A mixed-method study on antimicrobial resistance infection drivers in neonatal intensive care units: pathways, risks, and solutions

Abstract

Background

Antimicrobial resistance (AMR) in neonatal intensive care units (NICUs) complicates treatment of healthcare-associated infections, causing high morbidity and mortality, especially among low-birth-weight and critically ill infants. This study evaluates AMR prevalence, risk factors, outcomes and infection control measures at Felege Hiwot Hospital, aiming to guide clinical practices, antimicrobial stewardship, and improved neonatal health outcomes.

Methods

This mixed-methods study (Oct 2022–Jun 2023) assessed AMR in NICU neonates by analyzing 420 blood samples, environmental swabs, and staff insights. Bivariable and multivariable regressions identified significant variables, and content analysis was used for qualitative data.

Results

Out of 420 samples, 35% tested positive for AMR pathogens, with Coagulase-Negative Staphylococci (16.7%), Klebsiella pneumoniae (12.9%), and Acinetobacter spp. (5.6%) being the most prevalent. Resistance rates for Gentamicin, Cotrimoxazole, and Ciprofloxacin were alarmingly high (98–100%), while Amikacin demonstrated low resistance (3.0-5.56%), indicating potential efficacy. Among the neonates admitted, 91.8% survived, and 8.2% succumbed. Risk factor analysis revealed that improper PPE usage (AOR 3.90, p < 0.001), non-functional handwashing sinks (AOR 3.20, p < 0.001), and inadequate disinfection practices (AOR 2.70, p < 0.001) were strongly associated with microbial contamination. Environmental factors, including cockroach presence (AOR 1.80, p = 0.040) and high traffic flow (AOR 2.10, p = 0.005), were also significant contributors. The qualitative data analysis confirmed that improper PPE use, inadequate disinfection practices, pest control challenges, and non-functional handwashing sinks significantly contributed to microbial contamination risks in the NICU, aligning with the quantitative findings.

Conclusions

This study underscores key factors driving AMR in NICUs, such as inadequate IPC practices and environmental contamination, alongside high resistance to Cotrimoxazole and Ciprofloxacin. Amikacin shows promise as an effective treatment for CONS. Urgent actions, including strengthened IPC measures, staff training, and environmental management, are crucial to combat AMR, ensuring improved neonatal care and outcomes.

Background

Antimicrobial resistance (AMR) represents one of the most significant challenges to global public health today [1]. The rise in antibiotic-resistant infections has rendered many commonly used treatments ineffective, threatening the management of a wide range of diseases [2]. This issue is particularly pressing in hospital settings, where the risk of infections is heightened due to the complexity of care, the vulnerability of patients, and the heavy use of antibiotics. One of the most critical areas where AMR is a growing concern is in neonatal intensive care units (NICUs) [3]. Neonates are particularly susceptible to infections because of their underdeveloped immune systems, and many of them require intensive medical intervention, including antibiotic treatments [4]. Consequently, NICUs are environments where AMR can spread rapidly if proper infection prevention and control (IPC) measures are not rigorously implemented [5].

Healthcare-associated infections (HAIs) in NICUs have become a major contributor to morbidity and mortality, as the organisms responsible for these infections increasingly display resistance to multiple drugs [6]. The occurrence of AMR in NICUs is compounded by several factors, including the overuse or misuse of antibiotics, cross-contamination, and lapses in IPC practices [7]. Despite these concerns, many NICUs still struggle with enforcing consistent and effective IPC measures. Proper hand hygiene, environmental cleaning, isolation of infected patients, and adherence to antimicrobial stewardship programs (ASP) are vital in preventing the spread of resistant bacteria [8]. However, studies have shown that adherence to these practices can be inconsistent, influenced by factors such as staff workload, lack of resources, and insufficient training [9].

While much has been written about the prevalence of AMR in hospital settings, there remain gaps in understanding its specific impact in NICUs, especially in resource-limited settings [10]. Few studies have systematically evaluated the environmental and clinical sources of antibiotic-resistant bacteria in NICUs, nor have they explored the full spectrum of IPC practices or the barriers faced by healthcare providers in adhering to recommended protocols [11]. This research seeks to fill these gaps by conducting a comprehensive investigation into the prevalence of AMR in a NICU setting, evaluating IPC practices, and identifying the key factors contributing to the spread of resistance.

The present study, conducted at the NICU of FHCSH, aims to assess the prevalence of antibiotic-resistant bacteria in both the clinical and environmental settings, examine current IPC practices, and explore the perspectives of healthcare providers on the challenges and strategies for combating AMR. The study will provide important insights into the effectiveness of existing IPC measures, highlight areas for improvement, and contribute to the development of targeted interventions to address AMR in the NICU.

The primary objective of this study is to investigate the prevalence of AMR in the NICU at FHCSH, identify potential risk factors contributing to the spread of resistance, and evaluate the effectiveness of IPC measures currently in place. The study will also explore the challenges faced by healthcare providers in adhering to IPC practices, as well as their perceptions of AMR and antimicrobial stewardship.

By combining both quantitative and qualitative methods, the study aims to provide a well-rounded understanding of the AMR situation in the NICU and propose evidence-based recommendations for improving infection control practices, enhancing antimicrobial stewardship, and ultimately reducing the burden of AMR in neonatal care.

Methods

Study design

This study adopted a mixed-methods design, integrating both quantitative and qualitative data collection techniques. The quantitative component focused on the prevalence of antibiotic-resistant bacteria in environmental and clinical samples from the NICU, while the qualitative component sought to explore healthcare providers’ experiences with infection prevention and control (IPC) practices, challenges related to antimicrobial stewardship, and perceptions of AMR. By using a mixed-methods approach, the study combined the strengths of both data types to offer a more comprehensive and nuanced understanding of the issues surrounding AMR in the NICU. The study followed a cross-sectional design, with data collected at a single point in time. This approach allowed for an in-depth analysis of current conditions and practices in the NICU, providing a snapshot of AMR prevalence and IPC adherence at the time of the study.

Study setting and duration

The study was conducted at the NICU of FHCSH, a leading hospital and referral center for neonates requiring specialized care in the region. The NICU at FHCSH caters to a large and diverse population of critically ill neonates, some of whom are at high risk for infections due to prematurity, low birth weight, and other complex medical conditions. The NICU is a high-intensity environment where infection prevention and control practices are crucial to patient safety and treatment outcomes.

The study was carried out over a period of seven months, from 26/10/2022 to 26/06/2023, allowing sufficient time for the collection of environmental samples, direct observations, and interviews with healthcare providers. This time frame also enabled the researchers to gather comprehensive data across different stages of patient care, ensuring that all potential sources of AMR exposure were considered.

Sample size

To calculate the sample size based on a single population proportion-based study [12], In this study, the sample size was calculated using a single population proportion-based formula, where n is the required sample size, Z is the Z-value corresponding to the desired confidence level (1.96 for a 95% confidence level), p is the estimated prevalence (50% or 0.5, a conservative estimate when the exact proportion is unknown), and E is the margin of error (5% or 0.05). Based on these values, the required sample size was calculated to be approximately 385. To account for a 10% respondent rate, the sample size was adjusted accordingly, resulting in a total of 420 samples. Therefore, the 420 sample size is sufficient to ensure that the study can achieve the desired confidence level and margin of error while considering the expected response rate.

Study participants

Specific qualitative methods applied

The study utilized semi-structured interviews as the primary qualitative method to explore healthcare providers’ experiences and perspectives. These interviews were conducted individually to facilitate in-depth discussions and allow participants to share their insights freely.

Roles represented and reasons for selection: The roles represented in the study included NICU nurses, IPC committee members, and ASP representatives. These roles were chosen due to their direct involvement in antimicrobial resistance (AMR) management and infection prevention and control (IPC) practices within the NICU. Each group provided unique perspectives: NICU nurses: Responsible for direct patient care and daily implementation of IPC measures such as hand hygiene and environmental cleaning. IPC committee members: Tasked with monitoring and ensuring compliance with IPC guidelines. ASP representatives: Focused on managing antibiotic prescribing and promoting judicious use to mitigate resistance.

Topics covered in semi-structured interviews: The semi-structured interviews explored the following key topics: Challenges faced in implementing IPC measures, Perceptions of the effectiveness of current antimicrobial stewardship practices, Observations of AMR trends in the NICU and Suggestions for improving IPC and ASP interventions.

Selection of questions and use of frameworks or theories

The interview questions were developed based on a literature review of AMR and IPC practices in NICU settings. While no specific theoretical framework was used, the questions were informed by existing guidelines on IPC and ASP. This pragmatic approach aimed to ensure the relevance of the questions to participants’ roles and real-world challenges. Future studies may benefit from incorporating established frameworks to provide additional theoretical grounding.

A total of 420 neonatal blood samples and environmental samples were collected from high-touch surfaces within the NICU, including incubators, medical equipment, and bed rails. These samples were analyzed for the presence of antibiotic-resistant bacteria, focusing on key pathogens such as Staphylococcus aureus, Escherichia coli, and Acinetobacter spp. additionally, 420 hospital staff members were provided with self-administered questionnaires to assess determinants and compliance factors. These factors were measured quantitatively to provide insights into infection control practices and antimicrobial resistance dynamics.

Data collection methods

Data were collected using a combination of methods to provide both quantitative and qualitative insights into AMR prevalence and IPC practices. The methods included direct observations, environmental sampling, chart reviews, and semi-structured interviews with healthcare providers.

Direct observations

Direct observations were conducted by the research team to assess healthcare workers’ adherence to infection prevention and control practices. These observations focused on key IPC practices such as hand hygiene, the use of personal protective equipment (PPE), environmental cleaning, and the isolation of infected neonates. The observers followed a structured checklist to ensure consistency and comprehensiveness in their assessments.

Blood and environmental sampling

A total of 420 neonate’s blood and environmental samples were collected from high-touch surfaces within the NICU. These samples were swabbed using sterile collection tools, and the swabs were sent to the microbiology laboratory for analysis. The primary goal of the environmental sampling was to detect the presence of antibiotic-resistant bacteria in the NICU environment.

Chart review

Patient charts were reviewed to collect data on antibiotic usage, types of infections, and treatment outcomes. This information provided insights into the relationship between antibiotic use and the development of resistant infections.

Interviews

Twelve semi-structured interviews were conducted with NICU healthcare providers, IPC committee members, and ASP representatives. The interviews were designed to explore healthcare providers’ perspectives on AMR, IPC practices, challenges in implementing infection control measures, and the role of antimicrobial stewardship in the NICU. The interviews were audio-recorded, transcribed, and analyzed for recurring themes and insights.

Data analysis

For the quantitative data, statistical analysis was used to identify patterns of AMR in the environmental samples. Descriptive statistics were used to summarize the prevalence of antibiotic-resistant bacteria, and the data were analyzed to determine any correlations between bacterial contamination and specific IPC practices.

Qualitative data from the interviews were analyzed using thematic analysis. Transcripts were reviewed, coded, and categorized into key themes related to IPC practices, barriers to infection control, and perceptions of AMR. The thematic analysis allowed for the identification of common challenges faced by healthcare providers and provided insights into potential solutions.

Ethical considerations

Ethical approval

for the study was obtained from the institutional review board (IRB) of FHCSH. Informed consent was obtained from all interview participants, and confidentiality was maintained throughout the study. Ethical guidelines were followed during the collection of environmental samples and chart reviews to ensure patient privacy and data security.

Results

Proportions of AMR microbial isolation in NICU

Of the 420 samples analyzed for microbial contamination in the NICU, 35% tested positive, with Coagulase-Negative Staphylococci (CONS) isolated in 70 samples (16.7%), Klebsiella pneumoniae in 54 samples (12.9%), and Acinetobacter spp. in 23 samples (5.6%). The remaining 65% (273 samples) were negative. These findings highlight the need for stringent infection control measures and continuous surveillance to prevent nosocomial infections (Table 1).

Table 1 AMR microorganisms isolated from NICU samples (n = 420)

The AMR microbial contamination of inanimate surface in NICU

The sampling results indicate that Klebsiella pneumoniae was the only bacterial isolate found, present in 25 samples from the L&D incubators/radiant warmers. No bacterial contamination was detected in the NICU dress, nasal prongs (HLD), or NICU incubators/radiant warmers. These results highlight the importance of monitoring specific surfaces in high-risk areas like L&D for microbial contamination while emphasizing that other NICU areas remain free from detectable bacterial presence (Table 2).

Table 2 AMR bacterial contamination of inanimate surface in NICU

Resistance rates for isolated microorganisms

The bar chart illustrates the resistance rates of Coagulase-Negative Staphylococci (CONS), Acinetobacter spp., and Klebsiella pneumoniae to common antibiotics. It shows that all three pathogens exhibit high resistance to Gentamicin, Cotrimoxazole, and Ciprofloxacin (nearing 100%), with lower resistance to Amikacin, indicating its potential as a treatment option. Acinetobacter spp. and Klebsiella pneumoniae also demonstrate significant resistance to broad-spectrum antibiotics like Ceftazidime and Meropenem, highlighting the growing concern of antimicrobial resistance in neonatal care settings (Fig. 1).

Fig. 1

Antibiotic resistance rates of common pathogens isolated in neonatal care settings

The study reveals concerning high resistance rates among three pathogens—Coagulase-Negative Staphylococci (CONS), Acinetobacter spp., and Klebsiella pneumoniae—to several commonly used antibiotics, including Ceftazidime, Meropenem, Cotrimoxazole, Ciprofloxacin, and Gentamicin. These pathogens exhibited almost complete resistance to Gentamicin (100%), Cotrimoxazole (98–100%), and Ciprofloxacin (98–100%), indicating that these antibiotics are largely ineffective for treating infections caused by these microbes. Acinetobacter spp. and Klebsiella pneumoniae also showed very high resistance to Ceftazidime (94-95.7%) and Meropenem (91-92.6%), which are typically used as broad-spectrum treatments. However, Amikacin demonstrated significantly lower resistance (3.0–5.56%) across all pathogens, suggesting it could remain a valuable option for treatment, particularly for Coagulase-Negative Staphylococci (CONS), which displayed lower resistance to this antibiotic. The study highlights the critical need for alternative treatment strategies and emphasizes the importance of monitoring antibiotic resistance to guide effective therapy (Table 3).

Table 3 Antibiotic resistance rates for common pathogens isolated from clinical samples

Outcomes and key causes of neonatal admissions

Among the 420 neonates admitted, 91.8% (385 neonates) survived, while 8.2% (35 neonates) succumbed. The primary causes of admission included low birth weight (LBW) at 30% (126 neonates), followed by preterm births at 25% (105 neonates), respiratory distress syndrome (RDS) at 20% (84 neonates), neonatal jaundice at 15% (63 neonates), and sepsis, transient tachypnea of the newborn (TTN), or thrombus collectively accounting for 10% (42 neonates). These findings underscore the critical need for targeted interventions addressing LBW, prematurity, and respiratory complications to improve neonatal outcomes (Fig. 2).

Fig. 2

outcomes and key causes of neonatal admissions

Hand hygiene compliance

In the NICU, hand hygiene compliance was assessed through direct observation of 12 healthcare providers working directly in the NICU and self-administered questionnaires completed by 420 hospital staff members. The evaluation examined the availability of hand hygiene supplies, use of alcohol-based hand rubs, and adherence to the WHO 5 Moments of Hand Hygiene. Among staff observed, 75% had access to functional handwashing sinks, with 90% of these equipped with soap and paper towels. Additionally, 85% used alcohol-based hand rubs when soap and water were unavailable. Compliance rates varied by staff category: doctors showed 70% compliance (95% CI: 65–75%), nurses 80% (95% CI: 75–85%), and other healthcare workers 60% (95% CI: 55–65%). The highest compliance was noted during “Before Patient Contact” (85%) and “After Patient Contact” (80%), while the lowest was during “After Contact with Patient Surroundings” (55%) and “Before Aseptic Task” (50%) (Fig. 3).

Fig. 3

Hand hygiene compliance among healthcare workers, showing access to supplies and adherence to WHO 5 Moments

Compliance with aseptic practices and device management

An assessment of aseptic practices and the management of invasive procedures in the NICU revealed significant compliance gaps across several areas. Compliance with aseptic techniques during peripheral IV line insertion was observed in 70% of cases (95% CI: 65–75%), with common lapses including inadequate hand hygiene (30%) and improper use of sterile gloves (25%). Maintenance of IV lines showed even lower compliance at 60% (95% CI: 55–65%), with issues such as untimely dressing changes and contamination during line access. Adherence to aseptic techniques during other procedures, like blood draws and catheter insertions, was inconsistent, with a compliance rate of 65% (95% CI: 60–70%), often due to skipped hand hygiene steps and the use of non-sterile instruments. Proper handling of multidose IV medications was observed in 75% of instances (95% CI: 70–80%), but risks persisted due to improper storage and unlabeled opened vials. These findings highlight critical areas for improvement in aseptic practices to reduce infection risks.

Fig. 4

Illustrating the compliance rates for various aseptic practices and device management in the NICU with an ideal compliance threshold of 80%

Key infection control gaps and opportunities for improvement in the NICU

The integration of quantitative and qualitative findings highlights significant gaps in infection prevention and control (IPC) practices within the NICU, emphasizing the need for targeted interventions. Limited access to hygiene facilities for mothers and attendants was evident, with only 60% having functional handwashing stations and 50% able to wash clothes. Although 70% received training, compliance issues persisted, particularly in hand hygiene practices, underscoring the need for ongoing, comprehensive education alongside improved infrastructure. Overcrowding further exacerbated infection risks, with 40% of incubators shared among infants, a finding consistent with qualitative accounts of cross-infection concerns. Expanding NICU capacity and implementing strict cleaning protocols for shared equipment are crucial steps. Additionally, IPC staff and committee members faced challenges due to non-dedicated roles, leading to inconsistent protocol implementation despite periodic training. This gap highlights the necessity for full-time IPC roles and advanced, NICU-specific training. Lastly, limited refrigeration facilities (available to only 55% of mothers) and inconsistent hygiene during expressed breastmilk handling revealed contamination risks. Standardizing milk handling protocols and improving storage infrastructure are critical to addressing this issue. These findings collectively demonstrate the importance of a multifaceted approach combining infrastructure upgrades, enhanced training, dedicated IPC staffing, and robust monitoring to achieve sustainable improvements in NICU IPC practices (Table 4).

Table 4 Key infection control gaps and opportunities for improvement in the NICU

Factors associated with AMR microbial contamination in the NICU

The data reveals several key factors influencing antimicrobial resistance (AMR) microbial contamination in the NICU. Improper personal protective equipment (PPE) utilization, non-functional handwashing sinks, and improper medical equipment disinfection significantly increase the risk of microbial contamination, with high odds ratios indicating a strong association. Conversely, the presence of cockroaches and high traffic flow in the NICU also contribute to contamination risks. While cash audit compliance and attendants wearing PPE showed no significant effect, improper high-level disinfection (HLD) practices and cockroach presence were still notable risk factors. Qualitative findings support these results, with staff noting inconsistent PPE usage, inadequate disinfection practices, and the challenge of high traffic contributing to increased microbial contamination risks (Table 5).

Table 5 Factors associated with AMR microbial contamination in the NICU

PPE utilization

Qualitative finding

The In-depth interviews with NICU staff revealed a general lack of awareness regarding the critical importance of proper personal protective equipment (PPE) use in preventing microbial contamination. Several staff members mentioned that PPE was often improperly used due to time constraints, fatigue, or the perception that it was unnecessary for certain tasks.

Quantitative analysis support

This finding aligns with the high odds ratio (AOR 3.90, p < 0.001) observed for improper PPE utilization in the quantitative analysis, suggesting that improper use of PPE significantly increases the risk of microbial contamination and AMR spread in the NICU.

Attendants wearing PPE

Qualitative finding

The In-depth interviews with NICU staff revealed that while PPE use was generally mandated, there were instances when staff members, especially those in non-clinical roles, did not wear PPE regularly due to perceived low-risk scenarios. Some attendants noted that PPE compliance was more commonly observed in high-risk tasks, but not consistently across all activities.

Quantitative analysis support

The absence of a significant association in the quantitative findings for attendants wearing PPE (AOR 1.20, p = 0.540) may reflect inconsistent adherence to PPE protocols among non-clinical staff or in lower-risk situations.

Medical equipment disinfection

Qualitative finding

The In-depth interviews with NICU staff identified challenges in maintaining consistent disinfection practices for medical equipment, citing the lack of dedicated time and resources to clean equipment thoroughly between patient uses. Many staff indicated that routine disinfection procedures were occasionally bypassed, especially during high-patient flow periods.

Quantitative analysis support

The significant association for medical equipment not disinfected (AOR 2.70, p < 0.001) aligns with these qualitative findings, suggesting that insufficient or improper disinfection of medical equipment contributes to higher contamination risks and AMR spread.

HLD use (high-Level disinfection)

Qualitative finding

In-depth interviews with NICU healthcare providers revealed a misunderstanding about the proper use of high-level disinfectants (HLD). Some staff reported using disinfectants without following the recommended contact time or dilution instructions due to a lack of training or high staff turnover.

Quantitative analysis support

The improper HLD use (AOR 2.50, p < 0.001) observed in the quantitative analysis is supported by qualitative reports indicating that inconsistent HLD use increases the risk of microbial contamination, particularly in high-risk areas such as NICUs.

Cockroach presence

Qualitative finding

The In-depth interviews with NICU staff that while some staff members noticed the presence of cockroaches in less-visible areas of the unit, they were often not immediately addressed due to resource limitations and underestimation of the impact of pests on infection control.

Quantitative analysis support

The association between cockroach presence and microbial contamination (AOR 1.80, p = 0.040) highlights the importance of environmental cleanliness in the NICU. Qualitative findings suggest that pest control measures were inadequate, contributing to contamination risks.

CASH audit and compliance

Qualitative finding

Interviews with NICU healthcare staff revealed that CASH (Clean, Assess, Survey, and Hygiene) audits were inconsistently conducted, with corrective actions often delayed due to competing priorities and resource constraints. Staff frequently reported a lack of awareness regarding audit findings and emphasized critical shortfalls, such as shortages of hand hygiene supplies, non-functional handwashing sinks, and inconsistent adherence to infection control protocols, particularly during less visible moments like “After Contact with Patient Surroundings.” While some staff improvised solutions or raised concerns informally, delayed corrective actions and insufficient feedback to management undermined trust in the audit process. These findings indicate that inconsistent audit implementation, without immediate corrective actions, adequate resources, and stronger accountability mechanisms, limits the effectiveness of CASH audits in improving infection control practices.

Quantitative analysis support

The lack of a significant association for CASH audit compliance (AOR 0.80, p = 0.640) in the quantitative data could be explained by inconsistent implementation of the audit, suggesting that audits alone may not be sufficient to drive improvements in infection control practices unless combined with immediate corrective actions.

Handwashing sinks

Qualitative finding

Observational assessments revealed that non-functional handwashing sinks were a persistent problem in the NICU. Healthcare staff reported difficulty maintaining hand hygiene protocols due to the absence of functional sinks in critical areas, which led to alternative, less effective hand hygiene practices being adopted.

Quantitative analysis support

The association between non-functional handwashing sinks (AOR 3.20, p < 0.001) and microbial contamination supports qualitative findings, suggesting that the lack of accessible and functional handwashing facilities contributes to poor hand hygiene practices and increases contamination risks.

Traffic flow

Qualitative finding

Interviews with NICU staff indicated that high patient volume and frequent foot traffic in certain areas of the NICU increased the likelihood of cross-contamination between patient care areas. Staff expressed concerns that inadequate spatial arrangements and crowded conditions facilitated the spread of resistant microorganisms.

Quantitative analysis support

The significant association for high traffic flow (AOR 2.10, p = 0.005) in the quantitative analysis aligns with qualitative reports, suggesting that high traffic flow increases the likelihood of microbial contamination in the NICU.

Discussion

The results from the analysis of microbial contamination in the Neonatal Intensive Care Unit (NICU) underscore the critical importance of effective infection control measures. A significant portion of the samples (35%) tested positive for microbial contamination, with Coagulase-Negative Staphylococci (CONS), Klebsiella pneumoniae, and Acinetobacter spp. identified as the most prevalent pathogens. This finding aligns with other studies that report CONS as a major contributor to neonatal infections. CONS are opportunistic pathogens often associated with hospital-acquired infections, particularly in neonatal settings due to the immaturity of the infant’s immune system. Similar findings were reported in Saudi Arabia (2023), where CONS was found to be a dominant microorganism in NICUs, contributing significantly to nosocomial infections in neonates. These findings highlight the vulnerability of neonates to infections caused by multidrug-resistant organisms, which are often transmitted via healthcare-associated routes [13].

In addition to CONS, Klebsiella Pneumoniae and Acinetobacter spp. were frequently isolated in the NICU, pointing to the growing concern of antimicrobial resistance (AMR) in neonatal healthcare. Klebsiella pneumoniae, an enteric pathogen, is known for its ability to survive in hospital environments and for its resistance to various antibiotics, including third-generation cephalosporins and carbapenems. Acinetobacter spp., on the other hand, is a common environmental pathogen that has been increasingly recognized as a cause of hospital-acquired infections [14]. Studies like those of Gashaw et al. (2024), confirm that Klebsiella pneumoniae and Acinetobacter spp. are prevalent in neonatal units and are frequently associated with outbreaks of hospital-acquired infections. The high prevalence of these pathogens in the NICU observed in this study emphasizes the importance of rigorous antimicrobial stewardship and infection prevention strategies to limit their transmission [15].

The contamination of inanimate surfaces in the NICU was another critical finding in this study, with Klebsiella pneumoniae isolated from the L&D incubators and radiant warmers. This finding underscores the significant role of environmental surfaces in the transmission of pathogens in healthcare settings. A similar study by Dancer (2014) highlights the importance of cleaning and disinfection of hospital surfaces, especially in high-risk areas such as NICUs. In their research, Dancer found that surfaces, particularly those in constant contact with patients, such as incubators and monitoring equipment, serve as reservoirs for pathogens. This emphasizes the need for routine cleaning protocols and disinfection of surfaces that come into direct contact with neonates or their fluids, to prevent cross-contamination and reduce infection risks [16].

The analysis also identified several factors contributing to microbial contamination in the NICU, such as improper personal protective equipment (PPE) usage, inadequate hand hygiene, and non-functional handwashing sinks. These findings align with studies by Bhatta et al. (2023), who highlighted the critical role of hand hygiene and the proper use of PPE in preventing healthcare-associated infections [17]. Inadequate hand hygiene has long been recognized as a key factor in the transmission of pathogens in hospital settings, with studies showing that proper handwashing reduces the incidence of infections. In the NICU, where neonates are particularly susceptible to infections, strict adherence to hand hygiene protocols is crucial for preventing pathogen transmission. The study’s finding that handwashing sinks were non-functional suggests systemic infrastructural issues that need addressing to ensure proper hygiene practices are followed [18].

Staff training and awareness emerged as significant factors influencing infection control practices in the NICU. However, while training is crucial, relying solely on educational interventions may be insufficient to achieve sustained improvements in IPC compliance. Time constraints, resource limitations, and systemic barriers often undermine the effectiveness of training. As highlighted by Stone et al. (2017), regular training sessions improve compliance, but their impact is amplified when integrated into a multifactorial approach that addresses broader systemic and organizational challenges. In the NICU context, fostering collaboration across diverse roles, including nurses, IPC committee members, and ASP representatives, can enhance the implementation of infection control measures. For example, interdisciplinary teamwork, leadership support, and accountability frameworks are essential complements to education, creating an environment where IPC practices are more effectively adopted [19]. This study’s findings underscore the need for such multifaceted strategies, particularly in settings with resource constraints. Additionally, it is important to acknowledge the study’s limitations, such as the purposive selection of participants, which may limit the generalizability of findings to other NICU settings, and the absence of cleaning staff in the qualitative data, despite their critical role in maintaining hygiene standards. Addressing these limitations in future research could provide a more comprehensive understanding of the factors influencing IPC practices and contribute to the development of robust, context-specific interventions.

The presence of cockroaches in the NICU, as identified in this study, also points to an important environmental risk factor for microbial contamination. Insects, particularly cockroaches, have long been recognized as vectors for hospital-acquired pathogens. Studies like those by Moges et al. (2016) have shown that cockroaches can carry and spread a variety of pathogens, including bacteria such as Salmonella, Klebsiella, and E. coli. The presence of cockroaches in the NICU is a serious concern, as they may introduce new sources of infection or exacerbate existing contamination. This highlights the need for pest control and sanitation measures in neonatal care settings, which are critical to maintaining a safe and clean environment [20].

To enhance infection containment in NICUs, hospitals should prioritize expanding and optimizing isolation facilities to address space constraints. Regular maintenance of hand hygiene infrastructure, including functional sinks, soap, and alcohol-based hand rub supplies, is essential. Hospitals should also implement continuous training programs for healthcare workers to improve adherence to infection prevention protocols, particularly focusing on low-compliance moments like “After Contact with Patient Surroundings” and “Before Aseptic Tasks.” For researchers, further studies should explore innovative approaches to overcome space limitations in isolation areas and investigate the effectiveness of alternative infection control strategies, such as mobile isolation units or advanced barrier precautions, in resource-constrained settings. Collaborative research between hospitals and academic institutions can help develop evidence-based solutions to strengthen infection control practices and reduce neonatal sepsis rates [21].

This study provides a comprehensive mixed-methods approach to understanding antimicrobial resistance (AMR) in neonatal intensive care units (NICUs), combining quantitative data from blood samples, environmental swabs, and staff insights to identify key risk factors and outcomes. The study’s strengths include a large sample size of 420 neonates, the use of both statistical regression and qualitative content analysis, and the identification of critical infection prevention and control (IPC) issues, such as improper PPE use and non-functional handwashing sinks. These findings contribute valuable insights into AMR drivers and solutions in NICU settings. However, the study’s limitations include the cross-sectional design, which does not allow for causal inferences, and potential biases in participant selection and reporting, particularly regarding environmental factors and staff practices. Additionally, the study’s focus on a single hospital limits the generalizability of the findings to other NICU settings.

Conclusion and recommendation

Conclusions

The study highlights a concerning burden of antimicrobial resistance (AMR) in neonatal care, with Coagulase-Negative Staphylococci (CONS), Acinetobacter spp., and Klebsiella pneumoniae exhibiting alarmingly high resistance to multiple antibiotics. Common treatments like Gentamicin, Cotrimoxazole, and Ciprofloxacin were found largely ineffective against these pathogens, with Ceftazidime and Meropenem also showing reduced efficacy. However, Amikacin demonstrated much lower resistance (3.0–5.56%), suggesting it could be a viable treatment option for these resistant infections. Klebsiella pneumoniae was notably found as a significant environmental contaminant, particularly in labor and delivery incubators, emphasizing the need for stringent infection control practices in critical areas. Key risk factors for increased contamination included improper PPE use, non-functional hand washing stations, inadequate disinfection practices, and environmental factors such as cockroach presence and high traffic flow, underlining the importance of improving infection control protocols and environmental cleanliness to reduce microbial risks.

Recommendations

To enhance infection control and mitigate AMR in neonatal care, facilities must strengthen protocols in NICUs and labor areas, prioritize Amikacin for resistant infections. Future researchers should focus on intervention studies assessing the effectiveness of enhanced isolation practices, infrastructure improvements, and interdisciplinary collaboration in reducing AMR in neonatal care.