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Isolation for life: The curse of 'Iraqibacter'
'If it gets a foothold it is very difficult.'
Infection preventionists looking for guidance on discontinuing contact isolation for patients with multidrug-resistant Acinetobacter baumannii (MDR-Ab) remain in a quandary.
The latest recommendations by the Association for Professionals in Infection Control and Epidemiology (APIC) apparently will leave the situation unresolved, which is where it has been since so-called 'Iraqibacter' began its dramatic emergence in U.S. hospitals and nursing homes after initial cases were linked to soldiers returning from the Mideast wars.
The isolation issue came up in an exchange between audience members and a speaker previewing new APIC guidelines recently in New Orleans at the annual APIC educational conference. The APIC guidelines were slated to be released in the near future as this issue went to press. Speaking at the conference was Patricia Rosenbaum RN, CIC, an infection control consultant and a member of the taskforce that compiled the new APIC guidelines.
"Is there any indication in the new guidelines when you might be able to take [patients] out of isolation is it indefinite?" asked an infection preventionist from Toledo, OH, in the question and answer period following Rosenbaum's presentation.
"I would not take them out of isolation, and you want to flag them," Rosenbaum said.
"They are flagged, but we keep them in 'lifetime' at the moment because there are no good criteria out there [on] when to take them out," the IP responded.
Another APIC audience member echoed the concern, saying her MDR-Ab patients were in isolation from "here to eternity."
"My feeling is that I would keep them on isolation precautions," Rosenbaum reiterated.
For its part, the Centers for Disease Control and Prevention has left the discontinuation of isolation for such patients an unresolved issue, citing "a paucity of information in the literature."1 A policy on the website of Johns Hopkins Hospital in Baltimore, MD, (http://www.hopkinsmedicine.org/heic/ID/mdr) states that "at this time, there are no criteria for removing patients from isolation for MDR-Ab. Negative cultures do not indicate that the patient is free from colonization with the organism. This will be reconsidered as we acquire more data and experience controlling MDR-Ab."
Lives in the 'cracks and dust'
The excess of caution is due in large part to the harrowing task of trying to control outbreaks of MDR-Ab, which has the ability to persist in the environment and appears to transmit more readily than other resistant bugs.
"I can see where somebody would say, this is [another] multidrug resistant organism, so what's new?" Rosenbaum said. "What's different with this one is that it has a propensity for rapidly developing resistance to antibiotics. The other propensity which is more alarming is that if it gets a foothold in your facility it becomes very difficult to get rid of it. I think a lot of that is the environment. It lives in the cracks, in the dust, in machines. You must do very good environmental [cleaning]."
A recently published story found that gowns, gloves and the unwashed hands of health care workers were frequently contaminated with MDR-Ab, suggesting it is more easily transmitted than other resistant bacteria.2
"Their conclusion was that this organism was even more transmissible to gowns and gloves than MRSA and VRE," she said. "That's what they found, so it shows you how easily this could spread around a facility."
MDR-Ab is resistant to multiple drugs, and there are pan-resistant strains that are virtually impervious to the full formulary.
"The appearance of a single case of MDR-Ab in an area with no previously identified cases should prompt an investigation and the timely implementation of selected control measures," she said. "They should go into contact precautions right away."
The patient population affected is typically the very seriously ill undergoing multiple courses of antibiotics, she noted.
"I don't know how many of you have treated [these patients] in your ICUs, but you can almost see the resistance build in very compromised patients that have been there an extended period of time," Rosenbaum said. "It seems like with each wave of antibiotics used, there is more and more resistance built until there is nothing left."
MDR-Ab transmission in healthcare settings has a strong environmental component, she said. "It has the ability to form a biofilm and this promotes it's durability on surfaces and may contribute a great deal to the continuation of outbreaks," she said. "MDR-Ab can survive for days, weeks, months in the environment. It used to be thought of as a 'wet' organism, but now it is known to survive in dry environments."
In outbreak situations some IPs are having success with intensified cleaning regimens that include bleach solutions and the use of hydrogen peroxide vapor. "If transmission of the organism continues and the environment is suspect, the unit should be vacated and intensive cleaning performed," she said.
In any case, monitor environmental cleaning and make sure supplies like bleach wipes are being used properly, she emphasized.
"Remember it is one swipe with one wipe," she said. "If the cleaning person is using a wipe to go around the entire room they are portably taking it from place to place in the room."
Transfer between facilities common
Your risk assessment for MDR-Ab should be informed by local public health data and an awareness that the pathogen moves between facilities via patients, Rosenbaum said.
"It is very persistent in a geographic area," she said, noting that in her consulting work she had a group of six to eight hospitals exchanging cases. "The IPs all got together so we all knew it was going from one place to another place to another. You should be aware of that."
In that regard, an immediate alert of MDR-Ab history is essential at time of admission and at the time of transfer to another patient unit, another service or a different healthcare setting, she stressed.
"You want to make sure they know what they are getting," she said. "Your labs should have an alert notification system to let the IP department and the health care providers know when you are dealing with MDR-Ab."
In addition to hand hygiene and contact precautions, some facilities fighting outbreaks of MDR-Ab have tried a variety of enhanced precautions, she said.
"If you have a true outbreak, you'll begin to do anything to stop it," she said. "Some of the tactics and strategies that I have heard used in dealing with outbreaks include cohorting of staff and one-on-one nursing. Some hospitals have such a large outbreak that they open a unit just for [MDR-Ab patients]."
In an outbreak, the aforementioned contact isolation measures become all the more stringent, with many facilities deciding to do any additional procedures like dialysis in the patient's room.
"They don't come out of the room for anything," Rosenbaum said.