Apic Ab Guide

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    An APIC Guide

    2010

    Guide to the Elimination o

    Multidrug-resistantAcinetobacter baumanniiTransmission inHealthcare Settings

    About APICAPICs mission is to improve health and patient saety by reducing risks o inection andother adverse outcomes. The Associations more than 12,000 members have primary

    responsibility or inection prevention, control, and hospital epidemiology in healthcaresettings around the globe. APICs members are nurses, epidemiologists, physicians,microbiologists, clinical pathologists, laboratory technologists, and public healthproessionals. APIC advances its mission through education, research, consultation,collaboration, public policy, practice guidance, and credentialing .

    Financial Support or the Distribution o This Guide Provided by Clorox in the Form o anUnrestricted Educational Grant

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    Look for other topics in APICs Elimination Guide Series, including:

    Catheter-Associated Urinary Tract Infections Clostridium difcile

    CRBSIs Hemodialysis Mediastinitis MRSA in Hospital Settings MRSA in Long-Term Care Ventilator-Associated Pneumonia

    Copyright 2010 by APIC

    All rights reserved. No Part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any formor by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of thepublisher.

    All inquires about this document or other APIC products and services may be addressed to:

    APIC Headquarters1275 K Street, NWSuite 1000Washington, DC 20005

    Phone: 202.789.1890Email: APICinfo@apic.orgWeb: www.apic.org

    DisclaimerAPIC provides information and services as a benet to both APIC members and the general public. The material presentedin this guide has been prepared in accordance with generally recognized infection prevention principles and practices andis for general information only. The guide and the information and materials contained therein are provided AS IS, andAPIC makes no representation or warranty of any kind, whether express or implied, including but not limited to, warrantieso merchantability, noninringement, or ftness,or concerning the accuracy, completeness, suitability, or utility of any

    information, apparatus, product, or process discussed in this resource, and assumes no liability therefore.

    [Copy about cover image to be inserted here.]

    ISBN: 1-933013-48-6

    For additional resources, please visit http://www.apic.org/EliminationGuides

    On the Cover:Acinetobacter baumannii, magnified 1,546x. Public Health Image Library, ID# 10096. Courtesy of CDC/Janice Haney Carr.

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    Guide to the Elimination o Multidrug-resistantAcinetobacter baumannii Transmission in Healthcare Settings

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    Table o Contents

    Acknowledgements 4

    Foreword 5

    Guide Overview 6

    Laboratory ConsiderationsEpidemiologyPathogenicity 10

    Risk Assessment 17

    Surveillance 20

    Antibiotic Stewardship and Antibiograms 23

    Standard Precautions and ransmission-based Precautions 27

    Te Environment 33

    Outbreak Recognition and Control 39

    Special Settings: Long-term Care, Ambulatory Care, Pediatrics 46

    oolsAppendix A: Multidrug-resistantAcinetobacter baumannii(MDR Ab)

    Surveillance Line Listing 54Appendix B: Sae Donning and Removal o Personal Protective Equipment (PPE) 55Appendix C: Multidrug-resistantAcinetobacter baumannii(MDR Ab)

    Patient/Visitor Education 57Appendix D: Daily High ouch Cleaning Checklist 58

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    Guide to the Elimination o Multidrug-resistantAcinetobacter baumannii Transmission in Healthcare Settings

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    Acknowledgements

    APIC acknowledges the valuable contributions o the ollowing individuals:

    Authors

    Patricia Rosenbaum RNC, CIC, Lead Author

    PAR Consulting, LLC, Silver Spring, MD

    Kathy Aureden, MS, M(ASCP)SI, CIC

    Sherman Hospital, Elgin, IL

    Michael Cloughessy, MS, BSEH, REHS, CIC

    Cincinnati Childrens Hospital, Cincinnati, OH

    Linda Goss, MSN, ARNP, CIC, COHN-S

    Director, Inection Prevention and Control and

    University o Louisville Hospital

    Faculty, University o Louisville School o Nursing, Louisville, KY

    Marie Kassai, RN, BSN, MPH, CIC

    MRK Consulting, LLC, West Paterson, NJ

    Stephen A Streed, MS, CIC

    Lee Memorial Health System, Ft Myers, FL

    Reviewers

    Marcia R Patrick, RN, MSN, CIC

    MultiCare Health System, acoma, WA

    Sandra Von Behren, RN, MS, CIC

    Springeld, IL

    Marc Oliver Wright, M(ASCP), MS, CIC

    NorthShore University HealthSystem, Evanston, IL

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    Guide to the Elimination o Multidrug-resistantAcinetobacter baumannii Transmission in Healthcare Settings

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    Foreword

    Te writers o this guide encourage readers to consult the reerences we have provided at the end o each section

    We have identied many recent articles and technologies to help the inection preventionist (IP) be aware o allcurrent and emerging inormation on creating a program to eliminate the transmission o multidrug-resistant

    Acinetobacter baumannii(MDR Ab) in his or her acility

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    Guide to the Elimination o Multidrug-resistantAcinetobacter baumannii Transmission in Healthcare Settings

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    Guide Overview

    Purpose and Scope

    Te purpose o this guide is to provide the inection preventionist (IP) with a summary o the latest articles,studies, outbreak experiences, applicable guidelines and tools to manage and eliminate transmission omultidrug-resistantAcinetobacter baumannii(MDR Ab) in healthcare settings

    Specics related to pathogenesis, surveillance, resistance patterns and environmental controls as covered in thisdocument provide the IP with current advanced knowledge imperative to the transmission elimination process

    Special healthcare settingslong-term care, ambulatory care, and pediatricsare addressed at the end o the guideIn all sections o the guide, the use o the term patient reers to a patient, resident or client in a healthcare setting

    Key Concepts efacility-wideriskassessmentguidesthedevelopmentandimplementationofacomprehensiveMDR

    Ab prevention and elimination plan

    ecompletedriskassessmentidentiesthefacilitysburdenofMDRAbandtheriskoftransmissionwithin the acility Te IP incorporates this inormation into the development o the MDR Ab inectionprevention plan

    edevelopmentoftheinfectionpreventionplanrequiresanunderstandingoftheattributesofMDRAbso that eective interventions are targeted

    Background

    In past decades,Acinetobacterinections have been sporadically identied in hospitalized patients and healthcare-related outbreaks1,2,3 Tese inections have occurred most oten in critically ill patients receiving invasive medicalinterventions such as central lines, arterial lines, and mechanical ventilation In more recent years,Acinetobacterhasbeen increasingly recognized as a signicant healthcare-associated, opportunistic, multidrug-resistant pathogen4

    Widespread public awareness o the risk oAcinetobacterinection in healthcare has escalated, primarily as a resulto the media attention given inections in military populations serving in the Middle East (dubbed Iraqibacter bythe media)5

    Acinetobacterspecies are ubiquitous in nature and have been ound on or in soil, water, animals and humans6Acinetobacter baumanniiis known to be recoverable rom the skin, throat and rectum o humans, and has been

    reported to be a healthcare-acquired colonizer o the respiratory tract According to the Centers or DiseaseControl and Prevention (CDC), the speciesA. baumanniiaccounts or nearly 80% o reported Acinetobacterinections7

    Acinetobacteris capable o surviving or extended periods o time on inanimate suraces Tis prolonged survivalin the healthcare environmentalong with multidrug resistance, colonization potential, and contact transmission(hands, instruments, equipment)are some o the challenging actors inAcinetobacterprevention and control

    When outbreaks occur, and/or whenAcinetobactersurvives due to incomplete cleaning and becomes endemic toa healthcare setting, the diculties encountered in implementing successul sustainable eradication can severelychallenge the limited resources o the IP Pinpointing an outbreak source may require extensive detective work

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    when the source is not obvious For example, one reported outbreak o MDR Ab eventually ound the sourceto be associated with pulsatile lavage wound therapy8 It should be noted that in approximately 50% o reportedoutbreaks, the source could not be identied2