Investigation of Multidrug-Resistant Acinetobacter baumannii at a Hospital in Puerto Rico, Jan-Aug, 2013

Nora Chea, MD, MSc, Kimberly Pringle, MD, Shalon M. Irving, PhD, Amber Kerk, BS,
Division of Healthcare Quality Promotion Centers for Disease Control and Prevention August 28, 2013
National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

Disclaimer
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention

Outline

Background Methods/Epi-Aid activities Results Conclusion Recommendations Next steps Acknowledgements

Background

On July 17, 2013, PR DH contacted CDC/DHQP

MDR Acinetobacter baumannii at a local hospital Seven patients in ICU tested positive Additional 20 patients detected by active surveillance cultures (Three in July) Twelve died (no data to confirm that MDR-Ab caused the deaths)

Initial recommendations did not stop transmission PR DH requested assistance with the investigation

Background: Objectives of Investigation

Describe

basic epidemiology of all patient cases possible sources and modes of transmission

Evaluate

Assess

infection control practices in the hospital recommendations

Provide

Background: Acinetobacter baumannii

Gram negative rod Commonly found in soil and water Ab is ubiquitous, survives desiccation, and often MDR Causes outbreaks in
ICU Healthcare settings with very ill patients

Infection outside healthcare settings: Rare

CDC Healthcare Associated infection Website: http://www.cdc.gov/HAI/organisms/acinetobacter.html

Background: Acinetobacter baumannii

Clinical manifestations
Pneumonia Serious blood stream infections Wound infections

Can colonize without causing infections or symptoms

Tracheostomy sites Open wounds

CDC Healthcare Associated infection Website: http://www.cdc.gov/HAI/organisms/acinetobacter.html

Background: Acinetobacter baumannii

Transmission Person-to-person contact Contact with contaminated surfaces Prevention measures Strict infection control practices
Hand hygiene Environmental cleaning Reprocessing of medical equipment

CDC HealthcaEe Associated infection Website: http://www.cdc.gov/HAI/organisms/acinetobacter.html

Background: Acinetobacter baumannii

Environment (especially commonly used equipment) is a common problem with Acinetobacter - more than most other organisms

Methods

Case patient definition

A patient admitted to the hospital with a positive culture result for MDR Acinetobacter baumannii between January 1 and August 15, 2013

Multidrug resistant: resistant to 1 antibiotic in 3 categories

Methods

Case patients chart review using standard form Review hospital database (HMS)

Admission prevalence =

# of Pts with MDR Ab + Cx at admission X 100 # of Pts with Cx at admission

Weekly trans/incidence rate # of vent/trac Pts with 1st + MDR Ab Cx = X 100 Among vent/trac Pts # of vent/trac Pts without previous + Cx

At admission = within 72 hours of admission

Methods
Direct observation of staff practicing in the hospital Time
Day Evening Early morning

Professional category
Doctors Nurses Respiratory therapists Phlebotomists Maintenance/cleaners

Locations
Interim ICU Cohort area Regular ward

Methods

Assess hand hygiene compliance

Using CDC/WHO 5 moments for hand hygiene
HH compliance = # of HH performed by staff X 100 # of opportunities for HH

Assess hand wash techniques

Glo-Germ for hand wash Checklist with hand hygiene steps UV light to assess quality of hand wash

Methods
Procedures observed
Routine nursing care Aspiration of ET tube Blood draw Sputum collection Phlebotomy Dialysis CxR in contact precaution room Routine cleaning by nurses, cleaners, respiratory therapists Terminal cleaning by contractual company

Methods

Assess contact precaution compliance

Missing either gloves, gown, or mask when entering rooms with contact precaution is considered not compliant with contact precaution

Assess quality of routine & terminal cleaning

Before cleaning: Glo Germ on surfaces and high-touch areas After cleaning: UV light to check for Glo Germ

Methods

Interview key staff

Infection control personnel Head of respiratory therapy Nurse supervisor Person in charge of laryngoscope reprocessing Person in charge of ventilator reprocessing

Methods

19 MDR-Ab isolates (11 Pts) tested for PFGE by CDC lab HCW & Environmental samples tested by CDC
HCW hands Surfaces and equipment in contact precaution room Glucometer and its box Vital sign monitor Mobile X-ray machine Laryngoscope blade reprocessing area Ventilators

Results pending

Results
MDR-Ab Patients by Date of 1st Positive Cultures, Jul1, 2012-Aug 25, 2013

Results
MDR-Ab Patients by Date of 1st Positive Cultures, Jan1-Aug 25, 2013 Surveillance culture started

Results
Case patients timeline

Admission 1st positive culture Significance: Most documented infections were acquired within the hospital

Results

Surveillance culture started since epi-week 17

Results
Point prevalence at admission by month
Months # Pts with MDR Ab + 3 days since admission 0 1 0 2 3 2 1 # Pts with Cx drawn 3 days since admission 639 650 723 595 684 599 659 Point Prevalence 0.00% 0.15% 0.00% 0.34% 0.44% 0.33% 0.15%

January February March April May June July

Results
69 patients were identified Male: 39 (56.5%) Died: 32 (47%) Discharged to LTCF: 8 (11.76%) Mean age: 63.2 years (30-91) Mean hospitalization days: 24.3 days (1-90) Mean days admit-Positive: 8.5 days (1-58)

No data to confirm the patients died of Ab

Results
Wards where patients tested Positive ICU (When open) Medical Service (4th floor) Medical Service (5th floor) Medical Service ICU (4th floor) Medical Service ICU (5th floor) Surgery Service (3rd floor) Total # of patients 28 14 18 2 1 5 68 Percent 41% 20.5% 26.5% 3% 1.5% 7.5% 100%

Results
Procedures/Treatments Central line X-ray in ED (Mobile) X-ray after admission (Mobile) Tracheostomy Intubated in ED Intubated after admission # of Patients (%) 40/69 36/65 42/58 16 /69 31/69 26/69 Percent 58% 55.5% 72.5% 23% 45% 37.5%

Results
Culture #1 (Specimen) Sputum Rectal Urine Ulcer Wound Sputum, Rectal Blood, Sputum Catheter Tip Sputum, Urine Blood Endoth ETT Skin Wound, Sputum TOTAL # of Specimens 23 16 7 4 4 3 2 2 2 1 1 1 1 1 68 Percent 33.82% 23.53% 10.29% 5.88% 5.88% 4.41% 2.94% 2.94% 2.94% 1.47% 1.47% 1.47% 1.47% 1.47% 100.00%

Results
Infection control breaches Low hand hygiene compliance
HH compliance rate
Nurse (N=107): 39.25% Respiratory therapist (N= 26): 46.15% Phlebotomist (N=10): 40% X-Ray Tech (N=5): 0%

Of all opportunities for HH missed: 53% before patient contact and clean procedures combined Poor hand hygiene techniques
No No

hand sanitizer at point of care finger nail policy for staff

Results
Hand Hygiene Steps Performed by Staff During Patient Care
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Step 0 Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Step 9 Step 10 Step 11

Step 2

Step 3

Step 4

Step 5

Step 6

Step 7

Results
Infection control breaches Contact precautions
Standard precaution compliance = 86% Entering contact precaution room before gloves on Exit contact precaution room with dirty gloves on Shared glucometer Shared vital sign monitor Poor gowning in contact precaution rooms Family members not adherent to PPE requirements Shared bathroom: cross between rooms with dirty PPE

Results
Routine and terminal cleaning observations

High-touch areas (especially around patients)

Knobs IV stands Bedrails

Surfaces
Bedside tables Chairs Sinks

Results
Before Cleaning After Cleaning Before Cleaning After Cleaning

Results

Observations of cleaning process

EPA-approved disinfectant is used: good Dirty water (terminal/routine cleaning) into hand washing sink Wash wiping cloth in hand washing sink Wiping cloth soaking wet may lower disinfectant concentration Ineffective wiping on surfaces and high-touch areas

Results

Observations of cleaning process (Cont)

Responsibility (cleaners vs. nurses): not clear Adherence to manufacturers protocols for cleaning: not routinely practiced

Aggressive cleaning of commonly used equipment shared between patients and contact areas around patients is particularly important

Results
Reprocessing of laryngoscope blade
Same sink for dirty (before HLD) and clean (after HLD) blades Dirty looking container for soaking blades Dirty looking sink for rinsing blades after HLD Dry with paper towel before packaging No records for soaking time in HLD

Results: Laryngoscope Reprocessing Site

Conclusions

The outbreak started before January 2013 Outbreak occurred in the hospital Multiple infection control issues have contributed to transmission
Suboptimal cleaning Inadequate use of CP Low HH compliance

Transmission of MDR-Ab in hospital: ongoing, yet slower rate

Recommendations: Surveillance

Routine simple surveillance of MDR-Ab

Continue the Epi-curve Continue routine surveillance culture (sputum and rectal) at admission and during hospitalization among ventilated patients until weekly transmission rate comes down to zero for four consecutive weeks Monthly point prevalence of MDR-Ab among ventilated patients after weekly transmission rate comes down to zero for four consecutive weeks

Recommendations: Surveillance
Trace-back investigation of cases positive on admission
HCF admitted before this hospital admission Previous admission in this hospital with MDR-Ab cultures

Recommendations: Hand Hygiene

Improve hand hygiene practices

Regular interactive training (especially new staff) Regular observation for HH compliance Posters, flyers for HH techniques and 5 moments for HH Hand sanitizer available at point of care, i.e. bottle mounting on patient beds, small bottles in staff pockets Feedback of HH adherence to unit managers and front line staff

Recommendations: Contact Precaution

Improve contact precaution practices

Reinforce need for CP and proper procedures Do unit specific surveillance on rates of CP adherence with feedback to unit managers and frontline staff Equipment or supplies brought into the room should be dedicated to that patient or cleaned and disinfected well before use for another patient Restrict unnecessary touch on patient surroundings

Recommendations: Routine and Terminal Cleaning

Improve quality of terminal and routine cleaning

All surfaces need to be cleaned Designate specific responsibilities for cleaning Regular surveillance of daily and terminal cleaning

Follow manufacturers instructions regarding proper cleaning and disinfecting of all equipment and surfaces Use EPA-registered hospital disinfectants
All routine environmental cleaning (including rooms with NO contact precaution)

Recommendations: Cohorting Patients

Cohorting patients
Patients with HAIs in designated isolations Strict contact precaution Group patients with same infections

HCWs working with MDR-Ab patients

HCWs (especially nurses and respiratory therapists) who take care MDR-Ab positive patients should not take care of other patients (if possible)

Recommendations: Laryngoscope Reprocessing

Laryngoscope reprocessing
Clean and disinfect reprocessing areas regularly Sink for cleaning dirty blades (before HLD) should be separated from sink for rinsing blades after HLD if possible If filtered water rinse is used, should followed with alcohol rinse, then allow to dry before storage Need a timer for HLD soaking time

Recommendations: Education for new staff

Infection control session before starting work New staff
Nurses Respiratory therapists Phlebotomist MD

New

residents

Next Steps

Finalize epi analysis Trip report Finalize environmental samples (cultures) Ongoing communication (e.g , further calls with facility)

Acknowledgments

Hospital UPR Puerto Rico Department of Health CDC/DHQP