Abubakar Antimicrobial Resistance and Infection Control (2020) 9:63

https://doi.org/10.1186/s13756-020-00722-9

RESEARCH Open Access

Point-prevalence survey of hospital

acquired infections in three acute care
hospitals in Northern Nigeria
Usman Abubakar

Abstract
Background: Effective infection prevention and control strategies require reliable data describing the epidemiology
of hospital acquired infections (HAIs), and this is currently lacking in Nigeria. The objective of this study was to
evaluate the prevalence, types and risk factors associated with HAIs in acute care hospitals in Northern Nigeria.
Methods: A pilot point-prevalence survey was conducted in three acute care hospitals in Northern Nigeria between
April and May 2019 using a protocol developed by the European Centre for Disease Prevention and Control. Patients
admitted into the wards at or before 8.00 am on the survey date were included. Patients’ medical records were
reviewed by a clinical pharmacist with the support of the attending physician and nurse to identify HAIs.
Results: Of the 321 patients surveyed, 50 HAIs were identified among 46 patients translating into a point-prevalence of
14.3%. The most common HAIs were bloodstream infection (38.0%), surgical site infections (32.0%) and pneumonia
(12.0%). Neonatal (53.0%), pediatric surgical (26.7%) and surgical (10.1%) specialties had the highest prevalence. Device
associated infections represented 16% of all HAIs including bloodstream infections and pneumonia. Of all the HAIs, 15
(30.0%) were present at the time of admission while 75.5% originated from the current hospitals. Univariate analysis
showed that newborn (less than 1 month old) (OR: 4.687 95% CI: 1.298–16.927), intubation (OR: 3.966, 95% CI: 1.698–
9.261), and neonatal (OR: 41.538 95% CI: 4.980–346.5) and pediatric surgical (OR: 13.091 95% CI: 1.532–111.874)
specialties were significantly associated with HAI.
Conclusion: The prevalence of HAI was relatively high compared to other developing countries and was significantly
associated with neonatal and pediatric surgical specialties. Hospital infection control strategies should be strengthened
to reduce the burden of HAIs.
Keywords: Hospital acquired infection, Point-prevalence, Nigeria

Background HAI are resistant to antibiotics [4]. In Africa, higher rates

Healthcare Associated Infection (HAI) is a public health of antibiotic resistant (10–100%) are reported among iso-
problem affecting hospitalized patients and it is associated lates from HAIs [5, 6]. Available evidence shows that the
with morbidity, mortality, and healthcare costs [1–3]. prevalence and types of HAI varies among countries with
HAIs can be associated with antibiotic resistant pathogens lower rates observed in developed countries. In the United
which make treatment more difficult and expensive. In States (US), one in 24 hospitalized patients develops HAI
Europe, about one-third of micro-organisms isolated in with high rates for pneumonia, surgical site infection (SSI)
and gastro-intestinal infections [2]. In Europe, the preva-
Correspondence: pharmumma2@gmail.com
lence of HAI in acute care settings is 6.5% (range 5.4–
Pharmacy Department, Ibrahim Badamasi Babangida (IBB) Specialist Hospital, 7.8%). Pneumonia and other lower respiratory tract
Minna, Niger State, Nigeria

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Abubakar Antimicrobial Resistance and Infection Control (2020) 9:63 Page 2 of 7

infections, urinary tract infection, and SSI are the most internal medicine, surgery, obstetrics and gynecology,
common HAI in European acute care hospitals [4]. Ap- pediatrics, neonatal care, psychiatry, intensive care and
proximately 16% of hospitalized patients in developing ear, nose and throat care. The wards in each specialty in
countries are diagnosed with HAI [7]. The high rate of the selected hospitals were divided into male and female
HAI in developing countries is attributed to inadequate wards, and each ward was further subdivided into ‘A’
infection control practices owing to the lack of infection and ‘B’ respectively. None of the wards had more than
control policy and guideline, and the dearth of infection 30 patients on admission at the time of the survey. This
control health professionals [8]. Other factors include lack arrangement made the survey of all patients in one ward
of infrastructure, inconsistent surveillance [9], overcrowd- in a single day feasible.
ing, scarcity of resources [10], poor sanitation and poor
management of hospital waste [11]. Inclusion and exclusion criteria
HAIs can be prevented through implementation of in- All units/departments in the selected hospitals were sur-
fection control and prevention program, surveillance of veyed with the exception of outpatient, adult accident
HAIs, proper waste management and proper training of and emergency, and psychiatric units. Emergency
hospital staff on biosafety [12]. An effective infection pediatric unit was included because some patients are
prevention and control program requires active surveil- monitored for > 24 h. It is important to note that two of
lance to generate data that would describe the preva- the hospitals had an intensive care unit at the time of
lence and risk factors associated with HAI. In addition, this study. However, there was no patient on admission
surveillance data is needed to measure the impact of in- on the day the unit was scheduled for survey. The neo-
fection control and prevention programs and also to natal unit in the selected hospitals is divided into two
prioritize areas for further interventions and resource al- subunits: in-born (for neonates born in the hospital) and
location. The European Center for Disease Prevention out-born (for neonates born at home or at other health-
and Control (ECDC) and the National Health Safety care facilities) wings, and both wings were included in
Network (NHSN) provide continuous surveillance for the survey. All patients admitted into the ward and mon-
HAI and antibiotic consumption in Europe and the US itored for more than 24 h in the participating hospitals
respectively. In Nigeria, there is currently no surveillance were included in the survey. Patients who were in the
system to provide estimates of HAI in acute care hospi- ward before or at 8.00 a.m. and were not discharged at
tals. Previous estimates of HAI have reported prevalence the time of the survey were included. Daycare patients,
rates between 2.5 and 6.3% [6, 13, 14]. However, the those transferred out of the wards before the survey
studies used single center and retrospective design as were excluded.
against prospective active surveillance, which is the gold
standard [15]. Prospective active surveillance is capital Data collection
intensive and time-consuming. However, point-prevalence Information including patient's age, gender, dates of ad-
survey is a valid and reliable alternative to prospective ac- mission and survey, surgery since admission, presence of
tive surveillance to provide estimates of HAIs [16]. The any invasive device (peripheral and central vascular cath-
former method is more cost-effective than the latter and eters, urinary catheter and intubation), McCabe score,
could be conducted with few surveyors. Therefore, point- patient/consultant specialty, presence of HAI and the re-
prevalence study is suitable for use to estimate the burden sults of microbiological investigations were collected
of HAI in hospitals with limited resources. The objective using a data collection form. Information was obtained
of this pilot point-prevalence study was to determine the by reviewing the medical and nursing records of the sur-
point-prevalence and risk factors associated with HAI in veyed patients and identified HAIs were discussed with
acute care hospitals. the attending physician and nurse. Data was collected by
a clinical pharmacist who has expertise in infectious dis-
Method eases and experience in reviewing patient chart/record.
Study design and setting All the patients in a single ward were surveyed on the
This point-prevalence survey was conducted in 3 acute same day. Data collection lasted for 2 weeks in one of
care hospitals located in two states in Northern Nigeria the hospitals. The survey was conducted from 22 April
using a protocol adapted from the point prevalence sur- to 24 May 2019.
vey of healthcare-associated infections and antimicrobial
use in European acute care hospitals protocol version Outcome measures
5.3 [17]. The survey was conducted in one public univer- Hospital acquired infection and device-associated HAIs
sity teaching (approximately 560 beds) and two public were defined based on the criteria described in the point
general (200 and 100 beds respectively) hospitals. The prevalence survey of healthcare-associated infections and
selected hospitals provide acute care services including antimicrobial use in European acute care hospitals
Abubakar Antimicrobial Resistance and Infection Control (2020) 9:63 Page 3 of 7

Protocol version 5.3 [17]. Asymptomatic bacteriuria and Table 1 Hospital and clinical characteristics of the patients
ophthalmic neonatorum were not considered as HAIs. surveyed
The following criteria were used to determine device- Variable Frequency Percentage
associated HAI: i) presence of urinary catheter at least 7 Median age (IQR) 27 (1–93)
days before the onset of urinary tract infection, ii) central Median length of hospital stay (IQR) 8 (1–231)
and peripheral vascular catheter was in place at least 48 h
Gender
before onset of bloodstream infection, and iii) intubation
Male 129 40.2
in the preceding 48 h before the onset of pneumonia.
Female 186 57.9
Surgery since admission 93 29.0
Data analysis McCabe score
Data was entered into, double checked for coding errors, Non-fatal 228 71.0
cleansed and analyzed using Statistical Package for the So-
Ultimately fatal 7 2.2
cial Sciences (SPSS) version 23. Categorical data was re-
ported as frequency and percentage while continuous data Rapidly fatal 31 9.7
was presented as mean (standard deviation) or median. Unknown 19 6.7
Risk factors for HAI were determined using bivariate and Missing 36 11.2
multivariate regression analysis. Only variables that dem- Central catheter present on the survey date 9 2.8
onstrated statistical significance (P < 0.05) in the bivariate Peripheral catheter present on the survey date 174 54.2
analyses were included in the multivariate model.
Urinary catheter present on the survey date 48 15.0
Intubation on the survey date 28 8.7
Results Type of Hospital
Hospital characteristics Secondary 136 42.4
Three public hospitals participated in this pilot point- Tertiary 185 57.6
prevalence survey including one university teaching hos-
Specialty
pital and two general hospitals. The total bed capacity of
Pediatric medical 37 11.5
the selected hospitals was approximately 860 beds. A
total of 321 hospitalized patients were included in this Neonatal 28 8.7
pilot survey representing 37.3% of the total bed space in Medical 87 27.1
the hospitals. There was an active infection control and Surgical 69 21.5
prevention (IPC) team in two of the hospitals, however, Obstetrics and gynecology 70 21.8
none of the hospitals had an active surveillance program
Pediatric surgical 30 9.3
at the time of the survey. All the hospitals had a micro-
biology department with a functional laboratory to
process specimens which was opened on every day of Prevalence of hospital acquired infections
the week. However, lack of steady electricity supply af- A total of 50 HAIs were identified in 46 patients translat-
fects the processing of specimens collected for microbio- ing into a point-prevalence of 14.3%. Forty-two (91.3%)
logical culture and sensitivity test. patients had one HAI while the remaining four (8.7%) pa-
tients had 2 HAIs each. The prevalence of HAI in the ter-
tiary hospital (15.1%) was comparable to the prevalence in
Patient characteristics secondary hospitals (13.2%). The prevalence of HAIs
Three hundred and 21 hospitalized patients were in- ranged from 0.0 to 20.0% in the selected hospitals. The
cluded in the analysis with a median age of 27 years prevalence HAI was significantly higher in the neonatal
(range: 1–93 years). The median length of stay on the unit (53.6%) followed by pediatric surgical (26.7%), surgi-
survey date was 8 days (IQR; 1–231 days). Females con- cal (10.1%) and OBG (10.0%) units. About one-third of all
stituted approximately 58% of all patients surveyed and HAIs were detected in the neonatal unit while 18% each
about one-third of the patients had surgery during the were identified in medical and pediatric surgical units.
current admission. On the day of the survey, central Table 2 shows the prevalence of HAI among the patients
catheter, peripheral catheter, urinary catheter and intub- disaggregated based on the patient/specialty.
ation was present in 2.8, 54.2, 15.0 and 8.7% of the sur-
veyed patients, respectively. Table 1 describes the Types of hospital acquired infections
clinical and demographic characteristics of the surveyed Bloodstream infections; including neonatal sepsis and
patients. neonatal laboratory confirmed bloodstream infection
Abubakar Antimicrobial Resistance and Infection Control (2020) 9:63 Page 4 of 7

Table 2 Prevalence of HAI among the surveyed patients by aureus (sensitive to gentamicin, chloramphenicol, and
patient’s specialty clindamycin; and resistant to ciprofloxacin), Escheri-
Specialty Prevalence of HAI Prevalence among chia coli (sensitive to gentamicin, perfloxacin, strepto-
among surveyed all HAI N (%) mycin, and ofloxacin; and resistant to amoxicillin,
patients N (%)
ciprofloxacin, chloramphenicol, sparfloxacin, cotri-
Pediatric medical 1 (2.7) 2 (4.00)
moxazole and amoxicillin-clavulanic acid) and Proteus
Neonatal 15 (53.6) 15 (30.0) species (sensitive to ceftriaxone, ciprofloxacin and imi-
Medical 8 (9.2) 9 (18.0) penem; and resistant to amoxicillin, levofloxacin and
Surgical 7 (10.1) 8 (16.0) cefixime).
Obstetrics and gynecology 7 (10.0) 7 (14.0)
Factors associated with hospital acquired infections
Pediatric surgical 8 (26.7) 9 (18.0)
Univariate logistic regression analysis showed that new-
Total 47 (14.6) 50 (100.0)
born (less than 1 month) (OR: 4.687, 95% CI: 1.298–
16.927), intubation during hospitalization (OR: 3.966,
(5.9%) and surgical site infection (5.0%) were the most 95% CI: 1.698–9.261) and patients in neonatal (OR:
common HAI and represented 38.0 and 32.0% of all 41.538, 95% CI: 4.980–346.500) and pediatric surgical
HAI respectively. The prevalence of pneumonia was (OR: 13.091, 95% CI: 1.532–111.874) specialties were
1.9% and it constituted 12.0% of all the HAIs. Other significantly associated with HAI. There was no associ-
types of HAI include gastrointestinal infections (10.0%), ation between HAI and gender, duration of stay and sur-
EENT (6.0%) and SST (1.9%). Table 3 shows the distri- gery since admission. Table 4 summarizes the factors
bution of the types of HAIs based on patient’s specialty. associated with HAI. There was no significant associ-
ation between HAI and the variables in the multivariate
Device associated infections and micro-organisms regression model.
Of the HAI identified, 16% (8 infections) were device- Of the 321 patients surveyed, 257 (80.1%) used at least
associated infections. Overall, 26.3% (N = 5/19) of the pa- one antibiotic on the day of the survey. The indications
tients with bloodstream infections had central or periph- for antibiotic use included: community acquired infec-
eral catheter present 48 h before the onset of the infection. tion (38.7%), surgical antibiotic prophylaxis (22.5%), hos-
Devices-associated pneumonia occurred in 33.3% (N = 2/ pital acquired infection (16.3%), medical prophylaxis
6) of the cases while one patient who had urinary tract in- (14.9%) and unknown (7.6%). The most common antibi-
fection within 30 days after surgery had urinary catheter otics used were metronidazole (30.5%), ciprofloxacin
present in the 7 days preceding the infection. Overall, 15 (17.1%), ceftriaxone (16.8%), amoxicillin-clavulanic acid
(30.0%) HAIs were present at the time of admission and combination (12.5) and gentamicin (11.8%). The data for
consisted of 10 neonatal sepsis, two bloodstream infection, antimicrobial use among the patients has been published
two SSI, and one neonatal LCBI. Most of the HAI (75.5%) elsewhere [18].
originated from the current hospital while 18.9 and 5.6%
were from other hospitals and other/unknown origin, re- Discussion
spectively. Micro-organisms were isolated in four HAIs in- The current study revealed that the point-prevalence of
cluding Staphylococcus aureus (sensitive to gentamicin, HAI was 14.3% with bloodstream and surgical site infec-
erythromycin, streptomycin, ciprofloxacin, levofloxacin, ri- tions accounting for two-third of all the HAIs. Neonatal
fampicin, amoxicillin and norfloxacin; and resistant to and pediatric surgical specialties had the highest preva-
cotrimoxazole), Methicillin resistant Stapyhlococcus lence and represented more than 50% of all the HAI.

Table 3 Distribution of HAI based on patient’s specialty

HAI Prevalence among Prevalence Prevalence N (%)
survey patients among all HAI
Pediatric medical Neonatal Medical Surgical Obstetrics and Pediatric
gynecology surgical
BSI 19 (5.9) 19 (38.0) – 15 (100.0) 1 (11.1) – 1 (14.3) 2 (22.2)
SSI 16 (5.0) 16 (32.0) – – – 4 (50.0) 6 (85.7) 6 (66.7)
Pneumonia 6 (1.9) 6 (12.0) – – 4 (44.4) 2 (25.0) – –
GI 5 (1.6) 5 (10.0) – – 2 (22.2) 2 (25.0) – 1 (11.1)
EENTI 2 (0.6) 3 (6.0) 2 (100.0) 0 (0.0) 1 (11.1) – – –
SSTI 1 (0.3) 1 (2.0) – – 1 (11.1) – – –
BSI Bloodstream infection, SSI Surgical Site Infections, GI Gastrointestinal infection, EENTI Eye, Ear, Nose and Throat Infection, SSTI Skin and Soft Tissue Infection
Abubakar Antimicrobial Resistance and Infection Control (2020) 9:63 Page 5 of 7

Table 4 Univariate logistic regression analysis of factors hospitals. Bloodstream infections, particularly neonatal
associated with HAI sepsis, surgical site infections and pneumonia were the
Variable Odds ratio 95% CI P value most common HAIs in the current study, consistent
Age group with the findings of an Iranian study [22], but inconsist-
< 1 month 4.687 1.298–16.927 0.018 ent with the results in other countries [2, 4]. Previous
studies conducted in Nigeria demonstrated that urinary
1 month – 18 years 0.692 0.192–2.490 0.573
tract infection (UTI) was the most common HAI [6, 13].
18–65 years 0.439 0.133–1.451 0.177
In contrast, the current study did not identify any UTI
> 65 years Reference – – among the hospitalized patients surveyed and this could
Gender 0.807 0.425–1.533 0.513 be explained by the requirement to perform microbio-
Surgery since admission 0.583 0.305–1.116 0.104 logical investigation before diagnosing hospital acquired
McCabe score UTI which was not frequently observed. Intravascular
catheterization is an independent risk factor for hospital
Non-fatal Reference – –
acquired bloodstream infections [22].
Ultimately fatal 1.021 0.119–8.761 0.985
High rate of surgical site infections among the sur-
Rapidly fatal 0.656 0.188–2.286 0.508 veyed patients was consistent with the result of a previ-
Unknown 1.633 0.510–5.234 0.409 ous study conducted in South-Western Nigeria [13].
Any invasive device 0.634 0.324–1.240 0.183 These infections are preventable with adequate infection
Central catheter present 1.740 0.350–8.50 0.498 control, blood glucose control and surgical antibiotic
prophylaxis. However, compliance with surgical anti-
Peripheral catheter present 0.909 0.486–1.699 0.765
biotic prophylaxis recommendations in Nigeria is inad-
Urinary catheter present 2.022 0.945–4.327 0.070
equate [23]. Therefore, strategies to improve compliance
Intubation 3.966 1.698–9.261 0.001 with infection control and surgical antibiotic prophy-
Specialty laxis, particularly the use of antimicrobial stewardship
Pediatric medical Reference – – interventions, are recommended. Antimicrobial steward-
Neonatal 41.538 4.980–346.500 0.001 ship interventions were effective in improving compli-
ance with antibiotic selection, timing and duration of
Medical 3.646 0.439–30.247 0.231
surgical antimicrobial prophylaxis in a recent study con-
Surgical 4.065 0.481–34.379 0.198
ducted in Nigeria [24]. Of the surveyed patients, new-
Obstetrics and gynecology 4.000 0.473–33.826 0.203 born (less than 1 month old), those with intubation tube
Pediatric surgical 13.091 1.532–111.874 0.019 and those admitted under neonatal and pediatric surgi-
Duration of stay before the 1.007 0.995–1.019 0.261 cal specialties had significantly higher Odds for HAIs.
date of the survey This was consistent with previous studies for age [15]
Type of hospital and intubation [22, 25], respectively. The high risk of
Secondary care hospital Reference – – HAIs among newborns depict suboptimal levels of intra-
Tertiary care hospital 1.169 0.617–2.214 0.631
partum and post-delivery care, particularly among neo-
nates born outside the hospital.
The current study is the first prospective point-
The prevalence of HAI in the present study was higher prevalence study to describe the prevalence of HAI in
than the 2.6–6.3% reported in previous retrospective Northern Nigeria. There are some limitations in the
studies conducted in Nigeria [6, 13, 14]. However, the study, thus, the results should be interpreted with cau-
current study is comparable to the cumulative preva- tion. First, the findings cannot be generalized for the en-
lence of HAI in developing countries [7] and Ethiopia tire region and Nigeria at large because the data was
[19], but higher than the prevalence in Ghana [20], collected in three hospitals only. Secondly, the study de-
South Africa [21], Iran [22], the United States [2] and sign used (point-prevalence survey) which is not the gold
the European hospitals [4]. It is important to note that standard for the surveillance of HAI and the prevalence
methodological differences between these studies influ- reported could be either over- or under-estimated. How-
ence the findings and could explain the inconsistencies. ever, point-prevalence study is a valid method for the
Although overcrowding is not an issue in the selected surveillance of HAIs in resource limited settings [16].
hospitals, the rate of HAIs was high. This could be at- Thirdly, there was no concurrent validation of the col-
tributed to the lack of a national infection control policy lected data during the survey due to lack of resources
and guideline, poor infection control practices, lack of and as a result, the findings could be over- or under-
surveillance, inadequate clinical waste management and estimated. Fourthly, information regarding the number
the dearth of infection control personnel in the of laboratory- or radiologically-confirmed HAIs as well
Abubakar Antimicrobial Resistance and Infection Control (2020) 9:63 Page 6 of 7

as indicators of laboratory capacity and hospital infec- point-prevalence survey of health care–associated infections. N Engl J Med.
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AU conceived the idea, designed the study, collected, analyzed and on infectious diseases workshop on developing infection prevention and
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approved the final manuscript. 2017;1(57):138–43.
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This research did not receive any specific grant from funding agencies in the
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Ethics approval and consent to participate 15. Zarb P, Coignard B, Griskeviciene J, Muller A, Vankerckhoven V, Weist K,
Ethics approval was obtained from the Human Research and Ethics Goossens MM, Vaerenberg S, Hopkins S, Catry B, Monnet DL. The European
Committee in the participating hospitals with a waiver for patient informed Centre for Disease Prevention and Control (ECDC) pilot point prevalence
consent (reference number: ABUTHZ/HREC/G23/2019, HMB/GHM/136/VOL.III/ survey of healthcare-associated infections and antimicrobial use.
541 and MOH/ADM/744/VOL.1/716). Data was de-identified before analysis. Eurosurveillance. 2012;17(46):20316.
16. Ustun C, Hosoglu S, Geyik MF, Parlak Z, Ayaz C. The accuracy and validity of
Consent for publication a weekly point-prevalence survey for evaluating the trend of hospital-
Not applicable. acquired infections in a university hospital in Turkey. Int J Infect Dis. 2011;
15(10):e684–7.
Competing interests 17. European Center for Disease Prevention and Control. Point prevalence survey
The author declare that there is no competing interests. of healthcare associated infections and antimicrobial use in European acute
care hospitals – protocol version 5.3. Stockholm: ECDC; 2016.
Received: 15 October 2019 Accepted: 23 April 2020 18. Abubakar, U Antibiotic use among hospitalized patients in northern Nigeria:
a multicenter point-prevalence survey. BMC Infectious Diseases. 2020; 20:86.
doi.org/https://doi.org/10.1186/s12879-020-4815-4.
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