Rho_Neu final thesis 4-27-15

AN INVESTIGATION OF THE RELATIONSHIP OF WOUND INFECTION AND
EXPOSURE TO HOUSEHOLD PETS: A PILOT STUDY
A Thesis
Presented to the faculty of the School of Nursing
California State University, San Marcos
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SCIENCE
in
Nursing
Family Nurse Practitioner
by
Rhodora Neu
SPRING
2015

© 2015
Rhodora Neu
ALL RIGHTS RESERVED
ii

CALIFORNIA STATE UNIVERSITY SAN MARCOS
THESIS SIGNATURE PAGE
THESIS SUBMITTED IN PARTIAL FULLFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE
MASTER OF SCIENCE
IN
NURSING
THESIS TITLE: An investigation of the relationship of wound infection and exposure to
household pets: A pilot study
AUTHOR: Rhodora Neu
DATE OF SUCCESSFUL DEFENSE: April 17, 2015
THE THESIS HAS BEEN ACCEPTED BY THE THESIS COMMITTEE IN
PARTIAL FULLFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE IN NURSING.
Denise Boren, Ph.D., RN
THESIS COMMITTEE CHAIR SIGNATURE DATE
Patricia Hinchberger, Ed.D., GCNS, RN
THESIS COMMITTEE MEMBER SIGNATURE DATE
Linnea Axman, Dr.PH., MSN,FNP-BC,
FAANP
THESIS COMMITTEE MEMBER SIGNATURE DATE
iii

Student: Rhodora Neu
I certify that this student has met the School of Nursing format requirements, and that this thesis
is suitable for shelving in the Library and credit is to be awarded for the thesis.
__________________________, Director ___________________
Denise Boren, PhD, RN Date
School of Nursing
College of Education, Health, and Human Services
California State University San Marcos
iv

Abstract
of
An investigation of the relationship of wound infection and exposure to household pets: A pilot
study
by
Rhodora Neu
Statement of Problem
In most industrialized countries, pets are becoming a big part in households engaging and
sharing human lifestyles. In fact, it is estimated that 14%-62% of pet owners allow their dogs and
cats on their beds. However, pets can also carry and transmit pathogens to people causing public
health risks. Little is known about public knowledge and practices associated to pet related
diseases, otherwise known as zoonotic diseases. The closeness of pet owners and their animals
could pose a potential risk for transmission of at least 30 infectious agents. Zoonoses are
diseases communicable from animals to humans.
Sources of Data
Data was collected from a convenience sample of prospective, new patients at a Wound Care
Center in Southern California. A copy of the wound culture results was collected. Participants
completed an Exposure to Pet Survey Questionnaire that included demographic data, type of pet
in the household, frequency of time spent with the pet based on six items, and hand hygiene.
Conclusions Reached
The independent variable did not have significant correlation with the dependent variable
(p=.137). A large-scale study is suggested to further investigate this hypothesis. However, hand
washing showed a strong correlation with frequency of pet engagement (p=<.01), and suggests
an inverse relationship with documented wound infection.
_______________________, Committee Chair
Denise Boren, Ph.D., RN
_______________________
Date
v

ACKNOWLEDGEMENTS
I am indebted in the preparation of this thesis to my committee, Dr. Denise Boren, Dr. Patricia
Hinchberger, and Dr. Linnea Axman of California State University San Marcos. Each
contributed to this project in their own unique way. I wish to thank each one immensely for their
support, kindness, patience and for their words of wisdom and encouragement.
I would also like to thank my husband, Mark Neu who has been my rock since the beginning of
this journey. His unwavering love and support especially in times of stress and frustration have
been my constant source of drive and motivation. I could not have done this without him.
To my cat Bruno, who is now across the rainbow bridge was my late night companion, purring
away on my desk while I am studying and burning the midnight oil. He taught me how to love
unconditionally.
And last but not the least, to my dog Izzy whose persistent need for attention always reminded
me to take a study break for playtime.
.
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TABLE OF CONTENTS
Page
Preface............................................................................................................................i
Abstract..........................................................................................................................v
Acknowledgments........................................................................................................vi
List of Tables................................................................................................................ix
List of Figures................................................................................................................x
Chapter
1. INTRODUCTION ………………………………………………………………...1
Background and Significance...........................................................................2
The Problem...................................................................................................... 4
Purpose of the Research....................................................................................4
Research Questions…………………………………………………………….5
Research Variables…………………………………………………………….5
2. LITERATURE REVIEW.......................................................................................7
Introduction.......................................................................................................7
Major Variables Defined.................................................................................11
Theoretical Framework……………………………………………………….12
Summary……………………………………………………………………...14
3. METHODOLOGY………………………………………………………………..15
Introduction……………………………………………………………………15
Research Questions……………………………………………………………15
Identification of Setting……………………………………………………… 16
Research Design………………………………………………………………16
Population and Sample………………………………………………………..17
Measurement Methods………………………………………………………..19
Data Collection Process………………………………………………………20
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Coding and Scoring…………………………………………………………...20
Data Analysis…………………………………………………………………21
Bias……………………………………………………………………………21
Ethical Considerations………………………………………………………...22
Summary………………………………………………………………………22
4. RESULTS…………………………………………………………………………23
Introduction……………………………………………………………………23
Sample ………………………………………………………………………...23
Data Collection and Preparation……………………………………………….25
Instruments……………………………………………………………………..28
Results by Research Questions……………………………………………….. 30
Summary……………………………………………………………………….33
5. DISCUSSION……………………………………………………………………...34
Introduction ……………………………………………………………………34
Major Findings by Research Question ………………………………………...34
Limitations ……………………………………………………………………..36
Generalizability ………………………………………………………………...37
Implications for Nursing Research ……………………………………………..37
Recommendations for Future Research…………………………………………37
Summary…………………………………………………………………….......38
Appendix A. Approval to conduct study at wound care clinic………………………...40
Appendix B. CSUSM IRB Approval Letter…………………………………………...42
Appendix C. Palomar Health IRB Approval Letter with IRB-stamped Informed
Consent Form, California Bill of Rights and Exposure to
Pet Survey Questionnaire…………………………………………………43
References……………………………………………………………………………….49
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LIST OF TABLES
Tables Page
1. Frequency of Infection and type of pathogens………………………………… 25
2. Linear regression analysis showing collinearity statistics……………………....29
ix

LIST OF FIGURES
Figures Page
1. Schematic representation of antimicrobial use in small animals and humans…..10
2. Schematic representation of Germ Theory………………………………………14
3. A priori power analysis................................................................………….……18
4. Distribution for Age..............................................................................................26
5. Distribution for Chronic Diseases………………………………………………..27
6. Distribution for Hand washing post pet handling………………………………...28
x

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CHAPTER ONE: INTRODUCTION
Studies have shown that potential pathogens are found in the home environment
and these pathogens are introduced into the home in different ways including by pets
such as cats and dogs. Household pets are considered and frequently treated as members
of the family. There is high-level of physical contact between humans and pets which
will allow for the transmission of bacterial pathogens, including the widely known
Methicillin-resistant Staphylococcus Aureus (MRSA). This could result in a potential
public health concern because of the spread of MRSA from humans to pets, and from
those pets to other pets and finally to other humans. According to Whachter (2006), “the
household pet issue is a more concerning issue because of the degree, duration and
intensity of contact that we have with our pets in most situations” (Wachter, 2006). The
latter statement was also mentioned by J. Scott Weese (2006), D.V.M., a veterinarian and
a professor of large animal medicine at the University of Guelph in Ontario, Canada
during the annual Interscience Conference on Antimicrobial Agents and Chemotherapy in
2006. This study will investigate wound care patients in a small wound care clinic in
Southern California who have a wound infection and determine if there is a relationship
between wound infection and exposure to household pets.
This research study was based on the theoretical framework of Louis Pasteur on
Germ Theory of Disease. The theory states that specific microorganisms are the cause of
specific diseases. This theory led to the development of antibiotics and recommended

2
hygienic practices for individuals exposed to germs (Kusinitz, 2011). This theory will be
more thoroughly discussed in Chapter Two.
Background and Significance
Human beings have long valued their relationship with their pets. Dogs were first
domesticated in China about 15,000 years ago while the first domesticated cat originated
in Cyprus almost 9,500 years ago. In 2009 there were about 75 million dogs and 88
million cats owned in the United States. In the United Kingdom, there are about 27
million domestic pets, inhabiting about 43% of British households (Oehler, Velez,
Mizrachi, Lamarche & Gompf, 2009). Pets are an integral part of the household and are
part of human lifestyles (Bruno & Sun, 2011). For instance, an estimated 14%-62% of pet
owners allow their pets in the bedroom and let their pets sleep on the bed with them.
According to Oehler et al. (2009), the closeness of pet owners and their animals could
pose a potential risk for transmission of at least 30 infectious agents. Zoonoses are
diseases communicable from animals to humans (CDC website). Different species such
as Pasteurella, Streptococcus, Fusobacterium, and Capnocytophaga are examples of
isolates that contain a mix of anaerobes and aerobes cultured from patient’s skin and the
animal’s oral cavity. A study done by Rollof and colleagues found that 17 out of 21 dogs
(81%) harbor Pasteuralis multocida in their saliva (Rollof, Fredriksson, Holst, 1989).
Another study by Lin and his colleagues found that Staphylococcus aureus was present in
6.6% of dogs, 39% of cats, 83.8% of horses and 100% of pigs, rabbits, hamsters and rats.
Of these, 36.4 % were MRSA positive (Lin, Baker, Kislow, Kaldhone, Stemper,
Pantrangi, Moore, Hall, Frische, Novicki, Foley, Shukla, 2010). An example of a case

3
report presented by Knowles and colleagues in Nursing Times describes a patient who
developed cellulitis from the wound ulcers. The wound culture grew Staphylococcus
aureus (S. aureus) and blood culture grew β-hemolytic streptococci and Pasteurella
multocida. The patient recalled that his dog licked his wound a few days before the
symptoms manifested although the article did not specify that the dog was swabbed or
tested. (Knowles, Gould, Hartley & Gudi, 2000). In addition there were several cases
reported by Oehler et al, 2009, of C. canimorsus cultured from a wound, 59% of which
were from a dog bite, 10% were present on the skin from dog licking and with a mortality
rate of 31% due to sepsis.
Not much is known about the zoonotic transmission of bacterial pathogens in
companion animals in United States so it important to learn more about it. People can get
zoonotic diseases from contact with domesticated or wild animals. People with a
weakened immune system, children, elderly and pregnant women are more susceptible to
zoonotic diseases. Approximately 60% of human pathogens are zoonotic (CDC website).
The zoonotic transmission of MRSA from companion animals has not been well studied.
It is important to recognize and report the rate of prevalence of S. aureus and MRSA from
samples of animals requiring treatment at veterinary clinics (Lin et al., 2010). Moreover,
recognition and prevention of community-acquired pathogens, including MRSA will
reduce in-patient hospitalization or outpatient clinic visits. Mannion (2013) purported that
lower readmissions and improved quality of care may result from strategic infection
control program. Thus, a gap in knowledge focused on zoonoses should be explored more
in medicine and by nursing, should be taken into consideration when dealing with

4
patients that have an infectious disease. Further study in this target population is
considered beneficial to determine if wound infection is related to exposure of household
pets.
The Problem
There is an increased problem with zoonoses and its public health risk is
associated with practices such as allowing pets on the bed, giving kisses or allowing pets
to lick (Bruno & Sun, 2011). The degree of duration and the intensity of physical contact
between humans and their pets allow for transmission of pathogens (Wachter, 2006).
There are not enough studies that investigate if wound infections are related to the
exposure of household pets.
Purpose and Significance of the Research
The purpose of the study was to investigate the relationship between prospective,
new patients at a small wound care clinic in Southern California with wound infections
and exposure to household pets. The significance of the proposed study to nursing is the
importance of taking into consideration transmission of bacteria from pets to humans
when assessing a patients’ environmental setting at home. Upon admission to the wound
care clinic, nurses must find out if there are pets in the patient’s household. There is lack
of knowledge and public awareness of prevalence of S. aureus and MRSA in animals (Lin
et al, 2010). It is something to consider if pets are a potential source of infection. It is also
significant to educate patients with open wounds or ulcers to keep their pets away in
order to avoid further complications, thus preventing morbidities and mortalities. Proper
management and use of appropriate therapy for the specific infection will help reduce

5
hospital visits and alleviate enormous health care costs. As clinicians, it is vital that
prompt reporting is made to the CDC to help increase awareness and prevention of the
spread of infection. Prevention of acquiring community-acquired MRSA (CA-MRSA)
helps reduce hospital admissions (Mannion, 2013). And lastly, it is important to conduct
further research, on a larger scale, to investigate the relationship of wound infection and
exposure to household pets.
Research Questions
The research questions for this study were:
1) “Is there a relationship between people who present to wound care clinics for
would care and pet ownership?”
2) “What is the frequency of people with a pet that present to the wound care clinic
with wound infection?”
3) “Is there a statistically significant relationship between documented wound
infection and pet ownership?”
4) “Is there a difference in frequency of documented wound infections and the time
spent with household pets (low amount of time versus high amount of time)?”
Research Variables
The dependent variable in this study was wound infection regardless of whether it
was aerobic or anaerobic in nature. The independent variable was the patient’s exposure
to household pets. The degree of exposure was determined by exploring at the following
items: feeding the pet, cleaning the pet area, playing with pet, giving kisses to the pet,
letting the pet sleep on the bed and walking the pet. Demographic variables such as

6
proper hand washing after handling the pet, age and co-morbidities or chronic illnesses
were included in this investigation. These variables perhaps play an important role in
identifying relevance that might relate to this investigation.

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CHAPTER TWO: LITERATURE REVIEW
Introduction
The databases reviewed for this literature review included CINAHL, PubMed,
and Google Scholar. Twenty-five (25) abstracts of peer-reviewed articles including case
reports and letters to the CDC have been reviewed for inclusion. Literature search terms
included wound infection, dogs, cats, MRSA, zoonosis, bite wounds, bacterial infection
and bacterial colonization in pets, animal to human transmission of pathogens and
emergence of pathogens from animals to humans. The search was limited to English,
peer-reviewed articles published after 1990. The researcher focused on journal articles
and case reports that concentrated on the virulence of pathogens in companion animals or
household pets and the reason for wound infection.
Coyner (2012) purported that since the 1970s MRSA has been documented in
large animals but was not reported in dogs until the 1990s. In a study comparing 50 dogs
with normal skin and 59 dogs with inflamed skin, S. aureus was cultured in 12% of dogs
with inflamed skin and 17 % of these cases were methicillin resistant. MRSA in cats and
dogs is most frequently cultured from wounds, abscesses, otitis and pyodermas (Coyner,
2012). Another study conducted by Faires, et al. (2010) using dogs (n = 40) with MRSA
and dogs (n = 80) with Methicillin-Susceptible S. aureus (MSSA), showed most infections
were located on the skin (Faires, Traverse, Tater, Pearl, Weese, 2010).

8
In 2009, Loeffler, et al. conducted a case-control study investigating risk factor
for MRSA infection in dogs and cats between 2005 and 2008; 106 pets with MRSA and 91
pets with MSSA and veterinary staff and pet owners (n = 608) were screened for S.
aureus nasal carriage. Results showed that MRSA carriage was 12.3 % in veterinarians
attending MRSA-infected animals and 7.5% in their owners (Loeffler, Pfeiffer, Lloyd,
Smith, Soares-Magalhaes & Lindsay, 2009).
Several longitudinal studies conducted at veterinary hospitals revealed the
resistance to antimicrobial agents has emerged among pet isolates such as S. intermedius,
E. coli, MRSA, Vancomycin-resitant enterococci and Salmonella Typhimurium
(Guardabassi, Schwarz & Lloyd, 2004). Guardabasi et al., (2004) added that cats and
dogs are potential sources of antimicrobial resistance due to extensive use of
antimicrobial agents and their close contacts with humans. In the past, dogs were usually
kept outdoors but today they are often kept inside houses. The current perception that
pets are actual family members is manifested by close physical contact such as touching,
petting, and licking which occurs at high frequency. Dog owners affected with pyoderma
usually carry the same strain occurring in their dog and are usually resistant to
antimicrobial agents including penicillin, fusidic acid, macrolides, tetracyclines and
chloramphenicol. Pet-associated zoonoses are usually sporadic with frequencies not
easily determined because it is difficult to recognize and validate disease transmission
from pets. Transmission of antimicrobial-resistant genes poses a risk when the strain
harbors resistance genes that are of clinical relevance to human medicine (Figure 1). Bite
wounds in humans from cats and dogs can have serious consequences unless the

9
susceptibility of the infecting organism is determined and appropriate therapy is given
(Guardabassi, Schwarz & Lloyd, 2004).

10
Figure 1. Schematic representation of consequences of antimicrobial use in small animals
and transfer of resistant genes to humans which was obtained from the article Pet animals
as reservoirs of anti-microbial-resistant bacteria by Guardabassi, et al. 2004

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A case study was reported by Knowles (2000) on a 54 year old man who was
referred to the dermatology unit with persistent ulceration and edema on both legs. He
was admitted with rigors, pyrexia and increasing pain and erythema of both legs. On
examination, it was confirmed that he had cellulitis. A wound swab grew S. aureus and
blood culture grew β-hemolytic streptococci and P. multocida. The patient remembered
that his dog had licked his wound a few days before his symptoms occurred. Bacteremia
also occurs most commonly in patients with underlying chronic disease such as cirrhosis
of the liver, COPD, immunodeficiency and malignancies. Mortality rates can be as high
as 31% either from the disease or septicemia (Knowles, Gould, Hartley & Gudi, 2000).
Another case was of a 51 year old female who had a diabetic foot ulcer and
cultures grew MRSA (Duijkeren, Wolfhagen, Heck, & Wannet, 2005). She was treated
with trimethropim-sulfamethoxazole however, two months later she was still positive for
MRSA. She developed a urinary tract infection and was treated again using ciprofloxacin
and rifampin. This time the MRSA infection was eradicated for half a year. After these
findings, a source of the recurrent MRSA was suspected at home. The husband, son and
the dog were swabbed and all three were also positive for MRSA. They were treated with
ciprofloxacin and rifampin and this eradicated the MRSA carrier state of the husband, the
son and the dog.
Major Variables Defined
Dependent variable. Wound infection was based on the laboratory result
received from the microbiology laboratory of the wound culture. A wound culture order
is an order for culture and sensitivity of the tissue taken by the wound care physician post

12
debridement and prior to treatment. It took 72 hours to determine the specific aerobic and
anaerobic bacteria that grew from the culture and was indicated by light, moderate or
severe growth.
Independent variable. Exposure to household pet is defined as having a pet at
home, regardless of whether the pet is indoor or outdoor, and was determined by the total
number of the times per day the pet owner was in contact with the pet.
Demographic variables. The variables were defined as follows. Age is defined
as the amount of time during which the person has lived (Merriam Dictionary). This
variable was explored to determine if there is a difference in age when it comes to
ownership of pet. Co-morbidities are the presence of more than one disease in one person
at the same time. The Centers for Disease Control and Prevention describes co-
morbidities as conditions that are often long-term conditions (CDC website). Examples of
co-morbidities are diabetes mellitus, rheumatoid arthritis, HIV, renal failure, lupus,
chemotherapy, radiation, etc. Co-morbidities were also considered as a demographic
variable for this research study because it is a well-known fact that people with weakened
immune system have a higher risk of getting an infection (CDC website).
Theoretical Framework
As introduced in Chapter One, the proposed research study will be based on the
theoretical framework of Louis Pasteur’s Germ Theory of Disease in 1857. The Germ
Theory is the fundamental belief in medicine that microorganisms which are too small to
be seen without the aid of a microscope, can invade the body and cause certain diseases.
He discovered “diseases” of wine and beer. When asked by brewers why wine and beer

13
sometimes get spoiled, he explained that while yeasts produce alcohol from the sugar in
the brew, bacteria can change alcohol to vinegar. He suggested that brewers heat their
products enough to kill bacteria, thus the process called pasteurization. He made a
connection between food spoilage and microorganisms as a key step in demonstrating the
link between microorganisms and disease. He also observed that there are similarities
between the diseases of animals or man and the diseases of beer and wine. These
observations linked the activity of microorganisms to disease until 1876, when German
physician Robert Koch proved that bacteria can cause disease. He showed that the
bacterium Bacillus anthracis was the cause of anthrax in cattle and sheep and he also
discovered the organism that causes tuberculosis. It was Koch that developed a set
guidelines for determining the cause of infectious diseases. He postulated that an
organism must be present in every case of the disease and must be isolated from a host
with the corresponding disease and grown in pure culture. Then the samples from the
pure culture must cause the corresponding disease when inoculated into a susceptible
laboratory animal and the organism must be isolated from the inoculated animal and
identified as being identical to the original organisms isolated from the initial, disease
host (Figure 2). His notion laid the foundation for the study of infectious disease and
modern medical microbiology. This theory helps identify, understand and manage
infectious disease by identifying the contributing agent and then preventing and treating
the disease (Germ Theory, 2013).

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Figure 2: A schematic representation of a germ reproducing as it enters a host and
transfers to another host.
Summary
The relationship between Germ Theory of Disease and the major variables in this
research is illustrated in Figure 2. A germ is isolated from a host, in this study the
household pet; it reproduces and then is transmitted to another host, which is the human.
The same organism is isolated from the human and is identified as the original organism
isolated from the initial host.
The review of available literature indicated that household pets can be carriers of
virulent pathogens and can colonize humans while living in close contact with them.
These colonized pets can result in recurrent infection in humans. It is important to
recognize the risk of pets being the source of unexplained carriage or relapse of infection
in humans. The use of appropriate antimicrobial therapy, whether to infected humans or
pets, can eliminate recurrent pathogen carriage.

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CHAPTER THREE: METHODOLOGY
Introduction
This was a pilot study utilizing a quantitative approach. A self-report method of
data collection by way of a patient survey and prospective patient chart reviews were
conducted as part of the study design. The purpose of this study was to explore the
relationship between wound infection and exposure to household pets. The researcher
created the instrument that was used for this study which was called the Exposure to Pet
Survey Questionnaire. A post hoc analysis was performed after study completion to
determine reliability and validity of the questionnaire. Analysis of data was performed
using descriptive statistics and the relationship between wound infection and exposure to
household pet(s) was determined using correlation methods.
Research Questions
The research questions in this study were:
1) “Is there a statistically significant relationship between people who present to a
wound care clinic for wound care and pet ownership?”
2) “What is the frequency of patients that present to a wound care clinic with a
wound infection as documented by a positive wound culture that also have a pet?”
3) “Is there a statistically significant relationship between documented wound
infection and pet ownership?”
4) “Is there a difference in frequency of documented wound infections and the time
spent with household pets (low amount of time versus high amount of time)?”

16
Identification of Setting
The setting for the study was at a hospital-based wound care clinic in Southern
California (Appendix A). The clinic staff includes one nonclinical director, four certified
wound care physicians, five registered nurses, three licensed vocational nurses and one
hyperbaric technician. The clinic sees approximately 120 patients per month and about 60
new patients are referred every month. The clinic operates Monday through Friday from
8:00 a.m. to 4:30 p.m. The patients are seen on a weekly basis with an average healing
time of 8-12 weeks.
Research Design
As mentioned in the Introduction, this was a pilot study. A pilot study is a small-
scale version designed to test the methods to be used in a larger study (Polit & Beck, p.
195, Chapter 8). This is a quantitative, nonexperimental research design. In quantitative
studies, the variables are identified, operational definitions are defined then relevant data
is collected. The data are in numeric form (Polit & Beck, p. 53, Chapter 3). According to
Polit and Beck, many quantitative nursing studies aim to elucidate cause and effect (Polit
& Beck, p. 232, Chapter 9).
There were potential threats identified to the internal validity of this research
study. The temporal validity was a threat because it begs the question which infection
came first, the pet with MRSA or the human with MRSA. History was determined to be a
potential threat as well. There may have been a concurrent event that was happening to
the pet; perhaps; a recent visit to the veterinary clinic where MRSA could possibly been
contracted.

17
There were some limitations that were identified in this research study. The
researcher anticipated that there may be a reliability and validity to the instrument as it
was developed independently. This topic will be discussed further in Chapter Four. Pets
were not swabbed in this study so there was no evidence to prove that the pet was the
source of the infection. The researcher relied on peer-reviewed journals and used it as
evidence to prove the relationship of zoonotic diseases and transmission to humans.
Population and Sample
The participants were recruited using non-probability convenience sampling.
According to Polit & Beck, convenience sampling entails using the most conveniently
available people as participants (Polit & Beck, p. 276, Chapter 12). An Institutional
Review Board (IRB) approval was granted from Palomar Health IRB (Appendix C) and
California State University, San Marcos (CSUSM) IRB (Appendix B) to recruit
participants and conduct the study. Prospective, new patients to the wound care clinic
were recruited to participate in the study and informed about the study. All participants in
this study were over 18 years of age and proficient in English.
The total sample size for this study was calculated to be 67 in order to achieve a
power of .80 (Figure 3). The conventional standard for 1-β (power) is .08 (Polit & Beck,
p. 423, Chapter 17). The target sample size (n=80) provided for .30 effect size in a
correlation bivariate normal model with a significance level of .10. According to Polit
and Beck, an effect size is calculated based on findings from earlier studies. However, if
there are no relevant earlier findings, researchers use a conventional approach with
expectations of a small, medium or large effect. Most nursing studies have modest

18
(small-to-medium) effects (Polit & Beck, p. 423, Chapter 17). An additional 20% was
added to the calculated sample (n=67) for loss factors (e.g. failing to complete the
survey). Therefore, the target number of participants was set at 80 and the first 80 new
patients who were referred to the wound care clinic from the time the IRB granted
approval, were approached and asked to participate in the study. Figure 3 below is the
power analysis prior to data collection.
Figure 3. A priori power analysis

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With regard to the limitation of the sample’s generalizability, it was suspected
that not all participants own a pet and if they do, there were varying degrees of exposure
and physical contact with the pet.
Measurement Methods
As mentioned in the Introduction of this chapter, the researcher developed the
instrument that was used for this study. The measurements used for the different variables
in this study were the following: “wound infection” being the dependent variable was
measured as a nominal variable. It was determined based on whether or not the wound
culture grew certain bacteria after 72 hours. The independent variable, “exposure to
household pet(s)” was measured using ordinal measurement because the study looked at
how many times per day the patient was in physical contact with his or her pet.
According to Polit & Beck, frequency count is appropriate for ordinal level data (Polit &
Beck, p. 380, Chapter 16). To further explain what entails “exposure to household pet(s),
the six item questions in the Exposure to Pet Survey Questionnaire (Appendix C) were:
feed the pet, play with pet, clean pet area, give kisses to pet, let pet sleep on the bed, and
walk the pet and were categorized based on time spent with the pet. It was either 0-1 time
per day, 1-2 times per day and 2-3 times per day. Each category was assigned a score of
1, 2, or 3, respectively. Each check mark was indicated under the times per day column
for each of the six items; a sum of the score was entered into the SPSS database under
frequency score. The “exposure to household pet” is interchangeable to “time spent with
pet” which was later converted into a frequency score. Demographic variables such as
age was measured as a ratio variable while co-morbidities or chronic illness (e.g.

20
diabetes, rheumatoid arthritis, and end stage kidney failure) was measured as a ratio
variable as it determined the number of chronic illnesses the patient has.
Data Collection Process
As mentioned under Population and Sample, IRB approval from both California
State University San Marcos (Appendix B) and Palomar Health IRB (Appendix C), were
obtained prior to data collection. The researcher was IRB certified via CSUSM’s online
IRB training for protection of human rights. Study recruitment and data collection started
in June 2014. At week 0, during the new patient visit and admission to the wound care
clinic, the potential study participant was approached and was asked if he or she is
willing to participate in the study. An informed consent form was signed by the
participant for willingness to participate. The participant was also encouraged to take it
home if he/she wished to discuss the study with family members. On the following week,
the patient was asked to complete the Exposure to Pet Survey Questionnaire with the
wound culture available by then. The researcher collected a copy of the wound culture
result from the patient’s medical chart. All patient identifying information was de-
identified and data was stored in a locked cabinet in the supervisor’s office.
Coding and Scoring
The dependent and independent variables were dichotomized. The dependent
variable: 0 = for no wound infection and 1 = with wound infection; independent variable:
0 = for no pets and 1= with pets. The 6 items in the Exposure to Pet questionnaire were
coded as follows: 1=feed pet; 2= clean pet area; 3= play with pet; 4= give kisses all the
time; 5= let pet sleep on the bed; 6= walk pet. These items were based on the number of

21
times the participant spent time with their pet/s. It was scored as follows: 1=0-1 times per
day; 2= 2-3 times per day; 3= more 3 times per day. The scoring was explained under
Measurement Methods in this chapter.
Data Analysis
International Business Machines Statistical Package for the Social Science (IBM
SPSS) version 21.0 was used for data management and to perform data analysis. The
analysis consisted of descriptive statistics, frequency distributions and bivariate
correlations. The proposed analysis of data included the level of measurements (e.g.
ordinal, interval or ratio) as appropriate to the research problem. According to Polit &
Beck, correlation procedure describes relationship between two variables and it can be
graphed through a scatter plot using the X and Y axis to determine a positive or negative
relationship of the two variables based on the direction of the slope. (Polit & Beck, p.
390, Chapter 16). The level of significance was set at p=.10 for this pilot study.
Bias
The use of convenience sampling was a source of possible bias due to the
participants self-selecting to participate in the research study. The required sample may
not be representative of the target population. The fact that the researcher is also one the
wound care nurses at the wound care clinic where the research study was conducted was
another potential source of bias. There was a concern of participants being obligated to
participate due to feeling pressured to participate. Another cause for potential bias was be
that the researcher’s spouse is a non-scientific member of Palomar Health IRB. In order

22
to mitigate this issue, the researcher’s spouse recused himself when the study was
presented to the IRB committee for approval.
Ethical Consideration
As mentioned under Data Collection Process, the researcher sought IRB approval
first before conducting the study. Study participants were 18 years or older and were
admitted to the wound care clinic. No participants who were high risk, such as children or
those diagnosed with mental illness were recruited into the study. Participants spoke and
understood English and were willing to volunteer and participate in the study. No
incentives were offered for participation. Subject confidentially was protected by
assigning a study number to each participant. The participant study number was being
used as reference when data was entered into SPSS.
Summary
There were no challenges encountered during the data collection process. All
participants who participated in this research study were willing to participate and all
expressed interest in the study outcome. However, there was a delay in achieving the
desired number of research study participants as previously planned (September 2014)
because the wound care clinic had a slower than usual new patient registration in the fall
2014. Nevertheless, the research study investigator continued enrollment one month past
the enrollment deadline and was able to achieve the target number of participants needed
for this research study.

23
CHAPTER FOUR: RESULTS
Introduction
Chapter Four provides the results of the research questions. It presents the sample
and demographic variables. The results are presented by each research question. The
results of the reliability and validity evaluation of instrument used for this research study
is discussed. To reiterate, the research questions in this research study are the following:
1) Is there a statistically significant relationship between people who present to a
wound care clinic for wound care and pet ownership?
2) What is the frequency of patients that present to a wound care clinic with wound
infection as documented by a positive wound culture that also have a pet?
3) Is there a statistically significant relationship between documented wound
infection and pet ownership?
4) Is there a difference in frequency of documented wound infections and the time
spent with household pets (low amount of time versus high amount of time)?
Sample
All variables were examined for normality using mean, median, and mode. Study
participants were described using frequency distribution. There were 80 study
participants and three demographic variables were collected for the purpose of this study.
They were age, number of chronic diseases each individual participant has and, whether
or not hand washing was done after engaging with the pet(s). The participants’ age

24
ranged between 20-99 years of age, with the mean age at 73 years and the median at 75
years. A self- report number of chronic diseases showed an uneven distribution across the
study participants. The most frequent number of chronic diseases among the study
participants was two (f=25; 31.3%). With regards to hand washing after engaging with
pets, participants (f=25; 31.3%) reported that they wash their hands while others (f=14;
17.5%) reported that they do not wash their hands. The rest of the participants do not
have pets (51.2%) and left the question unanswered.
Wound infection (DV) was evident in (f=46; 56.3%) and (f=34; 42.5%) without
wound infection. Wound infection was based on the documented result of the wound
culture collected at Week 0. Of the culture test, S aureus was the most frequent bacterial
pathogen present in an open wound (f=28; 35%). See Table 1.
Participants (f=39; 48.8%) were fewer than those without pets (f=41; 51.2%).
Dogs were the most frequently owned pet (f=19; 23.8%) followed by cats (f=13; 16.3).
The majority of pets were kept indoors (f=21; 26.3%) while others were kept outdoors
(f=6; 7.5%). Other participants reported having their pets both indoors and outdoors
(f=12; 15.0%).

25
Data Collection and Preparation
After obtaining IRB approval from CSUSM and Palomar Health, data points were
collected using the study questionnaire found in Appendix C. The data were collected
over a six month period and were imported into SPSS 20.0. There was no missing data.
The database was double-checked for accuracy and then statistical analyses was
performed. All variables were analyzed for normality. The frequency of distribution as
far as age showed a negative skew (Figure 4). The M = 73.28, Md = 75.50 and Mode =
90 indicates that participants who presented to the wound care center for care were
mostly older adults.

26
Figure 4. Distribution for Age
Chronic diseases displayed a positive skew in the frequency distribution (Figure
5). Diabetes and venous insufficiency were the two most common chronic diseases (M =
2.31) contributing to chronic non-healing wounds based on medical history.

27
Figure 5. Distribution for Chronic Diseases
Hand washing post handling of pets also displayed a positive skew in the
frequency distribution (Figure 6) indicating that people with pets are more aware of
observing proper hand hygiene after engaging with their pet.

28
Figure 6. Distribution for Hand Washing Post Pet Handling
Instruments
The study investigator created the instrument that was used for this research
study. Face validity was established with creation of the instrument through literature
review and subject matter expert input. The reliability of the questionnaire was evaluated
using bivariate correlational analysis and Alpha and Split Half techniques. The reliability
analysis revealed a .95 for both Cronbach’s Alpha and Split Half analyses.

29
There were seven variables and items tested in this tool. The variables were:
“hand washing post pet handling”, “feed pet”, “clean pet area”, “play with pet”, “give
affection”, “pet sleep on bed”, and “walk pet”. There was suspicion of multicollinearity
of the scale variables. A multicollinearity evaluation was performed using multiple
regression. The Variance Inflation Factor (VIF) and tolerance are “both widely used
measures of the degree of multicollinearity on the independent variable with the other
independently variables in a regression model” (O’Brien, 2007). VIF was evaluated in
this study and results showed less than 10 on all study variables. There are some
guidelines that can be applied based on this outcome. A VIF less than 3.3 shows an
excellent value (Diamantopoulos and Siguaw, 2006) and a VIF less than 10 indicates that
no collinearity is commonly accepted (Hair et al., 1995). Thus, reliability evaluation for
formative constructs is to assess the assumption of no multicollinearity (Diamantopoulos
and Siguaw, 2006). Based on this criteria, multicollinearity did not exist in the frequency
of interaction scale with pets based on the VIF collinearity statistics presented in Table 2.
Table 2.
Linear regression analysis showing collinearity statistics
Variable Tolerance VIF
Feed pet .167 5.973
Clean pet area .158 6.319
Play with pet .133 7.500
Give affection .190 5.254
Pet sleep on bed .295 3.386
Walk pet .131 7.650
Hand washing post
pet handling .253 3.949

30
Results of Research Questions
All data were examined using IBM SPSS Statistics 20.0 software (2011) for
frequency, mean, median, mode, and distribution as applicable. Following frequency
distribution analysis, data were analyzed for correlations using Pearson’s correlation.
In a bivariate correlation analysis there was no statistical significance found
between the dependent variable “wound infection” and the independent variable
“frequency of pet interaction score” (p= .137). The significance demonstrated was a
negative correlation between frequency of pet interaction and wound infection. This is
because the effect size is small (.168). This study would have needed 190 participants,
with this small effect size and a .10 significance level and a power of .80 to determine
statistical significance.
Question number one was “Is there a statistically significant relationship between
people who present to a wound care clinic for wound care and pet ownership? A Pearson
correlation coefficient was computed to assess the relationship of the two variables:
people who presented to the wound care clinic, using age as the variable and pet
ownership using household pet as the variable. A negative (inverse) correlation was
demonstrated between age (r = 1, n = 80, p = .266) and household pet (r=-.126). No
statistical significance was found.
Question number two was “What is the frequency of patients that present to a
wound care clinic with wound infection as documented by a positive wound culture and
also have a pet?” Wound infection was identified from the laboratory wound culture

31
result. S aureus was the most frequent wound culture result (f = 28; 35.0%) followed by
Candida albicans (f = 14; 17.5%). Pseudomonas aeruginosa, MRSA and E.coli were
other bacterial pathogens found at a smaller percentage. As stated, the total sample
(n=80), 39 participants (48.8%) have pets and 41 subjects (51.2%) do not have pets.
Moreover, of those who have pets, dogs were ranked as the most common frequently
owned (f=19; 23.8%) followed by cats (f=13; 16.3%), and then having both (cat and dog)
or other pets (e.g. turtle and horses) at 6.3% and 1.3%, respectively.
Question number three was “Is there a statistically significant relationship
between documented wound infection and pet ownership?” There was negative (inverse)
correlation between documented wound infection (r =1, n = 80, p = .048) and household
pet (r=-.222) that demonstrated statistical significance at the 0.05 level (2-tailed). This
results suggests that infection goes up as pet ownership goes down. In other words,
people with pets probably wash their hands more after each interaction than people
without pets. In addition, a correlation between documented wound infection and whether
the pet is indoor or outdoor was also computed. There was also negative (inverse)
correlation between these variables demonstrating no statistical significance: indoor or
outdoor (r = -.086. n= 80, p= .451) with document wound infection (r=1).
Question number four was “Is there a difference in frequency of documented
wound infections and the time spent with household pets (low amount of time versus high
amount of time)?” Time spent with household pets was converted to a frequency score
and the latter reflected the total score the pet owner interacted with the pets. The total

32
score was based on the six item questions given in the Exposure to Pet Survey
Questionnaire. The scores were the following: 1= 0-1x/day; 2= 2-3x/day and 3= more
than 3x/day. Several correlation computations were made to explore and answer this
question thoroughly. First, the frequency of the two variables, infection and frequency of
interaction score were analyzed. Participants with infection represented 56.3% (f= 45)
out of the total participants (n=80) compared to (f=34) or 42.5% without infection. A
score of 8 (10%) was the most frequent time spent interacting with the pet(s).The
correlation between the two variables was analyzed and demonstrated a negative
correlation with no statistical significance: infection (r =1, p = .137, n = 80) frequency of
interaction score (r=-.168), suggesting that people who engage more with their pet(s)
tends to observe proper hand hygiene and have less rates of infection.
Second, a correlation was computed between infection, household pet (pet
ownership) and hand washing post pet handling. A strong positive correlation with
statistical significance was demonstrated between household pet (r =.897, p = .000, n =
80) and hand washing (r=1) at the 0.01 level (2-tailed), suggesting that people with pets
wash their hands more often than people who do not have pets. There was a negative
(inverse) correlation without statistical significance between infection (r =1, p = .418)
and hand washing (r= -.092) also suggesting that infection goes up as hand washing goes
down. There was no correlation between infection and household pets.
And last but not the least, the third analysis was performed to determine if there is
correlation between infection, hand washing and frequency of interaction score. Results

33
demonstrated a positive correlation between frequency of interaction score (r=1) and
hand washing post pet handling (r = .839, p =.000, n = 80) with statistical significance at
.01 level (2-tailed). Overall, as the frequency of interaction with pets score goes up, hand
washing goes up, and even though it did not reach statistical significance, infection, hand
washing and frequency of interaction score were inversely related.
Summary
A negative (inverse) correlation was found between the independent variable, the
“degree of exposure to pet(s) which is otherwise known as the frequency of interaction
score” and the dependent variable, “wound infection.” Hand washing post handling of
pet(s) is one of the demographic variables that was found to be a covariant in this study.
There is a positive correlation between frequency of interaction score and hand washing.
CHAPTER FIVE: DISCUSSION

34
Introduction
The findings in this study showed that the independent variable, “exposure to
household pet” (frequency of interaction score) was not statistically associated with the
dependent variable, wound infection (p=.137). While several studies in fact demonstrate
the potential role of pet animals in household transmission of bacterial pathogens
(Bramble, et al, 2011), this study may have required a larger sample in order to
demonstrate a statistically significant relationship between the variables, wound infection
and exposure to household pets.
One of the demographic variables, “hand washing post handling of pet(s)” r=.841
was found to have statistically significant positive correlation with the “frequency of
interaction score” (r =1; p=.000). The correlation was significant at the 0.01 level (2-
tailed). Overall, an inverse relationship occurred and as the frequency of interaction score
and hand washing increases, infection rate decreases.
Major Findings by Research Question
Despite having several publications supporting the idea regarding zoonotic
transmission to humans, this small pilot study could not validate those same findings. The
study did not find a correlation between wound infection and exposure to household
pet(s) also called the frequency of pet interaction score. However, the study did find a
positive correlation between frequency of pet interaction score and hand washing. There
was an inverse correlation between hand washing, frequency of pet interaction and
infection. As the frequency of interaction with pets and hand washing went up, the
frequency of infection went down. Hand washing can prevent disease transmission

35
associated with animal contact (Steinmuller et al., 2006). Steinmuller and his colleagues
indicated that washing hands with soap and water and drying hands with paper towel is
good enough to prevent unnecessary illness. Human contact with cats and dogs and other
pets result in several infections in the United States each year (Rabinowitz, Gordon &
Odofin, 2007). According to Rabinowitz (2007) and his colleagues, prevention involves
common sense measures such as adequate hand washing, proper disposal of animal waste
and ensuring that animals that are sick are properly diagnosed and treated.
Two factors are largely responsible for the threat of infectious diseases in the
coming years: first, the nature and range of pathogens to which we are exposed and
second, the demographic changes occurring in the community, which affect our
resistance to infection (Bloomfield, et al., 2007). According to Bloomfield et al, (2007),
hand hygiene is a key component of good hygiene practice in the home, producing
significant benefit to reducing the incidence of infection, such as gastrointestinal
infections, and respiratory tract and skin infections. From this study, the most common
documented wound culture result was mainly S aureus (35%) which is a type of bacteria
commonly found in skin and open wounds. The study did not demonstrate a high
percentage of the heavy type of bacteria like MRSA, Pseudomonas aeruginosa, E. coli,
and others like Candida albicans, although several veterinary peer-reviewed journals
have indicated that MRSA isolates were found in environmental surfaces at home and in
infected in dogs and cats (Scott et al., 2008). Particularly with MRSA, the battle against
this bacteria in wound infections is becoming more difficult because of the widespread
drug resistance and community acquired MRSA (Visavadia, 2008).

36
Bloomfield et al., (2007) reported that decontamination of hands can be carried
out either by hand washing with soap or by use of waterless hand sanitizers which helps
reduce contamination. It is important to convince people to apply hand hygiene
procedures correctly (e.g. wash their hands correctly) and at the correct time to reduce
risk of infectious diseases. And lastly to optimize health benefits, promotion of hand
hygiene should be accompanied by hygiene education and should also involve promotion
of other aspects of hygiene.
Companion animals such as dogs, cats and others benefit humans in so many
ways, including social interactions. However, “when interaction between humans and
animals increases, transmission of pathogens becomes a greater risk for humans and pet
alike. Good hygiene, including proper hand washing is important in halting zoonotic
transmission” (Esch & Petersen, 2013).
Limitations
Internal validity was influenced by a small scale study as this was a pilot study. A
larger study group would have been needed to demonstrate statistical significance and set
the study with a smaller effect size. The study was only limited to prospective, new
patients who presented at one wound care clinic. The pets were not swabbed in this study
therefore it poses the question whether or not the pets were the carriers of the infection or
not. Moreover, a question on temporal ambiguity remains whether or not the pets were
the carrier and transmitted the infection to the pet owner or vice versa.
Generalizability

37
The research generalizability is limited to prospective, new patients who
presented at the wound care clinic. The participants self-reported their responses to the
questions and rated the amount of time they engaged with their pets.
Implications for Nursing Research
This research study did not provide sufficient evidence that patients who present
to an outpatient wound care clinic with a positive wound infection that was caused by pet
ownership and the engagement with the pet(s). Little information is asked by the nurses
regarding the environmental setting at home when patients present to the wound care
clinic. Advanced practice nurses use research to provide evidence-based care that
promotes quality health outcomes for individuals. This research adds to the body of
knowledge about consideration of inquiring about pet ownership upon admission to any
outpatient or inpatient settings. There is a need to conduct an evidence-based project to
reduce the spread of infection and to increase education to the nursing staff, patients and
families on zoonotic transmission of bacterial pathogens. Furthermore, increased
communication and collaboration between nursing staff and physicians including
veterinarians is needed to improve overall zoonotic disease knowledge and develop
achievable approaches to help reduce pet associated infection to patients.
Recommendations for Future Research
To date no other studies were found on wound care clinics reporting results on
wound infections and the relationship to pet ownership. Future research is required to
determine the prevalence of bacterial pathogen cross contamination among pets at home
and wound care patients. This study can be replicated using a larger sample size and

38
power to determine if significance is reached with further analysis. Repeating this study
at other locations including in-patients hospitals, skilled nursing facilities, assisted living
facilities and other similar settings would be beneficial to determine the validity of this
study.
This study may have medical and nursing implications in terms of developing
tools to determine frequency of pet engagement at home or in a facility, piloting
educational materials and distributing these materials to patients and families to increase
knowledge and awareness of zoonotic disease risks.
In addition, a nationwide central database would be appropriate, for collection and
sharing on all zoonoses, and would provide a better understanding on incidence and
prevalence of these diseases (Smith, 2012). Health care facilities may develop risk
management strategies in zoonotic disease prevention and share this knowledge and
procedures to humane societies, animal shelter facilities and others that may serve as an
interface between pets and pet owners (Smith, 2012).
Summary
In conclusion, the study showed that there was not enough data to prove that there
is relationship between wound infection and exposure to household pet(s). However, one
interesting finding showed high incidence of hand hygiene compliance was evident for
those who have pet(s) at home. According to Bloomfield et al., (2007), in many homes
there is at least one family member who is more susceptible to infection for one reason or
another. So long as there are people, pets, and food in the home, there will always be the

39
risk of pathogenic microbes. Bloomfield and her colleagues (2007) stressed the
importance of hand hygiene as the key component of good hygiene in the home.
Because there is limited awareness of the zoonotic risks from pets despite
frequent pet contact within the house, educational efforts are needed by healthcare
personnel to increase awareness of potential bacterial infection due to zoonotic
transmission (Stull, 2012). One of the critical points or situations that Bloomfield, et al.,
(2007) indicated was that high risk occupants at home are children, ill people with low
immune status, and handling pets or domestic animals at home. Good hand washing is the
key to lower the burden of transmission of infectious diseases at home.

40
Appendix A
Approval to conduct study at wound care clinic

42
Appendix B
California State University, San Marcos (CSUSM) IRB Approval Letter

43
Appendix C
Palomar Health IRB Approval Letter with IRB-stamped Informed Consent Form;
California Bill of Rights and Exposure to Pet Survey Questionnaire

49
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