The great thing about working with HealthLeaders is that I learn at least one fascinating fact about healthcare every day, a benefit I missed when I took some time off last week.
On my first day back, a "good news" paper presented at a meeting of infection control professionals got my attention with another intriguing aspect of hospital care.
It told how a fast-acting Dallas hospital put an abrupt end to a cluster of an increasingly feared drug-resistant strain of bacteria, Acinetobacter baumanni. Ab, as it is referred to, has been terrorizing a growing number of health facilities in recent years since it was discovered imbedded in the wounds of military troops returning from Iraq nearly a decade ago.
The particular strain is called Ab-XDR, which stands for "extensively drug resistant." Only two antibiotics, colistin or polymyxin B—drugs that carry high risk for kidney damage—have some reliability to fight it.
Methodist Dallas Medical Center turned itself upside down after four hospital-acquired cases of the potentially devastating organism were identified during one week, last fall. Over the course of an aggressive investigation during the six weeks following the discovery, another nine patients were found colonized or infected.
Hospital officials immediately mobilized, according to Elizabeth Wallace, infection preventionist at Methodist Dallas, who presented a paper on the hospital's rapid response to the outbreak at the annual meeting of the Association for Professionals in Infection Control and Epidemiology (APIC).
Wallace explained that three of the cases were epidemiologically related "given their proximity in the Cardiac Care Unit, and the fact that all specimens were from the respiratory tract." Another case was found in a clinical culture from the hospital's Surgical Intensive Care Unit.
They sent isolates to the Texas Health Department for confirmation, and of those sent, 13 were determined to be hospital-acquired, and 11 were confirmed by molecular analysis as genetically identical.
- All patients were placed in contact precautions, where all staff were required to wear gloves and gowns upon entry to the patient rooms and visitors were strongly urged to do so too.
- Biweekly surveillance cultures were initiated, including endotracheal aspirate or sputum, would cultures from patients with draining wounds and rectal swabs.
"An exhaustive epidemiological investigation ensued, including evaluation of a possible environmental source," Wallace said.
An infection prevention and control team collected cultures of "numerous high-touch surfaces" in two patient rooms, in hand washing sinks, a blood glucose monitor, a supply room entry keypad, a computer used for charting, the room where clean ventilators were stored, a return air vent and a clean ventilator."
Also, the hospital launched environmental disinfection with complete cleaning of all involved rooms and units. The effort included removing and thoroughly cleaning ventilation ducts in each room, especially because one of the environmental cultures indicated presence of the strain from a return air vent specimen.
Hospital epidemiologist Zakir Shaikh, MD, Wallace and Methodist's quality vice president Virginia Davis said the hospital was able to arrest the outbreak in a much shorter time-frame compared with most other reported outbreaks of this bacterium, which can persist for months or years, because they enlisted every part of the hospital in the effort.
The three lab cultures came back early one afternoon, and "within a couple of hours we had the team assembled to decide how we were going to monitor this over time to make sure we could contain it," says Davis.
"As soon as we identified that initial cluster of three, it raised red flags for us and we instituted a team response," Wallace says. "The prevention department got hold of Dr. Shaikh immediately, and we called in all of the players, involving nursing, physicians, administration, the lab, environmental services and the physical plant—every department that directs patient care or does behind-the-scenes work."
Shaikh says that Methodist, a 515-bed tertiary hospital in the middle of downtown Dallas, is relatively unusual in its vigilance to culturing patients, a practice it engages during the admissions process. It spends more than $500,000 a year on gowns, gloves and cultures.
They started the practice started five years ago when the hospital started seeing an influx of patients coming in from long-term care facilities and nursing homes who had antibiotic resistant infections.
"As a preventive strategy, we put criteria together to do cultures on patients who were coming in from hospitals or nursing homes or who had draining wounds," in order to prevent the spread of multi-drug resistant organisms, he says.
Since discovered in wounds of military troops returning from Iraq, A. baumannii has been increasingly seen in healthcare settings. It does not cause infection in otherwise healthy people, but when it infects patients who are already very sick, often in the intensive care unit, it can exacerbate a trajectory to death.
Health experts say it's almost impossible to blame Ab-XDR as the ultimate cause of death. But many of the patients who become infected die than uninfected patients with similar diagnoses.
According to the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, this strain of bacteria is an increasing nosocomial threat to patients in healthcare settings, "particularly in intensive care units."
"Treatment of infections attributed to A. baumannii can be difficult because the organism has intrinsic resistance to certain antimicrobial agents and has acquired resistance to many others," the report says.
"In health-care settings, colonized and infected patients are often the sources of A. baumannii infections; however, the ability of the organism to survive for prolonged periods on environmental surfaces also has contributed to protracted outbreaks in these settings."
Cathryn Murphy, president of the Association for Professionals in Infection Control and Epidemiology, the organization holding the annual meeting where Wallace presented her report, praised Methodist Dallas for its rapid response.
"With outbreaks of pan-resistant Acinetobacter baumannii and other multi-drug resistant organisms in the rise, it is absolutely essential that infection prevention departments be fully staffed and adequately resourced," she said.
"Methodist Dallas Medical Center was proactive in their approach, responding rapidly and mobilizing an interdisciplinary team to control the outbreak. The experiences of infection preventionists such as Ms. Wallace serve as practical guidance for healthcare professionals combating multi-drug resistant pathogens. Their experience is a powerful reminder that aggressive infection prevention programs are required to protect patients and save lives."
This is all scary stuff. But it's reassuring to know that there are hospitals like Methodist Dallas that are leading the way to prevent the spread of these potentially deadly infections.