AN INVESTIGATION OF THE RELATIONSHIP OF WOUND INFECTION AND EXPOSURE TO HOUSEHOLD PETS: A PILOT STUDY

A Thesis

Presented to the faculty of the School of Nursing

California State University, San Marcos

Submitted in partial satisfaction of the requirements for the degree of

MASTER OF SCIENCE

in

Nursing

Family Nurse Practitioner

by

Rhodora Neu

SPRING 2015

© 2015

Rhodora Neu

ALL RIGHTS RESERVED

ii

CALIFORNIA STATE UNIVERSITY SAN MARCOS

THESIS SIGNATURE PAGE

THESIS SUBMITTED IN PARTIAL FULLFILLMENT OF THE REQUIREMENTS FOR THE DEGREE

MASTER OF SCIENCE

IN

NURSING

THESIS TITLE: An investigation of the relationship of wound infection and exposure to

household pets: A pilot study

AUTHOR: Rhodora Neu

DATE OF SUCCESSFUL DEFENSE: April 17, 2015

THE THESIS HAS BEEN ACCEPTED BY THE THESIS COMMITTEE IN PARTIAL FULLFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING.

Denise Boren, Ph.D., RNTHESIS COMMITTEE CHAIR SIGNATURE DATE

Patricia Hinchberger, Ed.D., GCNS, RNTHESIS COMMITTEE MEMBER SIGNATURE DATE

Linnea Axman, Dr.PH., MSN,FNP-BC, FAANPTHESIS COMMITTEE MEMBER SIGNATURE DATE

iii

Student: Rhodora Neu

I certify that this student has met the School of Nursing format requirements, and that this thesis

is suitable for shelving in the Library and credit is to be awarded for the thesis.

__________________________, Director ___________________Denise Boren, PhD, RN Date

School of NursingCollege of Education, Health, and Human ServicesCalifornia State University San Marcos

iv

Abstract

of

An investigation of the relationship of wound infection and exposure to household pets: A pilot study

by

Rhodora Neu

Statement of ProblemIn most industrialized countries, pets are becoming a big part in households engaging and sharing human lifestyles. In fact, it is estimated that 14%-62% of pet owners allow their dogs and cats on their beds. However, pets can also carry and transmit pathogens to people causing public health risks. Little is known about public knowledge and practices associated to pet related diseases, otherwise known as zoonotic diseases. The closeness of pet owners and their animals could pose a potential risk for transmission of at least 30 infectious agents. Zoonoses are diseases communicable from animals to humans.

Sources of DataData was collected from a convenience sample of prospective, new patients at a Wound Care Center in Southern California. A copy of the wound culture results was collected. Participants completed an Exposure to Pet Survey Questionnaire that included demographic data, type of pet in the household, frequency of time spent with the pet based on six items, and hand hygiene.

Conclusions ReachedThe independent variable did not have significant correlation with the dependent variable (p=.137). A large-scale study is suggested to further investigate this hypothesis. However, hand washing showed a strong correlation with frequency of pet engagement (p=<.01), and suggests an inverse relationship with documented wound infection.

_______________________, Committee ChairDenise Boren, Ph.D., RN

_______________________Date

v

ACKNOWLEDGEMENTS

I am indebted in the preparation of this thesis to my committee, Dr. Denise Boren, Dr. Patricia Hinchberger, and Dr. Linnea Axman of California State University San Marcos. Each

contributed to this project in their own unique way. I wish to thank each one immensely for their support, kindness, patience and for their words of wisdom and encouragement.

I would also like to thank my husband, Mark Neu who has been my rock since the beginning of this journey. His unwavering love and support especially in times of stress and frustration have

been my constant source of drive and motivation. I could not have done this without him.

To my cat Bruno, who is now across the rainbow bridge was my late night companion, purring away on my desk while I am studying and burning the midnight oil. He taught me how to love

unconditionally.

And last but not the least, to my dog Izzy whose persistent need for attention always reminded me to take a study break for playtime.

.

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TABLE OF CONTENTSPage

Preface............................................................................................................................i

Abstract..........................................................................................................................v

Acknowledgments.........................................................................................................vi

List of Tables................................................................................................................ix

List of Figures................................................................................................................x

Chapter

1. INTRODUCTION ………………………………………………………………...1

Background and Significance...........................................................................2

The Problem...................................................................................................... 4

Purpose of the Research....................................................................................4

Research Questions…………………………………………………………….5

Research Variables…………………………………………………………….5

2. LITERATURE REVIEW.......................................................................................7

Introduction.......................................................................................................7

Major Variables Defined.................................................................................11

Theoretical Framework……………………………………………………….12

Summary……………………………………………………………………...14

3. METHODOLOGY………………………………………………………………..15

Introduction……………………………………………………………………15

Research Questions……………………………………………………………15

Identification of Setting……………………………………………………… 16

Research Design………………………………………………………………16

Population and Sample………………………………………………………..17

Measurement Methods………………………………………………………..19

Data Collection Process………………………………………………………20

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Coding and Scoring…………………………………………………………...20

Data Analysis…………………………………………………………………21

Bias……………………………………………………………………………21

Ethical Considerations………………………………………………………...22

Summary………………………………………………………………………22

4. RESULTS…………………………………………………………………………23

Introduction……………………………………………………………………23

Sample ………………………………………………………………………...23

Data Collection and Preparation……………………………………………….25

Instruments……………………………………………………………………..28

Results by Research Questions……………………………………………….. 30

Summary……………………………………………………………………….33

5. DISCUSSION……………………………………………………………………...34

Introduction ……………………………………………………………………34

Major Findings by Research Question ………………………………………...34

Limitations ……………………………………………………………………..36

Generalizability ………………………………………………………………...37

Implications for Nursing Research ……………………………………………..37

Recommendations for Future Research…………………………………………37

Summary…………………………………………………………………….......38

Appendix A. Approval to conduct study at wound care clinic………………………...40

Appendix B. CSUSM IRB Approval Letter…………………………………………...42

Appendix C. Palomar Health IRB Approval Letter with IRB-stamped Informed

Consent Form, California Bill of Rights and Exposure to

Pet Survey Questionnaire…………………………………………………43

References……………………………………………………………………………….49

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LIST OF TABLESTables Page

1. Frequency of Infection and type of pathogens………………………………… 25

2. Linear regression analysis showing collinearity statistics……………………....29

ix

LIST OF FIGURESFigures Page

1. Schematic representation of antimicrobial use in small animals and humans…..10

2. Schematic representation of Germ Theory………………………………………14

3. A priori power analysis................................................................………….……18

4. Distribution for Age..............................................................................................26

5. Distribution for Chronic Diseases………………………………………………..27

6. Distribution for Hand washing post pet handling………………………………...28

x

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CHAPTER ONE: INTRODUCTION

Studies have shown that potential pathogens are found in the home environment

and these pathogens are introduced into the home in different ways including by pets

such as cats and dogs. Household pets are considered and frequently treated as members

of the family. There is high-level of physical contact between humans and pets which

will allow for the transmission of bacterial pathogens, including the widely known

Methicillin-resistant Staphylococcus Aureus (MRSA). This could result in a potential

public health concern because of the spread of MRSA from humans to pets, and from

those pets to other pets and finally to other humans. According to Whachter (2006), “the

household pet issue is a more concerning issue because of the degree, duration and

intensity of contact that we have with our pets in most situations” (Wachter, 2006). The

latter statement was also mentioned by J. Scott Weese (2006), D.V.M., a veterinarian and

a professor of large animal medicine at the University of Guelph in Ontario, Canada

during the annual Interscience Conference on Antimicrobial Agents and Chemotherapy in

2006. This study will investigate wound care patients in a small wound care clinic in

Southern California who have a wound infection and determine if there is a relationship

between wound infection and exposure to household pets.

This research study was based on the theoretical framework of Louis Pasteur on

Germ Theory of Disease. The theory states that specific microorganisms are the cause of

specific diseases. This theory led to the development of antibiotics and recommended

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hygienic practices for individuals exposed to germs (Kusinitz, 2011). This theory will be

more thoroughly discussed in Chapter Two.

Background and Significance

Human beings have long valued their relationship with their pets. Dogs were first

domesticated in China about 15,000 years ago while the first domesticated cat originated

in Cyprus almost 9,500 years ago. In 2009 there were about 75 million dogs and 88

million cats owned in the United States. In the United Kingdom, there are about 27

million domestic pets, inhabiting about 43% of British households (Oehler, Velez,

Mizrachi, Lamarche & Gompf, 2009). Pets are an integral part of the household and are

part of human lifestyles (Bruno & Sun, 2011). For instance, an estimated 14%-62% of pet

owners allow their pets in the bedroom and let their pets sleep on the bed with them.

According to Oehler et al. (2009), the closeness of pet owners and their animals could

pose a potential risk for transmission of at least 30 infectious agents. Zoonoses are

diseases communicable from animals to humans (CDC website). Different species such

as Pasteurella, Streptococcus, Fusobacterium, and Capnocytophaga are examples of

isolates that contain a mix of anaerobes and aerobes cultured from patient’s skin and the

animal’s oral cavity. A study done by Rollof and colleagues found that 17 out of 21 dogs

(81%) harbor Pasteuralis multocida in their saliva (Rollof, Fredriksson, Holst, 1989).

Another study by Lin and his colleagues found that Staphylococcus aureus was present in

6.6% of dogs, 39% of cats, 83.8% of horses and 100% of pigs, rabbits, hamsters and rats.

Of these, 36.4 % were MRSA positive (Lin, Baker, Kislow, Kaldhone, Stemper,

Pantrangi, Moore, Hall, Frische, Novicki, Foley, Shukla, 2010). An example of a case

3

report presented by Knowles and colleagues in Nursing Times describes a patient who

developed cellulitis from the wound ulcers. The wound culture grew Staphylococcus

aureus (S. aureus) and blood culture grew β-hemolytic streptococci and Pasteurella

multocida. The patient recalled that his dog licked his wound a few days before the

symptoms manifested although the article did not specify that the dog was swabbed or

tested. (Knowles, Gould, Hartley & Gudi, 2000). In addition there were several cases

reported by Oehler et al, 2009, of C. canimorsus cultured from a wound, 59% of which

were from a dog bite, 10% were present on the skin from dog licking and with a mortality

rate of 31% due to sepsis.

Not much is known about the zoonotic transmission of bacterial pathogens in

companion animals in United States so it important to learn more about it. People can get

zoonotic diseases from contact with domesticated or wild animals. People with a

weakened immune system, children, elderly and pregnant women are more susceptible to

zoonotic diseases. Approximately 60% of human pathogens are zoonotic (CDC website).

The zoonotic transmission of MRSA from companion animals has not been well studied.

It is important to recognize and report the rate of prevalence of S. aureus and MRSA from

samples of animals requiring treatment at veterinary clinics (Lin et al., 2010). Moreover,

recognition and prevention of community-acquired pathogens, including MRSA will

reduce in-patient hospitalization or outpatient clinic visits. Mannion (2013) purported that

lower readmissions and improved quality of care may result from strategic infection

control program. Thus, a gap in knowledge focused on zoonoses should be explored more

in medicine and by nursing, should be taken into consideration when dealing with

4

patients that have an infectious disease. Further study in this target population is

considered beneficial to determine if wound infection is related to exposure of household

pets.

The Problem

There is an increased problem with zoonoses and its public health risk is

associated with practices such as allowing pets on the bed, giving kisses or allowing pets

to lick (Bruno & Sun, 2011). The degree of duration and the intensity of physical contact

between humans and their pets allow for transmission of pathogens (Wachter, 2006).

There are not enough studies that investigate if wound infections are related to the

exposure of household pets.

Purpose and Significance of the Research

The purpose of the study was to investigate the relationship between prospective,

new patients at a small wound care clinic in Southern California with wound infections

and exposure to household pets. The significance of the proposed study to nursing is the

importance of taking into consideration transmission of bacteria from pets to humans

when assessing a patients’ environmental setting at home. Upon admission to the wound

care clinic, nurses must find out if there are pets in the patient’s household. There is lack

of knowledge and public awareness of prevalence of S. aureus and MRSA in animals (Lin

et al, 2010). It is something to consider if pets are a potential source of infection. It is also

significant to educate patients with open wounds or ulcers to keep their pets away in

order to avoid further complications, thus preventing morbidities and mortalities. Proper

management and use of appropriate therapy for the specific infection will help reduce

5

hospital visits and alleviate enormous health care costs. As clinicians, it is vital that

prompt reporting is made to the CDC to help increase awareness and prevention of the

spread of infection. Prevention of acquiring community-acquired MRSA (CA-MRSA)

helps reduce hospital admissions (Mannion, 2013). And lastly, it is important to conduct

further research, on a larger scale, to investigate the relationship of wound infection and

exposure to household pets.

Research Questions

The research questions for this study were:

1) “Is there a relationship between people who present to wound care clinics for

would care and pet ownership?”

2) “What is the frequency of people with a pet that present to the wound care clinic

with wound infection?”

3) “Is there a statistically significant relationship between documented wound

infection and pet ownership?”

4) “Is there a difference in frequency of documented wound infections and the time

spent with household pets (low amount of time versus high amount of time)?”

Research Variables

The dependent variable in this study was wound infection regardless of whether it

was aerobic or anaerobic in nature. The independent variable was the patient’s exposure

to household pets. The degree of exposure was determined by exploring at the following

items: feeding the pet, cleaning the pet area, playing with pet, giving kisses to the pet,

letting the pet sleep on the bed and walking the pet. Demographic variables such as

6

proper hand washing after handling the pet, age and co-morbidities or chronic illnesses

were included in this investigation. These variables perhaps play an important role in

identifying relevance that might relate to this investigation.

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CHAPTER TWO: LITERATURE REVIEW

Introduction

The databases reviewed for this literature review included CINAHL, PubMed,

and Google Scholar. Twenty-five (25) abstracts of peer-reviewed articles including case

reports and letters to the CDC have been reviewed for inclusion. Literature search terms

included wound infection, dogs, cats, MRSA, zoonosis, bite wounds, bacterial infection

and bacterial colonization in pets, animal to human transmission of pathogens and

emergence of pathogens from animals to humans. The search was limited to English,

peer-reviewed articles published after 1990. The researcher focused on journal articles

and case reports that concentrated on the virulence of pathogens in companion animals or

household pets and the reason for wound infection.

Coyner (2012) purported that since the 1970s MRSA has been documented in

large animals but was not reported in dogs until the 1990s. In a study comparing 50 dogs

with normal skin and 59 dogs with inflamed skin, S. aureus was cultured in 12% of dogs

with inflamed skin and 17 % of these cases were methicillin resistant. MRSA in cats and

dogs is most frequently cultured from wounds, abscesses, otitis and pyodermas (Coyner,

2012). Another study conducted by Faires, et al. (2010) using dogs (n = 40) with MRSA

and dogs (n = 80) with Methicillin-Susceptible S. aureus (MSSA), showed most infections

were located on the skin (Faires, Traverse, Tater, Pearl, Weese, 2010).

8

In 2009, Loeffler, et al. conducted a case-control study investigating risk factor

for MRSA infection in dogs and cats between 2005 and 2008; 106 pets with MRSA and 91

pets with MSSA and veterinary staff and pet owners (n = 608) were screened for S. aureus

nasal carriage. Results showed that MRSA carriage was 12.3 % in veterinarians attending

MRSA-infected animals and 7.5% in their owners (Loeffler, Pfeiffer, Lloyd, Smith,

Soares-Magalhaes & Lindsay, 2009).

Several longitudinal studies conducted at veterinary hospitals revealed the

resistance to antimicrobial agents has emerged among pet isolates such as S. intermedius,

E. coli, MRSA, Vancomycin-resitant enterococci and Salmonella Typhimurium

(Guardabassi, Schwarz & Lloyd, 2004). Guardabasi et al., (2004) added that cats and

dogs are potential sources of antimicrobial resistance due to extensive use of

antimicrobial agents and their close contacts with humans. In the past, dogs were usually

kept outdoors but today they are often kept inside houses. The current perception that

pets are actual family members is manifested by close physical contact such as touching,

petting, and licking which occurs at high frequency. Dog owners affected with pyoderma

usually carry the same strain occurring in their dog and are usually resistant to

antimicrobial agents including penicillin, fusidic acid, macrolides, tetracyclines and

chloramphenicol. Pet-associated zoonoses are usually sporadic with frequencies not

easily determined because it is difficult to recognize and validate disease transmission

from pets. Transmission of antimicrobial-resistant genes poses a risk when the strain

harbors resistance genes that are of clinical relevance to human medicine (Figure 1). Bite

wounds in humans from cats and dogs can have serious consequences unless the

9

susceptibility of the infecting organism is determined and appropriate therapy is given

(Guardabassi, Schwarz & Lloyd, 2004).

10

Figure 1. Schematic representation of consequences of antimicrobial use in small animals and transfer of resistant genes to humans which was obtained from the article Pet animals as reservoirs of anti-microbial-resistant bacteria by Guardabassi, et al. 2004

11

A case study was reported by Knowles (2000) on a 54 year old man who was

referred to the dermatology unit with persistent ulceration and edema on both legs. He

was admitted with rigors, pyrexia and increasing pain and erythema of both legs. On

examination, it was confirmed that he had cellulitis. A wound swab grew S. aureus and

blood culture grew β-hemolytic streptococci and P. multocida. The patient remembered

that his dog had licked his wound a few days before his symptoms occurred. Bacteremia

also occurs most commonly in patients with underlying chronic disease such as cirrhosis

of the liver, COPD, immunodeficiency and malignancies. Mortality rates can be as high

as 31% either from the disease or septicemia (Knowles, Gould, Hartley & Gudi, 2000).

Another case was of a 51 year old female who had a diabetic foot ulcer and

cultures grew MRSA (Duijkeren, Wolfhagen, Heck, & Wannet, 2005). She was treated

with trimethropim-sulfamethoxazole however, two months later she was still positive for

MRSA. She developed a urinary tract infection and was treated again using ciprofloxacin

and rifampin. This time the MRSA infection was eradicated for half a year. After these

findings, a source of the recurrent MRSA was suspected at home. The husband, son and

the dog were swabbed and all three were also positive for MRSA. They were treated with

ciprofloxacin and rifampin and this eradicated the MRSA carrier state of the husband, the

son and the dog.

Major Variables Defined

Dependent variable. Wound infection was based on the laboratory result

received from the microbiology laboratory of the wound culture. A wound culture order

is an order for culture and sensitivity of the tissue taken by the wound care physician post

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debridement and prior to treatment. It took 72 hours to determine the specific aerobic and

anaerobic bacteria that grew from the culture and was indicated by light, moderate or

severe growth.

Independent variable. Exposure to household pet is defined as having a pet at

home, regardless of whether the pet is indoor or outdoor, and was determined by the total

number of the times per day the pet owner was in contact with the pet.

Demographic variables. The variables were defined as follows. Age is defined

as the amount of time during which the person has lived (Merriam Dictionary). This

variable was explored to determine if there is a difference in age when it comes to

ownership of pet. Co-morbidities are the presence of more than one disease in one person

at the same time. The Centers for Disease Control and Prevention describes co-

morbidities as conditions that are often long-term conditions (CDC website). Examples of

co-morbidities are diabetes mellitus, rheumatoid arthritis, HIV, renal failure, lupus,

chemotherapy, radiation, etc. Co-morbidities were also considered as a demographic

variable for this research study because it is a well-known fact that people with weakened

immune system have a higher risk of getting an infection (CDC website).

Theoretical Framework

As introduced in Chapter One, the proposed research study will be based on the

theoretical framework of Louis Pasteur’s Germ Theory of Disease in 1857. The Germ

Theory is the fundamental belief in medicine that microorganisms which are too small to

be seen without the aid of a microscope, can invade the body and cause certain diseases.

He discovered “diseases” of wine and beer. When asked by brewers why wine and beer

13

sometimes get spoiled, he explained that while yeasts produce alcohol from the sugar in

the brew, bacteria can change alcohol to vinegar. He suggested that brewers heat their

products enough to kill bacteria, thus the process called pasteurization. He made a

connection between food spoilage and microorganisms as a key step in demonstrating the

link between microorganisms and disease. He also observed that there are similarities

between the diseases of animals or man and the diseases of beer and wine. These

observations linked the activity of microorganisms to disease until 1876, when German

physician Robert Koch proved that bacteria can cause disease. He showed that the

bacterium Bacillus anthracis was the cause of anthrax in cattle and sheep and he also

discovered the organism that causes tuberculosis. It was Koch that developed a set

guidelines for determining the cause of infectious diseases. He postulated that an

organism must be present in every case of the disease and must be isolated from a host

with the corresponding disease and grown in pure culture. Then the samples from the

pure culture must cause the corresponding disease when inoculated into a susceptible

laboratory animal and the organism must be isolated from the inoculated animal and

identified as being identical to the original organisms isolated from the initial, disease

host (Figure 2). His notion laid the foundation for the study of infectious disease and

modern medical microbiology. This theory helps identify, understand and manage

infectious disease by identifying the contributing agent and then preventing and treating

the disease (Germ Theory, 2013).

14

Figure 2: A schematic representation of a germ reproducing as it enters a host and transfers to another host.

Summary

The relationship between Germ Theory of Disease and the major variables in this

research is illustrated in Figure 2. A germ is isolated from a host, in this study the

household pet; it reproduces and then is transmitted to another host, which is the human.

The same organism is isolated from the human and is identified as the original organism

isolated from the initial host.

The review of available literature indicated that household pets can be carriers of

virulent pathogens and can colonize humans while living in close contact with them.

These colonized pets can result in recurrent infection in humans. It is important to

recognize the risk of pets being the source of unexplained carriage or relapse of infection

in humans. The use of appropriate antimicrobial therapy, whether to infected humans or

pets, can eliminate recurrent pathogen carriage.

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CHAPTER THREE: METHODOLOGY

Introduction

This was a pilot study utilizing a quantitative approach. A self-report method of

data collection by way of a patient survey and prospective patient chart reviews were

conducted as part of the study design. The purpose of this study was to explore the

relationship between wound infection and exposure to household pets. The researcher

created the instrument that was used for this study which was called the Exposure to Pet

Survey Questionnaire. A post hoc analysis was performed after study completion to

determine reliability and validity of the questionnaire. Analysis of data was performed

using descriptive statistics and the relationship between wound infection and exposure to

household pet(s) was determined using correlation methods.

Research Questions

The research questions in this study were:

1) “Is there a statistically significant relationship between people who present to a

wound care clinic for wound care and pet ownership?”

2) “What is the frequency of patients that present to a wound care clinic with a

wound infection as documented by a positive wound culture that also have a pet?”

3) “Is there a statistically significant relationship between documented wound

infection and pet ownership?”

4) “Is there a difference in frequency of documented wound infections and the time

spent with household pets (low amount of time versus high amount of time)?”

16

Identification of Setting

The setting for the study was at a hospital-based wound care clinic in Southern

California (Appendix A). The clinic staff includes one nonclinical director, four certified

wound care physicians, five registered nurses, three licensed vocational nurses and one

hyperbaric technician. The clinic sees approximately 120 patients per month and about 60

new patients are referred every month. The clinic operates Monday through Friday from

8:00 a.m. to 4:30 p.m. The patients are seen on a weekly basis with an average healing

time of 8-12 weeks.

Research Design

As mentioned in the Introduction, this was a pilot study. A pilot study is a small-

scale version designed to test the methods to be used in a larger study (Polit & Beck, p.

195, Chapter 8). This is a quantitative, nonexperimental research design. In quantitative

studies, the variables are identified, operational definitions are defined then relevant data

is collected. The data are in numeric form (Polit & Beck, p. 53, Chapter 3). According to

Polit and Beck, many quantitative nursing studies aim to elucidate cause and effect (Polit

& Beck, p. 232, Chapter 9).

There were potential threats identified to the internal validity of this research

study. The temporal validity was a threat because it begs the question which infection

came first, the pet with MRSA or the human with MRSA. History was determined to be a

potential threat as well. There may have been a concurrent event that was happening to

the pet; perhaps; a recent visit to the veterinary clinic where MRSA could possibly been

contracted.

17

There were some limitations that were identified in this research study. The

researcher anticipated that there may be a reliability and validity to the instrument as it

was developed independently. This topic will be discussed further in Chapter Four. Pets

were not swabbed in this study so there was no evidence to prove that the pet was the

source of the infection. The researcher relied on peer-reviewed journals and used it as

evidence to prove the relationship of zoonotic diseases and transmission to humans.

Population and Sample

The participants were recruited using non-probability convenience sampling.

According to Polit & Beck, convenience sampling entails using the most conveniently

available people as participants (Polit & Beck, p. 276, Chapter 12). An Institutional

Review Board (IRB) approval was granted from Palomar Health IRB (Appendix C) and

California State University, San Marcos (CSUSM) IRB (Appendix B) to recruit

participants and conduct the study. Prospective, new patients to the wound care clinic

were recruited to participate in the study and informed about the study. All participants in

this study were over 18 years of age and proficient in English.

The total sample size for this study was calculated to be 67 in order to achieve a

power of .80 (Figure 3). The conventional standard for 1-β (power) is .08 (Polit & Beck,

p. 423, Chapter 17). The target sample size (n=80) provided for .30 effect size in a

correlation bivariate normal model with a significance level of .10. According to Polit

and Beck, an effect size is calculated based on findings from earlier studies. However, if

there are no relevant earlier findings, researchers use a conventional approach with

expectations of a small, medium or large effect. Most nursing studies have modest

18

(small-to-medium) effects (Polit & Beck, p. 423, Chapter 17). An additional 20% was

added to the calculated sample (n=67) for loss factors (e.g. failing to complete the

survey). Therefore, the target number of participants was set at 80 and the first 80 new

patients who were referred to the wound care clinic from the time the IRB granted

approval, were approached and asked to participate in the study. Figure 3 below is the

power analysis prior to data collection.

Figure 3. A priori power analysis

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With regard to the limitation of the sample’s generalizability, it was suspected

that not all participants own a pet and if they do, there were varying degrees of exposure

and physical contact with the pet.

Measurement Methods

As mentioned in the Introduction of this chapter, the researcher developed the

instrument that was used for this study. The measurements used for the different variables

in this study were the following: “wound infection” being the dependent variable was

measured as a nominal variable. It was determined based on whether or not the wound

culture grew certain bacteria after 72 hours. The independent variable, “exposure to

household pet(s)” was measured using ordinal measurement because the study looked at

how many times per day the patient was in physical contact with his or her pet.

According to Polit & Beck, frequency count is appropriate for ordinal level data (Polit &

Beck, p. 380, Chapter 16). To further explain what entails “exposure to household pet(s),

the six item questions in the Exposure to Pet Survey Questionnaire (Appendix C) were:

feed the pet, play with pet, clean pet area, give kisses to pet, let pet sleep on the bed, and

walk the pet and were categorized based on time spent with the pet. It was either 0-1 time

per day, 1-2 times per day and 2-3 times per day. Each category was assigned a score of

1, 2, or 3, respectively. Each check mark was indicated under the times per day column

for each of the six items; a sum of the score was entered into the SPSS database under

frequency score. The “exposure to household pet” is interchangeable to “time spent with

pet” which was later converted into a frequency score. Demographic variables such as

age was measured as a ratio variable while co-morbidities or chronic illness (e.g.

20

diabetes, rheumatoid arthritis, and end stage kidney failure) was measured as a ratio

variable as it determined the number of chronic illnesses the patient has.

Data Collection Process

As mentioned under Population and Sample, IRB approval from both California

State University San Marcos (Appendix B) and Palomar Health IRB (Appendix C), were

obtained prior to data collection. The researcher was IRB certified via CSUSM’s online

IRB training for protection of human rights. Study recruitment and data collection started

in June 2014. At week 0, during the new patient visit and admission to the wound care

clinic, the potential study participant was approached and was asked if he or she is

willing to participate in the study. An informed consent form was signed by the

participant for willingness to participate. The participant was also encouraged to take it

home if he/she wished to discuss the study with family members. On the following week,

the patient was asked to complete the Exposure to Pet Survey Questionnaire with the

wound culture available by then. The researcher collected a copy of the wound culture

result from the patient’s medical chart. All patient identifying information was de-

identified and data was stored in a locked cabinet in the supervisor’s office.

Coding and Scoring

The dependent and independent variables were dichotomized. The dependent

variable: 0 = for no wound infection and 1 = with wound infection; independent variable:

0 = for no pets and 1= with pets. The 6 items in the Exposure to Pet questionnaire were

coded as follows: 1=feed pet; 2= clean pet area; 3= play with pet; 4= give kisses all the

time; 5= let pet sleep on the bed; 6= walk pet. These items were based on the number of

21

times the participant spent time with their pet/s. It was scored as follows: 1=0-1 times per

day; 2= 2-3 times per day; 3= more 3 times per day. The scoring was explained under

Measurement Methods in this chapter.

Data Analysis

International Business Machines Statistical Package for the Social Science (IBM

SPSS) version 21.0 was used for data management and to perform data analysis. The

analysis consisted of descriptive statistics, frequency distributions and bivariate

correlations. The proposed analysis of data included the level of measurements (e.g.

ordinal, interval or ratio) as appropriate to the research problem. According to Polit &

Beck, correlation procedure describes relationship between two variables and it can be

graphed through a scatter plot using the X and Y axis to determine a positive or negative

relationship of the two variables based on the direction of the slope. (Polit & Beck, p.

390, Chapter 16). The level of significance was set at p=.10 for this pilot study.

Bias

The use of convenience sampling was a source of possible bias due to the

participants self-selecting to participate in the research study. The required sample may

not be representative of the target population. The fact that the researcher is also one the

wound care nurses at the wound care clinic where the research study was conducted was

another potential source of bias. There was a concern of participants being obligated to

participate due to feeling pressured to participate. Another cause for potential bias was be

that the researcher’s spouse is a non-scientific member of Palomar Health IRB. In order

22

to mitigate this issue, the researcher’s spouse recused himself when the study was

presented to the IRB committee for approval.

Ethical Consideration

As mentioned under Data Collection Process, the researcher sought IRB approval

first before conducting the study. Study participants were 18 years or older and were

admitted to the wound care clinic. No participants who were high risk, such as children or

those diagnosed with mental illness were recruited into the study. Participants spoke and

understood English and were willing to volunteer and participate in the study. No

incentives were offered for participation. Subject confidentially was protected by

assigning a study number to each participant. The participant study number was being

used as reference when data was entered into SPSS.

Summary

There were no challenges encountered during the data collection process. All

participants who participated in this research study were willing to participate and all

expressed interest in the study outcome. However, there was a delay in achieving the

desired number of research study participants as previously planned (September 2014)

because the wound care clinic had a slower than usual new patient registration in the fall

2014. Nevertheless, the research study investigator continued enrollment one month past

the enrollment deadline and was able to achieve the target number of participants needed

for this research study.

23

CHAPTER FOUR: RESULTS

Introduction

Chapter Four provides the results of the research questions. It presents the sample

and demographic variables. The results are presented by each research question. The

results of the reliability and validity evaluation of instrument used for this research study

is discussed. To reiterate, the research questions in this research study are the following:

1) Is there a statistically significant relationship between people who present to a

wound care clinic for wound care and pet ownership?

2) What is the frequency of patients that present to a wound care clinic with wound

infection as documented by a positive wound culture that also have a pet?

3) Is there a statistically significant relationship between documented wound

infection and pet ownership?

4) Is there a difference in frequency of documented wound infections and the time

spent with household pets (low amount of time versus high amount of time)?

Sample

All variables were examined for normality using mean, median, and mode. Study

participants were described using frequency distribution. There were 80 study

participants and three demographic variables were collected for the purpose of this study.

They were age, number of chronic diseases each individual participant has and, whether

or not hand washing was done after engaging with the pet(s). The participants’ age

24

ranged between 20-99 years of age, with the mean age at 73 years and the median at 75

years. A self- report number of chronic diseases showed an uneven distribution across the

study participants. The most frequent number of chronic diseases among the study

participants was two (f=25; 31.3%). With regards to hand washing after engaging with

pets, participants (f=25; 31.3%) reported that they wash their hands while others (f=14;

17.5%) reported that they do not wash their hands. The rest of the participants do not

have pets (51.2%) and left the question unanswered.

Wound infection (DV) was evident in (f=46; 56.3%) and (f=34; 42.5%) without

wound infection. Wound infection was based on the documented result of the wound

culture collected at Week 0. Of the culture test, S aureus was the most frequent bacterial

pathogen present in an open wound (f=28; 35%). See Table 1.

Participants (f=39; 48.8%) were fewer than those without pets (f=41; 51.2%).

Dogs were the most frequently owned pet (f=19; 23.8%) followed by cats (f=13; 16.3).

The majority of pets were kept indoors (f=21; 26.3%) while others were kept outdoors

(f=6; 7.5%). Other participants reported having their pets both indoors and outdoors

(f=12; 15.0%).

25

Data Collection and Preparation

After obtaining IRB approval from CSUSM and Palomar Health, data points were

collected using the study questionnaire found in Appendix C. The data were collected

over a six month period and were imported into SPSS 20.0. There was no missing data.

The database was double-checked for accuracy and then statistical analyses was

performed. All variables were analyzed for normality. The frequency of distribution as

far as age showed a negative skew (Figure 4). The M = 73.28, Md = 75.50 and Mode =

90 indicates that participants who presented to the wound care center for care were

mostly older adults.

26

Figure 4. Distribution for Age

Chronic diseases displayed a positive skew in the frequency distribution (Figure

5). Diabetes and venous insufficiency were the two most common chronic diseases (M =

2.31) contributing to chronic non-healing wounds based on medical history.

27

Figure 5. Distribution for Chronic Diseases

Hand washing post handling of pets also displayed a positive skew in the

frequency distribution (Figure 6) indicating that people with pets are more aware of

observing proper hand hygiene after engaging with their pet.

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Figure 6. Distribution for Hand Washing Post Pet Handling

Instruments

The study investigator created the instrument that was used for this research

study. Face validity was established with creation of the instrument through literature

review and subject matter expert input. The reliability of the questionnaire was evaluated

using bivariate correlational analysis and Alpha and Split Half techniques. The reliability

analysis revealed a .95 for both Cronbach’s Alpha and Split Half analyses.

29

There were seven variables and items tested in this tool. The variables were:

“hand washing post pet handling”, “feed pet”, “clean pet area”, “play with pet”, “give

affection”, “pet sleep on bed”, and “walk pet”. There was suspicion of multicollinearity

of the scale variables. A multicollinearity evaluation was performed using multiple

regression. The Variance Inflation Factor (VIF) and tolerance are “both widely used

measures of the degree of multicollinearity on the independent variable with the other

independently variables in a regression model” (O’Brien, 2007). VIF was evaluated in

this study and results showed less than 10 on all study variables. There are some

guidelines that can be applied based on this outcome. A VIF less than 3.3 shows an

excellent value (Diamantopoulos and Siguaw, 2006) and a VIF less than 10 indicates that

no collinearity is commonly accepted (Hair et al., 1995). Thus, reliability evaluation for

formative constructs is to assess the assumption of no multicollinearity (Diamantopoulos

and Siguaw, 2006). Based on this criteria, multicollinearity did not exist in the frequency

of interaction scale with pets based on the VIF collinearity statistics presented in Table 2.

Table 2.

Linear regression analysis showing collinearity statistics

Variable Tolerance VIF

Feed pet .167 5.973Clean pet area .158 6.319Play with pet .133 7.500Give affection .190 5.254 Pet sleep on bed .295 3.386 Walk pet .131 7.650Hand washing post pet handling .253 3.949

30

Results of Research Questions

All data were examined using IBM SPSS Statistics 20.0 software (2011) for

frequency, mean, median, mode, and distribution as applicable. Following frequency

distribution analysis, data were analyzed for correlations using Pearson’s correlation.

In a bivariate correlation analysis there was no statistical significance found

between the dependent variable “wound infection” and the independent variable

“frequency of pet interaction score” (p= .137). The significance demonstrated was a

negative correlation between frequency of pet interaction and wound infection. This is

because the effect size is small (.168). This study would have needed 190 participants,

with this small effect size and a .10 significance level and a power of .80 to determine

statistical significance.

Question number one was “Is there a statistically significant relationship between

people who present to a wound care clinic for wound care and pet ownership? A Pearson

correlation coefficient was computed to assess the relationship of the two variables:

people who presented to the wound care clinic, using age as the variable and pet

ownership using household pet as the variable. A negative (inverse) correlation was

demonstrated between age (r = 1, n = 80, p = .266) and household pet (r=-.126). No

statistical significance was found.

Question number two was “What is the frequency of patients that present to a

wound care clinic with wound infection as documented by a positive wound culture and

31

also have a pet?” Wound infection was identified from the laboratory wound culture

result. S aureus was the most frequent wound culture result (f = 28; 35.0%) followed by

Candida albicans (f = 14; 17.5%). Pseudomonas aeruginosa, MRSA and E.coli were

other bacterial pathogens found at a smaller percentage. As stated, the total sample

(n=80), 39 participants (48.8%) have pets and 41 subjects (51.2%) do not have pets.

Moreover, of those who have pets, dogs were ranked as the most common frequently

owned (f=19; 23.8%) followed by cats (f=13; 16.3%), and then having both (cat and dog)

or other pets (e.g. turtle and horses) at 6.3% and 1.3%, respectively.

Question number three was “Is there a statistically significant relationship

between documented wound infection and pet ownership?” There was negative (inverse)

correlation between documented wound infection (r =1, n = 80, p = .048) and household

pet (r=-.222) that demonstrated statistical significance at the 0.05 level (2-tailed). This

results suggests that infection goes up as pet ownership goes down. In other words,

people with pets probably wash their hands more after each interaction than people

without pets. In addition, a correlation between documented wound infection and whether

the pet is indoor or outdoor was also computed. There was also negative (inverse)

correlation between these variables demonstrating no statistical significance: indoor or

outdoor (r = -.086. n= 80, p= .451) with document wound infection (r=1).

Question number four was “Is there a difference in frequency of documented

wound infections and the time spent with household pets (low amount of time versus high

amount of time)?” Time spent with household pets was converted to a frequency score

32

and the latter reflected the total score the pet owner interacted with the pets. The total

score was based on the six item questions given in the Exposure to Pet Survey

Questionnaire. The scores were the following: 1= 0-1x/day; 2= 2-3x/day and 3= more

than 3x/day. Several correlation computations were made to explore and answer this

question thoroughly. First, the frequency of the two variables, infection and frequency of

interaction score were analyzed. Participants with infection represented 56.3% (f= 45)

out of the total participants (n=80) compared to (f=34) or 42.5% without infection. A

score of 8 (10%) was the most frequent time spent interacting with the pet(s).The

correlation between the two variables was analyzed and demonstrated a negative

correlation with no statistical significance: infection (r =1, p = .137, n = 80) frequency of

interaction score (r=-.168), suggesting that people who engage more with their pet(s)

tends to observe proper hand hygiene and have less rates of infection.

Second, a correlation was computed between infection, household pet (pet

ownership) and hand washing post pet handling. A strong positive correlation with

statistical significance was demonstrated between household pet (r =.897, p = .000, n =

80) and hand washing (r=1) at the 0.01 level (2-tailed), suggesting that people with pets

wash their hands more often than people who do not have pets. There was a negative

(inverse) correlation without statistical significance between infection (r =1, p = .418)

and hand washing (r= -.092) also suggesting that infection goes up as hand washing goes

down. There was no correlation between infection and household pets.

33

And last but not the least, the third analysis was performed to determine if there is

correlation between infection, hand washing and frequency of interaction score. Results

demonstrated a positive correlation between frequency of interaction score (r=1) and

hand washing post pet handling (r = .839, p =.000, n = 80) with statistical significance at

.01 level (2-tailed). Overall, as the frequency of interaction with pets score goes up, hand

washing goes up, and even though it did not reach statistical significance, infection, hand

washing and frequency of interaction score were inversely related.

Summary

A negative (inverse) correlation was found between the independent variable, the

“degree of exposure to pet(s) which is otherwise known as the frequency of interaction

score” and the dependent variable, “wound infection.” Hand washing post handling of

pet(s) is one of the demographic variables that was found to be a covariant in this study.

There is a positive correlation between frequency of interaction score and hand washing.

34

CHAPTER FIVE: DISCUSSION

Introduction

The findings in this study showed that the independent variable, “exposure to

household pet” (frequency of interaction score) was not statistically associated with the

dependent variable, wound infection (p=.137). While several studies in fact demonstrate

the potential role of pet animals in household transmission of bacterial pathogens

(Bramble, et al, 2011), this study may have required a larger sample in order to

demonstrate a statistically significant relationship between the variables, wound infection

and exposure to household pets.

One of the demographic variables, “hand washing post handling of pet(s)” r=.841

was found to have statistically significant positive correlation with the “frequency of

interaction score” (r =1; p=.000). The correlation was significant at the 0.01 level (2-

tailed). Overall, an inverse relationship occurred and as the frequency of interaction score

and hand washing increases, infection rate decreases.

Major Findings by Research Question

Despite having several publications supporting the idea regarding zoonotic

transmission to humans, this small pilot study could not validate those same findings. The

study did not find a correlation between wound infection and exposure to household

pet(s) also called the frequency of pet interaction score. However, the study did find a

positive correlation between frequency of pet interaction score and hand washing. There

was an inverse correlation between hand washing, frequency of pet interaction and

35

infection. As the frequency of interaction with pets and hand washing went up, the

frequency of infection went down. Hand washing can prevent disease transmission

associated with animal contact (Steinmuller et al., 2006). Steinmuller and his colleagues

indicated that washing hands with soap and water and drying hands with paper towel is

good enough to prevent unnecessary illness. Human contact with cats and dogs and other

pets result in several infections in the United States each year (Rabinowitz, Gordon &

Odofin, 2007). According to Rabinowitz (2007) and his colleagues, prevention involves

common sense measures such as adequate hand washing, proper disposal of animal waste

and ensuring that animals that are sick are properly diagnosed and treated.

Two factors are largely responsible for the threat of infectious diseases in the

coming years: first, the nature and range of pathogens to which we are exposed and

second, the demographic changes occurring in the community, which affect our

resistance to infection (Bloomfield, et al., 2007). According to Bloomfield et al, (2007),

hand hygiene is a key component of good hygiene practice in the home, producing

significant benefit to reducing the incidence of infection, such as gastrointestinal

infections, and respiratory tract and skin infections. From this study, the most common

documented wound culture result was mainly S aureus (35%) which is a type of bacteria

commonly found in skin and open wounds. The study did not demonstrate a high

percentage of the heavy type of bacteria like MRSA, Pseudomonas aeruginosa, E. coli,

and others like Candida albicans, although several veterinary peer-reviewed journals

have indicated that MRSA isolates were found in environmental surfaces at home and in

infected in dogs and cats (Scott et al., 2008). Particularly with MRSA, the battle against

36

this bacteria in wound infections is becoming more difficult because of the widespread

drug resistance and community acquired MRSA (Visavadia, 2008).

Bloomfield et al., (2007) reported that decontamination of hands can be carried

out either by hand washing with soap or by use of waterless hand sanitizers which helps

reduce contamination. It is important to convince people to apply hand hygiene

procedures correctly (e.g. wash their hands correctly) and at the correct time to reduce

risk of infectious diseases. And lastly to optimize health benefits, promotion of hand

hygiene should be accompanied by hygiene education and should also involve promotion

of other aspects of hygiene.

Companion animals such as dogs, cats and others benefit humans in so many

ways, including social interactions. However, “when interaction between humans and

animals increases, transmission of pathogens becomes a greater risk for humans and pet

alike. Good hygiene, including proper hand washing is important in halting zoonotic

transmission” (Esch & Petersen, 2013).

Limitations

Internal validity was influenced by a small scale study as this was a pilot study. A

larger study group would have been needed to demonstrate statistical significance and set

the study with a smaller effect size. The study was only limited to prospective, new

patients who presented at one wound care clinic. The pets were not swabbed in this study

therefore it poses the question whether or not the pets were the carriers of the infection or

not. Moreover, a question on temporal ambiguity remains whether or not the pets were

the carrier and transmitted the infection to the pet owner or vice versa.

37

Generalizability

The research generalizability is limited to prospective, new patients who

presented at the wound care clinic. The participants self-reported their responses to the

questions and rated the amount of time they engaged with their pets.

Implications for Nursing Research

This research study did not provide sufficient evidence that patients who present

to an outpatient wound care clinic with a positive wound infection that was caused by pet

ownership and the engagement with the pet(s). Little information is asked by the nurses

regarding the environmental setting at home when patients present to the wound care

clinic. Advanced practice nurses use research to provide evidence-based care that

promotes quality health outcomes for individuals. This research adds to the body of

knowledge about consideration of inquiring about pet ownership upon admission to any

outpatient or inpatient settings. There is a need to conduct an evidence-based project to

reduce the spread of infection and to increase education to the nursing staff, patients and

families on zoonotic transmission of bacterial pathogens. Furthermore, increased

communication and collaboration between nursing staff and physicians including

veterinarians is needed to improve overall zoonotic disease knowledge and develop

achievable approaches to help reduce pet associated infection to patients.

Recommendations for Future Research

To date no other studies were found on wound care clinics reporting results on

wound infections and the relationship to pet ownership. Future research is required to

determine the prevalence of bacterial pathogen cross contamination among pets at home

38

and wound care patients. This study can be replicated using a larger sample size and

power to determine if significance is reached with further analysis. Repeating this study

at other locations including in-patients hospitals, skilled nursing facilities, assisted living

facilities and other similar settings would be beneficial to determine the validity of this

study.

This study may have medical and nursing implications in terms of developing

tools to determine frequency of pet engagement at home or in a facility, piloting

educational materials and distributing these materials to patients and families to increase

knowledge and awareness of zoonotic disease risks.

In addition, a nationwide central database would be appropriate, for collection and

sharing on all zoonoses, and would provide a better understanding on incidence and

prevalence of these diseases (Smith, 2012). Health care facilities may develop risk

management strategies in zoonotic disease prevention and share this knowledge and

procedures to humane societies, animal shelter facilities and others that may serve as an

interface between pets and pet owners (Smith, 2012).

Summary

In conclusion, the study showed that there was not enough data to prove that there

is relationship between wound infection and exposure to household pet(s). However, one

interesting finding showed high incidence of hand hygiene compliance was evident for

those who have pet(s) at home. According to Bloomfield et al., (2007), in many homes

there is at least one family member who is more susceptible to infection for one reason or

another. So long as there are people, pets, and food in the home, there will always be the

39

risk of pathogenic microbes. Bloomfield and her colleagues (2007) stressed the

importance of hand hygiene as the key component of good hygiene in the home.

Because there is limited awareness of the zoonotic risks from pets despite

frequent pet contact within the house, educational efforts are needed by healthcare

personnel to increase awareness of potential bacterial infection due to zoonotic

transmission (Stull, 2012). One of the critical points or situations that Bloomfield, et al.,

(2007) indicated was that high risk occupants at home are children, ill people with low

immune status, and handling pets or domestic animals at home. Good hand washing is the

key to lower the burden of transmission of infectious diseases at home.

40

Appendix A

Approval to conduct study at wound care clinic

41

42

Appendix B

California State University, San Marcos (CSUSM) IRB Approval Letter

43

Appendix C

Palomar Health IRB Approval Letter with IRB-stamped Informed Consent Form;

California Bill of Rights and Exposure to Pet Survey Questionnaire

44

45

46

47

48

49

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