CDC - Puerto Rico Acinetobacter Baumannii Jan-Aug 27, 2013

7/29/2019 CDC - Puerto Rico Acinetobacter Baumannii Jan-Aug 27, 2013

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Nora Chea, MD, MSc, Kimberly Pringle, MD,

Shalon M. Irving, PhD,

Amber Kerk, BS,Division of Healthcare Quality Promotion

Centers for Disease Control and Prevention

August 28, 2013

Investigation of Multidrug-Resistant

Acinetobacter baumannii

at a Hospital in

Puerto Rico, Jan-Aug, 2013

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion


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DisclaimerThe findings and conclusions in this report are those

of

the authors and do not necessarily represent the

officialposition of the Centers for Disease Control and

Prevention


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


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

MDRAcinetobacter baumannii at a local hospital Seven patients in ICU tested positive

Additional 20 patients detected by active surveillance cultures(Three in July)

Twelve died (no data to confirm that MDR-Ab caused the deaths) Initial recommendations did not stop transmission PR DH requested assistance with the investigation


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Background: Objectives of Investigation

Describe basic epidemiology of all patient cases

Evaluate possible sources and modes of transmission

Assess infection control practices in the hospital

Provide recommendations


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Background:Acinetobacter baumannii

Gram negative rod

Commonly found in soil and water

Ab is ubiquitous, survives desiccation, and oftenMDR

Causes outbreaks in ICU Healthcare settings with very ill patients

Infection outside healthcare settings: RareCDC Healthcare Associated infection Website: http://www.cdc.gov/HAI/organisms/acinetobacter.html


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Clinical manifestations Pneumonia

Serious blood stream infections

Wound infections Can colonize without causing infections or

symptoms Tracheostomy sites Open wounds

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


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Background:Acinetobacter baumanniiTransmission

Person-to-person contact Contact with contaminated surfaces

Prevention measures

Strict infection control practices Hand hygiene Environmental cleaning Reprocessing of medical equipment

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


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Environment (especially commonly used equipment)is a common problem withAcinetobacter- more than

most other organisms


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Methods Case patient definition

A patient admitted to the hospital with a positive culture result forMDRAcinetobacter baumannii between January 1 and August

15, 2013

Multidrug resistant: resistant to 1 antibiotic in 3categories


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

At admission = within 72 hours of admission

Admission prevalence =# of Pts with MDRAb + Cx at admission

# of Pts with Cx at admissionX 100

Weekly trans/incidence rate# of vent/trac Pts without previous + Cx

X 100# of vent/trac Pts with 1st + MDRAb Cx

Among vent/trac Pts=


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Methods

Time Day Evening Early morning

Locations Interim ICU Cohort area Regular ward

Professional category Doctors Nurses Respiratory therapists Phlebotomists Maintenance/cleaners

Direct observation of staff practicing in the hospital


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Methods Assess hand hygiene compliance

Using CDC/WHO 5 moments for hand hygiene

HH compliance = # of HH performed by staff# of opportunities for HH X 100

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


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Methods

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


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Methods Assess contact precaution compliance

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

precaution

Assess quality of routine & terminal cleaning Before cleaning: Glo Germ on surfaces and high-touch areas After cleaning: UV light to check for Glo Germ


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Methods Interview key staff

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


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Methods 19 MDR-Ab isolates (11 Pts) tested for PFGE by CDC

lab

HCW & Environmental samples tested by CDC HCW hands Surfaces and equipment in contact precaution room Glucometer and its box Vital sign monitor Mobile X-ray machine Laryngoscope blade reprocessing area Ventilators

Results pending


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


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Results

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

Surveillance culture started


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ResultsCase patients timeline

Admission

1st positive culture

Significance: Most documented infections were

acquired within the hospital


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Results

Surveillance culture started since epi-week 17


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Results

Months # Pts with MDR Ab + 3

days since admission

# Pts with Cx drawn 3

days since admission

Point

Prevalence

January 0 639 0.00%

February 1 650 0.15%

March 0 723 0.00%

April 2 595 0.34%

May 3 684 0.44%

June 2 599 0.33%

July 1 659 0.15%

Point prevalence at admission by month


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Results69 patients were identified

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

No data to confirm the patients died ofAb


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Results

Wards where patients tested Positive # of patients Percent

ICU (When open) 28 41%

Medical Service (4th floor) 14 20.5%

Medical Service (5th

floor) 18 26.5%Medical Service ICU (4th floor) 2 3%

Medical Service ICU (5th floor) 1 1.5%

Surgery Service (3rd floor) 5 7.5%

Total 68 100%


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ResultsProcedures/Treatments # of Patients (%) Percent

Central line 40/69 58%

X-ray in ED (Mobile) 36/65 55.5%

X-ray after admission (Mobile) 42/58 72.5%

Tracheostomy 16 /69 23%

Intubated in ED 31/69 45%

Intubated after admission 26/69 37.5%


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Results

Culture #1 (Specimen) # of Specimens Percent

Sputum 23 33.82%

Rectal 16 23.53%

Urine 7 10.29%

Ulcer 4 5.88%

Wound 4 5.88%

Sputum, Rectal 3 4.41%

Blood, Sputum 2 2.94%

Catheter Tip 2 2.94%

Sputum, Urine 2 2.94%

Blood 1 1.47%

Endoth 1 1.47%

ETT 1 1.47%Skin 1 1.47%

Wound, Sputum 1 1.47%

TOTAL 68 100.00%


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ResultsInfection control breaches

Low hand hygiene compliance HH compliance rate

Nurse (N=107): 39.25% Respiratory therapist (N= 26): 46.15% Phlebotomist (N=10): 40% X-Ray Tech (N=5): 0%

Of all opportunities for HH missed: 53% before patient contactand clean procedures combined

Poor hand hygiene techniquesNo hand sanitizer at point of care

No finger nail policy for staff


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Results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Step 0 Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Step 9 Step 10 Step 11

Hand Hygiene Steps Performed by Staff During Patient Care

Step 2 Step 3 Step 4 Step 5 Step 6 Step 7


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Results

Infection control breaches

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


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Results

High-touch areas (especially around patients) Knobs IV stands Bedrails

Surfaces Bedside tables Chairs Sinks

Routine and terminal cleaning observations


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Results

Before Cleaning Before CleaningAfter Cleaning After Cleaning


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Results

Observations of cleaning process

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


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Results

Observations of cleaning process (Cont)

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

practiced

Aggressive cleaning of commonly used equipmentshared between patients and contact areas around

patients is particularly important


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Results

Reprocessing of laryngoscope blade

Same sink for dirty (before HLD) and clean (after HLD) blades

Dirty looking container for soaking blades

Dirty looking sink for rinsing blades after HLD Dry with paper towel before packaging No records for soaking time in HLD


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Results: Laryngoscope Reprocessing Site


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Conclusions

The outbreak started before January 2013

Outbreak occurred in the hospital

Multiple infection control issues have contributed totransmission

Suboptimal cleaning Inadequate use of CP Low HH compliance

Transmission of MDR-Ab in hospital: ongoing, yetslower rate


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Recommendations: Surveillance

Routine simple surveillance of MDR-Ab Continue the Epi-curve Continue routine surveillance culture (sputum and rectal) at

admission and during hospitalization among ventilated patients

until weekly transmission rate comes down to zero for four

consecutive weeks

Monthly point prevalence of MDR-Ab among ventilated patientsafterweekly transmission rate comes down to zero for fourconsecutive weeks


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Recommendations: Surveillance

Trace-back investigation of cases positive onadmission

HCF admitted before this hospital admission Previous admission in this hospital with MDR-Ab cultures


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Recommendations: Hand Hygiene

Improve hand hygiene practices Regular interactive training (especially new staff) Regular observation for HH compliance Posters, flyers for HH techniques and 5 moments for HH Hand sanitizer available at point of care, i.e. bottle mounting on

patient beds, small bottles in staff pockets

Feedback of HH adherence to unit managers and front line staff


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Recommendations: Contact Precaution

Improve contact precaution practices Reinforce need for CP and proper procedures Do unit specific surveillance on rates of CP adherence with

feedback to unit managers and frontline staff

Equipment or supplies brought into the room should bededicated to that patient or cleaned and disinfected well before

use for another patient

Restrict unnecessary touch on patient surroundings


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Recommendations: Routine and TerminalCleaning

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

Follow manufacturers instructions regarding propercleaning and disinfecting of all equipment andsurfaces

Use EPA-registered hospital disinfectants All routine environmental cleaning (including rooms with NO

contact precaution)


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Recommendations: Cohorting Patients

Cohorting patients

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

HCWs working with MDR-Ab patients

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

patients (if possible)


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Recommendations: LaryngoscopeReprocessing

Laryngoscope reprocessing Clean and disinfect reprocessing areas regularly Sink for cleaning dirty blades (before HLD) should be separated

from sink for rinsing blades after HLD if possible

If filtered water rinse is used, should followed with alcohol rinse,then allow to dry before storage

Need a timer for HLD soaking time


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Recommendations: Education for new staff

Infection control session before starting work

New staff Nurses

Respiratory therapists Phlebotomist MD

New residents


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Next Steps

Finalize epi analysis

Trip report

Finalize environmental samples (cultures)

Ongoing communication (e.g , further calls withfacility)


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Acknowledgments

Hospital UPR Puerto Rico Department of Health CDC/DHQP

CDC - Puerto Rico Acinetobacter Baumannii Jan-Aug 27, 2013

Documents

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