Rajiv Gandhi University of Health Sciences, Bangalore-Karnataka s34

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE- KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. NAME OF THE Mr.JAGADISH st CANDIDATE 1 YEAR M.Sc (NURSING) AND ADDRESS AL KAREEM COLLEGE OF NURSING GULBARGA, KARNATAKA

2 NAME OF THE AL KAREEM COLLEGE OF NURSING GULBARGA. INSTITUTION

3. COURSE OF THE STUDY 1ST YEAR M.Sc(NURSING) AND SUBJECT MEDICAL & SURGICAL NURSING

4. DATE OF ADMISSION 01/08/2012

5. TITLE OF THE TOPIC “A STUDY TO ASSESS THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME REGARDING PREVENTION OF URINARY TRACT INFECTION IN PATIENTS WITH INDWELLING CATHETER AMONG STAFF NURSES. WORKING IN SELECTED HOSPITALS, GULBARGA.” 6. BRIEF RESUME OF THE INTENDED WORK: INTRODUCTION Human body is made up of complex structures which works properly with the synchronized work of all systems, such as respiratory system, digestive system, circulatory system, central nervous system, renal system. Elimination is mainly occurring through digestive system, renal system and integumentory system.1 Renal system is comprised of kidneys, Ureter, bladder, and urethra. The kidney balances urinary excretion of substances against the accumulation within the body through ingestion or production. The ureters conduct urine from the kidney to the bladder by peristaltic movement. The bladder is a distensible chamber that stores urine it is eliminated. The urethra is the exit passage way from the bladder and it carries urine for elimination from the body.2 Urine is a clear and amber in colour. Urine is composed of 96% of water, 2% of urea and remaining 2% is made up of uric acid, creatinine ammonia, sodium, potassium, chlorides, phosphates, sulphates, oxalates. A healthy adult passes 1000-1500 ml per day. The amount of urine produced, and the specific gravity vary according to the fluid intake and amount of solute excreated1. The urine does not contain microorganisms which are causing which causes urinary tract infection. 3 In some conditions person is unable to pass urine from the body, such as acute or chronic urinary retention, benign prostrate hyperplasia, incontinence and the effect of various diagnostic surgical interventions involving the bladder and prostrate in this conditions patients are undergoing catheterization.4 Catheterization is a process of draining urine from the bladder. Which is mainly used for two reasons; for the purpose of diagnosis and the other is for reliving the symptom or as a part of treatment. A catheter which is inserted into the bladder and allowed to remain in the bladder is called as indwelling catheter. A common type of indwelling catheter is Foleys catheter. Nosocomial Urinary Tract Infection (UTI) is a common consequence of indwelling catheterisation.2

6.1. NEED FOR THE STUDY “Prevention is better than cure” Urinary catheterization is the introduction of tube (catheter) through the urethra into the urinary bladder to drain the bladder5. Infection of any kidney, ureter, bladder, or urethra is called as Urinary tract infection. Urinary tract infections are the second most common bacterial disease and the most common bacterial infection in women. Pregnant women are at increased risk for UTIs . UTI’s complicate up to 20% of pregnancies and are responsible for 10% of all ante partum admissions. UTI’S account for more than 8 million of visits each year and are associated with direct costs of $ 1.8 billion more than 1 lack people are hospitalized annually because of UTI’s. More than 15% of patients who develop gram negative bacteriamia die, and 1/3rd of these cases are caused by bacterial infections originating in urinary tract.3 Catheter interferes with the body’s ability to clear microbes from the urinary tract. Bacteria travel through or around the catheter and established a place where they can threw within the bladder. A person who cannot urinate in the normal way or who is unconscious or critically ill often needs catheterization for more than few days. Most UTI’s are not serious but some infections can lead to serious problems such as kidney infection, chronic kidney infections, infections that recur or last a long time can cause permanent damage including kidney scars, poor kidney functioning, high blood pressure, and other problems. Some acute kidney infections that develop can be life threatening especially if the bacteria enter blood stream causing septicemia.6 Catheter associated infection is the most common nosocomial infection accounting for more than one million cases in hospitals and nursing homes. The risk of UTI’s increases with increase in duration of catheterization.7

Use of indwelling catheter can lead to complications. Most commonly catheter is associated with urinary tract infections. Duration of catheterization is the major risk factor. These infections can result in sepsis, prolonged hospitalization, additional hospital costs and mortality.8

Prevalence statistics for urinary tract infections: The following statistics relate to the prevalence of Urinary tract infections:

 1 in 5 women will develop UTIs in their lifetime in America (Kidney and Urology Foundation of America)

 34% of adults over 20 self-reported having at least one occurrence of a urinary tract infection in the US 1988-1994 (Weighted Analysis of 1988-1994 NHANES, 2003, NIDDK)  13.9% of adults aged 20-74 who self-reported having urinary tract infections were men in the US 1988-1994 (Weighted Analysis of 1988-1994 NHANES, 2003, NIDDK)

53.5% of adults aged 20-74 who self-reported having urinary tract infections were women in the US 1988- 1994 (Weighted Analysis of 1988-1994 NHANES, 2003, NIDDK)9Urinary tract infections account for 40% of all Hospital-acquired infections; 80%of those infections are associated with Indwelling urethral catheters.10 In India nurse patient ratio is high. In hurry or unknowingly or not following the universal precautions to prevent nosocomial infections or UTI while catheterization. So researcher is interested to work on this area to prevent the second most common infection of the body. 6.2. Review of the literature A review of literature on the search topic makes the researcher familiar with existing studies and provides information, which to base new knowledge. It creates accurate picture of the information found on the subject.11 A study was conducted on prevention of urinary tract infection in client with indwelling catheter, in Fortis hospital Mohali (India). Practices were monitored, certain observations were made and a team under the stewardship sister in-charge of that ICU was constituted .Education session were held with entire staff of the unit. Changes were made in practices, and these changes were so positive. The study result shows that, the incidence of urinary tract infection was reduced to ZERO for a FOUR month period. The staff was felicitated, they were publicly rewarded and motivation level went up considerably. However over a period of time, UTIs started again. This only emphasizes the need for constant efforts and re-dedication to the cause of stamping out HAI. The ward leadership has to be motivated- they must know what has to be done, and ensure that all staff from the nurses to be cleaning staff (including doctors) knows what their role is.12

A study was conducted to assess the efficacy of a program that combined staff education and performance feedback on Catheter Associated Urinary Tract Infection (CAUTI) incidence in 2 intensive care units (ICUs) in a private, 180-bed acute care facility in Buenos Aires, Argentina. One of the units cared for critically ill medical/surgical patients and the other was a coronary care unit. The intervention consisted of an educational program focusing on hand hygiene and the principles of urinary catheter management promulgated by the US CDC. However, the researchers reported that special emphasis was placed on several strategies to reduce CAUTI incidence. They were hand washing using an antiseptic cleanser prior to catheterization and positioning the catheter in a manner that avoided luminal compression by the leg. Feedback concerning CAUTI incidence and adherence to hand washing and catheter positioning was provided to staff in both units. CAUTI incidence was measured over a 3- month period prior to the educational intervention and over a period of 12 months following the intervention. The incidence of CAUTI declined from 21.3 days of infection per 1000 catheterized days at baseline to 12.4 per 1000 after the combined educational/feedback intervention (relative risk 0.58, 95% CI 0.39–0.86, P = .006), a statistically significant and clinically relevant difference.13

A study was conducted to reduce Catheter Associated Urinary Tract Infection (CAUTI) incidence in a Veteran's Affairs Medical Center in the northeastern United States. Staff education consisted of a videotaped review of catheter care provided to all professional and support staff in each participating unit. The researchers measured CAUTI incidence on a quarterly basis and shared those findings with the chief nursing officer of the facility and with each unit manager. The unit manager, in turn, reviewed the incidence with staff and graphic representations of quarterly incidences were posted for staff to view. This process was repeated quarterly over a period of 18 months, and serial incidence rates were calculated. The pre-intervention incidence of CAUTI was 32 per 1000 catheterized days. Within the first quarter following the intervention, the incidence fell more than 50%. After 18 months, the incidence of CAUTI was 17.4 per 1000 catheterized days (P = .002), a statistically significant and clinically relevant difference.14

A study was conducted to evaluated the effectiveness of a program to reduce the incidence of Catheter Associated Urinary Tract Infection (CAUTI) that included a revised policy for managing indwelling catheters, the addition of 2 additional infection control nurses to the existing staff of a single nurse, introduction of an “improved” closed drainage catheter, and educational classes for nursing staff focusing on the revised policy for catheter management. The setting was a 1400-bed community-based teaching hospital in Hong Kong. Prevalence rates for CAUTI were compared to rates collected approximately 3 years prior to the intervention. After institution of the program described above, the prevalence of CAUTI was measured every 6 months over a period of 30 months. During this period, the prevalence of CAUTI fell from 3.2% to 2.0% (P = .032), a statistically significant difference. Because the prevalence of patient-associated risk factors for CAUTI differed between survey times varied, results were reexamined, using a logistic regression analysis. The decline in CAUTI rates persisted, falling from 9.9% to 6.0% among the highest-risk group and 2.9% to 2.2% in the lower-risk group.15

Randomized and quasi-randomized study was conducted to assess currently marketed antimicrobial urinary catheters for preventing catheter-associated Urinary Tract Infection (UTI)., in Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota 55417, USA 2006 Jan. Data were collected by structured data collection instrument. However, effect size varied considerably and post randomization exclusions were very common. Effect size was greatest in trials of nitroflurazone-coated catheters (all post-1995) and in pre-1995 silver alloy-coated catheter trials and was smallest in post-1995 silver alloy-coated catheter trials. Control group bacteriuria rate, control catheter type (latex vs. silicone), and patient sample (urology vs. other) also predicted effect size. Few studies addressed secondary bloodstream infection, mortality, costs, or microbial resistance. Short-term adverse effects were minimal. Study concludes that antimicrobial urinary catheters can prevent bacteriuria in hospitalized patients during short-term catheterization, depending on antimicrobial coating and several other variables. Older data probably lack current relevance. Cost implications and effect on infectious complications remain undefined.16

A randomized controlled trail study was conducted to antimicrobial catheter to reduce the rate of symptomatic Urinary Tract Infection (UTI) during short term hospital use and is their use cost effective for the UKNHS. In Institute Of Cellular Medicine Newcastle University, Newcastle upon Tyne UK in 2012.elegible participants were randomized 1:1:1 to one of three types of urethral catheter to catheter in order to make the following pragmatic comparisons: nitroflurazone-impregnated silicon catheter compared with slandered Poly Tetra Fluro Ethelin (PTFE)-coated latex catheter: and silver alloy coated hydrogel latex catheter compared with standard PTFE coated latex catheter. Outcome analysis encompassed 6394(90%) of 1702 participants randomized the rate of symptomatic UTI within 6 weeks of randomization was 10.6%, in the nitroflurazone group(n=2153:-2.1% absolute risk differance) 12.5% in the silver alloy group (n=2097:-0.1% absolute risk difference) and 12.6% in th PTFE group (n=2144) the effectsize(odds ratio ([97.5%confidence interval(CI)] was 0.82(97.5% CI 0.66-1.01) for nitroflurazone(p=0.037) and 0.99(97.5% CI 0.81-1.22) for silver alloy (p=0.92) catheters. The nitrflurazone catheters were more likely to cause discomfort during use and on removal the primary economic analysis suggested that nitroflorazone impregnated catheters would be on everage. The least costly(>£7less than PTFE) and most effective option at current NHS prices. There was a 73% chance that nitroflurazone would be cost saving and an 84% chances that the incremental cost per qualy would be <£ 30,000. At the trail price (£6.46) silver alloy catheters were very unlikely to be cost effective theses results were unchanged in sensitivity analysis although when the length of stay cost was excluded. The incremental cost per qualy for nitro flurazone against PTFE was £28.602 economic analysis although associated with uncertainity suggested that nitro flurazone impregnated catheters may be cost effective.17

Studies were identified in MEDLINE, the Cochrane Library, Biosis, the Web of Science, EMBASE, and CINAHL through August 2008. Only interventional studies that used reminders to physicians or nurses that a urinary catheter was in use or stop orders to prompt catheter removal in hospitalized adults were included. Result shows that the rate of Catheter Associated Urinary Tract Infection( CAUTI) (episodes per 1000 catheter-days) was reduced by 52% (P < .001) with use of a reminder or stop order. The mean duration of catheterization decreased by 37%, resulting in 2.61 fewer days of catheterization per patient in the intervention versus control groups; the pooled standardized mean difference (SMD) in the duration of catheterization was -1.11 overall (P = 070), including a statistically significant decrease in studies that used a stop order (SMD, -0.30; P = .001) but not in those that used a reminder (SMD, -1.54; P = .071). Recatheterisation rates were similar in control and intervention groups. The study concludes that Urinary catheter reminders and stop orders appear to reduce the rate of CAUTI and should be strongly considered to enhance the safety of hospitalized patients.18

A conducted a national study to examine the current practices used by hospitals to prevent hospital-acquired Urinary Tract Infection (UTI). mailed written surveys to infection control coordinators at a national random sample

of nonfederal US hospitals with an intensive care unit and ⩾50 hospital beds (n=600) and to all Veterans Affairs

(VA) hospitals (n=119). The survey asked about practices to prevent hospital-acquired UTI and other device- associated infections. The result reveals that the response rate was 72%. Overall, 56% of hospitals did not have a system for monitoring which patients had urinary catheters placed, and 74% did not monitor catheter duration. Thirty percent of hospitals reported regularly using antimicrobial urinary catheters and portable bladder scanners; 14% used condom catheters, and 9% used catheter reminders. VA hospitals were more likely than non-VA hospitals to use portable bladder scanners (49% vs. 29%; P<.001), condom catheters (46% vs. 12%; P<.001), and suprapubic catheters (22% vs. 9%; P<.001); non-VA hospitals were more likely to use antimicrobial urinary catheters (30% vs. 14%; P=.002). the study concludes that, no strategy that appeared to be widely used to prevent hospital-acquired UTI. The most commonly used practices—bladder ultrasound and antimicrobial catheters—were each used in fewer than one-third of hospitals, and urinary catheter reminders, which have proven benefits, were used in <10% of US hospitals.19

A cohort study was conducted to determine the frequency and risk factors associated to bacteriuria after urinary catheterization in women submitted to elective gynecological surgery. At the Instituto de Medicina Integral Professor Fernando Figueira' from January to May of 2007. Among women submitted to gynecological surgery after urinary catheterization., the study included 249 women. At 24 hours after catheter removal, 23.6% of the urocultures collected were positive, while on days 7 to 10 this was reduced to 11.1%. Of all participants studied only 2.4% had symptomatic bacteriuria. Risk of bacteriuria at 7/10 days was reduced when the patient reported a positive history of treatment for vulvovaginitis in the previous three months. However this association was not found after multivariate analysis. There was no significant association with age, education, stage of reproductive phase, number of pregnancies and deliveries, type and duration of surgery, type of anesthetics, and use of prophylactic antibiotic, professional who introduced the catheter and time of urinary catheterization. The study concludes that there was no association between bacteriuria at 7/10 days and any of the variables analyzed. There was no association between bacteriuria at 7/10 days and any of the variables analyzed.20

Non-randomized pilot trial study was conducted to determine whether Escherichia coli 83972-coated urinary catheters in persons with spinal cord injury (SCI) practicing an Intermittent Catheterization Program (ICP) could (1) achieve bladder colonization with this benign organism and (2) decrease the rate of symptomatic Urinary Tract Infection (UTI). Participants had neurogenic bladders secondary to SCI, were practicing ICP, had experienced at least one UTI and had documented bacteruria within the past year. All participants received a urinary catheter that had been pre-inoculated with E. coli 83972. The catheter was left in place for 3 days and then removed. Participants were followed with urine. Cultures and telephone calls weekly for 28 days and then monthly until E. coli 83972 was lost from the urine. Outcome measures were (1) the rate of successful bladder colonization, defined as the detection (>or=10(2) cfu ml(-1)) of E. coli 83972 in urine cultures for >3 days after catheter removal and (2) the rate of symptomatic UTI during colonization with E. coli 83972. Result revels that thirteen participants underwent 19 insertions of study catheters. Eight participants (62%) became successfully colonized for >3 days after catheter removal. In these 8 participants, the rate of UTI during colonization was 0.77 per patient-year, in comparison with the rate of 2.27 UTI per patient-year before enrollment. The study concludes that E. coli 83972-coated urinary catheters are a viable means of achieving bladder colonization with this potentially protective strain in persons practicing ICP.21

6.3 STATEMENT OF THE PROBLEM

“A study to assess the effectiveness of planned teaching programme regarding prevention of urinary tract infection in patients with indwelling catheter among staff nurses, working in selected hospitals, Gulbarga.”

6.4 OBJECTIVES OF THE STUDY 1 To assess the knowledge regarding urinary tract infection and its prevention among staff nurses. 2 To prepare and implement a structured teaching programmme regarding prevention of urinary tract infection. 3 To assess the effectiveness of structured teaching programme regarding prevention of urinary tract infection. 4 To find out the association between knowledge and preventive measure regarding urinary tract infection among staff nurses with their selected demographic variables. 6.5 OPERATIONAL DEFINITIONS

Assess : refers to judging the extent of knowledge of staff nurses regarding prevention of urinary tract infection in patients with indwelling catheter

Effectiveness: In term of significant gain in the mean post test knowledge score as measured In this study it refers to the desired changes brought out by the teaching programme and it’s Measurement by a structured knowledge questionnaire prepared by investigator. Planned teaching programme: It refers to the systematically developed Teaching Programme and instructions regarding Prevention of Urinary Tract Infection in client with indwelling catheter with teaching aid designed for the staff nurses to practice the same on the patients.

Prevention: It refers to blocking from getting UTI among patients who are catheterized.

Urinary tract infection: It refers to any infection in the urinary tract or urinary system due to catheterization.

Patient: Refers to a person seeking for treatment and who has been catheterized.

Indwelling catheter: It refers to a catheter is introduced into the bladder through the urethra in order to drain bladder. Staff nurse : Refers to a registered nurse who has completed her diploma or B.Sc Nursing and working in hospital for more than 6 months.

6.6 ASSUMPTIONS Nurses working in selected hospitals may have knowledge regarding urinary tract infection in clients with indwelling catheter. 6.7 DELIMITATIONS The study will be limited only to the registered staff nurses working in hospitals of Gulbarga, Karnataka.

6.8 HYPOTHESIS H1- The mean post test knowledge on practice score of the staff nurses regarding prevention of urinary tract infection in client with indwelling catheter will be significant than the mean pre test knowledge scores. H2- There will be a significant association between the selected demographic variables and the mean knowledge on practice score of staff nurses regarding prevention of urinary tract infection in client with indwelling.

7. MATERIALS AND METHODS 7.1 Sources of Data – Staff Nurses working in selected hospital in Gulbarga. 7.1.1 Research design : Quasi experimental method with pre and post test Without control group and experimental approach was used.

O1 - X – O2 O2 - O1 = E The symbols used are explained as follows.

O1= Pre Test assessment of knowledge regarding prevention of urinary tract infection in client with indwelling catheter. X = Presentation of Planned Teaching Programme.

O2 = Post Test Assessment of Knowledge regarding prevention of urinary tract infection in client with indwelling catheter. E = Effectiveness of Planned Teaching Programme.

7.1.2Research Approach : Evaluative research 7.1.3 Setting of the study : Study will be conducted at selected Hospital Gulbarga. 7.1.4 Population : staff nurses working in hospitals at Gulbarga . 7.2 METHODS OF DATA COLLECTION

7.2.1Sampling technique :Non probability purposive sampling. 7.2.2Sample size :50 staff nurses.

7.2.3.: CRITERIA FOR SELECTION OF SAMPLE INCLUSIVE CRITERIA Staff Nurses who will be:  Working in selected hospitals, at Gulbarga.  Present at the time of data collection.  Qualified as B.Sc. / Diploma in nursing and midwifery.  Willing to participate in the study. EXCLUSIVE CRITERIA: Staff nurses who will be:  Auxiliary nurse and midwife.  Student nurse.  On leave during data collection period.  Not willing to participate.

7.2.2.: DATA COLLECTION TOOL: It consists of knowledge questionnaire to evaluate the pre-test and post test knowledge on practice of staff nurses regarding prevention of urinary tract infection in clients with indwelling catheter. A planned teaching programme will be prepared on the topic. Content validity of the tool will be obtained in consultation with guide and experts in the field of Nephrology, urology, urological nursing, education and biostatistics. Reliability of the tool will be established by test-retest method. The tentative period of collection will be from July-August-2011.

7.2.3: METHOD OF DATA ANALYSIS Descriptive and inferential statistics will be used for data analysis that is mean. Standard deviation, frequency, percentage distribution and paired‘t’ test to compare the pre and post test knowledge on practice scores and chi-square (χ2) test to find out association with the level of knowledge on practice and selected demographic variables of staff nurses. 7.3. DOES THE STUDY REQUIRE ANY INTERVENTIONS? YES. 1. Intervention as a planned teaching programme on prevention of urinary tract infection in clients with indwelling catheter will be conducted among staff nurses. 2. No other invasive procedures are performed as the intervention in this study. 7.4. HAS ETHICAL CLEARENCE BEEN OBTAINED? YES. 1. Confidentiality and anonymity of the subject will be maintained. 2. Informed consent will be obtained from the subjects. A written permission from institutional authority and hospital management will be obtained prior to the study.

8. LIST OF REFERENCES: 1. Anne Waugh . Allison grant. Ross and Wilson Anatomy and physiology in health and illness. Published bychurchil livingstone.9th edition.340-45. 2. Joyce M Black. Jane hokanson, Hawks.medical surgical nursing clinical management for positive outcomes.7th edition vol:1;766-7. 3. Lewis heitkemper Dirksen O’brine Bucher.medical surgical assessment and management of clinical problems.published by mosby. 7th edition. Page no 1136-53 4. Urinary catheterization. Available from URL:www.en.m.wikipedia.org/wiki/urinarycatheterisation. serial online cited on 30 dec 2012. 5. Sr nancy. Principals and practice of nursing. Nursing arts and procedures 5th edition volume 1: page no 312-313 6. Serial online available from URL:HTTP:// www.kidney.niddk.nih.gov/kudiseases/pubs/utiadult. Cited on 30 dec 2012 7. Serial online available from URL:http://www.ncbi.nlm.nih.gov/pubmed/12113866. cited on 30 dec 2012 8. Rev Assoc med Bras. 2009 March-April: 55(2): 181-7. 9. Serial online available from URL:http://www.ncbi.nlm.nih.gov/pubmed/. cited on 30 dec 2012. 10. Sharma LK. SERIAL ON LINE available from URL:http://www.rguhs.ac.in/ // 05_N108_16417 cited on 30 dec 2012 11. Polit and Hungler. nursing research.page no: 3 12. Joyce M Black. Jane hokanson, Hawks.medical surgical nursing clinical management for positive outcomes.8th edition vol:1. 13. Rosenthal VD, Guzman S, Safdar N. Effect of education and performance feedback on rates of catheter- associated urinary tract infection in intensive care units in Argentina. Infect Control Hosp Epidemiol. 2004;25:47–50. [Context Link] 14. Goetz AM, Kedzuf S, Waegner M, Muder RR. Feedback to nursing staff as an intervention to reduce catheter-associated urinary tract infections. Am J Infect Control. 1999;27:402–404. [Context Link] 15. French GL, Cheng AF, Wong SL, Donnan S. Repeated prevalence surveys for monitoring effectiveness of hospital infection control. Lancet. 1989;2(8670):1021–1023. [Context Link] 16. Johnson JR. kuskowski.MA. Wilt TJ.systematic review: antimicrobial urinary catheters to prevent catheter associated urinary tract infection in hospitalized patients.Ann intern Med.2006 jan 17:144(2):116- 26. Serial online available from URL:http://www. ncbi.nlm.nih.gov/pubmed/16418411 cited on 30 dec 2012. 17. Pickard R.Lam T.maclennan G.Stark. et al.types of urinary catheter forrendering symptomatic urinary tract infection, hospitaliesd adults requiring short termcatheterization;multicentered randomized controlled trial and economic evaluation of antimicrobial and antiseptic impregnated urethral catheter (the catheter trail) health technol assess 2012 nov : 16(47):1-197,doi:10.3310/hta16470. 1. Meddings J, Rogers MA, Macy M, Saint S. Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis. 2010 Sep 1;51(5):550-60. doi: 10.1086/655133.serial online available from URL:http://www.ncbi.nlm.nih.gov/pubmed/ 20673003.cited on30 dec 2012 18. Sanjay Saint. Christine P. Kowalski. Samuel R. Kaufman. Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study. Clin Infect Dis. (2008) 46 (2): 243-250. doi: 10.1086/524662 serial online available from URL:http://www. cid.oxfordjournals.org/ content/42/2/243.full. cited on 30 dec 2012 19. Hokanson Hawks P-727. 20. Archives internal medicine;vol.155 no.13,10 July,1995. 9 SIGNITURE OF CANDIDATE

10 REMARKS OF GUIDE

11 NAME AND DESIGNATION OF THE (IN THE BLOCK LETTERS) 11.1 GUIDE 11.2 SIGNATURE

11.3 CO-GUIDE (IF ANY) 11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT 11.6 SIGNATURE

12 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL

12.2 SIGNATURE