| Abstract|| |
Background: There is a dearth of knowledge on healthcare-associated infections (HAIs) in Cameroon. This study scrutinized HAI prevention and burden in three hospitals in Dschang, West Region of the country, in order to inform on current practices. Materials and Methods: From September 2008 to April 2009, patient records in three hospitals were assessed, questionnaires administered, and hand washing examined in 29 consenting nurses. A retrospective study on nosocomial infections (NIs) was performed by reviewing the records of 12917 in-patients who survived longer than 72 hours and were not transferred to other hospitals. Modified National Healthcare Safety Network protocols were employed and data analyzed using SPSS. Results: Study respondents (77%, P 0.0089) were aware of HAI control but lacked detailed knowledge including the five moments for hand hygiene. Of 35 staff evaluated, 74% (P 0.0093) used non-disposable hand towels, 9% disposable and a further 9% air-dried hands after washing. An alarming 72% of hand cultures grew coagulase-negative staphylococcus, Enteroccocus, Bacillus, fungi, Klebsiella, Enterobacter and other coliforms indicating fecal contamination. NI rates averaged 2.6 infections/100 admissions and four infected patients/1000 patient days; 17.4% and 12 infected patients/1000 days in surgical patients. Surgical site (38%), respiratory (26%), gastrointestinal (19%), bloodstream (8%) and urinary (7%) infections were predominant NIs, with a mean development time of 7-11 days and prolonged hospital stay by 12 days. Cost constraints precluded routine culture and antibiotic susceptibility testing; thus no data on clinical pathogens. Conclusion: Scrupulous hand hygiene and rub usage, adequate care facilities, staff education and HAI surveillance were paramount.
Keywords: Burden, Cameroon, hand hygiene, healthcare-associated infections, types
|How to cite this article:|
Kesah N F, Vincent K P, Chrysanthus N. Healthcare-associated infections in three hospitals in Dschang, West Region, Cameroon. Ann Trop Med Public Health 2013;6:23-9
|How to cite this URL:|
Kesah N F, Vincent K P, Chrysanthus N. Healthcare-associated infections in three hospitals in Dschang, West Region, Cameroon. Ann Trop Med Public Health [serial online] 2013 [cited 2020 May 28];6:23-9. Available from: http://www.atmph.org/text.asp?2013/6/1/23/115174
| Introduction|| |
Healthcare-associated infections (HAIs) encompass infections developed by healthcare practitioners (HCPs) consequential to healthcare administration, hospital infections manifesting during hospitalization or after patient discharge, nursing home-acquired, long term care-associated, outpatient-related (e.g. dialysis, chemotherapy) and also home care-associated infections.  HAIs have been encountered often but not always after healthcare intervention. HCPs in Cameroon have much to learn from major advances in HAI control. Data collection, analysis and information flow are necessary for the smooth functioning of any healthcare delivery system.
This work evaluated prevention practices and the impact of HAIs in Dschang, Cameroon.
| Materials and Methods|| |
The Dschang District Hospital (DDH), the Adlucem Medical Foundation Hospital (AH) and the "Hôpital Saint Vincent de Paul" (HSVP) in Dschang, chosen based on longevity of service and level of care offered in surgical, paediatric, general men and women, maternity and ophthalmology wards.
The DDH went operational in 1957. It is located above the bilingual primary school, opposite the Dschang University entrance and lies on latitude 10 o 03'724", longitude 5 o 26'843" and an altitude of 1391m. It has a capacity of 200 beds with a team of five doctors, six laboratory workers and 45 nurses.
The AH was created in 2003 and is located at Ngui quarter in Dschang. It lies on latitude 10 o 26'251", at an altitude of 1343m. It has a capacity of 37 beds, 18 staff comprising one doctor, two laboratory workers and 15 nurses.
The HSVP transformed from a dispensary to a full hospital in 2003. It is situated at "Grande Mission" quarter off the road to FongoTongo. It lies on latitude 10 o 02'814", longitude 5 o 27'475" and an altitude of 1422m. It has 110 beds, two administrators, four doctors, seven laboratory workers and 40 nurses.
| Ethical Clearance (Helsinki Declaration of 1975, revised in 2000)|| |
In the Western Region of Cameroon, the Chief Medical Officers of hospitals grant permission to execute research projects on humans after thorough scrutiny based on national and international regulations. Attempts at including some private healthcare institutions in this study were unsuccessful because the chief medical officers did not permit the work.
The study protocol was presented to the hospital directors and authorization letters were duly accepted and signed. Subsequent visits for the study of patient records and administration of questionnaires to staff were arranged with the general supervisors and nurse heads of the various specialties after obtaining informed consent.
Study of Patient Records
The researchers set out to study in-patient records in the three hospitals from 1990 to 2007. This was not possible due to the different times in which these hospitals were created. Only the DDH (surgical unit) had records available from 1990 to 2007 for study. The other two hospitals went operational only in 2003, thus patient records under consideration for these institutions were available only from 2003 to 2007. Patient records available were broadly categorized into complete and incomplete records. Complete records had patient details including the name, age, sex, date of admission, clinical history, laboratory tests, drugs prescribed, daily observations, discharge status and date. Incomplete records were lacking in one or more of the above -mentioned features. From registers, the total number of admissions and records missing or destroyed beyond study were determined.
Administration of Questionnaires
Many staff including some nurse heads refused to complete the questionnaires. Information sought from 35 workers (doctors, nurses, laboratory workers and administrative staff) included: their understanding of HAIs, availability and decontamination of care materials, problems related to disease diagnosis, hand hygiene including knowledge of the WHO multimodal hand hygiene improvement strategy, waste disposal, provision of basic amenities, bed spacing and staff-to-patient ratio.
Hand washing assessment
Sterile swab sticks moistened in sterile water were used to swab the hands of 29 consenting nurses after washing with soap and running tap water prior to patient care. The swab samples were inoculated on MacConkey and Sheep blood agar and incubated at 37°C for 24 hours. A second blood agar plate was incubated at 37°C in a candle extinction jar. Colonies grown were identified as recommended. 
A retrospective study of nosocomial infections
The records of 12,917 (68%) patients admitted and discharged from 2001 to 2007 for the DDH, and from 2003 to 2007 for the AH and HSVP respectively were reviewed; 32% of records were missing or incomplete. The use of the United States Center for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) protocols  had many drawbacks. Only infusion and urinary catheters were used without documenting device days. Pathogens involved in NIs could not be identified because in the absence of culture, laboratory findings were not specific, with only general ideas on the pathogen type, e.g. gram positive bacteria. The prolongation of hospital stay due to NIs could not be assessed by a one-to-one matching of infected versus uninfected patients because only few surgical patients in the DDH met the study criteria. Thus, a modified NHSN protocol was employed to suit the existing conditions. Noted were demographic characteristics, total number of patients admitted and discharged per unit, hospital and all hospitals, total number of hospital days, total number of deaths and transfers, this in all the wards of the hospitals were summed for the entire study period. To study the occurrence of NIs, disease diagnosis with accompanying clinical signs upon admission, and in course of hospitalization were sought. For surgical patients, procedure types and presence of pus at the operation sites were evaluated.
Overall rates were calculated by dividing the number of infected patients and NIs for the year/entire study period by the total number of patients admitted(x100) and patient days (x1000). SPSS was used in data analysis. The relationship between hospital stay, infection rates and age groups was determined. The mean stay in hospital for uninfected and infected patients was encrusted. Excess length of stay (LOS) was then calculated by subtracting the mean LOS for patients without NIs from the average LOS for those with NIs per unit/hospital/all hospitals. Differences between LOS for both groups were compared using the student t- test. The level of significance was tested at 5%.
| Results|| |
From the questionnaires administered, study respondents lacked detailed knowledge on HAIs, and reported gastrointestinal, respiratory, mouth, skin and sexually transmitted infections including HIV/AIDS; tetanus, meningitis and malaria as frequent HAIs. Staff further suggested caretakers, visitors, the air, floor, toilets, stool docks, door handles, accidents, clinical specimens, contaminated fluids and food, some personnel and inadequate bed spacing as sources or risks to NIs. In the 3 hospitals, HAIs were not given priority control and infection control teams did not exist, although 27 personnel (77%, P 0.0089) were aware of their importance.
Personnel were not aware of modern guidelines for hand hygiene and the wide use of hand rubs in healthcare establishments today, neither were there reminders in the work place nor plans for regular monitoring or evaluation of hand hygiene. After washing, 25 staff (74%, P 0.0093) used non -disposable hand towels, about 9% used disposable towels and a further 9% air dried hands. Non-disposable hand towels were not regularly washed i.e. at the end of each work shift, many staff used a common towel, taps did not run continuously, thus such towels could act as vehicles of transmission of pathogens, and this partially explained why some staff preferred air drying their hands (which was time consuming) or pulling toilet paper from their pockets (which was contaminated and sticky to fingers). To ensure the continuous presence of water, HCPs stored water in recipients for use when municipal supplies were interrupted. Of 29 hand swabs cultured, 21(72.4%) had growth of species of coagulase-negative staphylococcus, Enteroccocus, Bacillus, fungi, Klebsiella, Enterobacter and other gram-negative coliform bacteria. Eight staff air-dried their hands and only 1 (12.5%) had growth of Bacillus and fungi. Two (16.7%) of 12 staff using non-disposable towels and 5 (55.6%) of 9 nurses using disposable towels had sterile hand cultures.
Culture and antimicrobial susceptibility testing were not practised because patients could not afford for them and only 15 HCPs (43%, P 0.0046) thought these tests were vital. Drug prescription followed formularies not tested in vitro, reason why broad spectrum antibiotics were preferred. Local pathogens of public health importance were unknown.
Most staff (77%, P 0.0089) reported that patients received food from family members and friends, while a few patients got food from vendors around the hospital. At the time of this study, hospitals in Dschang did not have the means to supply food to patients, and although patient feeding was recognized as an integral part of healthcare, not all the hospitals ensured that patients on special diets consumed the right foods.
Approximately 69% of HCPs in the AH and HSVP believed that cleaning schedules were satisfactory, and waste disposal adequate (66%). Only 13 staff (40%, P 0.0054) received vaccines against hepatitis B, tuberculosis, tetanus, meningitis and poliomyelitis. Understaffing (at times one nurse stayed on guard per up to 30 beds), inadequate care materials such as cotton wool, sterilizers and thermometers, and patient taboos (cultural myths such as the administration of healthcare to some notables by particular HCPs) reportedly hampered care delivery. In mitigation, HCPs proposed hospitals should be renovated, beds as well as mattresses changed and always terminally disinfected before the installation of new arrivals, continuous formation and regular vaccination of personnel instituted, the entire hospital well electrified, computers, internet and intranet services introduced and new recruits considered.
Three hundred and thirty-six NIs from 277 patients were identified (183 patients and 227 NIs in the DDH, 72 patients and 83 NIs in the AH and 22 patients with 26 NIs in the HSVP). The majority of Nis_ 281 (83.6%) in 222 (80.1%) patients occurred in the surgical units. The overall NI patient rate was 2.1% with a rate of 2.6 infections/ 100 admissions [Table 1]a and b. The incidence densities were 4 patients and 4.8 infections per 1000 patient days. In the surgical units, the patient rate was 14.3%, NI rate 18.1%, and 12.4 infected patients- and 15.7 infections- per 1000 patient days. Patients operated for exploratory laparotomy (21.7%), appendicectomy and cesarean section (13.5%), and cystostomy (12.5%) had the highest infection rates [Table 2].Two hundred and seven (74.7%) patients had a single infection, 68(24.7%) had double infections and 2(0.7%) triple infections.
Surgical site infections_(SSIs) accounted for 105 (31.3%) of the 336 NIs recorded. There were 85 (25.3%) episodes of upper respiratory infections_(URTIs), 62 (18.5%) gastrointestinal infections_(GITs), 36 (10.7%) urinary tract infections (UTIs), 28 (8.3%) bloodstream infections-BSIs (nosocomial malaria), 8 (2.4%) ear, 7 (2.1%) skin and 5 (1.5%) eye infections [Figure 1] shows distribution in hospitals]. NIs reported on questionnaires but not documented in patient records included vaginal candidiasis, bacterial vaginosis, non-infectious vaginitis and trichomoniasis, and were linked to dirty lavatories, douching with chemicals, and usage of contaminated water and gynecological equipment. Contaminated beds and mattresses, non-usage of mosquito nets and insecticides, poor drainage systems, hygiene and sanitation, surgical procedures and in-dwelling catheters also predisposed to NIs. Also, there were no infection control personnel, who were given the time and training needed to conduct the necessary surveillance and raise awareness; to motivate staff to be conscious in noting all NI events .Thus, it was not surprising that some NIs reported by personnel on questionnaires were not seen in patient records.
The overall mean stay in all the hospitals was 7 days; but varied with the different wards: men's units 5 days, women's 4 days and surgical patients 12 days. The AH seemed to have kept patients more than the other hospitals. Mean time to NI from hospital admission ranged from 7 to 11 days depending on the infection type, minimum period varied from 3 to4 days, and the maximum spanned 26 to 34 days [Table 3]. No meaningful relationship was established between hospital patient days and infection rates. Most age groups stayed for an average of about 5to 6 days, except for the 70-90, which stayed longer [Figure 2]. Prolongation of stay ranged from 4 to 12 days in the AH, 7 to 13 days in the DDH and 5 to 11 days in the HSVP respectively. In all the hospitals, excess stay due to NIs was 12 days [Table 4].
|Figure 1: Distribution of Healthcare-associated infections by site in the three hospitals BSI- bloodstream infections, URTI-upper respiratory tract infections, GIT-gastrointestinal infections, UTI-urinary tract infections, SSI-surgical site infections|
Click here to view
| Discussion|| |
About 30% of HCPs reported HIV/AIDS as hospital-acquired. This was a worrisome finding since blood should be screened before transfusion, care taken to avoid accidental exposure, and HIV-positive personnel involved in teaching and administration and not in procedures that can put others at risk. This therefore brought to light the fact that personnel had limited knowledge on the occurrence of hospital infections and that not much was done to reduce such risks. The acquisition of STDs by hospitalized females due to broad spectrum antibiotic therapy, poor hygiene, contaminated gynecological equipment, the use of unclean water or medicated soap to bathe the genital region and frequent douching with chemicals was understood. Because beds were not disinfected before installing new arrivals, skin infections were anticipated. With dirty and dusty environments, respiratory tract infections were inevitable. However, HCPs reporting of tetanus and meningitis as NIs, and others not responding was a pointer to non-awareness on the subject.
Methods used for hand drying by staff were archaic. Electric dryers would have been preferable but for frequent power failure and the stand by generator which was never fuelled .Thus, hospitals were advised to supply staff with numerous small-sized or disposal towels, which could be used and discarded or cleaned daily. Enteroccocus species and enteric bacteria isolated from the hands of staff indicated fecalcontamination and inadequate washing or the use of contaminated water for washing, and the higher contamination rate associated with non-disposable portrayed recontamination from multiple usages. The importance of hand hygiene in reducing the incidence of HAIs cannot be overemphasized. ,,,, Understaffing or overcrowding is problematic as low patient-to-nurse ratio facilitates the spread of pathogens through relaxed attention to hand asepsis. The practice of handshaking in hospital in the study milieu should be discouraged since soiled hands lead to the spread of pathogens through hands- shakes. A close re-examination of hand washing and personnel hand carriage of resistant organisms was deemed imperative.
Practices like sleeping with patients predispose to cross infections and should be abolished through the institution of sanctions to defaulters. The common use of care materials like stool docks by patients must be discouraged. Dirty floors, carelessness, and poor collection, handling and storage of clinical specimens could pose danger in the hospital milieu. Authorities should endeavor to create adequate space between patient's beds to avoid cross infections; and also create ICUs to harbor critical cases.
The DDH and AH depended on municipal supplies of water. When interrupted, patients fetched untreated water from nearby springs and wells which had been certified contaminated,  and this might justify the high numbers of GITs in these hospitals. Katte et al.  recommended boiling or using sodium hypochlorite or chloramines to treat water from different sources in Dschang to meet acceptable standards.
Hospitals should be fenced to prevent people and animals moving in and out at will, to prevent cross infections. The engagement of cleaners in the DDH was important. In the cases of the AH and HSVP, adequate numbers should be recruited to avoid over- working those in place. The hospitals should be cleaned daily not leaving out weekends as in the AH. Waste should be separated and treated such that it did not constitute a hazard to the public. The hospital environment including lawns and wards should be cleaned twice a day, i.e., in the morning and late afternoons when patients and visitors must have littered the environment. In the DDH, the windows of the operation rooms were sometimes kept wide open; surgical material was exposed to dirty and dusty surroundings giving every reason that patients might leave this room already incubating pathogens. In the DDH, care materials were not always sterilized when heaters broke down and personnel had to make do with what they had, thereby giving room for cross infections.
Being a retrospective study, concerns were focused on patient records, many incomplete; thus, infection rates were based on complete records. These very difficulties were encountered by Jeong et al and Inan et al. The importance of vital statistics cannot be overstressed, and what Jelliffe and Stanfield  said of Africa still applies today: "the most important public health step would be the institution of proper statistical systems".
This was the first study on NIs in Dschang. Many patients who left the hospitals against medical advice might have gone away with NIs not discernable on departure. Also, records missing or incomplete might have included those of patients with NIs. In the study centers, the absence of culture and antimicrobial susceptibility meant that asymptomatic NIs in the incubation period would not be detected, thus, the ability to detect NIs would be low; and targeted narrow spectrum antibiotics could not be prescribed to eliminate the problem of costs associated with broad spectrum antibiotics. There were no available data in Cameroon for comparison. However, great caution was exercised to compare rates due to methodological differences.
Nosocomial malaria was identified in this study and has been documented else where. ,,, Inadequate health systems, poverty, poor drainage, the non-use of mosquito nets or insecticides, bushy/grassy surroundings, swamps, pools of water, streams and lakes have been associated with the acquisition of, relapses or re-infections with malaria in Cameroon.  The government and its partners have intensified efforts in the free distribution of mosquito nets to all, the use of insecticides, clearing bushes and reducing leaves of vegetables/trees around human habitations, and draining mashes and pools of water.
Tackling lapses in hand washing and decontamination practices, adequate staffing and supply of care materials, a sound hospital hygiene and that of the greater environment of the hospital, employee health and hygiene, post-operative nursing care, judicious use of invasive devices, antibiotics and malaria control strategies, improved medical and diagnostic facilities, and continuous surveillance of HAIs and staff education necessitated priority consideration in the study region. Effective programs on HAIs and hand hygiene were underway after this work. This study provided awareness and the necessary stimulus for the institution of change.
| Acknowledgment|| |
Special thanks go to the heads and entire personnel of the Dschang District Hospital (DDH), the Adlucem Medical Foundation Hospital (AH) and the "Hôpital Saint Vincent de Paul" (HSVP) in Dschangfor their cooperation to make this work possible.
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N Fusi-Ngwa Catherine Kesah
Department of Animal Biology, University of Dschang, P. O. Box 67, Dschang, West Region
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]