APIC Chapter 13 Journal Club - PowerPoint Presentation

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APIC Chapter 13

Journal Club

March 18,

2015

Evidence

for Practice

Infection Control Measures to prevent Carbapenem-resistant

Acinetobacter baumannii

in a hospital’s

ICUs

Presented by:

Elsa Santos-Cruz IP CIC

Mount Sinai Hospital

LEVEL I – Experimental Study

Setting:

- The Korean Nosocomial Surveillance System identified

Acinetobacter baumannii

as the

leading

cause of nosocomial infection in the ICUs.

A study was done in the

Gyeongsang

National University Hospital located in

South Korea

. The 890-bed teaching hospital has

a 19-bed

MICU,

a 14-bed SICU,

and

a 16-bed

general isolation ward.

A retrospective analysis was done to assess effectiveness of different Infection

Control

measures to prevent infection of

Carbapenem-Resistant

A

. baumannii

(CRAB).

Time Period of interventions

1- July 2007 to June

2009

All

patients with CRAB were placed on Contact PrecautionsDisposable gloves and gowns were required upon entry to the roomAlcohol-based hand sanitizer use was encouragedDaily environmental cleaning of cohorted rooms was done using sodium dichloro-isocyanurate (NaDCC)- containing solution (like bleach)Nasal screening for CRAB in all ICU patients w/in 24 hrs of admission and weekly thereafter if CRAB was identified in the ICU

2- July 2009 to Dec

. 2012

Biweekly

education

by Infection

Control team of the important of Infection Control protocols

Monitored

i

nfection control measures

Promoted

infection control practices in preparation for hospital accreditation

Control & Definitions

Patient with Nosocomial incidence of ESBL+

E

. coli

and K. pneumoniae (ESBL-EK) were managed with Standard Precautions only.Nosocomial was defined as a patient newly infected or colonized with CRAB more than 48 hrs. after admission.Patients with multiple positive samples were counted as one episode.

Sample size and composition

During the 6

year

study:

Total number of patient admissions = 1,658,999 Patients with positive CRAB = 588 (0.35/1000 pt. days) Patients with Nosocomial CRAB = 530 (90% of all CARB pts) Patients from ICU w/positive CRAB = 342 Pts. surveillance culture + for CRAB = 60 Pts. surveillance and clinical

culture + = 47

Pts

.

surveillance culture

+

only

=

13

True

infection w/ CRAB =

111/530

(21 %)

Pneumonia – 76%

Bacteremia – 10%

Other sites

– 14%

Infection Result-based conclusions

Nosocomial Incidence of CRAB/1000 pt

. days

2007 = 0.35 2010 = 0.46 P = 0.096 2012 = 0.06 P < .001 Using segmented regression analysis, there is significant change in the incidence density of CRAB between period 1 and 2.Nosocomial Incidence of ESBL-EK 2007 = 0.59 2012 = 1.00 P < .001Using segmented regression analysis, there is not significant

change for the

ESBL-EK

Other Result-based conclusions

Alcohol-based hand rub (AHBR) consumption per 1000 patient days was tracked during the study:

5.6L = 2007 5.5L = 2008 9.6L = 2009 7.5L = 2010 11.2L = 2011 11.9L = 2012 P = <.001AHBR consumption was not correlated with change in CRAB (P = .141) although AHBR use increased significantly over the course of the study.

Other Result-based conclusions

Antimicrobial consumption in Defined Daily Doses (DDD), was also tracked

total antimicrobial use

ß-Lactam/

ß-lactamase inhibitor combinationsExtended-spectrum cephalosporinsQuinolonesCarbapenemsBetween 2010 – 2012, antibiotic use decreasedin aggregate (P < .001), for carbapenems (P = .008) significantly correlated with a decrease in CRAB (no P value provided however).

Authors’ conclusions 1

Isolation and Surveillance cultures alone did not change CRAB incidence (2007-2009)

Between

2010 –

2012, additional education led to decreased CRAB incidenceOptimal CRAB screening is unknownInfection Control practices compliance was believed to be sub-optimal in first time periodIncreased compliance with IC practices is inferred by increased AHBR use in 2nd time period, correlated with preparation for national accreditation visitEducation about Infection Control is believed to be leading cause of reduced CRAB

Authors’ conclusions 2

Changes in AHBR use did not affect CR-EK rates (those pts were not tracked or put on isolation precautions)

Cohorting CRAB patients helped reduce rates of CRAB incidence over the course of the study

Cohorting and isolation helped increase AHBR use and compliance with Contact Precautions

Decreased use of antimicrobials helped reduce CRAB rates but not CR-EK ratesResults are similar to a survey in Japan that found that a reduction of CRAB was associated with Infection Control performance and hospital accreditation

Study

Limitations

Inappropriate screening site for

CRAB

Multiple changes were made without ability to evaluate each change’s impact on infection ratesUnable to identify the specific infection control measure(s) that reduced the incidence density of CRABCompliance with IC measures was not tracked (study was retrospective)Unable to evaluate the relationship antimicrobial consumption to the reduction of CRABCRAB isolates were not typed so patient-patient spread cannot be proven

Appraisal

Results

Level

II

– Experimental Study – Score: B