Bacteriology of Healthcare-Associated Infections in the Gynecology and Obstetrics Department of CHU Gabriel Touré

Introduction: Healthcare-associated infections (HAIs) are a public health issue. An infection is said to be associated with the care if it occurs during or after the care of a patient, and if it was neither present nor incubation at the beginning of the care. Objective: The purpose of this work was to study the bacteriology of infections associated with obstetric care in the gynecolo-gy-obstetrics department of CHU Gabriel Touré. Patients and Methods: This is an epidemiological, descriptive, analytical study conducted in the gy-necology-obstetrics department of the CHU Gabriel Touré, from April 11 th , 2016 to August 29 th , 2016 (5 months). Data collection focused on the clinical and laboratory characteristics of healthcare-associated infections in patients during their hospitalization. Included in the study were any patients hospitalized in the Gynecology and Obstetrics Department who agreed to participate in the study. The criteria used to diagnose the associated infection were those of the Atlanta CDC. Operative wound monitoring was done up to the 30th postoperative day. Results: We have recorded 200 patients, out of whom 138 were operated on and 23 cases of bacterial infection associated with care (11.50%). The average age of the patients was 32.52 years ± 13.36 years against 29.36 years ± 10.28 years for the patients who did not present the infection. Seven point five percent of the evacuated patients had an infection associated with care. The most common types of infection were surgical site infection (60.86%), urinary tract infection (26.08%), endometritis and sepsis with 13.04% each. The isolated organisms were all resistant to Amoxicillin, to Amoxicillin + Clavulanic acid (88.88%) and to Ciprofloxacin (77.77%). The average duration of hospitalization for patients who developed the infection was 14.70 days. The lethality was 1.50%. The average cost of management of patients who developed the surgical site infection was 119,837 FCFA. Conclusion: The bacterial infections associated with the care remain frequent in our service and dominated by the infections of the operating site. Isolated organisms were all resistant to amoxicillin in 88.88% case ciprofloxacin.


Introduction
An infection is said to be associated with the care (HAI) if it occurs during or after the care of a patient, and if it was neither present nor incubation at the beginning of the care. They constitute a public health issue. For operative site infections, HAI is defined as infections occurring within 30 days of surgery or if an implant or prosthesis is implanted within one year of surgery [1]. They are responsible for an increase in morbidity, mortality, hospital stay and patient care costs [2]. The WHO estimates that an average of 190 million people is hospitalized each year around the world and that 9 million people are infected with the disease [3]. Approximately 1 million patients die each year from these care associated infections [3]. In sub-Saharan Africa, the rate of infection associated with care is estimated at 40% of hospitalizations [2] [4]. HAI risk factors are in the order of three categories: patient-related factors, environmental factors, and medical practice factors [5]. In France, there are 15 million hospitalizations per year with 800,000 cases of nosocomial infections per year among which 4000 deaths per year are attributable to nosocomial infections with an estimated annual cost of 800 million euros [6]. The frequency of infections associated with care is 4.50% in the USA; 10.50% in Canada; 6.70% in France and 6.20% in Belgium [7] [8]. The risk of contracting an infection during health care is 2 to 20 times higher in developing countries than in developed countries. In Albania, the frequency was 19.10%; in Brazil, it is 14.00%; in Tunisia, it is 17.80% and 14.00% in Tanzania in 2009 [7]. A study conducted in Morocco in 2006 showed an infection rate of 17.80% [9]. In Mali, in 2011, a frequency of 14.00% was reported in the General Surgery Department of the University Hospital Gabriel Touré [10].
At the Gabriel Touré Teaching Hospital, few studies have been carried out on bacterial infections associated with care. We did not find a study in obstetrics in the department of gynecology-obstetrics hence the interest of our study.

Material and Methods
This is an epidemiological, analytical study, from April 11 th , 2016 to August 29 th ,

Socio-Demographic Data (See
The average age of patients with an infection associated with obstetric care was 32.52 ± 13.36 years.
Housewives with a HAI accounted for 14.00% of the sample versus 30.00% for civil servants. In our study, 22.00% of patients with low income had a HAI compared to 7.00% whose income level was high.

Risk Factors (See
Nineteen percent of patients who stayed in the 3rd-class of hospital wards reported healthcare-associated infection versus 4.00% of patients admitted to 1st-class wards. A. Bocoum et al. Twenty percent of our patients with anemia developed HAI compared to 7% of patients without anemia (P = 0.0000).
The diagnoses of the patients were the high blood pressure associated with the pregnancy in 28.00%, the uterine fibroma 11.50% and the Placental retro hematoma (PRH) in 10.00%.
In our study, 138 patients have undergone surgery, of which 78.50% were performed in emergencies versus 21.50% for scheduled interventions. The rate of infection associated with care was 7.00% for non-programmed interventions versus 3.50% for programmed interventions (P: 0.57, RR: 1.28).
Among the patients who underwent general anesthesia, 15.00% presented a HAI versus 6.00% for the so-called locoregional technique.
In our study, 45.00% of patients in whom the procedure lasted more than 90 minutes had a healthcare-associated infection.
Forty percent of patients with the National Nosocomial Infections Surveillance (NNIS) 2 Score experienced a care-associated bacterial infection versus 10.00% for NNIS 0 patients.
Healthcare-associated infection occurred in 32.00% of patients who had a bladder catheter versus 5.00% in bladder-free patients (P: 0.0001, RR: 6.6667).
Patients who received prophylactic antibiotic prophylaxis based on Amoxicillin developed a care-associated infection in 11.00% versus 23.50% for patients who did not receive (P: 0.027, RR: 4816).

Type of Healthcare Associated Infection and Germs in Origin
(See Table 5    On the result of six CBEUs requested, Escherichia coli was found in 83.00% and Enterococcus faecalis in 17.00% of cases.
Concerning infection of the operative site, Escherichia coli was found in 35.00%, followed by Acinetobacter baumanii (20

Result of Antibiogram
Escherichia coli was resistant to Amoxicillin in 100%, Amoxicillin + Clavulanic acid in 77.80%, Cefotaxime in 66.70% but sensitive in 100% to Nitrofurantoines.
Acinetobacter baumanii was resistant to Ciprofloxacin, Gentamicin and Cotrimoxazole in 75.00% of cases but sensitive to Nitrofurantoinesin 75.00%.
Enterococcus faecalis was sensitive to Nitrofurantoinesin 100%, 75% Gentamicin but resistant to Cefotaxime, Chloramphenicol and Ciprofloxacin in 100% of cases.

Socio-Demographic Data
The median age of patients with care-associated infection was 32.52 ± 13.36 years with extremes of 14 and 70 years. Diallo [11] reports an average age of 26.80 years with extremes of 16 and 45 years. Zhang [12] in China and Deptula [13] in Poland reported an average age of 55.90 ± 19.2 years and 64 ± 16 years, respectively. In our study, 22.00% of patients with low income had a HAI versus 9.00% for patients with a high-income level. There is a statistically significant difference between the patient's income level and the risk of healthcare-associated infections because poverty is a delay in acquiring drugs that are paid for by patients.

Type of Infection Associated with the Care and Germs Involved
Sixty-point eighty-seven percent (60.87%) of the patients who underwent surgery developed an infection of the operative site (OSI) and the median time of OSI onset was 1.5 ± 1.12 days.
According to the European Center for Disease Prevention and Control in 2016 [17], out of 5171 of OSI from 13 European countries, Staphylococcus aureus (17.9%) and Escherichia coli (14.7%) were the microorganisms the most Open Journal of Obstetrics and Gynecology commonly accounted for.

Result of the Antibiogram
Antibiotic resistance is today one of the most serious threats to global health, food security and development. It can affect anyone, at any age and in any country. Escherichia coli was resistant to Amoxicillin in 100%, Amoxicillin + Clavulanic acid in 77.80%, Cefotaxime in 66.70% but sensitive in 100% to Nitrofurantoines.
Acinetobacter baumanii was resistant to Ciprofloxacin, Gentamicin and Cotrimoxazole in 75.00% of cases but sensitive in 75.00% to Nitrofurantoines.
Enterococcus faecalis was sensitive to 100% Nitrofurantoines, 75% Gentamicin but resistant to Cefotaxime, Chloramphenicol and Ciprofloxacin in 100% of cases.
The most used antibiotic was Furadantine (26.66%) followed by Ciprofloxacin (13.66%) and Cefotaxime (13.33%). Furadantine was the most used antibiotic because of the sensitivity of all Escherichia coli strains to this antibiotic.
Jose [19] in Spain in 2016 and Micha [20] in Gabon in 2014 had a resistance of 34.90% and 57.00% of strains of Escherichia coli with Amoxicillin + clavulanic acid and a resistance of 53.5% and 35.7% with Ciprofloxacin. We can deduce that Escherichia coli has a strong resistance to beta-lactams and this resistance can be explained by the fact that this class of antibiotic is usually prescribed in the gynecology and obstetrics department of the CHU Gabriel Touré.
In India, in 2014, Mehta [21] reported in her study a sensitivity of strains of Acinetobacter baumanii in 50.00% to Cotrimoxazole.

Conclusion
The bacteriology study of care-associated infections is a key element in the prevention of healthcare-associated infections and an important tool for monitoring the effectiveness of prevention measures. Despite all the efforts made in the fight against and prevention of HAI, they remain worrying because of the risk factors, the diversity of hospital bacterial flora. Escherichia coli is the most recovered germ followed by Enterococcus faecalis in our study. Respecting asepsis in the operating room even as in hospital care in general reduces the risk of healthcare-acquired infections.