Nosocomial infections, also known as hospital-acquired infections, are infections that patients acquire while receiving healthcare in hospitals or other healthcare facilities (1). These infections typically manifest after 48 h of admission and are not present or incubating at admission (2). Various microorganisms contribute to nosocomial infections, with bacteria responsible for approximately 90% of cases, while viruses, fungi, and protozoa are less common culprits (3). The most prevalent types of nosocomial infections include bloodstream infections, urinary tract infections, surgical site infections, and pneumonia (4, 5).

The global impact of nosocomial infections is profound, affecting hundreds of millions of patients annually (6) and imposing significant economic burdens on healthcare systems (7). Incidence rates range from 5.7% to 19.1% in low- and middle-income countries and from 3.5% to 12% in developed nations (8).

Pediatric patients are particularly vulnerable due to factors such as immature immune systems, prolonged hospital stays, and nutritional challenges (9–11). The risk is exacerbated in developing countries, where inadequate infection prevention practices and increasing use of antimicrobial agents and medical devices heighten exposure (12, 13).

In high-income countries, nosocomial infections affect approximately 4%–8% of pediatric patients (14, 15). However, in African countries, the incidence is rising alarmingly due to negligence in adhering to infection prevention guidelines and insufficient healthcare funding (16). A study in Sub-Saharan Africa reported an incidence density of 26.7 infections per 1,000 pediatric patients per day (17).

Alarmingly, around 4.9 million children die from infectious diseases each year, with nosocomial infections contributing significantly to these fatalities (18). In neonatal populations, these infections account for between 4% and 56% of deaths among hospitalized babies (6). In Sub-Saharan Africa, 1.2 million newborns die before reaching 28 days of age, with a substantial portion of these deaths attributed to nosocomial infections (19).

The growing prevalence of nosocomial infections among pediatric patients raises concerns about increasing antibiotic resistance, prolonged hospital stays, and the financial burden on families and healthcare systems (18, 20–22). These infections are the most common complications faced by hospitalized children, often leading to emotional distress, functional disorders, and reduced quality of life (23).

While identifying the factors associated with nosocomial infections in pediatric patients is critical, there is a notable lack of studies focusing specifically on this demographic in Ethiopia, particularly at Jimma Medical Center. Key variables, such as immunization status and the variety of antibiotics used, have not been adequately investigated as predictors of nosocomial infections among pediatric patients. Therefore, this study aimed to assess the prevalence of nosocomial infections and their associated factors among children admitted to Jimma Medical Center in Southwest Ethiopia.

The data collection tools were adapted after a review of different relevant literature (25–27, 29, 31–34). The tools were prepared in the English language. The checklist consists of three parts: sociodemographic characteristics, clinical condition-related factors, and invasive medical device procedure-related factors Supplementary File 1.

The data collection process was carried out by three Bachelor of Science nurses with prior experience in data collection who reviewed the medical records meeting the inclusion criteria and extracted the necessary information. The data collection process was supervised by a principal investigator.

Before data collection, training was given to data collectors and supervisors for one day on the purpose of data collection, the content of the checklist, where the medical records are located, and how to extract the necessary data from medical records. A pretest was conducted at Jimma Medical Center (from 2019 admission) by taking 5% (23) of the total sample size one week before the actual data collection. Based on the pretest results, necessary modifications were made, such as removing items that could not be found in the medical records. The supervisor monitored the data collection process daily. Additionally, the principal investigator and supervisor reviewed the complete checklists filled out by the data collectors to ensure the completeness and consistency of the collected information.

Before analysis, the data were cleaned, verified, and coded. The cleaned data were then imported into Epidata version 4.6 and exported to SPSS version 26 for analysis. Descriptive statistics were initially computed to summarize the data characteristics. To assess linear correlations between independent variables, inferential statistics were employed. Multicollinearity was evaluated using tolerance and variance inflation factors (VIF). Variables exhibiting a VIF greater than 10 or a tolerance less than 0.1 were excluded from further analysis. Specifically, the VIF values ranged from less than 2.825, and tolerance values were above 0.354. The study utilized binary logistic regression to explore the relationship between dependent and independent variables. Additionally, multivariable logistic regression analysis was conducted to identify factors associated with nosocomial infections in pediatric patients. The model's fit was assessed through the omnibus test (p = 0.00), and Hosmer and Lemeshow's test indicated a good fit (p = 0.770). To gauge the strength of correlations, odds ratios and 95% confidence intervals were calculated. The statistical significance threshold was set at a p-value of less than 0.05. The findings were presented using appropriate tables, charts, figures, graphs, and narrative prose to ensure clarity and comprehensibility.

This research was conducted in keeping with the Helsinki Declaration. Ethical approval for this study was obtained from the Ethical Review Committee of Jimma University (Ref No: JUIH 414/23). Subsequently, a letter was submitted to the administration of Jimma Medical Center (JMC) to obtain permission before the actual data collection. The information gathered from medical records was confidential and used only for research purposes.

This study, conducted at Jimma Medical Center in southwest Ethiopia, found that 23.74% (95% CI: 19.64, 27.84) of pediatric patients acquired nosocomial infections. Significant factors associated with these infections included malnutrition, prolonged hospital stays, antibiotics received at admission, mechanical ventilation, blood transfusions, and urinary catheterization.

The prevalence of nosocomial infections among children in the current study is consistent with previous studies conducted at Hawassa Comprehensive Specialized Hospital (21.4%) (25) and Ayder Hospital (20.2%) (26). However, it is higher when compared to previous studies conducted in Ecuador (13.5%) (35), Switzerland (6.7%) (28), the Philippines (11.37%) (36), the South of Iran (14.57%) (37), and Kenya (2.62%) (38). These discrepancies may stem from differences in inclusion criteria and study designs. For instance, studies in Ecuador and South Iran included patients older than one month, while our study encompassed patients from birth to 17 years. The Swiss study limited participants to those hospitalized for over 24 h, whereas our criteria were over 48 h. Additionally, we included patients from the pediatric oncology ward, unlike the studies from the Philippines and Kenya, which focused solely on pediatric wards, PICU, and NICU.

Conversely, our prevalence is lower than Turkey's report of 68.4% (39). likely due to their exclusive focus on bloodstream infections and a smaller sample size.

Malnutrition was shown to increase the odds of nosocomial infections by 2.01 times, consistent with findings from Ecuador, Indonesia, and Hawassa (25, 27, 35). This vulnerability can be attributed to compromised immune systems in malnourished children, reducing their ability to combat pathogens (40).

Pediatric patients with hospital stays exceeding seven days had 3.19 times higher odds of infection, supporting similar findings in Indonesia (27). Extended hospitalizations often indicate severe illness, increasing exposure to potential infections (41).

Antibiotics received at admission raised infection odds by 4.76 times, similar to results from Ayder Hospital (26). This association may relate to antibiotic overuse, contributing to resistance and subsequent infections (42).

Mechanical ventilation was associated with 5.04 times higher odds of nosocomial infections, consistent with findings from Turkey (43). The irritation and inflammation caused by endotracheal tubes may facilitate airway colonization, increasing infection risks (44).

Additionally, pediatric patients who received blood transfusions had 4.51 times higher odds of developing nosocomial infections compared to those who did not. This finding is supported by a study in South Africa (33). Blood transfusions may temporarily suppress the immune system, compromising the patient's ability to combat infections (45). Aseptic technique during the vein puncture process may also play a role.

Finally, patients with urinary catheters had 3.26 times higher odds of nosocomial infections compared to those without catheters, supported by studies in Switzerland and Indonesia (27, 28). This association may be due to the prolonged duration of catheterization and potential lapses in aseptic techniques (46).

The study included a new variable, immunization status, and the number of types of antibiotics, which had not been previously investigated in Ethiopia. However, since the study relied on secondary data, some crucial independent variables were missing. Furthermore, the findings are limited in their generalizability since the study was conducted solely at Jimma Medical Center.

The findings of this study revealed that nearly a quarter of children developed nosocomial infections. Factors such as malnutrition, length of hospital stay, antibiotics received at admission, being on mechanical ventilation, having a blood transfusion, and a history of urinary catheterization were identified as significant predictors of nosocomial infections among children. Hence, the concerned bodies should focus intervention strategies on contributing factors to nosocomial infections among children. Upcoming researchers should conduct a prospective cohort study to incorporate variables not addressed in a retrospective study.