RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OFSUBJECTS FOR DISSERTATION

1NAME OF THE CANDIDATE AND ADDRESS

AAKASH CHAVDA

GAYATHRI COLLEGE OF NURSINGKOTTIGEPALYAMAGADI MAIN ROAD, BANGALORE – 91

2NAME OF THE INSTITUTION

GAYATHRI COLLEGE OF NURSING

3COURSE OF STUDY AND SUBJECT

FIRST YEAR M.Sc. NURSINGMEDICAL SURGICAL NURSING

4 DATE OF ADMISSION TO COURSE

24.10.2008

5 TITLE OF THE TOPIC

EFFECTIVENESS OF STRUCTURAL TEACHING PROGRAMME (STP) ON PREVENTION AND CONTROL OF METHICILLIN–RESISTANT STAPHYLOCOCCUS AUREUS IN TERM OF KNOWLEDGE AND PRACTICE AMONG STAFF NURSES OF SELECTED HOSPITAL AT BANGALORE.

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6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Silent Killer”

“Infection is the painful fact of life and chief cause of death, It’s often and

infection that turns disability to motility”

Clients in health care setting may have an increased risk of acquiring

infections. Nosocomial infection results from delivery of health services in a health care

facility. A hospital is one of the most likely places for acquiring an infection because it

harbors a high population of virulent strains of micro organisms that may be resistant to

antibiotics. Unfortunately, many nosocomial infections are transmitted by health care

workers.

Iatrogenic infections are a type of nosocomical infections resulting from a

diagnostic and therapeutic procedure. A urinary tract infection that develops after catheter

insertion is an example of an iatrogenic nosocomial infection. The incidence of nosocomial

infection can be reduce if Nurses use critical thinking when practicing aseptic techniques.

The nurse should always consider the clients risks for infection and anticipate how the a:

Pproach to care may increases or decreases the cause of infection transmission.

Nosocomial infection significantly increases costs of health care. Older adult have

increase susceptibility to these infection because of their affinity of chronic disease and the

aging process itself. Extended stay in health care institution, increase disability, increased

cost of antibiotics and prolonged recovery time add to the expenses of the clients, as well as

the expenses of the health care institution and funding bodies (eg: medi care). Often cost of

nosocomial infection is not reimbursed: as results, the prevention has a beneficial financial

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impact and is an important part of managed care. The risk of infection is influenced by

number of health care employees having direct contact with a client, the type and number of

invasive procedures, the therapy received, and length of hospitalization and major sites for

nosocomial infection include surgical and traumatic wounds, urinary and respiratory tracts

infection and the blood stream.

Nosocomial infection other wise known as hospital acquired infection (HAI)

is one which was not present or incubating at the time of admission to the hospital. Hospital

acquired infection are a world wide problem. Prevalence studies in serval countries have

shown that any one time between 6 percent and 12 percent hospital inpatient acquires an

infection after admission. Infection control is the responsibility of health care professionals

(plowman, 2000).

Nosocomial infection has existed since the time there have been hospital, but

attention was not focused on them until the middle of the 19 th century. The hygiene practice

of semmelweis in obstetrics, joseph lister in surgery and Florence nightingle in nursing

strengthened the foundation of infection controls. They began to transform hospital from

sites of pestilence and septic death to places of potential healing they made significant

contribution to sanitation, isolation practices and better hospital design (Ananthanarayan and

panicker 2000).

In 19th century, louis Pasteur founded the science of bacteriology and joseph

lister overcome surgical infection with phenol sparys, the concept of asepsis and its a:

Pplication in hospital practice reduce the incidence of infection, but hospital infection still

cause considerable mortality and morbidity (Ananthanaryana and Panicker 2000).

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Nosocomial infection is a major problem both in term of the cost to the health

services and more importantly because of the consequent increase in morbidity and mortality.

Nosocomial infection complicates the course of the original illness, increased cost of the

hospital stay delay recovery. The infections have increased along with advances in medical

technology and therapy.

Nosocomial infections may be exogenous or endogenous. An endogenous

infection arises from micro organisms external to the individual that do not exist as normal

flora: examples are salmonella organisms and clostridium tetani. An endogenous infection

can occur when part of the client’s flora becomes altered and overgrowth results examples:

are infections caused by enterococci, yeasts and streptococci.

Nosocomial infection is an important public health problem in developing

countries as well as in other developed countries. It has been estimated that over 2.1 million

nosocomial infection occurs annually in United States and a: Pproximately one third of these

infections can be prevented by adhering to established infection control guidelines (Jarvis

1996).

Nosocomial infection occurs is about 5-10 percent of hospital admission,

world wide. In India, the nosocomial infection rate is alarming and is estimated at about 30-

55 percent of all hospital infection (Mukherjee, 2000).

Adult inpatient in common specialties who developed hospital acquired

infection remained in hospital 2.5 times longer,incurred hospital cost almost three times

higher than uninfected patient. The large costs associated with hospital acquired infection

were for nursing (42 percent) and management (33 percent). (Plowman 2000)

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Each year numerous hospital outbreaks occur and provide an o: Pportunity to

identify new agents, sources or Mode of transmition. More than 25.000 Primary blood stream

infection ( BSIs ) were identified by 124 National Surveillance system. Hospital performing

hospital wide surveillance during the 10 year’s period 1980 – 1989. About 8 percent of All

Hospital acquired infection in united states were primary blood stream infections

( Bannerjee,Emori, Culver,1991

Methicillin resistant staphylococcus aureus (MRSA) is a major problem in

hospital in industrial nation. It is significant cause of morbidity and cost of health services.

Three hundred strain of staphylococcus aureus isolated from different clinical specimen from

patients treated at GTB hospital, New Delhi, India between may 1995 to April 1996.

MRSA was first described in 1959, although it was relatively rare during the

1960s and 1970s. There was a major increase during the 1980s and 1990s throughout Britian,

North America and Australia, it was probably detected in these countries first due to better

surveillance system, but MRSA is now a problem in hospital world wide (Enright et al,

2002).

Various strains of MRSA are now endemic throughout Britain and they are

especially concentrated in hospitals because people who are ill are more vulnerable to

infection (Health protection agency, 2006). Recognized as a health care associated infection,

MRSA infection is most likely to occur in areas such as intensive therapy units, orthopedic

wards, burns units and general surgical wards (RCN, 2005)

Over the last two decades MRSA has also become an increasing problem in

long term care facilities, particularly affecting older and more vulnerable people with

underling medical conditions (RCN, 2005). In addition around 30 percent of general

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population is colonized by staphylococcus aureus, so increasing number of people carry by

MRSA (DH, 2000). This means it is now frequently imported into hospitals from the

community (Guleri et al, 2007). Screening at lewisham hospital in south London found that

40 percent of elderly patient arriving from nursing homes carried MRSA and at university

college hospital, London, half of all patients were carrying MRSA before they reached the

ward (hinsliff, 2005)

MRSA is mainly spread on the hand of staff caring for infected patients. It

may also be airborne, especially it dust contain scales. There fore, hand washing is the most

important factor in preventing cross infection. Infected patients are nursed in a side room,

where possible to minimize the risk of airborne spread (Coia et al, 2006). Measure to reduce

the introduction of MRSA from outside sources have also been considered, including patients

with a previous history MRSA, reducing visiting times and encouraging visitors to wash

their hands when arriving and leaving the hospital (coia, 2006, RCM, 2005).

The general public receives dramatic and sensational message about the

spread and effects of MRSA rather than factual information and balance debut (hamour at al,

2003). Wilson (2004) observed that the UK media have developed a fascination with MRSA.

There fore, headlines such as ‘wards of filth’ (cox, 2003), ‘superbug crisis worse than feared’

(Marsh, 2004) and ‘Battle against the super bug’ (Hawkes, 2005) have become all too

familiar.

During the course of recent years , as the bacteria have managed to evolve,

MRSA has developed a resistance to the main antibiotics used to treat it and has left little

else to try and treat patients with .Left to spread in unsuspecting patients , MRSA can infect

the lungs causing instances of pneumonia, infect the heart ,bones ,and liver , and even cause

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septic shock .Each and every one of these complication is very serious and can even to death

among patients who are not able to recover from a serious infection of that type.

6.1 NEED FOR THE STUDY

Hospital acquired infection remains an important in medical institution today. These

infections may involve patient, health care workers and visitors. Inspite of increase

morbidity, they also account for a considerable financial and personal burden. Though their

prevention is simple extremely cost effectively and easy to practice, yet it is often over

looked. This is turn, leads to distressing consequences for both health care workers and their

patients minimum standard safety precaution therefore need to be adopted to ensure

compliance with the guidelines of the infection control programme, awareness need to be

created among the staff nurses about infection control.

M .Nixon, B.Jackson, P. Varghese, D. Jenkins and G. Taylor (2007) conducted a

study to examine the rates of infection and colonization by Methicillin - Resistant

staphylococcus aureus (MRSA) Between January 2003 and May 2004. Result in 2004 they

screened 1795 of 1796 elective admissions and MRSA was found in 23 (1.3 percent). They

also screened 1127 of 1147 trauma admissions and 43 (3.8 percent) were carrying MRSA.

The incidence of MRSA in trauma patients increased by 2.6 percent per week of inpatient

stay (r=0.97, P<0.001). MRSA developed in 2.9 percent of trauma and 0.2 percent of elective

patient during that admission (P<0.001).

M Mathur, S Taklikar, S Sarkar, D D’ Souza (2007) conducted a study to find the

prevalence of Methicillin - Resistant staphylococcus aureus (MRSA) in different specialties

as hospital various clinical sample (Pus, Blood, Urine, CSF) were processed and the

pathogens were identified as per the standard bacteriological techniques. The Results – A

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total 4847 (8.89 percent) staphy lococcus aureus isolated were isolated from 54,486 clinical

specimens. Amongst these, MRSA were 40.21 percent. Majority of the MRSA were from

wound swab (68.19 percent). Amongst Indoor patients, 91.49 percent MRSA were found

from wards and 8.51 percent were found from intensive care units.

Summaiya Mulla, Manish Patel, Latika Shah, Geetha Vaghela (2007) conducted

a study on antibiotic sensitivity pattern amongf Methicillin – Resistant and Methicillin -

sensitive Staphylococcus Aureus at Government Medical College, Surat, INDIA. There

objective was to determine the prevalence and pattern of antibiotic sensitivity among MRSA.

They collected the sample of Pus, Urine, Blood, Sputum, throat swabs. The Result shows that

Total 135 staphylococci were isolated, out of which, 48 (35.55 percent) were coagulase

positive. Methicillin resistance among the staphylococcus aureus isolated was 39.5 percent.

Resistance to all antibiotic tested among the Methicillin – resistance and Methicillin

Sensitive, Staphylococci was found to be 26.3 percent and 6.8 percent respectively.

MC Veigh, S.F. Fitz Gerald, L. E. Fenelon (2007) conducted a study on

prevalence of of Methicillin - Resistant Staphylococcus Aureus infection among patients

with MRSA. Patients were divided into two Groups; those who were colonized only and

those who were being treated for of Methicillin - Resistant Staphylococcus Aureus infection.

Result – 41 Patients were colonized with MRSA (9 percent of all inpatients) on the day of

study – 22 (54 percent) were Male, 19 (46 percent) Female and the average age were 68.4

years. 13 (32 percent) patients were being treated for MRSA infection of which 7 (17 percent

of MRSA – Colonized patient and 1.5 percent of all inpatients), had definite infection

according to CDS Criteria.

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Clark J., Archibald J., Kearns A., Barnass S. etal (2007) conducted a

study on prevalence of Methicillin -Resistant Staphylococcus Aureus among Staff Nurses at

district general hospital. They included 120 members of Staffs (21 Medical Staff, 54 Nursing

Staff, 11 Health Assistants, 15 Student Nurse, 19 Non-clinical Staff). Result – 10 (8.33

percent) were found to be carrying MRSA. All the isolates were from nursing staff of varying

grade.

R Monina Klevens, Melissa A. Morrison, Joelle Nadle, Susan Petit etal

(2007) conducted a study to describe the incidence and distribution of invasive Methicillin -

Resistant Staphylococcus Aureus disease in 9 US Communities Result – there were 8987

observed cases of invasive Methicillin - Resistant Staphylococcus Aureus reported during the

surveillance period. Most MRSA infection was health care - associated: 5250 (58.21 percent)

were community - onset infection; 1234 (13.70 percent) were community - associated

infection and 114 (1.30 percent) could not be classified. In 2005, the standardized incidence

rate of invasive MRSA was 31.8 per 100,000 (interval estimate, 24.4-35.2). Incidence rate

were highest among 65 year and olders (127.7 per 100,000: interval estimate 92.6 – 156.9).

Murugan S., Mani KR., Uma Devi P (2008) conducted a study about prevalence of

methicillin - resistant staphylococcus aureus among diabetic patients at Arts and Science

College, Coimbatore, Tamilinadu, INDIA. The Result shows that out of 2314 (37.82 percent)

Strains as Staphylococcus aureus isolated from diabetic foot ulcers, 992 (42.86 percent) were

found to be methicillin - resistant.

S. J. Roche, D. Fitzgerald, A. O. Rourke, J. P. Mccabe (2006) conducted

study a on incidence of Methicillin -Resistant Staphylococcus Aureus in an Irish orthopedic

centre, Galway, Ireland, this prospective five - year study analysis the impact of Methicillin -

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Resistant Staphylococcus Aureus on and Irish orthopedic unit. Result – they identified 318

cases of MRSA, representing 0.76 percent of all admissions (41971). A total of 240 (76

percent) cases were colonized with MRSA, while 120 (37.7 percent) were infected. Patients

were admitted from home (218: 68.6 percent), Nursing homes (72: 22.6 percent) and other

hospitals (28 ; 8.8 percent). A total of 115 cases (36.6 percent) were colonized or infected on

admission.

Anbumani N, Wilson Aruni A. Kalyani J., Mallika M. (2006) conducted a

study on prevalence of Methicillin Resistant Staphylococcus Aureus infection and their

antibiotic susceptibility pattern in hospital. Out of a total 805 strains of staphylococcus

aureus isolated from different clinical specimens 250(31 percent) were found to methicillin

resistant.MRSA strains were also multi-drug resistant. Antimicrobial susceptibility studies of

MRSA by disc diffusion methods showed 93 percent of isolates resistant to Gentamycin, 88

percent to Trimethoprim – sulphamethoxazole, 76 percent to Erthromycin and 62 percent to

ciprofloxacin.

Rashmi Yadave (2006) conducted a study showing rising incidence of

community - acquired methicillin -resistant staphylococcus Aureus (CA-MRSA) Muscle

infection. They investigate 45 cases of pyomyositis or myositis. In other wise healthy

children who were hospitalized at Texan children’s hospital from 2000 through 2005. Result

- sixteen out of these cases were caused by CA- Methicillin Resistant Staphylococcus Aureus

and ten by CA-MSSA (methicillin – susceptible staphylococcus aureus). The number of

cases increased year by year, from four cases in the first year of the study to a high of 12

cases in the fifth year of the study.

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Hilmar wispling hoff, Tammy Bischoff, Sandra M. Tallent, Harald

Seifert etal (2004) conducted a concurrent surveillance study to examine the epidemiology

and Microbiology of nosocomial Blood stream infection (BSIs) in united states. There study

detected 24,179 cases of nosocomial BSI in 49 US Hospitals over a 7- year period from

march 1995 through September 2002 (60 cases per 100,000 hospital admissions). 87 percent

of BSIs were monomicrobial. Gram positive organisms caused 65 percent of these BSIs,

Gram Negative caused 25 percent and fungi caused 9.5 percent. The crude Mortality rate was

27 percent. The most common organisms causing BSIs were coagulase. Negative

staphylococci (CoNS) (31 percent of isolates), staphylococcus aureus (20 percent), entero

cocci (9 percent) and candida species (9 percent).

C. C. Tai, A. A. Nirvani, A. Holmes, S. P. R. Hughes (2003) conducted a

prospectively studied the incidence of Methicillin - Resistant Staphylococcus Aureus

colonization and infection in an orthopedic and trauma unit in London, U K. Over 12 months

study period from January to December 2000, they found that 1.60 percent of the total

admission was diagnosed to be either MRSA infected or colonized, with an average of three

new MRSA Cases detected per month. MRSA infection or colonization contributed to an

increase length of hospital stay; 88 days compare to 11 days an average for non – MRSA

patients: 41 percent of the positive patient is still carried on discharge.

S. Anupuraba, M. R. Sen, G. Nath, B. M. Sharma etal (2003) conducted

a study on prevalence of Methicillin -Resistant Staphylococcus Aureus in tertiary referred

hospital in eastern Uttar Pradesh, India. Result out of total 549 strains of staphylococcus

aureus isolated from different clinical specimens 301 (54.85 percent) were found to be

methicillin - resistant. More than 80 percent of MRSA were found to be resistant to

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penicillin, cotrimoxazole, ciproflaxin, gentamicin, 60.50 percent to amikacin and 45 percent

to netilmicin. Many MRSA strains (32.0) were multi-drug resistant.

Saxena S., Singh K., Talwarv (2003) conducted a study to described the

incidence of Methicillin - Resistant Staphylococcus Aureus and carriage of this organism in

health care workers. Recently, even community acquired staphylococcus aureus strains have

shown resistance to Methicillin. Results a total of 319 nasal swabs were taken from both

anterior nares of healthy parents attending a well baby clinic. Of these, 94 yielded growth of

Staphylococcus aureus (29.4 percent). Out of these 94 isolates, 17 (18.10 percent) were

found resistant to oxacillin. These strains showed low level resistance only to clindamycin.

HORCAJADA J, MARCO F. MARTINEZ J, GOMEZ J. etal (2002)

conducted a study on prevalence of Methicillin Resistant Staphylococcus Aureus

colonization at admission in a tertiary hospital. During study period 1,421 patient were

admitted and 932 nasal swab were obtained (65, 5 percent). MRSA was isolated in 27 (2, 9

percent). No cases of MRSA infection were detected in the ward during the study period

(incidence: 0 percent). In the two previous year the number of patient with MRSA infection

in that ward was 7 and 5 respectively (incidence: 43 percent; P<0.05). During the study

period 4 patient with MRSA infection were detected (infection rate: 1, 3 percent).

Blegen, Vaughn and Goode (2001) conducted a study in colorado to

describe the relation between the quality of patient care with education and experience of the

nurse providing that care. Data from 81 inpatient units were collected and result provided

consistent su: Pport for the prevailing belief that nurses with more experience provide high

quality care.

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Richards, Michael J. MB, Edward, Jonathan etal (1999) conducted a study

to describe the epidemiology of nosocomial infection in medical intensive care unit in United

States. They included total 181,933 patients for study. They identified urinary tract infection

were the most frequent (31 percent) followed by pneumonia (27 percent) and primary blood

stream infection (19 percent).

Methicillin - Resistant Staphylococcus Aureus Strains were initially

described in 1961 and have emerged, in the last decade, as one of the most important

nosocomial pathogen, infected and colonized patient provide the primary reservoir and

transmission in mainly through hospital staff. The risk factor which contribute to MRSA, are

excessive antibiotic usages, prolonged hospitalization – especially in intensive care units and

intravascular catheterization. Most strains of MRSA exhibit resistance to both quinolones and

amino glycosides. Hence knowledge of prevalence of Methicillin Resistant.

Staphylococcus Aureus and their antimicrobial sensitivity profile become

necessary in the selection of a: Ppropriate empirical treatment of these infections and there is

in invitro susceptibility pattern of various antimicrobial agents in our hospital, which is

tertiary referred hospital.

6.2 REVIEW OF LITERATURE

The review of available literature was organized under the following headings

Studies related to incidence and prevalence of MRSA Nosocomial

infection.

Studies related to knowledge and practice of staff nurses regarding

MRSA

Nosocomial infection.

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Studies related to prevention of MRSA Nosocomial infection.

Studies related to incidence and Prevalence of MRSA

Supaletchimi Gopal Katherason, Lin Naing kamaruddin Jaalam,

Asma Ismail (2008) conducted a prospective cohort - targeted comprehensive surveillance

study on Nosocomial infection associated with usage of device in three intensive care unit at

Malaysia. In that patients who developed infection outside an ICU were excluded from the

study. The device associated Nosocomial infectionwas 21.1 percent. The mean duration for

development of Nosocomial infection was 10.0 – 7.44 days in ICU. The major device

associated infection were nosocomial pneumonia (18.7 percent) followed by bacteremia (8.5

percent) and urinary tract infection (4.7 percent) respectively. Nosocomial infection

incidence density rate was 20.6 per 1000 patient - day. Bactermia, urinary tract infection and

nosocomial pneumonia (NP) rates were 8.9, 4.7 and 20.5 per 1000 patient – day,

respectively.

Arti tyagi, Arti kapil, Padam sings (2008) conducted a study on incidence

of MRSA at all India institute of Medical Science, New Delhi a tertiary care hospital with

1,200 beds. The prevalence of MRSA is surgical wound infection at AIIMS in 2001-02 was

determined the analysis of 2080 per sample was done Result – A high incidence of

Staphylococcus Aureus was observed. The MRSA prevalence rate was 44 percent of all

staphylococcus aureus isolated. All isolates were sensitive to vancomycin, rifampicin and

teichoplanin.

Arif Maqsood Ali, Shahid Ahmed Abbasi Shezia Arif, Irfan Ali Mirza

etal (2007) conducted a prospective cross sectioned descriptive study to find out the extend

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of MRSA in hospitalized patient in military hospital Rawalpindi. Non - consecutive non-

duplicate clinical isolates of MRSA, isolated from different clinical sample of Pus, Tissues,

Blood, Sputum, Urine. Clinical specimens were cultured on blood and MacConkey agar for

24-48 hours at 37 c. Result - out of 238 non duplicate staphylococcal isolated recovered from

different clinical sample of pus, sputum, urine. One hundred (42.01 percent) were found to

MRSA. MRSA were most frequently isolated from pus, pus swab, blood and urine.

Frazee Bradley W., Dynnjeremy, Charlebois Edwin, Lambert Larry etal

(2005) conducted a study on high prevalence of Methicillin Resistant Staphylococcus Aureus

in emergency department patients with skin of soft tissue infection in urban public hospital in

California, Nares and infection site culture were obtained. Result: of 137 subjects, 18 percent

were homeless, 28 percent injected illicit drugs, 63 percent with deep abscess and 26 required

for admission for the infections. MRSA was present in 51 percent of infection site cultures of

119 staphylococcus aureus isolates, 89 (75 percent) were Methicillin Resistant

Staphylococcus Aureus. 76 percent of MRSA cases fits the clinical definition of community

associated.

Ulrich Seybold, Ekaterina V. Kourbatova, James, G Johnson, Sue. J.

Halvosa etal (2005) conducted a study on community - associated Methicilliin resistant

staphylococcus aureus genotype and its effect on health care - associated blood stream

infection. 132 cases of MRSA BSIs (blood stream infection) were documented over 7.5

months in 2004 (incidence, 6.79 per 1000 admission, 116 isolates were available for

genotyping. : PPGE demonstrated that 39 (34 percent) of the 116 isolated were the MRSA

USA 300 genotype, 34 (29 percent) were USA 100: 42 (36 percent) were USA 500: and 1(1

percent) was USA 800. MRSA USA 300 accounted for 28 percent of health care associated

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BSIs and 20 percent nosocomial MRSA BSIs. Results MRSA USA 300 genotype, the

predominant cause of community - associated MRSA infection, has now emerged as a

significant cause of health - associated and nosocomial blood stream infection.

Kepler A. Davis, Justin J. Stewart, Helen K. Crouch, Christopher E.

Fiorez etal (2004) conducted a study on Methicilliin resistant staphylococcus aureus Nares

colonization at hospital admission and its effect on subsequent MRSA infection. Of

the 758 patients who had cultures of nares samples performed at admission 3.4 percent were

colonized with Methicilliin resistant staphylococcus aureus and 21 percent were colonized

with Methicillin subsequent staphylococcus aureus. A total 19 percent of patient with MRSA

colonization at admission and 25 percent who acquired MRSA colonization during hospital

infection with MRSA, compared with 1.5 percent and 2.0 percent of patients colonized with

MSSA (P<0.01) and uncolonized (P<0.01) respectively, at admission. Result - MRSA

colonization of nares, either present at admission to the hospital or acquired during

hospitalization, increase the risk for MRSA infection.

Po-Ren Hsueh, Lee-jene Teng, wen-Hwei Chen, Mei-Lin chen etal (2003)

conducted a study on prevalence of Methicilliin resistant staphylococcus aureus causing

Nosocomial infection at university hospital in Taiwan0 Result - A rapid emergence of

nosocomial Methicilliin resistant staphylococcus aureus infection (from 26.3 percent in 1986

to 77 percent in 2001) was found. The susceptibility of 200 non-duplicate blood isolates of

MRSA and 100 MRSA isolates causing refractory bactermia.

Eili Klein, Daviel L. Smith, Ramahan Laxminarayan (2007) conducted a

study on hospitalized incidence and mortality caused by Methicilliin resistant staphylococcus

aureus in United States. They used national hospitalization and resistance data to estimate the

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incidence and deaths associated with staphylococcus Aureus and MRSA, from 1999 through

2005. Result - During this period, the estimated number of staphylococcus related

hospitalization increased 62 percent from 294, 570 to 447, 927 and the estimated number of

Methicilliin resistant staphylococcus aureus related hospitalization more than doubled, from

127,036 to 278,203 their finding suggest that Staphylococcus Aureus and Methicilliin

resistant staphylococcus aureus should be considered a national priority for disease control.

Mireya urres, Marti Pons, Marisa Serra, Cristina Latorre (2003)

conducted a prospective incidence study of nosocomial infection in a pediatric intensive care

unit. During the study period 257 patients were admitted; 15.1 percent (39) patient’s bad a

total of 58 nosocomial infection. Result - the study showed that the incidence of nosocomial

infection was 1.5 per 100 patients - days. Patient with cardiac surgery had the highest

nosocomial infection rate.

Review of Literature related to Prevention

Liangsu wang and John F. Barrett (2008) conducted a study to prevent the

Methicilliin resistant staphylococcus aureus infection in hospital setting. To deal with this

problem pathogen and others, infectious disease specialist have developed a variety of

procedure for prevention, involving such as decolonization, isolation of MRSA - patients,

hand washing, Expanding glove use and reducing time in hospital. Result - the study showed

that by using this all preventive measure the incidence of MRSA in reduce.

Tavolacci MP, Ladner J, Bailly L. (2008) conducted a study to prevent a

nosocomial infection and standard precaution among healthcare students at Roven

University. Three hundred fifty students were included in the study. Result - The Study

shows that over all score for infection compact indicates that instruction was effective

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however knowledge level were different by area (the best score were result of test of standard

precaution). Ward training for daily infection compact practice could be improved for health

care students.

Ghanem, Ghazi, Hachem, Ray Y etal (2008) conducted a study on the role

of molecular method in prevention of nosocomial methicillin-resistant staphylococcus aureus

cluster in cancer patient. In thisthe did molecular typing of 70 nosocomial methicillian –

resistant staphylococcus aureus isolated obtained identified a predominant health care-

associated clone A in the first trimester? Aggressive infection control measure led to a

significant decrease in the number of isolates per 10,000 hospital days between the first

trimester and the last two trimester of 2003 (6.4 VS 3.8: P= 0.04). This was attributed to

decrease in clone A.

Stephan Harbarth, Carolina Fankhauser, Jacques Schrenzel, Jan

Christenson etal (2008) conducted a study to use universal screening for Methicilliin

resistant staphylococcus aureus at hospital admission and nosocomial infection in surgical

patients. They included 21,754 surgical patients and used 2 MRSA Control strategies (rapid

screaming on admission plus standard infection control measures vs. standard infection

control alone). The study showed that a universal, rapid MRSA admission screaming strategy

did not reduce nosocomial MRSA infection in surgical department but relatively low rates of

MRSA infections.

Maryam Salaripour, Pet Mckernan, Roslyn Devlin (2006) conducted a

study on A Multidisciplinary a: Pproach to reducing out breaks and Nosocomial MRSA in a

university Affiliated hospital. In multidisciplinary a: Pproaches they used A

Multidisciplinary team for infection control and clinical units determined potential

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contributing factors, education for staff, environmental cleaning and elimination of sources

of infection. The study shows there was 60 percent decrease in nosocomial MRSA between

2000 and 2001 year.

Marilyn Ott RN, Jing Shen and sue Sherwood RN (2005) conducted a

study on evidenced based practice control for MRSA. The study shows that these act. Several

evidence -based study, strategies for controlling of MRSA infection include hand hygiene,

contact isolation and hospital environment hygiene, Aseptic technique.

R. Rinji Kawana , Shigero nagasawa , T. Tadaharu Endo , Yumiko

Fukyroi etal (2002 ) conducted a study on strategy on control of nosocomial infection by a:

Pplication of disinfected such as povidone – iodine . The study shows that anti sepsis with

providen-iodine is useful for the prevention of nosocomial and o: Pportunistic infection.

Pittet, Hugonnet, Harbarth, Mourougs (2002) conducted an observational

survey to find out the effectiveness of hospital wide programme to improve compliance with

hand hygiene in Geneva. They monitored the overall compliance with hand hygiene in

Geneva. They monitored the over all compliance with hand hygiene during routine patient

care before and during implementation of hand hygiene campaign. They observed 20,000 o:

Pportunity for hand hygiene from December 1994 to December 1997. Compliance improved

progressively from 48 percent in 1994 to 66 percent in 1997 during the study period.

Although recourse to hand washing with soap and water remained stable frequency of hand

disinfection substantially increased during study period (P<0.001). Hand hygiene improved

significantly among nurses and nursing assistant.

Flaxman, Lacey, Scales and Wilson (2001) conducted a study to find out

the usefulness of mask in preventing transient carriages of epidemic Methicilliin - resistant

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staphylococcus aureus in 24 nursing and 3 physiotherapy staff on to dedicated EMRS Units

in U K. In the first phase of the study staffs were screened for MRSA carriage immediately

before and after the Period of duty using nose throat and hand swabs. During the second

phase mask were worn by staff, when carrying out procedure associated with significant

EMRA exposure. In the first phase 48.1 percent of staff tested positive for EMRSA

compared to 25.9 percent during the second phase mask were worn. They stated that wearing

of mask by health care workers performing certain activity of EMRSA positive patient may

control EMRSA in hospital environment. The result showed that wearing mask significantly

reduce nasal and throat carriage EMRSA (P<0.05).

Gwenelle M. Vidal – Trecan, Natalie Delamare Jacqueline Lamory,

Francois Baudin (2001) conducted a study of compliance with isolation precaution to

control Multidrug – Resistant Bacterial infection in a paris university. Isolation practices in a

university hospital were analyzed for 137 patients with multidrug resistant bacteria. Isolation

was ordered in writing by physician for 40 percent and instituted by nurses for 60 percent: 74

percent were isolated. Compliance depended on physician order in writing (odds Ratio 36.3:

95 percent confidence interval 4.8 – 274.9). Nurses complied best with hand washing.

David L. Veenstra, Sanjay Saint, Sean D (1999) conducted a study to

estimate the incremental clinical and economic out comes associated with the use of

antiseptic – impregnated vs. Standard catheter. In the base – case analysis, use of antiseptic –

impregnated catheters resulted in a decreased incidence of catheter related Blood stream

infection (CR–BSI) of 2.2 percent (5.2 percent standard vs. 3.0 for antiseptic – impregnated

catheters); a decreased in the incidence of death of 0.33 percent (0.78 percent for standard vs.

0.45 percent for antiseptic – impregnated catheters; a decreases in the cost of $ 196 per

20

catheter used ($ 532 for standard vs. $ 336 for antiseptic – impregnated). The Result shows

that use of antiseptic – impregnated central venous catheter in patient at high risk for

catheter-related infection reduces the incidence. Catheter – related Blood Stream infection

and death and provide significant saying in cost. Used of these catheter comprehensive help

in Nosocomial infection control programme.

Yushi Utetera, Takao Matsumine, Yasuyuki Awane, Etsuko Yamazaki

etal (1998) a conducted a study related to presence of an infection control practitioner (ICP)

affects the results of infection control. Methicilliin resistant staphylococcus aureus

nosocomial infection of the centers of Disease control and prevention in the surgical ward

were retrospective studied in two periods: From February 1989 to January 1990 and from

January 1992 to December 1994. An ICP was present from November 1989 to June 1990 and

from July 1992 to December 1994 and supervised infection control so that the infection

control procedure were uniformly practiced by all staff in the surgical ward. After the a:

Ppointment of the ICP, the infection rate per 100 admission decreased from 3.2 to 1.2

(P<0.05) in the first period and from 1.00 to 0.67 in the second period. The Result showed

that infection rates decreased in the presence an infection control practitioner.

Studies related to Knowledge and Practice among the staff Nurses

Paudya l, priyamvada , Simkhada, Padma (2008 ) conducted a study to

assess the knowledge ,attitude and infection control practices among Nepalese health

worker . A study comprised a questionnaire survey of 324 staff nurses from acute care

hospital in Kathmandu, Nepal. A total of 158 doctors and 166 nurses participated , 27

percent of whom had received infection control training .Only 16 percent ,14 percent and 0.3

percent of respondents achieves maximum score for knowledge , attitude and practice items.

21

Staff had good knowledge and positive attitude towards most aspects of infection control,

although only half ha heard of methicillin – resistant staphylococuus aureus . The study

shows that there should be an o: Pportunity for improvement in current practice.

J B Suchitra , N Lakshmi Devi (2007 ) conducted a study on impact of

education on knowledge , attitude and practice among various categories of health care

worker on nosocomial infection. A total 150 health worker doctor (N= 50), and ward aides

(N=50) were included. A questionnaires was administered to health care workers to assess

there knowledge, attitude and practices on nosocomial infection. Total compliance was 63.3

percent and ward aides were most compliant 76.7 percent (adjusted wold 95 percent

CI=58.80 -80.48) . This results shows that education has a positive impact on retention of

knowledge, attitude and practices in all the categories of staff. There is need to be develop a

system of continuous education for all the categories of staff.

Josely pinto de moura, Elucir, Gir (2007) conducted a study to determine

nurses knowledge of Methicilliin resistant staphylococcus aureus infection and its

prevention. The sample consisted of 42 nursing staff from a medical clinical unit at general

hospital in Minas Gerdis, Brazil. Descriptive statistics were used to analyze and present the

data. The Result showed that lack of knowledge among nursing staff compromise adherence

to preventive measure and nursing Management of Methicilliin resistant staphylococcus

aureus.

M. Askrian, A. Khalooee and N. Nakhaeel (2006) conducted a study to

determine the nurses knowledge regarding hygiene practice and compliance with

recommended instructions for personal hygiene among staff in all 30 hospital affiliated to

Shiraz university of medical science. The result showed that physician and nurses were less

22

compliant with personal hygiene practice than clearness. Measures are needed to improve

health workers compliances.

Elizabeth Jenner and Benfletcher (2006) conducted study on universal

precaution (hand washing) Result 22 percent occasion, staff failed to wash their hand after

contact with Methicilliin resistant staphylococcus aureus patient, increase the risk that it

would be spread to the next patient they touched. So nursing person required adequate

knowledge regarding universal precaution.

Aarti Vij, Swapna N. Williamson, Shakti Gupta (2005) conducted a

study to assess the knowledge and practice of staff nurses on infection control measure and

the relationship between knowledge and practice was carried out in a super so specialty

teaching institute. The result showed the mean knowledge and mean practice of staff nurses

regarding infection control measure to be 73.1 percent and 62.7 percent respectively.

Benneh Glynis, Mansella (2004) conducted a study to explore community

nurses. Knowledge and practice of using universal precautions. A questionnaire survey was

used for this study. The Result shows that community nurses work in unique and

unpredictable environment which may result in a nurse unable to comply with existing

universal precaution guidelines.

Mehrdad Askarian, Ramin Shiraly, Mary – Louise (2005) conducted a

study on knowledge, attitudes and practices of contact precaution among Iranian nurses. Two

hundred seventy nurses, midwives and auxiliary nurses completed a questionnaire consisting

of 8 knowledge items with corresponding attitude and practice item. The result shows that

precaution practices was low, 19.5 percent and little more than half 51.8 percent held positive

attitude towards the guidelines, where as 65.5 percent could correctly answered all precaution

23

knowledge items. Although correct knowledge with compliance and positive attitude, the

proportion of nurses who held positive attitude also had good knowledge, and compliance

with practices was not abundant. Better training coverage may result in compliance with

precaution practices becoming the norm.

Haung, Jiang, Wang, Lio etal (2002) conducted a quasi experimental

study to evaluate the effect of an educational training programmers for 100 randomly

selected hospitals nurses on universal precaution in changsha, China. Questionnaires were

administernary to 100 nurses prior to and 4 months after the training the result showed that

educational training significantly improved Chinese nurses knowledge practice and behavior

related to universal precaution.

Regina, Molassiotis, Eunice, Virene etal (2002) conducted a cross

sectional survey to investigate the nurses knowledge of and compliance with universal

precaution in and acute hospital in Hong Kong. A total of 450 Nurses were randomly

selected from a population of acute care nurses and 306 were successfully recruited in the

study. The study revealed that the nurses knowledge of universal precaution was not only

insufficiently and ina: Ppropriately a: Pplied, but also selectively practiced. Nearly all

respondents knew that used needless should be disposed of in a sharp box after infection.

However, nurses had difficulty in distinguishing between deep body fluids and other general

body secretion that are not considered infections in universal precautions. A high compliance

was reported regarding hand washing, disposal of needle and gloves usage. However, the

uses of other protective wear such as masks or goggles were uncommon.

24

Kim, Chung and Kim etal (2001) conducted a survey to identify knowledge and

performance of universal precaution by nursing and medical students in corea. The

questionnaire was administered to a total of 714 nursing and medical students for the period

between 02, November 1998 and 30, April 2002. The result showed that the knowledge level

of the universal precaution of the nursing students (270.4 + 19.4) was higher than that of the

medical students (261+24.4). The average performance level of the universal precaution was

52.7+6.2.

Blegen, Vaughn and Gode (2001) conducted a study at Colorado to

describe the relationship between the quality of patient care with the education and

experience of the nurses providing that care. Data from 81 inpatient units were colleted and

the result provided consistent su: Pport for the prevailing belief that nurses with more

experience provides high quality care.

Baso (1995) conducted a study in two Govt. Hospital of Delhi found out that

the nursing personnel’s knowledge of hospital acquired infection and universal precaution

was inadequate.

I. F. Angelillo, A. Mazziotta and G. Nicotera (1998-having doubt)

conducted a study to examine the disinfection and sterilization practices used by hospital

operating theatres and evaluated the knowledge, attitude and behavior of nursing staff with

regard to infection control. Of 216 nurses responding, knowledge concerning such practices

was not consist since 10 percent did not believed that items should be rinsed in water after

contact with glutaraldehyde and more than 25 percent thoughts that 10 minutes contact time

provided sterilization. The Result shows that nurses in orthopedic surgery had a significant

lower level of knowledge compare with others.

25

Mark friedewald and Carolyn Elwin conducted a study on knowledge vs.

practice for new graduate nurses in infection control. Central coast health (CCH), Australia

comprises four campuses with a total number of bed in excess of 700 and has teaching

affiliation with the university of Newcastle. A number of sub-optimal infection control

practice (IC) by new graduate nurse has been reported across time and cohorts from a variety

of clinical sources. Educational strategies were utilized in an attempt to improve Infection

control practice. The result shows that while knowledge level remained relatively unchanged

following educational intervention, the actual practice of Infection Control Principles in the

clinical setting was improved.

G.R.Lugg, H.A.Ahmed conducted a study to explore the perception and

understanding of Methicilliin resistant staphylococcus aureus infections among adults and

children’s nurses. A cross sectional survey with a purposive sample was used. Adults and

children’s nurses (n=144) knowledge and self reported practices were studied. Adults nurses

scored significantly higher on knowledge (P=0.001) and self-reported practice (P=0.001)

than did children’s nurses. The result shows that Adult Nurses in this sample have higher

knowledge and self – reported practice than children nurses with regard to Methicilliin

resistant staphylococcus aureus.

6.3 STATEMENT OF THE PROBLEM

EFFECTIVENESS OF STRUCTURAL TEACHING PROGRAMME (STP) ON

PREVENTION AND CONTROL OF METHICILLIN–RESISTANT STAPHYLOCOCCUS

AUREUS IN TERM OF KNOWLEDGE AND PRACTICE AMONG STAFF NURSES OF

SELECTED HOSPITAL AT BANGALORE.

26

6.4 OBJECTIVES OF STUDY

1. To determine the level of knowledge of staff nurses

regarding MRSA Nosocomial infection.

2. To identify the skill of staff nurses regarding MRSA

Nosocomial infection.

3. To find out the effectiveness of structured teaching

programme (STP) on MRSA Nosocomial infection in terms of knowledge and skill

among staff nurses.

4. To find out the relationship between the following.

Pre- test knowledge score and pre- test skill scores.

Post- test knowledge score and post -test skill

scores.

5. To find the association between the following.

Post- test knowledge score and year of experience of the staff nurses.

Post- test skill score and year of experience of the staff nurses.

6.4 HYPOTHESIS

All hypotheses will be tested at 0.05 level of significance.

H1. Mean post- test knowledge score of staff nurse who received structured teaching

programme (STP) regarding MRSA Nosocomial infection will be significantly higher

than the mean pre- test knowledge score.

H2 Mean post- test skill score of staff nurse who received structured teaching programme

(STP) regarding MRSA Nosocomial infection will be higher than the mean pre- test

skill score.

H3 a. There will be a significant relationship between pre- test knowledge score and pre-

test skill score among staff nurses, who received STP regarding MRSA Nosocomial

infection.

27

b. There will be a significant relationship between post- test knowledge score and

post -test skill score among staff nurses, who received STP regarding MRSA

Nosocomial infection.

H4 a. There will be a significant association between post- test knowledge score and

selected demographic variables among staff nurses who revived structured teaching

programme (STP) MRSA Nosocomial infection.

b. There will be a significant association between post- test skill score and selected

demographic variables among staff nurses who received structured teaching

programme (STP) on MRSA Nosocomial infection.

6.7 OPERATIONAL DEFINITION OF TERMS

STP- Structured Teaching Programme : It refers to well planned teaching

material regarding MRSA Nosocomial infection given through lecture and discussion. It

will be here after referred as STP.

Prevention : It refers to action taken to stop methicilllin-resistant staphylococcus

aureus infection.

Control : It refers to action taken to limit the occurrence of new cases of MRSA

infection.

MRSA Nosocomial Infection : This refers to the pathogenic bacteria from the

Staphylococcus Aureus groups which resistant to antibiotics such as Methicillin,

Cephalsprin, and penicillin and especially troublesome in Nosocomial infection

Infection: It refers to the entry, lodgement and multiplication of an infectious agent

in the tissue of a host.

Nosocomial infection: Its refers to the infection which is acquired from hospital

setup.

Knowledge : It refers to the written responses of staff nurse regarding MRSA-

Nosocomial infection as measured by knowledge questionnaire.

28

Skill : Activities carried out by nursing personnel’s as a part of there care in relation

to preventive and control of MRSA infection in the hospital measured by observation

check list.

Staff Nurses : In this study it refers to those who have completed diploma in

nursing and Midwifery and who engaged in direct patient care.

Hospital : It refers to private general hospitals at Bangalore.

6.8 ASSUMPTIONS :

The study is based on the assumption.

Knowledge influence behavior.

Negligence leads to complications.

Nurses play vital role in control and

prevention of nosocomial infection.

Prevention is better than cure,

nosocomial infections are preventable if proper steps are taken at right time, place

and by following right techniques.

6.9 DELIMITATION

Study is delimited to

Staff nurses who have completed general Nursing and Midwifery.

Staff nurses who are engaged in direct patient care.

Staff nurses working in private hospitals, at Bangalore.

7. MATERIALS AND METHODS

7.1 SOURCES OF DATA: Staff nurse working in selected private hospitals, at Bangalore.

METHODS OF COLLECTION OF DATA.

Research Method : Evaluation a: Pproach.

29

Research Design : One group pre test post test design.

Sampling Technique : Purposive sampling

Sample Size : 40 Staff nurses

Setting of the Study : Study will be conducted at selected private hospitals at

Bangalore.

7.2 1 CRITERIA FOR SELECTION OF SAMPLE

Sample will be selected based on the following inclusion and exclusion criteria.

INCLUSION CRITERIA

Staff nurses who have complete

general Nursing and Midwifery.

Staff nurses of both sexes.

Staff nurses between 21 - 40 years.

Staff nurses who willing to participate in the research study.

EXCLUSION CRITERIA

Staff nurses who are engaged in admistrative

work such as ward sister, Nursing supervisor and superintendent.

Staff nurses of other categories like ANM,

Trained workers, Degree holders.

Staff nurses who are not willing to

participate.

7.2.2. DATA COLLECTION TOOL

Tool I: - A structured knowledge questionnaire will be prepared to determine the

knowledge of staff nurse regarding MRSA Nosocomial infection.

Tool II: - An observation check list will be prepared to find the skill of staff nurses regarding

30

prevention of MRSA Nosocomial infection in health education to MRSA

Nosocomial infection.

7.2.3 DATA ANALYSIS METHOD

Descriptive and Statistical analysis will be done for data analysis procedure.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR

INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER

HUMAN OR ANIMALS?

YES, The study requires intervention in the form of a structured teaching

programme ,no other interventions which cause any physical harm will not be done

for the subject.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED?

YES.

1. Confidentiality and anonymity of the subject will be maintained

2. A written permission from institutional authority will be obtained.

31

8. LIST OF REFERENCES

1. B T Basvantha: Ppa “Fundamental of Nursing” Jaypee brother publication

LTD New Delhi : Pp 140-150.

2. Brunner and Suddarth’s “Test Book of Medical Surgical Nursing” 10th edn. Philadelphia

Li: Ppincot. : Pp. 2122-2125.

3. Barbar Kozier ‘Fundamental of Nursing’ 7th edn India: Pp 668 – 674.

4. Brunner and Suddarth’s “Text Book of Medical Surgical Nursing” 9th edn Philadelphia

Li: Ppincot : Pp 1876 – 1879.

5. Dr. Santhosh V. “Essentials of Medical Micro Biology” G S Publication Ltd. Bangalore:

Pp 75-77.

6. Gaylene Bouska Althman “Fundamental and Advanced Nursing Skills” : Pp 144-150

7. Harkness Dinchee “Medical Surgical nursing “10th edn : Pp 327-349.

8. Hi: Pps “shafer’s Medical surgical nursing “7th edn. B.I. PublicationPVT LTD

New Delhi. : Pp 164-166.

9. Joyce M Black”Medical surgical Nursing “7th edn. Thomson press LTD: Pp421-431.

10. Lakhwinder Kaur “A Text Book of Nursing Foundation “: Pp 410-414.

32

11. O.P. Ghai “Essential pediatrics ‘6TH edn.O.P.Ghai Publisher Delhi: Pp 668-669.

12. Potter –Peery”Fundamental of Nursing” 6th edn. Missouri Mosby: Pp779-780.

13. R.Ananthanarayan “Text Book of Micro Biology”6th edn Orient Longman Private

Limited: Pp178-186.

14. R L Ichhpujaani “MicroBiology For Nurses “2nd edn.Jaypee Brother .New Delhi:

Pp 49-59.

15. Surensen and Luckmann’s “Basic Nursing”3rd edn : Pp 511-512.

16. V.S. Jayaram”Medical Microbiology for Nurses “1st edn. Gajanuna Book Publishers.

Banglore : Pp 91-93.

17. Anbumani N. Wilson Aruni A. Kalyani J. Mallika M.Prevelence of MRSA in a Tertiary

Referral Hospital in Chennai. South India .India Journals For Practicing Doctors .

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to MRSA in Hospital patients .Pakistan Journals Of Medical Science .

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19. Arti Vij. Swapna .N.Williamson.Shakti Gupta .Knowledge and practice of Nursing staff

towards infection control measure in a tertiary care hospital .Journal of the academy

of hospital administration.Vol 13

20. Benntt Glynis . Mansell .Lan .universal precautions a survey of community Nurses

experience and practice . Journal of clinical nurses. 2004: Pp 413-421.

21. C.C.Tai . A.A. nirvana . A. Halmes and S.P. F. Hughes . Incidence and prevalence of

MRSA. Journals of international Orthopaedics. : Pp 1432-6195.

22. David L. Veenstra. Sanjaysaint.Sean D. Sullivan etal..Cost effectiveness of antiseptic-

impregnated central venous catheter for the prevention of catheter relation blood

33

stream infection .Jama .1999: Pp 554-560

23. EiliKlein. David L. Smith. Ramanan Laxminarayan. Hospitalizations and deaths caused

by MRSA .United States .EID Journal home

24. Frazee Brales. Lynn Jeremy. Charlebols Edwin. High prevelance of MRSA in emergency

department skin and soft tissue infection. Ann Emergency medical Journals. 2005 :

Pp 311-322.

25. Gwenaelle M.Vidal-Trecan . Natalie Delamare etal. Multi-Resistant Bacterial infection

control.Journals infection control Hospital Epidemology.2001. : Pp 109-111.

26. H.A. Ahmed. Nurses perception of MRSA:impact on practice. British Journals of

infection control .Vol 9. 2008.

27. Hilmar Wisplinghoffr. Tammy Bischoff .Sandra M.Tallent.nosocomial blood stream

infection in US hospitals. Journals of clinical infection diseases.2004. : Pp 303-317.

28. I.F. Angelillo. A. Mazziotta and G.Nicotera etal . Nurses and hospital infection control:

knowledge. attitude and behavior of Italian operating theatre. journals of hospital.

Vol 42. : Pp 105-112.

29. JB Suchitra .N Lakshmi Devi .Impact of education on Knowledge . attitudes and

practices among various categories of health care worker on nosocomial infection.

Indian Journal medical microbiology. Vol-25. : Pp181-187.

30. Kepler A. Davis. Justin J. Stewart. Helen K Crouch etal. MRSA Nares colonization at

hospital admission and its effect on subsequent MRSA infection. journals of clinical

infection Disease. : Pp776-782.

31. Marilyn Ott. Jing Shen. Sue Sherwood etal . Evidence-based practice for control of

34

MRSA. AORN .Vol 81.2005. : Pp 359-372.

32. Mark Friedewold and Carolyn Elwin. New graduate nurses and infection

control.:knowledge versus practice. Journals of Australian infection control :

Pp 21-27.

33. Mireya Urrea. Marti Pons . Marisa Serra etal . Prospective incidence study of nosocomial

infection in a pediatric intensive care unit. pediatric infection disease journals.

34. M. Nixon. B. Jackson. P. Varghese et al. Incidence. spread. mortality. cost and control.

British Journals of bone and joints surgery. : Pp 812-817.

35. Murugan S . Mani K R . Uma Devu. Prevalence of MRSA among Diabetes patients with

foot ulsers and their antimicrobial susceptibility pattern. Journals of clinical and

Diagnostic Rrsearch. : Pp 979-984.

36. M Mathur. S Taklikar. S Sarkar . D D’ Souza . A four Year audit of MRSA in a tertiary

care hospital. Indian Journals of medical micro biology. : Pp 97984.

37. M. Askarian. A. Khalooee.. N.Nakhaee . Personnel hygiene and safety of governmental

hospital staff in Shiraz. Eastern Mediterranean Health Journal. Vol 12. NO 6. 2006.

38. Mehrdad Asjarian . Raminly Shiraly. Mary- Louise.Knowledge . Attitudes and practices

of contact precaution among Iranian nurses . Journals of infection central hospital

Epidemology .Vol-26. 2005. : Pp 105-108.

39. Maryam Salaripour. Pat McKernan . Roslyn Devlin. Multidisciplinary A: Pproach to

reducing out break and nosocomial MRSA in a university-affiliated hospital. Journals

of health care.2006. Vol 6. : Pp 54-68.

40. Po- Ren Hsueh. Lee- Jene Teng . Wen- Hweichen etal .Increasing prevalence of MRSA

35

causing Nosocomial infection at a university hospital in Taiwan. Antimicrobial Agent

And Chemotheraphy.2004. : Pp 1361-1364.

41. Paudyal. Priyamvada.Simkhada etal . Infection control knowledge. Attitude. and Practice

among Nepalese health workers. American journals of Infection Control. Vol-36.

and : Pp 595-597.

42. Richards. Michael J.. Edward. Jonathan. David. Nosocomial infection in medical

intensive care units in United States . Critical Care Medicine . : Pp 1999-2005.

43. R. Rinji Kawana. Shigeru Nagasawa . T. Tadaharu Endo etal . Strategy of control of

Nosocomial infections :A: Pplication of Disinfectants such as Providence- Iodine.

Dermatology.2002. : Pp 28-31.

44. Saxena S . Singh K. Talwar V. MRSA prevalence in community in the East Delhi Area .

JPN Journals of infectious Disease. 2003. : Pp. 54-56.

45. S.J. Roche. D. Fitzgerald . A. Orourke and J. P. McCabe etal. MRSA is an Irish

orthopedic centre 2006.British Journals of Bone and Joints Surgery. Vol 88. :

Pp 807-811.

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referral hospital in Eastern Uttar Pradesh . Indian Journals of Medical Biology2003 :

Pp 49-51.

47. Supaletchimi Gopal Katheresen. Lin Naing. Asma Ismail. Kamaruddin. Baseline

assessment of intensive care- acquired nosocomial infection Surveillance in three

adult intensive care units in Malaysia. Journals of infection Developing Countries.

2008. : Pp 364-368

48. Stephan Harbarth . Carolina Fankhauser . Jacques Schrenzes etal. Universal screening

36

for MRSA at hospital admission and nosocomial infection in surgical patients. Jama

2008. : Pp 1149-1157.

49. Tavolacci M P. Ladner J. Bailly L. Prevention of nosocomial infection and standard

precaution: knowledge and sourses of information among health care students.

Journals of infection control hospital Epidemiology. : Pp 642-647.

50. Ulrich Seybold. Ekaterina V. Kourbatova. James G. Johnson. SUE J. Halvosa etal.

Emergence of Community – Associated MRSA USA300 Genotype as a major cause

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ELECTRONIC MEDIA

1. www. Google.com.

2. www. Pubmed.com.

3. www. Nursingtimes.com.

4. www. Oxfordjournal.com.

5. www. Indiadaily.com.

37

9. SIGNTURE OF THE CANDIDATE: AAKASH CHAVDA

10. REMARKS OF GUIDE : Good

11. NAME AND DESIGN.

11.1 GUIDE : MRS. VANMATHI T, Prof

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT : MRS. VANMATHI T, Prof

11.6 SIGNATURE

38

12 12.1 REMARKS OF THE PRINCIPAL : Good

12.2 SIGNATURE

39