Carbapenem-resistant Acinetobacter baumannii (CRAB), an opportunistic pathogen primarily associated with hospital-acquired infections, is an urgent public health threat, according to the Centers for Disease Control and Prevention (CDC) reported in its Morbidity and Mortality Weekly Report.
Recent single-facility reports from the United States and Europe have described increased acquisition of multi-drug resistant organisms (MDROs) among patients hospitalized with COVID-19. In healthcare facilities, CRAB readily contaminates the patient care environment and healthcare providers’ hands, survives for extended periods on dry surfaces, and can be spread by asymptomatically colonized persons; these factors make CRAB outbreaks in acute care hospitals difficult to control. The CDC reported that an unknown Hospital experienced a large multidrug-resistant CRAB outbreak, primarily involving intensive care unit (ICU) patients, which extended across multiple units during a surge in COVID-19 cases.
Outbreaks of CRAB have been well documented in acute care hospitals, particularly among critically ill patients, and are often driven by factors that include breaches in infection control and persistent environmental contamination. Containing these outbreaks often requires multiple, targeted interventions, including increased surveillance, IPC audits, and environmental cleaning.
During COVID-19 preparations and the ensuing surge in cases, decreased vigilance for control of CRAB transmissions, including suspension of the MDRO workgroup, reduced surveillance cultures, reduced personnel numbers (which decreased capacity for overall auditing practices), and both intentional and unintentional changes in IPC practice likely contributed to this CRAB cluster. The lack of audits made identifying and correcting real-time IPC compliance issues difficult. Diminished colonization screening might have resulted in a higher threshold for recognizing increasing incident hospital-acquired CRAB cases. Reinstatement of conventional IPC strategies in ICUs, paired with enhanced cleaning procedures and hand hygiene reeducation, likely contributed to the rapid decline in cases.
The COVID-19 pandemic has required hospitals to take unprecedented measures to maintain continuity of patient care and protect healthcare personnel from infection. This outbreak highlights that MDROs can spread rapidly in hospitals experiencing surges in COVID-19 cases and cause serious infections in this setting. To reduce spread of MDROs and the risk of infection for patients, hospitals should remain vigilant to prevent and detect clusters of unusual infections and respond promptly when they are detected. Facilities should prioritize continuity of core IPC practices (e.g., training for and auditing of hand hygiene, PPE use, and environmental cleaning) to the greatest extent possible during surges in hospitalizations and make every effort to return to normal operating procedures as soon as capacity allows.
The hospital and the New Jersey Department of Health (NJDOH) conducted an investigation, and identified 34 patients with hospital-acquired multi-drug resistant CRAB infection or colonization from February to July 2020, including 21 (62 percent) who were admitted to two intensive care units (ICUs) dedicated to caring for COVID-19 patients. Twenty (59 percent) incident cases were identified from clinical specimens and 14 (41 percent) through colonization screening.
In late March, increasing COVID-19-related hospitalizations led to shortages in personnel, personal protective equipment (PPE) and medical equipment, resulting in changes to conventional infection prevention and control (IPC) practices at the hospital, the CDC said. As COVID-19 cases declined in late May, the hospital resumed normal procedures, including standard IPC measures, and CRAB cases subsequently returned to a pre-COVID-19 baseline (zero to two cases per month).
“This outbreak highlights that MDROs (multi-drug resistant organisms) can spread rapidly in hospitals experiencing surges in COVID-19 cases and cause serious infections in this setting. To reduce spread of MDROs and the risk of infection for patients, hospitals should remain vigilant to prevent and detect clusters of unusual infections and respond promptly when they are detected. Facilities should prioritize continuity of core IPC practices (e.g., training for and auditing of hand hygiene, PPE use, and environmental cleaning) to the greatest extent possible during surges in hospitalizations and make every effort to return to normal operating procedures as soon as capacity allows,” the CDC wrote.
