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1.1            Background to the Study

Nosocomial infection also known as Hospital Acquired Infections (HAI) is a localized or systemic infection acquired in a hospital or any other health care facility by a patient admitted for a reason other than the pathology present during admission. It may also include an infection acquired in a healthcare facility that may manifest 48 hours after the patient's admission into the health care facility or discharge (Hildron, Edwards, Patel, Horan, Sievert, Pollock & Fridkin, 2008). Epidemiological studies report that nosocomial infections are caused by pervasive pathogens such as bacteria (Lepelletier, Perron, Bizouarn, Caillon, Drugeon, Michaud & Duveau, 2005), viruses (De-Oliveira, White, Leschinsky, Beecham, Vogt, Moolenaar, Perz & Safranek, 2005) and fungi present in air, surfaces or equipment. The pathogens are not present or incubating prior to the patient's admission into healthcare facility and are most likely transmitted by direct person-to-person contact during invasive medical procedures (Anderson, Kaye, Chen, Schmader, Choi, Sloan & Sexton, 2009). Some of the pathogens are highly resistant to antimicrobial agents, andthis necessitates the prescription of more potent and costly antimicrobial agents (Mulvey & Simor,2009).

Nosocomial infections are prevalent nationally and internationally; and occur in patients of all age groups: neonates (Aly, Herson, Duncan, Herr, Bender, Patel & EI-Mohandes, 2005), immuno-compromised adults and the elderly (Lepelletier, Perron, Bizouarn, Caillon, Drugeon, Michaud& Duveau, 2005).  The  most frequent  types  of nosocomial  infections  are  those associated  with  the  urinary tract,  surgical  wounds,  respiratory  tract and  blood  stream (Lo, 2008). It is a serious global public health issue, causing the suffering of 1.4 million people across the world at any given time (WHO, 2007).

Nosocomial infection in developing countries is difficult to address because it is such a complex problem with diverse underlying causes. International non-governmental organizations (INGOs) and inter-governmental organizations such as United Nations agencies add a unique perspective to the push for infection control measures in hospitals in the developing world.  However, these organizations have not been able to address all facets of the problem such as infrastructure, leadership and individual health care worker behavior.  Nosocomial infection control is not simply a matter of encouraging hand hygiene in settings where clean water and soap may not be consistently available. Nor is infection control a matter of providing supplies to health care workers who are not trained to use them properly (WHO, 2010).

The burden of HAI is already substantial in developed countries, where it affects from 5% to 15% of hospitalized patients in regular wards and as many as 50% or more of patients in intensive care units (ICUs) (WHO, 2009). In developing countries, the magnitude of the problem remains underestimated or even unknown largely because HAI diagnosis is complex and surveillance activities to guide interventions require expertise and resources (Allegranzi & Pittet, 2008). Surveillance systems exist in some developed countries and provide regular reports on national trends of endemic HAI (Pittet, Allegranzi, Sax, Bertinato, Concia & Cookson, 2005) such as the National Healthcare Safety Network of the United States of America or the German hospital infection surveillance system. This is not the case in most developing countries (WHO, 2010) because of social and health-care system deficiencies that are aggravated by economic problems. Additionally, overcrowding and understaffing in hospitals result in inadequate infection control practices, and a lack of infection control policies, guidelines and trained professionals also adds to the extent of the problem.

Hospital-wide HAI prevalence varied between 2.5% and 14.8% in Algeria (Vincent, Rello, Marshall, Silva, Anzueto & Martin, 2009), Burkina Faso (DiA, Ka, Dieng, Diagne, Dia & Fortes, 2008), Senegal and the United Republic of Tanzania (Atif, Bezzaoucha, Mesbah, Djellato, Boubechou & Bellouni, 2006). Overall HAI cumulative incidence in surgical wards ranged from 5.7% to 45.8% in studies conducted in Ethiopia (Messele, Woldemedhin, Demissie, Mamo & Geyid, 2009) and Nigeria (Kesah, Egri-Okwaji, Iroh & Odugbemi, 2009). The latter reported an incidence as high as 45.8% and an incidence density equal to 26.8 infections per 1000 patient-days in paediatric surgical patients (Kesah, Brewer, Yingrengreung & Fairchild, 2009). In a study conducted in the surgical wards of two Ethiopian hospitals, the overall cumulative incidence of patients affected by HAI was 6.2% and 5.7% (Messele, Grottolo, Renzi, Paganelli, Sapelli, Zerbini & Nardi, 2009). In a study from Nigeria, the implementation of an infection control programme in a teaching hospital succeeded in reducing the rate of HAI from 5.8% in 2003 to 2.8% in 2006 (Abubakar, 2007).

In Nigeria, nosocomial infection rate of 2.7 % was reported from Ife, while 3.8 % from Lagos and 4.2 % from Ilorin (Odimayo, Nwabuisi & Adegboro, 2008).  The cause of nosocomial infections might be endogenous or exogenous. Endogenous infections are caused by organism present as part of the normal flora of the  patient,  while  exogenous  infections  are acquired  through  exposure  to  the  hospital environment,  hospital  personnel  or  medical devices (Medubi, Akande & Osagbemi, 2006).  Nosocomial infection rates vary substantially by body site, by type of hospital and by the infection control capabilities of the institution. The proportion of infections at each site is also considerably different in each of the major hospital services and by level of patient risk (Taiwo, Onile & Akanbi, 2005).This is exemplified by surgical site infections (SSIs) which are most common in general survey, whereas urinary tract infections and blood stream infections are most frequent in medical services and nurseries.  Rates of nosocomial infection vary by surgical subspecialty, low in ophthalmology and high in general surgery. The differences are largely due to variations in exposure to high risk devices or procedures (Tolu, 2007).

Urinary tract infections (UTI) represent the most common (34%) type of nosocomial infections. Indwelling catheters cause the majority while others are caused by genito urinary procedures (Tolu, 2007). Surgical  wound  infections  represent  17% nosocomial  infection  and  are  the  second  most common  hospital  acquired  infections. The classification of wound infections is based on the degree of bacterial contamination, including clean, clean contaminated and contaminated. Co-morbid and contamination of the surgical site contribute to the infection rate. The risk factors for surgical wound infections include age, obesity, concurrent infection and prolonged hospitalizations. The origin of the bacterial agent is dependent on direct inoculation from a host’s flora, cross-contamination, the surgeon’s hands, air-borne contamination and devices such as drains and catheters (Odimayo, Nwabuisi& Adegboro, 2008). Lower respiratory infection (LRI) or pneumonia represents 13 % of nosocomial infections (Taiwo, Onile & Akanbi II, 2005).  This is the most dangerous of all nosocomial infections with acase fatality rate of 30%.  It manifests in the intensive care unit or post-surgical recovery room.  Endotracheal intubation and tracheostomy dry the lower respiratory tract mucous and provide entry for microbes.

This study therefore aims at investigating nursing measures utilized for the prevention of nosocomial infection in the labour ward of University of Calabar Teaching Hospital (UCTH), Calabar, Cross River State, Nigeria.

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