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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
Investigation of Multidrug-Resistant
Acinetobacter baumannii
at a Hospital in
Puerto Rico, Jan-Aug, 2013
National Center for Emerging and Zoonotic Infectious Diseases
Division of Healthcare Quality Promotion
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DisclaimerThe findings and conclusions in this report are those
of
the authors and do not necessarily represent the
officialposition of the Centers for Disease Control and
Prevention
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Outline Background Methods/Epi-Aid activities Results Conclusion Recommendations Next steps Acknowledgements
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Background On July 17, 2013, PR DH contacted CDC/DHQP
MDRAcinetobacter 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
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Background: Objectives of Investigation
Describe basic epidemiology of all patient cases
Evaluate possible sources and modes of transmission
Assess infection control practices in the hospital
Provide recommendations
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Background:Acinetobacter baumannii
Gram negative rod
Commonly found in soil and water
Ab is ubiquitous, survives desiccation, and oftenMDR
Causes outbreaks in ICU Healthcare settings with very ill patients
Infection outside healthcare settings: RareCDC Healthcare Associated infection Website: http://www.cdc.gov/HAI/organisms/acinetobacter.html
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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
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Background:Acinetobacter baumanniiTransmission
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
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Background:Acinetobacter baumannii
Environment (especially commonly used equipment)is a common problem withAcinetobacter- more than
most other organisms
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Methods Case patient definition
A patient admitted to the hospital with a positive culture result forMDRAcinetobacter baumannii between January 1 and August
15, 2013
Multidrug resistant: resistant to 1 antibiotic in 3categories
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Methods Case patients chart review using standard form Review hospital database (HMS)
At admission = within 72 hours of admission
Admission prevalence =# of Pts with MDRAb + Cx at admission
# of Pts with Cx at admissionX 100
Weekly trans/incidence rate# of vent/trac Pts without previous + Cx
X 100# of vent/trac Pts with 1st + MDRAb Cx
Among vent/trac Pts=
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Methods
Time Day Evening Early morning
Locations Interim ICU Cohort area Regular ward
Professional category Doctors Nurses Respiratory therapists Phlebotomists Maintenance/cleaners
Direct observation of staff practicing in the hospital
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Methods Assess hand hygiene compliance
Using CDC/WHO 5 moments for hand hygiene
HH compliance = # of HH performed by staff# of opportunities for HH X 100
Assess hand wash techniques Glo-Germ for hand wash Checklist with hand hygiene steps UV light to assess quality of hand wash
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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
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Methods Assess contact precaution compliance
Missing either gloves, gown, or mask when entering rooms withcontact 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
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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
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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
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Results MDR-Ab Patients by Date of 1st Positive Cultures, Jul1, 2012-Aug 25, 2013
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Results
MDR-Ab Patients by Date of 1st Positive Cultures, Jan1-Aug 25,2013
Surveillance culture started
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ResultsCase patients timeline
Admission
1st positive culture
Significance: Most documented infections were
acquired within the hospital
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Results
Surveillance culture started since epi-week 17
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Results
Months # Pts with MDR Ab + 3
days since admission
# Pts with Cx drawn 3
days since admission
Point
Prevalence
January 0 639 0.00%
February 1 650 0.15%
March 0 723 0.00%
April 2 595 0.34%
May 3 684 0.44%
June 2 599 0.33%
July 1 659 0.15%
Point prevalence at admission by month
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Results69 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 ofAb
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Results
Wards where patients tested Positive # of patients Percent
ICU (When open) 28 41%
Medical Service (4th floor) 14 20.5%
Medical Service (5th
floor) 18 26.5%Medical Service ICU (4th floor) 2 3%
Medical Service ICU (5th floor) 1 1.5%
Surgery Service (3rd floor) 5 7.5%
Total 68 100%
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ResultsProcedures/Treatments # of Patients (%) Percent
Central line 40/69 58%
X-ray in ED (Mobile) 36/65 55.5%
X-ray after admission (Mobile) 42/58 72.5%
Tracheostomy 16 /69 23%
Intubated in ED 31/69 45%
Intubated after admission 26/69 37.5%
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Results
Culture #1 (Specimen) # of Specimens Percent
Sputum 23 33.82%
Rectal 16 23.53%
Urine 7 10.29%
Ulcer 4 5.88%
Wound 4 5.88%
Sputum, Rectal 3 4.41%
Blood, Sputum 2 2.94%
Catheter Tip 2 2.94%
Sputum, Urine 2 2.94%
Blood 1 1.47%
Endoth 1 1.47%
ETT 1 1.47%Skin 1 1.47%
Wound, Sputum 1 1.47%
TOTAL 68 100.00%
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ResultsInfection 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 contactand clean procedures combined
Poor hand hygiene techniquesNo hand sanitizer at point of care
No finger nail policy for staff
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Results
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Step 0 Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Step 9 Step 10 Step 11
Hand Hygiene Steps Performed by Staff During Patient Care
Step 2 Step 3 Step 4 Step 5 Step 6 Step 7
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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
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Results
High-touch areas (especially around patients) Knobs IV stands Bedrails
Surfaces Bedside tables Chairs Sinks
Routine and terminal cleaning observations
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Results
Before Cleaning Before CleaningAfter Cleaning After Cleaning
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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
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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 equipmentshared between patients and contact areas around
patients is particularly important
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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
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Results: Laryngoscope Reprocessing Site
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Conclusions
The outbreak started before January 2013
Outbreak occurred in the hospital
Multiple infection control issues have contributed totransmission
Suboptimal cleaning Inadequate use of CP Low HH compliance
Transmission of MDR-Ab in hospital: ongoing, yetslower rate
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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 patientsafterweekly transmission rate comes down to zero for fourconsecutive weeks
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Recommendations: Surveillance
Trace-back investigation of cases positive onadmission
HCF admitted before this hospital admission Previous admission in this hospital with MDR-Ab cultures
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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
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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 bededicated to that patient or cleaned and disinfected well before
use for another patient
Restrict unnecessary touch on patient surroundings
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Recommendations: Routine and TerminalCleaning
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 propercleaning and disinfecting of all equipment andsurfaces
Use EPA-registered hospital disinfectants All routine environmental cleaning (including rooms with NO
contact precaution)
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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 takecare MDR-Ab positive patients should not take care of other
patients (if possible)
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Recommendations: LaryngoscopeReprocessing
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
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Recommendations: Education for new staff
Infection control session before starting work
New staff Nurses
Respiratory therapists Phlebotomist MD
New residents
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Next Steps
Finalize epi analysis
Trip report
Finalize environmental samples (cultures)
Ongoing communication (e.g , further calls withfacility)
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Acknowledgments
Hospital UPR Puerto Rico Department of Health CDC/DHQP