Scientific letter
Control of an Acinetobacter baumannii multidrug resistance endemic in the ICU. Recalling the obvious
Control de una endemia de Acinetobacter baumannii multirresistente en la UCI. Recordando lo obvio
D. Escudero
, L. Cofiño, L. Forcelledo, B. Quindós, C. Calleja, L. Martín
Corresponding author
Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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Recalling the obvious" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "497" "paginaFinal" => "499" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "D. Escudero, L. Cofiño, L. Forcelledo, B. Quindós, C. Calleja, L. Martín" "autores" => array:6 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Escudero" "email" => array:1 [ 0 => "lolaescudero@telefonica.net" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Cofiño" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Forcelledo" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Quindós" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Calleja" ] 5 => array:2 [ "nombre" => "L." "apellidos" => "Martín" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Control de una endemia de <span class="elsevierStyleItalic">Acinetobacter baumannii</span> multirresistente en la UCI. Recordando lo obvio" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1462 "Ancho" => 2678 "Tamanyo" => 152059 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Number of patients colonized/infected by multiresistant <span class="elsevierStyleItalic">Acinetobacter baumannii</span> during the years 2015 and 2016. The arrow indicates when the intervention started.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Environmental contamination in intensive care units (ICU) plays a very important role in the transmission of pathogens like <span class="elsevierStyleItalic">Acinetobacter baumannii (A. baumannii).</span> The healthcare professionals’ hand and glove contamination after contact with the patients and the environmental contamination is one of the mechanisms of usual transmission.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a> Some studies have shown that patients hospitalized in a room previously occupied by a patient colonized/infected by multiresistant microorganisms (MRM) have a much higher risk of acquiring one of these pathogens than a patient hospitalized in a room whose prior occupant was not colonized/infected.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,4</span></a> The terminal decontamination that is usually conducted after a patient is discharged from the hospital is not enough. This has been proven in various studies that confirm that up to 50 per cent of the room surfaces cannot be adequately decontaminated.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> In order to reduce environmental contamination several methods of disinfection have been developed using hydrogen peroxide and ultraviolet light.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Due to the existence of multiple machines and medical equipment, the process of decontaminating an ICU examination room is a hard task that is loaded with obstacles, and almost impossible to accomplish thoroughly in a short period of time. In high-volume centres—with permanent and urgent change of patients, carrying out this thorough decontamination process becomes nearly impossible, which gradually increases the bacterial load favouring the transmission of microorganisms. This added to the specific characteristics of critical patients, the difficulties trying to observe the strict/permanent hand washing protocols, and the lack of scrupulous observance in the isolation of colonized/infected patients, leads to the <span class="elsevierStyleItalic">perfect storm</span> that explains the elevated number of ICU nosocomial infections.</p><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">A. baumannii</span> is a huge problem and a global healthcare challenge. It is one of the most common microorganisms responsible for the infections of critical patients and causes serious infections such as ventilator-associated pneumonias or bacteriemias.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> Some of its characteristics are its high adhesiveness; its capacity to survive in the environment; and the difficulties found when trying to eliminate it with the usual hygienic measures, which allows its easy colonization of surfaces and medical equipment. In studies conducted on epidemic outbreaks in ICUs, <span class="elsevierStyleItalic">A. baumannii</span> has been identified in reservoirs such as respirators, screens, humidifiers, pressure transducers, thermometers, or mattresses.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,9</span></a> These outbreaks may last in time and become endemic due to the large environmental colonization load, becoming a huge problem of great clinical/epidemiological repercussions that aggravates due to its usual multiresistance. The hospital fomites, the colonizations/infections of patients, and the healthcare providers make up an interrelated triangle that feeds back and forth perpetuating the transmission of this microorganism and maintaining the endemic situation, which is why the strict observance of hand hygiene by the healthcare personnel is always essential if we want to control an endemic situation.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Our hospital polyvalent ICU experienced one multiresistant <span class="elsevierStyleItalic">A. baumannii</span> endemia for eighteen years. During all this time, the classical measures recommended by the medical literature were implemented: cultures for epidemiological monitoring; isolation of colonized/infected patients; when possible, isolation of colonized/infected patient cohorts in a specific unit; programmes of annual thorough environmental decontamination (included new paint on the surfaces); hand hygiene; and personnel training (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). All these measures proved ineffective and the endemia was even more serious after we moved to a new hospital, indicative that a new architectonic environment free from MRM that, a priori, is a favourable scenario does not solve a situation of endemia if we implement the same measures. The colonized/infected patients and the contaminated medical equipment were transferred to the new hospital, but the historic endemic situation was maintained since this transfer was not followed by new strategies against <span class="elsevierStyleItalic">A. baumannii.</span></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Because everything proved again ineffective, and given that a single terminal decontamination is not enough, an intervention of thorough cleaning maintained in time at the beginning of April 2016 was proposed. When a patient was discharged, the ICU examination room would be locked for two full days. During that time, in morning and afternoon shifts, a total of four terminal decontaminations would be conducted. If the patient had been colonized/infected by MRM or was a risk patient, six terminal decontaminations would be conducted and registered in a document that would be signed by the nurse/nurse assistant, and personnel responsible for the decontamination. If the microorganism isolated was <span class="elsevierStyleItalic">A. baumannii</span> the same cycles of cleaning were implemented but in a variable way and depending on bed availability - sometimes even up to 12 terminal decontaminations would be conducted. Also hydrogen peroxide disinfection would be used in a very restricted way, since most of the examination rooms did not have doors, which is why the hydrogen peroxide disinfection could only be conducted in 8 out of the 38 examination rooms and in a limited way during 1–2 days/month. During the month of July, the last patients who still remained colonized/infected were kept in isolation in a special unit, and during the months of July, August, and September, when the volume of patients was lower, we proceeded to disinfect using hydrogen peroxide in three out of the four ICU examination rooms.</p><p id="par0030" class="elsevierStylePara elsevierViewall">After the implementation of this thorough campaign of decontamination, <span class="elsevierStyleItalic">A. baumannii</span> decreased significantly from 98 patients colonized/infected in 2015 (rate of 9.8 patients/1000 days of hospital stay) to 27 in 2016 – September included (rate 3.9 patients/1000 days of hospital stay), out of which 21 were patients from the 1st trimester of the year, that is, before starting the decontamination campaign. In a six-month period before and after the intervention, from October 2015 through March 2016, the number of colonized/infected patients was 51 (rate 9.7 patients/1000 days of hospital stay) compared to 6 patients for the months of April through September 2016 (rate 1.4 patients/1000 days of hospital stay). One of the goals of the Resistance Zero initiative was to reduce to 20 per cent the rate of patients with MRM infections. In our ICU thanks to the intervention of thorough decontamination and compared to a 6-month period before and after the intervention, we reduced the number of colonized/infected patients by 88.3 per cent. The decrease of <span class="elsevierStyleItalic">A. baumannii</span> lead to significant reductions in the healthcare costs of colistin. In the year 2015, 8380 vials (80<span class="elsevierStyleHsp" style=""></span>mg) were used at €46.146 versus 4274 vials at €23.961 until September 2016, even when the spending from 2016 is attributed to the 1st trimester before the intervention started. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the number of colonized/infected patients due to <span class="elsevierStyleItalic">A. baumannii</span> during 2015–2016.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The early detection, isolation of colonized patients, and environmental decontamination are some of the measures recommended in order to control <span class="elsevierStyleItalic">A. baumannii</span> outbreaks.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,7,9,10</span></a> In our case, these routine measures proved ineffective for years. Only the additional implementation of a thorough environmental decontamination campaign maintained through time and complemented by specific disinfections using hydrogen peroxide controlled the endemic situation.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Improving the environmental decontamination is one of the interventions recommended as a key intervention to mitigate <span class="elsevierStyleItalic">A. baumannii</span> transmissions. We know it and it is obvious, but we still need to reinforce it and keep working actively if we want to control these outbreaks in the ICU setting. In our own experience, the old message of implementing a truly thorough environmental decontamination campaign—constant through time and in a protocolized way worked satisfactory.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Escudero D, Cofiño L, Forcelledo L, Quindós B, Calleja C, Martín L. Control de una endemia de <span class="elsevierStyleItalic">Acinetobacter baumannii</span> multirresistente en la UCI. Recordando lo obvio. Med Intensiva. 2017;41:497–499.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1462 "Ancho" => 2678 "Tamanyo" => 152059 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Number of patients colonized/infected by multiresistant <span class="elsevierStyleItalic">Acinetobacter baumannii</span> during the years 2015 and 2016. The arrow indicates when the intervention started.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Epidemiological research</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Genotyping \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Monitoring cultures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Environmental cultures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Measures of strict isolation</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Isolation of patient cohorts</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Better observance of hand hygiene</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Better cleaning and environmental disinfection</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Educational measures</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1577190.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Control strategies of <span class="elsevierStyleItalic">Acinetobacter baumannii</span>.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of the surface environment in healthcare-associated infections" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 4 | 6 |
| 2024 October | 62 | 55 | 117 |
| 2024 September | 39 | 28 | 67 |
| 2024 August | 56 | 39 | 95 |
| 2024 July | 47 | 34 | 81 |
| 2024 June | 62 | 75 | 137 |
| 2024 May | 55 | 52 | 107 |
| 2024 April | 88 | 41 | 129 |
| 2024 March | 68 | 35 | 103 |
| 2024 February | 92 | 46 | 138 |
| 2024 January | 59 | 37 | 96 |
| 2023 December | 66 | 37 | 103 |
| 2023 November | 97 | 40 | 137 |
| 2023 October | 64 | 29 | 93 |
| 2023 September | 70 | 41 | 111 |
| 2023 August | 49 | 12 | 61 |
| 2023 July | 71 | 31 | 102 |
| 2023 June | 68 | 24 | 92 |
| 2023 May | 82 | 42 | 124 |
| 2023 April | 57 | 19 | 76 |
| 2023 March | 74 | 37 | 111 |
| 2023 February | 75 | 37 | 112 |
| 2023 January | 86 | 29 | 115 |
| 2022 December | 95 | 49 | 144 |
| 2022 November | 84 | 39 | 123 |
| 2022 October | 116 | 55 | 171 |
| 2022 September | 103 | 37 | 140 |
| 2022 August | 84 | 51 | 135 |
| 2022 July | 47 | 47 | 94 |
| 2022 June | 57 | 32 | 89 |
| 2022 May | 49 | 42 | 91 |
| 2022 April | 46 | 43 | 89 |
| 2022 March | 67 | 86 | 153 |
| 2022 February | 45 | 44 | 89 |
| 2022 January | 65 | 42 | 107 |
| 2021 December | 92 | 61 | 153 |
| 2021 November | 99 | 43 | 142 |
| 2021 October | 130 | 71 | 201 |
| 2021 September | 72 | 42 | 114 |
| 2021 August | 43 | 43 | 86 |
| 2021 July | 42 | 35 | 77 |
| 2021 June | 58 | 35 | 93 |
| 2021 May | 81 | 64 | 145 |
| 2021 April | 126 | 104 | 230 |
| 2021 March | 140 | 59 | 199 |
| 2021 February | 112 | 39 | 151 |
| 2021 January | 106 | 30 | 136 |
| 2020 December | 99 | 34 | 133 |
| 2020 November | 78 | 35 | 113 |
| 2020 October | 60 | 35 | 95 |
| 2020 September | 82 | 34 | 116 |
| 2020 August | 62 | 24 | 86 |
| 2020 July | 49 | 33 | 82 |
| 2020 June | 63 | 28 | 91 |
| 2020 May | 53 | 21 | 74 |
| 2020 April | 48 | 19 | 67 |
| 2020 March | 29 | 23 | 52 |
| 2020 February | 134 | 94 | 228 |
| 2020 January | 39 | 28 | 67 |
| 2019 December | 81 | 30 | 111 |
| 2019 November | 57 | 27 | 84 |
| 2019 October | 67 | 31 | 98 |
| 2019 September | 44 | 36 | 80 |
| 2019 August | 32 | 28 | 60 |
| 2019 July | 37 | 31 | 68 |
| 2019 June | 26 | 41 | 67 |
| 2019 May | 62 | 47 | 109 |
| 2019 April | 30 | 26 | 56 |
| 2019 March | 33 | 47 | 80 |
| 2019 February | 37 | 36 | 73 |
| 2019 January | 26 | 41 | 67 |
| 2018 December | 67 | 38 | 105 |
| 2018 November | 46 | 59 | 105 |
| 2018 October | 58 | 36 | 94 |
| 2018 September | 44 | 11 | 55 |
| 2018 August | 31 | 9 | 40 |
| 2018 July | 42 | 16 | 58 |
| 2018 June | 44 | 19 | 63 |
| 2018 May | 29 | 4 | 33 |
| 2018 April | 38 | 15 | 53 |
| 2018 March | 39 | 8 | 47 |
| 2017 November | 1 | 1 | 2 |
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