Coming Clean: Use of ATP Sanitation Monitoring as Part of an Infection Control Bundle during Simultaneous Outbreaks of CRE and XDR-Acinetobacter baumannii in an ICU

Background: Drug resistant gram negative bacteria such as extreme-drug resistant Acinetobacter baumannii (XDR-AB) and carbapenem-resistant Enterobacteriaceae (CRE) have emerged as serious threats to patients in intensive care units (ICUs) and are a vexing challenge to infectious disease and control practitioners. From January to April of 2010, we responded to concurrent outbreaks of XDR-AB (resistant to all available antibiotics including colistin and tigecycline) and CRE in the surgical ICU (SICU) of our hospital.

Objective: To describe use of an infection control “bundle”, including the use of an ATP bioluminescence assay system to evaluate cleaning practices, during a concurrent outbreak of XDR-AB and CRE.

Methods: In January 2010, clusters of XDR-AB and CRE infection were identified in the SICU. Consequently, patients were screened for XDR-AB and/or CRE colonization or infection, microbial samples were collected, and charts were retrospectively reviewed. A bundled intervention was implemented February 1, including (a) interdisciplinary meetings, (b) staff/physician education, (c) universal contact precautions, (d) cohorted rooms, (e) cohorted nursing/respiratory personnel, (f) restricted public access to rooms and common areas, (g) semiweekly to weekly surveillance cultures and point prevalence surveys with molecular strain typing, (h) terminal cleaning of all SICU rooms and enhanced cleaning of common areas, and (i) cleaning validation and instruction using the ATP bioluminescence assay system (SystemSURE II, Hygiena) during 3 unannounced visits to the SICU.

Results: Three patients infected or colonized with XDR-AB and 8 with CRE were identified during the first 3 weeks of the outbreaks. ATP bioluminescence assays were obtained from a variety of moderate and high touch surfaces in patient rooms and common areas of the SICU at onset of the outbreak. Readings of 6 (26.1%) of 23 sampled items exceeded predefined limits suggesting inadequate cleaning. Education of environmental services, nursing and respiratory care was performed. Subsequent readings exceeded set limits 1 (6.3%) of 16 times one week, 0 (0%) of 16 times two weeks and 4 (19%) of 21 five weeks post-education. The increase in “ATP failures” five weeks post-education led to renewed efforts to sustain optimal environmental cleaning practices among staff. Three patients infected/colonized with PDR-AB and 2 with CRE were identified during the 8 week period following implementation of the bundled intervention. No additional XDR-AB or CRE infections were identified over the subsequent 3 months.

Conclusions: Implementation of a bundled set of interventions, including use of ATP bioluminescence to rapidly assess and improve the effectiveness of environmental disinfection, led to the successful control of simultaneous outbreaks of XDR-AB and CRE in an ICU.