Abstract
Background
Hospital environments serve as reservoirs of diverse airborne microorganisms, including fungi and multidrug-resistant bacteria, which pose serious risks to neonatal health. Although vernix caseosa provides initial protection against these microorganisms, neonates remain vulnerable to healthcare-associated infections due to their immature immune system and fragile protective barriers.
Methods
A longitudinal study involving 59 neonates was conducted at the maternity ward of the University of Cape Coast Hospital from October to December 2023. A total of 845 swab samples were collected from indoor air, high-touch surfaces, neonatal skin and the palms of the neonates’ mothers and nurses. Samples were cultured on Sabouraud Dextrose Agar, Nutrient Agar, and MacConkey Agar and incubated for bacterial and fungal growth. Fungal isolates were identified using phenotypic methods, while bacterial isolates were identified using Gram staining and standard biochemical tests. Data were analyzed using SPSS version 27.0, and the chi-square test was employed to assess the association between early microbial colonization and post-discharge neonatal infections, with statistical significance set at p < 0.05.
Results
Staphylococcus epidermidis was the most prevalent isolate recovered from indoor air and neonatal skin, accounting for 19.1% (60/314) and 34.9% (29/83), respectively, while Aspergillus niger (15.1%, 31/205) was the predominant isolate recovered from high-touch surfaces in the maternity ward. Initial bacterial colonization of the skin was observed in 79.7% (47/59) of neonates after birth. Out of these, 11 (23.4%) developed infections during follow-up, with skin infections accounting for the majority of cases (72.7%, 8/11). However, bacterial colonization after birth was not statistically associated with bacterial infections after discharge (p = 0.06).
Conclusion
Considering the high levels of bacterial and fungal contamination recovered from indoor air and high-touch surfaces within the maternity ward, neonates may be exposed to potentially pathogenic microorganisms, highlighting the importance of infection prevention and environmental hygiene measures.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12866-026-05330-y.
Keywords: Bacterial contamination, Fungal contamination, Indoor air, Neonatal skin colonization, Healthcare-associated infections, Neonatal infections, Microbial exposure
Introduction
Healthcare-Associated Infections (HAIs) in neonates, also known as neonatal nosocomial infections, are a significant concern in healthcare settings, particularly in maternity wards and neonatal intensive care units (NICUs) [1]. These infections can have serious consequences, leading to prolonged hospital stay, increased healthcare costs, and, in severe cases, mortality [2]. Neonates are particularly susceptible to HAIs due to their immature immune systems and their underdeveloped skin barrier [3]. According to the US Center for Disease Control and Prevention, nearly 1.7 million hospitalized patients acquire HAIs annually while being treated for other health issues, and more than 98,000 of these patients (1 of 17) die due to HAIs [4]. Most of the microorganisms that cause HAIs are multidrug-resistant strains, concentrated in the surrounding air, which makes them resistant against first-line antibiotics and antifungal agents, posing a lot of inconveniences to the mother and the neonate [5, 6].
Air facilitates the spread of microorganisms in the environment, allowing them to travel, deposit on surfaces, and create a risk of infection through inhalation, touching contaminated objects, or ingestion [7, 8]. It is estimated that around 10% of HAIs are associated with airborne microbial contamination, which refers to the presence of pathogenic microorganisms or microbial concentrations that exceed acceptable thresholds in the air [9]. Among these airborne agents, molds and bacteria are the most common contributors to HAIs [10].
Molds are filamentous multinucleated fungi made up of hyphae. They produce mycotoxins and other biological compounds that are volatile in the surroundings and are readily exposed to neonates [11, 12]. Bacteria are also important contributors to airborne contamination in healthcare environments, with species such as Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii, Staphylococcus epidermidis and Staphylococcus aureus frequently implicated in HAIs [13]. These organisms can survive in aerosols, settle on surfaces, and persist on medical equipment, thereby facilitating transmission to vulnerable patients, including neonates [14].
Despite these, Vernix caseosa, a whitish, cheesy, waxy substance that covers the skin of a neonate at birth, provides a protective barrier against these microorganisms [15]. It specifically acts as a mechanical barrier to microbial invasion, preventing the growth of pathogenic bacteria on the skin [16, 17]. However, despite the protective mechanism of vernix caseosa, exposure of neonates to airborne microbes puts them at a high risk of contracting HAIs. In Ghana, researchers have conducted studies on HAIs in maternity wards and the NICU, including studies at Korle-Bu Teaching Hospital [18, 19] and Cape Coast Teaching Hospital [20], as well as studies conducted internationally [21, 22].
However, there is currently limited evidence investigating the interplay between early-life microbial exposure, microbial air quality, environmental contamination, and the potential protective role of vernix caseosa in relation to healthcare-associated infections among hospital-born neonates at the University of Cape Coast Hospital. This, therefore, made it necessary to assess bacterial and fungal contamination of indoor air, high-touch surfaces, neonatal skin, and the palms of mothers and nurses to determine the potential risk of healthcare-associated infections among neonates in the maternity ward of the University of Cape Coast Hospital.
Methods
Study design, population, and setting
This was a longitudinal observational study conducted at the maternity ward of the University of Cape Coast Hospital from October to December 2023. The study included 59 neonates and their mothers, as well as nurses who were in close contact with the neonates. Neonates born within the sampling period and whose parents provided informed consent were included.
Sampling of indoor air
Indoor air was sampled using the passive air sampling method [23]. Petri plates with 25-ml aliquots of the tetracycline-supplemented Sabouraud dextrose agar (SDA) (Oxoid, UK), Nutrient agar (NA) (Biomark Laboratories, India), and MacConkey agar (MA) (Biomark Laboratories, India) were exposed to indoor air for 30 min twice a day, three times a week, for five weeks to collect microbial air particles.
Swab sampling and inoculation
The skin surfaces of the neonates, the palms of neonatal mothers and nurses, as well as floors, sinks, delivery beds, nursing station tables, baby warmer and dressing stations, beds in lying rooms, and windows in the maternity ward, were swabbed using sterile swab sticks. These samples were transported to the University of Cape Coast laboratory within 2 h of collection and inoculated onto NA, MA, and SDA [24].
Incubation of inoculated culture plates
The petri dishes containing enriched NA and MA were incubated at 37 °C for 18–24 h, and those of SDA at 25 °C for 7 days to observe bacterial and fungal growth, respectively [25].
Isolation and identification of fungi
Phenotypic identification methods (staining, microscopy, and picture identification) were used for fungal identification [26]. An amount of fungal isolate was removed with an inoculation needle from the SDA onto an ethanol-sterilized glass slide, after which it was covered with a drop of lactophenol cotton blue dye for 3 min. The stained slide was then covered with a cover slip. Excess dye was removed with a Whatman No. 1 filter paper and observed under an Olympus microscope.
Identification of bacteria
Bacterial isolates were Gram differentiated and were subsequently identified biochemically using TSI, citrate, urea, indole, catalase, and coagulase tests.
Neonatal follow-up after 7 days of discharge
Neonates were followed up for potential signs of infection, and clinical evaluations were performed during their routine weekly postnatal visits to the hospital for review. Swab samples were collected from the identified neonatal infection sites and transported to the laboratory for microbiological analysis.
Data collection
Data on the socio-demographic characteristics (age and educational status) of the neonates’ mothers and the isolates from the microbial identification were captured and entered into Microsoft Excel for later analysis.
Data analysis
The data obtained was analyzed using Microsoft Excel 2016 and SPSS version 27.0. Descriptive statistics were used to summarize sociodemographic characteristics and microbiological findings, including frequencies and percentages. Chi-square analysis was done to assess the association between early bacterial colonization and bacterial infections after neonatal discharge. Statistical significance was set at a p-value < 0.05.
Ethical considerations and patients’ consent
Ethical approval was sought from the Institutional Review Board (IRB) of the University of Cape Coast (REF: UCCIRBCANS/2023/11). The study was conducted in accordance with the ethical norms of the IRB of the University of Cape Coast and the ethical principles of the Declaration of Helsinki. Informed consent was obtained from all the participants, including the mothers of the neonates and the nurses.
Results
Socio-demographic characteristics of the neonates’ mothers
The majority of the neonates’ mothers were aged 26–30 years (21/59, 36.2%), whereas only a small proportion were within the 36-40-year age group (5/59, 8.6%). Regarding educational status, 42.4% (25/59) of the mothers had attained tertiary education at the time of sampling, while 8.5% (5/59) had no formal education (Table 1).
Table 1.
Socio-demographic characteristics of the neonates’ mothers
| Variables | Frequency (n) | Percentage (%) |
|---|---|---|
| Age group (years) | ||
| Mean (± SD) | 28.8 (± 4.65) | |
| 20–25 | 15 | 25.4 |
| 26–30 | 21 | 35.6 |
| 30–35 | 18 | 30.5 |
| 36–40 | 5 | 8.5 |
| Educational Status | ||
| No formal education | 5 | 8.5 |
| Junior High School | 16 | 27.1 |
| Senior High School | 13 | 22.0 |
| Tertiary education | 25 | 42.4 |
SD Standard deviation
Bacterial growth on neonatal skin and the palms of neonates’ mothers and nurses
Bacterial growth was most prevalent on neonates’ skin, with 79.7% (47/59) showing positive cultures, while 20.3% (12/59) showed no bacterial growth. Among the neonatal mothers, 67.8% (40/59) of palm swabs yielded bacterial growth. In contrast, nurses’ palms demonstrated the lowest prevalence of bacterial growth at 22.0% (13/59), with the majority, 78.0% (46/59), showing no bacterial growth (Table 2). The microorganisms isolated from each of the neonates are presented in Supplementary Table 1.
Table 2.
Bacterial growth on neonatal skin and the palms of neonates’ mothers and nurses
| Neonatal skin n (%) |
mothers’ palms n (%) |
nurses’ palms n (%) |
|
|---|---|---|---|
| Bacteria growth | 47 (79.7) | 40 (67.8) | 13 (22.0) |
| No bacterial growth | 12 (203) | 19 (32.2) | 46 (78.0) |
n: number; %: percentage
Microorganisms isolated from neonatal skin and the palms of neonates’ mothers and nurses
A total of 145 microbial isolates were recovered from neonatal skin and the palms of their mother’s and nurses. Among the organisms isolated from the three sites, Staphylococcus epidermidis was the most predominant microorganism, accounting for 34.9% (29/83) of isolates from neonatal skin, 30.4% (14/46) from mothers’ palms, and 37.5% (6/16) from nurses’ palms. This was followed by Micrococcus spp., which constituted 16.9% (14/83), 26.1% (12/46), and 25.0% (4/16) of isolates from neonatal skin, mothers’ palms, and nurses’ palms, respectively. Candida albicans was the most predominant fungal isolate recovered from neonatal skin, accounting for 6.0% (5/83) of the isolates (Table 3).
Table 3.
Microorganisms isolated from neonatal skin and the palms of neonates’ mothers and nurses
| Microorganism | Isolated from neonatal skin N = 83 n (%) |
Isolated from mothers’ palms N = 46 n (%) |
Isolated from nurses’ palms N = 16 n (%) |
|---|---|---|---|
| Staphylococcus epidermidis | 29 (34.9) | 14 (30.4) | 6 (37.5) |
| Micrococcus Sp. | 14 (16.9) | 12 (26.1) | 4 (25) |
| Streptococcus pneumoniae | 11 (13.3) | 3 (6.5) | 1 (6.3) |
| Escherichia coli | 8 (9.6) | 7 (15.2) | - |
| Staphylococcus aureus | 6 (7.2) | 5 (10.9) | 1 (6.3) |
| Pseudomonas aeruginosa | 3 (3.6) | 2 (4.3) | 1 (6.3) |
| Proteus vulgaris | 2 (2.4) | 1 (2.2) | 1 (6.3) |
| Bacillus Sp. | 1 (1.2) | - | - |
| Klebsiella pneumoniae | 1 (1.2) | - | 1 (6.3) |
| Providencia stuartii | 1 (1.2) | - | - |
| Morganella morganii | 1 (1.2) | - | - |
| Candida albicans | 5 (6.0) | 1 (2.2) | 1 (6.3) |
| Aspergillus flavus | 1 (1.2) | 1 (2.2) | - |
N: total number of microorganisms; n: number of isolates; -: none
Bacterial and fungal contamination across indoor air sampling periods
At the end of the first week, bacterial and fungal contamination of the indoor air was 88.9% and 68.9%, respectively. The level of bacterial growth decreased during the second (35.3%) and third (37.3%) weeks, then increased again to 56.6% in the fourth week. However, the highest levels of contamination were recorded in the fifth week, where 94.1% and 78.4% of sampled plates showed bacterial and fungal growth, respectively (Table 4). The microorganisms isolated over the five weeks are presented in Supplementary Table 2.
Table 4.
Bacterial and fungal contamination across indoor air sampling periods
| Air sampling period | Bacteria contamination | Fungal contamination | ||
|---|---|---|---|---|
| Bacteria growth n (%) |
No bacterial growth n (%) |
Fungal growth n (%) |
No fungal growth n (%) |
|
| Week 1 | 40 (88.9) | 5 (11.1) | 31 (68.9) | 14 (31.1) |
| Week 2 | 18 (35.3) | 33 (64.7) | 21 (41.2) | 30 (58.8) |
| Week 3 | 19 (37.3) | 32 (62.7) | 39 (76.5) | 12 (23.5) |
| Week 4 | 30 (56.6) | 23 (43.4) | 40 (78.4) | 11 (20.8) |
| Week 5 | 48 (94.1) | 3 (5.9) | 42 (79.2) | 11 (21.6) |
n: number of plates
Microorganisms isolated from high-touch surfaces in the maternity ward after five weeks
A total of 205 isolates were recovered from baby warmer and dressing stations, sinks, nurses’ station tables, floors, delivery beds, windows, and beds in lying rooms of the maternity ward. Of these isolates, the majority were fungal species (107/205, 52.2%), while 98/205 (47.8%) were bacterial. Most of the isolates were recovered from the windows in the maternity ward (56/205, 27.3%), while only a few were recovered from baby warmers and dressing stations (3/205, 1.5%). Staphylococcus epidermidis (26/98, 26.5%) and Aspergillus niger (31/107, 29.0%) were the most predominant bacterial and fungal species isolated, respectively (Table 5).
Table 5.
Microorganisms isolated from high-touch surfaces in the maternity ward after the five weeks
| Microbial isolates | Items Swabbed | |||||||
|---|---|---|---|---|---|---|---|---|
| Baby warmers and dressing stations N = 3 n (%) |
Sinks N = 41 n (%) |
Nurses station tables N = 18 n (%) |
Floors N = 36 n (%) |
Delivery bed N = 22 n (%) |
Windows N = 56 n (%) |
Beds in lying rooms N = 29 n (%) |
Total N = 205 n (%) |
|
| Staphylococcus epidermidis | 3 (100%) | 4 (9.8) | 3 (16.7) | 5 (13.9) | 2 (9.1) | 5 (8.9) | 4 (13.8) | 26 (12.7) |
| Proteus vulgaris | - | 5 (12.2) | - | - | - | - | - | 5 (2.4) |
| Klebsiella pneumoniae | - | 3 (7.3) | - | 1 (2.8) | - | 2 (3.6) | - | 6 (2.9) |
| Klebsiella aerogenes | - | 3 (7.3) | - | - | - | - | - | 3 (1.5) |
| Pseudomonas aeruginosa | - | 3 (7.3) | - | - | 1 (4.5) | 5 (8.9) | - | 9 (4.4) |
| Escherichia coli | - | 1 (2.4) | - | 1 (2.8) | 2 (9.1) | 3 (5.4) | - | 7 (3.4) |
| Streptococcus pneumoniae | - | 4 (9.8) | - | 2 (5.6) | 1 (4.5) | 5 (8.9) | - | 12 (5.9) |
| Staphylococcus aureus | - | 4 (9.8) | - | 1 (2.8) | - | 3 (5.4) | - | 8 (3.9) |
| Micrococcus spp. | - | 4 (9.8) | - | 4 (11.1) | 1 (4.5) | 5 (8.9) | 2 (6.9) | 16 (7.8) |
| Bacillus spp. | - | - | 1 (5.6) | 1 (2.8) | - | 4 (7.1) | - | 6 (2.9) |
| Aspergillus flavus | - | 3 (7.3) | 5 (27.8) | 3 (8.3) | 5 (22.7) | 1 (1.8) | 3 (10.3) | 20 (9.8) |
| Aspergillus niger | - | 5 (12.2) | 4 (22.2) | 6 (16.7) | 5 (22.7) | 5 (8.9) | 6 (20.7) | 31 (15.1) |
| Aspergillus terreus | - | - | - | 3 (8.3) | 2 (9.1) | - | 4 (13.8) | 9 (4.4) |
| Candida albicans | - | 2 (4.9) | - | - | 1 (4.5) | 1 (1.8) | 3 (10.3) | 7 (3.4) |
| Histoplasma capsulatum | -- | - | - | 3 (8.3) | - | 2 (3.6) | 2 (6.9) | 7 (3.4) |
| Mucor spp. | - | - | 5 (27.8) | 3 (8.3) | 1 (4.5) | 6 (10.7) | 2 (6.9) | 17 (8.3) |
| Stachybotrys chartarum | - | - | - | 3 (8.3) | 1 (4.5) | 1 (1.8) | 3 (10.3) | 8 (3.9) |
| Penicillium glabrum | - | - | - | - | - | 3 (5.4) | - | 3 (1.5) |
| Aspergillus fumigatus | - | - | - | - | - | 3 (5.4) | - | 3 (1.5) |
| Blastomyces dermatitidis | - | - | - | - | - | 2 (3.6) | - | 2 (1.0) |
N: total number of isolates; n: number of specific isolates; %: percentage
Neonatal bacterial infections after 7 days of discharge
Out of the 59 neonates who visited the hospital for postnatal review, 11 (18.6%) showed signs of microbial infections, with the majority presenting with skin infections (8/11, 72.7%) (Table 6). The microorganisms isolated from the sites of infection are presented in Supplementary Table 3.
Table 6.
Neonatal bacterial infections after 7 days of discharge
| Neonates infected (n) | Percentage (%) | |
|---|---|---|
| Infection | ||
| Yes | 11 | 18.6 |
| No | 48 | 81.4 |
| Sites of infection | ||
| Ear | 1 | 9.1 |
| Skin | 8 | 72.7 |
| tongue | 1 | 9.1 |
| Skin and tongue | 1 | 9.1 |
n: number of neonates infected; %: percentage
Association between bacterial colonization after birth and infection after 7 days of discharge
Among the 47 neonates whose skin showed bacterial growth after birth, 11 (23.4%) developed bacterial infections after 7 days of discharge. However, the presence of bacterial growth after birth was not statistically associated with the occurrence of post-discharge bacterial infections (p = 0.06) (Table 7).
Table 7.
Association between bacterial colonization after birth and infection after 7 days of discharge
| Bacterial colonization after birth | Infections after 7 days of discharge | χ² | P-value | ||
|---|---|---|---|---|---|
| Yes n (%) |
No n (%) |
Total n (%) |
|||
| Yes | 11 (23.4%) | 36 (76.6%) | 47 (100%) | 3.45 | 0.06 |
| No | 0 | 12 (100%) | 12 (100%) | ||
n: number of neonates; %: percentage; χ²: chi-square value
Discussion
This study revealed a high prevalence of bacterial growth on neonatal skin (79.7%), indicating a high exposure to microorganisms during delivery or shortly after birth. This early colonization was expected as neonates rapidly acquire microbes from the maternal canal, caregivers’ hands, and the hospital environment. This suggests that the immediate postnatal environment may play a significant role in facilitating microbial transmission to neonates. Our finding was higher than that reported by [27], who documented bacterial acquisition rates ranging from 33.9% to 71.4% across different neonatal skin sites among hospitalized preterm neonates. Nurses’ palms showed the lowest bacterial growth (22.0%) compared to mothers’ palms (67.8%). This may be attributed to stricter adherence to hand hygiene practices among nurses, who routinely follow infection prevention measures during patient care [28–30]. Of the microorganisms isolated from neonatal skin, mothers’ palms, and nurses’ palms, Staphylococcus epidermidis was the most predominant, accounting for 34.9% (29/83), 30.4% (14/46), and 37.5% (6/16), respectively. However, this was lower than that reported in a previous study, where Staphylococcus epidermidis accounted for 98.9% of the isolates recovered from neonatal skin swabs [31]. Micrococcus spp. was the next predominant bacterial species, which accounted for 16.9% (14/83) of neonatal skin isolates, 26.1% (12/46) of mothers’ palm isolates, and 25.0% (4/16) of nurses’ palm isolates. This prevalence was higher than the 0.7% of Micrococcus spp. isolates recovered from nurses’ palms in a previous NICU study [32]. Among the fungal isolates, Candida albicans was the most predominant species recovered from neonatal skin, accounting for 6.0% (5/83). This could be attributed to neonatal exposure during delivery, particularly through contact with maternal genital flora during passage through the birth canal. Compared to previous studies, this was lower than the prevalence of Candida spp. on neonatal skin reported in Israel (57%) [33].
Microbial air quality assessment demonstrated high levels of bacterial and fungal contamination within the maternity ward environment over the five-week sampling period. In the first week, bacterial and fungal contamination levels were high, at 88.9% and 68.9%, respectively, but showed a fluctuating pattern and peaked in the fifth week at 94.1% for bacterial contamination and 79.2% for fungal contamination. This pattern of bacterial contamination is comparable to findings from a study conducted at Dilla University Hospital in Ethiopia [34]. Among the bacterial isolates, Staphylococcus epidermidis was the most frequently recovered species (19.1%, 60/314), followed by Bacillus spp. (18.8%, 59/314) and Streptococcus pneumoniae (18.5%, 58/314). These organisms are common microbiota of the skin and respiratory tract, and their high prevalence suggests considerable human-associated shedding within the ward [35–37]. This finding was higher than that reported in a study conducted at Jimma University Specialized Hospital in Southwest Ethiopia, where lower prevalences of Bacillus spp. (6.1%) and Streptococcus spp. (4.27%) were recovered from indoor hospital air samples [38]. Staphylococcus aureus and Escherichia coli, the leading causative organisms of neonatal sepsis, were also detected in the airborne samples, accounting for 15.3% (48/314) and 13.4% (42/314) of the bacterial isolates, respectively. Their presence in indoor air suggests a potential environmental exposure source, indicating that neonates may be at increased risk of developing neonatal sepsis [39, 40]. Among the fungal isolates, Aspergillus was the most prevalent, with A. flavus (16.2%), A. fumigatus (15.6%), A. niger (11.3%), and A. terreus (5.5%) collectively accounting for a substantial proportion of the total fungal burden. A similar study conducted in the NICU of a maternity hospital in Iran reported low levels of A. fumigatus (6.7%) and A. niger (10%), compared with the present study [41]. These species are predominantly found in poorly ventilated or humid environments, indicating ongoing fungal exposure within the maternity ward [42]. Further studies are required to determine the clinical significance of this exposure.
Among the microbial isolates recovered from different sites in the maternity ward, Aspergillus niger was the most predominant, accounting for 15.1% (31/205) of the isolates, with most of them recovered from beds in lying rooms (19.4%, 6/31) and floors (19.4%, 6/31). Studies conducted in a tertiary hospital in Nigeria and a university hospital in Iran similarly reported high prevalences of Aspergillus niger isolated from bed rails, with prevalences of 64.2% and 43.7%, respectively; however, these prevalences were considerably higher than that observed in the present study [43, 44]. Only 3 of the 205 isolates were recovered from baby warmers and dressing stations. This may reflect more effective cleaning practices or reduced microbial burden at the baby warmer and dressing station compared with other sampled areas. The majority of the isolates were recovered from the windows in the maternity ward (27.3%, 56/205), with Mucor spp. being the predominant ones (10.7%, 6/56). In contrast, a previous hospital environmental study also reported microbial contamination on window surfaces (17.9%); however, floor surfaces (28.6%) constituted the predominant site of contamination in that study [45]. Proteus vulgaris, which accounted for 2.4% (5/205), was isolated from only sinks. A similar study reported higher bacterial contamination in sink environments, with Klebsiella pneumoniae and Staphylococcus aureus being more frequently isolated; however, Proteus vulgaris accounted for only about 10% of isolates recovered from sinks [46]. 42.9% (3/7) of the Candida albicans recovered were isolated from the beds in lying rooms. This may be due to frequent contact of beds with mothers’ skin and sweat, leading to their shedding on the surface. This is similar to a previous study in Brazil [47].
In this study, all the 59 neonates were followed up during their weekly postnatal review visits. Out of these, 11 (18.6%) showed signs of bacterial infection. Staphylococcus epidermidis (72.7%, 8/11) was the predominant bacterial isolate recovered from the sites of infection, followed by Proteus vulgaris (18.2%, 2/11) and Staphylococcus aureus (9.1%, 1/11). However, bacteria isolated from neonates after birth were not statistically associated with bacterial infections developed after 7 days post-discharge (p = 0.06). Despite this, all observed infections occurred in neonates who demonstrated bacterial growth after birth. This may be attributable to neonatal factors, including immune system immaturity, birth weight, mode of delivery, and duration of hospital stay, as well as microbial factors such as the virulence of the colonizing organisms, which may increase susceptibility to infection and facilitate progression from colonization to infection [48]. A similar report from a prospective study conducted in India revealed comparable findings, where 473 bacterially colonized infants were followed up, of whom 12% subsequently developed infections, but not all infections were caused by the initial colonizing organisms [49]. Another possible explanation for the reduced progression from bacterial colonization to subsequent infection may be the protective role of vernix caseosa, which has been reported to support neonatal skin barrier function and may help protect against pathogenic microbial invasion [50, 51]. However, this was not directly assessed in the present study, and hence, future studies should include direct evaluation of vernix caseosa and its antimicrobial components to better understand its potential role.
The findings of this study demonstrate substantial microbial exposure within the maternity ward environment. However, larger prospective studies are needed to elucidate the relationship between environmental contamination, neonatal colonization, and subsequent infections and to identify independent predictors of neonatal infection.
Limitations and perspectives
This study was limited by the short follow-up period, as neonates were only monitored for one week after discharge, which may not be sufficient to fully capture late-onset infections or establish stronger associations between early microbial colonization and subsequent infections. In addition, the study was conducted in a single maternity ward, which may limit the generalizability of the findings to other healthcare settings. Furthermore, neonatal factors such as birthweight, gestational age, mode of delivery, duration of hospital stay, and feeding practices, which could influence neonatal susceptibility to infection, were not taken into account. The study was also limited by the relatively small sample size of the neonates, which may affect the statistical inferences and the generalizability of the findings. Additionally, reliance solely on phenotypic and biochemical methods without molecular confirmation of the microorganisms may have limited the accuracy of organism identification and could have introduced misclassification bias in the microbiological findings.
Future studies should consider longer follow-up periods and multicenter study designs to better capture late-onset infections and improve the generalizability of findings across different healthcare settings. In addition, neonatal clinical factors should be incorporated in future studies to provide a more comprehensive understanding of risk determinants for neonatal infection. Future research should also include larger sample sizes to improve the robustness of statistical inferences and the generalizability of study findings. Furthermore, the use of molecular diagnostic techniques alongside phenotypic and biochemical methods is recommended to enhance the accuracy and specificity of microbial identification and reduce the risk of misclassification bias. Finally, antibiotic and antifungal susceptibility testing of isolated organisms should be included to guide effective treatment and strengthen infection control strategies.
Conclusion
High levels of bacterial and fungal contamination were identified on neonatal skin, mothers’ palms, indoor air, and environmental surfaces within the maternity ward. Although early bacterial colonization after birth was not associated with subsequent infections, possibly due to the protective role of innate neonatal defense mechanisms, neonates remain at high risk of infection due to continuous exposure to potentially pathogenic microorganisms in the maternity ward environment.
Supplementary Information
Acknowledgements
Not applicable.
Abbreviations
- HAI
Healthcare-associated infection
- NICU
Neonatal intensive care unit
- SDA
Sabouraud dextrose agar
- NA
Nutrient agar
- MA
MacConkey
- USA
United States of America
Authors’ contributions
MF and EO: conception and design, collection and/or assembly of data, data analysis and interpretation, and manuscript writing. CA: conception and design, collection and/or assembly of data, data analysis and interpretation, manuscript writing and editing. DKWO: conception and design, collection and/or assembly of data, data analysis and interpretation, manuscript writing and editing, and final approval of manuscript. All authors read and approved the final.
Funding
No funding was received for conducting this study.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethical approval and consent to participate
Ethical approval was sought from the Institutional Review Board (IRB) of the University of Cape Coast (REF: UCCIRBCANS/2023/11). The study was conducted in accordance with the ethical norms of the IRB of the University of Cape Coast and the ethical principles of the Declaration of Helsinki. Informed consent was obtained from all the participants, including the mothers of the neonates and the nurses.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Cynthia Ayefoumi Adinortey, Email: cadinortey@ucc.edu.gh.
Dickson Kofi Wiredu Ocansey, Email: dickson.ocansey@ucc.edu.gh.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.