Unusual sources of hospital-acquired infections in intensive care units and operating rooms at Tanta University Educational Hospital

Norhan Ahmed Abo Mansour; Mona O Ramadan; Hoda A Ahmed Ezz; Mohamed Z Hussein

doi:10.4103/tmj.tmj_61_21

ORIGINAL ARTICLE

Year : 2023 | Volume : 51 | Issue : 2 | Page : 144-149

Unusual sources of hospital-acquired infections in intensive care units and operating rooms at Tanta University Educational Hospital

Norhan Ahmed Abo Mansour¹, Mona O Ramadan², Hoda A Ahmed Ezz³, Mohamed Z Hussein²
¹ Demonstrator of Medical Microbiology and Immunology, Faculty of Medicine, Tanta University, Tanta, Egypt
² Medical Microbiology and Immunology, Faculty of Medicine, Tanta University, Tanta, Egypt
³ Anesthesiology & Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission	10-Mar-2021
Date of Acceptance	11-Jul-2021
Date of Web Publication	14-Sep-2023

Correspondence Address:
Norhan Ahmed Abo Mansour
Demonstrator of Medical Microbiology and Immunology, Faculty of Medicine, Tanta University, Tanta, El Gharbia
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/tmj.tmj_61_21

Abstract

Background Fomites can serve as a vehicle in transmission of health care-associated pathogens especially in intensive care units (ICUs) and operating rooms (ORs) where the patients are immunocompromised and at high risk of acquiring multidrug-resistant bacteria. Aim To assess bacterial contamination on inanimate surfaces and equipment in ICUs and ORs at Tanta University Educational Hospital to detect the potential reservoirs of hospital-acquired infections (HAIs) and to give appropriate recommendations for corrective actions. Materials and methods The samples were collected in sterile nutrient broth and incubated for 24 h. The isolation and identification of pathogenic bacteria were done through standard microbiological methods. Antibiotic susceptibility tests of the isolates were assessed by disc diffusion method. Results The contamination levels from group I (hospital samples) and group II (control samples) were 88.3% and 84%, respectively. In group I, Gram-negative bacilli were the most frequent isolates followed by Gram-positive cocci then Gram-positive bacilli, fungi, and lastly Gram-negative cocci that represented 35.7%, 34.4%, 25.9%, 3.2%, and 0.8%, respectively. In group II, all bacterial isolates were Gram-positive bacilli that represented 100%. Conclusion The presence of potential pathogenic-resistant bacteria on inanimate surfaces in hospital is of great health concern and these surfaces can serve as sources of HAIs.

Keywords: hospital-acquired infections, intensive care units and operating rooms

How to cite this article:
Mansour NA, Ramadan MO, Ezz HA, Hussein MZ. Unusual sources of hospital-acquired infections in intensive care units and operating rooms at Tanta University Educational Hospital. Tanta Med J 2023;51:144-9

How to cite this URL:
Mansour NA, Ramadan MO, Ezz HA, Hussein MZ. Unusual sources of hospital-acquired infections in intensive care units and operating rooms at Tanta University Educational Hospital. Tanta Med J [serial online] 2023 [cited 2023 Sep 26];51:144-9. Available from: http://www.tdj.eg.net/text.asp?2023/51/2/144/385707

Introduction

Hospital-acquired infections (HAIs) are localized or systemic conditions resulting from adverse reaction to the presence of infectious agent or its toxins acquired from health care settings that were not incubating or symptomatic at the time of admission to the healthcare facility [1].

Fomites are one of the sources of HAIs that include any inanimate objects capable of carrying infectious organisms [2].

Contamination of the inanimate surfaces and equipment in intensive care units (ICUs) and operating rooms (ORs) has been identified in outbreaks and cross-transmission of pathogens among critically ill patients [3].

The emergence of multidrug-resistant (MDR) bacteria has become a public health problem creating a new burden on medical care in hospitals. More than 70% of the bacteria that cause HAIs are resistant to at least one of the drugs that most frequently used to treat them [4].

The aim of this study is to assess bacterial contamination on inanimate surfaces and equipment in ICUs and ORs at Tanta University Educational Hospital to detect the potential reservoirs of HAIs and to give appropriate recommendations for corrective actions.

Methodology

Place and duration of the study

This study was carried out at Medical Microbiology and Immunology Department, Faculty of Medicine, Tanta University on 350 environmental samples collected during the period of research (September 2019 to February 2020).

Type of the study and number of samples

A cross-sectional study was designed to collect 350 environmental samples that included two groups. Group I, 300 test samples from door handles, elevator buttons, faucets, writing pens, medical charts, electrocardiography (ECG) leads, stethoscopes, and wrist watches in ICUs and ORs at Tanta University Educational Hospital. Group II, 50 similar samples from houses of people outside the medical fields as teachers and accountants as control samples.

Inclusion criteria

Environmental samples from door handles, elevator buttons, faucets, writing pens, medical charts, ECG leads, stethoscopes, wrist watches that revealed aerobic, aerobic facultative anerobic bacteria, and candida.

Exclusion criteria

Anaerobic bacteria, viruses, and fungi rather than Candida.

Methods

Ethical approval for this study was obtained from Institutional Research, Ethical committee, Quality Assurance Unit, Faculty of Medicine, Tanta University (code:33125/05/19).

Sample collection and transportation

All samples were collected under complete aseptic precautions by swab rinse technique by rubbing and rotating sterile swabs moistened with sterile saline and then introduced into a test tube containing sterile nutrient broth. Samples were labeled as regard to the items, number, location, and date then transported as soon as possible to the laboratory of the Medical Microbiology and Immunology Department. The test tubes that contain the samples were incubated overnight [5].

Isolation and biochemical characterization of the isolates

After 24 h incubation in nutrient broth, each sample was streaked on nutrient agar, MacConkey agar, blood agar and Sabouraud’s dextrose agar plates. The plates were incubated for 24 h at 37°C aerobically. The bacterial and fungal growth was identified by using the routine microbiological methods.

Antibiotic sensitivity testing

Antimicrobial susceptibility of the isolates was performed by Kirby-Bauer disc diffusion method on Mueller–Hinton agar according to Clinical and Laboratory Standard Institute guidelines [6]. Gram-positive organisms were tested against Penicillin G (10 units), Oxacillin (5 μg), Piperacillin (100 μg), Cefoxitin (30 μg), Vancomycin (30 μg), Clindamycin (2 μg), Linezolid (30 μg), Gentamicin (10 μg), Ciprofloxacin (5 μg), Erythromycin (15 μg), Cotrimoxazole (1.25/23.75 μg), and Novobiocin (5 μg), whereas Gram-negative organisms were tested against Amoxicillin clavulanic acid (30 μg), Piperacillin /tazobactam (100/10 μg), Ampicillin-Sulbactam (10/10 μg), Ampicillin (10 μg), Cefoxitin (30 μg), Ceftazidime (30 μg), Cefotaxime (30 μg), Ceftriaxone (30 μg), Cefepime (30 μg), Gentamicin (10 μg), Amikacin (30 μg), Sulfamethoxazole/trimethoprim (1.25/23.75 μg), Ciprofloxacin (5 μg), Meropenem (10 μg), Aztreonam (30 μg), Colistin (10 μg), and Tetracycline (30 μg).

Statistical analysis

Sorting and analysis of data were performed by using Statistical Package for Social Sciences (SPSS) version 21. In this study, the qualitative variables were prescribed using number and percent, χ² test was used for analysis (Mont Carlo exact test and Fisher’s exact test were used as alternatives for χ² test if there were many small expected values). P value (&leq;0.05) was adopted as the level of significance, P values <0.001 were considered highly significant, whereas P values >0.05 were considered statistically not significant.

Results

Contamination level of samples

Contamination levels of samples in group I and group II were 88.3% and 84%, respectively. In groups I and II, the highest contamination level was detected on door handles and elevator buttons that represented 100% for each. There was no statistically significant difference between the contamination level in both groups ([Table 1]).

Table 1: Contamination level of inanimate surfaces in both study groups

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Culture results of samples

Number of samples yielded no growth, monomicrobial growth, and polymicrobial growth were 35, 177, and 88, respectively, in group I, whereas numbers of samples were 8, 42, and 0, respectively, in group II. There was a statistically significant difference in culture results between both groups ([Table 2]).

Table 2: Culture results of collected samples in both study groups

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Frequency of occurrence of the isolates

The most frequent isolated organism in group I was Staphylococcus aureus that represented 14.6%. Door handles were the highest contaminated surface with S. aureus, but in group II, Diphtheroid was the most frequent isolated organism that represented 59.5% and most of Diphteroid was detected on elevator buttons. There was a statistically significant difference in some types of isolated bacteria between both groups ([Table 3]).

Table 3: Frequency of occurrence of different isolates from all inanimate surfaces in both study groups

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Percentage of multidrug-resistant bacteria

MDR bacteria included 42.6% of S. aureus, 25% of coagulase-negative Staphylococcus (CoNS), 39.1% of Enterococcus spp., 62.7% of Escherichia coli, 93.3% of Klebsiella pneumonia, 50% of Citrobacter spp., 50% of Enterobacter spp., 50% of Serratia marcescens, 100% of Proteus vulgaris, 37.5% of Acinetobacter spp., and 36.7% of Pseudomonas spp ([Table 4]).

Table 4: Multidrug resistance bacteria isolated from different inanimate surfaces in group I

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Percentage of resistant patterns: 42.6% of S. aureus were Methicillin resistant, 25% of CoNS were Methicillin resistant, 39.1% of Enterococcus spp. were Vancomycin resistant, and 27.1% of Enterobacteriaceae were extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae ([Table 5]).

Table 5: Different resistant patterns isolated from inanimate surfaces in group I

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Discussion

HAIs create main problem for health workers because they continue to delay effective management of health care services in hospitals all over the world [7]. MDR bacteria have been identified on contaminated surfaces that are frequently used as medical equipment and high-touched surfaces in ICUs [8].

In the present study, the contamination level of all inanimate surfaces in group I was 88.3%. In agreement with this result, Gebremariam and Declaro [9] and Bhatta et al. [10] reported that contamination level of hospital surfaces was 80% and 78%, respectively.

On the other hand, Abosalif and Ejaz [11] and Essien-Baidoo et al. [12] detected higher contamination level that was 96.2% and 98%, respectively, whereas lower contamination level was observed by Ahmed et al. [13] at Assiut University in Egypt that was 25.6%.

The discrepancies between studies may be due to different sample size and different hygienic practices of health care workers and patients.

According to this study in group I, 11.7% of samples yielded no growth, whereas 59% and 29.3% of samples yielded monomicrobial growth and polymicrobial growth, respectively. Supporting this result, Chaoui et al. [14] found that 12% of samples showed no growth. On the other hand, this result was inconsistent with studies by Różańska et al. [15] and Ahmed et al. [13] in Egypt who found that multibacterial contamination of the hospital samples was estimated to be 11% and 7%, respectively.

According to this study in group II, 16% of samples yielded no growth and 84% of samples yielded monomicrobial growth, whereas 0% of samples yielded polymicrobial growth. This result was in agreement with a study by Onwubiko and Chinyeaka [16] who detected that 86% of samples of public door handles yielded growth but 14% of samples yielded no growth. On the other hand, a study by Na’was and Fakhoury [17] found that 31.3% of samples of public door handles yielded more than one type of bacterial isolates.

Discrepancies between studies may reflect variable factors such as the epidemiology, differences in the measurement between studies, the different quality of environmental cleaning besides the method of sampling, and organism cultivability.

In the present study in group I, the most frequent isolated organism was S. aureus (14.6%). Supportive to this result, Merlin et al. [18] in Cameron found that the most prevalent organism was S. aureus (37.81%). Isolation of S. aureus from almost all the fomites indicates their ubiquitous nature. This is anticipated as it is a major component of the normal flora of the skin and nostrils.

The results of the present study were less correlated with Bohra and Bhatnagar [19] in India who found that Bacillus species was the most frequent isolate (48.27%) from hospital surfaces that is considered to be an environmental contaminant. This difference may be related to better hygienic conditions in Indian hospitals and different samples sizes.

In group II, the most frequent isolated organisms were Diphtheroid (59.5%) followed by Anthracoid (40.5%). In agreement with this study, Donkor et al. [20] detected that the most prevalent isolated bacteria was Bacillus spp. that represented 46.8%. On the other hand, Aloma et al. [21] found that the most frequent isolate from public door handles was S. aureus that represented 81.2%. This difference may be referred to that samples were collected from public door handles not the houses’ door handles as in this study. In the present study, MDR bacteria included 42.6% of S. aureus, 25% of CoNS, 39.1% of Enterococcus spp., 62.7% of E. coli, 93.3% of K. pneumonia, 50% of Citrobacter spp., 50% of Enterobacter spp., 50% of S. marcescens, 100% of P. vulgaris, 37.5% of Acinetobacter spp., and 36.7% of Pseudomonas spp.

This result was less correlated with a study by Worku et al. [22] who found higher rate of MDR among S. aureus and CoNS that was 79% and 47%, respectively, whereas lower rate of MDR among Gram-negative bacilli (Klebsiella spp, Proteus spp, Pseudomonas spp, and Serratia spp) that was 53.8%, 44.4%, 33.3%, and 30%, respectively.

In this study, 42.6% of S. aureus were Methicillin resistant, 25% of CoNS were Methicillin resistant, 39.1% of Enterococcus spp. were Vancomycin resistant, and 27.1% of Enterobacteriaceae were ESBL-producing Enterobacteriaceae. Supportive to this result, Chaoui et al. [14] found that 44.7% of the isolated S. aureus was identified as Methicillin-resistant S. aureus (MRSA), Tajeddin et al. [23] found that Vancomycin-resistant Enterococci (VRE) were found among 25% of the isolated Enterococcus spp and Bennani Mechita et al. [24] found that percentage of ESBL was 25.9%.

On the other hand, Bhatta et al. [10] found lower rate of MRSA that was 36.4% of isolated S. aureus, Worku et al. [22] found that percentage of MRCoNS was 58.8%, Teng et al. [25] found that no VRE was detected from the isolated Enterococcus faecalis and Lestari et al. [26] detected that 12% of isolated Enterobacteriaceae was ESBL.

The discrepancies of antibiotic sensitivity between the results may be referred to different antimicrobial stewardship policy between the hospitals in different countries, different sample size, and so different number of isolated organisms.

The rising cases of antibiotics resistance strains have been attributed to misuse and abuse of drugs without prescription that creates a favorable environment for the environmental opportunistic bacteria to acquire resistant genes.

Conclusion

From the results of this study, we can conclude that most of the hospital samples were contaminated with potential pathogenic bacteria, whereas the control samples were contaminated with commensal bacteria. The high prevalence of MDR bacteria and multiple resistant patterns in ICUs can lead to lethal outcomes.

We recommend that:

(1)More research on a larger scale to assess the prevalence of bacterial contamination on other fomites that are unrecognized by the health care workers and patients and may cause HAIs.

(2)Decontamination of inanimate surfaces with alcohol-based disinfectants would reduce the microbial flora from these sites and regular disinfection of stethoscopes and ECG leads between patients.

(3)3-Non-hand touch techniques for door handles and substitution of the handle faucets with the sensor faucets.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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