Neonatal infections are an important reason for infant mortality and morbidity worldwide. In our study, incidence of HAI/1000 patient days was 5.57 which were consistent with the results of other studies. As per WHO prevalence study amongst 55 hospitals in four WHO Regions (Europe, Eastern Mediterranean, South- East Asia and western Pacific) 8.7% HAI rates were reported.⁷ A meta analysis by Neeraj et al estimated that different HAI  rates were found varying from 1.4% upto 30% in numerous studies done across the globe.⁶ In another study, by Bolat et al the incidence of HAI was 10.3% per 1000 patient days.⁸ According to a survey to determine the point prevalence of HAI in 29 high- risk nurseries in 1999 by the US Pediatric Prevention Network, 11. 4% neonates had an active nosocomial infection on the day of the survey.⁹ Bloodstream and lower respiratory tract infection were the most frequent infections in the study.⁹

Fig. 2: Incidence rates of BSI and HAI

Table (2):
Attack rates of BSI and HAI in NICU.

In our study out of the total thirty HAI episodes reported over a period of one year, 20 (66.6%) were nosocomial blood stream infections. Our findings are supported by observation in another study where BSIs (59.1%) were the most common HAI in this age group.¹⁰ On the contrary, in a recent study from Egypt, pneumonia was the most frequently occurring infection (11.3%) followed by blood stream infection (8.8%) in NICU.¹¹According to recent studies primary bloodstream infection represents about 15% of all nosocomial infections and affects approximately 1% of all hospitalized patients.¹² BSI increases the mortality rate and prolongs intensive care unit (NICU) and  hospital length of stay with added financial burden.¹³ Our study observed 12.74% BSI/1000 catheter days. Our findings are supported by two studies where BSI incidence rates were 8.5 per 1000 discharges to 18 per 1000 patient days.^{14, 15}

Fig. 3: Prevalence of isolates in blood cultures

Table (3):
Incidence rates of BSI and HAI.

* p-values are calculated for comparison of incidence rate of particular month with the average using Gaussian (z) test.

Our study recorded average attack rates of hospital acquired infection and blood stream infection as 2.76% and 1.93% respectively. A similar study on 367 hospitalized patients, identified 29 patients with nosocomial BSI with attack rate of 7.9%.¹⁶

Our study observed that Staphylococcus aureus was the most frequently isolated organisms (32.4%) among the blood culture. Our findings were supported by another study where Staphylococcus aureus was the most frequent pathogen in culture positive BSI.¹⁷ On the contrary in another descriptive hospital based study carried out in the NICU of the Mansoura University Children’s Hospital, the investigators reported that Klebsiella spp. were the most frequently isolated organisms followed by E. coli.¹¹ Gram- negative bacteria were the most common causative agents in hospital acquired bloodstream infection in the 1960s and 1970s.¹⁸ However, around the same time frame, gram-positive bacteria became more predominant, probably correlated with the greater use of prophylactic antibiotics for at risk patients with use of intravascular devices.¹⁸

Fig. 5: Antimicrobial susceptibility for gram negative bacilli isolates

Infection control is an integral part of pediatric practice. Infection surveillance in nurseries and NICU should be conducted on a priority basis. The infection and the attack rates can be used as a benchmark to drive improvements in the quality and safety of care. Surveillance is also essential to decrease the mortality rate, economic burden and for rational antimicrobial prescription. Regular training programs on the standard precautions, hand hygiene, personal protective equipment, clinical sample collection and transport should be incorporated. Hand washing and regular use of alcohol based hand rub are the simplest and most effective methods of preventing transmission of infectious agents.¹⁹ Sterilization of resuscitation bags and masks, use of sterile suctioning techniques, and avoiding overcrowding are simple ways to prevent nosocomial infections in nurseries and NICUs.²⁰ Careful preparation and storage of infant formulas, minimizing the attempts at venipuncture and, using single dose administration of medications such as albumin are measures to be undertaken to prevent nosocomial BSIs.²¹ Judicious insertion and maintenance of indwelling lines with minimization of the number of catheter days lowers the risk of device associated BSI.²¹