Chapter II

Review of Related Literature and Studies

Conceptual Literature

Up to now, science has documented a total of 1,407 microbes that causes disease

in humans. Of these, 538 are bacteria, 317 are fungi, 287 are helminths, 208 are viruses

and 57 are protozoan. There are plenty of conditions and diseases that have no known

cause as of now (Cowan, 2015). One of those thousand microbes that cause disease is

Candida Albicans.

News reported by (Alvarez, 2017) states that there are some hospitals spend a lot

of time, energy and money on getting rid from healthcare associated infection. The

doctors and staff in England had been battled a hardy Japanese fungus called the Candida

Albicans, this fungus had showed resistance against commonly prescribed medicines, a

problem undoubtedly caused by the overuse of antibiotics. There are 20 separate

hospitals have experienced outbreak last year and over 30 more had seen cases of

infection. To make it worse, a few outbreaks had occurred in which hospitals had trouble

in controlling the fungal infection from spreading. Though, the Public Health of England

has been declared that the outbreak is officially over. One of the reasons that Candida

auris spread easily is that this type of fungus actually lives on the skin as well as the

body. Hospitals in United Kingdom had reported that the infection can spread within a

few hours from initial contact with a person. This also means that the hospital staff may
not always be properly disinfecting themselves and their equipment. Furthermore,

another reason that this infection can spread easily is that the patient don’t always shows

symptoms resulting from likely more severe infection. Luckily, only a handful of patients

had suffered from sepsis in England and none had died from infection.

Another news related to healthcare associated infection reported by Firger (2011)

stated that each year, in the United States, thousands of patients seek medical care at both

inpatient and outpatient facilities, but emerge from routine, urgent or surgical care with

an additional and sometime untreatable- life-threatening illness. Typically, these

infections are a result of unhygienic practices at medical facilities, including ambulatory

surgical centers, hospice centers, nursing homes and rehabilitation centers. Some

infections become prevalent as a result of overusing common antibiotics in medical

facilities to the point where they are no longer effective. The first report, published in the

New England Journal of Medicine, is based on a 2011 survey of 183 hospitals in 10

states. In that year alone, there were approximately 721,800 infections in 648,000

patients. Around 75,000 of these patients died that year as a result of a health care-

associated infection. The report found the most common healthcare-associated infections

were pneumonia, surgical site infections and gastrointestinal infections. Urinary tract

infections and bloodstream infections were less common. According to the report, the

most common bacteria associated with hospital infections were C. difficile, methicillin-

resistant Staphylococcus aureus (MRSA), Klebsiella, E. coli, Enterococcus and

Pseudomonas. Klebsiella and E. coli are from Enterobacteriaceae bacteria family.

 Further news reported by Dr. Ananya Mandal in 2012 stated that Staphylococcus

aureus is a type of bacteria. It stains Gram positive and is nonmoving small round shaped

or nonmotile cocci. It is found in grapelike (staphylo) clusters. This is why it is called

Staphylococcus. Staphylococcus aureus belongs to the family Staphylococcaceae. It

affects all known mammalian species, including humans. Further due to its ability to

affect a wide range of species, S. aureus can be readily transmitted from one species to

another. This includes transmission between humans and animals. The most common

method of transmission is through direct contact with objects that are contaminated by

the bacteria or by bites from infected persons or animals. Approximately 30% of healthy

humans carry S. aureus in their nose, back of the throat and on their skin. When S. aureus

is isolated from an abscess or boil or other skin lesion, it is usually due to its secondary

invasion of a wound rather than the primary cause of disease. S. aureus may similarly be

isolated from abscesses, breast absecesses or mastitis, dermatitis or skin infections and

genital tract infections. S. aureus causes numerous infections at various sites of the body.

Some of these include: Skin infections – S. aureus causes boils, furuncles, styes, impetigo

and other superficial skin infections in humans; Infections of surgical and trauma wounds

– Those with chronic illness, diabetes, traumatic injury, burns or immunosuppression are

susceptible to more severe skin, deeper tissue infections and deep abscesses; Urinary tract

infections; and infections of organs include pneumonia (lung infection), osteomyelitis

(bone infection), endocarditis (heart infection), phlebitis (infection ofveins and blood

vessels), mastitis (infection of breast and formation of abscesses) and meningitis (brain
infections). These infections are more common in hospitalized patients rather than

healthy individuals in the community.

Research Literature

According to Perez et al. (2010) aimed to determine the presence of potentially

pathogenic bacteria in paraphernalia used in vital signs, to detect which among the

stethoscopes bells, diaphragms and blood pressure cuffs contain the highest number of

pathogens and to identify which among the different special areas (Delivery Room,

Operating Room, Emergency Room and Outpatient Department) of Gregorio T. Luch

Memorial Hospital of Iligan City has the most type of potentially pathogenic bacteria.

Result showed that out of 29 selected bacterial isolates, 13.8 % were presumptively

identified to be Staphylococcus sp., Bacillus sp., and Lactobacillus sp., respectively.

Streptococcus sp., Micrococcus sp., Neisseria sp., and Pseudomonas sp., compromised

10.3% of the total isolates and only 3.4% was classified as coagulase-negative

staphylococcus whereas the remaining 3.4% was unidentified bacteria. Among the

paraphernalia used in taking the vital signs included in the study and of which samples

were taken, the blood pressure cuff specifically the inner side had the highest number of

identified pathogenic bacteria (14), followed by the stethoscope bell (8) and lastly would

be the stethoscope diaphragm (7). The most common bacteria found in the blood pressure

cuffs were Micrococcus sp. and Lactobacillus sp. while Staphylococcus aureus was the

most primarily found in the stethoscope. These finding would lead us to the implication
that the blood pressure cuffs were possibly the least disinfected or cleaned hence the

transmission of potential bacteria to one person to another is probable. Stethoscope was

also capable of transmitting infection, but the possibility would vary depending in the

occurrence of disinfection done by the staff. Of the different special areas included in the

study, the out-patient departments got the highest number pathogen with 10 identified

bacteria, followed by the delivery room with 7 identified bacteria and lastly were

recovery room and emergency room with 6 identified bacteria. The out-patient

department presented the most number of bacteria which may attribute to the number of

patients going there for consultation.

In 2012, Fegarido et al. determined whether blood pressure cuffs may serves as a

medium of bacterial transmission. The participants of the study were the patients

admitted in the medical and obstetric ward of Jose Abad Santos General Hospital. A total

of 30 participants were involved in the study. The study utilized experimental research

design in order to determine the colony forming units in the skin bacterial isolates before

and after the use of blood pressure cuff. The specimen collected via swab method was

diluted. Based on the results out of 30 participants, 20 (66.67%) showed an increase CFU

of skin bacterial isolates after use of blood pressure cuff whereas 10 participants

(33.33%) showed an decrease CFU of skin bacterial after use of blood pressure cuff.

Thus emphasizing the crucial significance of administration of disinfection or cleaning

procedure on blood pressure cuffs as an infection control measure.

 In addition, a foreign study in Nigeria conducted by Uneke (2011) verified the

presence of microbial contamination of thermometers and BP cuffs used by health

workers. 58 thermometers and 28 blood pressure cuffs from nursing station, emergency,

orthopedic, medical ward, outpatient and children’s ward were the samples used in the

study. Results have shown that 62.1% of the thermometers and 82.1% of blood pressure

cuffs examined were contaminated with Staphylococcus aures, Psuedomonas aeruginosa

or Enterococcus faecalis. S. aureus was the most common bacterial isolate, constituting

86.1% and 73.9% of the isolates from thermometers and blood pressure cuffs,

respectively. Up to 80% and 100% of the thermometers and blood pressure cuffs from the

nursing unit and medical ward were contaminated.

A research study authored by Jeyakumari and others (2016) determined the level

of bacterial contamination in the stethoscope. They used prospective, cross sectional

method and conducted at tertiary care teaching hospital for two months. Each 50

stethoscopes used by physicians, surgeons and students from all the wards were sampled

before and after cleaning with 70% isopropyl alcohol by using sterile swab soaked in

sterile saline. Samples were processed as per standard microbiological procedures. The

colony count ≥20 CFU/diaphragm was considered as significant contamination for

stethoscope. Their showed that out of 50 stethoscope, 30 (60%) stethoscopes were

showing significant bacterial colonization, 7 (14%) stethoscopes showed insignificant

colonization and no growth was seen in 13 (26%) stethoscopes. All the samples (n=50)

collected after cleaning with 70% isopropyl alcohol have shown no growth and become

sterile. The bacteria isolated were Methicillin Resistant Staphylococcus aurues (MRSA)
(14%), Methicillin Sensitive Staphylococcus aureus (MSSA) (12%), Coagulase Negative

Staphylococcus (CNS) (14%), Klebsiella species (20%). The highest rate of colonization

was noted with stethoscopes used by Gynecologists (100%), followed by Physicians

(67%), Surgeons (60%), Interns (60%) and students (30%).

Moreover, according to Gupta et al. in 2014 assessed the microbes that

were contaminated in the stethoscope used by clinicians and nurses and determined the

effectiveness of 70% ethanol as a disinfecting agent. Stethoscopes of 50 healthcare

workers from different department were included in the study. Bacteriological cultures of

samples were done on blood agar and MacCokey agar plates. Fifty-two organisms were

identified from 50 stethoscopes. This study showed that the average number of colonies

per stethoscope was 30, with a minimum number of 10 colonies from a stethoscope

sampled from the Anesthesia Department and a maximum number of 80 colonies seen

from one each in surgery ward and MICU. Coagulase-negative staphylococci were the

predominant isolates 40 (77%). The rest were Acinetobacter species 3 (5%),

Staphylococcus aureus 3 (5%), Bacillus species 2 (4%), Aspergillus fumigatus 2 (4%),

Pseudomonas stutzeri 1 (2%), and Citrobacter koseri 1 (2%). Cleaning the stethoscopes

with 70% ethanol demonstrated a significant decrease in the bacterial count. 3 out of 20

randomly cleaned the stethoscopes showed colonization with growth of decreased

number of colonies (3-5), thus demonstrating the effectiveness of cleaning.

A comprehensive study by Baruah et. al conducted in the year 2008 investigated

the contamination of blood pressure cuffs on medical, surgical, pediatric and intensive
care areas in a university teaching school. They qualitatively and quantitatively evaluated

the bacterial contamination on blood pressure cuffs of 100 sphymomameters used in 10

hospital units. Result has shown that the inner sides of the cuffs were found to harbor

more organism (97%) compared to the outer surface (89%). The inner cuffs also had a

much higher level of contamination, 29% having >100 colony forming units(cfu)

compared to only 8% with >100 cfu on the outer cuff. On average, most cuffs were found

to have organism in the 10-100 cfu range. The most heavily contaminated cuffs (>100

cfu) were found on the general intensive care unit. Coagulase negative Staphylococcus

was the most commonly isolated organism found in 67% of samples.

Synthesis

The rate of healthcare associated infection can be as low as 0.1% or as high as

20% of all patients that are admitted depending on the clinical settings, with an average

of about 5%. In the number of admission, this adds up to 2 to 4 million of cases a year

which result in nearly 90,000 deaths (Cowan, 2015). Generally, patient can acquire HCAI

if the health care staff didn’t practice the proper aseptic technique. As mentioned in the

research literature most of the paraphernalia were contaminated with Staphylococcus

aureus and Pseudomonas aeruginosa. Staphylococcus aureus can cause serious

infections such as bloodstream infections, pneumonia, or bone and joint infections

(Minnesota, 2017). While Pseudomonas aeruginosa can cause bacterimia, pneumonia,

follicutis, external ear canal infection and eye infection (Cafasso, 2016). But the

investigation of actual cases of HCAI was not acquired due to the lack of revelant data

such as the medical diagnosis of the patients that confirms HCAI.

Theoretical Framework

Florence Nightingale, as we all know she is the mother of nursing who

emphasized that environment is one of the factor that affect the person’s health.

Through the years many paraphernalia had been introduced in the hospitals. Some

of it were the blood pressure, thermometer and many more. What we don’t about, it is the

paraphernalia itself can be a reservoir for organism. As stated by Mahta (2014) not just

the sanitation but high quality of cleaning patent equipment such as bedrails, and

doorknobs is an essential part of infection prevention. Nightingale also passionately

advocated for equipment sanitation and isolation of patient from infection. In addition, it

is also imperative to maintain clean patent environment. This includes keeping hospital

equipment sanitized after patient care and in between patient use.

Education also plays an important role is Nightingale’s principle of sanitary

conditions. She consistently educates other nurses and volunteers she worked with,
ensuring sanitized properly. But what is lacking is that the proper education that increase

the awareness of nurses regarding the use of paraphernalia without disinfecting it. This

could lead to nosocomial infection.

Conceptual Framework

Below is the paradigm of the conceptual frame work of the present study. This is

made using the system approach with input, process and output as framework for

evaluation.

INPUT PROCESS OUTPUT

 Collection of samples thru

swabbing.
 Isolation and purification
 Approval letter  Culture and Identification Prevalence of
 Letter for the 1. Morphological test and Vital Signs
Hospital Gram Stain Contamination in
Institution 2. Biochemical Analyses the Clinical Area
a. Catalase test
b. Mannitol Salt
Agar
c. Coagulase test
d. Eosin Methylene
Blue
e. Triple Sugar Iron
 Analysis and Interpretation of
data
 FIGURE 2.1 Paradigm of the Study

The figure illustrates the paradigm of the study. The input is composed of the

approval letter and the letter for the hospital institutions.

The process includes the collection of samples thru swabbing. Afterwards

isolation and purification, culture and the identification of bacteria and lastly analysis

and interpretations of samples.

The output is the result of the study, which is the, prevalence of vital signs

contamination in the clinical area in Don Manuel Lopez Memorial District Hospital and

Apacible Memorial District Hospital.

Hypothesis

There is no significant difference in the prevalence of vital signs contamination in

terms of type, microbes and hospital area.

Definition of Terms

For clarification purposes, the following terms were defined conceptually.

 Prevalence. The proportion of individuals in a population having a disease or

characteristic. It is a statistical concept referring to the number of cases of a disease that

are present in a particular population at a given time (MedicineNet.com).

Contamination. The presence of an infectious agent on a body surface; also on or

in clothes, bedding, toys, surgical instruments or dressings, or other inanimate articles or

substances including water, milk, and food, or that infectious agent itself (MediLexicon ).

Paraphernalia. It is an equipment, or apparatus, used in or necessary for a

particular activity (TheFreeDictionary).

Infection. The invasion of the body with organisms that have the potential to

cause disease (MediLexicon ).

Asepsis. A condition in which no living disease-causing microorganisms are

present (ScienceDirect).