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An APIC Guide

2010

Guide to the Elimination o

Multidrug-resistant Acinetobacter baumannii Transmission inHealthcare Settings

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

responsibility or inection prevention, control, and hospital epidemiology in healthcaresettings around the globe. APIC’s 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



Look for other topics in APIC’s 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

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Phone: 202.789.1890Email: [email protected] Web: www.apic.org

Disclaimer APIC 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”, and APIC 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

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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.



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

3

Table o Contents

Acknowledgements 4

Foreword 5

Guide Overview 6

Laboratory Considerations—Epidemiology—Pathogenicity 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-resistant Acinetobacter baumannii (MDR Ab)

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

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




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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 Children’s 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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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 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 o multidrug-resistant Acinetobacter 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 settings—long-term care, ambulatory care, and pediatrics—are 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

• ecompletedriskassessmentidentiesthefacility’sburdenofMDRAbandtheriskoftransmission within 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, Acinetobacter inections 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, Acinetobacter hasbeen increasingly recognized as a signicant healthcare-associated, opportunistic, multidrug-resistant pathogen4

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

Acinetobacter species are ubiquitous in nature and have been ound on or in soil, water, animals and humans6 Acinetobacter baumannii is 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 species A. baumannii accounts or nearly 80% o reported Acinetobacterinections7

Acinetobacter is capable o surviving or extended periods o time on inanimate suraces Tis prolonged survivalin the healthcare environment—along with multidrug resistance, colonization potential, and contact transmission(hands, instruments, equipment)—are some o the challenging actors in Acinetobacter prevention and control

When outbreaks occur, and/or when Acinetobacter survives due to incomplete cleaning and becomes endemic toa healthcare setting, the diculties encountered in implementing successul sustainable eradication can severely challenge 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

Elimination o an identied source may require multiple or novel interventions, such as the introduction o a new

disinectant technology (or example, hydrogen peroxide vapor) to interrupt an ongoing MDR Ab outbreak at along-term acute care acility9 Te reader is encouraged to ollow the peer-reviewed literature closely or reportso the ecacy o these and other emerging technologies which may ultimately provide more ecacious roomdecontamination than is now achieved using traditional cleaning methods

Defnitions

MDR Acinetobacter baumannii (MDR Ab): A. baumannii with multidrug resistance to more than two o theollowing ve drug classes: antipseudomonal cephalosporins (cetazidime or ceepime), antipseudomonalcarbapenems (imipenem or meropenem), ampicillin/sulbactam, uoroquinolones (ciprooxacin or levooxacin),and aminoglycosides (Gentamicin, tobramycin, or amikacin)4 Tis denition is given or the purposes o this

document; readers may wish to reer to a local antibiogram when dening multidrug-resistant Ab in theirown acilities

Pan-drug resistant Acinetobacter baumannii: A. baumannii with additional antimicrobial resistance in all drugclasses, plus resistance to polymyxin and/or colistin 10,11 (note there is no standardized denition o pan resistant

Acinetobacter baumannii the authors could nd, please review reerences given)

Ambulatory care: Healthcare rendered or acute or chronic diseases, and or surgical interventions where a patient’slength o stay is less than 24 hours

Cohort or MDR Ab: Placement o residents/patients colonized or inected with MDR Ab in rooms (cohorted)

with other MDR Ab residents/patients

Cohort stang related to MDR Ab: Assignment o personnel to care only or residents/patients known to becolonized or inected with MDR Ab

Colonization with MDR Ab: Presence o MDR Ab in or on body without signs or symptoms o active inection

Contact Precautions: ransmission-based Precautions method recommended by the Centers or Disease Controland Prevention (CDC) Tis method requires barrier precautions and personal protective equipment (PPE) ordirect contact with residents/patients or contaminated equipment

Contamination: Presence o a potentially inectious agent on a surace, on a material, or in a uid

Endemic: A baseline rate established by ongoing surveillance o the usual requency o an organism, inection ordisease in a given setting

Epidemic: A higher incidence than usual o an organism, inection or disease in a dened population in a givenperiod o time

Healthcare-associated inection (HAI): An inection that develops in a patient/resident in a healthcare setting, andthe inection was not present or incubating at the time o admission




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Incidence o MDR Ab: Number o new cases o MDR Ab colonization or inection identied in a specicpopulation in a given time period New cases can be dened as occurring three days or more ater admission tothe acility12

Long-term care acility (LCF): A healthcare setting that provides rehabilitative, restorative, and/or ongoing

skilled nursing care to patients or residents in need o assistance with activities o daily living Long-term careacilities include nursing homes, rehabilitation acilities, inpatient behavioral health acilities, and long-termchronic care hospitals

Long-term acute care (LAC): A healthcare setting that manages complex medical care and rehabilitation o patients with multiple acute healthcare needs

Outbreak o MDR Ab: An increase in the incidence o MDR Ab cases in a healthcare setting above the endemiclevel, or a cluster o new MDR Ab cases that are epidemiologically linked

Prevalence o MDR Ab: Te total number o patients with MDR Ab inection or colonization in a given

population at a point in time

Reservoir: Any animate or inanimate surace in which an inectious agent may survive to become a source o transmission to a susceptible host

Surveillance: Te ongoing systematic collection, analysis and interpretation o healthcare data

Standard Precautions: Precautions taken to protect against exposure to blood and potentially inectious body uids when caring or patients/residents Tese precautions are always taken without regard or the diagnosis or perceiveddiagnosis and are never discontinued

erminal cleaning: Comprehensive, deep cleaning o a patient room at the time o discharge rom the healthcaresetting or termination o transmission-based precautions based on the policy o the acility13

Guide Overview Reerences1 Beck-Sagué CM, Jarvis WR, Brook JH, Culver DH, Potts A, Gay E, Shotts BW, Hill B, Anderson RL, Weinstein MPEpidemic bacteremia due to Acinetobacter baumannii in ve intensive care units Am J Epidemiol 1990 Oct;132(4):723–733

2 Villegas MV, Hartstein AI Acinetobacter outbreaks,1977-2000 Inect Control Hosp Epidemiol 2003 Apr;24(4):284–295

3 Lortholary O, Fagon JY, Hoi AB, Slama MA, Pierre J, Giral P, Rosenzweig R, Gutmann L, Saar M, Acar J Nosocomialacquisition o multiresistant Acinetobacter baumannii : risk actors and prognosis Clin Inect Dis 1995 Apr;20(4):790–796

4 Peleg AY, Seiert H, Paterson DL Acinetobacter baumannii : emergence o a successul pathogen Clin Microbiol Rev 2008 Jul;21(3):538–582

5 Davidson M Te Iraqibacter: Medical experts wary o dangerous germ now striking war wounded troops American LegionMagazine, 2008 Mar 1 Available at: http://wwwlegionorg/magazine/1516/medical-experts-wary-dangerous-germ-now-striking-war8209wounded-troops

6 Beavers SF, Blossom DB, Wiemken L et al. Comparison o risk actors or recovery o Acinetobacter baumannii duringoutbreaks at two Kentucky hospitals, 2006 Public Health Rep 2009 Nov-Dec;124(6):868–874




9

7 Centers or Disease Control and Prevention (CDC) Overview o drug-resistant Acinetobacter inections in healthcaresettings Available at: http://wwwcdcgov/ncidod/dhqp/ar_acinetobacterhtml

8 Maragakis LL, Cosgrove SE, Song X, Kim D, Rosenbaum P, Ciesla N, Srinivasan A, Ross , Carroll K, Perl M An outbreak o multidrug-resistant Acinetobacter baumannii associated with pulsatile lavage wound treatment JAMA2004 Dec 22;292(24):3006–3011

9 Ray A “Te use o vaporized hydrogen peroxide room decontamination in the management o an outbreak o multidrug-resistant Acinetobacter baumannii ” 36th Annual APIC Educational Conerence and International MeetingProceedings, Fort Lauderdale, FL 2009 Jun 10

10 Hsueh PR, eng LJ, Chen CY, Chen WH, Yu CJ, Ho SW, et al Pandrug-resistant Acinetobacter baumannii causingnosocomial inections in a university hospital, aiwan Emerg Inect Dis 2002;8:827–832

11 Valencia R, Arroyo LA, Conde M, Aldana JM, orres MJ, Fernández-Cuenca F, Garnacho-Montero J, Cisneros JM,Ortíz C, Pachón J, Aznar, J Nosocomial outbreak o inection with pan-drug-resistant Acinetobacter baumannii in a tertiary care university hospital Inect Control Hosp Epidemiol 2009 Mar;30(3):257–263

12 Cohen A, et al. Recommendations or metrics or multidrug-resistant organisms in healthcare settings: SHEA/HICPACPosition Paper Inect Control Hosp Epidemiol 2008;29:1099–1106

13 American Society or Healthcare Environmental Services (ASHES) Practice Guidance or Healthcare EnvironmentalCleaning 2008;59:62




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Laboratory Considerations—Epidemiology—Pathogenicity

Te genus Acinetobacter is a member o the amily Moraxellaceae in the order Pseudomonadales1 More than25 species within the genus Acinetobacter have been described; however, member species in this genus are dicultto dierentiate and only some have been ocially named Te most important species o this genus in humanpathology is Acinetobacter baumannii Tis organism is a member o a group o phenotypically similar species thatare oten grouped together in the A.calcoaceticus-A.baumannii complex In healthcare settings, the organisms in thisgroup are the ones generally implicated in outbreaks and hospital-associated inections2 Tere have been occasionalreports o opportunistic inections in immunocompromised individuals caused by A. lwoi and other species3,4

Bacteria in the genus Acinetobacter are strictly aerobic, gram negative bacteria On gram stain, they are described ascoccobacillary, having an intermediate shape between a rod (bacillus) and a sphere (coccus)

Acinetobacter bacteria oten appear more bacillus-like during growth phase and rom uids Tey are oten seenin pairs, and although gram-negative, will sometimes appear gram-variable on a gram stain Tey readily grow in culture on standard microbiology media at temperatures between 20 and 30 degrees C Tey are non-motilebacteria, oxidase-negative, usually nitrate- negative, and are non-lactose ermenting, although they can be partially lactose ermenting when grown on MacConkey’s agar

Most clinical microbiology laboratories identiy members o the genus Acinetobacter at the level o theollowing groups:

• Acinetobacter calcoaceticus-baumannii complex : glucose-oxidizing non-hemolytic ( A.baumannii can beidentied by OXA-51 serotyping)5

• Acinetobacter lwoi : non glucose-oxidizing, non-hemolytic

• Acinetobacter haemolyticus : hemolytic

Figure 1. Scanning Electron Micrograph o clusterso Acinetobacter baumannii bacteria under amagnication o 6,182x. Content provider: CDC/ Janice Haney Carr. Creation Date: 2007. Photo at Public Health Library: http://phil.cdc.gov/phil/home.asp; search “ Acinetobacter.”




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Te Clinical and Laboratory Standards Institute (CLSI) has published susceptibility testing interpretations or Acinetobacter in the monograph Perormance Standards or Antimicrobial Susceptibility esting: Nineteenth InormationalSupplement CLSI M100-S19 (2009) In able 2B-2 “ Acinetobacter spp.,” incubation is required in ambient air, 20–24 hours,at 35 ± 2 degrees C Zone diameters and MIC interpretations or antimicrobial agents in nine classes are provided in thistable6 Additional considerations or laboratorians are available in a review article by Peleg, Seiert, and Paterson7

Specimen Collection

Clinical Culture

Tere are no special specimen collection requirements related to clinical culture Reer to the clinical laboratory’sspecimen manual or the appropriate collection method and supplies

Patient Screening (Surveillance) Culture Specimens

In outbreak situations, surveillance cultures o patients involved in the outbreak or who are deemed at risk or colonization/inection with the outbreak organism are oten part o the planned intervention A recent

investigation into the eectiveness o screening cultures by Marchaim et al ound that detection o MDR Abin surveillance (screening) cultures was suboptimal (around 55%), with a low sensitivity even when surveillancecultures were obtained rom six body sites (throat, nose, skin, wounds, rectum, endotracheal aspirates) In addition,these reseachers reported that persistent carriage o MDR Ab occurs in a substantial proportion o patients8

At this time, a specic recommendation regarding best practice or surveillance cultures is not available, in partdue to the lack o veried eectiveness o screening protocols However, the decision to use screening cultures may be part o an enhanced intervention when rates are increasing, when an outbreak is identied, or when exogenoussources o colonization pressure are suspected or identied (eg, nursing home transers to acute care) It isimportant to keep in mind that detection eectiveness will be enhanced i a number o body sites are screenedCandidate body sites or screening cultures may include the nose, the throat, skin sites such as the axilla and/orgroin, the rectum, open wounds and endotracheal aspirates

When screening cultures are deemed necessary, apply the ollowing components:

• Useapre-determinedstandardizedcollectionprotocol,includingsitestobecultured

• Collaboratewithlaboratoryregardingsupplies

• Collaboratewithlaboratoryregardingtimingofcollectionforoptimaldeliveryandset-up

• Collaboratewithlaboratoryregardingappropriatetestorder(asscreeningtest)

• Collaboratewithlaboratoryregardingtestresult,comment,orimmediatenoticationsasappropriate

• Includeprotocolspecicactionswhentargetorganismisfound(privateroom,cohortingofpatientsand/orsta, roommate considerations, precautions/isolation, other)

• Implementprotocolswithappropriatecommunicationandstatrainingasnecessary

Environmental Specimens

When the environment can play a role in an outbreak situation, environment or equipment culturing may be used toidentiy an ongoing source o the outbreak organism Culture swabs, usually pre-moistened with liquid culture mediaor phosphate buered saline, and water source samples collected in sterile test tubes, can be obtained rom the suspectenvironment or equipment However, the recovery o Acinetobacter using the swabbing method has been suggested tobe sub-optimal, and the use o pre-moistened sterile gauze pads,9 or “sponge sticks” prepackaged in neutralizing buerhave been reported to maximize chance o recovery rom environmental/equipment suraces and crevices 10




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Genotypic Testing o Acinetobacter

MDR Ab that has been isolated rom clinical or surveillance culture may be saved by the microbiology laboratory or possible additional analysis Te IP should know the capability o the laboratory used by the acility orstoring and strain testing during outbreaks I this option is not available, the IP should know what contacts to

make to accomplish this in the event o outbreaks When characterizing endemic Acinetobacter , identiying acommon source o contamination, and/or in outbreak situations, specialized laboratory testing may be o great

value Although not normally available in hospital laboratories, strain typing (serotyping, multilocus enzymeelectrophoresis) or DNA-based methodologies (such as polymerase chain reaction, ribotyping, or pulse eld gelelectrophoresis) may be available rom public health, university-based, or reerence laboratories It is beyond thescope o this guide to review these techniques, but many reerences are available to guide the laboratorian and IP

when urther characterization is needed11,12,13,14

Epidemiology

Acinetobacter species are widely distributed in nature and are recoverable readily rom moist and dry suraces

Acinetobacter can be ound in soil, sewage, water, consumables (including ruits and vegetables), and on healthy skin and other body sites Te organism is relatively resistant to low humidity (drying) conditions and has beenshown to be readily recoverable rom dry environmental niches15,16 A. baumannii , a species oten identied inhealthcare inections and outbreaks, can remain viable in dry environmental conditions or a ew weeks to amonth or more2

Community-acquired pneumonia and other inections (meningitis, cellulitis, bacteremia) due to Acinetobacter have been noted and, in some instances, may be related to underlying conditions (eg, alcoholism, diabetes,cancer)17,18,19 Acinetobacter inections during wartime (eg, Korean and Vietnam wars) and during times o naturaldisasters have been previously described20,21 In the recent decade, inectious complications have occurred insoldiers acquiring Acinetobacter rom the environment or during hospitalization in non-native locales Tis became

apparent with the increase in wound and other inections caused by multidrug-resistant strains o this organismin troops wounded and treated while in Iraq, Kuwait and Aghanistan Wounded troops, upon return to theirnative countries, have received care in acilities (hospitals, rehabilitation centers)—some o which experiencedsubsequent outbreaks and, as a result, established endemicity with a transplanted multidrug-resistant strain insome o these settings22,23,24,25

Acinetobacter rom a healthcare environment may be acquired as a colonizer o healthy or non-immunocompromisedindividuals, or as opportunistic pathogens o compromised and debilitated patients In a prospective ve-month study by Corbella et al26, cultures o axilla, rectal and pharyngeal areas were obtained rom patients in a critical care unitIn more than hal o the 73 patient cohort, screening cultures became positive (time o “onset” rom <48 hours up to1 week) In nearly one-third o the cohort, Acinetobacter was subsequently isolated rom clinical cultures Te study authors identied the digestive tract as a signicant reservoir o Acinetobacter acquired in that healthcare setting

Clinical inection with Acinetobacter in healthcare settings oten relate to invasive procedures and underlying ordebilitating conditions Prior antibiotic use, prolonged hospitalization, high APACHE II score, colonizationpressure (a unit with high incidence o Acinetobacter ), and enteral eeding have all been implicated in risk o

Acinetobacter inection2,17 Hospital-associated Acinetobacter respiratory tract inections, including ventilator-associated pneumonia, urinary tract inection related to urinary catheters, bloodstream inections, and woundinections have all been well documented in medical literature27,28 In addition, there have been reports o

Acinetobacter meningitis, endocarditis, osteomyelitis, and corneal peroration and inection associated withperitoneal dialysis




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Te distribution and types o inections caused by Acinetobacter also can show variation per location and by seasonality2 Te SENRY report o 2001 validated the geographic dierences across the world or endemic strainand antimicrobial resistance to the most requently chosen antimicrobials (carbapenems, uoroquinolones, andaminoglycosides)29,30 Antibiograms at the acility and local levels can be expected to be unique to the source, andshould be maintained and updated in order to assist providers caring or patients with Acinetobacter inections

As an environmental organism, it is not dicult to understand that Acinetobacter transmission in healthcaresettings has an environmental component Te ability o Acinetobacter to participate in biolm ormation promotesdurability in and on suraces and may contribute to continuation o environmental sources during outbreaks31,32

Contamination in healthcare environments has been identied on many suraces and equipment, includingsuctioning equipment, washbasins, bedrails, bedside tables, ventilators, sinks, pillows, mattresses, hygroscopicbandages, resuscitation equipment, and trolleys17 Te hands o healthcare workers requently touch these objectsin patient environments Hands become the vectors o transmission i scrupulous compliance to all components o applicable Standard Precautions and ransmission-based Precautions are not applied2

Tere has been a published report o a healthcare worker exposure to MDR Ab that resulted in clinicalpneumonia33 Prevention o exposures requires strict compliance to the use o personal protective equipment (PPE)to prevent exposure and transmission

Pathogenicity

Acinetobacter spp can colonize almost any human body site either transiently or as normal ora A. baumannii is an emerging opportunistic pathogen in healthcare settings, and its presence can signiy important pathology

when identied in clinical culture, especially in an immunocompromised patient Host contributions topathogenicity include a history o alcoholism, smoking, and chronic lung disease34 Invasive procedures such asmechanical ventilation, catheters (bloodstream and urinary) and surgery are well characterized predisposing events

Acinetobacter can cause suppurative inection in any organ or tissue, and in the lungs, has been associated withmultilobar inection, cavitation, and pleural eusion35

Inherent bacterial virulence actors are not well elucidated, although it is known that the organism is encapsulated, which may enable it to “escape” phagocytosis, and the production o an exopolysaccharide protects it rom otherinnate immune mechanisms7 Te ability o this organism to participate in biolms at epithelial cell interaces,and its innate iron acquisition systems or survival in a host’s iron-poor environment also contribute to itspathogenicity32,36

A. baumannii inections are even more dicult to manage when the inecting strain exhibits multidrug resistanceIn recent decades, carbapenem resistance has been one o the main challenges in managing Acinetobacter healthcare-associated inections27,29,30 In addition, there have recently been reports o outbreaks with pan-resistant

A. baumannii (additional resistance to polymyxin and colistin)30,37,38

A major resistance actor is the intrinsic carbapenem-hydrolyzing oxacillinase enzyme, causing resistance tocarbapenems and penicillins Te expression o this resistance may vary Additional drug resistance strategieso drug-resistant Acinetobacter strains include porins, pencillin-binding protein modications, aminoglycoside-modiying enzymes, plasmid-mediated quinolone resistance, and an efux pump mechanism39 Susceptibility testing o Acinetobacter isolates is an essential component o clinical culture that can assist decisions regardingappropriate treatment and prevention o treatment ailure




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Laboratory Considerations Reerences1 Schreckenberger PC, Daneshvar MI, Weyant RS, Hollis DG Acinetobacter, Achromobacter, Chryseobacterium, Moraxella, and other nonermentative gram-negative rods In: Murray PR, Baron EJ, Jorgensen JH, Paller MA, Yolken RH, editorsManual o clinical microbiology 8th ed Washington, DC: American Society or Microbiology Press, 2007:770–779

2 Fournier PE, Richet H Te epidemiology and control o Acinetobacter baumannii in health care acilities Clin Inect Dis2006 Mar 1;42(5):692–699

3 ega L, Raieta K, Ottaviani D, Russo GL, Blanco G, Carraturo A Catheter-related bacteremia and multidrug-resistant Acinetobacter lwoi [letter] Emerg Inect Dis [serial on the Internet] 2007 Feb Available at: http://wwwcdcgov/EID/content/13/2/355htm

4 Ku SC, Hsueh PR, Yang PC, Luh K Clinical and microbiological characteristics o bacteremia caused by Acinetobacter lwoi Eur J Clin Microbiol Inect Dis 2000;19:501–505

5 urton JF et al. Identication o Acinetobacter baumannii by detection o the bla OXA-51-like carbapenemase gene tntrinsicto this species J Clin Microbiol 2006;44(8):2974–2976

6 Clinical and Laboratory Standards Institute Perormance Standards or Antimicrobial Susceptibility esting; NineteenthInormational Supplement CLSI document M100-S19 2009 Available at: http://wwwclsiorg/source/orders/ree/m100-s19pd

7 Peleg AY, Seiert H, Paterson DL Acinetobacter baumannii : Emergence o a successul pathogen Clin Microbiol Rev 2008 Jul;21(3):538–582 Available at: http://wwwpubmedcentralnihgov/picrendercgi?artid=2493088&blobtype=pd

8 Marchaim D, Navon-Venezia S, Schwartz D, arabeia J, Feer I, Schwaber MJ, Carmeli Y Surveillance cultures andduration o carriage o multidrug-resistant Acinetobacter baumannii J Clin Microbiol 2007 May;45(5):1551–1555 Epub 2007Feb 21 Available at: http://wwwpubmedcentralnihgov/picrendercgi?artic=1865886&blobtype=pd

9 Corbella X, Pujol M, Argerich MJ, Ayats J, Sendra M, Peña C, Ariza J Environmental sampling o Acinetobacter baumannii :

Moistened swabs versus moistened sterile gauze pads Inect Control Hosp Epidemiol 1999 Jul;20(7):458–460

10 Linda K Goss, MSN, ARNP, CIC, COHN-S, University o Louisville Hospital/Inection Control, Louisville, KY,personal communication, July 8, 2009)

11 Saeed, S, Fakih G, Riederer K, Shah AR, Khatib R Interinstitutional and intrainstitutional transmission o a strain o Acinetobacter baumannii detected by molecular analysis: comparison o pulsed-eld gel electrophoresis and repetitive sequence-based polymerase chain reaction Inect Control Hosp Epidemiol 2006;27:981–983

12 Ecker JA, Massire C, Hall A, et al. Identication o Acinetobacter species and genotyping o Acinetobacter baumannii by multilocus PCR and mass spectrometry J Clin Microbiol 2006 Aug;44(8):2921–2932

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Valentine SC, Contreras D, an S, Real LJ, et al. Phenotypic and molecular characterization o Acinetobacter baumannii clinical isolates rom nosocomial outbreaks in Los Angeles County, Caliornia J Clin Microbiol 2008 Aug;46(8):2499–2507

14 enover FC, Arbeit RD, Goering RV, Mickelsen PA, Murray BE, Persing DH, Swaminathan B Interpretingchromosomal DNA restriction patterns produced by pulsed-eld gel electrophoresis: criteria or bacterial strain typing J ClinMicrobiol 1995 Sept;33(9):2233–2239

15 Wendt C, Dietze B, Dietz E, Rüde H Survival o Acinetobacter baumannii on dry suraces J Clin Microbiol 1997 Jun;35(6):1394–1397




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16 Jawad A, Seiert H, Snelling AM, Heritage J, Hawkey PM Survival o Acinetobacter baumannii on dry suraces: comparisono outbreak and sporadic isolates J Clin Microbiol 1998 Jul;36(7):1938–1941

17 Joly-Guillou ML Clinical impact and pathogenicity o Acinetobacter Clin Microbiol Inect 2005 Nov;11(11):868–873

18 Anstey NM, Currie BJ, Hassell M, Palmer D, Dwyer B, Seiert H Community-acquired bacteremic Acinetobacter pneumonia in tropical Australia is caused by diverse strains o Acinetobacter baumannii , with carriage in the throat in at-risk groups J Clin Microbiol 2002 Feb;40(2):685–686

19 Falagas ME, Karveli EA, Kelesidis I, Kelesidis Community-acquired Acinetobacter inections Eur J Clin MicrobiolInect Dis 2007 Dec;26(12):857–868

20 Murray CK, et al. Acinetobacter inection: what was the true impact during the Vietnam conict? Clin Inect Dis2006;43:383–384

21 Oncül O, et al. Hospital-acquired inections ollowing the 1999 Marmara earthquake J Hosp Inect 2002 May;51(1):47–51

22 Sebeny PJ, Riddle MS, Petersen K Acinetobacter baumannii skin and sot-tissue inection associated with war trauma ClinInect Dis 2008 Aug 15;47(4):444–449

23 Davis KA, Moran KA, McAllister CK, Gray PG Multidrug-resistant Acinetobacter extremity inections in soldiers EmergInect Dis [serial on the Internet] 2005 Aug;11:1218–1224 Available at: http://wwwcdcgov/ncidod/eid/vol11no08/05-0103htm

24 Centers or Disease Control and Prevention (CDC) Acinetobacter baumannii inections among patients at military medicalacilities treating injured US service members, 2002-2004 MMWR Morb Mortal Wkly Rep 2004 Nov;53(45):1063–1066

25 urton JF, et al. Comparison o Acinetobacter baumannii isolates rom the United Kingdom and the United States that wereassociated with repatriated casualties o the Iraq conict J Clin Microbiol 2006 July;44(7):2630–2634

26 Corbella X, et al. Epidemiological signicance o cutaneous, pharyngeal, and digestive tract colonization by multiresistant Acinetobacter baumannii in ICU patients J Hosp Inect 1997 Dec;37(4):287–295

27 Maragakis LL, Perl M Acinetobacter baumannii : epidemiology, antimicrobial resistance, and treatment options ClinInect Dis 2008 Apr 15;46(8):1254–1263

28 Villegas MV, Hartstein AI Acinetobacter outbreaks,1977-2000 Inect Control Hosp Epidemiol 2003 Apr;24(4):284–295

29 Gales AC, Jones RN, Forward KR, Linares J, Sader SH, Verhoe J Emerging importance o multidrug-resistant Acinetobacter species and Stentrophomonas maltophilia as pathogens in seriously ill patients: geographic patterns,epidemiological eatures and trends in the SENRY Antimicrobial Surveillance Program (1997–1999) Clin Inect Dis2001;32(Suppl 2):104–113 Available at: http://wwwjournalsuchicagoedu/doi/pd/101086/320183

30 Van Looveren M, Goossens H ARPAC Steering Group Antimicrobial resistance o Acinetobacter spp in Europe ClinMicrobiol Inect 2004 Aug;10(8):684–704

31 omaras AP, Dorsey CW, Edelmann RE, Actis LA Attachment to and biolm ormation on abiotic suraces by Acinetobacter baumannii : Involvement o a novel chaperone-usher pili assembly system Microbiology 2003 Dec;149(Pt 12):3473–84

32 Lee HW, Koh YM, Kim J, Lee JC, Lee YC, Seol SY, Cho D, Kim J Capacity o multidrug-resistant clinical isolates o Acinetobacter baumannii to orm biolm and adhere to epithelial cell suraces Clin Microbiol Inect 2008 Jan;14(1):49–54Epub 2007 Nov 13




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33 Whitman J, et al. Occupational transmission o Acinetobacter baumannii rom a United States serviceman wounded in Iraqto a health care worker Clin Inect Dis 2008 Aug 15;47(4):439–443

34 albot GH, Bradley J, Edwards JE Jr, Gilbert D, Scheld M, Bartlett JG Bad bugs need drugs: an update on thedevelopment pipeline rom the Antimicrobial Availability ask Force o the Inectious Diseases Society o America ClinInect Dis 2006 Mar 1;42(5):657–658 Epub 2005 Jan 25

35 Urban C, Sega-Maurer, Rahal JJ Considerations in control and treatment o nosocomial inections due to multidrug-resistant Acinetobacter baumannii Clin Inect Dis 2003 May 15;36(10):1268–1274 Epub 2003 May 1

36 Dorsey CW, omaras AP, Connerly PL, olmasky ME, Crosa JH, Actis LA 2004 Te siderophore-mediated ironacquisition systems o Acinetobacter baumannii ACC 19606 and Vibrio anguillarum 775 are structurally and unctionally related Microbiology 2004;150:3657–3667

37 Hsueh PR, eng LJ, Chen CY, Chen WH, Yu CJ, Ho SW, et al. Pandrug-resistant Acinetobacter baumannii causingnosocomial inections in a university hospital, aiwan Emerg Inect Dis 2002;8:827–832

38 Valencia R, Arroyo LA, Conde M, Aldana JM, orres MJ, Fernández-Cuenca F, Garnacho-Montero J, Cisneros JM,Ortíz C, Pachón J, Aznar, J Nosocomial outbreak o inection with pan-drug-resistant Acinetobacter baumannii in a tertiary care university hospital Inect Control Hosp Epidemiol 2009 Mar;30(3):257–263

39 Bonomo RA, Szabo D Mechanisms o Multidrug Resistance in Acinetobacter Species and Pseudomonas aeruginosa ClinInect Dis 2006;43:S49–S56




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Risk Assessment

Te purpose o a risk assessment is to evaluate the degree or magnitude o pathogen transmission or hospital

association inection risk within the acility1 Te completed risk assessment is used to develop acility andunit-specic strategies to reduce transmission and inection risk to patients/residents, sta and visitors Tisrequires consistent surveillance, ongoing monitoring, eective policies and protocols, and enhanced interventions

when appropriate

Key Concepts

• eriskassessmentisapartoftheinfectionpreventionandcontrolprogram’sassessmentofthepotentialor the spread o inection in the acility

• Riskassessmentisbasedonidentiedriskgroup/population/location,surveillancedataevaluation,prevalence calculations, and incidence rates

• eriskassessmentisreviewedandupdatedannually.

• eriskassessmentidentiestheappropriatedatacollectionforthefacility.

• Datacollectionisongoingsothattrendsintransmissionand/orinfectionsaremonitoredandinvestigatedpromptly

• Evaluationofriskassessmentdataislinkedtoclearlydenedoutcomeorprocessmeasuresforthemanagement o MDR Ab in the acility

Background

Perorming a risk assessment is an important rst step in determining organism prevalence, transmission level

and unique risk actors within a acility A acility’s inection prevention and control program must have a systemto monitor and investigate causes o healthcare-associated inection and community-acquired inection, as well as the manner o spread or transmission o inections within the acility An eective program will providetimely recognition and analysis o inection clusters and increases in incidence, identiy changes in prevalence o organisms, and conduct an annual risk assessment based on acility data2 Surveillance data collected to monitorand investigate inections in the acility provides the basis o the risk assessment

• eHICPACguideline“ManagementofMultidrug-ResistantOrganisms(MDRO)inHealthcareSettings, 2006”3 recommends monitoring trends in the incidence o a target MDRO Surveillance isconsistently perormed over time and surveillance data is evaluated using appropriate statistical methods

Tis assessment results in accurate data analysis that can demonstrate trends in resident acquisition o theseorganisms and in rates o inection

• eHICPACMDROguidelinealsorecommendsintensiedinterventionstopreventMDROtransmissionand inection when the incidence or prevalence o MDROs are not decreasing despite implementation o,and correct adherence to, the routine control measures Surveillance during a period o intensied inectionprevention interventions will demonstrate whether the strategies implemented are eective

Organism Risk—Location-specifc Factors

Acinetobacter geographic data related to risk groups or populations may be available rom local public healthdepartment surveillance or investigations Other sources o location or population specic actors may be oundin published data rom acilities o similar demographic and geographic characteristics When available, this data




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may help in identiying possible high-risk groups, populations or services o relevance to a given acility In someinstances, a acility will identiy a risk group while investigating a cluster o cases (or example, long-term ventilatorpatients admitted rom an LAC) to include in the risk assessment or this organism

Risk—Patient-specifc Factors

In their review o healthcare-associated Acinetobacter , Fournier and Richet identied the ollowing as risk actors or epidemic A. baumannii inections and/or colonizations: High APACHE II score, enteral eeding,prematurity, length o stay, contaminated parenteral solutions, blood products administration, stay in ward

with high Acinetobacter endemicity, high ward workload, previous antibiotic treatment (carbapenems,uoroquinolones, third generation cephalosporins, aminoglycosides, and procedures such as surgery, ventilation,and use o catheters4 Ongoing surveillance o sporadic, endemic, and outbreak situations should includeidentication o patients, and known or suspected risk actors Tese ndings are included in the Acinetobacter risk assessment

Perorming the Risk Assessment

Preparation or the risk assessment requires identiying and obtaining:

• Administrativesupport

• Facilitytechnicalsupport

• Resourcessuchaslaboratoryandpharmacycapabilities

• Infectionpreventionandcontrolstang(FTE)and/orhoursassignedtoinfectionpreventionandcontrol

• Publichealthsupportasapplicable

• Currentinfectionpreventionandcontrolinterventions(e.g.,handhygiene,contactprecautions,etc.)

• Measurementparametersforthecurrentinterventions

• Comprehensivelinelistofidentiedcolonizedandinfectedpatients

Te baseline determination o the risk or the acility may start with known high-risk populations, but the ongoingacility surveillance may detect other risk groups Tis inormation is used to validate and, when appropriate, toenhance the acility ’s surveillance prevention and control program Ater the baseline is determined, surveillanceand data evaluation is ongoing and provides the comparative basis or annual assessment, trends, and identicationo outbreaks

Developing Risk Assessment Outcomes and Measures

When the acility risk assessment shows that transmission and/or inection rates are increasing, additional inectionprevention interventions should be implemented Consequently, an important aspect o the inection preventionplan is the choice o appropriate and quantiable outcomes or goals Clear expectations o the inection preventionplan implementation must be expressed in measurable terms

Example o outcome measure:

• decreasehealthcare-associated Acinetobacter inections in the ventilator unit by X% in the next six months

Example o process measure:

• increasecompliancewithContactPrecautionsontheventilatorunittothe % level as measured by themonthly isolation compliance monitor




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Standardizing Data Collection

Data collection necessary or the outcome or process measurements must be clear and appropriate or the measure A sta team responsible or data collection needs to be well educated about the collection process Standardize theprocess so that data collection is consistent and accurate5

(See Surveillance section)

Taking Actions Based on Findings

Once the data is collected and evaluated, results o outcomes and process measures must be shared with key stakeholders Involve key stakeholders in identiying and implementing interventions when the results indicate a needto improve rates or stop an outbreak Once the interventions have been implemented, reanalyze to determine thesuccess o the interventions and, i needed, implement additional interventions to improve the process as necessary

Recommendations

Using the acility-specic Acinetobacter risk assessment:

• Establishbaselineprevalenceand,whenapplicable,incidenceratesforthewholefacilityorforaspecicunit using available data (clinical culture, history, screening culture)

• Identifyhigh-riskpopulationsand/orunitsbasedonincidencerates,localdemographicriskdata,orknownrisk actors rom scientically based evidence

• Evaluatedataovertimeforthefacilityand/orspecicunitstocharacterizeprevalenceortransmissionrates

• Identifyclustersintransmissioninriskpopulationsand/orunitstodetermineifenhancedinterventionsmay be appropriate

• Basedonsurveillanceandriskassessment,nalize,implement,andreanalyzebasedonaninterventionplan developed with key stakeholders

Risk Assessment Reerences1 Lee B, Montgomery OG, Marx J, Olmsted RN, Scheckler WE Recommended practices or surveillance: Association orProessionals in Inection Control and Epidemiology (APIC), Inc Am J Inect Control 2007;35(7):427–440

2 Arias,K , Soule,B eds Inection Prevention and Control Workbook, 2nd ed Joint Commission 2010

3 Siegel JD, Rhinehart E, Jackson M, Chiarello L Healthcare Inection Control Practices Advisory Committee Managemento multidrug-resistant organisms in healthcare settings, 2006 Am J Inect Control 2007 Dec;35(10 Suppl 2):S165–193

4 Fournier PE, Richet H Te Epidemiology and Control o Acinetobacter baumannii in Health Care Facilities Clin InectDis 2006 Mar 1;42(5):692–699

5 Cohen AL, et al. Recommendations or metrics or multidrug-resistant organisms in healthcare settings SHEA/HICPACPosition Paper Inect Control Hosp Epidemiol 2008;29(10):901-913 Available at: http://wwwjournalsuchicagoedu/doi/pd/101086/591741




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Surveillance

Te surveillance program or MDR Ab provides the denitions, measurements and data analysis needed to

evaluate the success o inection prevention and control programs and o any appropriate intensied interventionstaken to eliminate the transmission o MDR Ab

MDR Ab Surveillance Basics

Surveillance requires an organized process o collecting, tabulating and consolidating data Te collectedinormation is then evaluated, analyzed and reported to the appropriate persons, committees and/or governmentagencies as necessary Te elements o a routine surveillance program include:1,2

• Selectionofsurveillancemethodology(laboratoryresults,observationalmonitor,etc.)

• Denitionofthepopulation(s)tobestudied

• Choiceoftheoutcomeorprocesstomonitor

• Selectionoftimeperiod

• Selectionofsurveillancedenitions

• Selectionofdataelementstobecollected

• Choiceofmethodsfordataanalysis

• Developmentofmethodsfordatacollectionandmanagement

• Identicationofkeystakeholderstoreceivesurveillancereport

• Developmentofwrittensurveillanceplan

MDR Ab Surveillance Methodology is targeted (ocused) surveillance3

Population is the complement o patients in the healthcare setting(s) being surveyedIndicator/monitor is MDR Ab inection and colonization in the healthcare population

ime period must be sucient to accrue an adequate number o cases or a valid analysisSurveillance criteria include the case denition and denitions o the numerator and denominator or the ratecalculations

Surveillance criteria must be clear and consistent throughout the surveillance period Any change in denitions will aect the data by preventing accurate comparison to previously gathered data Examples o changes thatcould aect surveillance include instituting a new active surveillance culture program, closure or merging o apatient unit, and/or change in the sensitivity or specicity o MDR Ab testing methods Evaluation o MDR Ab

surveillance must take into account any changes that have occurred

MDR Ab Case Denition: Any patient/resident with a positive laboratory culture, or history o a positivelaboratory culture, or Multidrug-resistant Acinetobacter baumannii (See denitions)

Document each case in MDR Ab surveillance records Commonly used documentation methods include recordingo cases on the MDR Ab Line Listing (see Appendix A: Multidrug-resistant Acinetobacter baumannii SurveillanceLine Listing) or case entry in electronic surveillance sotware4




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Incidence Surveillance

Numerator: Number o newly identied patients with MDR Ab who meet the case denition

Sample case denition or surveillance in a unit: MDR Ab isolated rom culture obtained greater than or equal to 72 hours

ater admission to the unit, no history, and the patient was not incubating at the time o admission

Denominator: Te denominator can be derived rom average daily census or indicated timerame in the acility orunit being monitored, and is oten calculated per 1,000 patient days

# o new MDR Ab identied patients on the unit during the month # o patient days on the unit/month × 1,000

= incidence o healthcare-associated MDR Ab rate per 1,000 unit patient days

NOE: In an outpatient population or ambulatory setting, use the ollowing ormula:

# o new inections / 1,000 patient visits

Data elements or MDR Ab Surveillance

Data elements include demographic and personal inormation that will be useul in characterizing MDR Abcases4 (See Appendix A)

Tese elements include patient age and sex, admission date, location/room number, location rom which the patient was admitted (another hospital, LC healthcare setting, LAC, home, ambulatory setting, dialysis, etc), onset date

or rst positive culture date(s), culture source(s) and site(s), antibiotic susceptibility patterns and presence o knownMDR Ab risk actors as published in the literature

Other MDR Ab surveillance data elements to be collected may include procedures perormed, use o invasivedevices, underlying conditions and diseases, colonization status (i known), and clinical signs and symptoms o inection Inormation related to known or suspected MDR Ab risk actors or a certain geographic region ordemographic population (eg, hemodialysis patients, ventilator units, wound care units, etc) should also be collected

Methods o data collection may be real time or retrospective Most data collection is a unction o identication o MDR Ab rom clinical culture, MDR Ab surveillance culture, or PCR testing i available Additional data romenhanced surveillance includes pulsed eld gel electrophoresis (PFGE) inormation on isolates or other genotypic

laboratory analysis, and antimicrobial susceptibility testing per isolate as appropriate per antibiogram analyses

Surveillance Data Management

Maintain a line listing or other data management system or all patients identied with MDR Ab Te line listingshould contain all o the elements listed above in the Data Elements section5

Essential Notifcation o positive MDR Ab rom Culture or History

“Flagging” o MDR Ab-positive patients is an important component o MDR Ab surveillance programs, and isa tier 1 surveillance recommendation in the HICPAC 2006 MDRO guideline Laboratories should have an alert




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notication methodology or MDR Ab that includes the IP as well as the patient’s healthcare provider(s) Animmediate alert o MDR Ab history is essential at time o admission and at the time o transer to another patientunit, another service or a dierent healthcare setting

Facilities using electronic medical records may have programs that automatically ag MDR Ab patients on

admission Facilities that do not have access to an electronic agging system should develop an admission processeature that will identiy a patient with an MDR Ab history Tere should also be a transer communication systemthat noties transerring acilities o positive MDR Ab patients/residents Some hospitals and long-term careacilities have had success with a notication box on a transer sheet that notes MDROs, including MDR Ab Otheracilities have a “phone tree” to acilitate phone/e-mail communication between inection prevention departments

MDR Ab Reports

Te IP should collaborate with the laboratory regarding MDR Ab result notication6 Laboratory reports o MDR Ab must clearly identiy the isolate as “multidrug-resistant” in addition to including a susceptibility report as appropriate to the culture methodology Communication regarding positive cultures may also includepredetermined comments regarding the inection prevention intervention to use or patients with MDR Ab, andthe instructions or notiying the clinical unit or medical provider

Surveillance Reerences1 Lee B, Montgomery OG, Marx J, Olmsted RN, Scheckler WE Recommended practices or surveillance: Association orProessionals in Inection Control and Epidemiology (APIC), Inc Am J Inect Control 2007;35(7):427–440

2 Arias, Kathleen Surveillance APIC ext o Inection Control and Epidemiology. 3rd ed. Washington, DC: Association orProessionals in Inection Control and Epidemiology, Inc 2009: Chapter 3 1–17

3 Perl, , Pottinger, J Herwalt, L Basics o Surveillance: An Overview Lautenbach,E Woeltje, K eds Practical Handbook or Healthcare Epidemiologists 2nd ed Toroare, NJ Slack2004:45–66

4 Siegel JD, Rhinehart E, Jackson M, Linda C Healthcare Inection Control Practices Advisory Committee Managemento multidrug-resistant organisms in healthcare settings, 2006 Available online at wwwcdcgov/ncidod/dhqp/pd/ar/mdroGuideline2006pd

5 Cohen AL, et al. Recommendations or metrics or multidrug-resistant organisms in healthcare settings SHEA/HICPACPosition Paper Inect Control Hosp Epidemiol 2008; 29(10):901–913 Available at: http://wwwjournalsuchicagoedu/doi/pd/101086/591741

6 Arias, Kathleen, eds Surveillance Programs in Healthcare Settings 2nd ed Washington,DC APIC, 2009




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Antibiotic Stewardship and Antibiograms

Key Concepts

• Antibioticuse,whetherclinicallyappropriateornot,unavoidablyintroducesaselectivesurvivaladvantageto non-susceptible strains o microbes and leads to development/expression o antibiotic resistance

• epaceofdevelopmentofnewantibioticsisnotkeepingupwiththepaceofemergenceofantibiotic-resistant strains

• Amultifacetedantibioticstewardshipinitiativeisseenasacontributoryelementintheghttopreventemergence o antibiotic resistant strains and to preserve existing therapeutic options or treatinginections

• AntibiogramsareusedtoassesschangesinmultidrugresistanceofMDRAbisolatesfromspecicacilities or units, and to provide data or antimicrobial stewardship initiatives

Overview

Like all living entities, microbes continuously ace challenges to their own survival as conditions in theirenvironment or ecosystem change Tey are constantly subjected to survival selection pressure in a true Darwiniansense, and in order to survive, they acquire, develop or evolve specic coping mechanisms that give them a selectiveadvantage vis-a-vis their competition

Unlike many living entities; however, microbes have an evolutionary advantage, in that their “lie cycle” isoten very short and they have a seemingly innite number o opportunities or even a single advantageousgenetic mutation to occur In addition, microbes have oten been ound capable o acquiring or sharing extra-chromosomal genetic material, including antibiotic-resistance actors, between related and unrelated species

through a variety o mechanisms Tis genetic “nimbleness” enables microbes to respond very quickly to changesin their environment that adversely aect their survival In the context o healthcare settings and patient care ingeneral, the presence o inection or colonization, ollowed by antibiotic therapy, represents a signicant changein the ecosystem that can trigger the development or emergence o resistant strains in response Tus, the use o antibiotics may have certain unintended consequences, and decisions regarding the use o antibiotics should beapproached with consideration o both the benet to the patient and the potential adverse consequences

Experts in inectious diseases, clinical pharmacy, inection prevention and clinical microbiology have longpromoted eective antibiotic stewardship as one tool to prevent or delay the emergence o antibiotic-resistantorganisms Te key elements or strategies o an antibiotic stewardship program were described by Fishman1 and aresummarized below:

Elements o Antibiotic Stewardship

Education

Physician/prescriber education regarding the compelling rationale or antibiotic stewardship and the variouselements o the stewardship program as they apply to antibiotic use is essential to the success o the programPrescriber education can take place through both ormal and inormal channels and can include internal iers, suchas a “Pharmacy Newsletter”, direct one-on-one consultative sessions, presentations at section meetings and thedevelopment and dissemination o written prescribing guidelines




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Formulary Restriction

Use o a closed ormulary, that is, one in which only certain drugs are available or physicians to prescribe, isa highly eective tool in antibiotic stewardship Formulary choices should be made in consideration o localantibiotic resistance trends in addition to site and pathogen-specic incidence data Tese trends should becontinuously monitored and recorded in an antibiogram, and the ormulary should be periodically adjustedas conditions warrant However, even a restricted ormulary will include broad spectrum antibiotics with aconcomitant potential or their misuse, especially in cases o empiric treatment awaiting culture and sensitivity results Tere should be a mechanism in place to acilitate reconciliation o empiric therapy with subsequentculture and sensitivity results, and opportunities to switch to a narrower spectrum antibiotic should be promoted

Prior Approval Programs

Tese programs require the prescribing physician to obtain some orm o approval or permission beore theantibiotic will be dispensed Tis approach may require a verbal communication to justiy a proposed treatment, orit may involve pre-printed order orms, automatic stop orders, etc Prior approval programs are the most restrictiveo control systems as well as one o the more cost eective approaches to antibiotic stewardship In its most

restrictive orm, expert individuals who are amiliar with the nuances o minimum inhibitory concentration (MIC)interpretation, the pathogens and drug tissue availability and pharmacokinetics serve as “gatekeepers” Te benetso prior approval programs include better control o antibiotic costs2 and improved patient outcomes3

Streamlining

Tis term reers to the automatic switching rom broad-spectrum empiric therapy to narrower-spectrum agents when the culture and sensitivity results become available With the growing integration o clinical inormationsystems and data mining tools, pharmacy and laboratory data can oten be merged and opportunities to adjustantibiotics, eliminate redundant therapies and change intravenous (IV) to oral (PO) administration routes canoccur without active eort on the part o the clinician

Antibiotic Cycling

Tis is the practice o rotating two or more classes o ormulary drugs on a regular basis Basically, by regularly altering the antibiotic selection pressure; the hope is to prevent microbes rom having sucient “incentive” and timeto become resistant Alternatively, in areas where resistance is already a problem, rotating antibiotics hypothetically removes the selective advantage the resistant organisms possess when compared to non-resistant strains Te moretreatable, non-resistant strains will theoretically outdo the resistant strains While there are some studies that tend tosupport antibiotic cycling as a means to control/slow the emergence o resistance, 4,5,6 this still remains controversial,as at least two mathematical models have suggested that antibiotic cycling is either ineective7 or may in act lead toincreased resistance8 Accordingly, i antibiotic cycling is used as a part o an overall antibiotic stewardship program,resistance data should be careully monitored to acilitate early detection o undesired trends Cycling is not routinely

recommended (see Guideline Recommendations or Antimicrobial Stewardship Programs)

Automated (Computer-assisted) Prescribing

Te hospital’s computer systems provide comprehensive inormation (and advice) to the clinician withrespect to antibiotic selection and dosing by taking into consideration the patient’s laboratory values(eg, liver or renal unction), their existing drug prescription prole and culture and sensitivity results 9

Tis process requires data extraction and collation rom the various clinical data bases and the application o pre-determined decision algorithms to support the recommendations As these expert clinical systems evolve,computer-assisted prescribing may become more heavily relied upon by clinicians and, as a consequence, bringabout less variation in antibiotic prescribing patterns




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Guideline Recommendations or Antimicrobial Stewardship Programs

Te 2007 guideline rom the Inectious Diseases Society o America (IDSA) and the Society or HealthcareEpidemiology o America (SHEA) recommends two core strategies or hospital antimicrobial stewardship programs:

• Prospectiveauditofantimicrobialusewithdirectinteractionandfeedbacktotheprescribingphysician

• Formularyrestrictionandpreauthorizationrequirementscanleadto,signicantreductionsinantimicrobialuse and may be benecial as part o a response to a healthcare associated outbreak (B-III)

In addition, the guide proposes positive impact rom any o a number o supplementary strategies, includingeducation related to clinical treatment strategies, streamlining or de-escalating o empiric antibiotic therapy basedon culture results, evidence-based practice guidelines derived rom local organism-specic resistance patterns,antimicrobial order orms with automatic stops requiring physician justication or continuation, computer-assistedprograms Te guide concludes that there is insucient evidence to routinely recommend antibiotic cycling orcombination therapy to prevent resistance at the present time

MDR Ab Management and Antimicrobial Stewardship

It is unclear whether antibiotic control measures and stewardship can contribute directly to the elimination o an outbreak o MDROs or MDR-Ab However, based on the contribution that the use o extended spectrumcephalosporins and quinolones have had on the development o antibiotic resistance in Acinetobacter baumannii 10,and the demonstrated control o Clostridium dicile inection achieved by restricting antibiotic usage11 it isprudent to develop an antimicrobial stewardship plan in healthcare acilities It is the normal role o the Pharmacy and Terapeutics Committee to establish the acility ormulary, develop treatment protocols, and monitor drugutilization In conjunction with the microbiology laboratory, inectious disease experts, and inection preventionists,a careul monitor or trends in increasing resistance in microbes may prevent or at least delay the rapiddevelopment o multi-drug resistance thus extending the useul lie o currently available antibiotics

Antibiogram: Analysis and Presentation o Cumulative AntimicrobialSusceptibility Test Data

Susceptibility (Sensitivity/Resistance) Patterns

A reported susceptibility pattern or each MDR Ab isolate is essential It should be readily and quickly accessibleby physicians and caregivers Not only are these data essential or patient treatment regimens, but they are also

valuable in MDR Ab surveillance and in the epidemiologic investigation o outbreaks

Antibiogram

Unlike the bacterial susceptibility o a single isolate, antibiograms are used to track changing sensitivity patternsand are based on collated susceptibility data rom many isolates derived rom patient clinical cultures Compilingan antibiogram is usually done by the microbiology laboratory using data accrued rom clinical culture in a acility or rom a specic unit For the A.baumannii antibiogram, susceptibility results rom multiple (minimum o 30) A.baumannii isolates are compiled during a specied timerame (usually one year) and updated at least annually Teresulting antibiogram reects the antibiotic sensitivity patterns or A. baumannii within that acility or unit

Antibiograms can be used by physicians to guide decisions regarding appropriate empiric antimicrobial treatmentchoices at times when a susceptibility report is not yet available Just as important, they can be used by the inectionpreventionist to assess changes in A. baumannii antimicrobial resistance specic to the acility and/or to units, andprovide data or antimicrobial stewardship initiatives




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Te Clinical and Laboratory Standards Institute (CLSI) is a recognized authority in quality assurance o laboratory testing Antibiograms must ollow the standards that have been established by CLSI and published inCLSI M39-A212

Reerences1 Fishman N Antibiotic Stewardship Am J Inect Control 2006;34:S55–63

2 John JF, Fishman NO Programmatic role o the inectious diseases physician in controlling antimicrobial costs in thehospital Clin Inect Dis 1997;24:471-485

3 Frank MO, Batteiger BE, Sorensen SJ, et al Decrease in expenditures and selected nosocomial inections ollowingimplementation o an antimicrobial-prescribing improvement program Clin Perorm Qual Health Care 1997;5:180–188

4 Gerding DN, Larson A Aminoglycoside resistance in gram-negative bacilli during increased amikacin use Comparisono experience in 14 United States hospitals with experience in the Minnesota Veterans Administration Medical Center Am J

Med 1985;79:1–7

5 Young EJ, Sewell CM, Coza MA, Clarridge JE Antibiotic resistance patterns during aminoglycoside restriction Am J Med Sci 1985;290:223–227

6 Raymond DP, Pelletier SJ, Crabtree D, et al Impact o a rotating empiric antibiotic schedule on inectious mortality in anintensive care unit Crit Care Med 2001;29:1101–1108

7 Bergstrom Lo M, Lipsitch M Ecological theory suggests that antimicrobial cycling will not reduce antibiotic resistance inhospitals Proc Natl Acad Sci USA 2004;101:13285–90

8 Magee J Te resistance ratchet: theoretical implementations o cyclic selection pressure J Antimicrobial Chemother 2005;56:427-30

9 McGregor JC, Weekes E, Forrest GN, Standiord HC, Perencevich EN, Furuno JP, Harris AD Impact o a ComputerizedClinical Decision Support System on Reducing Inappropriate Antimicrobial Use: a Randomized Control rial J Am Med

Inorm Assoc. 2006 Jul–Aug;13(4):378–84

10 Fournier PE, Richet H Te Epidemiology and Control o Acinetobacter baumannii in Health Care Facilities Clinical Inectious Diseases 2006;42:692–9

11 McNulty C, Logan M Donald IP, et al Successul control o Clostridium dicile inection in an elderly care unit throughuse o a restrictive antibiotic policy J Antimicrobial Chemother 1997;40:707–11

12 Clinical and Laboratory Standards Institute Analysis and Presentation o Cumulative Antimicrobial Susceptibility estData: Approved Guideline, 2nd ed CLSI document M39-A2 Reston, VA: Clinical and Laboratory Standards Institute; 2005




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Standard and Transmission-based Precautions

Te main goal o MDR Ab inection prevention and management program is the prevention o the transmission

o MDR Ab in a healthcare setting Using ransmission-based (Contact) Precautions in addition to StandardPrecautions is an important component o the inection prevention intervention to reduce the risk o MDR Abtransmission within the healthcare setting

Background

In 1996, the Centers or Disease Control and Prevention (CDC) developed an approach to reduce transmissiono microorganisms Tis approach—named “Standard Precautions and ransmission-based Precautions”—wasbased on elements o the previously established “Universal Precautions (UP)” and “Body Substance Isolation(BSI)” guidelines, but added an emphasis on an inection’s mode o transmission, to enhance the isolation processStandard Precautions instruct healthcare workers to protect themselves against all body uids except sweat by

use o PPE Standard Precautions are always used, and ransmission-based Precautions are used as a supplementto address specic organisms Te HICPAC 2006 multidrug-resistant organism (MDRO) guideline1 and theHICPAC 20072 guideline or isolation precautions continue to promote the use o ransmission-based Precautionsas an appropriate approach to MDRO control

Key Concepts

• Pathogenicorganismsexistinreservoirswithinahealthcarecaresetting.

• Pathogenicorganismshavedierentmodesoftransmission.

• TechniquesthatimpacttransmissionofMDRAbmustbeimplementedinthehealthcaresetting.

• CompliancewithStandardPrecautionsandTransmission-basedPrecautionsbreaksthechainofinfection

by interrupting transmission o pathogenic organisms, including MDR Ab

Modes o MDR Ab Transmission

Te most common mechanism o transmission attributed to MDR Ab is contact transmission Contacttransmission is divided into two subgroups, direct and indirect3

Direct transmission can occur when MDR Ab is transerred rom an MDR Ab colonized or inected person toanother person without a contaminated intermediate object or person

Indirect transmission is the transer o an inectious agent through a contaminated intermediate object or person

In healthcare, transmission is most commonly associated with MDR Ab contaminated skin, body uids,equipment, or environment Although anything that contacts a contaminated patient or object can be the source o transmission, the most common vehicles o MDR Ab spread in healthcare settings are the hands o healthcare staf.

A. baumannii outbreaks oten involve environmental contamination o items such as suctioning equipment, ventilators, shower trolleys, washbasins, inusion pumps, pillows and mattresses, bedrails, sinks, resuscitationequipment, bedside tables, hygroscopic bandages, and stainless steel carts4




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Hand Hygiene

Hand hygiene is the keystone o any inection prevention and control program, and plays an integral role inreducing the transmission and occurrence o inection All healthcare settings must have a comprehensive handhygiene program and policies and procedures in place Te importance o hand hygiene in the elimination o MDR

Ab transmission should be greatly stressed to all hospital healthcare sta It is strongly recommended that the IPreview the ollowing documents or inormation to create a comprehensive hand hygiene program:

• HICPAC“GuidelineforHandHygieneinHealthcareSettings,2002.”5

• WorldHealthOrganization(2009)“WHOGuidelinesonHandHygieneinHealthCare.”eguidelineis meant to be used by healthcare acilities, managers, and developers o policies or institutions TeHICPAC “Guideline or Hand Hygiene in Healthcare Settings, 2002” was used as a basis or thisdocument, with the addition o new topics and inormation3

• eJointCommissionauthoredamonographentitled“ Measuring Hand Hygiene Adherence: Overcoming the Challenges.” In collaboration with inection prevention organizations, including APIC, hand hygieneguidelines and strategies were reviewed to determine approaches or implementing and measuringadherence to hand hygiene compliance best practice Te monograph oers inormation on the issues

involved in hand hygiene observation, presents examples o successul programs, and oers realisticsolutions or improvement activities6

Major components o a hand hygiene program5

1 Implement a hand hygiene program including all levels o healthcare providers and other patient contact workers7,8,9

2 Educate visitors to wash their hands, or use an alcohol-based hand rub on entering and leaving the room3 (See Appendix B: Sae Donning and Removal o Personal Protective Equipment)

3 Wear gloves or all contact with blood, body uids and moist body suraces

•

Remove gloves ater caring or patient, and use hand hygiene• Change gloves when moving rom a contaminated site to a clean site on the same patient

• Remove gloves and use hand hygiene beore care o the next patient

4 Always perorm hand hygiene ater removing gloves3

5 Perorm hand hygiene beore and ater contact with a patient

6 Perorm hand hygiene beore and ater contact with the patient’s environment

7 Monitor compliance with hand hygiene or all levels o sta Provide eedback o compliance rates based onobservations or volume o hand hygiene products used8,9,10,11

8 Hold healthcare care providers and administrators accountable or implementing a culture that supportsand promotes appropriate hand hygiene practices3,12,13,14

9 Gloves3,15 should be worn to protect against contact with body uids

• HCWs should know how to properly don and remove gloves

• Gloves are removed and hand hygiene perormed ater caring or one patient beore caring oranother patient

• Gloves are changed when moving rom a more contaminated area o a patient’s body to a lesscontaminated area

• Gloves are not worn in the hall

• Gloves are removed and hand hygiene perormed i gloves become torn or punctured




29

Tere is no standardized method or monitoring hand hygiene compliance Tere are many good resources thatprovide tools or orms or monitoring o hand hygiene Tese orms can be customized or the acility and basedon the monitoring system It is important to monitor sta or hand hygiene compliance, post signs and reminders,have convenient hand hygiene stations and supplies available, and provide educational venues14,15,16

Beore touching a patient1 Beore clean/aseptic procedures

2 Ater body uid exposure/risk

3 Ater touching a patient

4 Ater touching patient surroundings

Issues Associated with Hand Hygiene

Artifcial Fingernails

Several studies have been done on the harboring o pathogens by articial nails Tere is evidence that wearing

articial nails can result in carriage o Gram-negative organisms and yeast17,18 It is recommended that personsgiving patient care not wear articial nails or extenders Natural nails should be kept short, approximately ¼ inch long5

Jewelry

Studies have shown increased presence o colonization o organisms under rings as compared to other areas o thehand without rings Rings with rough suraces may remain dirty in crevasses ater washing hands; rings may teargloves and may possibly injure patients during care Te consensus recommendation to healthcare settings is tostrongly discourage the wearing o rings and jewelry when giving patient care19

Patient Placement and Contact PrecautionsIn LAC and LCF settings, a patient with MDR Ab should be placed in a private room I this option isnot available, the patient should be cohorted with another patient inected with the same organism I neithero these options are available, the patient should be placed in a room with another patient who is consideredlow risk or acquisition o MDR Ab Examples would be patients with no wounds, no invasive devices, notimmunocompromised, etc1

• InhospitalsandLTACfacilities,ContactPrecautionsareusedforallpatientsidentiedashavingMDR Ab inection or colonization

• InLTCFs,theindividualpatient’sclinicalsituationandtheincidenceofMDRAbinthefacilityshouldbeconsidered when deciding to implement or modiy Contact Precautions

• Inambulatorycaresettingsandhomecare,useStandardPrecautions.

1

Basics o Contact Precautions

(See Appendix B)

• Donglovesbeforeorimmediatelyuponentrytoroom.Changeglovesaftercontactwithinfectiousmaterial

• Changegloveswhenmovingfromacontaminatedbodysitetoacleanbodysite.

• Removeglovesanddecontaminatehandsbeforeleavingapatient’sroom.






31

Reerences1 Siegel JD, Rhinehart E, Jackson M, Chiarello L Healthcare Inection Control Practices Advisory CommitteeManagement o multidrug-resistant organisms in healthcare settings, 2006 Am J Inect Control 2007 Dec;35(10 Suppl 2):S165–193

2 Siegel JD, Rhinehart E, Jackson M, Chiarello L Healthcare Inection Control Practices Advisory Committee 2007Guideline or isolation precautions: preventing transmission o inectious agents in health care settings Am J Inect Control2007 Dec;35(10 Suppl 2):S65–164

3 WHO Guidelines on Hand Hygiene in Health Care Geneva: World Health Organization 2009

4 Fournier PE, Richet H Te epidemiology and control o Acinetobacter baumannii in health care acilities Clin Inect Dis2006 Mar 1;42(5):692–699

5 HICPAC/SHEA/APIC/IDSA Hand Hygiene ask Force Guideline or Hand Hygiene in Health-Care Settings:Recommendations o the Healthcare Inection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene ask Force MMWR Recomm Rep 2002;51(RR16):1–45 Available at: http://wwwcdcgov/ncidod/

dhqp/g1_handhygienehtml

6 Measuring hand hygiene adherence: overcoming the challenges Te Joint Commission Observing Adherence to HandHygiene Guidelines Chapter 3:21

7 Gordin FM, Schultz ME, Huber RA, Gill JA Reduction in nosocomial transmission o drug-resistant bacteria aterintroduction o an alcohol-based hand rub Inect Control Hosp Epidemiol 2005;26:650–653

8 MacDonald A, Dinah F, MacKenzie D, Wilson A Perormance eedback o hand hygiene, using alcohol gel as theskin decontaminant, reduces the number o inpatients newly aected by MRSA and antibiotic costs J Hosp Inect2004;56:56–63

9 Pittet D, Allegranzi B, Sax H, et al. Evidence-based model or hand transmission during patient care and the role o improved practices Lancet Inect Dis 2006;6:641–652

10 McGuckin M, aylor A, Martin V, Porten L, Salcido R Evaluation o a patient education model or increasing handhygiene compliance in an inpatient rehabilitation unit Am J Inect Control 2004;32:235–238

11 McGuckin M, Waterman R, Storr J, et al. Evaluation o a patient-empowering hand hygiene programme in the UK JHosp Inect 2001;48:222–227

12 Goldmann D System ailure versus personal accountability—the case or clean hands N Engl J Med 2006;355:121–123

13 Gawande A On Washing Hands N Engl J Med 2004;350:1283–1286

14 Pittet D, Hugonnet S, Harbarth S, et al. Eectiveness o a hospital-wide programme to improve compliance with handhygiene Lancet 2000;356:1307–1312

15 Institute or Healthcare Improvement How-to guide: improving hand hygiene A guide or improving practices amonghealth care workers Cambridge, MA: Institute or Healthcare Improvement 2006 Available at: http://wwwihiorg/NR/rdonlyres/E12206F9-6A81-4520-B92F-4BCB844133C2/3266/HandHygieneHowtoGuidepd




32

16 University o Geneva Hospitals, Geneva Switzerland Hand Hygiene Campaign Swiss-NOSO (Nosokomiale Inektionenund Spitalhygiene) 2006 Available at: http://wwwhopisaech/nexthtml

17 Pottinger J, Burns S, Manske C Bacterial carriage by articial versus natural nails Am J Inect Control 1989;17:340–344

18 Hedderwick SA, et al. Pathogenic organisms associated with articial ngernails worn by health care workers InectControl Hosp Epidemiol 2000;21:505–509

19 WHO Guidelines on Hand Hygiene in Health Care Patient Saety Geneva: World Health Organization Practical issuesand potential barriers to optimal hand hygiene practices Chapter 23:132




33

The Environment

Environmental and Equipment Cleaning and Disinection

A. baumannii has emerged as an important healthcare-associated pathogen1 Hospitals have experienced outbreaksand, in some hospital settings, this organism has become endemic Environmental contamination has a recognizedrole in the transmission o A. baumannii inections In the event o an outbreak, environmental testing can beperormed as a method to determine the spread or persistence o the organism and also the ecacy o the cleaningagent esting o the environment requires standardized methods o specimen collection and laboratory testingto acilitate identication o A. baumannii in the environment Acinetobacter species are able to grow at varioustemperatures and pH conditions, which allows them to persist in either moist or dry conditions in the hospitalhealthcare environment

Studies have shown that A. baumannii strains could be isolated rom a hospital bed rail or nine days ater

the discharge o an inected patient2

In another study, Wendt et al showed that A. baumannii strains isolatedrom dry sources had better survival rates than strains isolated rom wet sources3 Acinetobacter spp. havebeen identied on some inanimate hospital objects or up to ve months Ventilators, suctioning equipment,mattresses, sinks and portable radiology equipment are some o the more common sources that remain colonizedor extended periods

Environmental Services

Cleaning and disinection protocols are eective tools or providing and maintaining consistent management o environmental contamination with antimicrobial resistant pathogens All personnel directly or indirectly involvedin patient care, including environmental services, must be aware o multidrug resistant organisms, including MDR

Ab and its role in contamination o the environment

An environmental cleaning and disinection plan includes policies or protocols that speciy appropriate use o cleaning and disinecting products Te plan must speciy that environmental suraces be cleaned with the properdilution and amount o the standard acility-approved disinecting agents, with compliance to contact timesProtocols should be in place or rooms o patients who are placed in isolation on precautions, with daily cleaning,terminal cleaning and enhanced cleaning during outbreak situations4

Proper cleaning and/or disinecting o electronic equipment is necessary Personal care electronic equipmentand multi-use electronic items, including any equipment used during delivery o patient care and mobile devicesthat are moved in and out o residents’ rooms, may have special manuacturer instructions or meeting cleaningand disinection requirements raining sta to careully ollow manuacturer instructions is an important saety component o an eective cleaning and disinection process and protection o equipment5

An environmental cleaning and disinection plan should include policies or protocols that speciy a denedschedule o environmental cleaning Daily cleaning o patient rooms by trained environmental sta is anessential policy component Healthcare acilities can assign dedicated environmental sta to targeted patientcare areas to provide consistency o appropriate cleaning and disinection procedures Monitoring o sta,education and reinorcement o training is required to maintain appropriate cleaning and disinection o theenvironment




34

A acility or specic units in a acility that are experiencing high or increasing inection rates should considerincreasing the requency o cleaning and disinection It is important to stress that high-touch areas undergoeective cleaning and disinection4 High-touch areas include, but are not limited to, bed rails, light switches,over-bed tables, bedside commodes, bathroom xtures in the resident’s room, doorknobs, any equipment inthe immediate area o the resident, and any equipment that is multi-use between residents In addition, it is

important to make sure the oor is cleaned completely, including the moving o equipment to allow or access toall suraces

Equipment cleaning that is not perormed by environmental services sta must be clearly delegated to theappropriate healthcare sta per acility protocols For instance, respiratory therapists may be responsible orcleaning respiratory equipment Facility cleaning and disinection policy or protocol will address the specic patientcare sta responsibility or disinection o equipment that may be taken rom one resident to another

Environmental Cleaning

Environmental cleaning and equipment cleaning/disinection done eectively will help reduce the risk o

transmission o MDR Ab

6

Properly trained environmental services sta, the use o approved disinectants/germicides, eective protocols and/or checklists are key elements in the management o MDR Ab

• Properuseofcleaninganddisinfectionproducts(EPA-registereddisinfectant)requiresthatproductmanuacturer’s instructions and contact times to be careully observed I wipes are used, sta should beaware that a separate wipe is needed between areas so that cross-transmission is prevented

• Allpersonnelmusttakeresponsibilityforensuringthattheenvironmentandequipmentisappropriatelycleaned and disinected in between patient interactions Communicating this to the sta is important tosuccessully control the spread o MDR Ab All sta, including nurses, respiratory therapists, radiology techs and phlebotomists, among others, will need education regarding the appropriate cleaning o critical equipment used or patients Manuacturers’ recommendations should be ollowed to avoid any damage to equipment

• Dedicatenon-criticalmedicalequipmenttotheMDRAbpatient.

Environmental cleaning should be done daily or more requently, depending on the situation, and include a ocuson high-touch areas (See Appendix D: Daily High ouch Cleaning Checklist)

Outbreak Situation—Intensiy Environmental Cleaning Eorts

• Ensuretheuseofpatient-dedicatednon-criticalequipment.

• Reinforceenvironmentalstacleaningprocedures.

• Considerplacingdedicatedcleaningstatooutbreakareas.

• Monitorcleaningperformancebyenvironmentalstausingobservationand/oruseofuorescentstaining.(Consider adenosine triphosphate bioluminescense assay as a means to monitor cleaning eectiveness7, 8)

• Ensureconsistentcleaninganddisinfectionofhigh-touchareas(checklistscanbeusedtoguaranteeconsistency)

• PerformenvironmentalculturesiftheenvironmentisimplicatedintransmissionoftheMDRAb.

• Vacate and perorm intensive cleaning o the unit i transmission o the organism continues and theenvironment is suspect,

• Considerhypochloritesolutionuse(eectiveincontrollingoutbreaksituations).




35

Terminal Cleaning

Tere is no inormation in the HICPAC Isolation (2007) or MDRO (2006) guidelines regarding terminalcleaning o rooms ater Contact Precautions are discontinued erminal cleaning has been adopted by someacilities as a mechanism to ensure successul removal o organisms rom the environment between patients For

those acilities choosing to adopt terminal cleaning, guidance in the 1996 Guidelines or Isolation Precautions inHospitals9, which preceded the 2007 isolation guide, specically addressed the concept o a terminal cleaning asollows: “Te room, or cubicle, and bedside equipment o patients on ransmission-based Precautions are cleanedusing the same procedures used or patients on Standard Precautions, unless the inecting microorganism(s)and the amount o environmental contamination indicates special cleaning In addition to thorough cleaning,adequate disinection o bedside equipment and environmental suraces (eg, bedrails, bedside tables, carts,commodes, doorknobs, aucet handles) is indicated or certain pathogens, which can survive in the inanimateenvironment or prolonged periods o time”

erminal cleaning is also addressed by the American Society or Healthcare Environmental Services (ASHES)4 inits publications

• Hypochloritesolutionshavebeenreportedaseectiveincontrollingoutbreaksituations.

Monitoring Environmental Cleaning

Use o a monitoring tool to assess the cleaning eectiveness o environmental sta will ensure consistency incleaning and disinection procedures Monitoring should include an assessment o the cleaning o high-touchareas10 and suraces in close proximity to the patient, including bedrails, nurse call lights, carts, doorknobs, bedsidecommodes, bedside tables and aucet handles

Te use o a standardized environmental cleaning checklist11 may increase ecacy o cleaning A checklist can alsoserve as a training tool or new sta, and as the basis or a cleaning monitor When cleaning monitors indicateinadequacy o cleaning on a unit or throughout a acility, an enhanced or updated checklist that addresses theinadequacies should be implemented as an intervention to improve cleaning outcomes

A Suggested Technique or Monitoring and Improving Room/Area Cleaning

A new and dierent approach to monitoring was tried by 3 hospitals to evaluate cleaning12 Gel containingmaterial that uoresces under a black light can be applied to targeted high-touch sites Sites can be chosen basedon the CDC’s recommendations or improved cleaning o high-touch areas that are requently contaminated withhospital-associated pathogens Apply the gel beore routine cleaning has been completed or terminal cleaning hasbeen completed, and mark the selected suraces Ater the next cleaning, shine a black light on the marked suracesto determine i the high-touch areas have been cleaned Use o this technique allows the observer to determine

whether an attempt has been made to suciently clean the surace Te observer can determine this by noting

which o the ollowing conditions exists:

1 Gel remains with no evidence o removal

2 Gel partially remains with evidence o attempted removal

3 Gel has been completely removed

Educational programs, including eedback o monitoring results, should be provided to environmental cleaningsta It is important that members o the environmental cleaning sta are recognized as active participants andcontributors to a clean and sae patient care environment




36

Environmental Inormation Oering Possibilities to be Considered or Cleaning andInvestigation in Outbreak Situations:

Patient Care Area Curtains

Patient care area curtains (curtains around the patient’s bed) are addressed here due to the act they may becomecontaminated and possibly become a source o pathogen transmission13 Curtains are requently touched by patients, visitors and healthcare workers Tey are requently touched by persons wearing contaminated glovesPeople may not perorm hand hygiene ater touching curtains In many healthcare institutions, the curtains arenot cleaned or changed on a consistent basis Curtains contaminated by carbapenem-resistant A. baumannii andMRSA have been ound in recent studies, although the contribution to transmission o pathogens is not known14

Mattresses and Pillows

Standard mattresses and pillows can become contaminated with body substances during patient care i the coverso these items become compromised Mattress covers should be replaced when torn, and mattresses should bereplaced i they are visibly stained and/or torn Wet mattresses, in particular, can be a substantial environmental

source o microorganisms Inections and colonizations caused by Acinetobacter spp, MRSA, and Pseudomonas aeruginosa have been described, especially among burn patients All mattresses that become damp or wet should beremoved Pads and covers should be cleaned and disinected between patients Pillows and their covers should beeasily cleanable, preerably in a hot water laundry cycle9

Cleaning Wipes/Disinectant Cloths

It is essential, as with all cleaning products, to know what a product can do and how to properly use it A study published in 2009 examined the use o two wipes available to hospitals, and their eectiveness against bothmethicillin-resistant and methicillin-susceptible Staphylococcus aureus rom contaminated suraces15 Sodiumhypochlorite based wipes, when used according to manuacturer’s instructions, are eective against Ab16 It wasound the wipes could reduce the bacteria rom a surace; however, there was the potential or spreading the bacteria

by continuing to use the same wipe on dierent suraces Te recommendation rom this study: “We recommendthat a wipe not be used on more than one surace, that it be used only on a small area, and that it be discardedimmediately ater use, to reduce the risk o microbial spread—a one-wipe, one-application per surace policy”13

Dry Environment

Experiments were done to test the ability o Acinetobacter to survive in a dry environment It was ound theorganism could survive our months or more in dry conditions It is concluded by the authors that in prolongedoutbreaks, the patient’s environment may play a role, and intense cleaning and disinection may be needed to endthe outbreak3

Dust Recent studies have shown that MDR Ab is able to survive in dry conditions Dust contaminated with MDR

Ab can become a possible source or transmission o this organism Investigations into two outbreaks in an acutecare acility were, in time, traced to respiratory equipment When the equipment was cleaned and dust lters werereplaced, the outbreaks ended16

Water Pipes

An outbreak o MDR Ab in an ICU was suspected to originate in the water or aucet area o the sinks located inthe unit Further investigation revealed that the clonal strain o the MDR Ab was in the horizontal pipe system,




37

which could potentially contaminate any o the sinks located in the unit Tis paper demonstrates that an outbreak can persist despite increased interventions such as hand hygiene and education until the reservoir o the organismis identied and eliminated An interesting approach to eradication o the organism was suggested by the hospitalengineer Te approach consisted o using bleach in all sinks connected to the system, at certain designated times,and treating all sinks simultaneously Once this was done, the outbreak ceased17

Toys

All healthcare acilities should have policies and procedures in place or the care and cleaning o toys All toysoered to children should be washable or cleanable oys can become contaminated and potentially transmitorganisms18 Due to the potential o toys to transmit Ab, procedures or cleaning and disinection are required19

Use o New Technologies—An Oral Presentation at APIC 2009 Annual EducationalConerence & International Meeting

During January 2008, a cluster o three patients with MDR Ab was detected in a 24-bed long-term acutecare hospital ward in Cleveland, Ohio Te isolates were multidrug-resistant with identical antibiotic

susceptibility proles Despite tightening o basic inection control measures—including improved handhygiene and use o PPE, prolonged isolation and cohorting o aected patients, and a change in disinectantproduct—ve new cases occurred in March 2008 An environmental survey revealed that swabs o high-touch objects (the call bell, bedrail, and bedside table) obtained rom seven patient rooms grew MDR Abon culture Given the environmental contamination pattern within the immediate patient environment andhigh attack rate, the unit was closed to admissions and vaporized hydrogen peroxide technology (VHP) wasutilized to serially decontaminate rooms In addition to the use o the VHP technology as a supplement toterminal cleaning, subsequent steps included upgrading surace disinectants and hand hygiene products Anintensive educational program in combination with innovative strategies was required to break the cycle o Abtransmission within the acility

Note: Hydrogen peroxide vapor (VHP) is a new technology that is being used and evaluated in many dierentareas20, 21, 22

Reerences1 Abbo A, Navon-Venezia S, Hammer-Muntz O, Krichali , Siegman-Igra Y, Carmeli Y Multidrug-resistant Acinetobacter baumannii : abstract and introduction Emerg Inect Dis 2005;11(1):22–29

2 Catalano M, Quelle LS, Jeric PE, DiMartino A, Maimonet SM Survival o Acinetobacter baumannii on bed rails during anoutbreak and during sporadic cases J Hosp Inect 1999;42:27–35

3 Wendt,C, Dietze, B, Dietz,E, Ruden, H Survivial o Acinetobacter baumannii on Dry Suraces Journal o Clinical

Microbiology 1997; 1394–1397

4 Environmental Services Basics Practice Guidance or Healthcare Environmental Cleaning American Society orHealthcare Environmental Services (ASHES) Costello P, editor 2008:6 Available at http://wwwashesorg

5 Public Health Notication rom FDA, CDC, EPA and OSHA: Avoiding Hazards with Using Cleaners and Disinectantson Electronic Medical Equipment 2007 Oct 31 Available at: http://wwwdagov/cdrh/saety/103107-cleanershtml

6 Siegel JD, Rhinehart E, Jackson M, Chiarello L Healthcare Inection Control Practices Advisory Committee Managemento multidrug-resistant organisms in healthcare settings, 2006 Am J Inect Control 2007 Dec;35(10 Suppl 2):S165–193




38

7 Boyce JM, Havill NL, Dumigan DG, Golebiewski M, Balogun O Rizvani R Monitoring the eectiveness o hospitalcleaning practices by use o an adenosine triphosphate bioluminescence assay Inect Control Hosp Epidemiol 2009 Jul; 30(7):678–684

8 Cooper RA, Grith CJ, Malik, RE, Obee P, Looker N Nonitoriing the eectiveness o cleaning in our British hospitals Am J Inect Control 2007 June; 35 (5):338–341

9 Garner JS Hospital Inection Control Practices Advisory Committee (HICPAC) Guideline or isolation precautions inhospitals Inect Control Hosp Epidemiol 1996 Jan;17(1):53–80

10 Sehulster LM, Chinn RYW, Arduino MJ, Carpenter J, Donlan R, Ashord D, Besser R, Fields B, McNeil MM, Whitney C, Wong S, Juranek D, Cleveland J Guidelines or environmental inection control in health-care acilitiesRecommendations rom CDC and the Healthcare Inection Control Practices Advisory Committee (HICPAC) Chicago,IL American Society or Healthcare Engineering/American Hospital Association 2004 pg 75

11 APIC Guide to the Elimination o Methicillin-Resistant Staphylococcus aureus (MRSA) ransmission in HospitalSettings 2007 pg 63

12 Carling PC, Briggs J, et al. An evaluation o patient area cleaning in 3 hospitals using a novel targeting methodology Am JInect Control 2006;34:513–519

13 rillis F, Eckstein E, Budavich R, Pultz MJ, Donskey CJ Contamination o hospital curtains with healthcare-associatedpathogens Inect Control Hosp Epidemiol 2008 Nov;29(11):1074–1076

14 Das I, Lambert P, Hill D, Noy M, Bion J, Elliott Carbapenem-resistant Acinetobacter and role o curtains in anoutbreak in intensive care units J Hosp Inect 2002;50:110–114

15 Williams GJ, Denyer SP, Hosein IK, Hill DW, Maillard J-Y Limitations o the ecacy o surace disinection in thehealthcare setting Inect Control Hosp Epidemiol 2009; 30:570–573

16 Bernards A, Harinck HIJ, Dijkshoorn L, van der Reijden JK, van den Broek PJ Persistent Acinetobacter baumannii ?Look inside your medical equipment Inect Control Hosp Epidemiol 2004;25:1002–1004

17 La Forgia C, Franke J, Hacek DM, Tomson RB Jr, Robicsek A, Peterson LR Management o a multidrug-resistant(MDR) Acinetobacter baumannii outbreak in an intensive care unit using novel environmental disinection: A 38-monthreport Am J Inect Control 2010 May; 38(4): 259–263

18 Naesens R, Jeurissen A, Vandeputte C, Cossey V, Schuermans A Washing toys in a neonatal intensive care unit decreasesbacterial load o potential pathogens J Hosp Inect 2009 Feb;71(2):197–198 Epub 2008 Dec 18

19 Avila-Aguero ML, German G, Paris MM, Herrera JF Sae oys Study Group oys in a pediatric hospital: Are they abacterial source? Am J Inect Control 2004 Aug;32(5):287–290

20 Boyce J, Havill N, Otter J, et al. Impact o hydrogen peroxide vapor room decontamination on Clostridium dicile environmental contamination and transmission in a healthcare setting Inect Control Hosp Epidemiol 2008;29:723–729

21 Otter J, Puchowicz M, Ryan D, et al. Feasibility o routinely using hydrogen peroxide vapor to decontaminate rooms in abusy United States hospital Inect Control Hosp Epidemiol 2009;30:574–577

22 Ray A “Te use o vaporized hydrogen peroxide room decontamination in the management o an outbreak o multidrug-resistant Acinetobacter baumannii ” 36th Annual APIC Educational Conerence and International MeetingProceedings, Fort Lauderdale, FL 2009 Jun




39

Outbreak Recognition and Control

Key Concepts

• Acinetobacter baumannii is a resilient organism that can survive or extended periods in the careenvironment

• MDRAbmayresultinlongtermcolonization,andserveasapotentialsourcefortransmissiontoadditional patients

• NumerousoutbreaksofMDRAbhavebeenreported,manyofwhichhaveinvolvedmanypatientsandrequired multiple interventions

• Reservoiridentication,eliminationorcontainmentmayrequirethesimultaneousandsustainedimplementation o many o the control measures described below

Introduction Te emergence and sustained propagation o MDR Ab in healthcare settings has been widely described in themedical literature, with the involvement o almost every type o care setting, ranging rom intensive care (mostrequent) and step-down units, to general medical-surgical oors and various long-term care entities Ampleevidence demonstrates interacility transmission o MDR Ab, with point-source introductions o this pathogenollowed by numerous secondary cases identied over subsequent months1 Te escalating impact and importanceo Acinetobacter inections is evidenced by the act that roughly 25% o all “nosocomial acinetobacter PubMedcitations in the past 20 years appeared in 2005 and 2006”2 In this section, common control strategies are compiledbased on reports o successul MDR Ab outbreak control

What is an Outbreak o MDR Ab? Te prevalence o a given organism is oten used to characterize and determine endemic versus epidemic level o the organism’s presence in an environment or location As with many other pathogens, there are no hard-and-astrules to describe exactly when the MDR Ab outbreak threshold has been crossed Many investigators are o theopinion that even a single MDR Ab patient represents the potential source or transmission to other patients andor contamination o reusable patient care equipment or the environment Accordingly, the appearance o a singlecase o MDR Ab in an area with no previously identied cases should prompt the timely implementation o selectedcontrol measures as described below Te appearance o two or more temporally or geographically associated MDR

Ab cases should evoke a correspondingly heightened response by the inection preventionist and by the acility

Antimicrobial Susceptibility

Te denition o MDR Ab has been discussed elsewhere in this guide, but it seems prudent at this juncture tointroduce an important consideration regarding classication MDR-Ab Certain strains o MDR Ab have beenound to contain as many as 54 resistance genes, with 45 residing on a single “resistance island” alone3 and at any given time, the expression or relative quiescence o resistance genes is driven in part by antibiotic selection pressure

Clinically, the rst indication o a strain’s heightened level o resistance typically comes rom the microbiology laboratory, which reports the culture and sensitivity test results on a clinical isolate Antimicrobial susceptibilitiesas reported on the “sensitivity results” are characterizations o the organism’s phenotype (eg, observable physical orbiochemical characteristics, as determined by both genetic makeup and environmental inuences) at the time o the




40

in vitro “sensitivity versus resistance” measurements An ot-used “tool” in the investigation and control o clusterso pathogens involves the comparison o the antimicrobial susceptibilities o several clinical isolates o the samegenus and species Generally speaking, comparable antimicrobial susceptibilities are taken to be strong evidence o the relatedness o the isolates, and disparate antibiograms are oten used to eliminate some isolates rom inclusionin the cluster However, with Acinetobacter strains, discriminating between somewhat sensitive strains, MDR Ab

strains and pan-resistant Ab strains using antimicrobial susceptibility patterns alone can be problematic Tis actis illustrated by examining unpublished data rom an outbreak o pan-resistant Ab that occurred in 2006-2007in Florida4 Te antibiotic susceptibility pattern rom isolate #1 in able I, while not radically dierent rom theindex case, tended to exclude it rom the cluster, which was ocused around isolates antibiotic susceptibilitieslike isolate #2, one o the two index cases in this outbreak However, subsequent molecular typing using theDiversiLab Acinetobacter DNA Fingerprinting Kit and DiversiLab Analysis Sotware (ampa General Hospital,Shannon Moroney, PhD, personal communication) showed that isolate #1 was indistinguishable rom the indexpan resistant strain Conversely, isolate #3 was pan-resistant by antibiogram (and thus appeared to be a part o theinitial cluster related to the index case), but on molecular typing was ound to be a dierent strain, leading to theconclusion that there were two temporally and geographically overlapping but clonally distinct clusters occurringsimultaneously Tus, while antimicrobial susceptibilities are necessary or patient management decisions, their use

in case inclusionary/exclusionary criteria can lead to over- or underestimating the true scope o an outbreak Teinection preventionist is advised to submit suspect isolates or appropriate molecular testing, such as PFGE orother genotypic methodologies that may be available in order to denitively classiy the possible outbreak cases

Critical Elements in the Control o MDR Ab Outbreaks

Administrative Support

Several reported clusters o MDR Ab have involved in excess o 100 patients and lasted or many months5, 6 Accordingly, it is essential that key hospital administrative, risk management, nancial, clinical and support serviceleaders are inormed o an apparent outbreak MDR Ab as soon as possible and that all are suitably impressed withthe potential scope, duration and clinical impact o such an outbreak Te inection preventionist should secure an

organizational commitment to support the agreed upon interventions and provide the needed resources A largecluster that lingers or weeks or months will be costly in terms o added supplies, personnel and laboratory costs,possible unit closures and other possible expenses Resource commitment and administrative support must be inplace to successully control an outbreak o MDR Ab

Public Relations

Te inection preventionist should seek the involvement o the organization’s public/media relations (PR)department, as a sustained outbreak, especially one that involves unit closures and diversion o admissions, willlikely come to the attention o the local media All external communications and media interviews should bechanneled through and guided by the organizational PR department

Table I. Antibiotic and MIC

Isolate Amp/Sul Amp CFZ CFP CFT CTZ CTR GE IM Lev Pip/TZ Tob Tri/Sul

#1 16I >32R >64R 2S >64R - - >16R >16R 0.25S R 4S -

#2 >32 R >32R >64R >64R >64R >64R >64R >16R >16R >8R >128R 8I >320R

#3 >32 R >32R >64R >64R >64R >64R >64R >16R >16R >8R >128R 8I >320R

Amp/Sul= Ampicillin/Sulbactam, Amp = Ampicillin, CFZ = Ceazolin, CFP = Ceapime, CF = Ceotetan, CZ = Cetazadime,CR = Cetriaxone, GE = Gentamicin, IM = Imipenem, LEV = Levoox, PIP/Z = Piperacillin/azobactam, ob =obramicin, rim/Sul=rimethoprim/Sulamethoxazole




41

Clinical Components in the Control o MDR Ab Outbreaks

Te ollowing are a series o interventional strategies that have been implemented, usually in conjunction withseveral others in a “bundle,” and have been reported to aid in controlling outbreaks o MDR-AB7

CommunicationReports o inter- and intra-acility transmission o MDR Ab1 highlight the need or eective communication o apatient’s MDR-Ab status at the time o internal transer, transer to another acility or even discharge to home Teresponsibility should lie with the reerring entity to clearly identiy the known MDR Ab patient to the receivingentity at the time o transer in order to acilitate the timely implementation o control measures upon admission

Tis might involve the development o a standardized “hando” protocol and documentation that explicitly addresses the patient’s overall MDRO history In addition, the acility should have a method to “ag” both theMDR Ab patient’s hard copy medical record as well as their electronic medical record so that it is obvious to thenext care team in the event o subsequent readmission to the acility By doing so, precautionary measures can be(re)instituted without delay

EducationEvery caregiver and support group should receive MDR Ab-specic education as a part o the outbreak controlprocess Visitors and amily should also be educated verbally and printed educational material (See Appendix C:Patient/Visitor Education Sheet) Tey should be reminded o the importance o hand hygiene, proper PPE use,the characteristics o MDR Ab as they relate to transmission, environmental cleaning, equipment reprocessing, etc

All shits should be included and attendance should be documented

Reservoir Identifcation and Elimination

Tis is a basic tenet o outbreak control and several authors have reported identiying and eliminating specicMDR Ab reservoirs and thus controlling the outbreak Bernards et al8 described recovering an outbreak strain o

MDR Ab in ventilators and other medical equipment and was able to end the outbreak by dusting the machinesand replacing their dust lters Tere are multiple reports o both respiratory and non-respiratory care equipmentinvolvement o MDR Ab clusters9 and the inection preventionist should keep an open mind when searchingor a common source reservoir Ling et al5 describe controlling an ICU MDR Ab outbreak by rst screening allpatients in the aected area or the presence o MDR Ab and subsequently cohorting aected patients in contactprecautions or D’Agenta, et al10 reported an increased incidence o MDR Ab among patients cared or in areas

where there were higher numbers o pre-existing MDR Ab patients, leading the authors to conclude that cross-transmission rom inected patients leads to a higher incidence o newer cases A similar observation has been maderelative to the likelihood o VRE acquisition in areas with high levels o pre-existing VRE, and has been termed“colonization pressure” by Bonten, et al11

A previously unrecognized reservoir and mode o transmission was described by Maragakis, et al12

, wherein anoutbreak o MDR Ab was associated with pulsatile lavage wound treatment Te authors concluded that there

was probable aerosolization and subsequent deposition o the MDR Ab strain on nearby environmental suracesdue to this orm o wound treatment Tis outbreak was controlled by changes in the inection preventionrecommendations o the equipment manuacturer, changes in the PPE worn by the therapist and supplied to thepatient, changes in the conguration o the treatment room itsel (private room only with readily cleaned suracesand closed storage), and changes to the post-treatment cleaning regimen

Patient and environmental surveillance cultures may be used to identiy reservoirs such as colonizedpatients or items in the care environment Corbella, et al13 suggested that the use o moistened sterile gauze




42

pads is more eective or the recovery Acinetobacter strains rom environmental sources (See Laboratory Considerations—Epidemiology—Pathogenicity section regarding specimen collection) Te inectionpreventionist should work closely with the microbiology laboratory to coordinate the collection andprocessing o environmental samples

Cohorting o Patients

Tis involves the placement o several patients with MDR Ab in the same geographical area, possibly onesemi-private room, several rooms designated or that purpose or even one or more intensive care unitsIn each case, the purpose would be to geographically separate patients with MDR Ab rom others, and,combined with caregiver cohorting (described below), would physically and operationally segregate inectedrom non-inected patients

Cohorting o Caregivers

Tis practice involves assigning certain caregivers to care only or those patients in the MDR Ab cohortduring any given shit A person assigned to the cohort would not be assigned non-cohort patients Te

inection preventionist can expect resistance to this strategy, as normal stang patterns and ratios may need to be altered, with a corresponding adverse impact on labor costs In addition, employee satisactionmay suer i sta assigned to care solely or cohorted patients eel that they are consistently being givenundesirable work assignments

Deerring Admissions and Unit Closure

Several authors have described the need to either close an aected unit or a period o time 5 or deer admissionsin order to control an outbreak o MDR-Ab14 In part, this assumes the presence o one or more environmentalreservoirs within the unit, and that those reservoirs cannot be eliminated while the unit is occupied ypically,admissions to an aected unit are curtailed until natural attrition allows or the complete closure o the ward

When the unit is closed, equipment may be removed or cleaning and reprocessing, extensive environmentalcleaning takes place, and thorough culling o potentially contaminated supplies is accomplished Again, this iscostly control strategy as closing a unit or this reason may result in a loss o bed capacity and income or theacility Wilks et al6 described the successul containment o an MDR Ab outbreak without having to resort tounit closure or patient isolation by instead ocusing on enhanced environmental cleaning, sta education andhand hygiene

“Hyperaggressive” Room/Environment Cleaning

Acinetobacter baumannii is known to persist in the environment; it is desiccation-tolerant and has otenbeen recovered rom the environment ater routine discharge room cleaning Hypochlorite solutions havebeen reported as eective in controlling outbreak situations19 Label instructions or many o the hospital-

grade disinectant detergent cleaning agents call or suraces being disinected to remain wet or up to tenminutes Te standard room turnaround time or discharge cleaning is oten less than 30 minutes, leavinglittle opportunity or sucient “dwell or contact” time o the disinectant agents on environmental suraces,especially vertical suraces Furthermore, Environmental Services (ES) personnel are oten reluctant (oreven prohibited rom) cleaning the surace o certain medical equipment, such as IV pumps or monitorsUnortunately, nursing may be under the impression that these items are being cleaned by EVS; and hence, theitems are not being cleaned at all Because o the strong environmental component o MDR AB, all aspectso room cleaning should be careully scrutinized, with a determination o how each item is to be cleaned and

who is responsible or doing so Existing cleaning protocols should be reviewed, and how those protocols are




43

actually put into practice should be observed by the inection preventionist It might prove useul to createa checklist o all items in the rooms and clearly designate the accountability or cleaning those items upondischarge Make sure there is sucient supervisory oversight to veriy and document that the room has beencleaned to the required specications

On the horizon, there are several emerging technologies under investigation that show promise or eectiveroom decontamination Tese include room ogging with hydrogen peroxide vapor (HPV), room ogging withactivated hydroxyl radicals (OH–) derived rom hydrogen peroxide, room ogging with a low-concentrationmixture o hydrogen peroxide and peroxyacetic acid, and surace exposure to intense ultraviolet light

Te reader is encouraged to ollow the peer-reviewed literature closely or reports o the ecacy o thesetechnologies that may ultimately provide more ecacious room decontamination than is now achieved usingtraditional cleaning methods

Review o Respiratory Care Equipment Reprocessing

Tere are numerous reports o outbreaks involving respiratory care equipment and supplies8, 9 Te inectionpreventionist should careully review all aspects related to respiratory care equipment processing and handlingi the investigation reveals that several aected patients are ound to have received respiratory care treatments o any kind Tis review should include care o bronchoscopes, nebulizers, ventilator circuits, ventilators, incentivebreathing devices and liquids used in the treatments All reprocessing processes should be reviewed to veriy standards or cleaning and disinection o this equipment are being met

Hand Hygiene Improvement

Hand carriage o MDR Ab, most likely o a transient nature, has been reported in several instances 15, 16 andcertain healthcare worker hands must be considered as a possible mode o transmission or outbreak strains

Accordingly, healthcare worker hand hygiene must be heavily stressed early on as a part o any outbreak controleort Either an antimicrobial soap and water or an alcohol-based hand cleanser can be used or this purpose

Healthcare workers should be reminded that gloves are not a substitute or eective hand hygiene and thatseveral studies have shown requent contamination o caregiver hands ater glove removal Verication by directobservation o hand hygiene compliance may be necessary to inuence caregivers to comply with hand hygieneprotocols without exception

Contact Precautions Compliance Improvement

Contact Precautions are a well known control strategy that is implemented in addition to StandardPrecautions (used or all patients) in cases o MDRO, including MDR Ab, and is based upon CDC/HICPACguidelines17, 18 Te purpose o Contact Precautions are to prevent the actual transer o inectious agents romthe patient or the environment to the caregiver, who may in turn either acquire the agent or more likely, serve asa vector or the transport o the agent to a susceptible patient Te key elements o Contact Precautions involve

placing the patient in a private room (except when cohorting is unavoidable) and the use o personal protectiveequipment (PPE), gowns and gloves, by caregivers when entering the room and contact with the patient and/or items potentially contaminated by the patient is anticipated Since it is oten dicult to accurately anticipate

whether patient contact will occur, many organizations have simplied the process by speciying PPE use by all persons entering the room Te inection preventionist should work with supply chain management to makesure there are sucient PPE supplies available at the point o need in instances where a cluster o inections may increase usage levels well above the normal In addition, there should be no exceptions to PPE use: Physicians,nurses, therapists, dietary, social services, case management, pastoral care, etc all should use the PPE accordingto the established protocols




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Below is a template to help in the development o a comprehensive plan to control an outbreak o MDR Ab:

Checklist o Potential MDR Ab Control Measures

Date Control Measure Comments

Y N Administrative support

Y N Communication

Y N Education

Y N Reservoir search and ID, environmental cultures

Y N Cohort patients

Y N Cohort sta

Y N Ward closure/deerred admits

Y N Hyper-aggressive room cleaning

Y N Equipment reprocessing review

Y N Hand hygiene monitoring

Y N Contact Precautions & PPE use monitoring

Reerences1 Saeed S, Fakih MG, Reiderer K, Shah AR, Khatib R Interinstitutional and Intrainstitutional ransmission o a Strain o

Acinetobacter baumannii Detected by Molecular Analysis: Comparison o Pulsed-Field Gel Electrophoresis And RepetitiveSequence-Based Polymerase Chain Reaction, Inect Control Hosp Epidemiol 2006;27:081–993

2 Silvia Munoz-Price L, Weinstein RA Acinetobacter Inection N Engl J Med 2008;358:1271–81

3 Fournier P-E, Vallenet D, Barbe V, et al Comparative Genomics o Multidrug Resistance in Acinetobacter baumanniiPLoS Genet 2006;2:(1)e7 0062–0072

4 Author’s personal communication, data

5 Ling ML, Ang A, Wee M, Wang GCY A Nosocomial Outbreak o Multiresistant Acinetobacter baumannii OriginatingFrom an Intensive Care Unit Inect Control Hosp Epidemiol 2001;22:48–49

6 Wilks M, Wilson A, Warwisk S, et al Control o an Outbreak o Multidrug-Resistant Acinetobacter baumannii-calcoaceticus Colonization and Inection in an Intensive Care Unit (ICU) Without Closing the ICU or Placing Patients inIsolation Inect Control Hosp Epidemiol 2006;27:654–658)

7 Rodríguez-Baño J, García L, Ramírez E, Martínez-Martínez L, Muniain M, Fernández-Cuenca F, Beltrán M, Gálvez J,Rodríguez J, Velasco C, et al Long-term control o hospital-wide, endemic multidrug-resistant Acinetobacter baumanniithrough a comprehensive “bundle” approach Am J Inect Control 2009;37:715–722

8 Bernards A, Harinck HIJ, Dijkshoorn L, van der Reijden JK Persistent Acinetobacter baumannii? Look Inside YourMedical Equipment Inect Control Hosp Epidemiol 2004;25:1002–1004

9 Villegas MV, Hartstein AI Acinetobacter Outbreaks, 1977–2000 Inect Control Hosp Epidemiol 2003;24:284–295

10 D’Agata EMC, Tayer V, Schaner W An Outbreak o Acinetobacter baumannii: Te Importance o Cross-ransmission Inect Control Hosp Epidemiol 200;21:588–591

11 Bonten NJM, Slaughter S, Ambergen AW, et al Te role o colonization pressure in the spread o vancomycin-resistantenterococci: an important inection control variable Arch Intern Med 1998;158:1127–1132




45

12 Maragakis LL, Cosgrove SE, Xiaoyan S, et al An Outbreak o Multidrug Resistant Acinetobacter baumannii Associated With Pulsatile Lavage Wound reatment JAMA 2004;292:3006–3011

13 Corbella X, Pujol M, Argerish MJ, et al Letter to the Editor Inect Control Hosp Epid 1999;20:45–460

14 Fierobe L, Lucet J-C, Decre D, et al An Outbreak o Imipenim-Resistant Acinetobacter baumannii in Critically IllSurgical Patients Inect Control Hosp Epidemiol 2001;22:35–40

15 Bayuga S, Zeana C, Sahni J, Della-Latta P, El-Sadr W, Larson E Prevalence and antimicrobial patterns o A baumanniion hands and nares o hospital personnel and patients: the iceberg phenomena again Heart Lung 2002;31:382–390

16 Huang YC, Su LH, Wu L Outbreak o Acinetobacter baumannii in a neonatal intensive care unit: clinical implicationsand genotyping analysis Pediatr Inect Dis 2002;21:1105–9

17 Siegel JD, Rhinehart E, Jackson M, Linda C Healthcare Inection Control Practices Advisory Committee Managemento multidrug-resistant organisms in healthcare settings, 2006 Available online at wwwcdcgov/ncidod/dhqp/pd/ar/mdroGuideline2006pd

18 Seigel JD, Rhinehart E, Jackson M, Chiarello L Healthcare Inection Control Practices Advisory Committee Guidelineor Isolation Precautions: Preventing ransmission o Inectious Agents in Healthcare Settings, June 2007 Available onlineat wwwcdcgov/ncidod/dhqp/pd/isolation2007pd

19 La Forgia C, Franke J, Hacek DM, Tomson RB Jr, Robicsek A, Peterson LR Management o a multidrug-resistant Acinetobacter baumannii outbreak in an intensive care unit using novel environmental disinection: A 38-month report Am JInect Control 2009 Nov [Epub ahead o print]




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Special Settings: Long-term Care, Ambulatory Careand Pediatrics

Long-term Care Facilities (LTCF)

Colonized and inected residents may become reservoirs and vehicles or MDR Ab transmission to other residentsin a acility Te residents can also be a source o transmission when transerred to or rom other healthcare settings,including acute care acilities1 In a study done in 2006 at Johns Hopkins Hospital, MDR Ab surveillance cultures

were obtained on adult patients admitted to ve hospital units in order to screen or MDR Ab Patients admittedrom LCFs, or who had been in LCFs within the previous six months, were ound to be the patient type mostlikely to be colonized or inected with MDR Ab2

Te IP must be aware o MDR Ab reservoirs and populations in the community Te state or local health

department will be able to provide this inormation Tis data should be part o the acility risk assessment MDR Ab-positive patients can be identied rom inormation provided on transer orms and/or rom laboratory results Te IP should arrange with the laboratory contracted by the LCF to be contacted immediately about any positiveculture MDR Ab residents Te MDR Ab inormation should be entered on a line listing; this inormation willassist with resident placement, identiying risk actors and calculation o rates

Newly identied MDR Ab-positive residents should be evaluated or risk actors and or the possibility that theMDR Ab was acquired within the LCF Based on surveillance data and evaluation, MDR Ab prevalence andincidence rates can be calculated and analyzed Te acility should be alert or outbreaks or increased transmissiono MDR Ab I transmission is occurring in the acility, the IP must review the inection prevention interventions,assess sta compliance, and intensiy education and compliance monitoring as appropriate

Te medical director should be kept inormed o MDR Ab prevalence and o any possible transmission o MDR Ab among residents in the acility MDR Ab incidence rates should be reported at Inection PreventionCommittee meetings and, during periods o possible transmission or outbreak, the need or enhanced interventionsmust be communicated Te IP in an LCF should be aware o state and local regulations concerning thereporting o outbreaks o MDR Ab and should work closely with the health department and/or a consultant IP asappropriate or assistance in interrupting the outbreak

Te IP and the medical director should be knowledgeable about antimicrobial use in the acility Antibiogramsshould be provided by the contracted microbiology lab “Studies have ound substantial inappropriate use o antimicrobials in LCF residents, ranging rom 25-75%”3 Reports on antibiotic use should be provided to all

resident attending physicians and healthcare providers

Eorts should be taken to place MDR Ab-positive resident in a private room (see also the patient placement section)at time o admission and ater a positive culture result on a current resident A private room may not be possible inall situations, as there are a limited number o private rooms in LCFs Tereore, it may be necessary to cohort theresident with another resident known to have the same organism, or place the resident with a low-risk resident who isnot currently on antibiotic medication, has no invasive devices, and has no wounds or other major skin disruptions4

Te LCF must have policies and procedures addressing MDROs5,6,7,8 Te policy should deal with placement,surveillance, isolation precautions, specimen collection and any other issues that may impact transmission o the




47

organism Contact Precautions are used to prevent transmission in hospital and LAC settings (See StandardPrecautions and ransmission-based Precautions section) However, based on the HICPAC MDRO Guideline2006, use o Contact Precautions or MDROs in the LCF can be based on the resident’s clinical situation andacility resources Many acilities use Contact Precautions i the resident has an inection with MDR Ab I theresident is colonized and the clinical situation allows—and the resident can maintain good hygiene, and can ollow

instructions to prevent transmission—Standard Precautions may be used Te quality o lie o LC residents isassociated with socialization and participation in group activities; thereore, modiying the type o precautions thatcan be saely used with MDR Ab residents is an important consideration

Hand hygiene is extremely important Hand hygiene and Standard Precautions or Contact Precautionsinormation/education must be provided or residents and their visitors Residents should be instructed toperorm hand hygiene at appropriate times, and residents who cannot discern when to perorm hand hygieneshould be assisted in hand hygiene by sta and/or by their amilies Family members and other visitors o LCresidents oten have more extensive contact with the resident and the resident’s environment than visitors o patients in hospital settings9 It is not uncommon or visitors to assist LC residents in care activities, accompany residents to common areas, and visit other residents’ rooms It can be expected; thereore, that LC visitors

may have requent opportunities to acquire inectious agents rom either residents or their environments It isimportant to reduce the risk o MDR Ab transmission to visitors, some o whom may be at increased risk o inection due to underlying conditions It can also be expected that visitors may be a source o transmission o acquired “contamination” via their own hands or rom their clothes or accessories Education o amilies and other

visitors is the rst step in ensuring that visitors o MDR Ab-positive residents do not contribute to MDR Abtransmission in the LC acility

Environmental cleaning is o great importance in preventing the transmission o organisms10 A multidisciplinary approach should be used; all sta should be empowered to maintain a clean environment Cleaning should bemonitored, with special attention to high-touch areas, in the resident’s room, halls and activities areas Sta shouldhave access to cleaning supplies, i needed, at all times Cleaning o medical equipment should be assigned to

whomever can saely perorm the cleaning; those cleaning equipment should ollow all manuacturers’ instructionsto prevent harm to the equipment

Special Settings: Long-term Care Reerences1 Siegel JD, Rhinehart E, Jackson M, Chiarello L Healthcare Inection Control Practices Advisory Committee Managemento multidrug-resistant organisms in healthcare settings, 2006 Am J Inect Control 2007 Dec;35(10 Suppl 2):S165–193

2 Maragakis LL, ucker MG, Miller RG, Carroll KC, et al. Incidence and prevalence o multidrug-resistant Acinetobacter using targeted active surveillance cultures JAMA 2008 Jun 4;299(21):2513–2514 Available at: http://jamaama-assnorg/cgi/content/ull/299/21/2513

3

Richards C, Lewis D Inections in Long erm Care Facilities Hospital Inections Bennett & Brachman WJarvis Editor5th ed Wolters Kluwer/ Lippincott Williams & Wilkins Baltimore 2007 Chapter 28:476

4 Smith P, Bennett G, Bradley S, et al. SHEA/APIC Guideline: Inection prevention and control in the long-term careacility Inect Control Hosp Epidemiol 2008;29(9):785–814

5 Fardo R, Keane J, aylor K Nursing Procedures Policy or Control o Multidrug-Resistant Organism (MDRO) InectionSection VII:26

6 Rosenbaum P, Zeller J, Franck J Long erm Care APIC ext o Inection Control and Epidemiology 3rd ed 2009Volume II, Chap 52:1–17




48

7 Arias K Long-term care outbreaks reported in the long term care setting Quick Reerence to Outbreak Investigation andControl in Health Care Facilities Jones & Bartlett 2000 Chapter 4 91–103

8 Siegel JD, Rhinehart E, Jackson M, Chiarello L Healthcare Inection Control Practices Advisory Committee 2007Guideline or isolation precautions: preventing transmission o inectious agents in health care settings Am J Inect Control2007 Dec;35(10 Suppl 2):S65–164

9 Aureden, K, Burdsall, D Harris, M, Rosenbaum, P Guide to the elimination o methicillin-resistant Staphylococcus aureus (MRSA) transmission in the long-term care acility APIC Elimination Guide 2009

10 French, G Antimicrobial Resistance in Flora and Nosocomial Inections In Hospital Epidemiology and Inection ControlMayhall,G Editor 3rd ed Lippincott Williams and WilkinsPhiladelphia 2004 Chapter 91:1620




49

Ambulatory Care

Te Management o Multi-Drug Resistant Organisms in Healthcare Settings , published in 2006, outlines the optimal

inection prevention program or the ambulatory care setting1 Te initial recommendation is to make MDR Abprevention in the center a priority by implementing systems to communicate inormation to administration and thehealth authorities as required I a patient is inected or colonized with MDR Ab, the acility should communicatethis to any acility receiving a patient rom the center

Te sta should be educated about MDR Ab, proper hand hygiene, environmental cleaning, and their role inprevention and control within the ambulatory care acility2

Te inection prevention program should include the surveillance or, and monitoring o, MDR Ab in the centerCultures o a site potentially inected should be done pre-procedure and results communicated to the physician andsta Positive culture patients can be scheduled as the last case o the day

Ambulatory care sta will use Standard Precautions at all times3,4 I the patient or the physician reports MDR Abprior to the patient arriving at the acility, or a wound is identied during initial assessment, a decision will be madeas to whether additional precautions are necessary Te sta is required to use gowns and gloves or contact with allblood or body uids, including uncontrolled drainage, draining wounds, ecal or urinary incontinence, and contentso drainage bags In addition, masks should be donned or potential exposure to splash-generating procedures

I the patient cannot control his or her secretions, the procedure may be rescheduled, or the patient should beseparated rom the other patients, and Contact Precautions implemented5

Ater discharge, the environment in contact with the patient should be cleaned and disinected or sterilized

according to recommended guidelines2 Intensied interventions should be taken i an outbreak is identiedStrategies may include use o a bleach solution to clean the environment In addition, it is important to intensiy hand hygiene monitoring and education about the transmission o the organism

Special Settings: Ambulatory Care Reerences1 Siegel JD, Rhinehart E, Jackson M, Chiarello L Healthcare Inection Control Practices Advisory Committee Managemento multidrug-resistant organisms in healthcare settings, 2006 Am J Inect Control 2007 Dec;35(10 Suppl 2):S165–193

2 Friedman C, Petersen K Organizing or Inection Prevention , Surveillance and Control Inection Control in Ambulatory Care Jones and Bartlett Publishers Sudbury, Mass 2004 Chapter 24:190

3 Peterson K Ambulatory Care APIC ext o Inection Control and Epidemiology Washington,DC 3rd ed 2009 VolumeII, Chapter 49:6

4 Bennett G Inection Prevention Manual or Ambulatory Care ICP Associates/APIC Washington,DC2009; Section 4:4

5 Arias K Ambulatory Care Quick Reerence to Outbreak Investigation and Control in Health Care Facilities Jones & Bartlett Gaithersburg, Maryland 2000; Chapter 5:108






51

medical devices and host actors also play a role in colonization and inection1, 3, 5, 9, 10 Medically complexpopulations in the outpatient and ambulatory setting should also be assessed or risk o colonization and inectionbased on population and setting4

Unortunately, the availability o appropriate pediatric antibiotics is jeopardized by emerging strains o Acinetobacter

that are resistant to many commercially available antibiotics11

Neonates

Numerous MDR Ab outbreaks have occurred in neonatal intensive care units (NICU) internationally Teseoutbreaks have primarily aected patients with low birth weight and preterm neonates within the rst our weekso lie who were residing in the NICU6

Te paper by Simmonds et al6 o an MDR Ab outbreak among extremely low birth weight neonates ollowingthe transer o an extremely premature neonate rom a reerring hospital describes how it was successully stoppedOver an outbreak period o 22 days, there were seven patients involved and our patient deaths All seven patients

were<

750 g extremely low birth weight neonates, who had been born at<

26 weeks gestational age and were<7 days postnatal age at time o exposure6 In addition to enhanced inection control strategies, three spatially separated cohorts were established Te cohorts included 1) colonized or inected patients, 2) exposed patients, and3) non-exposed patients Equipment and care providers were assigned to each cohort Surveillance cultures werecollected at regular intervals rom perianal areas, neck-skin olds and tracheal or nasopharyngeal cultures Exposedand positive patients were managed in contact isolation Suspect cases prompted consultation with inectiousdisease and inection control personnel Compliance with measures was accomplished by observational monitoring,including environmental cleaning All personnel providing services in the NICU were educated6 ransmission viadirect and indirect contact modes was successully interrupted by the measures taken during this outbreak

Rapid cohorting is essential, because MDR Ab can spread rapidly in the NICU setting due to the environmental

persistence o MDR Ab, multiple hosts with immature immune systems, underdeveloped skin, congenitalanomalies and prolonged hospitalizations In addition, inants may have limited vascular access, and catheters may remain in place or extended periods5 Further study is warranted to better understand transmission potential dueto co-bedding or kangaroo care5

Environment

As part o their development, children interact closely with their environment7 Both the environment and thehands o HCWs can become contaminated and serve as reservoirs or MDR Ab Pathogenic bacteria have beenrecovered rom toys in hospital and other healthcare settings1,12–16 oys have the potential to transmit MDR Ab;thereore, procedures or cleaning and disinection are required Tere must be cleaning procedures or othertoy-like items such as oor mats, laptops, mobiles and distraction devices used by Child Lie

In pediatrics, clean oors are important, because young children may spend time on them17 Lactation equipmentand rooms, baby scales and other equipment can become contaminated;and thereore, require procedures to cleanbetween patients4,17 As in the adult setting, environmental contamination o suraces and equipment contributeto transmission o MDR Ab A system or monitoring the eectiveness o cleaning should be developed andimplemented4, 17

Interacility patient transer is a recognized method o introducing MDR Ab into an institution9 Patients,equipment and sta that move between acilities can spread MDR Ab Establish reerral hospital communications




52

to prepare or transer o a known MDR Ab colonized or inected patient Plans should be implemented toidentiy, clean and disinect equipment rom outside hospitals Sta such as moonlighters, specialists and studentsshould receive documented education on the institution’s prevention measures

Inection Prevention and Control

Te prudent practice o inection prevention and control measures mitigate colonization o HCW sta andcontamination o the environment6,9 A plan or controlling the spread and preventing the establishment o anendemic MDR Ab strain should be developed1,4

Outbreaks o MDR Ab are dicult to control, because patients may become colonized or inected, andenvironmental contamination can persist 6,9 Surveillance methods should be identied and implemented or early recognition o the presence o MDR Ab.

As in the adult setting, contact isolation precautions are used to interrupt transmission o the child and caregiver,the use o masks, which hide acial expressions, can be scary, inhibit communication and prevent visualizing

expressions o concern and care Gowns may draw attention and embarrass the amily or patient by being illtting or brightly colored Development o amily and patient isolation education, communication and support areimportant to minimizing challenges associated with the use o personal protective equipment

Special Settings: Pediatrics References

1 Siegel JD, Rhinehart E, Jackson M, Chiarello L Healthcare Inection Control Practices Advisory Committee 2007Guideline or isolation precautions: preventing transmission o inectious agents in health care settings Am J Inect Control2007 Dec;35(10 Suppl 2):S65-164

2 National Nosocomial Inections Surveillance (NNIS) System Report, data summary rom January 1992 through June 2004,issued October 2004 Am J Inect Control 2004 Dec;32(8):470-485

3 Smith MJ Catheter-related bloodstream inections in children Am J Inect Control 2008 Dec, 36(10):S173e1-3

4 Siegel JD, Rhinehart E, Jackson M, Chiarello L Healthcare Inection Control Practices Advisory Committee Managemento multidrug-resistant organisms in healthcare settings, 2006 Am J Inect Control 2007 Dec;35(10 Suppl 2):S165-193

5 Long SS, Pickering LK, Prober CG Principles and practice o pediatric inectious diseases 3rd ed Philadelphia, PA:Churchill Livingstone Elsevier; 2008

6 Simmonds A, Munoz J, Aguero-Roseneld M, Carbonaro C, Montecalvo M, Clones B, LaGamma EF: Outbreak o Acinetobacter inection in extremely low birth weight neonates Pediatr Inect Dis J 2009;28(3):210-214

7

Posay-Barbe KM, Zerr DM, Pittet D Inection control in paediatrics Lancet Inect Dis 2008;8(1):19-31

8 Facility Guidelines Institute, Academy o Architecture or Health: 2010 Guidelines or design and construction o healthcare acilities Washington, DC: American Institute o Architects

9 Fournier PE, Richet H Te epidemiology and control o Acinetobacter baumannii in health care acilities Clin Inect Dis2006 Mar 1,42(5):692-699

10 Simon A, Bode U, Beutel K Diagnosis and treatment o catheter-related inections in paediatric oncology: an updateClin Microbiol Inect 2006:12(7):606-620




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11 Munoz-Price LS, Weinstein RA Acinetobacter inection N Engl J Med 2008; 358:1271-1281

12 Randle J, Fleming K Te risk o inection rom toys in the intensive care setting Nurs Stand 2006;20(40):50-54

13 Naesens R, Jeurissen A, Vandeputte C, Cossey V, Schuermans A Washing toys in a neonatal intensive care unit decreasesbacterial load o potential pathogens J Hosp Inect 2009 Feb;71(2):197-198 Epub 2008 Dec 18

14 Little K, Cutclie S Te sae use o children’s toys within the healthcare setting Nurs imes 2006;102(38):34-37

15 Fleming K, Randle J oys – riend or oe? A study o inection risk in a paediatric intensive care unit Paediatr Nurs 2006;18(4):14-18

16 Buttery JP, Alabaster SJ, Heine RG, Scott SM, Crutcheld RA, Bigham A, abrizi SN, Garland SM: MultiresistantPseudomonas aeruginosa outbreak in a pediatric oncology ward related to bath toys Pediatr Inect Dis J 1998;17(6):509-513

17 Hota B Contamination, disinection, and cross-colonization: are hospital suraces reservoirs or nosocomial inection? ClinInect Dis 2004;39(8):1182-1189

18 Youngster I, Berkovitch M, Heyman E, Lazarovitch Z, Goldman M Te stethoscope as a vector o inectious diseases inthe paediatric division Acta Paediatr 2008;97(9):1253-1255




54

A p p e n d i x A : M

u l t i d r u g - r e s i s t a n

t A c i n e t o b a c t e r b a u m a n n i i ( M D R

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U n i t /

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A d m i t t e d

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t i o n /

C o l o n i z a t i o n w i t h

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D a t e T r a n s e r r e d

t o A n o t h e r F a c i l i t y /

N a m e o F a c i l i t y

R i s k

F a c t o r s

I n v a s i v e D e v i c e s

P r o c e d u r e s / D a t e s

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55

Appendix B: Sae Donning and Removal o Personal Protective Equipment (PPE)

DONNING PPE

GOWN

Fully cover torso rom neck to knees, arms to end o wrist, and wrap around the back

Fasten in back at neck and waist

MASK OR RESPIRATOR

Secure ties or elastic band at middle o head and neck

Fit exible band to nose bridge

Fit snug to ace and below chin

Fit-check respirator

GOGGLES/FACE SHIELD

Put on ace and adjust to t

GLOVES

Use non-sterile gloves or isolation

Select according to hand size

Extend to cover wrist o isolation gown

REMOVING PPE

Remove PPE at doorway beore leaving patient room, or in anteroom

GLOVES

Outside suraces o gloves are contaminated!

Grasp outside o glove with opposite gloved hand; peel o

Hold removed glove in gloved hand

Slide ngers o ungloved hand under remaining glove at wrist

GOGGLES/FACE SHIELD

Outside suraces o goggles or ace shield are contaminated!

o remove, handle by “clean” head band or ear pieces

Place in designated receptacle or reprocessing or in waste container




56

GOWN

Gown ront and sleeves are contaminated!

Unasten neck, then waist ties

Remove gown using a peeling motion; pull gown rom each shoulder toward the same hand; gown will

turn inside out Hold removed gown away rom body, roll into a bundle and discard into waste or linen receptacle

MASK OR RESPIRATOR

Front o mask/respirator is contaminated – DO NO OUCH!

Grasp ONLY bottom, then top ties/elastics and remove

Discard in waste container

HAND HYGIENE

Perorm hand hygiene immediately ater removing all PPE!

Reerence:Siegel JD, Rhinehart E, Jackson M, Chiarello L Healthcare Inection Control Practices Advisory Committee 2007Guidelines or isolation precautions: preventing transmission o inectious agents in healthcare settings Available at: http://

wwwcdcgov/ncidod/dhqp/pd/guidelines/isolation2007pd




57

Appendix C: Patient/Visitor Education about Multidrug-resistant Acinetobacter baumannii (MDR Ab)

Acinetobacter (as-i-ne´tō-bak´ter) is a group o bacteria commonly ound in soil and water It can also be oundon the skin o healthy people Acinetobacter species are bacteria that can live or long periods o time in theenvironment However, i this organism enters the body where it is not normally ound, it may cause serious illness

Not everyone will get an inection rom this organism Healthy people rarely get serious inections rom thisorganism Acinetobacter inections rarely occur outside o healthcare settings Persons most likely to become ill are:

• Patientswhoareinthehospitalalongtime

• Patientswhohavetakenmanyantibioticsusedtokillbacteria

• Patientswhoaretakingmedicationsorhaveadiseasethataectsthebody’sabilitytoghtinfection

• Patientswhohavebeeninanursinghomeorlong-termcaresetting• Patientswhoareonventilatorsormachinesthathelpthemtobreathe

• Patientswhoareveryseriouslyill

“Drug-resistant” or “multidrug-resistant” means that the organism has developed a means o ghting or resistingthe antibiotics usually used to kill them Inections then become more dicult to treat

Acinetobacter can live on the skin and may survive in the environment or several days Hand hygiene, the most important infection prevention procedure, must be perormed to prevent spreading the organism rom person toperson, and rom inected objects in the patient ’s room

Hand Hygiene Basics for Patients and Visitors:

• Washyourhandswithsoapandwaterfor15–20secondsoruseanalcoholhandrub.

• Usethealcoholhandrubaslongasyoudonothavedirtyhands.

• Ifyouhavedirtyhands,usesoapandwatertocleanthem.

• Cleanyourhandsbeforeyoueat.

• Cleanyourhandsafteryouusethebathroomorbedpan.

• Cleanyourhandsbeforeyouleaveyourroom.

• Familyandvisitorsshouldcleantheirhandsbeforetheyenterandleaveyourroom.

• Family/visitorsshouldcleantheirhandsiftheyhelpcareforyou,andbeforetheyeat.

• Donothesitatetoasksta,familyorvisitorstowashtheirhands.




Appendix D: Daily High Touch Cleaning Checklist

Multidrug Resistant Acinetobacter baumannii

Environmental Cleaning

Daily cleaning o high touch areas

Area Yes No Comments/ Reason not done

Door knobs

Bedrails

Light switches

Bathroom aucet handles

Toilet fush Handles

Wall area around thetoilet

Remote controls

Phone

Overbed Tables

Bedside Stands- topand drawer handles

Medical Equipment

May be assigned to other personnel such as nurses or Respiratory Services

Call Light Controls

Reerences:1 Guidelines or Environmental Inection Control in Health-Care Facilities Recommendations o CDC and the Healthcare

Inection Control Practices Advisory Committee (HICPAC) 2003 pages 75, 832 Practice Guidance or Healthcare Environmental Cleaning American Society or Healthcare Environmental Services(ASHES) Patient Room –Occupied Pg 68