Synopsis on Investigation and Action Planning of the Severe Outbreak of

Pseudomonas Aeruginosa Infections in Hematology Unit.

Prepared and Submitted By:

Keshab Rijal,
Student ID No: 2019552016
Global Health Security Program (Batch-3),
Graduate School of Public Health,
Yonsei University
Email: keshabrijal2008@gmail.com

For the partial fulfillment of the semester evaluation of the Winter semester of
Hospital Infection Control.

17th Feb 2020.

Title of the Project: Investigation and Action Planning of the Severe
Outbreak of Pseudomonas Aeruginosa Infections in Hematology Unit.

Background:
The 2016 Political Declaration of the High-level Meeting of the United Nations General Assembly
on Antimicrobial Resistance represented a landmark in the world’s commitment to tackling
antimicrobial resistance, calling for greater urgency and action in response to its many challenges. In
the political declaration, Member States requested the Secretary-General, in consultation with the
Food and Agriculture Organization of the United Nations (FAO), the World Organization for
Animal Health (OIE) and the World Health Organization (WHO) to convene an ad hoc interagency
coordination group (IACG) co-chaired by the Executive Office of the Secretary-General and the
Director-General of WHO to provide practical guidance for approaches needed to ensure sustained,
effective global action to address antimicrobial resistance. It also requested the Secretary-General to
submit a report for consideration by Member States by the seventy-third session of the General
Assembly in 2019 on the implementation of the political declaration and on further developments
and recommendations emanating from the IACG, including on options to improve coordination,
considering the 2015 Global Action Plan on Antimicrobial Resistance.

Statement of the Problem:

The burden of healthcare associated infection low and middle income countries has been under-
appreciated in the past, with the extent and impact of infections due to multi-resistant organisms
such as Pseudomonas aeruginosa, in particular being under-estimated. In the absence of well-
resourced surveillance systems, outbreak reports can serve to highlight serious pathogens. While
such outbreaks are frequently reported in the published literature, relatively few of these reports
originate from low income countries. P. aeruginosa is a common cause of infection among
hospitalized patients. It is inherently resistant to certain antibiotics due to a variety of resistance
mechanisms. Treatment is further limited by the ability of the organism to rapidly develop additional
resistance during treatment. Risk factors for P. aeruginosa infection include presence of indwelling
devices, admission to an intensive care unit, prior antibiotic use, length of hospitalization, severe
underlying disease and impaired immunity.
Context and given Condition:
Between November and December, 1993 three cases were infected with multiply resistant P.
aeruginosa isolates and the hospital clinicians on a hematology unit notified to Program of Hospital
Epidemiology (PHE). These cases were resistant to gentamicin, tobramycin, ticarcillin and
piperacillin, intermediately susceptible or resistant to cefotaxime and ceftriaxone and susceptible to
amekacin, ceftazidime, imipenem and ciprofloxacin. The extent of condition raveled a serious
situation although it seems only few was affected.

Objective:
The objective of this task is to investigate an outbreak of P. aeruginosa bloodstream infection that
occurred in the hematology unit of Civil Service Hospital, a tertiary hospital in Kathmandu, Nepal
(Assumption).

Hypothesis:
H0: Quality improvement system can play vital role in early detection of AMR infections.
Ha: Quality improvement system can play vital role in early detection of AMR infections.

Initial Analysis:
From initial analysis, cases, it was found that three
Fig. 1: Initial Morbidity and
cases were affected, among them one died of disease. Mortality
The mortality rate was 33.33%. Died case had extra
Died Cases Live Cases
symptom of refractory anemia, which could be the
subject of search. There was need of immediate public
health measure; isolation and review of medical records 33%
of similar cases of all registered hospital cases to collect
further data for defining the problem and analyze the
67%
risk of infection.
Initial mortality of 33 % leads for discussion to the
respected service unit to search for the determinants of
this problem. All three isolated cases were found from the same strain (PFGE report).

In the above case, the problem was identifies only on January 1994; that is the 4th case’s blood
cultures grew P. aeruginosa has a similar antibody. Early warning system should be linked with
quality improvement and other related functions.
Immediately on initial rapid assessment, it was found three cases infected with multiply resistant P.
aeruginosa from organ transplant unit and pediatric bone marrow transplant unit. Till the time, sum
of seven cases with hematological malignancies acquired serious infections caused by a same strain
of multiply resistant P. aeruginosa in 14 months of study period. The clinical manifestations were
found diarrhea in most of cases; average of vitals include temperature 39.2C heart beat rate 123, RR
31 and the blood pressure was 110/57. Four cases reported with chills.

Descriptive Epidemiology:
All of reported cases were found male, had infections
Figure 2: Associated
with the same epidemic strain. It suggests high risk of
Symptoms
primary disease and resistant P. aeruginosa among
2.00
male. One case had suffered from pneumonia and 1.50
bloodstream infection observed in the analysis period. 1.00
Six cases had reported with bloodstream infections, 0.50
0.00
whereas one case had a urinary tract infection and an Dec. Apr. Sep. Nov. Jan.
infection of his Hickman catheter in the exit site. The 1993 1994 1994 1994 1995

primary signs symptoms include diarrhea, high fever Total Cases Diarrhoea
Chills
with chills tachycardia, and tachypnea. When we see the
outcome of the disease 2/7 gets died, rest of cases are
also vulnerable towards the complications and death.

Decision:
In the above case it seems only a few number of cases are affected in the study period. Although
there were only seven explored cases, the situation was very serious due to a high mortality and
serious condition associated with MDR among mostly available AMR. The P. aeruginosa isolated
with this character were very unusual and because a time and space cluster of infections was
identified. All of these conditions suggest to determine this condition as an epidemic of serious
nature and to take immediate interventions in a serious manner.

Conclusion and Recommendation:

It is conclude as a serious outbreak of MDR infection in this hospital esp. in the hematology unit. In
order to resolve these issues, following recommendations are provided.
Recommendations Rationale Key Stakeholders
Initiation of MDR Surveillance To detect AMR as MoH, WHO, CDC, Professional Org,
System early as possible. Research Inst., Bilateral Org and
Hospitals etc.
Starting infectious diseases monitoring To ensure hospital Hospital Leadership, Infectious
System in the Hospital M&E system Disease Department, Medical Record
Section etc.
Strengthen hospital infection To ensure patient Hospital Leadership, CSSD, Logistic,
prevention practices through CME and and provider safety Finance, all service units.
recommended standard practice. and enhance
quality of services.
Provision of IPC Nurse. To manage IPC Hospital Leadership.
practices.
Annex 1: Initial Line list of Reported Affected Cases
PT. Code Age Underlying Disease Site Outcome Remarks
A 54 AML-new Blood, Tracheal aspirate Lived
B 57 AML-new stool, Blood, Hickman site Lived
refractory anemia Died of
C 54 with subsequent AML Urine, Hichman site Disease

Annex 2: Analyzed Line list with associated Symptoms of Cases

Pt. Code A B C D E F G Mean

Temp.(C) 39.7 39.1 39.1 39.1 39.7 38.3 39.7 39.2
Dec, Sep,
Apr, 1994 Sep, 1994 Nov, 1994 Nov, 1994 Dec, 1994 NA
Month of Diagnosis 1993 1994
Heart Rate 120 96 140 106 124 140 141 123
BP 92/48 140/70 69/30 124/78 122/48 138/77 87/48 110/57
RR 32 40 28 16 24 20 60 31
Chills Yes No No No Yes No Yes NA
Diarrhea Yes Yes Yes No Yes Yes Yes NA
Age/ Gender 40/M 54/M 22/M 51/M 57/M 54/M 59/ M 48.1
Ref.
AML- AML- ALL- AML-
AML-New Anemia AML- New NA
New Relapse Relapse New
Underlying disease with AML
Died of
Lived Lived Lived Lived Lived Died NA
Outcome Disease
Blood,
Stool,
Blood Urine, Blood from
Blood Blood,
Blood Tracheal Blood Hickman Bronchial NA
Stool Hickman
Aspirate site alveolar
site
Site of Sample lavage
Annex 3: Action Plan:
Activity Time Period Remark
Jan- Feb March April May June July Aug Sep.
1995 1995 1995 1995 1995 1995 1996 1996 1996
Verification of Subjected
Diagnosis to change
Confirmation of an as per
Epidemic policy and
need.
Defining the Disease
statement and Problem
Description of Cases
Formulation of
Hypothesis
Evaluation of
Hypothesis
Interventions for
Epidemic
Management*
Submission of Report
and Communicating
Findings

* need to be implemented in a continuous manner.