Infection Preventionists’ Detective Work Stopped an Outbreak of CRAB

Detective work and teamwork led to halt of a potentially deadly outbreak in a Louisiana hospital. The infection preventionists (IPs) in the hospital reached out to the state Department of Health, and the 2 teams coordinated and solved the situation before it grew worse. The report about this situation was published in the American Journal of Infection Control, and originally presented as a poster at the Association for Professionals in Infection Control and Epidemiology (APIC) 2022 Annual Conference, held June 13-15, 2022, in Indianapolis, Indiana. The lead investigator, Erica Washington, MPH, CPH, CIC, CPHQ, FAPIC, and the health care-associated infection and antibiotic resistance program coordinator for the Louisiana Department of Health, spoke to Infection Control Today^® (ICT^®) about how the situation was resolved.

Infection Control Today^® (ICT^®):Please give a summary of the key findings and why they are important.

Erica Washington, MPH, CPH, CIC, CPHQ, FAPIC: This poster [study] surrounded an investigation of carbapenem-resistant Acinetobacter baumannii that was identified in a cluster of patients who were admitted to an acute care hospital. The infection preventionists at the hospital noticed that they were being admitted from the same ventilator skilled nursing facility (VSNF). So they alerted my team at the Louisiana Department of Health. We activated an investigation, first doing chart abstractions of the patients from the records at the acute care hospital and then working with the VSNF to do first an infection control assessment in person, then colonization screenings to identify additional cases, and make sure that transmission was not ongoing of this potentially deadly bug. The colonization screenings were done in coordination with the Centers of Disease Control and Prevention (CDC) antibiotic resistance laboratory network. The key findings were that 1 patient was admitted to the same room that a previous patient was discharged from. That [situation] led to some of our recommendations surrounding environmental cleaning hand hygiene, and additional infection control inclusive efforts of with environmental services and reupping on infection control competencies within that setting.

ICT^®: What do you think the practical application is for the key findings for infection preventionists?

EW: Practically, even beyond looking at the infection control recommendations, I think we can look a bit upstream. The IPs at the acute care hospital were skilled at cluster detection. I think that [detection] was commendable. All [the IPs] were certified. Their director of infection prevention [were] touting the fact that they all got certified in infection control…and they quickly coordinated with public health. And while we do receive reports of these infections, their detection was swift and very timely that activated a quick and coordinated approach.

The second thing would be communications. [The IPs'] communications with us and then subsequently within the facility itself, so communications between infection control departments at an acute care hospital and a long-term care setting then became strengthened as well. We're always promoting that patients do go between setting types of facilities [and IPs] need to understand how to handle patients upon discharge or admission. I think that was a good outcome [of this study] as well. Then, also, understanding the fact that identifying additional cases through colonization screening can inform infection control, and whether the facilities need to promote or strengthen infection control efforts within a facility.

ICT^®: What results from the study surprised you?

EW: The first thing that we looked at from the chart abstractions, and but when we did the chart abstractions, I first clued into the fact that the resistance patterns among the isolates. For cases 1 and 3, were the same. So I had a bit of information that those cases had some crossover on some level. It turns out the case 3 was admitted to the same room as case 1 after case 1 was discharged. On rounding, so I can't underestimate or speak more highly of doing infection control rounding during infection control assessments. Because when looking at the layout of the ventilator unit, I saw that the rooms were laid out right across from each other as well. So that also led to some recommendations around potentially [increasing] hand hygiene, aside from environmental cleaning, as well. I recommended that the facility have a policy against gel and acrylic nails because I did observe some personnel having gel and acrylic nails. After CDC did their workup for the isolates, they saw that those isolates for cases 1 and 3, were pan resistant, and carbapenem producing. I think that we get a lot of information out of contributing to the body of knowledge around resistance patterns in our own populations, how the resistance patterns are changing, as well. And just informing and making sure that the facilities understand that colonization versus infection as well. So making sure that antibiotic stewardship is working in concert with the colonization screenings, so that we're not inappropriately treating people who don't necessarily have infection. But I think that we had suspicions around cases 1 and 3, but then confirmed on rounding when looking at the room layouts. And then also looking at the confirmatory testing from CDC.

ICT^®: Do you have any plans on doing any further observations to gather more information?

EW: So the way that colonization screenings work is that we ensure that transmission is stopped, by asking facilities to do 2 rounds of screenings. And if 2 rounds occur where no additional cases are identified, then we can be confident that transmission is stopped. So that's the prospective way that we can ensure patient safety. And then, we do the surveillance statewide, as well, as far as ensuring the quality side of best practices for infection control and the setting. We certainly confirm recommendations to the facility regarding environmental cleaning, hand hygiene, and the like, in education. But, [those recommendations are] something that are worth ongoing training. Those are also some things that our health department is working with APIC to do. We have in the past, I believe in 2018, contracted APIC to do long-term care trainings in Louisiana. And we're working, hopefully, in the next 6 to 12 months to contract them to do additional trainings in our state, around long-term care-focused trainings and infection control.

ICT^®: Do you have anything else that you would like to add?

EW: Considering your audience consists of infection preventionist across the provider section, I want them to know that all health departments, or all state health departments and some local and city health departments, are staff with health care-associated infection coordinators like myself who work with the CDC on activities just like this. So working with the antibiotic resistance laboratory network, [I want to tell them] to make sure that we are detecting and containing and responding to antibiotic resistant threats. If we reach out to you to ask, for your help with colonization, screenings, understand that the materials, supplies, and shipping are free of cost. We know that the personal time is not free, but this goes far to contributing to the body of knowledge about changing resistance, but then also understanding how you can be informed about transmission-based precautions and protecting patient safety, and the health of your patients within health care states.

This article has been edited for length and clarity.