1. 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

2. 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).

3. 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

4. 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.

5. 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%

6. Infection Result-based conclusions
Nosocomial Incidence of CRAB/1000 pt. days
2007 = 0.35
2010 = P = 0.096
2012 = 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 = P < .001
Using segmented regression analysis, there is not significant change for the ESBL-EK

7. Other Result-based conclusions
Alcohol-based hand rub (AHBR) consumption per 1000 patient days was tracked during the study:
5.6L = L = L = L = L = L = P = <.001
AHBR consumption was not correlated with change in CRAB (P = .141) although AHBR use increased significantly over the course of the study.

8. 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).

10. Authors’ conclusions 1
Isolation and Surveillance cultures alone did not change CRAB incidence ( )
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

11. 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

12. 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

13. Appraisal Results
Level II – Experimental Study – Score: B