Continuing Education

Acinetobacter baumannii
An Emerging MultidrugResistant Pathogen in Critical Care
Kerry Montefour, RN, BSN, CIC Jeanne Frieden, BA, RN, BSN, CIC Sue Hurst, RN, MSN, CCRN Cindy Helmich, RN, MBA, CCRN Denielle Headley, RN, BSN Mary Martin, PharmD Deborah A. Boyle, RN, MSN, AOCN

cinetobacter baumannii is a troublesome and increasingly problematic healthcare-associated pathogen, especially in critical care.1-4 It may be associated with hospitalacquired infections with considerable clinical and economic costs. In physiologically compromised patients, morbidity and mortality are common sequelae of hospitalThis article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives: 1. Identify factors that contribute to the emergence and significance of Acinetobacter baumannii in healthcare environments 2. Describe the characteristics of A baumannii and the associated risk factors for development of A baumannii infections 3. Discuss nursing interventions, infection control measures, and clinical recommendations for prevention and containment of A baumannii infections


acquired infections.4-7 Hence, multiple professional organizations have identified multidrug-resistant Authors

(MDR) pathogens as a critical target that requires intervention (Tables 1 and 2).

All authors are associated with Banner Good Samaritan Medical Center, Phoenix, Arizona. Kerry Montefour is the director of the infection control program. Jeanne Frieden is an infection control practitioner. Sue Hurst is a critical care clinical nurse specialist in medical-surgical and transplant intensive care units. Cindy Helmich is the director of nursing for the medical cardiology service and inpatient wound care. Denielle Headley is the nurse education specialist for the medical-surgical and transplant intensive care unit. Mary Martin is the associate director of the antimicrobial management team. Deborah A. Boyle is the practice outcomes nurse specialist and Magnet coordinator.
Corresponding author: Kerry Montefour, RN, BSN, CIC, Banner Good Samaritan Medical Center, 1111 E McDowell Rd, Phoenix, AZ 85006 (e-mail: To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail,


For example. The evolution of this infection commonly occurs in chronically ill patients who have multiple comorbid conditions. Target the pathogen 4. Vaccinate 2. Isolate the pathogen 12. urinary tract. and are of advanced age. Key elements of outbreak control and nursing care interventions associated with this resistant strain had not been identified. or undiagnosed Prevent transmission 11. and its outbreak potential. Treat infection. Treat infection. Get catheters out Diagnose and treat infection effectively 3. its association with antimicrobial resistance. Morphological findings vary according to the phase of cell growth and exposure to antimicrobial agents. A baumannii grows at various temperatures and pH environments and uses a vast variety of substrates for growth. moist surfaces. the formation of a biofilm on the surface of the endotracheal tube may be the source of colonization of the lower part of the airway. The role of A baumannii in hospital-acquired infections is associated with 3 factors: its diverse reservoir. not colonization 9. have multiple invasive procedures.4. we provide a synthesis of the 16 CRITICALCARENURSE Vol 28. In this article. which resulted in few findings. surgical wounds. Use local data 7. Ask the experts Use antimicrobials wisely 5. The organism can survive for long periods on both dry and Our experience with managing an outbreak of MDR A baumannii in a medical intensive care unit (ICU) prompted an evidence-based review of the literature. The respiratory tract. . not contamination 8.6 A total of 19 strains of A baumannii have been identified.6 Widely distributed in soil and water. central nervous system. A baumannii infections may be fatal in those with suboptimal immune defenses. a chronology of our efforts to control the outbreak.Table 1 Actions of professional organizations and recommended interventions for outbreaks of infections caused by multidrug-resistant organisms Centers for Disease Control and Prevention • Identified antimicrobial resistance and lack of new drugs coming to market as a major health threat (1997) • Created a 12-step initiative to increase awareness of resistance and implement strategies to prevent the development of resistance in various populations8 Centers for Disease Control and Prevention and Food and Drug Administration • Cochaired a 10-agency task force (1999) • Published A Public Health Action Plan to Combat Antimicrobial Resistance9 Infectious Disease Society of America • Initiated the program Bad Bugs No Drugs10 to enlighten federal policymakers about the inadequacy of the pharmaceutical pipeline in the development of new antimicrobial agents American Society for Microbiology and the Society for Healthcare Epidemiology of America • Created the Antimicrobial Resistance Prevention Initiative.12 Although inconsequential to hosts with intact immune systems. administer medications. the reservoirs of this pathogen are poorly understood.11 The indiscriminate nature of this organism and its recent acquisition of MDR intensify its emergence and significance in healthcare environments.5 Acinetobacter baumannii normally inhabits skin. aerobic.3. unlikely. in patients receiving mechanical ventilation. and recommendations for responding to A baumannii infections in ICU settings. Practice antimicrobial control 6.2. and soil. FEBRUARY 2008 http://ccn.6 Acinetobacter baumannii is nonselective in its habitat (Table 4) and can survive indefinitely. mucous membranes. a program providing ongoing education exploring epidemiology and molecular mechanisms of resistance Clinical and Laboratory Standards Institute • Developed standard reference methods for antimicrobial susceptibility tests Table 2 Centers for Disease Control and Prevention: 12 steps to prevent antimicrobial resistance among hospitalized adults8 Prevent infection 1. blood. are hospitalized for long periods. and eyes may be sites of infection or colonization. gram-negative coccobacillary rod. Stop treatment when infection is cured. opportunistic. and provide lifesaving support may also be sources of colonization. pleural fluid. Break the chain of contagion medical literature on A baumannii. No. Growth Reservoir Although risk factors for A baumannii infection have been well described.11 Invasive devices used to facilitate fluid monitoring. 1.6.15 Inert surfaces such as those listed in Table 4 appear to be improbable sources of Literature Review Characteristics of A baumannii and A baumannii Infections Acinetobacter baumannii is a nonfermentive. Risk factors encompass those for hospital-acquired MDR infections and ventilator-associated pneumonias (Table 3).aacnjournals. Know when to say no to vancomycin 10. peritoneum.

21. In the previous 6 months. and poor tissue penetration by the antimicrobial agent.30-33 These genes are acquired rapidly and contribute to the development of Table 4 Potential hospital environmental sources of Acinetobacter baumaniii 3. increased incidence of MDR A baumannii in military personnel injured in Iraq.3.13-16 Advanced age Antimicrobial therapy within past 90 days Use of artificial devices • Dialysis (chronic) within past 30 days • Mechanical ventilation • Sutures • Catheters • Central venous • Intravenous • Urinary Evidence of high-frequency antibiotic resistance in the community or hospital Severe immunocompromise due to disease or therapy Multiple comorbid conditions Prolonged hospitalization (especially critical care) or residence in an extended care facility numerous surfaces in providing care.12. antimicrobial resistance probably originated from resistance genes that are transferred between bacterial species.Table 3 Risk factors for acquiring Acinetobacter baumannii 4-6. Phoenix. abbreviated or interrupted courses of treatment.9. and Afghanistan has been reported. Development of Antimicrobial Resistance Antimicrobial resistance has become a national problem.4.17. urinary) Injection of medications from multidose vials Room variables Bed rails Blood pressure cuffs Cupboards Door handles Intravenous stands Linens Foam mattresses Paper towel dispensers Pillows Containers for sharp objects Sinks Table tops Mechanized equipment Air conditioners Hemodialysis machinery Infusion pumps Key panels of monitors. the microbiology specialist at Banner Good Samaritan Medical Center.15. Despite the diversity of host sites of A baumannii. FEBRUARY 2008 17 .16 including administration of subtherapeutic doses of antimicrobial agents.24-26 An organism is considered resistant when its growth in vitro is not inhibited by an antimicrobial agent that has been associated with eradication of the organism in vivo.8.25. continuous venovenous hemodialysis machinery Mattresses with pneumatic pumps Ventilators. inadequate hand hygiene remains a significant factor in the transmission of this pathogen.aacnjournals. but culturing of specimens obtained from these areas has indicated the prominence of the surfaces in the evolution of A CRITICALCARENURSE Vol 28. computers. This number was a dramatic increase.18 Cross-transmission of MDR A baumannii occurs via direct contact from hands (especially in persons with damaged skin from chronic dermatitis) and gloves from healthcare professionals to patients. reported that 5 extremely resistant isolates of A baumannii had been cultured during a 2-week period. No.12.22 An Outbreak of MDR A baumannii In mid-December of 2005.28 In A baumannii. Arizona. Kuwait. Infection with A baumannii was diagnosed after the personnel were transferred to major military hospitals in Western Europe.5.6. drug overuse.18 Colonization on the skin and contamination on glove surfaces may be direct or indirect as the healthcare provider touches the patient and/or http://ccn. All of the December isolates were from 5 patients in medical ICUs. central lines.10.6.18 Of note. resistant A baumannii had been isolated from only 11 specimens.4. 1.19 The majority of the injured had had traumatic injuries in the field. and all 5 patients were receiving mechanical ventilation.20-29 Acinetobacter baumannii organisms are readily removed by most hand cleansing agents and by the environmental cleaning done in hospital settings. respiratory equipment Liquids Blood products Enteral formulas Saline Soaps and detergents Water • Distilled • In humidifers • Nonsterile A baumannii.18 Supplies Crash cart Weighing hammocks Protective masks Shared equipment Invasive equipment and interventions Catheters (ie. Causes of resistance vary but are often linked to inappropriate initial antimicrobial therapy.

8 0.8 39. organism among patients and may be predictive of an impending outTable 5 Susceptibility of Acinetobacter baumannii isolates to antimicrobials at Banner break of A baumannii infections. cle. Potenit into a different bacterial cell. imipenem (Table 5). FEBRUARY 2008 http://ccn.4 23.3 72. Resistant A baumannii often become apparent as a cluster of infections caused by the bacterium. Resistance to baumannii in meropenem for the MDR isolates the ICU have 5 antimicrobial resistance.LLC. January 2005-April 2006 Plasmid donor Plasmid 8 Susceptibility of isolates. (b) During the time of our outbreak.9 National39 (>8000 isolates) 80.6 62.1 Not available 47. classes of whole plasmids containing one or more genes into bacteria.25. Dust has the genes are inherited. 1. such as imipenem outbreaks occur gene resistance genes and meropenem.3 16.2 19.36 Currently. received close scrutiny. some emerge Tests for susceptibility to colistin been identified as a potential vehi17 from random DNA mutations in and tigecycline were also performed.18 testing resulted in an unpreceagents. single source a Plasmid Because of the scope of technological with widespread transfer Resistance gene equipment within critical care.5. An outbreak may Antimicrobial Amikacin Ampicillin/sulbactam Aztreonam Cefepime Ceftazidime Ciprofloxacin Gentamicin Imipenem Levofloxacin Piperacillin/tazobactam Trimethoprim/ sulfamethoxazole Tobramycin Medical center (18 isolates) 25.25. in bial resistance may be a harbinger.5 . viral delivery bacterium response in infections caused by Most MDR MDR A baumannii.4 Good Samaritan Medical Center and in the United States.8 15. carbapenems have can be veriDead b Transfer by 4.aacnjournals. mannii.5.0 16.0 16. of transmission of the Laboratory Standards Institute did hemodialysis machinery. tigecycline and colistimethrecovered from dust within pneuEvidence of A baumannii antimicroate are 2 of the most frequently used matic and electronic equipment.and air conditioner parts despite filoriginate from a ters placed at air inlets and outlets. ventilators. No. the outbacteria. A baumannii Bacterium Resistance receiving carbapenems.7 70. % Outbreak Potential The evolution of A baumannii infections and their associated relationship with outbreaks correlate with the virulence of the strain.6 42.2 41. involve resistsusceptibility testing is still required Figure 1 Bacterial acquisition of resistance genes.1 6.1 18 CRITICALCARENURSE Vol 28. The Clinical and air filters of continuous veno-veno or indication.4 Cases are often aggregated by time and place within settings.0 52. In one investigation. and others are imported For carbapenem-resistant A baubreak strain of A baumannii was 33 from related bacteria (Figure 1). dented 38% resistance rate to tial sources of A Reprinted from Levy.33-37 resulted in the best therapeutic fied. unknown mechanisms appear to impede desiccation of this pathogen. and (c) bacteria assimilate genebearing components of DNA within their immediate vicinity.2 16. with permission from Tomo Narashima/Tane+1.0 52. this environmental Resistance potential source of A baumannii contamination gene should receive further investigation. Bacteria gain ance to multiple resistance genes by 3 major methods: (a) donor cells transmit when this pathogen is identified. Some of was close to 100%. antimicrobial a virus acquires a resistance gene from a bacterium and injects 4.8 20. remain the widely in critical care Bacterium infected recognized drug of choice for A bausettings and by a virus mannii infections.38 Nevertheless. alternative agents.4 67. or where no c Transfer of free DNA reservoir for the Antimicrobial Management contamination Historically. Inherent.

and pulmonary toxic effects are significant adverse events associated with this drug. indicating the potential clinical effectiveness of tigecycline. the susceptibility of MDR A baumannii at the medical center February through June 2006 was 71%.5 to 8 hours. a parenteral antimicrobial produced by Bacillus colistinus.aacnjournals. The combination of colistimethate and tigecycline was prescribed for many of our patients because the severity of illness. Of note. Tigecycline’s mechanism of action involves binding to the 30S ribosomal subunit and blocking protein synthesis. Colistimethate was used clinically because of its proven ability to treat infections caused by MDR A baumannii and other MDR organisms. Contact precautions were implemented for the patients who had infections caused http://ccn.not provide interpretation of “susceptible”.0 μg/mL for 739 isolates of Acinetobacter. Colistin acts as a cationic detergent to damage the bacterial cell wall. limited susceptibility information.39 In one study. By the E-test strip method. with a maintenance dose of 50 mg every 12 hours. Nephrotoxic. In mid-February 2006. No. No commercial method for monitoring the therapeutic level of colistin is available in the United States. No dose adjustment is required for patients with renal impairment or mild to moderate hepatic impairment. Tigecycline has a 7 to 9 L/kg volume of distribution and a half-life of approximately 42 hours. Hence. The goal is to determine the in vitro minimum inhibitory concentration. 1. During the outbreak. Colistin is eliminated via the kidneys and has a half-life of 1.38 in susceptibility testing. a new broad-spectrum minocycline derivative. FEBRUARY 2008 19 . Colistimethate Colistimethate is an not well established.40 According to The Surveillance Network. discussions occurred between personnel in infection control and the nurse managers of the affected ICUs.5%).) Results and interpretations of the E-tests were provided to clinicians according to the Food and Drug Administration’s interpretive guidelines to provide more standardized and informational guidance to physicians. the minimum inhibitory concentration required to inhibit the growth of 90% of organisms in vitro was 2. resulting in leakage of intracellular substances and cell death. this resistance pattern has emerged despite restriction of tigecycline to treatment of MDR organisms that were sensitive only to colistin and tigecycline. only 39% of isolates obtained from July through December 2006 were susceptible. received approval from the Food and Drug Administration in June 2005.7%). Major side effects include nausea (29. (E-test strips are impregnated with a predefined antibiotic gradient. Susceptibility to tigecycline has rap- idly declined. Tigecycline Tigecycline. and dose and interval adjustments of the drug are recommended. no polymyxin B–resistant organisms were identified. is approved for treatment of complicated skin and skin structure infections and intra-abdominal infections caused by susceptible organisms.7%). and 22% of those obtained from January through June 2007. Tigecycline. Dose and interval adjustments are recommended for patients with creatinine clearance less than 75 mL/min.41 The most common dose of colistimethate is 2. “intermediate.4%. dosing modifications for patients with renal impairment are broad-spectrum bacteriostatic agent.5 mg/kg intravenously every 12 hours for patients with normal renal function.37 the susceptibility of A baumannii isolates to polymyxin B in the United States is CRITICALCARENURSE Vol 28. also known as polymyxin E. However.38. Colistin is poorly removed by hemodialysis.” and “resistant” for susceptibility to tigecycline because of a lack of correlating clinical data. It became commercially available in 1959. Patients with renal impairment require monitoring of renal function.36 Infection Control Measures Once the cluster of MDR A baumannii was recognized. vomiting (19. It is approved by the Food and Drug Administration for treatment of acute or chronic infections due to susceptible gramnegative bacteria. only the size of the area of growth inhibition could be reported. Colistimethate is hydrolyzed to colistin. the interpretation of these findings was left up to individual physicians. They are placed on agar culture plates that have been inoculated with the organism. Use of this agent has been limited because of its nephrotoxicity and the availability of less toxic agents. the use of tigecycline E-test strips was implemented by our microbiology laboratory. and diarrhea (12. Without an interpretation. and lack of clinical outcome data for tigecycline. neurotoxic. A loading dose of 100 mg is recommended.39 We subsequently used tigecycline because of the reported in vitro susceptibility of A baumannii to this drug.

Additional education was done with clinical staff (nurses. 80% were the same type. physicians. As new patients continued to be identified. had not been following strict contact precautions. contact precautions were implemented empirically for all patients in that nursing unit who were receiving mechanical ventilation. verifying that the cleaning with our disinfectant was MDR A baumannii. 1. Recent reports of PFGE testing to prove clonal spread is useful in determining the appropriate actions to control an outbreak. and in both instances. portable x-ray machine). bed rails.43 The results of our request for PFGE testing prompted the state health department to investigate the prevalence of MDR A baumannii throughout Phoenix. ready for use. Extensive education was done with the environmental services staff about the importance of attention to detail in room cleaning. 20 CRITICALCARENURSE Vol 28. 2006. and a quarter of those had indications of single point mutations. The bronchoscopes were tracked. and ventilator faces. Random specimens for culturing were taken in patients’ rooms from frequently touched surfaces. Transmission via bronchoscopes was also investigated. in addition. automatic medication-dispensing machines. including beds. This precaution has continued. All specimens were negative for A baumannii. A new procedure for active surveillance was initiated. Equipment was dedicated to that unit as well (eg. Ventilator use did not explain patient transmission. use of the bronchoscope in patients who became infected with A baumannii was separated by at least a 2-week period. indicating that although the isolates appeared to come from a single source. and so on. hand hygiene. and all the technicians were well trained and had received updated annual in-service education. No. this organism had been circulating in the area for a while. and the unit was closed to other patients. In order to verify that the isolates were related. data on the positive environmental cultures were used to reinforce the need for strict contact precautions with gowns. Nursing staff reported that some colleagues. as per hospital policy for any patient with an MDR organism. is a strategic intervention to limit outbreaks of infections caused by MDR organisms. It was verified that our hospital disinfectant (a quaternary ammonium compound) was effective against Acinetobacter. Each time MDR A baumannii was isolated from a new patient receiving mechanical ventilation. 6 occurred in patients receiving mechanical ventilation. Exhalation filters on several random ventilators. but also other staff working on and off the units. Additionally. the circuits on the machine were discarded and the outside of the machine was disinfected. No new technicians were cleaning the bronchoscopes. and their use in patients affected by the outbreak was determined. so attention was focused on the ventilators. isolates from 4 patients were sent to the Arizona state laboratory for ribotyping and pulse field gel electrophoresis (PFGE). We investigated environmental sources of contamination at the medical center. Cohorting was discontinued on March 1. Of the first 9 cases at the medical center.42 The patients were moved to a single ICU.aacnjournals. and respiratory therapists). It was verified that when mechanical ventilation was discontinued. and the instrument was used in between on other patients who did not become infected. Only 2 bronchoscopes were used on more than a single patient with MDR A baumannii. The investigation indicated some unrecognized endemicity of this organism in the greater Phoenix area. FEBRUARY 2008 http://ccn. Of 13 cultures. contact precautions were implemented empirically until a sputum specimen negative for A baumannii was obtained. all were negative for A baumannii. it became apparent that contact precautions were not controlling the . 7 were positive for A baumannii. were cultured. Cleaning procedures were reviewed. particularly physicians. intravenous pumps. The ventilators used on patients who had A baumannii infections were. Of the Phoenix isolates tested. Cohorting or keeping patients who have the same illness together. Later. and computers). telephones. The use of the precautions was continued until a sputum specimen negative for MDR A baumannii was obtained from each patient. for any patient admitted from an outside facility who was receiving mechanical ventilation or had a tracheostomy. Results confirmed that the isolates were identical. sent to the decontamination department for extensive cleaning. Nursing and respiratory staff were dedicated to that unit: they did not respond to code calls or assist in other units during their shift. The respiratory therapy department created a spreadsheet to track specific ventilator use on individual patients. specimens were obtained from vacant cleaned rooms in the cohort nursing unit and at the nurses’ station (ie.

Staff Responses to the Outbreak At the beginning of the outbreak. with this model of cohorting infectious patients.aacnjournals. booties. including physicians. The staffing implications also affected respiratory therapy staff. As the outbreak continued and core staff began to understand the need and purpose for cohorting. tests. Questions and uncertainties filled the day: Should I shower at work? Should I change my scrubs before going home? Will I become infected? News of the unit’s cohorting status quickly spread throughout the hospital.” These names created an even deeper sense of isolation for the nursing staff working there. Of note was their need to coach all healthcare workers. and most of the nurses were unfamiliar with the threat it posed to themselves and their families. Staffing these cohort units increased the variance between budgeted and actual costs. and isolation signs covered the entire unit. because they were restricted to the cohort unit for the duration of a shift. As isolation precautions intensified. no tracheostomies. extensive education was CRITICALCARENURSE Vol 28. As might be expected. these personnel needed more resources to provide ongoing. The unit became known as the “quarantine” or the “bug unit. The latter patients had to be at low risk for infection: no mechanical ventilation. Acinetobacter baumannii was an unknown organism to the staff. and how long the unit would remain cohorted. Second. A second cohort unit was started at the end of May 2006.when only 2 patients remained in the unit and no new patients had been identified for 3 weeks. the nursing management and infection control teams made rounds at least daily. The initial days were characterized by questions about what to wear. Everyone seemed to have a fear of working here. what not to touch. and no surgical or open wounds. fear dissipated and the staff assumed ownership of this special http://ccn. After 3 weeks. 3 patients remained. on a continuing basis. The staff were stigmatized and characterized as being different. Information: Getting Out a Consistent Message During the cohort experience. FEBRUARY 2008 21 . Some staff members asked to be transferred. As a result. Most of the patients required a 1 to 1 nurse to patient ratio because of the frequency of treatments. how often to wash hands. No new clusters of patients infected with this organism have occurred since that time. and at times more often. First. timely. The flyer was updated periodically to keep the staff informed of any new issues or pertinent clinical changes related to Acinetobacter. Some would refuse. who interacted with patients to ensure that proper contact precautions were being adhered to during patient contact. but when 8 patients in different ICUs with such infections were identified during the same time frame. so did patient acuity. to increase compliance with contact precaution measures. Nurses feared for their health and that of their families. No. an “Acinetobacter update” flyer (Figure 2) was created. the decision was made to open a cohort unit. challenges during the use of a cohort unit included matching the number and types of staff required with available resources. The nurses who remained felt an overwhelming sense of exhaustion as each day the requirement to gown and glove upon entering a patient’s room seemed increasingly burdensome. it was necessary to update all healthcare providers around the clock. One staff nurse said the following: I remember working on the A baumannii unit for the first time: gowns. Additionally. we used multiple strategies to quickly bring the most current information about the cohorting procedure to the nursing staff. Intermittent cases of MDR A baumannii infections had been identified. and often that ICU did not require a respiratory therapist full time. gloves. and drug therapies. nearly 3 months after the first cohort unit had closed. a general sense of fear and uncertainty existed in the unit. and the unit was opened up to patients who did not have A baumannii infections. to update the staff about the situation and to address questions. These rounds provided a time for day and night nursing staff to speak with infection control staff and to inform managerial staff of the nurses’ needs. members of the nursing staff were required to assume additional responsibilities. 1. Because the members of the nursing staff were the liaisons and primary educators for what was transpiring in the units. Staffing Impact Staffing needs of a cohort unit vary from the usual. and accurate information to a variety of colleagues involved in the unit’s functioning. In addition.

Question of the Week What kind of patient can be paired with an Acinetobacter patient? Ideally. . vent. compiling education posters for display throughout our hospital so that others could understand more about this bacterial outbreak. this may be an organism that is here to stay. mechanical ventilation. we are no longer cohorting patients. √ Notify Infection Control x 34390. Acinetobacter baumannii is most common in ICU and burn patients. The most recent nosocomial isolates of resistant Acinetobacter were in sputum specimens from 2 of our patients. draining wound. the routine process of sending a patient for a medical imaging procedure became a seemingly unyielding event because of the increased demands for preparation. Please call ***** (x 34390 or page 555-5555) if you have any concerns and please refer to these evolving updates for continued information. ICU. have a trach. often found in soil and water and can be isolated readily from many sources in the environment. Patients at highest risk are very ill. LTC. FEBRUARY 2008 http://ccn. I became an advocate for proper education to doctors. and nursing management. a 1:1 assignment is preferred. Arizona. or have large or draining wounds. nurses. timely information. The Arizona Department of Health Services has been collecting isolates from hospitals around Arizona and most have turned out to be identical strains. It poses very little risk to healthy people. and performing the procedure. In hospitals. the nurse should be assigned to a non-vented/non-trached patient. Such patients are placed into Contact Precautions upon admission. population of patients. on ventilators. intensive care unit. For example. The initial struggle evolved into a shared ownership between the critical care nursing staff.. If that is not possible. √ Obtain a culture of the site (i. and remain so until screening cultures are finalized. An added burden was also imposed on staff 22 CRITICALCARENURSE Vol 28. may leave a message. trach. Resistant strains of this bacteria have developed recently throughout the United States and are difficult to treat. It had been a month since the last one was identified on 2/26/06. draining wound. have open wounds and/or have many invasive devices. or who are vented: √ Immediately upon Admission. transportation. I remember working on the A baumannii outbreak unit for 3 months straight.e. 2006 Due to the newness of this pathogen and the evolving nursing care requirements associated with this patient population. Phoenix. Strict adherence to Contact Precautions and optimum hand hygiene remain the standard of care. and other healthcare providers. For patients admitted from LTC with a trach. infection control specialists. It can survive for long periods of time in the environment and tolerates both moist and dry conditions. Reprinted with permission of Banner Good Samaritan Medical Center. endotracheal tube.aacnjournals. 1. both collected on 3/22/06. a periodic newsletter will be sent to critical care areas to ensure all staff have access to updated. Definition: Acinetobacter baumanii is a gram-negative bacteria.Critical Care Nursing News Acinetobacter Update March 24. and one with few invasive devices or draining wounds. long-term care. for a patient in an ICU. or ET tube). As of March 1st. One nurse remarked as follows: Core staff became comfortable with the isolated unit. Figure 2 Example of an Acinetobacter update flyer. tracheostomy. The need to compre- hensively educate the hospital and public became a joint venture. This is the second newsletter in this series of updates. Abbreviations: ET. planning. place the patient in Contact Precautions. These resistant organisms have been found in many hospitals around our valley. In the long term. trach. We are continuing to screen all patients being transferred to us from long term care facilities if they are vented. one who has not had recent surgery.

track patient use Educate and communicate with staff Develop educational programs for all departments: respiratory therapy. when done on inpatients. who remained in the unit to oversee patient care in the absence of the nurse deemed responsible for care during this time. Patients with known clinical infection most likely represent only a small percentage of microbial colonization/ contamination. and equipment Cohort patients. check disinfectant. the support of nursing management and the infection control specialists sustained the core nursing staff by providing daily effective communication and listening to staff members’ concerns about and reactions to this intense experience. effective hand hygiene. have tools to Attention to detail is what is needed preventive educate and coach other colleagues in complying with precautions procedures Environmental cleaning: verify procedures and education of housekeeping staff. health departments) Save emails Start a sequential list of patients Cohort patients. and so on Environmental culturing: can be done if for no other reason than to reassure staff Bronchoscopes (if implicated by culture sites): review cleaning and sterilization process. patients from long-term care facilities who were receiving mechanical ventilation or had a tracheotomy and any patient with draining wounds were high risk. he or she is often heavily pretreated and highly compromised and thus vulnerable to a number of potentially fatal sequelae.aacnjournals. meetings. facilitates earlier uses of contact precautions for colonized and infected patients Organize response Start a time line: include all actions. close unit to noninfected and noncolonized patients Cohort staff: respiratory therapists and nurses remain in the cohort unit. physicians and visitors. giving all staff the benefit of others’ questions Emotionally healthy staff can change the experience for patients.Table 6 Recommendations for control of Acinetobacter baumanii outbreaks Action Recommendations Rationale Actions can be reviewed in an organized manner to help determine next steps Organization facilitates financial assessment of outbreak if required at a later date Cohorting assists in containing organism Cohorting helps nursing staff enforce meticulous attention to hand hygiene and contact precautions Use of active surveillance cultures facilitates earlier use of contact precautions for colonized and infected patients Use of active surveillance cultures and empiric precautions while awaiting results. as the decrease in the number of infected patients became obvious. No. transport. medical imaging. portable x-ray machine) Use active surveillance cultures on admission of high-riska patients throughout hospital If cohort unit is discontinued. Although staff nurses were obviously approaching “burnout” near the culmination of this experience. FEBRUARY 2008 23 . it can be the difference between success and failure Provide emotional Anticipate emotional needs of cohort staff: provide food. dietary/nutrition Develop a newsletter or other communication tool to address concerns or information needs Create a question box and post the questions and answers daily Knowledge equals power All staff must be included to ensure comprehensive team effort Information in writing avoids pitfalls of misinterpretation of answers and missed CRITICALCARENURSE Vol 28. type of filters Often an outbreak ends without an are all in Contact precautions: verify that staff have enough personal identified culprit compliance with protective equipment. education. signifying the http://ccn. and institutional education had worked together to combat the spread of MDR A baumannii. are following procedures. consider active surveillance cultures on all high-risk patients in a nursing unit each time a new patient with resistant A baumannii is identified Ensure that staff Ventilators: determine cleaning used. staff. staff realized how the combination of cohorting. Finally. use support for chaplaincy or music therapy in-house teams. do not respond to code calls during shift Cohort equipment (eg. how it is mixed. 1.4 By the time a patient arrives in the ICU. to outbreak consultations (eg. Clinical Recommendations The first and foremost clinical recommendation for preventing outbreaks of MDR A baumannii infec- tion is early recognition: develop a method to track the incidence and resistance patterns of all Acinetobacter isolates in your critical care areas. arrange for times to professional vent/share frustrations on a regular basis caregivers a During the outbreak at Banner Good Samaritan Medical Center. environmental services.

and • Laboratory services (eg. Mark F. type. additional surveillance cultures. These complex patients also require fine-tuned teams with respect for specialty knowledge. 24 CRITICALCARENURSE Vol 28. particularly in critical care. interdisciplinary. Banner Health.44 In the United States. Adarsh Khalsa.4 We make no recommendations about staffing for patients with MDR pathogens. psychologist unit manager. with a total cost of nearly $5 billion. number physicians.22 Increases in the number of such patients will require added nursing resources and expertise. Consideration of Cost The costs associated with a hospital-acquired infection are significant. and intensity of adverse reactions to multiple drug therapies remain unknown. In our experience with an outbreak of infections caused by MDR A baumannii. and ICU staff and physicians at Banner Good Samaritan Medical Center.45 The cost of treating resistant hospital-acquired infections is staggering. pulse field gel electrophoresis testing) polypharmacy) • Staff comIndirect • Onsite time for chaplain. Laboratory Sciences of Arizona. the hospital may lose more than $2 million in potential revenue because of the loss of nearly 300 hospital-bed days because of room closings. and most researchers did not describe the monitoring of infection control practices. yet account for more than 30% of hospital budgets and 8% of healthcare costs45-47 (Table 7).aacnjournals. Frequency of culturing. an extended mean length of hospitalization of 24 days. Our list of recommendations for facilities that must address the management of A baumannii infections fall into 5 categories (Table 6). MD. Financial Disclosures None reported. a high-quality team effort was responsible for a timely. cohorting patients. equipment) and its impact on the magnitude of the outbreak Variations in nursing care interventions for ICU patients infected with MDR organisms have not been identified. and ultimately successful effort to contain a potentially widespread outbreak. No. age. associated mortality rates of 35%. communication strategies. According to one estimate. Saubolle. nurse-promoted multidisciplinary inquiries could target the following areas: • Proactive planning to anticipate the emergence of MDR organisms • Ongoing collaboration with infection control practitioners regarding trends of outbreaks of infections caused by MDR organisms and prevention strategies • Providing a forum to enhance Table 7 Costs of an outbreak staff nurses’ critical thinking Direct • Prolonged length of stay • Identifying • Consumption of supplies (eg. Infectious Disease Division. FEBRUARY 2008 http://ccn.24 ICU beds account for 5% to 10% of inpatient beds. Although our review did not include quantification of cost. disposal of supply cart contents after patient is discharged) ship of host factors • Use of professional services (eg. PhD. 1. staff. pliance with stanintensive care nurses dard precaution • Loss of intensive care unit bed days requirements (ie.2. dedicated respiratory personnel) and severity of • Dedicated equipment for the unit (eg.48 the overall cost to contain an outbreak was $220000 per patient. an estimated 250000 episodes of hospital-acquired infection occur annually. types of cohorting. Banner Good Samaritan Medical Center.”6 Prevalence of infection in the setting may be only partially realized. effect of antibiotic environmental and patient screening. Microbiology Technical Specialist. high work load can be a contributing factor for the acquisition of antimicrobial-resistant organisms. personal protective the . consultations with (eg. and added costs exceeding $40000 per survivor. • $220 000 per patient gown use) 48 Conclusion A new class of patient has unintentionally evolved in healthcare: the chronically critically ill. Additionally. Chairman. Rudinsky.“iceberg phenomenon. we recommend the integration of cost data in future analyses of outbreaks. Preventive interventions are difficult to measure.45 personnel from numerous healthcare disciplines interact with patients in the ICU.7.18 Quality Improvement and Nursing Research Indices Although infection is a nursesensitive indicator of quality care. Medical Director. • Investigation of intervention timing (eg. Outbreak containment hand hygiene. portable electrocardiographic and x-ray machines) comorbid condi• Pay for nursing full-time equivalents tions.10. Banner Health. prevalence. Infection Control Committee. Acknowledgments We wish to acknowledge significant contributions for this article from Michael A. however. In order to improve outcomes in patients with MDR and potentially fatal infections.

2006. Mah MW. Sherwood PR. Arch Intern Med. Persistent Acinetobacter baumannii? Look inside your medical equipment. 2006. 41 Lacy CF. 23. Acinetobacter baumannii pseudomeningitis.21:588-591. Ang A.278:46-53. 12. ventilator-associated and healthcare-associated pneumonia. Cardoso CL. 2003. Cunha BA. et al.focusdx. Direct costs of multidrug-resistant Acinetobacter baumannii in the burn unit of a public teaching hospital. 14. Todd B. AACN Clin Issues. 2005 . Infect Control Hosp Epidemiol. 2004. and trends in the SENTRY Antimicrobial Surveillance Program (1997-1999). 2002. Crit Care Med. Utku T. Quale JM. Siegel JD. Villegas MV. multidisciplinary. The Surveillance Network Database—USA.29:222-224. Tigecycline [package insert]. et al. FEBRUARY 2008 25 . Drug Information Handbook: With International Trade Names Index. 17.52(4):259-262.References 1.32(6): 342-344. 2005. Dzidic S. 2001. 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Clin Ther. Romero DV. Infect Control Hosp Epidemiol. 22.22(1): 35-40. Bayuga S. The cost of antibiotic resistance: effect of resistance among Staphylococcus aureus. Prevention of infection in the intensive care unit: current advances and opportunities for the future. 46. Washington DC: National Academy Press. 2007.32(4):773-784. 16. Brooklyn Antibiotic Resistance Task Force. Setter S. Bhalla A. Beyond MRSA: VISA and VRSA: what will ward off these pathogens in health care facilities? Am J Nurs. 2007:35(4):212-215.27:12-22. 1. Decré D. Impact of antibiotic resistance on clinical outcomes and cost of care. 20.162(13):1515-1520. Livermore DM. 2002. Monitoring the health of military personnel. Chiarello L. Nurs Pract.29(suppl 4):N114-N120. Hudson. Levy SB. In: Magnet Recognition Program: Application Manual. rituals. Citywide clonal outbreak of multiresistant Acinetobacter baumannii and Pseudomonas aeruginosa in Brooklyn. Am J Infect Control. Goldman MP. 7. el-Sadr W. 36. 6. 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coccobacillary rod b. Male sex b. CFRN.0 Fee: AACN members. Aztreonam 5. anaerobic mycobacteria Test answers: Mark only one box for your answer to each question. Acinetobacter baumannii is a normal inhabitant in which area of the body? a. CA 92656. $10 Passing score: 10 correct (71%) Category: A. What is the most significant factor in the transmission of A baumannii? a. $40 000 b. staff. Implementation of contact precautions for patients who have infections caused by MDR A baumannii d. and additional education with all clinical staff d. infection control measures. Gram-positive. Post flyers and informational literature throughout the facility. Contact precautions on all mechanically ventilated patients. Ensure proper cleaning of ventilators and bronchoscopes. K a Kb Kc Kd 9. CCRN Program evaluation Objective 1 was met Objective 2 was met Objective 3 was met Content was relevant to my nursing practice K My expectations were met K This method of CE is effective for this content K The level of difficulty of this test was: K easy K medium K difficult To complete this program. K a Kb Kc Kd 14. K a Kb Kc Kd 4. K a Kb Kc Kd 11. Institutional education. Widespread overuse of broad-spectrum antibiotics b. 12. b.CE Test Test ID C081: Acinetobacter baumannii: An Emerging Multidrug-Resistant Pathogen in Critical Care Learning objectives: 1. Infections caused by this organism are most prevalent in extended-care and rehabilitation settings. AACN programming meets the standards for most other states requiring mandatory continuing education credit for relicensure. BSN. The term “cohorting” refers to which of the following? a. opportunistic fungi c. and cohorting 11. Depression d. Skin and mucous membranes 2. d. $730 000 1. Which of the following statements about A baumannii is true? a. nonmembers. Discuss nursing interventions. K a Kb Kc Kd 13. . Inadequate hand hygiene among healthcare providers d. Eradication of the organism from hospital surfaces requires specially formulated cleaning solutions and particular cleaning techniques. $0. 15 c. The organism cannot survive on moist surfaces for long periods. The organism is inconsequential to hosts with intact immune systems. Paying attention to the infection rates specific to critical care settings c. cohorting. it took me hours/minutes. standardized antibiotic therapy. 19 b. K a Kb Kc Kd 12. Which of the following is a recommendation of the Centers for Disease Control and Prevention’s 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults? a. Tigecycline b. Identify factors that contribute to the emergence and significance of Acinetobacter baumannii in healthcare environments 2. Placement of patients who have the same illness together 6. and equipment? a. Extensive education for environmental services staff about the importance of attention to detail in room cleaning 7. K a Kb Kc Kd 3. What is an expected outcome of establishing a cohort/isolation unit? a. Gram-positive. The organism’s resistance to multiple hand-cleansing agents 3. K Discover K Check Expiration Date The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. not colonization of the bacteria. $510 000 d. Concurrent use of a combination of 1 or more antimicrobial agents c. How many strains of A baumannii have been identified thus far? a. CEN. Mechanical ventilation 13. and review of cleaning procedures c. and Louisiana (#ABN12). c. Require that staff on the cohort unit do not respond to code calls during shifts. AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062). What is a recommendation to aid in cohorting patients. Successful prevention of the spread of MDR A baumannii infections includes which of the following combinations? a. 14 4. Gastrointestinal tract b. Risk factors for acquiring A baumannii include which of the following? a. Improved productivity of nursing and respiratory therapy staff b. Synergy CERP A Test writer: Ann Lystrup. What is the estimated cost of outbreak containment per patient? a. RN. K a Kb Kc Kd 10. Direct contact with persons who have contact dermatitis c. d. 14. K a Kb Kc Kd Test ID: C081 Form expires: February 1. K a Kb Kc Kd 6. Imipenem c. nonfermentive spirochete d. 101 Columbia Aliso Viejo. Fall or winter season c. Sterilize and disinfect all ventilator circuits used on the cohort unit between patients. Rapid understanding and acceptance of the need for cohorting 10. K a Kb Kc Kd 7. Lungs d. Which of the following drug’s associated nephrotoxicity requires that doses and intervals be adjusted for patients with renal impairment? a. take this CE test online at http://ccn. K a Kb Kc Kd 2. Acinetobacter baumannii is what kind of bacteria? a. Colistimethate d. and enhanced infection control practices b. Improved staffing. Begin antimicrobial treatment with multiple agents at first and eliminate as soon as possible when susceptibility results are available. Increased ease of matching the number and types of staff required with available resources c. 21 d. Colonization of A baumannii on the skin of susceptible persons b. $220 000 c. 2010 Contact hours: 1. 1/St Payment by: Card # Signature K Visa K M/C RN Lic. b. c. Use antimicrobial-treated catheters. The use of a multidisciplinary team to establish infection control measures for each healthcare facility b. c. Increased interdisciplinary involvement. 2/St K AMEX Phone Member # State ZIP For faster processing. and clinical recommendations for prevention and/or containment A baumannii infections 8. You may photocopy this form. K a Kb Kc Kd 8. tracking of specific ventilator use on individual patients. Treat the infection. California (#01036). 1. Treat the infection according to the most recent national data. Plasma c. Increased variance between budgeted and actual costs d. K a Kb Kc Kd 5.aacnjournals. 9. d. Describe the characteristics of A baumannii and the associated risk factors for development of A baumannii infections 3. effective hand (“CE Articles in this issue”) or mail this entire page to: AACN. Yes K K K No K K K K K K Name Address City Country E-mail RN Lic. Gram-negative. Implementation of strict contact isolation procedures for patients at high risk for development of multidrug-resistant (MDR) infections d. What is the first and foremost recommendation made by the authors for preventing outbreaks of MDR A baumannii infections? a. Gram-negative. b.

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