287 Search and Destroy: A bundle Intervention for the Control of Carbapenem-Resistant Acinetobacter baumannii (CRAB) outbreaks

Saturday, April 2, 2011
Trinity Ballroom (Hilton Anatole)
L. Silvia Munoz-Price, MD , University of Miami, Miami, FL
Gabriel Coro, RN , Jackson Memorial Hospital, Miami, FL
Timothy Cleary, PhD , University of Miami, Miami, FL
Madelaine Tamayo, RN , Jackson Memorial Hospital, Miami, FL
Amos Adedokum, RN , Jackson Memorial Hospital, Miami, FL
Lisa Francois, RN , Jackson Memorial Hospital, Miami, FL
Regina McDade, EdD, RN , Jackson Memorial Hospital, Miami, FL
Maria Socarras, RN , Jackson Memorial Hospital, Miami, FL
Stephen Adams, RN , Jackson Memorial Hospital, Miami, FL
Laurent Poirel, PhD , Hopital de Bicetre, Bicetre, France
Background: Carbapenem-resistant Acinetobacter baumannii (CRAB)has become a major pathogen in intensive care units (ICUs) across the world. Controlling outbreaks caused by this organism represent major challenges for the hospital epidemiologist.  

Objective: Describe the results of a bundle intervention aimed at controlling consecutive CRAB outbreaks at a single institution.

Methods: Tracheal aspirates among ventilated patients and rectal cultures upon admission to the ICUs and weekly thereafter were implemented from 4/26/10 until 9/17/10 and from 10/25/10 until 11/7/10 . Cultures were aimed to detect CRAB. These cultures were performed across 8 adult intensive care units from a 1,500 bed public teaching hospital within the Miami area. ICUs experiencing 2 or more new acquisitions of CRAB underwent a bundle intervention. This bundle, in addition to weekly point prevalence surveillance cultures, consisted of: a. cohorting colonized or infected patients, b. cohorting nurses, nursing aids,  and respiratory staff, c. daily cleaning of high touch areas within patient rooms, d. ultraviolet powder surveillances, e. contact isolation for colonized/infected patients (gowns and gloves), f. decreasing unnecessary traffic from patient to patient, and g. hand disinfection before and after all patient encounters and after contact with the environment.

Results: During the first 20 weeks of surveillance, a total of 982 patients were screened for CRAB, out of which 42 (4.3%) were detected positive after 48 hours of admission. During this phase, a cyclical pattern of cases across the ICUs was detected: 3 non-consecutive weeks showed trauma ICU (TICU) having 2 or more new acquisitions of CRAB, 2 consecutive weeks within surgical ICU-B (SICU-B) and 1 week within the medical ICU (MICU). Weekly mass electronic feedback with this data was sent to the hospital administration, units’ medical and nursing leadership, respiratory therapy, and environmental services. Due to staff shortage, weekly surveillances stopped on 9/17/10. Subsequently, an increase in the number of acquisitions among MICU, TICU, SICU-B and the neurosurgical ICU (NSICU) was noted. On 10/25/10, weekly point prevalence surveillances and bundle interventions were reinstituted. New acquisitions decreased from 9 to 2 within 2 weeks. During the month of October and the first week of November, 25 cases of CRAB were acquired, out of which 16 (64%) were from respiratory sources. Previous workup of consecutive CRAB isolates (1999-2010) at this institution showed a monoclonal process with an OXA-producing strain(data not shown).

Conclusions: A “search and destroy” bundle intervention was successful in temporarily controlling the number of newly acquired cases of CRAB at different ICUs within a single institution.