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BACKGROUND: Rare in Oregon, carbapenem-resistant Acinetobacter baumannii are endemic in other U.S. regions, have limited treatment options, and are associated with increased mortality. Two carbapenem-resistant A. baumannii cases reported within 2 months from an Oregon skilled nursing facility prompted an investigation to determine the scope, source, and mode of transmission, and prevent spread among Oregon healthcare facilities.
METHODS: A case was defined as a clinical or surveillance isolate of A. baumannii resistant to ≥1 carbapenem tested using Clinical Laboratory Standards Institute 2012 breakpoints in a person receiving care in an Oregon healthcare facility since January 1, 2012. Microbiology laboratories serving >90% of population searched laboratory reports since January 1, 2012. We reviewed case patient medical records for common exposures, and oversaw 2 patient and 1 environmental point prevalence surveys at 2 facilities. The public health laboratory used pulsed-field gel electrophoresis (PFGE) with SMA-1 to perform strain typing.
RESULTS: We identified 19 cases (16 clinical, 3 surveillance) exposed to 35 facilities during 2012 January–2013 October by case report (2), active case-finding (2), point prevalence survey (3), and active surveillance (12). Of 18 isolates tested, 15 shared ≥90% PFGE homology. Of these, 13 reported admissions to Facility A or B, a long-term acute care hospital and skilled nursing facility, respectively. In total, 15 PFGE-related and 1 epi-linked case (Facility A patient, missing isolate) were aged 25–92 years (median: 69 years); 10 (63%) were male. One patient had repeatedly positive clinical isolates from wound, respiratory, and urine during admission to Facility A. However, this information was incompletely communicated to Facility B, and contact precautions were not enforced despite transmission risks (e.g., bedbound, wounds, catheters). The patient’s arrival corresponded with onset of cases at Facility B. An environmental survey at Facility B 7 months later did not identify a single source. Contact precautions, chlorhexidine wipe baths, and enhanced environmental cleaning were recommended for case patients. Nursing facility patients were encouraged to participate in rehabilitation and social activities provided they performed basic hygiene and secretions were contained. We created guidelines which recommended education, active surveillance, augmented environmental cleaning, and interfacility communication.
CONCLUSIONS: Extensive traceback of Oregon’s first carbapenem-resistant A. baumannii outbreak identified a “super-spreader” patient and contaminated environment. Public health collaboration with exposed healthcare facilities appeared to halt the spread, most likely through increased scrutiny, review of environmental cleaning, improved staff education and precautions use, and development of transfer communication protocols.