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Impact of Contact Isolation Precautions on Multi-Drug Resistant Acinetobacter baumannii in the Pediatric Intensive Care Unit

Published online by Cambridge University Press:  05 June 2015

Adam Tawney,
Lynn Semproch,
Paul Lephart,
Kevin Valentine,
Ronald Thomas,
Basim I. Asmar,
Teena Chopra and
Eric J. McGrath
Adam Tawney
Affiliation:
Wayne State University School of Medicine, Detroit, Michigan
Lynn Semproch
Affiliation:
Children’s Hospital of Michigan, Detroit, Michigan
Paul Lephart
Affiliation:
Detroit Medical Center University Laboratories, Detroit, Michigan
Kevin Valentine
Affiliation:
Riley Hospital for Children, Indianapolis, Indiana
Ronald Thomas
Affiliation:
Wayne State University School of Medicine, Detroit, MichiganCarman and Ann Adams Department of Pediatrics, Detroit, Michigan
Basim I. Asmar
Affiliation:
Wayne State University School of Medicine, Detroit, MichiganChildren’s Hospital of Michigan, Detroit, MichiganCarman and Ann Adams Department of Pediatrics, Detroit, MichiganDivision of Pediatric Infectious Diseases, Detroit, Michigan
Teena Chopra
Affiliation:
Wayne State University School of Medicine, Detroit, MichiganDepartment of Internal Medicine, Division of Infectious Diseases, Detroit, Michigan
Eric J. McGrath*
Affiliation:
Wayne State University School of Medicine, Detroit, MichiganChildren’s Hospital of Michigan, Detroit, MichiganCarman and Ann Adams Department of Pediatrics, Detroit, MichiganDivision of Pediatric Infectious Diseases, Detroit, Michigan
*
Address correspondence to Eric McGrath, MD, Children’s Hospital of Michigan, Division of Infectious Diseases, 3901 Beaubien Blvd., Detroit, MI 48201 (emcgrath@med.wayne.edu).
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Abstract

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Information

Type
Research Briefs
Information
Infection Control & Hospital Epidemiology , Volume 36 , Issue 9 , September 2015, pp. 1108 - 1110
Copyright
© 2015 by The Society for Healthcare Epidemiology of America. All rights reserved 

The emergence and dissemination of multidrug-resistant organisms (MDROs), including Acinetobacter baumannii has caused continued concern. This organism is capable of surviving on dry surfaces for 4 monthsReference Wendt, Dietze, Dietz and Ruden 1 and has been linked to prolonged colonization.Reference Marchaim, Navon-Venezia and Schwartz 2 The empiric use of contact (barrier) precautions in the management of A. baumannii as a specific interventionReference Gbaguidi-Haore, Legast, Thouverez, Bertrand and Talon 3 , Reference Lefebvre, Gbaguidi-Haore, Bertrand, Thouverez and Talon 4 and as a bundle componentReference Rodriguez-Bano, Garcia and Ramirez 5 has been studied in both outbreak and non-outbreak settings. However, the optimal isolation precautions and required duration of such precautions remain unresolved, especially in pediatric intensive care units (PICUs). We analyzed the isolation precautions for A. baumannii in a tertiary PICU and their effectiveness in a non-outbreak setting over 6 years.

Methods

Case Selection and Setting

All patients with A. baumannii–positive clinical cultures cared for at the Children’s Hospital of Michigan (CHM) PICU from January 2008 to December 2013 were identified retrospectively based on the first positive culture for A. baumannii. Surveillance cultures were not performed. Standard microbiology laboratory methods were used for organism identification, and antimicrobial susceptibilities were determined using Microscan ID (Siemens Healthcare, Malvern PA). This study was approved by the Wayne State University Human Investigation Committee.

Isolation Precautions

During the study period, 3 separate isolation precaution regimens were implemented based on changes in CHM infection control policy. From January 2008 through July 2010, standard precautions were implemented for all A. baumannii culture-positive patients (Cohort 1). From August 2010 to January 2012, contact precautions (eg, donning gown and gloves before patient contact) with private room/cohort (two patients, single-room cohort) for all A. baumannii culture-positive patients were implemented for the duration of hospitalization (Cohort 2). Finally, from February 2012 through December 2013, contact precautions with private room/cohort were implemented only for multidrug-resistant (MDR)–A. baumannii cases for duration of hospitalization (Cohort 3). Standard precautions were implemented for patients with susceptible A. baumannii isolates in Cohort 3. Maximum duration of contact precaution isolation with private room/cohort in Cohort 2 and Cohort 3 continued for up to 12 months for patients requiring prolonged hospitalization, in accordance with CHM infection control policy.

Definitions

Susceptible A. baumannii isolates were defined as resistant to ≤2 drug classes. MDR A. baumannii was defined as isolates resistant to ≥3 drug classes. Hospital-acquired (HA) cases were defined as those with a positive clinical culture for A. baumannii obtained >48 hours post admission and a prior negative culture, from the same body site, during the same admission; cases defined as “probable” HA cases lacked the negative culture requirement. Community-acquired (CA) cases were defined as those with a positive A. baumannii culture ≤48 hours after admission. All patients with clinical specimens positive for A. baumannii were considered to be either colonized or infected.Reference Gbaguidi-Haore, Legast, Thouverez, Bertrand and Talon 3 HA incidence density was defined as the number of new HA and probable HA cases per 1,000 patient days within the cohort.Reference Rodriguez-Bano, Garcia and Ramirez 5

Statistical Analysis

Descriptive statistics were performed for appropriate variables. A nonparametric Fisher’s exact χ2 test was used to compare categorical variables regarding proportional differences. A parametric, independent-samples t test was used to compare continuous variables regarding mean differences. If violations of normality and/or homogeneity of variance occurred, a nonparametric Mann-Whitney U test was substituted. P values ≤.05 were deemed significant. Data were examined using SPSS version 21.0 (IBM SPSS, Armonk, NY).

Results

A total of 48 patient cases (26 male, 22 female) were included in this study. Primary medical conditions for PICU admission varied. Mean age was 44 months±SD 64.5 months (range, 0.5–245 months).

Clinical isolates were recovered from 42 respiratory cultures, 4 wound cultures, and 3 blood cultures. A. baumannii was isolated alone in 15 of 48 cultures (31%) and as part of polymicrobial infection and/or colonization in 33 of 48 cases (69%).

HA and probable HA cases decreased significantly from 20 of 21 (95%) in Cohort 1 to 9 of 14 (64%) in Cohort 2 to 9 of 13 (69%) in Cohort 3 (P=.03). Individual comparisons showed a significant decrease of HA and probable HA cases from 20 of 21 (95%) in Cohort 1 to 9 of 14 (64%) in Cohort 2 (P=.02) and from 20 of 21 (95%) in Cohort 1 to 9 of 13 (69%) in Cohort 3 (P=.04). HA incidence density was 1.1 cases per 1,000 patient days in Cohort 1; 0.85 in Cohort 2; and 0.63 in Cohort 3. Cohort characteristics and results are summarized in Table 1.

TABLE 1

Cohort Characteristics and Results

NOTE. NS, not significant; MDR, multidrug resistant; HA, hospital acquired.

a MDR A. baumannii isolates were present in 7 of 48 cases (15%).

b Overall comparison P value. Individual comparisons: Cohort 1 to Cohort 2, P=.02; Cohort 1 to Cohort 3, P=.04.

Discussion

Starting in August 2010, CHM and all Detroit Medical Center (DMC) hospitals required contact precautions with private room/cohort for all intensive care patients with A. baumannii–positive clinical cultures for the duration of hospitalization (up to a maximum of 12 months) per the institutional infection control policy. This policy was implemented in response to a report of susceptible strains developing resistance in other medical centersReference Stephens, Francis, Abell, DiPersio and Wells 6 and to an increase in MDR–A. baumannii cases within the DMC.Reference McGrath, Chopra and Abdel-Haq 7 , Reference Reddy, Chopra and Marchaim 8

As a referral center, many of our CHM PICU patients have complex medical conditions requiring prolonged admission. This condition makes continued adherence to contact precautions with private room/cohort placement cumbersome to staff and costly; these issues have been reported elsewhere.Reference Dhar, Marchaim and Tansek 9 , Reference Spence, Dammel and Courser 10 Starting in February 2012, the CHM IC committee decided to maintain contact precautions with private room/cohort only for PICU patients positive for MDR A. baumannii. Following this change, the rate of MDR-A. baumannii–positive cultures from clinical sources did not increase, and the total number of A. baumannii cases remained nearly unchanged.

These data demonstrate that targeted contact precautions with private room/cohort for only MDR A. baumannii (vs all A. baumannii cases) appears to be safe in our PICU because it did not lead to increased HA or probable HA A. baumannii cases. Furthermore, a clinically significant decrease in HA incidence density was observed between Cohort 1 and Cohort 2, and continued reduction (not increase) was observed in Cohort 3. Concurrent benefits included freeing up restricted rooms, reducing staff burden, and associated cost reductions.

The limitations of this study include its retrospective, single-center design. The time periods per cohort varied based on real-time policy changes regarding infection control. Cost analysis and long-term follow-up were not performed.

Acknowledgments

Financial support: No financial support was provided relevant to this article.

Potential conflicts of interest: All authors report no conflicts of interest relevant to this article.

References

1. Wendt, C, Dietze, B, Dietz, E, Ruden, H. Survival of Acinetobacter baumannii on dry surfaces. J Clin Microbiol 1997;35:1394–1397.CrossRefGoogle ScholarPubMed
2. Marchaim, D, Navon-Venezia, S, Schwartz, D, et al. Surveillance cultures and duration of carriage of multidrug-resistant Acinetobacter baumannii . J Clin Microbiol 2007;45:1551–1555.Google Scholar
3. Gbaguidi-Haore, H, Legast, S, Thouverez, M, Bertrand, X, Talon, D. Ecological study of the effectiveness of isolation precautions in the management of hospitalized patients colonized or infected with Acinetobacter baumannii . Infect Control Hosp Epidemiol 2008;29:1118–1123.Google Scholar
4. Lefebvre, A, Gbaguidi-Haore, H, Bertrand, X, Thouverez, M, Talon, D. Impact of barrier precautions and antibiotic consumption on the incidence rate of acquired cases of infection or colonization with Acinetobacter baumannii: a 10-year multi-department study. Am J Infect Control 2011;39:891–894.CrossRefGoogle ScholarPubMed
5. Rodriguez-Bano, J, Garcia, L, Ramirez, E, et al. Long-term control of hospital-wide, endemic multidrug-resistant Acinetobacter baumannii through a comprehensive “bundle” approach. Am J Infect Control 2009;37:715–722.Google Scholar
6. Stephens, C, Francis, SJ, Abell, V, DiPersio, JR, Wells, P. Emergence of resistant Acinetobacter baumannii in critically ill patients within an acute care teaching hospital and a long-term acute care hospital. Am J Infect Control 2007;35:212–215.CrossRefGoogle Scholar
7. McGrath, EJ, Chopra, T, Abdel-Haq, N, et al. An outbreak of carbapenem-resistant Acinetobacter baumannii infection in a neonatal intensive care unit: investigation and control. Infect Control Hosp Epidemiol 2011;32:34–41.CrossRefGoogle Scholar
8. Reddy, T, Chopra, T, Marchaim, D, et al. Trends in antimicrobial resistance of Acinetobacter baumannii isolates from a metropolitan Detroit health system. Antimicrob Agents Chemother 2010;54:2235–2238.Google Scholar
9. Dhar, S, Marchaim, D, Tansek, R, et al. Contact precautions: more is not necessarily better. Infect Control Hosp Epidemiol 2014;35:213–221.Google Scholar
10. Spence, MR, Dammel, T, Courser, S. Contact precautions for methicillin-resistant Staphylococcus aureus colonization: costly and unnecessary? Am J Infect Control 2012;40:535–538.CrossRefGoogle ScholarPubMed
Figure 0

TABLE 1Cohort Characteristics and Results