The Relationship Between Nurses' Professional Characteristics and Enteral Contamination Level: An Intensive Care Assessment

The Relationship Between Nurses' Professional Characteristics and Enteral Contamination Level: An Intensive Care Assessment | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Relationship Between Nurses' Professional Characteristics and Enteral Contamination Level: An Intensive Care Assessment Alev YILDIZ ILIMAN, Merve YURTTAŞ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6504346/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Nutrition is vital for critically ill patients in intensive care, but enteral product contamination poses a risk. This study examines whether intensive care nurses' demographic and professional traits affect contamination levels. This study aims to compare enteral contamination levels based on nursing variables and to explain the underlying reasons for potential differences. Methods This descriptive study was conducted in the intensive care unit of a university hospital in Turkey between September and November 2024. The study included 32 intensive care nurses and samples collected from enteral products prepared by these nurses. The contamination levels of Escherichia coli, Staphylococcus sp ., total aerobic mesophilic bacteria, and coliform pathogenic microorganisms in enteral products were examined. The logarithmic values were analyzed in relation to nurses' characteristics using the Mann-Whitney U test, Kruskal-Wallis test, and Spearman correlation test in a statistical software program. Results It was determined that 75% and 100% of the analyzed 32 enteral samples exceeded the US Food and Drug Administration threshold values in terms of total aerobic mesophilic bacteria and coliform counts, respectively. Coagulase testing was not performed on Staphylococcus species; therefore, results were reported as Staphylococcus sp. Escherichia coli was detected in three samples (9.37%). No significant differences were found in enteral contamination levels based on nurses' age, gender, education level, years of professional experience, years of intensive care experience, or possession of an intensive care certification. Conclusion This study found that bacterial contamination in enteral products exceeded US Food and Drug Administration limits, indicating hygiene deficiencies. The presence of pathogens like Staphylococcus sp . and Escherichia coli highlights contamination risks. Nurses' characteristics did not affect contamination levels, emphasizing the need for stricter hygiene adherence in enteral nutrition. Relevance to clinical practice This study demonstrates that adherence to hygiene protocols during the preparation of enteral nutrition in intensive care units is critical for patient safety. Although nurses' professional characteristics do not influence contamination levels, the high microbial load indicates systemic deficiencies in practice. This highlights the necessity of standardized hygiene training and monitoring procedures. enteral nutrition intensive care intensive care nurses contamination BACKGROUND Nutrition plays a crucial role in the treatment of critically ill patients in intensive care units (ICUs). 1 Guidelines recommend initiating enteral nutrition (EN) as early as possible when oral intake is not feasible. 2 , 3 It has been reported that compared to parenteral nutrition, early initiation of EN in critically ill patients improves clinical outcomes, reducing mortality rates, length of hospital stay, and healthcare-related costs. 4 Additionally, numerous studies have emphasized the clinical significance of EN support for patients in the intensive care unit (ICU) setting. 5 Despite the benefits of EN in critically ill patients, several complications are associated with this feeding method. Some of these risks include mechanical complications, such as incorrect tube placement, tube displacement, and tube obstruction, as well as gastrointestinal complications, including nausea, vomiting, and diarrhea. Furthermore, pulmonary aspiration and infections pose potential risks for critically ill patients. 6 Although the contamination of enteral products is one of these risks, its significance is often overlooked. However, enteral nutrition is the most frequently administered nutritional therapy in ICUs. When contaminated enteral products are administered to patients, severe complications such as diarrhea, abdominal distension, aspiration pneumonia, and even sepsis may develop. This risk is even more critical for ICU patients who are elderly or immunocompromised. 7 Patients receiving treatment in the ICU are at high risk for hospital-acquired infections due to immunosuppression caused by factors such as trauma, invasive procedures, and corticosteroid therapy. 8 Therefore, it is crucial for healthcare professionals working in ICUs to adhere to hand hygiene practices, follow infection control measures during patient care, and ensure that the medical equipment used complies with hygiene and standardization guidelines. 9 Contamination of enteral products can occur during production, storage, preparation, and administration. ICU nurses play a key role in preventing such contamination. As they are responsible for initiating, managing, monitoring risks, and detecting potential complications associated with enteral nutrition. 10 – 12 Therefore, ICU nurses must possess adequate knowledge, skills, and experience to safely administer enteral nutrition to critically ill patients. 13 Studies conducted in ICUs have detected the presence of pathogenic microorganisms in enteral products. A systematic review reported that a significant proportion of enteral infusion samples were contaminated with Coliforms, Staphylococcus aureus , Mesophilic bacteria, and Escherichia coli (E. coli). 14 , 15 Several studies in the literature support these findings. 16 , 17 When examining the causes of contamination, failure to adhere to basic hygiene principles, particularly hand hygiene, has been identified as a major issue. Another significant factor is the lack of adherence to standardized protocols for enteral nutrition administration. It has been found that ICUs that follow clinical practice guidelines for enteral nutrition achieve better clinical outcomes. 3 , 8 Numerous studies have been conducted to investigate nurses’ knowledge, attitudes, and practices regarding enteral nutrition contamination. 19 , 20 However, no studies that specifically examine the relationship between enteral contamination and nurses' demographic and professional characteristics have been detected. Nevertheless, the literature suggests that the characteristics of individuals involved in food preparation influence hygiene behaviors, which in turn increase the risk of food contamination. 21 , 22 Studies conducted on individuals administering enteral nutrition at home support this finding. This descriptive study aims to determine whether nurses' demographic and professional characteristics influence enteral contamination levels. By identifying the relationship between demographic variables and enteral contamination levels, this study will provide insight into ICU nurses' adherence to hygiene principles. In doing so, it will contribute more concrete data to the existing literature, which primarily focuses on nurses' knowledge and attitudes regarding enteral nutrition. METHODS This study aims to compare enteral contamination levels based on nursing variables and to explain the underlying reasons for potential differences. Study Design This study was designed as a descriptive study and was conducted between September and November 2024 in the intensive care unit of a university hospital in Turkey. Do enteral contamination levels differ based on the demographic characteristics of nurses? Do enteral contamination levels differ based on the professional characteristics of nurses? The primary outcome of this study is the contamination levels of enteral products. The secondary outcomes include determining whether these contamination levels vary according to nurses' demographic and professional characteristics. The common variables in this study include the levels of E. coli, Staphylococcus sp ., total aerobic mesophilic bacteria, and coliform microorganisms detected in enteral products. The study population consisted of 40 nurses working in the adult intensive care unit of a university hospital. The sample size was determined using the known population sampling formula. Based on a 5% margin of error and 80% power, the required sample size was calculated as 32 nurses. A simple random sampling method was used to select participants. Data Collection Tools A data collection form was developed based on similar studies to collect relevant data from nurseS. 23,24 This form included questions regarding nurses' age, gender, education level, years of professional experience, years of ICU experience, ICU certification status, and sources of information used for enteral nutrition. Ethics Approval and Consent to Participate Nurses were informed about the study both in writing and verbally. Following the information session, written informed consent was obtained from the nurses who voluntarily agreed to participate. No procedures or interventions were performed on patients. Ethical approval for the study was obtained from the Amasya University Non-Interventional Clinical Research Ethics Committee (ID NO: E-76988455-050.04-213841). Additionally, institutional permissions were secured from the university hospital where the study was conducted. Throughout the study, the identities of the nurses were kept confidential and the samples were coded. In the analysis results, the identities of the nurses who collected the contaminated and uncontaminated samples were kept confidential. We declare that we have complied with all ethical principles stated in the Declaration of Helsinki of the World Medical Association. Sample Collection Process Nurses who provided informed consent were included in the study. To prevent potential biases, the date and time of enteral product sampling were kept confidential from the nurses. Each nurse was responsible for preparing the enteral feeding equipment, connecting it to the patient, and conducting a 24-hour infusion process. Thus, each nurse completed the entire enteral feeding procedure. Following this, the nurse disconnected the enteral feeding set from the patient, and the researcher collected samples from the set. The distal end of the enteral feeding set was wiped with a sterile alcohol swab, 5 mL of feeding solution was discarded, and then 30 mL of enteral feeding solution was transferred into a sterile sample container. The collected samples were placed in a cold chain transport box and cultured in the laboratory within one hour. Each sample was coded to ensure confidentiality, and the identities of nurses were anonymized. The researcher analyzing the data was blinded to the nurses' personal information. Aseptic techniques were strictly followed during the sample collection process to prevent contamination of the feeding solutions. Microbiological Analysis For the enumeration of Total Aerobic Mesophilic Bacteria (TAMB) and Staphylococcus sp ., Plate Count Agar and Mannitol Salt Agar were used, respectively, with incubation at 35–37°C for 24–48 hours. The enumeration of coliforms and E. coli was carried out according to the EMS method using Lauryl Sulfate Tryptose Broth supplemented with MUG. Plate Count Agar and Mannitol Salt Agar were used for the enumeration of TAMB and Staphylococcus sp ., respectively, with incubation at 35–37°C for 24–48 hours. The enumeration of coliforms and E. coli was performed using the EMS method with Lauryl Sulfate Tryptose Broth supplemented with MUG. Statistical Analysis The statistical analyses were conducted using IBM SPSS 25 software. The Mann-Whitney U test was used to compare two groups, while the Kruskal-Wallis test was applied for comparisons involving three or more groups. The Spearman rho test was used to determine correlations between two continuous variables. Results which were at p < 0.05 were considered statistically significant. RESULTS The results of microbiological counts and the proportion of samples exceeding US Food and Drug Administration (FDA) threshold values (%) are presented in Tables 1 and 2. In this study, 75% of the samples obtained from enteral feeding tubes after patient disconnection exceeded the FDA threshold for TAMB, while 100% exceeded the threshold for coliform counts. Staphylococcus sp . (>10 CFU/mL) was detected in 23 enteral product samples (71.9%). Coagulase testing was not performed on Staphylococcus species; therefore, the results were reported as Staphylococcus sp . A total of three samples (9.37%) tested positive for E. coli (table 3). The mean age of the nurses included in the study was 33.03±8.34 years. Among the participants, 65.6% were female, and 75% held a bachelor's degree (Table 4). The logarithmic values of the detected microorganism counts in enteral products were determined. These logarithmic values were analyzed in relation to nurses' characteristics using the Mann-Whitney U test, Kruskal-Wallis test, and Spearman's correlation test in the statistical program (Table 5). A statistically significant negative correlation was found between nutrition education and the level of Staphylococcus sp . contamination (p < 0.05). Table 1. Microbiological Count Results CFU: Colony Forming Unit Sample No TAMB Staph. sp. Coliform (MPN/mL) E.coli 1 4x10³ <10ª 3 - 2 1x10³ 35x10¹ 3,6 - 3 13x10³ 8x10³ 3 - 4 11x10⁴ 39x10¹ 1100 - 5 17x10³ 5x10³ 1100 - 6 10x10⁴ 61x10³ 1500 - 7 4x10² 14x10¹ 36 - 8 20x10⁵ 17x10² 74 - 9 45x10⁴ 17x10³ 30 - 10 <10ª <10ª 30 - 11 15x10⁵ 9x10⁴ 930 - 12 18x10⁵ 12x10⁴ 74 + 13 <10ª <10ª 30 - 14 13x10⁴ 6x10¹ 1500 - 15 2x10³ 39x10¹ 30 - 16 28x10⁴ 9x10² 430 + 17 15x10⁵ 66x10³ 750 - 18 50x10⁵ 33x10³ 750 - 19 50x10³ 37x10³ 36 - 20 5x10⁵ 7x10⁴ 11000 - 21 18x10⁵ <10ª 11000 - 22 1x10³ <10ª 30 - 23 2x10⁵ <10ª 30 - 24 <10ª 12x10¹ 30 - 25 3x10⁴ 32x10² 11000 - 26 12x10⁵ 13x10³ 11000 - 27 13x10⁴ 72x10³ 36 - 28 3x10⁴ 43x10² 4600 - 29 40x10⁴ <10ª 11000 - 30 17x10⁵ <10ª 11000 - 31 <10ª <10ª 11000 - 32 1x10⁴ 51x10¹ 11000 + Abbreviations: -: microorganism is not detective. ª: Colony counting was performed according to the Compendium of Methods for the Microbiological Examination of Foods guidelines. Petri dishes with no visible colony formation were considered to have a microorganism count of <10 CFU/mL. For petri dishes with <25 CFU/mL, the colony count was obtained by multiplying by the dilution factor. TAMB, total aerobic mesophilic bacteria; Staph. sp., Staphylococcus sp.; Escherichia coli, E. coli. Table 2. Percentage of Samples Exceeding FDA Threshold Values for Microorganisms Microorganism Samples (n:32) TAMB 75ª % Coliform 100ª % Abbreviations: TAMB: Total aerobic mesophilic bacteria ª: Sample rate exceeding microorganism limit values according to US Food and Drug Administration Table 3. E. coli-Positive Samples Sample no E.coli Sample 12 + Sample 16 + Sample 32 + Escherichia coli, E. coli. Table 4. Demographic and Professional Characteristics of Nurses Variables Min-Max X±ss Age 24-51 33.03±8.34 Professional experience (years) 1-31 10.88±8.26 Intensive care experience 1-15 5.90±3.52 Variables N (%) Gender Female 21 (65.6) Male 11 (34.4) Education level Associate Degree 6 (18.8) Bachelor's Degree 24 (75) Master's Degree 2 (6.3) Intensive care certification Yes 7 (21.9) No 25 (78.1) Information need regarding enteral feeding I need it 27 (84.4) Sometimes I need it 4 (12.5) I don’t need it 1 (3.1) Information sources used in enteral feeding Internet 17 (53.1) Physician 6 (18.8) Internet and physician 2 (6.3) Internet and nurse 2 (6.3) Internet, physician, and nurse 3 (9.4)) Guidelines 2 (3.3) Table 5. Relationship Between Nurses' Demographic and Professional Characteristics and Microorganism Levels Variables TAMB Staph sp. Coliform Gender -,815* ,415**** -,186* ,852**** -1,167* ,243**** Intensive Care Certification Yes No -1,256* ,209**** -,548* ,584**** -1,525* ,127**** Education Level ,401** ,818**** 1.502** ,472**** ,350** ,839**** Information Need Regarding Enteral Feeding ,272** ,873**** 2,744** ,254**** ,194** ,908**** Information Sources Used in Enteral Feeding 3,388** ,640**** 5.507** ,357**** 3,602** ,608**** Age ,136*** ,458**** ,157*** ,392**** -,218*** ,230*** Professional Experience (years) ,092*** ,616*** ,149*** ,416**** -,192*** ,292**** Intensive Care Experience (years) ,073*** ,691**** ,146*** ,426**** -,262*** ,148**** *Man witney Z **Kruskal-Wallis Test ***Spearman rho ****Sigma TAMB, total aerobic mesophilic bacteria; Staph. sp., Staphylococcus sp. DISCUSSION Enteral nutrition, frequently administered in intensive care units, poses various risks and can lead to serious patient safety concerns. One of these risks is the contamination of enteral solutions with pathogenic microorganisms. Numerous studies have been conducted to determine the contamination levels of enteral products, but very few have focused on the relationship between enteral contamination and the characteristics of nurses. However, nurses play an active role in all stages of enteral feeding. Therefore, nurses are key in preventing contamination in enteral products. Studies on the safe use of enteral products often examine the level of knowledge among nurses, but it remains unclear whether demographic and professional characteristics that may affect nurses' hygiene behaviors have an impact on contamination levels. To address this uncertainty, our study compared the levels of total aerobic bacteria, coliforms, S. aureus, and E. coli microorganisms in enteral products based on nurse-related variables. Total mesophilic aerobic bacteria represents the total number of microorganisms, an important indicator used to assess the hygiene level of food products. 25 The presence of total mesophilic aerobic bacteria is a critical indicator of the microbiological safety and quality of enteral products. These bacteria can proliferate in environments with temperatures between 20-45°C and live in oxygenated environments. Their high presence may indicate that the product was not produced under hygienic conditions or was not stored properly. Monitoring the microbial load in food is an essential criterion for evaluating the effectiveness of hygiene and quality control processes. 26 When reviewing studies on the microbiological quality of enteral products, TAMB microorganisms have been identified in some studies. 27 In our study, the TAMB microorganism level exceeded the FDA limits in three-fourths of the samples. We hypothesize that contamination may have occurred only after the product cap was opened, as commercially available ready-to-use enteral products are produced and stored in appropriate conditions, with the production and storage processes of all products in our study being identical. However, the microbial loads varied. We believe that the contamination may have resulted from the failure to adhere to hygiene principles during the processes of opening the product packaging, adding solutions to enteral sets, connecting the set to the patient, adding solution to the set, and joining and disconnecting connection points. Coliforms are microorganisms commonly found in the intestines of mammals and humans. These microorganisms are particularly significant in food safety because their presence can indicate fecal contamination. The presence of coliforms may signal inadequate hygienic conditions and the potential presence of harmful pathogens. Additionally, coliforms are frequently used to assess the microbiological quality of water sources and food products. The presence of coliforms in enteral products is an important indicator for evaluating the hygienic condition of these products. 28 The presence of coliforms in enteral products suggests that hygienic standards were not sufficiently maintained during the preparation or application stages. 14 In our study, coliform levels were found to exceed FDA limits in all samples. A review of other studies reveals that while coliforms were detected in commercial ready-to-use enteral products similar to ours 7,29 , some studies did not find them. 30,31 We believe that one of the main causes of fecal contamination in enteral products is nurses' hand hygiene behaviors. This is because nurses perform many procedures with a high risk of fecal pathogens in the intensive care unit, such as colostomy drainage, enema applications, genital care, and stool cleaning. Nurses' adherence to hand hygiene protocols after these procedures is crucial for preventing fecal-derived coliform pathogens. However, it has been emphasized that intensive care unit nurses often neglect hand hygiene after using gloves. 32 In our study, another potential cause of coliform contamination may be the tap water used for cleaning the tubes. A review of the literature has identified a correlation between the use of tap water to clean or dilute enteral products and the presence of coliforms. 7 In a very few number studies, no coliform growth was observed with the use of tap water. This, however, is not enough to reach a conclusion that tap water is safe to use for these procedures. Even water without tap sources can pose a risk to pathogens if left in the bag for extended periods. The frequency of diarrhea in intensive care units ranges from 11% to 66%. 33 Although diarrhea caused by fecal-origin infections is not commonly encountered in intensive care units, it is important for patient outcomes. Diarrhea can lead to negative effects in critically ill patients, such as dehydration, electrolyte imbalances, hemodynamic instability, malnutrition, and skin lesions. It has been determined that diarrhea in intensive care patients increases mortality and length of hospital stay. Furthermore, it is recommended that nurses assess diarrhea as a symptom of infection in intensive care patients. Therefore, strict hygienic measures in the application of enteral products are of vital importance. Fatigue and burnout due to excessive workload in intensive care units negatively impact adherence to hand hygiene protocols. Additionally, the frequency of emergency interventions and excessive workload creates time constraints, which act as barriers to hygiene practices. Observational studies have shown that nurses working day shifts wash their hands less frequently than those working night shifts. 34 The inappropriate physical design of intensive care units has also been noted to affect hygienic behavior. Moreover, the harmful effects of chemical agents on the skin from repeated handwashing after continuous tasks have been reported as barriers by nurses. 18 Some studies also indicate that the lack of adequate hand hygiene and drying materials impedes proper hygiene practices. 35 Intensive care units are also high-risk areas for contamination sources. A study conducted by Ho (2012) identified a relationship between nurses' hand hygiene and contamination of enteral tubes, enteral sets, and enteral nutrition. In another study, contamination sources were examined. 36 According to this study, the major contamination sources were oxygen masks (81.8%), ventilators (82.9%), and bed linens (67.7%). 37 This finding is important because another study emphasized that 38% of infections occurred due to cross-contamination. 38,39 Among the most important sources of Staphylococcus sp . are the mucosal nasal flora, skin, gastrointestinal, and genital systems. It has been reported that approximately 15-35% of healthy individuals are constant carriers, and 35-50% are intermittent carriers of Staphylococcus . Staphylococcus sp ., which has been associated with numerous infections and toxicities, can cause a range of conditions from simple skin lesions to more serious issues such as pneumonia and meningitis. It can also cause food poisoning through the production of enterotoxins. 40 Despite having mild clinical symptoms, it is one of the most commonly observed poisonings worldwide, and although the detected mortality rate is low, the economic losses caused by it are significant. In our study, Staphylococcus sp . was detected in 23 enteral products (71.9%) with levels exceeding 10 CFU/mL. In a study conducted by Baniardalan et al. (2014) in an intensive care unit, the growth rate was higher than in our study (24, 86%) (14). In the study by Lafourcade et al. (2002), similar results were found to our study. 41 However, this study was conducted using a closed-system enteral set. In the studies by Moazen et al. (2014) and Da Silva (2015), coagulase-positive Staphylococcus was found in 1 (5%) and 1 (12.5%) samples, respectively, while in other studies, it was either found at very low rates or not at all. 16,42 Due to its ability to withstand solid substances and low water activity conditions, Staphylococcus sp. can survive in dry environments (surfaces and clothing), increasing the risk of enteral contamination. Another factor contributing to this risk is the lack of use of sterile gloves during enteral feeding. In procedures where sterility is not maintained, healthcare workers do not pay enough attention to hand hygiene and glove usage, thereby increasing the risk of cross-contamination. In addition, nurse uniforms can also be a source of cross-contamination. This is highly likely in intensive care units where the frequency of care procedures and emergency interventions is high, leading to nurse uniforms being contaminated by the patient and surfaces the patient has come into contact with. A study examining the contamination of nurse uniforms found that all nurses' uniforms were contaminated with Staphylococcus , but the rate was significantly higher among intensive care unit nurses. Furthermore, Staphylococcus sp . microorganisms can be transmitted via the respiratory route. This risk of contamination may increase if nurses do not wear masks during enteral feeding preparation and application. Additionally, aspiration procedures, which are frequently performed in intensive care units, can also be considered a significant risk factor. During aspiration, contamination of the patient’s bed, nurse uniforms, and other care equipment is likely, further increasing the risk of enteral contamination. Another potential source of contamination could be the nurses' mobile phones. Recent studies have shown that the bacterial load on mobile phones of intensive care nurses is at high levels. 43,44 E. coli microorganisms are widely used as indicator microorganisms in the evaluation of the microbiological quality of food due to their ecological characteristics that are similar to pathogenic microorganisms (45). E. coli is the species associated with fecal contamination. However, this indicator is not sufficient to trace the origin of contamination. 26 In our study, E. coli was found to be positive in 3 samples (9.37%). When reviewing studies conducted with commercially prepared enteral products, one study reported growth at similar rates to our study (2/20, 10%) 45 , while another study reported growth within the accepted safe limits (<3 CFU/g) 16 . One of the transmission routes for E. coli microorganisms is tap water. 26 This finding is supported by a study, as E. coli was found to grow only in powdered enteral products, which confirms its transmission via water. 46 In our study, tap water was also added to the enteral sets. This can be considered as one of the factors causing contamination. The sterility of enteral feeding products is of vital importance for both food safety and clinical outcomes. Even if there is no significant problem with food safety during the production process of enteral products, the preparation of these products raises the potential risk of contamination. Therefore, the use of sterile sets in the preparation and application processes of enteral foods, the application of aseptic techniques during preparation and application, and strict attention to personnel hygiene are necessary. The relationship between the demographic and professional characteristics of nurses and microorganism levels in enteral products In our study, no relationship was found between the age variable of nurses and the contamination levels. No study in the literature has established a connection between enteral contamination levels and the age of nurses. However, in a study conducted with home care patients, it was found that 62.5% of commercial solutions had aerobic mesophilic microorganisms and total coliform (103) values exceeding the accepted limits. In this study, 47% of the individuals performing enteral application were 50 years old or older. 47 Many studies on the attitudes and behaviors of nurses and other healthcare workers toward hygiene practices suggest that an increase in age positively affects compliance with hygiene behaviors. 39 Additionally, it is emphasized that the positive influence of older individuals in this regard plays an important role in younger and inexperienced healthcare workers' compliance with hand hygiene behaviors by acting as role models. Another benefit of older healthcare workers being role models for hygiene behaviors is the ability to provide immediate feedback through direct observation. This, in turn, improves the quality of care and patient safety. 48 One reason for not finding a difference based on the age variable in our study could be the low sample size. Another reason may be the relatively low average age of the nurses in our study. Another variable examined in our study was the educational level of nurses. No difference was found between the educational level and enteral contamination levels. The educational level plays an important role in the learning and application of hygiene behaviors by caregivers. A higher educational level also facilitates access to information sources and is important for the use of this knowledge. 47 It is known that there is a significant relationship between the educational level of nurses and their knowledge levels. 49 However, a higher level of knowledge does not always mean the same level of compliance with application. 50 Despite having a high level of knowledge, nurses' compliance with hand hygiene protocols is below average. However, nurses' adherence to hygiene behaviors is important in preventing enteral contamination. It has been determined that infection control training significantly reduces enteral contamination levels. 36 This highlights the importance of continuous education in enteral contamination. In our study, professional experience and intensive care unit (ICU) experience duration were other important variables. No relationship was found between these variables and microorganism contamination levels. Additionally, contamination levels did not differ based on ICU certification. However, some studies have shown a positive relationship between longer work experience and improved hygiene behaviors. The more experience a nurse has, the more adhere s/he is to hygiene. 39 The main reason for the differences between studies is methodological, as many studies rely on nurses' self-reports regarding their hygiene behaviors. Nevertheless, no study has been found that reveals the relationship between longer work experience and contamination levels. LIMITATIONS This study has several limitations. First, it was conducted in a single university hospital’s intensive care unit, which may limit the generalizability of the findings to other institutions or healthcare settings. Second, the relatively small sample size (32 nurses and 32 enteral product samples) may affect the statistical power and limit the ability to detect smaller associations. Third, the study did not perform coagulase testing on Staphylococcus species, so pathogenicity could not be fully determined. Finally, as a descriptive cross-sectional study, it captures data at one point in time and cannot establish causality between variables. RECOMMENDATIONS OR IMPLICATIONS FOR PRACTICE In line with the findings of our study, developing strategies to improve hygiene practices during the enteral feeding process will significantly contribute to reducing hospital-acquired infections and enhancing the quality of patient care. Implementing training programs aimed at increasing ICU nurses’ compliance with hygiene protocols may be effective in ensuring patient safety. The data obtained from this study will be shared with the relevant clinical departments, and the development of in-service training programs is expected to enhance patient safety. As a result, it is anticipated that patient outcomes will improve and healthcare costs will be reduced. CONCLUSION In this study, microbiological contamination was detected in a significant proportion of the samples obtained from enteral feeding sets that were disconnected from patients. The fact that TAMB and coliform counts exceeded the FDA's limit values highlights deficiencies in hygiene practices and presents potential contamination risks. The presence of potential pathogens, such as Staphylococcus sp . and E. coli, underscores the importance of maintaining hygiene standards throughout the enteral feeding process. No significant relationship was found between variables such as the nurses' age, educational level, professional experience, and ICU length of experience and the levels of enteral contamination. Our findings emphasize the need for stricter adherence to hygiene standards in enteral feeding practices. In particular, proper hand hygiene, the use of sterile sets, the selection of appropriate water sources, and the assurance the working environment complies with hygiene standards are critical to preventing contamination. Abbreviations ICUs: İntensive care units EN: enteral nutrition ICU: intensive care unit E. coli: Escherichia coli FDA: US Food and Drug Administration TAMB: Total aerobic mesophilic bacteria Declarations Ethics approval and consent to participate Nurses were informed about the study both in writing and verbally. Following the information session, written informed consent was obtained from the nurses who voluntarily agreed to participate. No procedures or interventions were performed on patients. Ethical approval for the study was obtained from the Amasya University Non-Interventional Clinical Research Ethics Committee (ID NO: E-76988455-050.04-213841). Additionally, institutional permissions were secured from the university hospital where the study was conducted. Throughout the study, the identities of the nurses were kept confidential and the samples were coded. In the analysis results, the identities of the nurses who collected the contaminated and uncontaminated samples were kept confidential. We declare that we have complied with all ethical principles stated in the Declaration of Helsinki of the World Medical Association. Consent for publication Not applicable Availability of data and Materials Not applicable Competing interests The authors declare that they have no competing interests Funding None to declare. Authors' Contributions AYI took part in the processes of planning the research, literature review, obtaining ethics committee and institutional permissions, collecting data, performing statistical analyses, reporting the data and preparing it for publication. MY took part in the processes of planning the research, collecting data, performing microbiological analyses, reporting the data and preparing it for publication. All authors reviewed the manuscript. Acknowledgements We would like to thank the clinic's responsible physician and nurses for their support in conducting the study. References van Nieuwkoop MM, Ramnarain D, Pouwels S. Enteral nutrition interruptions in the intensive care unit: a prospective study. Nutrition. 2022; 96: 111580. McClave SA, Taylor BE, Martindale RG, et al. 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Implementing an educational program to improve critical care nurses' enteral nutritional support. Australian Critical Care. 2019;32(3):218-22. Jordan EA, Moore SC. Enteral nutrition in critically ill adults: Literature review of protocols. Nursing in critical care. 2020;25(1):24-30. Das S, Patra D, Pradhan P. Critical care nurses’ knowledge and skill regarding enteral nutrition in critically Ill patients at a glance. J Nurs Sci Pract. 2015;4(3):35-42. Bahramian B, Sarabi-Jamab M, Nattagh-Eshtivani E, Rezaie M. Microbiological contamination of commercial enteral feeding and blenderized tube feeding: A systematic review. Environmental Health Engineering And Management Journal. 2022;9(4):355-64. Yıldız Ilıman A, Yurttaş M, Ergül DF, Tutkaoğlu S. Comparison of microbiological loads of enteral products at two different ambient room temperatures. Nutrition in Clinical Practice. 2025;40(1):167-75. Moazen M, Rahmdel S, Abdollah ZSM, Ranjbar ZM, Mazloomi SM. Microbiological quality of commercial enteral feedings used in two public hospitals in Shiraz, Iran. 2014. Borges LJ, Campos MRH, Andre MCDPB, Serafini AB. Microbiological quality and phenotypic characterization of microorganisms isolated from enteral feeding, food handlers and environments of two public Brazilian hospitals. Journal of Food Safety. 2011;31(1):125-31. Reintam A, Parm P, Kitus R, Kern H, Starkopf J. Gastrointestinal symptoms in intensive care patients. Acta Anaesthesiologica Scandinavica. 2009;53(3):318-24. Doménech Briz V, Gea-Caballero V, Chover-Sierra E, et al. Knowledge Level of ICU Nurses Regarding Nutritional Assessment of Critically Ill Patients: A Systematic Review. Nursing Reports. 2024;14(1):586-602. Al-Qalah TAH, Alrubaiee GG. Associated ICU nurses' characteristics to clinical enteral nutrition knowledge at public hospitals in Sana'a, Yemen: A basis for remodeling safety and quality of care standards. F1000Research. 2023;9:759. Al-Sakkaf A. Domestic food preparation practices: a review of the reasons for poor home hygiene practices. Health Promotion International. 2015;30(3):427-37. Gong S, Wang X, Yang Y, Bai L. Knowledge of food safety and handling in households: A survey of food handlers in Mainland China. Food Control. 2016;64:45-53. Ramuada L, Veldsman L, Livhuwani N, Blaauw R. Assessment of knowledge, attitude and practice of nurses regarding enteral nutrition at a military hospital. South African Journal of Clinical Nutrition. 2023;36(2):63-9. Zare-Kaseb A, Sarmadi S, Nazari AM, Ryahin A, Emami Zeydi A. Knowledge, attitude, and practice of nurses regarding enteral feeding: a systematic review. BMC nursing. 2025;24(1):155. Korkmaz BİO, Aydın A, Kılıç N. Investigation of enteral nutrition products for Mesophilic Aerobic Bacteria and Cronobacter sakazakii contamination. 2021. Aycicek H, Oguz U, Karci K. Determination of total aerobic and indicator bacteria on some raw eaten vegetables from wholesalers in Ankara, Turkey. International journal of hygiene and environmental health. 2006;209(2):197-201. Mathus‐Vliegen EM, Bredius MW, Binnekade JM. Analysis of sites of bacterial contamination in an enteral feeding system. Journal of Parenteral and Enteral Nutrition. 2006;30(6):519-25. Lee MJ, Park SY, Ha S-D. Reduction of coliforms in rice treated with sanitizers and disinfectants. Food Control. 2007;18(9):1093-7. Uniat KC, Stangarlin‐Fiori L, Kruger JF, Schieferdecker MEM, Rabito EI. Microbiological quality of enteral formulations handled at home: A systematic review. Journal of Parenteral and Enteral Nutrition. 2022;46(8):1787-96. Johnson TW, Milton D, Johnson K, et al. Comparison of microbial growth between commercial formula and blenderized food for tube feeding. Nutrition in Clinical Practice. 2019;34(2):257-63. Pereira S, Vanetti M. Molecular characterization of Klebsiella isolates from enteral diets. J Food Process Technol. 2015;6(12):528. Nazari R, Haji Ahmadi M, Dadashzade M, Asgari P. Study of hand hygiene behavior among nurses in Critical Care Units. Iran J Crit Care Nurs. 2011;4(2):95-8. Taito S, Kawai Y, Liu K, et al. Diarrhea and patient outcomes in the intensive care unit: Systematic review and meta-analysis. J Crit Care. 2019;53:142-8. Kouni S, Kourlaba G, Mougkou K, et al. Assessment of hand hygiene resources and practices at the 2 children’s hospitals in Greece. The Pediatric infectious disease journal. 2014;33(10):e247-e51. Ahmadipour M, Dehghan M, Ahmadinejad M, Jabarpour M, Mangolian Shahrbabaki P, Ebrahimi Rigi Z. Barriers to hand hygiene compliance in intensive care units during the COVID-19 pandemic: A qualitative study. Frontiers in public health. 2022;10:968231. Ho S, Tse M, Boost M. Effect of an infection control programme on bacterial contamination of enteral feed in nursing homes. Journal of Hospital Infection. 2012;82(1):49-55. Tajeddin E, Rashidan M, Razaghi M, et al. The role of the intensive care unit environment and health-care workers in the transmission of bacteria associated with hospital acquired infections. Journal of infection and public health. 2016;9(1):13-23. Sickbert-Bennett EE, DiBiase LM, Willis TMS, Wolak ES, Weber DJ, Rutala WA. Reducing health care–associated infections by implementing a novel all hands on deck approach for hand hygiene compliance. American journal of infection control. 2016;44(5):e13-e6. Al-Hussami M, Darawad M, Almhairat II. Predictors of compliance handwashing practice among healthcare professionals. Healthcare Infection. 2011;16(2):79-84. Çakıcı N, Demirel Zorba N, Akçalı A. Food industry employees and staphylococcal food poisoning Gida endüstrisi çalisanlari ve stafilokokal gida zehirlenmeleri. Turk Hijyen ve Deneysel Biyoloji Dergisi. 2015;72(4). Lafourcade P, Boulestreau H, Arnaud-Battandier F, et al. Is a 24-h cyclic closed enteral feeding system microbiologically safe in geriatric patients? Clinical Nutrition. 2002;21(4):315-20. da Silva TK, Berbigier MC, Rubin BdA, Moraes RB, Corrêa Souza G, Schweigert Perry ID. Phase angle as a prognostic marker in patients with critical illness. Nutrition in Clinical Practice. 2015;30(2):261-5. Luque N, Guerrero L, Rojas N, et al. 359: Bacterıal contamınatıon of healthcare workers’cell phones ın a peruvıan ıntensıve care unıt. Critical Care Medicine. 2019;47(1):161. Dhayhi N, Kameli N, Salawi M, et al. Bacterial Contamination of Mobile Phones Used by Healthcare Workers in Critical Care Units: A Cross-Sectional Study from Saudi Arabia. Microorganisms. 2023;11(8):1986. Vieira MMC, Santos VFN, Bottoni A, Morais TB. Nutritional and microbiological quality of commercial and homemade blenderized whole food enteral diets for home-based enteral nutritional therapy in adults. Clinical Nutrition. 2018;37(1):177-81. Mahinkazemi M, Tarighat-Esfanjani A, Safaiyan A. Bacterial contamination and nutritional adequacy of enteral tube feedings in Iran. Progr Nutr. 2017;19(3):283-90. Galindo CdO, Beux MR, da Costa RL, et al. Home‐prepared enteral tube feeding: evaluation of microbiological contamination, hygiene, and the profile of the food handler. Nutrition in Clinical Practice. 2021;36(3):704-17. Alshagrawi S, Alhodaithy N. Determinants of hand hygiene compliance among healthcare workers in intensive care units: a qualitative study. BMC public health. 2024;24(1):2333. Hadera T, Worku T, Tuli W. Nurses Knowledge, Practice, and Associated Factors with Enteral Nutrition in Adult Intensive Care Units of Public Hospitals. Ethiopian Journal of Health Sciences. 2022;32(2). Jang T-H, Wu S, Kirzner D, et al. Focus group study of hand hygiene practice among healthcare workers in a teaching hospital in Toronto, Canada. Infection Control & Hospital Epidemiology. 2010;31(2):144-50. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6504346","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":467062974,"identity":"ef96661a-37ce-4618-871a-e71206df736e","order_by":0,"name":"Alev YILDIZ ILIMAN","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIiWNgGAWjYDACdhBhYMEDJBkfwEV58GlhBmuRAKlhNkDWIoFfC0SeDaEKnxb+ZuZjEgwFEjK67WePVfzMsbM3OH6A8cHbNoY68wbsWiQOs6VJgBxmdiYv7WbvtuTEDWcSmA3ntjFIyBzAYc1hHmMDsJYDOWY3eLcxJxgcSGCT5gVqweUy+cP8nyFazr8xK/y7rd7e4PwD9t/4tBgc5gGGLUjLjRwzZt5thxk33EhgY8anxfAwm+GDBLCWN8bSstuOJ8688bBZcs45CckZOLTIHW9+cODDHxt7s/M5hh/fbqu25zuffPDDmzIbftwRAwQJyByFA4wNDPhiEhPIN5CgeBSMglEwCkYEAAB0i1EzCCY9XgAAAABJRU5ErkJggg==","orcid":"","institution":"Amasya University","correspondingAuthor":true,"prefix":"","firstName":"Alev","middleName":"YILDIZ","lastName":"ILIMAN","suffix":""},{"id":467062975,"identity":"b7cad2b4-1cfd-4cc2-8df2-993e4de1888f","order_by":1,"name":"Merve YURTTAŞ","email":"","orcid":"","institution":"Amasya University","correspondingAuthor":false,"prefix":"","firstName":"Merve","middleName":"","lastName":"YURTTAŞ","suffix":""}],"badges":[],"createdAt":"2025-04-22 12:38:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6504346/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6504346/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108602604,"identity":"d40ccc4a-42ef-4383-9729-ce3d9d48e888","added_by":"auto","created_at":"2026-05-06 11:43:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":434938,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6504346/v1/b6a0ca5a-34b1-42aa-a801-626b4fef67c7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Relationship Between Nurses' Professional Characteristics and Enteral Contamination Level: An Intensive Care Assessment\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eNutrition plays a crucial role in the treatment of critically ill patients in intensive care units (ICUs).\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Guidelines recommend initiating enteral nutrition (EN) as early as possible when oral intake is not feasible.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e It has been reported that compared to parenteral nutrition, early initiation of EN in critically ill patients improves clinical outcomes, reducing mortality rates, length of hospital stay, and healthcare-related costs.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Additionally, numerous studies have emphasized the clinical significance of EN support for patients in the intensive care unit (ICU) setting.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite the benefits of EN in critically ill patients, several complications are associated with this feeding method. Some of these risks include mechanical complications, such as incorrect tube placement, tube displacement, and tube obstruction, as well as gastrointestinal complications, including nausea, vomiting, and diarrhea. Furthermore, pulmonary aspiration and infections pose potential risks for critically ill patients.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Although the contamination of enteral products is one of these risks, its significance is often overlooked. However, enteral nutrition is the most frequently administered nutritional therapy in ICUs. When contaminated enteral products are administered to patients, severe complications such as diarrhea, abdominal distension, aspiration pneumonia, and even sepsis may develop. This risk is even more critical for ICU patients who are elderly or immunocompromised.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePatients receiving treatment in the ICU are at high risk for hospital-acquired infections due to immunosuppression caused by factors such as trauma, invasive procedures, and corticosteroid therapy.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Therefore, it is crucial for healthcare professionals working in ICUs to adhere to hand hygiene practices, follow infection control measures during patient care, and ensure that the medical equipment used complies with hygiene and standardization guidelines.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Contamination of enteral products can occur during production, storage, preparation, and administration. ICU nurses play a key role in preventing such contamination. As they are responsible for initiating, managing, monitoring risks, and detecting potential complications associated with enteral nutrition.\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Therefore, ICU nurses must possess adequate knowledge, skills, and experience to safely administer enteral nutrition to critically ill patients.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eStudies conducted in ICUs have detected the presence of pathogenic microorganisms in enteral products. A systematic review reported that a significant proportion of enteral infusion samples were contaminated with Coliforms, \u003cem\u003eStaphylococcus aureus\u003c/em\u003e, Mesophilic bacteria, and \u003cem\u003eEscherichia coli (E. coli).\u003c/em\u003e\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Several studies in the literature support these findings.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e When examining the causes of contamination, failure to adhere to basic hygiene principles, particularly hand hygiene, has been identified as a major issue. Another significant factor is the lack of adherence to standardized protocols for enteral nutrition administration. It has been found that ICUs that follow clinical practice guidelines for enteral nutrition achieve better clinical outcomes.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Numerous studies have been conducted to investigate nurses\u0026rsquo; knowledge, attitudes, and practices regarding enteral nutrition contamination.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e However, no studies that specifically examine the relationship between enteral contamination and nurses' demographic and professional characteristics have been detected. Nevertheless, the literature suggests that the characteristics of individuals involved in food preparation influence hygiene behaviors, which in turn increase the risk of food contamination.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Studies conducted on individuals administering enteral nutrition at home support this finding.\u003c/p\u003e \u003cp\u003eThis descriptive study aims to determine whether nurses' demographic and professional characteristics influence enteral contamination levels. By identifying the relationship between demographic variables and enteral contamination levels, this study will provide insight into ICU nurses' adherence to hygiene principles. In doing so, it will contribute more concrete data to the existing literature, which primarily focuses on nurses' knowledge and attitudes regarding enteral nutrition.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study aims to compare enteral contamination levels based on nursing variables and to explain the underlying reasons for potential differences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was designed as a descriptive study and was conducted between September and November 2024 in the intensive care unit of a university hospital in Turkey.\u003c/p\u003e\n\u003cp\u003eDo enteral contamination levels differ based on the demographic characteristics of nurses?\u003c/p\u003e\n\u003cp\u003eDo enteral contamination levels differ based on the professional characteristics of nurses?\u003c/p\u003e\n\u003cp\u003eThe primary outcome of this study is the contamination levels of enteral products. The secondary outcomes include determining whether these contamination levels vary according to nurses\u0026apos; demographic and professional characteristics. The common variables in this study include the levels of \u003cem\u003eE. coli, Staphylococcus sp\u003c/em\u003e., total aerobic mesophilic bacteria, and coliform microorganisms detected in enteral products.\u003c/p\u003e\n\u003cp\u003eThe study population consisted of 40 nurses working in the adult intensive care unit of a university hospital. The sample size was determined using the known population sampling formula. Based on a 5% margin of error and 80% power, the required sample size was calculated as 32 nurses. A simple random sampling method was used to select participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Tools\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA data collection form was developed based on similar studies to collect relevant data from nurseS.\u003csup\u003e23,24\u003c/sup\u003e This form included questions regarding nurses\u0026apos; age, gender, education level, years of professional experience, years of ICU experience, ICU certification status, and sources of information used for enteral nutrition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNurses were informed about the study both in writing and verbally. Following the information session, written informed consent was obtained from the nurses who voluntarily agreed to participate. No procedures or interventions were performed on patients. Ethical approval for the study was obtained from the Amasya University Non-Interventional Clinical Research Ethics Committee (ID NO: E-76988455-050.04-213841). Additionally, institutional permissions were secured from the university hospital where the study was conducted. Throughout the study, the identities of the nurses were kept confidential and the samples were coded. In the analysis results, the identities of the nurses who collected the contaminated and uncontaminated samples were kept confidential. We declare that we have complied with all ethical principles stated in the Declaration of Helsinki of the World Medical Association.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Collection Process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNurses who provided informed consent were included in the study. To prevent potential biases, the date and time of enteral product sampling were kept confidential from the nurses. Each nurse was responsible for preparing the enteral feeding equipment, connecting it to the patient, and conducting a 24-hour infusion process. Thus, each nurse completed the entire enteral feeding procedure. Following this, the nurse disconnected the enteral feeding set from the patient, and the researcher collected samples from the set.\u003c/p\u003e\n\u003cp\u003eThe distal end of the enteral feeding set was wiped with a sterile alcohol swab, 5 mL of feeding solution was discarded, and then 30 mL of enteral feeding solution was transferred into a sterile sample container. The collected samples were placed in a cold chain transport box and cultured in the laboratory within one hour. Each sample was coded to ensure confidentiality, and the identities of nurses were anonymized. The researcher analyzing the data was blinded to the nurses\u0026apos; personal information. Aseptic techniques were strictly followed during the sample collection process to prevent contamination of the feeding solutions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMicrobiological Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor the enumeration of Total Aerobic Mesophilic Bacteria (TAMB) and \u003cem\u003eStaphylococcus sp\u003c/em\u003e., Plate Count Agar and Mannitol Salt Agar were used, respectively, with incubation at 35\u0026ndash;37\u0026deg;C for 24\u0026ndash;48 hours. The enumeration of coliforms and \u003cem\u003eE. coli\u003c/em\u003e was carried out according to the EMS method using Lauryl Sulfate Tryptose Broth supplemented with MUG.\u003c/p\u003e\n\u003cp\u003ePlate Count Agar and Mannitol Salt Agar were used for the enumeration of \u0026nbsp;TAMB and \u003cem\u003eStaphylococcus sp\u003c/em\u003e., respectively, with incubation at 35\u0026ndash;37\u0026deg;C for 24\u0026ndash;48 hours. The enumeration of coliforms and \u003cem\u003eE. coli\u003c/em\u003e was performed using the EMS method with Lauryl Sulfate Tryptose Broth supplemented with MUG.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe statistical analyses were conducted using IBM SPSS 25 software. The Mann-Whitney U test was used to compare two groups, while the Kruskal-Wallis test was applied for comparisons involving three or more groups. The Spearman rho test was used to determine correlations between two continuous variables. Results which were at p \u0026lt; 0.05 were considered statistically significant. \u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe results of microbiological counts and the proportion of samples exceeding US Food and Drug Administration (FDA) threshold values (%) are presented in Tables 1 and 2. In this study, 75% of the samples obtained from enteral feeding tubes after patient disconnection exceeded the FDA threshold for TAMB, while 100% exceeded the threshold for coliform counts. \u003cem\u003eStaphylococcus sp\u003c/em\u003e. (\u0026gt;10 CFU/mL) was detected in 23 enteral product samples (71.9%). Coagulase testing was not performed on \u003cem\u003eStaphylococcus\u003c/em\u003e species; therefore, the results were reported as \u003cem\u003eStaphylococcus sp\u003c/em\u003e. A total of three samples (9.37%) tested positive for \u003cem\u003eE. coli\u0026nbsp;\u003c/em\u003e(table 3).\u003c/p\u003e\n\u003cp\u003eThe mean age of the nurses included in the study was 33.03\u0026plusmn;8.34 years. Among the participants, 65.6% were female, and 75% held a bachelor\u0026apos;s degree (Table 4). The logarithmic values of the detected microorganism counts in enteral products were determined. These logarithmic values were analyzed in relation to nurses\u0026apos; characteristics using the Mann-Whitney U test, Kruskal-Wallis test, and Spearman\u0026apos;s correlation test in the statistical program (Table 5). A statistically significant negative correlation was found between nutrition education and the level of \u003cem\u003eStaphylococcus sp\u003c/em\u003e. contamination (p \u0026lt; 0.05).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Microbiological Count Results CFU: Colony Forming Unit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003eSample No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003eTAMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cem\u003eStaph.\u003c/em\u003e sp.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eColiform\u003c/p\u003e\n \u003cp\u003e(MPN/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cem\u003eE.coli\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e4x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026lt;10\u0026ordf;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e1x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e35x10\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e3,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e13x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e8x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e11x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e39x10\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e17x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e5x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e10x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e61x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e4x10\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e14x10\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e20x10⁵\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e17x10\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e45x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e17x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026lt;10\u0026ordf;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026lt;10\u0026ordf;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e15x10⁵\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e9x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e930\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e18x10⁵\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e12x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026lt;10\u0026ordf;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026lt;10\u0026ordf;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e13x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e6x10\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e2x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e39x10\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e28x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e9x10\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e430\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e15x10⁵\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e66x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e750\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e50x10⁵\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e33x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e750\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e50x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e37x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e5x10⁵\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e7x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e11000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e18x10⁵\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026lt;10\u0026ordf;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e11000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e1x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026lt;10\u0026ordf;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e2x10⁵\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026lt;10\u0026ordf;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026lt;10\u0026ordf;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e12x10\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e3x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e32x10\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e11000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e12x10⁵\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e13x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e11000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e13x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e72x10\u0026sup3;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e3x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e43x10\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e4600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e40x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026lt;10\u0026ordf;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e11000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e17x10⁵\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026lt;10\u0026ordf;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e11000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u0026lt;10\u0026ordf;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026lt;10\u0026ordf;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e11000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e1x10⁴\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e51x10\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e11000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003eAbbreviations:\u003c/p\u003e\n \u003cp\u003e-: microorganism is not detective.\u003c/p\u003e\n \u003cp\u003e\u0026ordf;: \u0026nbsp;Colony counting was performed according to the Compendium of Methods for the Microbiological Examination of Foods guidelines. Petri dishes with no visible colony formation were considered to have a microorganism count of \u0026lt;10 CFU/mL. For petri dishes with \u0026lt;25 CFU/mL, the colony count was obtained by multiplying by the dilution factor. TAMB, total aerobic mesophilic bacteria;\u003cem\u003e\u0026nbsp;Staph.\u003c/em\u003e sp., \u003cem\u003eStaphylococcus sp.;\u003c/em\u003e \u003cem\u003eEscherichia coli, E. coli.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 586px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2. Percentage of Samples Exceeding FDA Threshold Values for Microorganisms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eMicroorganism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 359px;\"\u003e\n \u003cp\u003eSamples (n:32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eTAMB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 359px;\"\u003e\n \u003cp\u003e75\u0026ordf; %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eColiform\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 359px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e100\u0026ordf; %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 586px;\"\u003e\n \u003cp\u003eAbbreviations:\u003c/p\u003e\n \u003cp\u003eTAMB: Total aerobic mesophilic bacteria\u003c/p\u003e\n \u003cp\u003e\u0026ordf;: Sample rate exceeding microorganism limit values according to US Food and Drug Administration\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 586px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3. E. coli-Positive Samples\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample no\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eE.coli\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eSample 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eSample 16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003eSample 32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eEscherichia coli, E. coli.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 604px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4. Demographic and Professional Characteristics of Nurses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin-Max\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u0026plusmn;ss\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e24-51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e33.03\u0026plusmn;8.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eProfessional experience (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e1-31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e10.88\u0026plusmn;8.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eIntensive care experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e1-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e5.90\u0026plusmn;3.52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e21 (65.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e11 (34.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eAssociate Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e6 (18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eBachelor\u0026apos;s Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e24 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eMaster\u0026apos;s Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e2 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eIntensive care certification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e7 (21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e25 (78.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eInformation need regarding enteral feeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eI need it\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e27 (84.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eSometimes I need it\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e4 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eI don\u0026rsquo;t need it\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eInformation sources used in enteral feeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eInternet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e17 (53.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003ePhysician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e6 (18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eInternet and physician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e2 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eInternet and nurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e2 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eInternet, physician, and nurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e3 (9.4))\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eGuidelines\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e2 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 624px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTable 5. Relationship Between Nurses\u0026apos; Demographic and Professional Characteristics and Microorganism Levels\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTAMB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaph sp.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eColiform\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e-,815*\u003c/p\u003e\n \u003cp\u003e,415****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e-,186*\u003c/p\u003e\n \u003cp\u003e,852****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e-1,167*\u003c/p\u003e\n \u003cp\u003e,243****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003eIntensive Care Certification\u003c/p\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e-1,256*\u003c/p\u003e\n \u003cp\u003e,209****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e-,548*\u003c/p\u003e\n \u003cp\u003e,584****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e-1,525*\u003c/p\u003e\n \u003cp\u003e,127****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003eEducation Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e,401**\u003c/p\u003e\n \u003cp\u003e,818****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.502**\u003c/p\u003e\n \u003cp\u003e,472****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e,350**\u003c/p\u003e\n \u003cp\u003e,839****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003eInformation Need Regarding Enteral Feeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e,272**\u003c/p\u003e\n \u003cp\u003e,873****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2,744**\u003c/p\u003e\n \u003cp\u003e,254****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e,194**\u003c/p\u003e\n \u003cp\u003e,908****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003eInformation Sources Used in Enteral Feeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e3,388**\u003c/p\u003e\n \u003cp\u003e,640****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e5.507**\u003c/p\u003e\n \u003cp\u003e,357****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3,602**\u003c/p\u003e\n \u003cp\u003e,608****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e,136***\u003c/p\u003e\n \u003cp\u003e,458****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e,157***\u003c/p\u003e\n \u003cp\u003e,392****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e-,218***\u003c/p\u003e\n \u003cp\u003e,230***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003eProfessional Experience (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e,092***\u003c/p\u003e\n \u003cp\u003e,616***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e,149***\u003c/p\u003e\n \u003cp\u003e,416****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e-,192***\u003c/p\u003e\n \u003cp\u003e,292****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003eIntensive Care Experience (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e,073***\u003c/p\u003e\n \u003cp\u003e,691****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e,146***\u003c/p\u003e\n \u003cp\u003e,426****\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e-,262***\u003c/p\u003e\n \u003cp\u003e,148****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 624px;\"\u003e\n \u003cp\u003e*Man witney Z\u003c/p\u003e\n \u003cp\u003e**Kruskal-Wallis Test\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e***Spearman rho\u003c/p\u003e\n \u003cp\u003e****Sigma\u003c/p\u003e\n \u003cp\u003eTAMB, total aerobic mesophilic bacteria; Staph. sp., \u003cem\u003eStaphylococcus sp.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eEnteral nutrition, frequently administered in intensive care units, poses various risks and can lead to serious patient safety concerns. One of these risks is the contamination of enteral solutions with pathogenic microorganisms. Numerous studies have been conducted to determine the contamination levels of enteral products, but very few have focused on the relationship between enteral contamination and the characteristics of nurses. However, nurses play an active role in all stages of enteral feeding. Therefore, nurses are key in preventing contamination in enteral products. Studies on the safe use of enteral products often examine the level of knowledge among nurses, but it remains unclear whether demographic and professional characteristics that may affect nurses\u0026apos; hygiene behaviors have an impact on contamination levels. To address this uncertainty, our study compared the levels of total aerobic bacteria, coliforms, S. aureus, and \u003cem\u003eE. coli\u003c/em\u003e microorganisms in enteral products based on nurse-related variables.\u003c/p\u003e\n\u003cp\u003eTotal mesophilic aerobic bacteria represents the total number of microorganisms, an important indicator used to assess the hygiene level of food products.\u003csup\u003e25\u003c/sup\u003e The presence of total mesophilic aerobic bacteria is a critical indicator of the microbiological safety and quality of enteral products. These bacteria can proliferate in environments with temperatures between 20-45\u0026deg;C and live in oxygenated environments. Their high presence may indicate that the product was not produced under hygienic conditions or was not stored properly. \u0026nbsp;Monitoring the microbial load in food is an essential criterion for evaluating the effectiveness of hygiene and quality control processes.\u003csup\u003e26\u003c/sup\u003e When reviewing studies on the microbiological quality of enteral products, TAMB microorganisms have been identified in some studies.\u003csup\u003e27\u003c/sup\u003e In our study, the TAMB microorganism level exceeded the FDA limits in three-fourths of the samples. We hypothesize that contamination may have occurred only after the product cap was opened, as commercially available ready-to-use enteral products are produced and stored in appropriate conditions, with the production and storage processes of all products in our study being identical. However, the microbial loads varied. We believe that the contamination may have resulted from the failure to adhere to hygiene principles during the processes of opening the product packaging, adding solutions to enteral sets, connecting the set to the patient, adding solution to the set, and joining and disconnecting connection points. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eColiforms are microorganisms commonly found in the intestines of mammals and humans. These microorganisms are particularly significant in food safety because their presence can indicate fecal contamination. The presence of coliforms may signal inadequate hygienic conditions and the potential presence of harmful pathogens. Additionally, coliforms are frequently used to assess the microbiological quality of water sources and food products. The presence of coliforms in enteral products is an important indicator for evaluating the hygienic condition of these products.\u003csup\u003e28\u003c/sup\u003e The presence of coliforms in enteral products suggests that hygienic standards were not sufficiently maintained during the preparation or application stages.\u003csup\u003e14\u003c/sup\u003e In our study, coliform levels were found to exceed FDA limits in all samples. A review of other studies reveals that while coliforms were detected in commercial ready-to-use enteral products similar to ours\u003csup\u003e7,29\u003c/sup\u003e, some studies did not find them.\u003csup\u003e30,31\u003c/sup\u003e We believe that one of the main causes of fecal contamination in enteral products is nurses\u0026apos; hand hygiene behaviors. This is because nurses perform many procedures with a high risk of fecal pathogens in the intensive care unit, such as colostomy drainage, enema applications, genital care, and stool cleaning. Nurses\u0026apos; adherence to hand hygiene protocols after these procedures is crucial for preventing fecal-derived coliform pathogens. However, it has been emphasized that intensive care unit nurses often neglect hand hygiene after using gloves.\u003csup\u003e32\u003c/sup\u003e In our study, another potential cause of coliform contamination may be the tap water used for cleaning the tubes. A review of the literature has identified a correlation between the use of tap water to clean or dilute enteral products and the presence of coliforms.\u003csup\u003e7\u003c/sup\u003e In a very few number studies, no coliform growth was observed with the use of tap water. This, however, is not enough to reach a conclusion that tap water is safe to use for these procedures. \u0026nbsp;Even water without tap sources can pose a risk to pathogens if left in the bag for extended periods. The frequency of diarrhea in intensive care units ranges from 11% to 66%.\u003csup\u003e33\u003c/sup\u003e Although diarrhea caused by fecal-origin infections is not commonly encountered in intensive care units, it is important for patient outcomes. Diarrhea can lead to negative effects in critically ill patients, such as dehydration, electrolyte imbalances, hemodynamic instability, malnutrition, and skin lesions. It has been determined that diarrhea in intensive care patients increases mortality and length of hospital stay. Furthermore, it is recommended that nurses assess diarrhea as a symptom of infection in intensive care patients. Therefore, strict hygienic measures in the application of enteral products are of vital importance. Fatigue and burnout due to excessive workload in intensive care units negatively impact adherence to hand hygiene protocols. Additionally, the frequency of emergency interventions and excessive workload creates time constraints, which act as barriers to hygiene practices. Observational studies have shown that nurses working day shifts wash their hands less frequently than those working night shifts.\u003csup\u003e34\u003c/sup\u003e The inappropriate physical design of intensive care units has also been noted to affect hygienic behavior. Moreover, the harmful effects of chemical agents on the skin from repeated handwashing after continuous tasks have been reported as barriers by nurses.\u003csup\u003e18\u003c/sup\u003e Some studies also indicate that the lack of adequate hand hygiene and drying materials impedes proper hygiene practices.\u003csup\u003e35\u003c/sup\u003e Intensive care units are also high-risk areas for contamination sources. A study conducted by Ho (2012) identified a relationship between nurses\u0026apos; hand hygiene and contamination of enteral tubes, enteral sets, and enteral nutrition. In another study, contamination sources were examined.\u003csup\u003e36\u003c/sup\u003e According to this study, the major contamination sources were oxygen masks (81.8%), ventilators (82.9%), and bed linens (67.7%).\u003csup\u003e37\u003c/sup\u003e This finding is important because another study emphasized that 38% of infections occurred due to cross-contamination.\u003csup\u003e38,39\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAmong the most important sources of \u003cem\u003eStaphylococcus sp\u003c/em\u003e. are the mucosal nasal flora, skin, gastrointestinal, and genital systems. It has been reported that approximately 15-35% of healthy individuals are constant carriers, and 35-50% are intermittent carriers of \u003cem\u003eStaphylococcus\u003c/em\u003e. \u003cem\u003eStaphylococcus sp\u003c/em\u003e., which has been associated with numerous infections and toxicities, can cause a range of conditions from simple skin lesions to more serious issues such as pneumonia and meningitis. It can also cause food poisoning through the production of enterotoxins.\u003csup\u003e40\u003c/sup\u003e Despite having mild clinical symptoms, it is one of the most commonly observed poisonings worldwide, and although the detected mortality rate is low, the economic losses caused by it are significant. In our study, \u003cem\u003eStaphylococcus sp\u003c/em\u003e. was detected in 23 enteral products (71.9%) with levels exceeding 10 CFU/mL. In a study conducted by Baniardalan et al. (2014) in an intensive care unit, the growth rate was higher than in our study (24, 86%) (14). In the study by Lafourcade et al. (2002), similar results were found to our study.\u003csup\u003e41\u003c/sup\u003e However, this study was conducted using a closed-system enteral set. In the studies by Moazen et al. (2014) and Da Silva (2015), coagulase-positive \u003cem\u003eStaphylococcus\u003c/em\u003e was found in 1 (5%) and 1 (12.5%) samples, respectively, while in other studies, it was either found at very low rates or not at all.\u003csup\u003e16,42\u003c/sup\u003e Due to its ability to withstand solid substances and low water activity conditions, \u003cem\u003eStaphylococcus sp.\u003c/em\u003e can survive in dry environments (surfaces and clothing), increasing the risk of enteral contamination. Another factor contributing to this risk is the lack of use of sterile gloves during enteral feeding. In procedures where sterility is not maintained, healthcare workers do not pay enough attention to hand hygiene and glove usage, thereby increasing the risk of cross-contamination. In addition, nurse uniforms can also be a source of cross-contamination. This is highly likely in intensive care units where the frequency of care procedures and emergency interventions is high, leading to nurse uniforms being contaminated by the patient and surfaces the patient has come into contact with. A study examining the contamination of nurse uniforms found that all nurses\u0026apos; uniforms were contaminated with \u003cem\u003eStaphylococcus\u003c/em\u003e, but the rate was significantly higher among intensive care unit nurses. Furthermore, \u003cem\u003eStaphylococcus sp\u003c/em\u003e. microorganisms can be transmitted via the respiratory route. This risk of contamination may increase if nurses do not wear masks during enteral feeding preparation and application. Additionally, aspiration procedures, which are frequently performed in intensive care units, can also be considered a significant risk factor. During aspiration, contamination of the patient\u0026rsquo;s bed, nurse uniforms, and other care equipment is likely, further increasing the risk of enteral contamination. Another potential source of contamination could be the nurses\u0026apos; mobile phones. Recent studies have shown that the bacterial load on mobile phones of intensive care nurses is at high levels.\u003csup\u003e43,44\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eE. coli\u003c/em\u003e microorganisms are widely used as indicator microorganisms in the evaluation of the microbiological quality of food due to their ecological characteristics that are similar to pathogenic microorganisms (45). \u0026nbsp;\u003cem\u003eE. coli\u003c/em\u003e is the species associated with fecal contamination. However, this indicator is not sufficient to trace the origin of contamination.\u003csup\u003e26\u003c/sup\u003e In our study, \u003cem\u003eE. coli\u003c/em\u003e was found to be positive in 3 samples (9.37%). When reviewing studies conducted with commercially prepared enteral products, one study reported growth at similar rates to our study (2/20, 10%)\u003csup\u003e45\u003c/sup\u003e, while another study reported growth within the accepted safe limits (\u0026lt;3 CFU/g)\u003csup\u003e16\u003c/sup\u003e. One of the transmission routes for \u003cem\u003eE. coli\u003c/em\u003e microorganisms is tap water.\u003csup\u003e26\u003c/sup\u003e This finding is supported by a study, as \u003cem\u003eE. coli\u003c/em\u003e was found to grow only in powdered enteral products, which confirms its transmission via water.\u003csup\u003e46\u003c/sup\u003e In our study, tap water was also added to the enteral sets. This can be considered as one of the factors causing contamination. The sterility of enteral feeding products is of vital importance for both food safety and clinical outcomes. Even if there is no significant problem with food safety during the production process of enteral products, the preparation of these products raises the potential risk of contamination. Therefore, the use of sterile sets in the preparation and application processes of enteral foods, the application of aseptic techniques during preparation and application, and strict attention to personnel hygiene are necessary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe relationship between the demographic and professional characteristics of nurses and microorganism levels in enteral products\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our study, no relationship was found between the age variable of nurses and the contamination levels. No study in the literature has established a connection between enteral contamination levels and the age of nurses. However, in a study conducted with home care patients, it was found that 62.5% of commercial solutions had aerobic mesophilic microorganisms and total coliform (103) values exceeding the accepted limits. In this study, 47% of the individuals performing enteral application were 50 years old or older.\u003csup\u003e47\u003c/sup\u003e Many studies on the attitudes and behaviors of nurses and other healthcare workers toward hygiene practices suggest that an increase in age positively affects compliance with hygiene behaviors.\u003csup\u003e39\u003c/sup\u003e Additionally, it is emphasized that the positive influence of older individuals in this regard plays an important role in younger and inexperienced healthcare workers\u0026apos; compliance with hand hygiene behaviors by acting as role models. Another benefit of older healthcare workers being role models for hygiene behaviors is the ability to provide immediate feedback through direct observation. This, in turn, improves the quality of care and patient safety.\u003csup\u003e48\u003c/sup\u003e One reason for not finding a difference based on the age variable in our study could be the low sample size. Another reason may be the relatively low average age of the nurses in our study.\u003c/p\u003e\n\u003cp\u003eAnother variable examined in our study was the educational level of nurses. No difference was found between the educational level and enteral contamination levels. The educational level plays an important role in the learning and application of hygiene behaviors by caregivers. A higher educational level also facilitates access to information sources and is important for the use of this knowledge.\u003csup\u003e47\u003c/sup\u003e It is known that there is a significant relationship between the educational level of nurses and their knowledge levels.\u003csup\u003e49\u003c/sup\u003e However, a higher level of knowledge does not always mean the same level of compliance with application.\u003csup\u003e50\u003c/sup\u003e\u0026nbsp; Despite having a high level of knowledge, nurses\u0026apos; compliance with hand hygiene protocols is below average. However, nurses\u0026apos; adherence to hygiene behaviors is important in preventing enteral contamination. It has been determined that infection control training significantly reduces enteral contamination levels.\u003csup\u003e36\u003c/sup\u003e This highlights the importance of continuous education in enteral contamination.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our study, professional experience and intensive care unit (ICU) experience duration were other important variables. No relationship was found between these variables and microorganism contamination levels. Additionally, contamination levels did not differ based on ICU certification. However, some studies have shown a positive relationship \u0026nbsp;between longer work experience and improved hygiene behaviors. The more experience a nurse has, the more adhere s/he is to hygiene.\u003csup\u003e39\u003c/sup\u003e The main reason for the differences between studies is methodological, as many studies rely on nurses\u0026apos; self-reports regarding their hygiene behaviors. Nevertheless, no study has been found that reveals the relationship between longer work experience and contamination levels.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLIMITATIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. First, it was conducted in a single university hospital\u0026rsquo;s intensive care unit, which may limit the generalizability of the findings to other institutions or healthcare settings. Second, the relatively small sample size (32 nurses and 32 enteral product samples) may affect the statistical power and limit the ability to detect smaller associations. Third, the study did not perform coagulase testing on Staphylococcus species, so pathogenicity could not be fully determined. Finally, as a descriptive cross-sectional study, it captures data at one point in time and cannot establish causality between variables.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRECOMMENDATIONS OR IMPLICATIONS FOR PRACTICE\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn line with the findings of our study, developing strategies to improve hygiene practices during the enteral feeding process will significantly contribute to reducing hospital-acquired infections and enhancing the quality of patient care. Implementing training programs aimed at increasing ICU nurses\u0026rsquo; compliance with hygiene protocols may be effective in ensuring patient safety. The data obtained from this study will be shared with the relevant clinical departments, and the development of in-service training programs is expected to enhance patient safety. As a result, it is anticipated that patient outcomes will improve and healthcare costs will be reduced.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn this study, microbiological contamination was detected in a significant proportion of the samples obtained from enteral feeding sets that were disconnected from patients. The fact that TAMB and coliform counts exceeded the FDA\u0026apos;s limit values highlights deficiencies in hygiene practices and presents potential contamination risks. The presence of potential pathogens, such as \u003cem\u003eStaphylococcus sp\u003c/em\u003e. and \u003cem\u003eE. coli,\u003c/em\u003e underscores the importance of maintaining hygiene standards throughout the enteral feeding process. No significant relationship was found between variables such as the nurses\u0026apos; age, educational level, professional experience, and ICU length of experience and the levels of enteral contamination.\u003c/p\u003e\n\u003cp\u003eOur findings emphasize the need for stricter adherence to hygiene standards in enteral feeding practices. In particular, proper hand hygiene, the use of sterile sets, the selection of appropriate water sources, and the assurance the working environment complies with hygiene standards are critical to preventing contamination.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003eICUs: İntensive care units\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEN: enteral nutrition\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eICU: intensive care unit\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eE. coli: Escherichia coli\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFDA: US Food and Drug Administration\u003c/li\u003e\n \u003cli\u003eTAMB: Total aerobic mesophilic bacteria\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNurses were informed about the study both in writing and verbally. Following the information session, written informed consent was obtained from the nurses who voluntarily agreed to participate. No procedures or interventions were performed on patients. Ethical approval for the study was obtained from the Amasya University Non-Interventional Clinical Research Ethics Committee (ID NO: E-76988455-050.04-213841). Additionally, institutional permissions were secured from the university hospital where the study was conducted. Throughout the study, the identities of the nurses were kept confidential and the samples were coded. In the analysis results, the identities of the nurses who collected the contaminated and uncontaminated samples were kept confidential. We declare that we have complied with all ethical principles stated in the Declaration of Helsinki of the World Medical Association.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAYI took part in the processes of planning the research, literature review, obtaining ethics committee and institutional permissions, collecting data, performing statistical analyses, reporting the data and preparing it for publication. MY took part in the processes of planning the research, collecting data, performing microbiological analyses, reporting the data and preparing it for publication. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the clinic\u0026apos;s responsible physician and nurses for their support in conducting the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003evan Nieuwkoop MM, Ramnarain D, Pouwels S. Enteral nutrition interruptions in the intensive care unit: a prospective study. Nutrition. 2022; 96: 111580.\u003c/li\u003e\n \u003cli\u003eMcClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). 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Determinants of hand hygiene compliance among healthcare workers in intensive care units: a qualitative study. BMC public health. 2024;24(1):2333.\u003c/li\u003e\n \u003cli\u003eHadera T, Worku T, Tuli W. Nurses Knowledge, Practice, and Associated Factors with Enteral Nutrition in Adult Intensive Care Units of Public Hospitals. Ethiopian Journal of Health Sciences. 2022;32(2).\u003c/li\u003e\n \u003cli\u003eJang T-H, Wu S, Kirzner D, et al. Focus group study of hand hygiene practice among healthcare workers in a teaching hospital in Toronto, Canada. Infection Control \u0026amp; Hospital Epidemiology. 2010;31(2):144-50.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"enteral nutrition, intensive care, intensive care nurses, contamination","lastPublishedDoi":"10.21203/rs.3.rs-6504346/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6504346/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNutrition is vital for critically ill patients in intensive care, but enteral product contamination poses a risk. This study examines whether intensive care nurses' demographic and professional traits affect contamination levels. This study aims to compare enteral contamination levels based on nursing variables and to explain the underlying reasons for potential differences.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003e This descriptive study was conducted in the intensive care unit of a university hospital in Turkey between September and November 2024. The study included 32 intensive care nurses and samples collected from enteral products prepared by these nurses. The contamination levels of \u003cem\u003eEscherichia coli, Staphylococcus sp\u003c/em\u003e., total aerobic mesophilic bacteria, and coliform pathogenic microorganisms in enteral products were examined. The logarithmic values were analyzed in relation to nurses' characteristics using the Mann-Whitney U test, Kruskal-Wallis test, and Spearman correlation test in a statistical software program.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIt was determined that 75% and 100% of the analyzed 32 enteral samples exceeded the US Food and Drug Administration threshold values in terms of total aerobic mesophilic bacteria and coliform counts, respectively. Coagulase testing was not performed on Staphylococcus species; therefore, results were reported as \u003cem\u003eStaphylococcus sp. Escherichia coli\u003c/em\u003e was detected in three samples (9.37%). No significant differences were found in enteral contamination levels based on nurses' age, gender, education level, years of professional experience, years of intensive care experience, or possession of an intensive care certification.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study found that bacterial contamination in enteral products exceeded US Food and Drug Administration limits, indicating hygiene deficiencies. The presence of pathogens like \u003cem\u003eStaphylococcus sp\u003c/em\u003e. and \u003cem\u003eEscherichia coli\u003c/em\u003e highlights contamination risks. Nurses' characteristics did not affect contamination levels, emphasizing the need for stricter hygiene adherence in enteral nutrition.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRelevance to clinical practice\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study demonstrates that adherence to hygiene protocols during the preparation of enteral nutrition in intensive care units is critical for patient safety. Although nurses' professional characteristics do not influence contamination levels, the high microbial load indicates systemic deficiencies in practice. This highlights the necessity of standardized hygiene training and monitoring procedures.\u003c/p\u003e","manuscriptTitle":"The Relationship Between Nurses' Professional Characteristics and Enteral Contamination Level: An Intensive Care Assessment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-09 12:28:23","doi":"10.21203/rs.3.rs-6504346/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a701e96d-ee90-4389-82e3-336d95edea33","owner":[],"postedDate":"June 9th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Withdrawn","date":"2026-05-06T11:26:46+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T11:41:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-09 12:28:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6504346","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6504346","identity":"rs-6504346","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}