Alexander J. Freiman, MPH, CPH CDC/CSTE Applied Epidemiology Fellow

1. Case-Control Investigation of a Drug-Resistant 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

2. 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)

3. 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

4. Background • Response team assembled from KDPH and began on-site evaluation • CDC collaboration • Medical epidemiologist • Laboratory experts

5. 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

6. Methods • Study Design • Case-control • Case definition: • Laboratory-confirmed cultures of MDR A. baumannii ≥72 hours after hospital admission • ICU admission • January-September 2010

7. 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

8. Methods • Abstracted information from medical records • Demographics • Admission/discharge • Medical history • Laboratory results • Consultations • Procedures • Medications

9. 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

10. Methods • Collected environmental samples using wide sponge culturettes • Site selection • High touch surfaces in areas with infected patients • Identified in previous studies • CDC recommendations

11. 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

12. 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

13. Case Selection

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17. Results

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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 * * Patient 4 from another healthcare facility

25. Results

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30. 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%

31. 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

32. Discussion • Limitations • Generalizability • Small sample • Reliability • Cases: Controls only 1:1 • Validity • Lack of true electronic medical records • Incomplete line listing from healthcare facility

33. 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

34. Acknowledgments 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 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

35. 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.

36. Contact Information Alex Freiman CDC/CSTE Applied Epidemiology Fellow Kentucky Department for Public Health Phone: (502)564-3261 x3278 Email: Alex.Freiman@ky.gov