Marianna Meschiari1, José-María Lòpez-Lozano2, Vincenzo Di Pilato3, Carola Gimenez-Esparza4, Elena Vecchi5, Erica Bacca6, Gabriella Orlando6, Erica Franceschini6, Mario Sarti7, Monica Pecorari8, Antonella Grottola8, Claudia Venturelli7, Stefano Busani9, Lucia Serio9, Massimo Girardis9, Gian Maria Rossolini10,11,12, Inge C Gyssens13, Dominique L Monnet14, Cristina Mussini6. 1. Infectious Disease Clinic, Azienda Ospedaliero-Universitaria Policlinico and University of Modena and Reggio Emilia, Modena, Italy. mariannameschiari1209@gmail.com. 2. Medicine Preventive-Infection Control Team, Hospital Vega Baja, Orihuela-Alicante, Spain. 3. Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy. 4. Chief. Intensive Care Unit, Hospital Vega Baja, Orihuela-Alicante, Spain. 5. Hospital Hygiene and Infection Control, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy. 6. Infectious Disease Clinic, Azienda Ospedaliero-Universitaria Policlinico and University of Modena and Reggio Emilia, Modena, Italy. 7. Clinical Microbiology Laboratory, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy. 8. Laboratory of Virology and Molecular Biology, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy. 9. Anesthesia and Intensive Care Unit, Azienda Ospedaliero-Universitaria Policlinico and University of Modena and Reggio Emilia, Modena, Italy. 10. Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy. 11. IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy. 12. Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy. 13. Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, 6525 GA, Nijmegen, The Netherlands. 14. European Centre for Disease Prevention and Control (ECDC), Solna, Sweden.
Abstract
BACKGROUND: Carbapenem-resistant Acinetobacter baumannii (CRAB) infection outbreaks are difficult to control and sometimes require cohorting of CRAB-positive patients or temporary ward closure for environmental cleaning. We aimed at controlling the deadly 2018 CRAB outbreak in a 12 bed- intensive care unit (ICU) including 9 beds in a 220 m2 open space. We implemented a new multimodal approach without ward closure, cohorting or temporarily limiting admissions. METHODS: A five-component bundle was introduced in 2018 including reinforcement of hand hygiene and sample extension of screening, application of contact precautions to all patients, enhanced environmental sampling and the one-time application of a cycling radical environmental cleaning and disinfection procedure of the entire ICU. The ICU-CRAB incidence density (ID), ICU alcohol-based hand rub consumption and antibiotic use were calculated over a period of 6 years and intervention time series analysis was performed. Whole genome sequencing analysis (WGS) was done on clinical and environmental isolates in the study period. RESULTS: From January 2013, nosocomial ICU-CRAB ID decreased from 30.4 CRAB cases per 1000 patients-days to zero cases per 1000 patients-days. Our intervention showed a significant impact (-2.9 nosocomial ICU-CRAB cases per 1000 bed-days), while no influence was observed for antibiotic and alcohol-based hand rub (AHR) consumption. WGS demonstrated that CRAB strains were clonally related to an environmental reservoir which confirms the primary role of the environment in CRAB ICU spreading. CONCLUSION: A five-component bundle of continuous hand hygiene improvement, extended sampling at screening including the environment, universal contact precautions and a novel cycling radical environmental cleaning and disinfection procedure proved to be effective for permanently eliminating CRAB spreading within the ICU. Cohorting, admission restriction or ICU closure were avoided.
BACKGROUND: Carbapenem-resistant Acinetobacter baumannii (CRAB) infection outbreaks are difficult to control and sometimes require cohorting of CRAB-positive patients or temporary ward closure for environmental cleaning. We aimed at controlling the deadly 2018 CRAB outbreak in a 12 bed- intensive care unit (ICU) including 9 beds in a 220 m2 open space. We implemented a new multimodal approach without ward closure, cohorting or temporarily limiting admissions. METHODS: A five-component bundle was introduced in 2018 including reinforcement of hand hygiene and sample extension of screening, application of contact precautions to all patients, enhanced environmental sampling and the one-time application of a cycling radical environmental cleaning and disinfection procedure of the entire ICU. The ICU-CRAB incidence density (ID), ICU alcohol-based hand rub consumption and antibiotic use were calculated over a period of 6 years and intervention time series analysis was performed. Whole genome sequencing analysis (WGS) was done on clinical and environmental isolates in the study period. RESULTS: From January 2013, nosocomial ICU-CRAB ID decreased from 30.4 CRAB cases per 1000 patients-days to zero cases per 1000 patients-days. Our intervention showed a significant impact (-2.9 nosocomial ICU-CRAB cases per 1000 bed-days), while no influence was observed for antibiotic and alcohol-based hand rub (AHR) consumption. WGS demonstrated that CRAB strains were clonally related to an environmental reservoir which confirms the primary role of the environment in CRAB ICU spreading. CONCLUSION: A five-component bundle of continuous hand hygiene improvement, extended sampling at screening including the environment, universal contact precautions and a novel cycling radical environmental cleaning and disinfection procedure proved to be effective for permanently eliminating CRAB spreading within the ICU. Cohorting, admission restriction or ICU closure were avoided.
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