) HAI. UTIs were significantly higher in surgical and medical wards, surgical site infections in obstetrics and gynecology wards, and soft tissue infections and bacteremia in pediatric wards (P<0.05). Gram-negative infections occurred about four times as often as gram-positive infections with Klebsiella sp. and staphylococcus aureus being the predominant isolates (34.3%) and (20.1%) respectively. Conclusion: Efforts to limit HAI should be guided by local surveillance data if progress is to be made in improving the quality of patient care in Nigeria.
Keywords: Hospital-acquired infections, infection control, Nigeria, surveillance
|How to cite this article:|
Ige O K, Adesanmi A A, Asuzu M C. Hospital-acquired infections in a Nigerian tertiary health facility: An audit of surveillance reports. Niger Med J 2011;52:239-43
|How to cite this URL:|
Ige O K, Adesanmi A A, Asuzu M C. Hospital-acquired infections in a Nigerian tertiary health facility: An audit of surveillance reports. Niger Med J [serial online] 2011 [cited 2020 Jul 10];52:239-43. Available from: http://www.nigeriamedj.com/text.asp?2011/52/4/239/93796
| Introduction|| |
In the 21 st century it is unacceptable that a person who is ill runs the additional risk of acquiring an infection while seeking respite from his present ailment.  Hospital-acquired infections (HAI) are thus a major patient safety issue as a cause of preventable illness and death. As a result, the prevention and control of these infections have become a priority. Surveillance or monitoring of these infections has been recognized as key to the control of these infections. 
Concern about HAI is global; however, in developing countries where the burden is estimated to be highest, information on surveillance activities in the prevention and control of HCAI is not often available.  The developments in the surveillance and monitoring of HAI in these countries also lag behind those of more industrialized countries and the mandatory surveillance requirements as it obtains in some other countries have largely not being implemented.  As a result of this relative lack of information there has been no significant change to improve existing surveillance systems. ,,
In Nigeria also, the inadequate knowledge of the risks of HAI and the measures of risk reduction have limited control activities. To prevent HAIs it is necessary to identify sources and modes of transmission of infection and to implement data driven prevention guidelines and practices.  This study therefore aimed to evaluate the pattern and occurrence of HAI in a foremost tertiary health facility over a 5-year period for the purpose of reinforcing control efforts.
| Materials and Methods|| |
The study was carried out at a foremost tertiary hospital in south west Nigeria by reviewing records from the infection control unit of the hospital for 2005-09. The hospital is an 850-bed hospital with surgical, medical, obstetrics, gynecology, and pediatric departments. Data were primarily collected by the infection control nurses using a surveillance form which documents the results of samples from in-patients who had undergone microscopy culture and sensitivity. These samples had been obtained from patients meeting the criteria for HAI during admission (i.e., infections not present and without evidence of incubation at the time of admission to the hospital). Information on the number of infections, total number of admissions in each ward (including the intensive care unit), sites of infection, and isolated pathogens was obtained from the surveillance forms. Prevalence of HAI was determined for each year based on the number of HAI divided by the total number of admissions. Data were analyzed with Epi-Info 2000. Proportions were determined and the chi-square test was used to explore the differences in the proportions of HAI at a significance level of 5%.
| Results|| |
[Figure 1] shows the prevalence of HAI for each year studied. Rates climbed slowly from 2.4% in 2005 to 3.1% in 2008; a decline was however noted in 2009 with a rate of 2.3%. The overall prevalence of HAI for the 5-year period was 2.6% (95% CI: 2.4-2.8).
Distribution of hospital-acquired infections in each ward
The prevalence of HAI in each ward is shown in [Table 1]. Overall, 48.3% of all infections were from the surgical wards, 20.5% from medical, 15.1% from pediatric, and 16.1% from obstetrics and gynecology wards. The highest ward prevalence of HAI was in surgical wards 4.4% followed by pediatric wards 2.4%.
In each year reviewed, surgical wards consistently recorded the highest prevalence of HAI compared to other wards as shown in [Figure 2]. HAI peaked in 2008 with the highest prevalence of 5.9% in surgical wards and the least occurrence in obstetric wards at 1.4%.
[Table 2] shows the cross-tabulation of HAI and type of ward. Surgical wards significantly had more HAI than other wards (P<0.05)
Sites of infections
[Table 3] shows the different sites of infections; urinary tract infections occurred most often (43.96%), followed by surgical site infections (30.7%).
Hospital-acquired infections by sites of infection in each type of ward
As shown in [Figure 3], urinary tract infections were the most common infections in surgical, obstetrics, and gynecology and medical wards. However, soft tissue/cutaneous infections were the most common type of infections in pediatric wards.
Isolates from hospital-acquired infections
Gram-negative organisms constituted more than three quarters (78.3%) of all causative organisms in HAI. The isolates from HAI are shown in [Table 4].
Klebsiella sp. was the predominant isolate (34.3%), followed by staphylococcus aureus (20.1%).
[Table 5] shows the isolates from each site of infection. Staphylococcus aureus was the most often isolated organism in surgical site infections (29.2%), bacteremia 45.5%, and burn infections 31.2%. Klebsiella spp. was the predominant isolate in urinary tract infections (42.7%) and soft tissue infections (33.6%). E. coli was the most common organism in meningitis 30%.
| Discussion|| |
The trend of HAI over a 5-year period in a tertiary health facility in Nigeria was presented. Prevalence ranged between 2% and 3% with no significant variation over the 5-year study period. An overall infection rate of 2.6% was found, revealing a slight decline from 3.0% to 4.9% reported in previous clinical audits for the years
1999-2004 and 1989-91 respectively for the same institution.  This decline may be indicative of better infection control measures in the hospital and recent efforts to limit the duration of hospital stay for in-patients. The observed trend of HAI is comparable to other studies from the country, , but lower than rates reported from some other countries. ,, However, direct international comparisons of HAI are often difficult due to methodological differences resulting from definitions of HAI, type of HAI covered and the health units surveyed. 
Consistent with other studies, , surgical wards continue to be hot spots for HAI. This is often due to the breached skin defenses resulting from invasive surgical procedures. Urinary tract infections (UTI) emerged as the predominant HAI similar to other studies. ,, Pneumonia and blood stream infections were however not as prominent as reported by some other studies. , This can be explained by the infrequent use of central intravenous catheters and mechanical ventilators, making urinary catheters the most commonly used invasive device and hence the high prevalence of UTI as established by other studies. ,
Gram-negative bacilli have been commonly associated with hospital-acquired infections. , Our findings also showed a predominance of gram-negative bacilli. A U.S. study reported a similar ratio of gram-negative bacilli to gram-positive cocci as 4:1.  Staphylococci were also prominent particularly in blood stream infections similar to other studies.  A noticeable gap in this surveillance system was the lack of routine screening for Methicillin Resistant Staphylococcus Aureus (MRSA) which has been made mandatory in some countries. 
Data were not disaggregated by age- or sex-limiting knowledge of demographic variables which might impact on susceptibility to HAI. Although this study was done in the largest tertiary hospital in Nigeria, findings cannot be assumed to be representative of the whole country due to differences which may exist in the patient profile and the spectrum of clinical activity. The inability of the hospital to determine the presence of important micro-organisms involved in HAI such as MRSA, Vancomycin Resistant Staphylococcus Aureus, Vancomycin Resistant Enterococci and Extended Spectrum Beta-Lactamases. Gram-negative bacteria and fungi limit the comparability of these findings.
This study provides an update on HAI rates and also provides insight into infection control status in this major Nigerian hospital. Useful information for benchmarking purposes was provided.
| Conclusions|| |
For the 5 years reviewed HAI rates had been increasing albeit marginally and a downward trend was only observed in 2009, with UTI as a major contributor. HAIs are preventable harms and surveillance has been a key component of the activities to drive down rates of HAI in other countries. It is important that surveillance data are utilized in clinical decision making particularly in the prudent use of urinary catheters to limit the persistent high rates of UTI in this hospital. The use of a more robust surveillance system which is web-enabled can aid access to surveillance data by healthcare providers. Developing national infection control targets and standardized data collection procedures with rigorous performance management would allow for easier evaluation of healthcare systems in the country.
| Acknowledgment|| |
We are grateful to the infection control nurses who collected these data and to the Head of Department of Medical Microbiology, U.C.H Ibadan for the permission to use the routine surveillance records for this work.
| References|| |
|1.||Health protection agency. Mandatory surveillance of healthcare associated infection report, 2006. London: Health Protection Agency; 2006. |
|2.||Pittet D, Allegranzi B, Storr J, Bagheri Nejad S, Dziekan G, Leotsakos A, et al. Infection control as a major World Health Organization priority for developing countries. J Hosp Infect 2008;68:285-92. |
|3.||Health protection agency. Surveillance of healthcare associated infections report: 2008. London: Health Protection Agency; 2008. |
|4.||Avasarala AK. Epidemiology of nosocomial infections (NCIs) Part-1. Prathima institute of medical sciences, Karimnagar, India; 2008. Available from: http:// www.pitt.edu/~super7/22011-23001/22391.ppt. [Last cited on 2010 Mar 3] |
|5.||Okezie OA, Onyemelukwe NF. Nosocomial infection in a Nigerian rural maternity centre: A series of nine cases. East Afr Med J 2007;84:83-7. |
|6.||Chandra PN, Milind K. Lapses in measures recommended for preventing hospital-acquired infection. J Hosp Infect 2001;47:218-22. |
|7.||Harbath S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: An overview of published reports. J Hosp Infect 2003;54:258-66. |
|8.||Oni A, Ewete AF, Gbaja AT, Kolade AF, Mutiu WB, Adeyemo DA, et al. Nosocomial infections: Surgical site infection in UCH Ibadan, Nigeria. Niger J Surg Res 2006;8:19-23. |
|9.||Abubakar S. Implementation of an infection control programme in Kano. Northern Nigeria: IJIC Org; 2007. |
|10.||Lahsaeizadeh S, Jafari H, Askarian M. Healthcare-associated infection in Shiraz, Iran 2004-2005. J Hosp Infect 2008;69:283-7. |
|11.||Merchant M, Karnad DR, Kanbur AA. Incidence of nosocomial pneumonia in a medical intensive care unit and general medical ward patients in a public hospital in Bombay, India. J Hosp Infect 1998;39:143-8. |
|12.||Zaidi AK, Huskins WC, Thaver D, Bhutta ZA, Abbas Z, Goldmann DA. Hospital-acquired neonatal infections in developing countries. Lancet 2005;365:1175-88. |
|13.||Samuel SO, Kayode OO, Musa OI, Nwigwe GC, Aboderin AO, Salami TAT, Taiwo SS. Nosocomial infections and the challenges of control in developing countries. Afr J Clin Exp Microbiol 2010;11:102-10. |
|14.||Peterson LR, Brossette SE. Hunting health care-associated infections from the clinical microbiology laboratory:passive, active and virtual surveillance. J Clin Microbiol 2002;40:1-4. |
|15.||Klavs I, Bufon Luznik T, Skerl M, Grgic-Vitek M, Lejko Zupanc T, Dolinsek M, et al. Prevalance of and risk factors for hospital-acquired infections in Slovenia-results of the first national survey, 2001. J Hosp Infect 2003;54:149-57. |
|16.||Mayon-White R, Ducel G, Kereselidze T, Tikomirov E. An international survey of the prevalence of hospital-acquired infection. J Hosp Infect 1988;11 Suppl A:43-8. |
|17.||Azzam R, Dramaix M. A one-day prevalence survey of hospital-acquired infections in Lebanon. J Hosp Infect 2001;49:74-8. |
|18.||Gikas A, Pediaditis J, Papadakis JA, Starakis J, Levidiotou S, Nikolaides P, et al. Prevalence study of hospital-acquired infections in 14 Greek hospitals: planning from the local to the national surveillance level. J Hosp Infect 2002;50:269-75. |
|19.||Singh S, Pandya Y, Patel R, Paliwal M, Wilson A, Trivedi S. Surveillance of device-associated infections at a teaching hospital in rural Gujarat-India. Indian J Med Microbiol 2010;28:342-7. |
|20.||Robert G, Edwards JR. Overview of nosocomial infections caused by gram-negative bacilli. Clin Infect Dis 2005;41:848-54. |
|21.||Bell JM, Turnidge JD. High prevalence of oxacillin-resistant Staphylococcus aureus isolates from hospitalized patients in Asia-Pacific and South Africa: Results from SENTRY antimicrobial surveillance program, 1998-1999. Antimicrob Agents Chemother 2002;46:879-81. |
|22.||Wisplinghoff H, Bischoff T, Tallent SM, Seifert H, Wenzel RP, Edmond MB. Nosocomial bloodstream infections in US hospitals: Analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis 2004;39:309-17. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]