Nosocomial infections, also referred to as health care–associated infections (HAIs), are infections acquired during the course of receiving medical care that were neither present nor incubating at the time of hospital admission. [1] These infections typically develop 48 to 72 hours after hospitalization and represent a significant global challenge, compromising patient safety and the quality of health-care delivery systems worldwide. [2–5] The impact of HAIs extends beyond clinical complications, as they contribute to prolonged hospital stays, increased diagnostic and therapeutic interventions, and substantial economic burden on both patients and health-care infrastructures.[6]

Efforts to reduce the incidence of HAIs can result in considerable savings for hospitals, national health systems, and society at large.[7] However, in developing countries, financial limitations often hinder effective infection control practices. Beyond extending hospital stays, HAIs may spread to patients’ relatives through casual contact, further endangering public health.[7] These infections are not confined to specific groups they can affect any patient or hospital staff member, contributing to increased morbidity and mortality rates in hospital settings.[8]

The most commonly reported HAIs include urinary tract infections (UTIs), respiratory tract infections (RTIs), bloodstream infections, and surgical site infections.[9–11] A World Health Organization (WHO) study involving 55 hospitals across 14 countries reported an average HAI prevalence of 8.7%, with higher rates in the Eastern Mediterranean region and lower rates in the Western Pacific.[12–13] While North America and parts of Europe reported prevalence rates around 5%, some countries in Asia, Latin America, and Africa reported rates as high as 40%.[15,16] In Europe, one study noted an HAI prevalence of approximately 2.9%.[17]

Multiple factors contribute to the development of HAIs, including invasive medical procedures, inadequate environmental hygiene, and lapses in personal hygiene among health-care staff and patients.[17,18] However, the leading cause remains non-compliance with established hospital infection control protocols.[18] Although complete eradication of HAIs is unfeasible—even in the most advanced medical settings—strict adherence to infection prevention guidelines can substantially reduce their occurrence.[19,20]

In the current era of technological advancement and increased demand for quality health care, it is imperative to assess the prevalence and underlying causes of HAIs.[21] Accurate epidemiological data is essential for the formulation of effective infection control strategies. Inadequate surveillance and data gaps hinder intervention planning and contribute to elevated health-care costs. [22, 23]

The burden of HAIs is particularly high in low- and middle-income countries due to challenges such as overcrowding, inadequate infection control measures, limited resources, and insufficient surveillance systems. Regular monitoring of infection rates and identification of prevalent pathogens is essential for implementing targeted infection prevention and control (IPC) strategies.

This study aims to assess the prevalence of HAIs in a tertiary care centre, identify the most commonly affected systems and causative organisms, and evaluate potential risk factors. The findings are expected to provide valuable insights for strengthening hospital infection control policies and improving patient outcomes.

This cross-sectional study was conducted in the Department of General Medicine at F.H. Medical College and Hospital, Etmadpur, Agra. The study was carried out over a period of 18 months. A total of 300 patients with suspected nosocomial infections were included in the study.

Inclusion Criteria

Patients fulfilling the following criteria were included:

1. Patients of either gender and of any age group.
2. Patients with post-operative infections.
3. Patients with catheter-associated urinary tract infections (UTIs).
4. Post-operative patients without wound infections.
5. All patients admitted in Intensive Care Units (ICU) and Coronary Care Units (CCU).

Exclusion Criteria

Patients were excluded if they met any of the following:

• History of hospitalization within the previous 30 days.
• Use of antibiotics within 48 hours prior to admission.
• Infection as the primary reason for admission.
• Patients who were unwilling to participate in the study.
• Patients presenting with fever on admission.

Methodology

Samples were collected from patients admitted to post-operative wards, ICUs, or those undergoing medical interventions or catheterization, where nosocomial infection was suspected. These specimens were promptly transported to the Department of Microbiology for culture and microbial identification.

Microbiological Evaluation

Isolates were obtained by inoculating and subculturing the specimens on blood agar and MacConkey agar media. Microorganisms were identified using colony morphology, Gram staining, and standard biochemical tests.

Antimicrobial susceptibility testing was performed using the Kirby-Bauer disc diffusion method. Antibiotics tested included ampicillin (AM), co-trimoxazole (TS), cephalexin (CFX), tetracycline (T), ceftriaxone (CRO), ceftazidime (CAZ), ciprofloxacin (CIP), and gentamicin (GM). The potency of the antibiotic discs was standardized using ATCC reference strains Escherichia coli (No. 25922) and Pseudomonas aeruginosa (No. 27272). Interpretation of susceptibility was done according to NCCLS guidelines (1998), classifying organisms as sensitive (S), moderately sensitive (M), or resistant (R) based on the zone of inhibition.

Preservation and Plasmid Analysis

For plasmid profile analysis, all isolates were preserved in 15% glycerol broth and stored at –20°C. Plasmid DNA was extracted using the Miniprep method from Escherichia coli, Pseudomonas spp., and Klebsiella isolates. This analysis was carried out to investigate the potential sources and patterns of nosocomial infections.

Data Analysis

The data was recorded on a semi-structured proforma and entered using Microsoft Excel 2023. Statistical analysis was performed using IBM SPSS software version 25.0. Qualitative data were presented as frequencies and percentages, while continuous variables were summarized using mean ± standard deviation (SD). The Chi-square test was used for comparing categorical variables, and independent samples t-test was applied to compare continuous data. A p-value of less than 0.05 was considered statistically significant at a 95% confidence interval.

The present study aimed to evaluate the prevalence of nosocomial infections in a tertiary care center using a total of 300 clinical specimens collected from various wards and sources. Table 1 summarizes the sociodemographic characteristics of the patients from whom these samples were obtained.

The age of the study population ranged between 2 and 80 years, with the highest proportion of patients (n=133; 44.3%) falling within the 20–40-year age group. This was followed by patients aged 40–60 years (29.7%), 60–80 years (15.3%), and those under 20 years of age (10.7%). The mean age was 41.14 ± 17.72 years.

In terms of gender distribution, there were 147 males (49%) and 153 females (51%), resulting in a sex ratio of 0.96. A significant majority of patients (90%) resided in rural areas. Regarding socioeconomic status, most patients (n=274; 91.3%) belonged to the lower socioeconomic class, while the remaining 26 patients (8.7%) were categorized as upper lower class.

Table 1: Socio demographic Profile of source population (n=300)

Table 2: Distribution of cases according to duration of hospital stay

Mean duration ± SD (Range) in days 9.46±1.76 (7-18)

Table 2 shows the distribution of cases based on the duration of hospital stay. The majority of patients, 201 (67.0%), stayed for 8–10 days, followed by 66 patients (22.0%) who stayed for 11–15 days, and 32 patients (10.7%) who had a 7-day stay. Only 1 patient (0.3%) had a hospital stay of more than 15 days. The mean duration of hospital stay was 9.46 ± 1.76 days, with a range of 7 to 18 days.

Table 3: Distribution of cases according to medical and surgical history

Among patients with a medical history, the most frequent condition was chronic obstructive pulmonary disease (COPD) reported in 21 patients (7%), followed by diabetic ketoacidosis in 19 patients (6.3%), tubercular meningitis in 13 (4.3%), ischaemic cerebrovascular accident (CVA) in 12 (4%), and tuberculosis in 11 patients (3.7%). Other conditions included chronic liver disease and uraemic encephalopathy (8 patients each; 2.7%), hepatic encephalopathy (4; 1.3%), chronic kidney disease (3; 1%), congestive heart failure (2; 0.7%), and both bronchial asthma and type 1 diabetes mellitus (1 patient each; 0.3%).

Among patients with a surgical history (n=195), the most common procedure was lower segment caesarean section (LSCS) in 63 patients (21%), followed by orthopaedic surgery in 42 (14%), general surgery in 40 (13.3%), urosurgery in 24 (8%), neurosurgery in 16 (5.3%), and hysterectomy in 10 patients (3.3%).

Table 4: Distribution of cases according to source type

                Table 4 presents the distribution of cases based on the source type. The majority of cases were post-operative, accounting for 57.3% (172 cases). This was followed by ICU-related cases, which comprised 35.0% (105 cases). Intervention-related cases contributed to 5.3% (16 cases), while post-catheterization urinary tract infections (UTIs) were the least common, making up 2.3% (7 cases). This indicates that post-operative and ICU settings were the primary sources associated with infections in the study.

Table 5: Distribution of cases according to specimen type

 Table 5 shows the distribution of cases based on specimen type collected for culture. Blood samples accounted for the highest proportion, comprising 41.0% (123 cases) of the total. This was followed by urine specimens, which made up 37.7% (113 cases). Foley’s catheter tip samples were the third most common at 13.7% (41 cases). Less frequently collected specimens included ET tube tips (4.7%, 14 cases), sputum (2.3%, 7 cases), and catheter tips (0.7%, 2 cases). This distribution highlights that blood and urine were the primary specimen types used for detecting infections in this study.

Table 6: Distribution of cases according to culture sensitivity, Gram stain status and pathogen isolated

 Out of 300 samples tested, 100% were Gram stain negative, and none showed Gram-positive organisms. Culture sensitivity results revealed that only 10 samples (3.3%) were culture positive, while the vast majority, 290 samples (96.7%), were culture negative. Among the 10 positive cultures, the most commonly isolated pathogens were E. coli and Klebsiella spp.—each accounting for 40% of isolates. Within Klebsiella, Klebsiella pneumoniae was found in 3 cases and Klebsiella oxytoca in 1 case. Pseudomonas aeruginosa was identified in 2 cases (20%).

Table 7: Association of Nosocomial Infections with demographic profile of patients and duration of hospital stay

 The study found no significant association between nosocomial infection rate and patient characteristics such as age (mean 44.40 vs. 41.03 years; p=0.555), sex (50% male in both groups; p=0.949), place of residence (100% rural in culture-positive vs. 89.7% in culture-negative; p=0.284), and socioeconomic status (90% lower SES in culture-positive vs. 91.4% in culture-negative; p=0.879). However, the mean duration of hospital stay was significantly longer in culture-positive patients (10.80 ± 1.55 days) compared to culture-negative ones (9.41 ± 1.76 days), with a p-value of 0.014, indicating a statistically significant difference.

Table 8: Association of Nosocomial Infections with medical/surgical history, source and specimen type

The analysis compares culture-positive (n=10) and culture-negative (n=290) patients. Culture-positive cases were significantly associated with a medical history (70% vs. 33.8%; p=0.018), ICU source (60% vs. 34.1%), and post-catheterization UTI (20% vs. 1.7%), all showing statistical significance (p<0.001). Specimen-wise, urine (50%) and ET tube tip fluid (40%) were the most common sources in culture-positive cases, compared to higher blood sample representation (42.4%) in the culture-negative group (p<0.001). These findings suggest that culture positivity is more likely in patients with medical histories, ICU admissions, catheter-associated infections, and when urine or ET tube specimens are tested.

Healthcare-associated infections (HAIs) continue to pose a substantial challenge in tertiary care settings, contributing significantly to patient morbidity, mortality, and financial burden on healthcare systems. Despite constituting only 15–20% of hospital beds, Intensive Care Units (ICUs) are responsible for more than half of all severe nosocomial infections, underscoring their role as critical zones for infection control. [24–27] The incidence of HAIs observed in the present study appears higher than that reported in similar studies across various global regions, [28, 29] thereby necessitating localized assessments of infection dynamics and preventive strategies.

This study evaluated 300 clinical specimens obtained from patients admitted across various wards and units, aiming to assess the prevalence and microbiological profile of nosocomial infections in a tertiary care hospital. Demographically, the majority of patients were aged between 20 and 40 years (44.3%), with an almost equal male-to-female ratio. Notably, 90% of the participants were from rural areas, and 91.3% belonged to a lower socioeconomic stratum. Such findings reflect the healthcare-seeking behavior in many Indian tertiary centers, where rural populations, often referred from peripheral healthcare institutions, comprise a significant proportion of patients. Socioeconomic challenges, inadequate sanitation, and limited health literacy likely contribute to increased susceptibility to HAIs in this demographic. A study by Voidazan S, et al. [30] similarly emphasized that while the HAI rate in high-income countries hovers around 7.5%, it varies broadly between 5.7% and 19.2% in low-income countries, highlighting disparities rooted in infrastructure and infection control practices.

The average duration of hospital stay among patients was 9.46 ± 1.76 days, with a notable 67% remaining hospitalized between 8 and 10 days. Existing literature establishes a strong correlation between prolonged hospital stays and the risk of nosocomial infections. It is widely recognized that infection rates are negligible in the first week of admission but tend to rise sharply beyond this period due to increased exposure to invasive procedures and hospital flora.[31] Dasgupta S, et al. [32] also reported a mean MICU stay of 8.1 days for patients with nosocomial infections. Furthermore, an infection rate of 16.71 per 1000 patient-days and a 17.7% infection prevalence among MICU patients were reported in other studies, underscoring the high-risk nature of prolonged hospitalization.[33]

Approximately two-thirds (65%) of the study population had undergone surgical interventions, with lower segment cesarean section (LSCS) being the most frequently performed procedure (21%), followed by orthopedic and general surgeries. Among medically managed cases, chronic respiratory illnesses such as COPD (7%) and systemic metabolic disorders like diabetic ketoacidosis (6.3%) were prominent. These underlying conditions may impair host immunity and predispose patients to infection.

Regarding the source of clinical specimens, postoperative (57.3%) and ICU-related (35%) infections were predominant. This trend aligns with previous findings that identify these settings as high-risk environments due to factors such as surgical wounds, invasive devices, and compromised host defenses. Infection prevalence across hospital units further corroborates this pattern, with the transplant unit exhibiting the highest rate (0.77), followed by neonatal (0.69) and ICU wards (0.68).[34] A study by Ayala D, et al. [35] in Ethiopia also noted a high incidence of surgical site infections (SSIs), while Ketata N, et al. [36] identified SSIs as the most prevalent form of HAI in low- and middle-income countries.

Blood (41%) and urine (37.7%) constituted the most commonly collected samples in this study, reflective of standard protocols in suspected systemic and urinary tract infections. Similar trends were documented by Panis C, et al., who reported frequent sampling of blood, urine, sputum, and surgical sites in the evaluation of HAIs.[37] Despite comprehensive sample collection, Gram staining failed to detect organisms in all cases, and only 3.3% of the specimens yielded culture-positive results. Notably, Gram-negative bacilli were predominant among the positive cultures, consistent with findings by Kumar A, et al., [38]

Among the 10 culture-positive cases, Escherichia coli and Klebsiella spp. each accounted for 40% of isolates, while Pseudomonas aeruginosa was isolated in the remaining 20%. These organisms are widely recognized as leading causes of HAIs globally, with Klebsiella pneumoniae in particular exhibiting notable multidrug resistance. Choudhuri AH, et al., [39] reported K. pneumoniae as the most frequent pathogen in nosocomial infections, contributing to approximately 8% of all HAIs and up to 14% of primary bacteremia cases.[40]

No statistically significant associations were found between nosocomial infection rates and demographic variables such as age, sex, residence, or socioeconomic status. However, a significant correlation was observed between culture positivity and longer hospital stay, with infected patients averaging a hospital duration of 10.80 ± 1.55 days compared to 9.41 ± 1.76 days in their non-infected counterparts (p = 0.014). This observation reinforces earlier conclusions by Choudhuri AH, et al., [39] and underscores the importance of reducing hospital stay duration wherever feasible through early discharge protocols and enhanced clinical monitoring.

Our study highlights the persistent burden of nosocomial infections in tertiary care settings and points to critical areas for intervention. The low culture positivity rate despite strong clinical suspicion calls for improvements in diagnostic accuracy, including better sampling techniques and timely microbiological evaluation. Strengthening infection control protocols, conducting routine surveillance, and promoting rational antibiotic use remain imperative to reducing HAIs and improving patient outcomes.

This study was conducted to analyze the prevalence and characteristics of nosocomial infections in a tertiary care center using 300 clinical specimens. The results indicate a low prevalence (3.3%) of culture-positive nosocomial infections, with Escherichia coli and Klebsiella spp. as the most common pathogens. The study population primarily consisted of rural residents (90%) and individuals from lower socioeconomic backgrounds (91.3%), with an almost equal gender distribution and a predominant age group of 20–40 years. While demographic factors such as age, sex, residence, and socioeconomic status showed no significant association with infection, a longer hospital stay was significantly linked to culture-confirmed infections (p = 0.014), highlighting prolonged hospitalization as a key risk factor.

However, gaps remain in understanding the full spectrum of nosocomial infections, particularly regarding pathogen detection methods and infection sources in various hospital settings. These findings are important for healthcare providers and policymakers, emphasizing the critical need for stringent infection control practices, especially among patients with extended hospital stays, those undergoing surgery, and those in intensive care units.

We recommend implementing targeted infection prevention strategies focusing on these high-risk groups to reduce infection rates, improve patient safety, and minimize healthcare costs. Given the significant impact of nosocomial infections on hospital performance and patient outcomes, continuous surveillance and effective control programs remain essential in tertiary care centers.

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