Increase in Hospital-acquired Carbapenem-resistant Acinetobacter baumannii Infection and Colonization in an Acute Care Hospital During a Surge in COVID-19 Admissions

New Jersey, February-July 2020

Stephen Perez, PhD; Gabriel K. Innes, VMD, PhD; Maroya Spalding Walters, PhD; Jason Mehr, MPH; Jessica Arias; Rebecca Greeley, MPH; Debra Chew, MD

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(48):1827-1831. 

In This Article

Abstract and Introduction

Introduction

Carbapenem-resistant Acinetobacter baumannii (CRAB), an opportunistic pathogen primarily associated with hospital-acquired infections, is an urgent public health threat.[1] In health care facilities, CRAB readily contaminates the patient care environment and health care providers' hands, survives for extended periods on dry surfaces, and can be spread by asymptomatically colonized persons; these factors make CRAB outbreaks in acute care hospitals difficult to control.[2,3] On May 28, 2020, a New Jersey hospital (hospital A) reported a cluster of CRAB infections during a surge in patients hospitalized with coronavirus disease 2019 (COVID-19). Hospital A and the New Jersey Department of Health (NJDOH) conducted an investigation, and identified 34 patients with hospital-acquired multidrug-resistant CRAB infection or colonization during February–July 2020, including 21 (62%) who were admitted to two intensive care units (ICUs) dedicated to caring for COVID-19 patients. In late March, increasing COVID-19–related hospitalizations led to shortages in personnel, personal protective equipment (PPE), and medical equipment, resulting in changes to conventional infection prevention and control (IPC) practices. In late May, hospital A resumed normal operations, including standard IPC measures, as COVID-19 hospitalizations decreased, lessening the impact of personnel and supply chain shortages on hospital functions. CRAB cases subsequently returned to a pre–COVID-19 baseline of none to two cases monthly. The occurrence of this cluster underscores the potential for multidrug-resistant organisms (MDROs) to spread during events when standard hospital practices might be disrupted; conventional IPC strategies should be reinstated as soon as capacity and resources allow.

Hospital A is an urban, acute-care hospital in New Jersey with approximately 500 beds. In May 2020, hospital A notified NJDOH of an increase in CRAB (A. baumannii with meropenem minimum inhibitory concentration testing of ≥8 μg/mL) isolates from weekly ICU point prevalence surveys (colonization screening) and from clinical infections. Hospital A retrospectively reviewed microbiology records for CRAB isolated from inpatient specimens since November 2019 and instituted prospective surveillance of laboratory results to identify all CRAB isolates. Inpatients with hospital-acquired CRAB infection were defined as those for whom CRAB was isolated from clinical or colonization screening specimens collected on or after hospital day 3 and who had no earlier CRAB isolated from specimens during the same hospitalization; incident CRAB was a patient's first CRAB infection or colonization. Patients' demographic characteristics, diagnoses, treatments, disposition, and COVID-19 status were collected from medical records. Diagnoses of CRAB infection or colonization were determined by infectious disease specialists. NJDOH began an investigation to assess IPC practices at hospital A and gather additional data. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.*

During February–July 2020, 34 patients with hospital-acquired CRAB infection or colonization were identified, including 28 (82%) whose incident CRAB infection or colonization occurred during the facility's surge in COVID-19 cases (March–June 2020) (Figure), and 17 (50%) who had confirmed infection with SARS-CoV-2, the virus that causes COVID-19 (Table). Twenty (59%) incident cases were identified from clinical specimens and 14 (41%) through colonization screening. Median age of patients with CRAB infection was 55 years (interquartile range [IQR] = 48–64 years), and 28 patients (82%) were admitted from home. No patients had prior documented CRAB infection or colonization. The median interval from admission to incident CRAB infection was 19 days (IQR = 11–28 days). Twenty-five (74%) patients were intubated and mechanically ventilated at the time of specimen collection; those with COVID-19 were placed in a prone position. CRAB infection was diagnosed in 20 (59%) of the 34 patients, including 14 (41%) with clinically diagnosed CRAB ventilator-associated pneumonia, four of whom had bacteremia. At the time of this report, 23 (68%) patients with CRAB infection had been discharged, 10 (29%) had died, and one remained hospitalized.

Figure.

Number of admitted patients with COVID-19 (N = 846) and hospital-acquired carbapenem-resistant Acinetobacter baumannii (CRAB)* (N = 34), by month — hospital A, New Jersey, February–July 2020
Abbreviation: COVID-19 = coronavirus disease 2019.
*CRAB infection or colonization.

The multidrug-resistant CRAB definition (A. baumannii with documented resistance to three or more classes of antibiotics) was applied to hospital clinical laboratory antimicrobial susceptibility data for incident cases;[4] all 34 met multidrug-resistant CRAB criteria. Thirty isolates were further evaluated for carbapenemase genes through real-time polymerase chain reaction testing. Twenty-six isolates harbored the gene encoding the OXA-23 carbapenemase. Among these isolates, two from specimens collected in February and March harbored an additional carbapenemase gene, encoding New Delhi metallo-β-lactamase (a gene rarely present in CRAB isolates from patients in the United States), indicating that at least one CRAB introduction occurred before the surge of COVID-19 cases.[5] Four specimens were nonviable or did not yield CRAB growth.

During March–August 2020, hospital A admitted approximately 850 patients with COVID-19. The number of cases peaked on April 9, with 36 new hospitalizations and 61% of the inpatient census having a diagnosis of confirmed or suspected COVID-19. Pandemic-related resource challenges necessitated intentional changes to IPC measures. Before the pandemic, ventilator circuits and suctioning catheters were changed at specified intervals of every 14 days and every 3 days, respectively, unless malfunctioning or visibly soiled. To conserve equipment during the surge, the hospital's respiratory therapy unit instituted a policy to extend the use of ventilator circuits and suctioning catheters for individual patients, replacing them only if they were visibly soiled or malfunctioning. To conserve PPE, gown use as part of Contact Precautions§ was suspended for care of patients with the endemic MDROs vancomycin-resistant Enterococcus spp. and methicillin-resistant Staphylococcus aureus but was maintained for nonendemic MDROs such as CRAB. Gowns and gloves continued to be used for all patients when indicated for Standard Precautions, including wearing a gown when skin or clothing was likely to be exposed to blood or body fluids.** Anticipating shortages, hospital A also adopted an extended-use PPE protocol for N95 respirators and face shields. To prioritize personnel resources, activities of the MDRO workgroup, a multidisciplinary team responsible for guiding IPC policy around MDRO prevention efforts at hospital A, were suspended, along with biweekly bedside central venous catheter and indwelling urinary catheter maintenance rounds. Routine audits of appropriate PPE use, hand hygiene compliance, and environmental cleaning were also temporarily discontinued.

Responding to COVID-19–related care needs also resulted in other unintentional changes in standard practices for preventing the spread of MDROs and device-associated infections. IPC leadership noted less frequent patient bathing with chlorhexidine gluconate and a 43% reduction in ICU CRAB screening tests. These changes resulted from competing clinical priorities, challenges in personnel availability, and an effort to minimize staff members' interaction time with patients. The facility experienced critical shortages in personnel for nursing and environmental services, resulting from staff members' illness, quarantine, and a surge in the number of patients with COVID-19. Nursing resources were supplemented through agency and government entities; however, increased patient-to-staff member ratios and the need to minimize patient contact might have led to unidentified IPC breaches.

In early May, hospital A's IPC leadership advised physicians, unit managers, and environmental services of the CRAB cluster. Environmental services cleaned common areas and high-touch surfaces of ICUs with bleach. Proper hand hygiene and PPE use were reinforced through unit-based education, and compliance audits were restarted by mid-May. At the end of May, environmental services terminally cleaned and disinfected the COVID-19 dedicated ICUs and associated portable medical and respiratory equipment. IPC personnel and unit leadership reinforced CRAB surveillance culture protocol adherence.

*45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
Real-time polymerase chain reaction testing for carbapenemase genes was performed at the Clinical Laboratory Improvement Amendments (CLIA)–certified Northeast Regional Antimicrobial Resistance Laboratory located at the Wadsworth Center at the David Axelrod Institute in Albany, New York.
§ https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html#anchor_1564057963.
https://www.nj.gov/health/cd/documents/topics/NCOV/COVID_ppe_for_mdro_patients.pdf.
**https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....