APIC Chapter 13 Journal Club March 18, 2015 Evidence for Practice Infection Control Measures to prevent Carbapenem-resistant Acinetobacter baumannii in a hospital’s ICUs Presented by: Elsa Santos-Cruz IP CIC Mount Sinai Hospital

LEVEL I – Experimental Study Setting: - The Korean Nosocomial Surveillance System identified Acinetobacter baumannii as the leading cause of nosocomial infection in the ICUs. A study was done in the Gyeongsang National University Hospital located in South Korea. The 890-bed teaching hospital has a 19-bed MICU, a 14-bed SICU, and a 16-bed general isolation ward. A retrospective analysis was done to assess effectiveness of different Infection Control measures to prevent infection of Carbapenem-Resistant A. baumannii (CRAB).

Time Period of interventions 1- July 2007 to June 2009 All patients with CRAB were placed on Contact Precautions Disposable gloves and gowns were required upon entry to the room Alcohol-based hand sanitizer use was encouraged Daily environmental cleaning of cohorted rooms was done using sodium dichloro-isocyanurate (NaDCC)- containing solution (like bleach) Nasal screening for CRAB in all ICU patients w/in 24 hrs of admission and weekly thereafter if CRAB was identified in the ICU 2- July 2009 to Dec. 2012 Biweekly education by Infection Control team of the important of Infection Control protocols Monitored infection control measures Promoted infection control practices in preparation for hospital accreditation

Control & Definitions Patient with Nosocomial incidence of ESBL+ E. coli and K. pneumoniae (ESBL-EK) were managed with Standard Precautions only. Nosocomial was defined as a patient newly infected or colonized with CRAB more than 48 hrs. after admission. Patients with multiple positive samples were counted as one episode.

Sample size and composition During the 6 year study: Total number of patient admissions = 1,658,999 Patients with positive CRAB = 588 (0.35/1000 pt. days) Patients with Nosocomial CRAB = 530 (90% of all CARB pts) Patients from ICU w/positive CRAB = 342 Pts. surveillance culture + for CRAB = 60 Pts. surveillance and clinical culture + = 47 Pts. surveillance culture + only = 13 True infection w/ CRAB = 111/530 (21 %) Pneumonia – 76% Bacteremia – 10% Other sites – 14%

Infection Result-based conclusions Nosocomial Incidence of CRAB/1000 pt. days 2007 = 0.35 2010 = 0.46 P = 0.096 2012 = 0.06 P < .001 Using segmented regression analysis, there is significant change in the incidence density of CRAB between period 1 and 2. Nosocomial Incidence of ESBL-EK 2007 = 0.59 2012 = 1.00 P < .001 Using segmented regression analysis, there is not significant change for the ESBL-EK

Other Result-based conclusions Alcohol-based hand rub (AHBR) consumption per 1000 patient days was tracked during the study: 5.6L = 2007 5.5L = 2008 9.6L = 2009 7.5L = 2010 11.2L = 2011 11.9L = 2012 P = <.001 AHBR consumption was not correlated with change in CRAB (P = .141) although AHBR use increased significantly over the course of the study.

Other Result-based conclusions Antimicrobial consumption in Defined Daily Doses (DDD), was also tracked total antimicrobial use ß-Lactam/ß-lactamase inhibitor combinations Extended-spectrum cephalosporins Quinolones Carbapenems Between 2010 – 2012, antibiotic use decreased in aggregate (P < .001), for carbapenems (P = .008) significantly correlated with a decrease in CRAB (no P value provided however).

Authors’ conclusions 1 Isolation and Surveillance cultures alone did not change CRAB incidence (2007-2009) Between 2010 – 2012, additional education led to decreased CRAB incidence Optimal CRAB screening is unknown Infection Control practices compliance was believed to be sub-optimal in first time period Increased compliance with IC practices is inferred by increased AHBR use in 2nd time period, correlated with preparation for national accreditation visit Education about Infection Control is believed to be leading cause of reduced CRAB

Authors’ conclusions 2 Changes in AHBR use did not affect CR-EK rates (those pts were not tracked or put on isolation precautions) Cohorting CRAB patients helped reduce rates of CRAB incidence over the course of the study Cohorting and isolation helped increase AHBR use and compliance with Contact Precautions Decreased use of antimicrobials helped reduce CRAB rates but not CR-EK rates Results are similar to a survey in Japan that found that a reduction of CRAB was associated with Infection Control performance and hospital accreditation

Study Limitations Inappropriate screening site for CRAB Multiple changes were made without ability to evaluate each change’s impact on infection rates Unable to identify the specific infection control measure(s) that reduced the incidence density of CRAB Compliance with IC measures was not tracked (study was retrospective) Unable to evaluate the relationship antimicrobial consumption to the reduction of CRAB CRAB isolates were not typed so patient-patient spread cannot be proven

Appraisal Results Level II – Experimental Study – Score: B