INTRODUCTION:

Globally 2.5 million neonatal mortality was recorded in 2017 accounts to 47% of all under-five mortality that has increased by 7% in 27 years¹. Each year nearly 0.748 million new-born deaths occur in India, contributing to 26% or 1/3rd of the world’s neonatal death².

Indian Neonatal Mortality Rate (NMR) is diversified, ranges from 7 to >30 per 1000 live births³. According to one of the report dominating cause of neonatal deaths are preterm, birth asphyxia, pneumonia, sepsis and other causes⁴. These are also the primary reasons for the Intensive Care Unit (ICU) admission and development of healthcare-associated infections (HAIs)⁵. The rate of HAIs reported by World Health Organization (WHO) in South Asian countries ranges from 11.3-23.6%. More than 1/3rd of neonatal mortality is due to neonatal infections that are preventable⁶. To accelerate the preventable cause of neonatal mortality, it requires to identify and take actions to improve the condition². Indian studies have reported bloodstream HAIs, Ocular infection (Healthcare-associated conjunctivitis), urinary tract infection and skin infection among neonates^7–13.

A prospective study in Neonatal ICU, carried out at Iran, for one year, showed growth of gram-negative bacteria like E-coli, Klebsiella and Pseudomonas. Studies have also shown growth of gram-negative pathogens and coagulase-negative staphylococci with resistance patterns in Neonatal ICU causing HAIs^14,15. Neonates admitted to NICU in Italy, on a cardiopulmonary supportive device like ventilator, central line, umbilical catheter, were carrying the varied class of pathogens, i.e. P. aeruginosa, C. parapsilosis, E. coli, as a predominant pathogen. Whereas, less dominant but more fatal pathogens were C. albicans, Non-Extended Spectrum Beta-Lactamase (ESBL) K. pneumoniae, and Coagulase-Negative staphylococci¹⁶. The reported microorganisms by various studies from India are Escherichia coli, Malassezia species, MSSA/ MRSA bacteraemia, Pseudomonas species, Enterobacter species, Acinetobacter species, Candida tropicalis, C. albicans, and C. guillermondii^10–13,17. These spectra of microorganism from India is not the same as the rest of the world. The listing out of preventable risk factors from India becomes essential to target and enact upon^18,19. Duration of ventilator care, presence of central line, water source, contaminated IV infusions, poor hand hygiene are few listed risk factors reported in various studies from India^9,20–22.

There are various reasons and preventable risk factors attributing to neonatal HAIs that are reported for the different microorganism in India. Hence, the systematic review is being carried out to critically “appraise” the quality of the study, “categorise” the identified risk factors and “consolidate” the preventable risk factors associated with neonatal HAIs in India.

MATERIALS AND METHODS:

Operational Definitions:

Neonatal Healthcare-Associated Infections:

It is defined as any systemic or localised infection developed after 48hrs of admission to Neonatal Intensive Care Unit (NICU)²³. This will include Surgical Site Infection (SSI), Urinary Tract Infection (UTI), Blood Stream Infections (BSI), Lower Respiratory Tract Infection (LRTI)/pneumonia, Upper Respiratory Tract Infection (URTI), Line related Infections (LRI), Conjunctivitis/Ocular infection, Osteoarthritis, Endocarditis, Central Line-Associated Blood Stream Infection (CLABSI), Skin Infection, Infections affecting central nervous system, Gastrointestinal infections, and others as adapted from the definition of CDC and WHO^23,24.

India: All the states the Union Territories of India.

Infrastructure: It includes the location in a hospital, number of beds, number of healthcare workers, built environment and spacing between the beds.

Health system: Protocol or policy related to neonatal care, the kind and type of equipment, facilities, transportation method and consumable/pharmaceuticals storage method.

The following methodology will be used for the studies to be included in the review for screening and analysis.

Types of studies:

The studies reporting risk factors and determinants for Neonatal Healthcare-Associated Infections. Reporting of the outbreak/surveillance/riskfactor/determinants reporting nosocomial or cross-infection or HAIs, among neonate using CDC or WHO driven diagnostic criteria confirming health-care-associated infections (HAIs). Preferably published articles in the English language will be included. Publication period 1st July 1997 to 30 June 2017.

Inclusion criteria(s):

a) Analytical studies like Cohort studies or Case-Control studies or analytical cross-sectional studies or interventional studies where pre-intervention characteristics, including risk factors that are analysed and described for preterm or term neonates <28days of life.

b) Descriptive studies like ecological studies, descriptive cross-sectional studies or case series. Fact sheets/ Reports/ secondary data reporting quantitative analysis on risk factors associated with neonatal HAIs among preterm or term neonates <28days of life. Location of each study must be India

Exclusion Criteria: The following types of studies will be excluded:

· Letter to the editor, editorial, interventional studies without analysis and description of the risk factors before the intervention, commentaries, media reports,

· All types of review or meta-analysis,

· Qualitative research and conference proceeding or papers.

· Studies describing the early-onset infection, or neonate with a congenital malformation, or comorbid illnesses like retroviral positive will be excluded from the review.

Type of Population:

The population must include preterm and or term neonates <28 days of life from India. Risk reporting among neonates acquiring HAIs, if done, in any of the study reporting adult, children or infant. We will include neonatal studies describing only late-onset nosocomial infections. However, we will include any research if late-onset infections among neonates are described and analysed separately.

We will not consider studies including Infant (child age >28 days to < 1 year), or Children (Child age >1 year to <12 years) unless the risk factors associated with neonates are described and analysed separately.

Type of Intervention (s) or Exposure (s):

Studies must include a group diagnosed with healthcare-associated infections among neonate as per the diagnostic criteria of CDC or WHO. The neonate has to get healthcare services exposure for >48 hrs. Only late-onset infection shall be considered for inclusion. Exposure also includes the risk factors like preterm birth, low birth weight, presence of venous lines, invasive procedures, gestational age, birth weight, breast milk vs formula feeds, IV lines, Invasive/Non-invasive ventilation, early antibiotic therapy^25–29. In the comparator group, we may find a PICC line versus central line or IV line similarly, and we may find non-invasive ventilation versus invasive ventilation.

Type of Comparator(s)/Control:

Analytical studies may have a comparator group without systemic infection or neonate admitted to the ward. The studies can be a cohort study or cross-sectional study without a comparator that will be considered to be included in the review.

Type of Outcome(s) measures:

Outcomes will be of two categories related to risk factors of neonatal HAIs and spectrum of microorganism, causing neonatal HAIs (Table 1):

The primary findings of the review will be:

· Risk factors related to HAIs leading to septicemia in general

· Disease-specific risk factors like meningitis, pneumonia, Urinary Tract Infection (UTI), necrotizing enterocolitis (NEC), etc. Secondary outcomes will be:

· The microbiological spectrum of neonatal HAIs among the states or union territories of India.

· The healthcare practices contributing to the development of neonatal healthcare-associated infections in India.

Table 1: Planned anticipated the type of outcome measures

Outcome	Outcome Measures
A. Risk factors of neonatal HAIs
Patient-Related	Incidence/ prevalence of patient-related risk factors (e.g. immunocompromised, very low/ low birth weight, small for gestational age, preterm or very preterm delivery or different clinical conditions requiring interventions), and measures of association of patient associated risk factors with neonatal HAIs (e.g. risk ratio/odds ratio).
Healthcare worker practices	Incidence/prevalence of healthcare worker practices (e. g. Hand washing practices, housekeeping practices, and aseptic procedure-related practices) and measure of association between healthcare worker practices, and neonatal HAIs.
Infrastructure/ health system	Incidence/prevalence of Infrastructure/ health system (e. g. built environment, transport, HVAC system, space between cradles, location of hand wash basin etc.) and measure of association between Infrastructures/ health system and neonatal HAIs.
Maternal practices	Incidence/prevalence of maternal practices (e.g. Maternal bathing, hand washing, maternal infection, etc.) and measure of association between maternal practices and neonatal HAIs.
B. Spectrum of Microorganism
The spectrum of Microorganism in states and Union territories of India	Incidence/prevalence of microorganism spectrum (e.g. Incidence/prevalence of Acinetobacter baumanii in Coastal regions of Karnataka, E. coli prevalence in Delhi.)
Type of HAIs	Incidence/prevalence in the kind of neonatal HAIs (e.g. Prevalence of CLABSI, VAP, SSI, BSI in India at different states or union territories.)

Data Sources and search methods for identification of studies:

Electronic search on PubMed, Scopus, Web of Science, CINAHL, Ovid MedLine, POPLINE, and Google Scholar whose results will be sorted as per relevance, and first 100 retrieved articles sorted for its relevance to the keywords will be screened. We will perform back-referencing (reference list of obtained articles) for the articles to examine the potentiality to include in the current study.

Search Strategy:

We will build a comprehensive search strategy using the guidelines of the Center for Reviews and Dissemination’s (CRD), using scientific databases providing indexing to most of the journals. The search strategy will specify free text, and key terms related to neonatal HAIs such as: ‘neonate’, ‘cross-infection’, and ‘India’ (Table 2). We will use database subject headings, medical subject heading (MeSH) and free terms for the search. We will use the following key terms for developing the search strategy: ‘neonate,' ‘cross infections,' ‘infections’ and ‘India’.' The search strategy will be accompanied by the abbreviations like VAP, UTI, CLABSI, BSI, NEC and SSI. We will use the Boolean operator ‘AND’ to combine the words within these each domain followed by each main domain by adding another Boolean operator ‘OR.' This search is restricted to Human, India, studies published in the last twenty years and to English language only. Unavailability of the country-specific filter will give rise to adding India, Indian states, Indian union territories in the search domain to each search strategy. The studies from all the states or territories of India shall be considered. Publication period 1st July 1997 to 30 June 2017.

Table 2: Sample search strategy for the search engine ‘Pub Med’.

(sepsis) OR (Pneumonia*) OR (Pneumon*) OR (Catheter related infection) OR (Line related infection)OR ("hospital acquired pneumonia") OR ("nosocomial pneumonia") OR ("ventilator associated pneumonia") OR (catheter associated infection) OR ("late onset pneumonia") OR ("infective pneumonia") OR ("infectious pneumonia") OR (ventilator associated pneumonia) OR (device associated infection) OR (healthcare associated infection) OR (sepsis*) OR ("acute respiratory infections") OR (ocular infection) OR (eye infection) OR (conjunctivitis) OR ("late onset sepsis") OR (infection*) OR ("nosocomial infection") OR (central nervous system infection) OR ("late onset infection") OR ("acute lower respiratory infection") OR ("hospital acquired infection") OR (unknown site infection) OR (CLABSI) OR (BSI) OR ("central-line-associated bloodstream infection") OR (CLABSI) OR (bloodstream infection) OR (skin infection) OR (gastritis) OR (meningitis) OR (VAP) OR (surgical site infection) OR (SSI) OR (UTI) OR (urinary tract infection)OR (osteomyelitis) OR (arthritis) OR (conjunctivitis))) OR sepsis [MeSH Terms]) OR pneumonia, ventilator associated [MeSH Terms]) OR infection, catheter related [MeSH Terms]) OR eye infection [MeSH Terms]) OR central nervous system infection [MeSH Terms]) OR urinary tract infection [MeSH Terms]) OR osteomyelitis [MeSH Terms]) OR arthritis [MeSH Terms]) OR skin infection [MeSH Terms])

("Risk factor") OR (determinant*) OR (risk*) OR (predictor*) OR ("relative risk") OR ("odds ratio") OR ("attributable risk") OR ("population attributable fraction")))) OR risk factor [MeSH Terms]) OR risk factors [MeSH Terms]) OR epidemiologic determinants [MeSH Terms]) OR attributable risk [MeSH Terms])

(neonate) OR (neonat*) OR (newborn) OR (newborn*) OR ("young infant") OR (infant*))) OR neonate [MeSH Terms]) OR neonates [MeSH Terms]) OR newborn [MeSH Terms])

((India) OR (Jammu) OR (Kashmir) OR (Himachal Pradesh) OR (Uttaranchal) OR (Uttarakhand) OR (Punjab) OR (Haryana) OR (Delhi) OR (National Capital Region) OR (NCR) OR (Uttar Pradesh) OR (Bihar) OR (Jharkhand) OR (Madhya Pradesh) OR (Chhattisgarh) OR (Rajasthan) OR (Bengal) OR (Gujarat) OR (Maharashtra) OR (Goa) OR (Orissa) OR (Odisha) OR (Karnataka) OR (Telangana) OR (Andhra Pradesh) OR (Kerala) OR (Tamil Nadu) OR (Arunachal Pradesh) OR (Meghalaya) OR (Assam) OR (Nagaland) OR (Manipur) OR (Tripura) OR (Mizoram) OR (Sikkim) OR (Chandigarh) OR (Lakshadweep) OR (Andaman) OR (Nicobar) OR (Daman) OR (Diu) OR (Dadra) OR (Nagar Haveli) OR (Puducherry) OR (Pondicherry))

(1 AND 2 AND 3 AND 4)

Data Collection and Management:

To manage search results and to remove duplicates Endnote x7 will be used. Microsoft Excel will be used for study selection and data extraction.

Study Selection:

Two independent researchers (UR and MS) considering the inclusion and exclusion criteria for selection will review each article in the three-stage process of title, abstract and full-text screening. We will follow the below-mentioned process for the selection of the articles:

Stage 1: Title Screening: Two independent authors (UR and MS) will move the article to stage 2 if either of the authors select the article based on its title will be included for further review. However, irrelevant articles will be removed from further screening. If any article found to be uncertain for inclusion, then the third author (LE) will finally decide to retain or eliminate the article’s progression. Articles rejected by both the authors shall not be considered for further screening.

Stage 2: Abstract Screening: Two independent authors (UR and MS) will screen the abstracts for inclusion in the review. We will move the abstract to stage 3 if either of the authors finds it suitable for inclusion in the review. We will exclude the abstracts rejected by both the authors. However, if either of the authors finds the article uncertain to consider or not, then the third author (LE) will finally decide to retain or eliminate the study progression.

Stage 3: Full-text Screening: We will obtain the full text(s) of the studies selected in stage 2 for review. In this stage, two independent authors (UR and MS) must accept the study for inclusion. If anyone of the authors does not accept the study for inclusion, we will move the study to the third author (LE) for the final decision; such study shall be included in all three authors mutually after discussion agrees for its inclusion. We will exclude the study rejected by both the authors.

We will prepare a final list of included articles for data extraction. Two independent authors (UR and MS) will extract the data from a standardised, pretested data extraction form. A senior author (LE) will resolve any disagreement mutual discussion, understanding, and consensus among the authors. The selected studies will be further classified as “types of studies”.

Data Extraction:

Data extraction will be done in standard pilot-tested Microsoft excel sheet by two authors (UR and MS) independently for analysis to ensure agreement and to eliminate errors. The review will be done by the third author (KC) extract the data under the following categories and the characteristics (List is not exhaustive):

· Study characteristics: Last name, First name of authors; Year of publication; publication journal; issue, volume and page number.

· Study description: aims and objective, study setting, study design, recruitment procedure, inclusion and exclusion criteria, length of follow-up, etc.

· Participant description: baseline characteristics, target population, the process of case identification of HAIs, etc.

· Statistical data/ reported result: risk factors, Odds ration or relative risk, statistical techniques used, direction and magnitude of association, confounding factors adjusted for precision, etc.

Disagreement will be resolved by a senior author (LE) through discussion and consensus. However, if any disagreement remains, unresolved will be reported separately in the final review. A separate data extraction form will be used; it is a sample data extraction form original data extraction form might be varied, as shown below (Table 3).

Table 3: Sample data extraction form for selected articles in stage 3 of full-text screening

S. No	Items Category	Subitems	Notes
1.	Study characteristics	Last name, First name of authors; Year of publication; publication journal; issue, volume and page number, Study ID
2.	Eligibility	Eligibility decision
3.	Study description	Aims and objective, Study setting, Study design, Total study duration, Sample size, Sample size calculation, Recruitment procedure, Inclusion and exclusion criteria, Length of follow-up, etc
4.	Participant description	Baseline characteristics, Target population, Process of identification of HAIs, Gender, State or Union Territory, Ethnicity, etc.
5.	Data collection methods	Time-motion study, observation, records, databases, interview, etc.
6.	Disease Characteristics	Diagnostic criteria as per CDC or WHO.
7.	Type of HAIs Identified	SSI, CLABSI, VAP, BSI, UTI, Skin, etc
8.	Microorganism Identified	Klebsiella pneumonia, Acinetobacter baumannii, E. coli, Pseudomonas aeruginosa etc.
9.	Outcome	Mortality rate, Morbidity rate, Loss to follow up.
10.	Statistical data/ result	Risk factors, statistical techniques used, classification, direction magnitude of association confounding factors adjusted for precision etc.
11.	Reviewer comments	Correspondence required Miscellaneous comments by review authors

Risk of bias (RoB) assessment:

Two authors (UR and MS) will independently assess the risk of bias among the included studies and will be reviewed by the third author (KC). We will follow the following quality assessment tool/ scale for the various study designs:

· Case-Control - Quality Assessment of Case-Control Studies, NIH, National heart, lung and blood institute^30–32^.

· Cohort and Cross-sectional studies - Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, NIH, National heart, lung and blood institute^30–32.

· Interventional studies – Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group by NIH, National heart, lung and blood institute^30–32.

· Case Series - The Quality Assessment Tool for Case Series Studies by NIH, National heart, lung and blood institute^30–32.

The author will request additional information from the study author to clarify methodology or results if needed. The effort will be made to use “Grading of Recommendations Assessment, Development, and Evaluation” (GRADE) approach³³. The author will try to make summary of findings tables, choosing comparison and outcomes for summary of findings, assessing the risk of bias, and grading the evidence obtained by various articles. An effort to assess publication bias will also be made.

Data analysis and synthesis:

We anticipate that all our outcome measures are dichotomous; we will capture and report relative risk (RR) as the effect measure. We will use frequency or percentage tables and or graphs for narratively synthesised data such as study setting, the design of the study, exposure and or outcomes measured. We will summarise the risk factors along with a quality assessment of the studies. If we obtain data suitable for meta-analysis, we will perform meta-analysis by inverse variance approach. We will adopt the random-effects model for meta-analysis as we anticipate a substantial heterogeneity among the studies. We will use Chi-square statistic for determining the significant presence of heterogeneity and I-squared statistic for expressing the heterogeneity as a proportion³⁴. We will consider I-squared more than 70% as significant or substantial heterogeneity. We will perform the statistical analysis in STATA 13 software using ‘Metan’ package.

Subgroup analysis:

We will perform analysis of subgroups or subsets to compare the risk factors according to, but not limited to types of HAIs, types of the healthcare setting, regional location, and spectrum of microorganisms.

Publication bias:

If the number of studies is more (>10), we will assess publication bias using the funnel plot and degree of symmetry by Egger’s test³⁵.

An effort will be made to use “Grading of Recommendations Assessment, Development, and Evaluation” (GRADE) approach. We will try to make summary of findings tables, choosing comparison and outcomes for summary of findings, assessing the risk of bias, and grading the evidence obtained by various articles. An effort to assess publication bias will also be made using GRADE approach

“The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols” (PRISMA-P) is being followed while preparing the protocol that is registered in PROSPERO (CRD42017072861). The systematic review will be conducted and reported in accordance with PRISMA guidelines adopted from standard Cochrane

DISCUSSION:

The burden of neonatal healthcare-associated infection in South East Asian countries is exceedingly high and in India it is one of the leading causes of neonatal mortality. The detriments leading to neonatal HAIs is unexplored in India. Microbiological spectrum in India might be different compared to other South East Asian Countries, and it is indeed required to explore the risk factor of neonatal HAIs. The systematic review will help the policymaker to provide capacity building in neonatal health in India^36,37. To best of our knowledge this is the first systematic review listing and categorising the risk factors causing neonatal HAIs. The protocol also provides a detailed methodology to search and include the suitable articles in the review followed by the precise appropriate statistical analytical tool that will be used for further analysis. The protocol shall also give rise to a new further area of research in neonatal HAIs and may also stimulate further reporting of such articles in the journals.

LIST OF ABBREVIATIONS:

BSI: Blood Stream Infection; CLABSI: Central Line-Associated Blood Stream Infection; CDC: Center for disease control; CRD: Center for Reviews and Dissemination; HAIs: Healthcare-Associated Infections; ICU: Intensive Care Unit; LRI: Line Related Infection; LRTI: Lower Respiratory Tract Infection; MeSH: Medical Subject Heading; MOOSE: Meta-analysis of Observational Studies in Epidemiology; MRSA: Methicillin-resistant Staphylococcus aureus; MSSA: Methicillin-sensitive Staphylococcus aureus; NICU: Neonatal Intensive Care Unit; NIH: National Institute of Health; PRISMA-P: Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols; RoB: Risk of Bias; SSI: Surgical Site Infection; URTI: Upper Respiratory Tract Infection; UTI: Urinary Tract Infection; WHO: World Health Organization

Declarations:

Ethics Approval and Consent to Participate:

Not applicable.

Consent for Publication:

Not applicable

Availability of Data and Material:

The supporting data of the study findings can be availed through the corresponding author on request.

Competing Interest:

The author declares that they do not have any competing interests.

Funding:

This research did not receive any grant from any funding agency at the public, private or not-for-profit sector.

Author’s contribution:

UR is the generator of the systematic review. All the author conceptualised the research idea and contributed to the manuscript. Overall technical guidance is provided by MS, LE, MG, KC, and RN. Search strategies are developed by MG, UR, SN and LE and conducted the preliminary search. Data extraction form is developed by UR, MS, MG, LE and KC. UR, MG, RN and LE drafted the protocol and written the manuscript. All authors have approved the final protocol.

ACKNOWLEDGEMENTS:

We acknowledge the support and assistance of Manipal Academy of Higher Education, Manipal and Kasturba Hospital, Manipal, Karnataka, India.

AUTHOR’S INFORMATION:

The views in the article do not represent the view of any of the Organisations/Institutions that the author is affiliated to. UR is the first author and corresponding author. LE is the PhD Guide, Professor at Neonatology and author of the manuscript.

REFERENCE:

1. World Health Organisation. Newborns: reducing mortality. http://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality. Accessed October 26, 2018.

2. UNICEF India. Neonatal Health. http://unicef.in/Whatwedo/2/Neonatal-Health. Published 2015. Accessed June 19, 2017.

3. Zodepay S and Paul V K P, AIIMS. State of India’s Newborns 2014. Delhi; 2014. http://www.newbornwhocc.org/SOIN_PRINTED 14-9-2014.pdf. Accessed June 19, 2017.

4. Vanmathi SM, Star MM, Venkateswaramurthy N, Kumar RS. Preterm Birth Facts: A Review. Res J Pharm Technol. 2019;12(3):1383. doi:10.5958/0974-360X.2019.00231.2

5. Liu L, Johnson HL, Cousens S, et al. Global, regional, and national causes of child mortality: An updated systematic analysis for 2010 with time trends since 2000. Lancet. 2012;379(9832):2151-2161. doi:10.1016/S0140-6736(12)60560-1

6. G. Ducel, J. Fabry LN. Prevention of hospital-acquired infections. World Heal Organ. 2002:1-64. doi:WHO/CDS/CSR/EPH/2002.12

7. Afjeh SA, Sabzehei MK, Karimi A, Shiva F, Shamshiri AR. Surveillance of ventilator-associated pneumonia in a neonatal intensive care unit: characteristics, risk factors, and outcome. Arch Iran Med. 2012;15(9):567-571. doi:012159/AIM.0012

8. Apisarnthanarak A, Holzmann-Pazgal G, Hamvas A, Olsen MA, Fraser VJ. Ventilator-Associated Pneumonia in Extremely Preterm Neonates in a Neonatal Intensive Care Unit: Characteristics, Risk Factors, and Outcomes. Pediatrics. 2003;112(6):1283-1289. doi:10.1542/peds.112.6.1283

9. Kamath S, Mallaya S, Shenoy S. Nosocomial infections in neonatal intensive care units: profile, risk factor assessment and antibiogram. Indian J Pediatr. 2010. doi:10.1007/s12098-010-0005-5

10. Goel K, Randhawa VS, Saili A, et al. Incidence, Etiology and Risk Factors Associated with Neonatal Healthcare-Associated Conjunctivitis: A Prospective Study from a Tertiary Care Hospital in India. J Trop Pediatr. 2016;62(1):10-18. doi:10.1093/tropej/fmv064

11. Gupta P, Chakrabarti A, Singhi S, Kumar P, Honnavar P, Rudramurthy SM. Skin Colonization by Malassezia spp. in Hospitalized Neonates and Infants in a Tertiary Care Centre in North India. Mycopathologia. 2014;178(3-4):267-272. doi:10.1007/s11046-014-9788-7

12. Eshwara VK, Munim F, Tellapragada C, et al. Staphylococcus aureus bacteremia in an Indian tertiary care hospital: Observational study on clinical epidemiology, resistance characteristics, and carriage of the Panton-Valentine leukocidin gene. Int J Infect Dis. 2013;17(11):e1051-5. doi:10.1016/j.ijid.2013.06.002

13. Kamath S, Mallaya S, Shenoy S. Nosocomial infections in neonatal intensive care units: Profile, risk factor assessment and antibiogram. Indian J Pediatr. 2010;77(1):37-39. doi:10.1007/s12098-010-0005-5

14. Yalaz M, Altun-Köroğlu Ö, Ulusoy B, et al. Evaluation of device-associated infections in a neonatal intensive care unit. TurkJPediatr. 2012;54(0041-4301 (Print)):128-135. http://www.ncbi.nlm.nih.gov/pubmed/22734298. Accessed April 19, 2016.

15. Lu W, Yu J, Ai Q, Liu D, Song C, Li L. Increased constituent ratios of Klebsiella sp., Acinetobacter sp., and Streptococcus sp. and a decrease in microflora diversity may be indicators of ventilator-associated pneumonia: A prospective study in the respiratory tracts of neonates. PLoS One. 2014;9(2):e87504. doi:10.1371/journal.pone.0087504

16. Crivaro V, Bogdanović L, Bagattini M, et al. Surveillance of healthcare-associated infections in a neonatal intensive care unit in Italy during 2006–2010. BMC Infect Dis. 2015;15(1):152. doi:10.1186/s12879-015-0909-9

17. Karthikeyan G, Premkumar K. Neonatal sepsis: Staphylococcus aureus as the predominant pathogen. Indian J Pediatr. 2001;68(8):715-717.

18. Oommen A. Neonatal Health Care Services in India. Asian J Nurs Educ Res. 2015;5(4):545. doi:10.5958/2349-2996.2015.00112.3

19. Lolita S.M. D’Souza., Malarvizhi M. JJ. Prevention of Nosocomial infection in NICU. Asian J Nur Edu Res. 2014;4(2):255-257.

20. Datta P, Rani H, Chauhan R, Gombar S, Chander J. Health-care-associated infections: Risk factors and epidemiology from an intensive care unit in Northern India. Indian J Anaesth. 2014;58(1):30-35. doi:10.4103/0019-5049.126785

21. Bassani DG, Kumar R, Awasthi S, et al. Causes of neonatal and child mortality in India: A nationally representative mortality survey. Lancet. 2010;376(9755):1853-1860. doi:10.1016/S0140-6736(10)61461-4

22. Sachdeva Seema, Koul Pity, Batra Kiran. Effectiveness of Suction Protocol on Nurse’s and Patient’s Outcome in ICU. Asian J Nurs Edu Res. 2017;7(4):589-595.

23. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36(5):309-332. doi:10.1016/j.ajic.2008.03.002

24. World Health Organization. The burden of healthcare-associated infection worldwide: A Summary. World Heal Organ. 2011:3. http://www.who.int/gpsc/country_work/summary_20100430_en.pdf.

25. Saurabh Bharadwaj, U.V.S. Teotia, Kishan Singh, Rajib Sharma, Yogendra Singh. Effect of Antibiotic on Various Microorganisms Isolated from Nosocomial Infected Patients in General Hospital. Res J Pharm Tech. 2014;7(4):408-414.

26. Dr. Priyadarshini M. Deodurg, Dr. Srikanth, Dr. Praveen Kumar Doddamani, Shireen Rana, Bilal Ahmad Mir. Prevalence and Antimicrobial Susceptibility Pattern of Pseudomonas aeruginosa in a Tertiary Care Hospital. Res J Pharm Tech. 2014;7(5):517-520.

27. Anitha Victoria Noronha, Prof. Sheela Williams, Mr. Rakesh A N, Mr. Shashikumar H N. Practice of Staff Nurses regarding Intravenous Infusion (IV). Asian J Nurs Edu Res. 2017;7(2):206-208.

28. E.M.A. Mahmood Waffa, F. Islahudin, A.F.Shamsuddin. Complications of Parenteral Nutrition in Neonates. Res J Pharm Tech. 2014;7(7):779-782.

29. Shidiki A, Pandit B, Vyas A. Incidence and antibiotic profile of bacterial isolates from neonatal septicemia in national medical college and teaching hospital, Birgunj, Nepal. Res J Pharm Technol. 2018;11(6):2238. doi:10.5958/0974-360X.2018.00414.6

30. NHLBI. Study Quality Assessment Tools | National Heart, Lung, and Blood Institute (NHLBI). https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools. Accessed July 10, 2018.

31. Rosário F, Santos MI, Angus K, Pas L, Fitzgerald N. Factors influencing the implementation of screening and brief interventions for alcohol use in primary care practices: A systematic review protocol. Acta Med Port. 2018;31(1):45-50. doi:10.20344/amp.9753

32. McKay R, Mah A, Law MR, McGrail K, Patrick DM. Systematic Review of Factors Associated with Antibiotic Prescribing for Respiratory Tract Infections. Antimicrob Agents Chemother. 2016;60(7):4106-4118. doi:10.1128/AAC.00209-16

33. Introduction to GRADE | Cochrane Training. https://training.cochrane.org/introduction-grade. Accessed October 29, 2018.

34. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557-560. doi:10.1136/bmj.327.7414.557

35. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629-634. doi:10.1136/BMJ.315.7109.629

36. Jose S. Effect of Planned Teaching Programme on Knowledge of Immediate Care of Low Birth Weight Babies among Staff Nurses working in Neonatal Intensive Care Unit in selected Hospitals of an Urban Area. Asian J Nurs Educ Res. 2017;7(2):209. doi:10.5958/2349-2996.2017.00043.X

37. Yadav S, Sonia. Knowledge regarding selected neonatal infections and their prevention among primigravida mothers. Int J Adv Nurs Manag. 2016;4(2):97. doi:10.5958/2454-2652.2016.00021.4

Received on 18.08.2019 Modified on 21.11.2019

Research J. Pharm. and Tech. 2020; 13(4): 1672-1678.

DOI: 10.5958/0974-360X.2020.00303.0