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Case-Control Investigation of a DrugResistant Acinetobacter baumannii Outbreak at a Regional Medical Center in Eastern Kentucky, 2010 Alexander J. Freiman, MPH, CPH CDC/CSTE Applied Epidemiology Fellow Kentucky Department for Public Health June 15, 2011 1 Background A. baumannii Aerobic, gram negative bacteria Persist in environment Person-person or direct contact Drug resistance Outbreaks of multi drug-resistant (MDR) A. baumannii in healthcare setting a growing concern Healthcare-associated infection Especially in intensive care units (ICUs) 2 Background Kentucky Department for Public Health (KDPH) notified of Acinetobacter outbreak in September, 2010 66 cases initially reported Assistance requested from KDPH New Infection Preventionist Reported gaps in infection control process Hand hygiene Lacked comprehensive environmental cleaning protocols 3 Background Response team assembled from KDPH and began on-site evaluation CDC collaboration Medical epidemiologist Laboratory experts 4 Objectives Two main objectives Identify risk factors associated with recovery of A. baumannii in hospitalized ICU patients Investigate potential environmental sources of A. baumannii in healthcare facility 5 Methods Study Design Case-control Case definition: Laboratory-confirmed cultures of MDR A. baumannii ≥72 hours after hospital admission ICU admission January-September 2010 6 Methods Control definition ICU admission December 2009-October 2010 No history of A. baumannii infection in chart Controls were matched to cases 1:1 ICU admission date ICU length of stay 7 Methods Abstracted information from medical records Demographics Admission/discharge Medical history Laboratory results Consultations Procedures Medications 8 Methods Statistical Analysis Frequencies T-test, Chi square test, Fisher’s exact test Odds ratios between potential risk factors and MDR A. baumannii recovery using logistic regression Univariate Multivariate Conducted using SPSS software 9 Methods Collected environmental samples using wide sponge culturettes Site selection High touch surfaces in areas with infected patients Identified in previous studies CDC recommendations 10 Methods One sample taken at each of five sites ICU glucometer ICU medication dispensing unit ICU nursing station digital camera Portable x-ray machine Countertops in radiology unit 11 Methods Five environmental and three patient samples sent to state and CDC labs for pulsed field gel electrophoresis (PFGE) typing Similarity between strains from environmental and patient samples determined using computer software 12 Case Selection 13 Case Selection 14 Case Selection 15 Case Selection 16 Results Number of cases Epidemic curve for MDR A. baumannii cases in an eastern Kentucky regional medical center, 2010 (N=30) 9 8 7 6 5 4 3 2 1 0 Jan Feb Mar Apr May Jun Jul Aug Sep Month 17 Results Selected Characteristics of Cases and Controls Characteristic Race/Ethnicity Caucasian Non-Hispanic Age (in years) Mean Median Range Sex Female Comorbidity Diabetes Case n (%) Control n (%) P value 29 (97) 29 (97) 29 (97) 29 (97) 1.00 1.00 68 70 40-87 67 69 38-105 0.72 12 (40) 17 (57) 0.30 18 (60) 10 (33) 0.04 18 Results Source of MDR A. baumannii culture from cases (N=30) Source Respiratory Blood Wound Urine n (%) 19 (63) 5 (17) 4 (13) 2 (7) 19 Results Environmental culture results Site Portable x-ray machine ICU nursing station digital camera ICU medication dispensing unit ICU glucometer Countertops in radiology unit Result Positive Positive Negative Negative Negative 20 Results * * Patient 4 from another healthcare facility 21 Results * * Patient 4 from another healthcare facility 22 Results * * Patient 4 from another healthcare facility 23 Results * * Patient 4 from another healthcare facility 24 Results Crude Associations for Risk Factors and Positive MDR A. baumannii Culture Risk Factors Received subcutaneous or intravenous insulin Fingersticks performed Total number of chest x-ray procedures Diabetic Central line performed Decubitis ulcer present Consulted with occupational therapist Did patient have cardiovascular issues Obese *p value ≤ 0.05 OR 4.97 5.02 1.10 3.00 3.14 2.62 3.08 3.27 2.41 P value 0.014* 0.025* 0.032* 0.041* 0.043* 0.072 0.094 0.107 0.111 95% Confidence Interval (1.39, 17.82) (1.23, 20.49) (1.01, 1.21) (1.05, 8.60) (1.03, 9.55) (0.92, 7.46) (0.82, 11.50) (0.77, 13.83) (0.82, 7.10) 25 Results Crude Associations for Risk Factors and Positive MDR A. baumannii Culture Risk Factors Received subcutaneous or intravenous insulin Fingersticks performed Total number of chest x-ray procedures Diabetic Central line performed Decubitis ulcer present Consulted with occupational therapist Did patient have cardiovascular issues Obese *p value ≤ 0.05 OR 4.97 5.02 1.10 3.00 3.14 2.62 3.08 3.27 2.41 P value 0.014* 0.025* 0.032* 0.041* 0.043* 0.072 0.094 0.107 0.111 95% Confidence Interval (1.39, 17.82) (1.23, 20.49) (1.01, 1.21) (1.05, 8.60) (1.03, 9.55) (0.92, 7.46) (0.82, 11.50) (0.77, 13.83) (0.82, 7.10) 26 Results Crude Associations for Risk Factors and Positive MDR A. baumannii Culture Risk Factors Received subcutaneous or intravenous insulin Fingersticks performed Total number of chest x-ray procedures Diabetic Central line performed Decubitis ulcer present Consulted with occupational therapist Did patient have cardiovascular issues Obese *p value ≤ 0.05 OR 4.97 5.02 1.10 3.00 3.14 2.62 3.08 3.27 2.41 P value 0.014* 0.025* 0.032* 0.041* 0.043* 0.072 0.094 0.107 0.111 95% Confidence Interval (1.39, 17.82) (1.23, 20.49) (1.01, 1.21) (1.05, 8.60) (1.03, 9.55) (0.92, 7.46) (0.82, 11.50) (0.77, 13.83) (0.82, 7.10) 27 Results Adjusted Associations for Risk Factors and MDR A. baumannii Culture for Sampled Equipment Risk Factors OR P value 95% Confidence Interval Fingersticks performed* 4.34 0.048 (1.01, 18.62) Total number of chest x-ray procedures† 1.10 0.065 (0.99, 1.22) Decubitis ulcer photographed* 2.71 0.083 (0.88, 8.37) *Model adjusted for age, type of admission, and mechanical ventilation †Model adjusted for age, type of admission, and fingersticks 28 Results Adjusted Associations for Risk Factors and MDR A. baumannii Culture for Sampled Equipment Risk Factors OR P value 95% Confidence Interval Fingersticks performed* 4.34 0.048 (1.01, 18.62) Total number of chest x-ray procedures† 1.10 0.065 (0.99, 1.22) Decubitis ulcer photographed* 2.71 0.083 (0.88, 8.37) *Model adjusted for age, type of admission, and mechanical ventilation †Model adjusted for age, type of admission, and fingersticks 29 Discussion Lab cultures identified two possible sources for MDR A. baumannii transmission to patients in the facility Portable chest x-ray machine Digital camera used for wound photography PFGE pattern similarity between environmental and patient samples matched between 92-100% 30 Discussion Epidemiologic analysis suggests receiving fingersticks is a risk factor for becoming a case Breakdowns in disease prevention activities Hand hygiene Cleaning shared equipment Lack of clear equipment-cleaning responsibility might have contributed to ongoing transmission 31 Discussion Limitations Generalizability Reliability Small sample Cases: Controls only 1:1 Validity Lack of true electronic medical records Incomplete line listing from healthcare facility 32 Discussion Have procedures in place to clean all shared equipment Recognition of an outbreak and immediate implementation of effective controls is CRITICAL to preventing MDR A. baumannii transmission in the healthcare setting 33 Acknowledgments Kentucky Department for Public Health Margaret A. Riggs, PhD, MPH, MA Fontaine Sands, DrPH, MSN, CIC David R. Reese, MA, MPH, FRSPH Kraig E. Humbaugh, MD, MPH Doug Thoroughman, PhD, MS Robert L. Brawley, MD, MPH, FSHEA Centers for Disease Control and Prevention, Division of Healthcare Quality and Promotion Alexander J. Kallen, MD, MPH Judith Noble-Wang, PhD Heather A. O’Connell, PhD 34 Acknowledgments This study was supported in part by an appointment to the Applied Epidemiology Fellowship Program administered by the Council of State and Territorial Epidemiologists (CSTE) and funded by the Centers for Disease Control and Prevention (CDC) Cooperative Agreement Number 5U38HM000414. 35 Contact Information Alex Freiman CDC/CSTE Applied Epidemiology Fellow Kentucky Department for Public Health Phone: (502)564-3261 x3278 Email: [email protected] 36