An outbreak of extremely drug-resistant Acinetobacter baumannii at multiple facilities in Oregon underscores an open secret as bad bugs move across the healthcare continuum: There are disincentives to telling the receiving facility that the patient has a history of a drug-resistant bacteria or other problematic pathogens.

This has been going on in one form or another since hospitals and nursing homes were blaming each other for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) patients going back and forth between facilities in the 1980s and 1990s. The rise of multidrug-resistant organisms (MDRO), particularly gram negatives such as A. baumannii and carbapenem-resistant Enterobacteriaceae, has heightened the stakes considerably. Some of these pathogens are virtually pan-resistant and carry transmissible plasmids that can confer drug resistance in other bacteria.

“We know that patients move throughout the healthcare system across the continuum,” says Jon Furuno, PhD, a co-author of the recently published investigation1 and associate professor at Oregon State University in Corvalis. “We all kind of recognize that that’s happening. There are a lot of data out there now [showing] that we are just not great at providing information to optimize care as [patients] move between these different care settings.”

The multifacility outbreak in Oregon resulted in a state law requiring a transferring healthcare institution to notify the receiving organization that the patient being transferred has a history of infection or colonization with a pathogen of concern.

“It requires that healthcare facilities provide written communication about MDROs and Clostridium difficile status to the receiving facility,” Furuno says. “It also includes transport [to notify] the folks transferring the patients as well.”

Other states may take similar action. At the federal level, CMS issued a proposed rule last year to address the patient transfer issue. It had not been finalized as this issue went to press.2 “Given the number of facilities through which a patient might travel, [CMS] proposes to increase the involvement of hospital infection prevention and control programs [to] facilitate communication across settings,” the agency stated in the proposed rule. While the multifacility outbreak was a primary driver of the Oregon law, the investigators were reluctant to assign blame or suggest there was any intention by healthcare facilities to mislead the receiving organization.

“You hear about it anecdotally. People do worry about how they are going to get someone to take this patient if they have this organism,” Furuno says. “There is that concern out there, but I’m not sure if that happened in this scenario. But sure, the way the healthcare system works, patients tend to move between various levels of acuity. The way the reimbursement system works, there are incentives to discharge patients and [that leads to] concern about things that may affect your ability to do that.”

Lead author Genevieve L. Buser, MD, an infectious disease physician at Providence (OR) Medical Group, says the investigation revealed no effort by any facility to intentionally withhold information about a transferring patient.

“Having spoken to the skilled nursing homes, long-term care, and hospitals, everyone wants to know this information — that’s for sure,” she says. “However, prior to having more formal requirements for communication of that [with the new Oregon state law] I believe — by oversight, mostly — it was buried within the progress notes. Usually these were patients with prolonged stays, and maybe they had that infection somewhere in the middle [of care]. That may have been a multidrug-resistant organism which they were able to clear, but it’s still a part of their microbiome and needs to be part of their current history. These organisms can hang around in the gut and in wounds, and really remain a part of that person’s current history for some time. Everybody needs to know about it and share; let’s not hide it under the rug. We need to be open about it so we can have that knowledge and prepare for this.”

The investigators identified 21 cases of A. baumannii, most of which were highly related by molecular epidemiology and suggestive of a single clone moving between care sites. Overall, 17 patients (81%) were admitted to either long-term acute care hospital (LTACH) A (8), or skilled nursing facility (SNF) A (8), or both (1).

“Interfacility communication of patient or resident [drug-resistant] status was not performed during transfer between facilities,” the authors noted. “An entire chain of transmission at SNF-A might have been prevented if its staff had been notified by LTACH-A of the MDRO status of one patient.”

Reviewing the epidemiologic evidence and genetic sequencing data, the authors concluded that three persistently colonized patients transmitted A. baumannii to at least a dozen other patients and residents. Risk factors for prolonged colonization included chronic wounds, morbid obesity, tracheostomies, and indwelling urinary catheters.

The outbreak, which occurred over a period of two years, required considerable detective work to trace back the transfers and the transmission within facilities. It was originally discovered by an infection preventionist performing a routine review of drug-resistant organisms.

“The IP was reviewing isolates and sensitivities, particularly those in which this resistance was noted,” Buser says. “They actually happened to be isolates that were processed through the hospital lab, but weren’t from inpatients. Two of these resistant isolates had been sent in by the same skilled nursing facility. Not only were they an unusual gram negative resistant to carbapenems, but the specimens had been sent in by the same facility. So, with that information, she contacted county public health.”

The state health department also was performing surveillance for MDROs as part of its role as an Emerging Infections Program sponsored by the CDC.

“We discovered that [long-term care] residents had common healthcare contacts in that skilled nursing facility, and that turned this into a larger investigation,” Buser says. “Ultimately, by tracing it back [it involved] many healthcare facilities. Chronologically, it appears that this carbapenem-resistant Acinetobacter initially appeared at the LTACH in January of 2012, related to a patient before we started doing the investigation. That’s as far as we can trace it back.”

That linked not only other facilities, but a neighboring state, as that patient had been previously treated in Washington.

“Then one of the patients, as care improved, was transferred [from the LTACH] down to the skilled nursing facility and she likely took the bug with her,” Buser says. “A couple of months later, we ended up with the two cases that came to the infection preventionist’s attention.”

Infection control lapses at the facilities involved included lax bronchoscope reprocessing and poor handwashing compliance. In addition to placing the identified patients under contact precautions, the patients received chlorhexidine baths and their surrounding environments were rigorously cleaned and disinfected.

Acinetobacter is a very hardy bacteria,” she says. “It can remain on fomites and hands. It probably became endemic in each facility and then popped up every once in a while as clinical cultures, and those are what we saw as the cases.”

Carbapenem resistance typically means providers are reduced to last-line drugs such as colistin, which was used in at least one of the cases of invasive infection. There was one patient death retrospectively identified, but A. baumannii was not definitively implicated as the cause of death.

In addition to improving communication, the authors are trying to raise awareness and emphasize the need for education to prevent such incidents in the future.

“These skilled nursing facilities and other non-hospital facilities need to be comfortable managing this and caring for these patients,” Buser says. “That’s another piece that Oregon is trying to work on. What we can see with [the new law] is that it is becoming part of the hospital discharge notation. With electronic medical records there is better flagging [of transmissible pathogens] in the chart.”

REFERENCES

  1. Buser GL, Cassidy M, Cunningham MC, et al. Failure to Communicate: Transmission of Extensively Drug-Resistant blaOXA-237-Containing Acinetobacter baumannii—Multiple Facilities in Oregon, 2012–2014. Infect Control Hosp Epidemiol 2017;1–7.
  2. CMS. Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes To Promote Innovation, Flexibility, and Improvement in Patient Care. Proposed Rule. Fed Reg June 16, 2016. Available at: http://1.usa.gov/291FtIc. Accessed Nov. 7, 2017.