Pattern Of Bacterial Colonization With Dry Cord Care Among Preterm Neonates .

https://doi.org/10.33698/NRF0222- Daiahunlin Lyngdoh ,Sukhjit Kaur, Praveen Kumar, Vikas Gautam, Sandhya ghai

Abstract : Introduction : The umbilical cord is an excellent medium for bacterial colonization during the intrapartum period while passage through the birth canal and immediate postpartum from the environment. Preterm babies have immature immune system as compared to term babies , therefore, the chance of infection is increased in preterm babies. Current routine cord care in India includes keeping the cord dry. However studies have shown that bacterial colonization occurs with dry cord care. Objective : To determine bacterial colonization pattern with dry cord care in preterm newborn. Methods: Descriptive design was used for the study. Thirty five preterm newborn born in PGIMER, Chandigarh were recruited between 3 to 12 hours after birth. The characteristics of the newborn such as birth weight, gestational age, sex was recorded. The first Umbilical cord swab sample was then taken. Further, cord swab sample was again taken at 72±12 hours and 120±12 hours after birth and were cultured from each of the subjects. Results: Among 35 enrolled newborn, the mean gestational age was 31 weeks. Majority had birth weight of >1400 grams.51.1% were males. With the 1st swab culture, only 2.9% had bacterial colonization, 51.4% had bacterial colonization in the 2nd swab culture and 71.4% in the 3rd culture. The pathogenic microorganisms that were cultured includes Klebsiella pneumonia, E.coli, Enterococcus fecalis, Acinatobacter baumanii, Staphylococcus homonis, Enterococcus faecium, Staphyloccocus hemolyticus, Streptoccoccus. Conclusion : There is increase pattern in bacterial colonization with dry cord care especially in preterm neonates with their immature immune system. Hence, it is recommended that antiseptic agents such as chlorhexidine should be used to reduce colonization

Keywords

Dry cord care, bacterial colonization, preterm

Correspondence at

 Dr. Sukhjit Kaur

Clinical Instructor

National Institute of Nursing Education (NINE) PGIMER, Chandigarh.

Introduction

The umbilical cord of newborn serves as a portal of entry for bacterial colonization during the intrapartum period and immediate postpartum from the environment.1 The environmental source of infection includes the hands of the caregivers2. Delay in cord detachment may increase the risk of bacterial infection3. The tissue of the cord stump can serve as a medium for bacterial growth. This is particularly true in cases where the stump is left moist and certain unclean substances are applied to it. The umbilical stump is a common means of entry for systemic care such as applying of harmful substances are reduced but Bhatt B et al (2015) reported in their study that oil or ghee including cream, turmeric powder was infection in the newborn infant.3 Umbilical applied on the umbilical cord7. cord infection can either be localized to the cord (omphalitis) or can spread through the blood stream and become systemic causing neonatal sepsis.3 In hospital settings, Staphylococcus aurues is the most common organism being cultured. The other common organisms that have the potential to cause cord infections in hospitals includes group B streptococci and E.coli.3 Mir F. et al (2011)reported that 80% of all pathogens that caused community acquired omphalitis are S.aureus and beta hemolytic streptococci. Cord infection is most prevalent among newborns born in developing countries and it contributes to potential risk of developing life threatening neonatal sepsis4.Preterm babies have immature immune system as compared to term babies, therefore, the chance of infection is increased in preterm babies.

Umbilical cord care after birth until its separation is an important component of newborn care. Usually, the umbilical cord can become colonised with potential pathogenic bacteria during the intrapartum or postpartum period .These pathogenic bacteria are likely to invade the umbilical stump, which can lead to omphalitis.5 Colonization of the cord stump by pathogenic organisms leading to infection can cause morbidity and mortality of newborn.6 Although the practices of cord.

Current routine cord care in India includes keeping the cord dry in most of the health care institutes. However, findings from the study conducted by Kaur P (2011) demonstrated 100% positive for pathogenic bacteria with dry cord care. Other studies in literature has also shown that colonization rate was higher in dry cord care6,8,9 still the practice of keeping the cord dry is being carried out in many institutes including our institute as well. Discussion to change the cord care practice is being considered. However, prior to implementation of the changes, a need was felt to determine colonization pattern with the current dry cord care practice.

Objective

To determine the pattern of bacterial colonization with dry cord care in preterm newborn.

Materials and Methods

A descriptive design was used for the study. A total of 35 preterm newborn ≤ 34 weeks of gestation born in Nehru hospital , PGIMER, Chandigarh were recruited between 3-12 hours after birth. Ethical clearance and approval for conducting this study was obtained from the Institute Ethics Committee and permission from the concerned departments were taken. Mothers of these newborn were informed about the aim of the study and written consent was obtained. An interview schedule was used to gather information about the characteristics of subjects. After the interview, the 1st umbilical cord swab sample was taken from each of the neonate. Thereafter, cord swab was again taken at 72±12 hours and at 120±12 hours after birth. Swab culture was taken making a single stroke with sterile cotton swab stick at umbilical cord stump and single round stroke at umbilical cord base. The samples were then send to the microbiology department for pathogenic bacterial study within 4-5 hours after collection of sample. At the microbiology lab,10µl of suspension streaked on Mac’Conkey and blood agar medium. Plates were incubated at 370C for 48 hrs. MALDI (Matrix Assisted Laser Desorption Ionization) was done for identification of the type of microorganism cultured. Reports were then collected after 48 hours .

The analysis was done using SPSS version 20 software. Frequency, percentage,mean and standard deviation was calculated for characteristics of subjects and number of subjects with bacterial colonization.

Results

Table 1 describes the characteristics of subjects. The gestational age ranges from 26 to 34 weeks with the mean gestational age of 31 weeks. The mean weight was 1400 grams .

Table 1: Characteristics of subjects

N=35

Variables n(%)
Sex of newborn  
Male 20(57.1)
Female 15(42.9)
Gestational age (in weeks)  
<31 7(20)
31-32 16(45.7)
33-34 12(34.3)
Weight in grams  
<1000 2(5.7)
1000-1249 9(25.7)
1250-1499 8(22.9)
>1499 16(45.7)

Mean gestational age ±SD-31.41±1.014 Mean weight ±SD-1479.89±384.36

Table 2 depicts the number of newborn colonized by pathogenic bacteria at 1st, 2nd and 3rd culture swab. In the 1st swab culture, only 2.9% had bacterial colonization. 51.4% had bacterial colonization in the 2nd swab culture and 71.4% in the 3rd swab culture.

Table 2: Pathogenic bacterial colonization

Culture swab (hours of age) Newborn with bacterial colonization (n=35)
1st culture(≤12 ) 1(2.9)
2nd culture(72±12 ) 18(51.4)
3rd culture(120 ±12 ) 25(71.4)

Table 3 describe the correlation between characteristics of newborn and 2nd and 3rd swab culture. There was no correlation found between the culture swab with gestational age and birth weight of the newborn.

Table 3: Correlation between gestational age, birth weight and swab culture

Variables 2nd swab culture (72±12 hours of age) 3rd swab culture

(120 ±12 hours of age)
r(P value) r(P value)
Gestational age -0.2(0.3) -0.2(0.3)
Birth weight -0.1(0.5) -0.1(0.4)

(r) Pearson’s correlation significant at 0.05

Discussion

The umbilical cord is an important entry site for pathogenic bacteria .Necrotic tissue of the umbilical cord is an excellent medium for bacterial growth and becomes rapidly colonised with bacteria which can cause infection. Therefore, when the cord is kept dry, chance of colonization is high. Preterm neonates, on the other hand, have an increase risk of colonisation because of their immature immune system. Hence, it is necessary to determine colonisation pattern in this vulnerable group.

In the present study, the 1st cord swab culture was taken between 3-12 hours after birth. The cord swab sample was taken within 12 hours after birth to reduce risk of contamination that can occur with prolonged time interval from birth. Similar procedure was followed by Mahrous E et al where baseline umbilical cord swab was taken after birth10.The umbilical cord swab sample for bacterial colonization was taken by using sterile cotton swab stick and single stroke was made at the umbilical cord base. This procedure is matched with that of Abd El Hamid AA et al where the first cord swab was taken from the umbilical cord stump after delivery2.Three cord swab sampling were taken–1st cord swab(≤12 hours after birth), 2nd culture at 72±12 hours and 3rd sample at 120 ±12 hours which is a standardised procedure followed for all babies.This is in contrast with that of Hamid AA et al whereby two cord swab sample were taken immediately at birth and after 3 days2. 54% of the neonates’ first swab culture was taken within 6 hours of birth in the dry cord care group respectively. Hamid AA et al in their study comparing different cord care regimens took the first swab 3 hours after birth2. In the 1st swab culture, only 2.9% had bacterial colonization. 51.4% had bacterial colonization in the 2nd swab culture and 71.4% in the 3rd culture. This study is comparable to findings by Mahrous E et al where there was a significant difference in bacterial colonisation during the follow up visits10.

The different pathogenic microorganisms that colonised the umbilical cord were Klebsiella pneumonia, E.coli, Enterococcus fecalis, Acinatobacter baumanii, Staphylococcus homonis, Enterococcus faecium, Staphyloccocus hemolyticus , Streptoccoccus and is in accordance with findings reported in various studies where the most common pathogenic microorganisms were E.coli, Klebsiella pneumonia, Pseudomonas, Staphyloccocus.10,11 No correlation was found between swab culture with gestational age and sex of newborn. It can be concluded that there is increase pattern in bacterial colonization with dry cord care especially in preterm neonates with their immature immune system. Hence, it is recommended that antiseptic agents such as chlorhexidine should be used to decrease colonization rate. Also, health care professional should be sensitised about cord care regimen that will help reduce colonisation and hence improve neonatal outcome. Further, breast milk application, to some extend , can help reduce bacterial colonization and is a better alternative to dry cord care.

References

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