CE

Continuing Education

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Acinetobacter
baumannii
An Emerging MultidrugResistant Pathogen in
Critical Care
Kerry Montefour, RN, BSN, CIC
Jeanne Frieden, BA, RN, BSN, CIC
Sue Hurst, RN, MSN, CCRN
Cindy Helmich, RN, MBA, CCRN
Denielle Headley, RN, BSN
Mary Martin, PharmD
Deborah A. Boyle, RN, MSN, AOCN

cinetobacter baumannii is a
troublesome and increasingly problematic healthcare-associated pathogen, especially in critical care.1-4 It
may be associated with hospitalacquired infections with considerable clinical and economic costs. In
physiologically compromised
patients, morbidity and mortality
are common sequelae of hospitalThis article has been designated for CE credit.
A closed-book, multiple-choice examination follows this article, which tests your knowledge of
the following objectives:
1. Identify factors that contribute to the
emergence and significance of Acinetobacter
baumannii in healthcare environments
2. Describe the characteristics of A baumannii
and the associated risk factors for development
of A baumannii infections
3. Discuss nursing interventions, infection
control measures, and clinical recommendations
for prevention and containment of A baumannii
infections

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acquired infections.4-7 Hence, multiple professional organizations have

identified multidrug-resistant

(MDR) pathogens as a critical target

that requires intervention (Tables 1
and 2).

Authors
All authors are associated with Banner Good Samaritan Medical Center, Phoenix, Arizona.
Kerry Montefour is the director of the infection control program.
Jeanne Frieden is an infection control practitioner.
Sue Hurst is a critical care clinical nurse specialist in medical-surgical and transplant
intensive care units.
Cindy Helmich is the director of nursing for the medical cardiology service and inpatient
wound care.
Denielle Headley is the nurse education specialist for the medical-surgical and transplant intensive care unit.
Mary Martin is the associate director of the antimicrobial management team.
Deborah A. Boyle is the practice outcomes nurse specialist and Magnet coordinator.
Corresponding author: Kerry Montefour, RN, BSN, CIC, Banner Good Samaritan Medical Center, 1111 E
McDowell Rd, Phoenix, AZ 85006 (e-mail: Kerry.montefour@bannerhealth.com).
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

CRITICALCARENURSE Vol 28, No. 1, FEBRUARY 2008 15

Table 1 Actions of professional organizations and recommended interventions

for outbreaks of infections caused by multidrug-resistant organisms
Centers for Disease Control and Prevention
Identified antimicrobial resistance and lack of new drugs coming to market as a
major health threat (1997)
Created a 12-step initiative to increase awareness of resistance and implement
strategies to prevent the development of resistance in various populations8
Centers for Disease Control and Prevention and Food and Drug Administration
Cochaired a 10-agency task force (1999)
Published A Public Health Action Plan to Combat Antimicrobial Resistance9
Infectious Disease Society of America
Initiated the program Bad Bugs No Drugs10 to enlighten federal policymakers
about the inadequacy of the pharmaceutical pipeline in the development of new
antimicrobial agents
American Society for Microbiology and the Society for Healthcare Epidemiology of
America
Created the Antimicrobial Resistance Prevention Initiative, a program providing
ongoing education exploring epidemiology and molecular mechanisms of resistance
Clinical and Laboratory Standards Institute
Developed standard reference methods for antimicrobial susceptibility tests

Table 2 Centers for Disease Control

and Prevention: 12 steps to prevent
antimicrobial resistance among hospitalized adults8
Prevent infection
1. Vaccinate
2. Get catheters out
Diagnose and treat infection effectively
3. Target the pathogen
4. Ask the experts
Use antimicrobials wisely
5. Practice antimicrobial control
6. Use local data
7. Treat infection, not contamination
8. Treat infection, not colonization
9. Know when to say no to vancomycin
10. Stop treatment when infection is
cured, unlikely, or undiagnosed
Prevent transmission
11. Isolate the pathogen
12. Break the chain of contagion

Our experience with managing

an outbreak of MDR A baumannii in
a medical intensive care unit (ICU)
prompted an evidence-based review
of the literature, which resulted in few
findings. Key elements of outbreak
control and nursing care interventions associated with this resistant
strain had not been identified. In this
article, we provide a synthesis of the

medical literature on A baumannii, a

chronology of our efforts to control
the outbreak, and recommendations
for responding to A baumannii
infections in ICU settings.

Literature Review
Characteristics of A baumannii
and A baumannii Infections
Acinetobacter baumannii is a nonfermentive, aerobic, opportunistic,
gram-negative coccobacillary rod.
Morphological findings vary according to the phase of cell growth and
exposure to antimicrobial agents.2,6
Widely distributed in soil and water,
A baumannii grows at various temperatures and pH environments and
uses a vast variety of substrates for
growth.3,11 The indiscriminate nature
of this organism and its recent acquisition of MDR intensify its emergence and significance in healthcare
environments.5
Acinetobacter baumannii normally
inhabits skin, mucous membranes,
and soil. The organism can survive
for long periods on both dry and

16 CRITICALCARENURSE Vol 28, No. 1, FEBRUARY 2008

moist surfaces.6 A total of 19 strains

of A baumannii have been identified.12
Although inconsequential to hosts
with intact immune systems, A baumannii infections may be fatal in those
with suboptimal immune defenses.
The evolution of this infection commonly occurs in chronically ill
patients who have multiple comorbid conditions, are hospitalized for
long periods, have multiple invasive
procedures, and are of advanced
age. Risk factors encompass those
for hospital-acquired MDR infections and ventilator-associated
pneumonias (Table 3). The role of A
baumannii in hospital-acquired
infections is associated with 3 factors:
its diverse reservoir, its association
with antimicrobial resistance, and
its outbreak potential.
Growth Reservoir
Although risk factors for A baumannii infection have been well
described, the reservoirs of this
pathogen are poorly understood.6
Acinetobacter baumannii is nonselective in its habitat (Table 4) and can
survive indefinitely. The respiratory
tract, blood, pleural fluid, peritoneum, urinary tract, surgical
wounds, central nervous system,
skin, and eyes may be sites of infection or colonization.4,6,11 Invasive
devices used to facilitate fluid monitoring, administer medications, and
provide lifesaving support may also
be sources of colonization. For
example, in patients receiving
mechanical ventilation, the formation of a biofilm on the surface of
the endotracheal tube may be the
source of colonization of the lower
part of the airway.15 Inert surfaces
such as those listed in Table 4
appear to be improbable sources of

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numerous surfaces in providing

care.8,10,20-29 Acinetobacter baumannii
organisms are readily removed by
most hand cleansing agents and by
the environmental cleaning done in
hospital settings.15,21,22

Table 3 Risk factors for acquiring Acinetobacter baumannii 4-6,13-16

Advanced age
Antimicrobial therapy within past 90 days
Use of artificial devices
Dialysis (chronic) within past 30 days
Mechanical ventilation
Sutures
Catheters
Central venous
Intravenous
Urinary
Evidence of high-frequency antibiotic resistance in the community or hospital
Severe immunocompromise due to disease or therapy
Multiple comorbid conditions
Prolonged hospitalization (especially critical care) or residence in an extended care facility

An Outbreak of MDR
A baumannii

Table 4 Potential hospital environmental sources of Acinetobacter baumaniii 3,4,6,12,17,18

Supplies
Crash cart
Weighing hammocks
Protective masks
Shared equipment
Invasive equipment and interventions
Catheters (ie, central lines, urinary)
Injection of medications from
multidose vials
Room variables
Bed rails
Blood pressure cuffs
Cupboards
Door handles
Intravenous stands
Linens
Foam mattresses
Paper towel dispensers
Pillows
Containers for sharp objects
Sinks
Table tops

A baumannii, but culturing of specimens obtained from these areas has

indicated the prominence of the surfaces in the evolution of A baumannii.18 Of note, increased incidence of
MDR A baumannii in military personnel injured in Iraq, Kuwait, and
Afghanistan has been reported.19
The majority of the injured had had
traumatic injuries in the field. Infection with A baumannii was diagnosed after the personnel were
transferred to major military hospitals in Western Europe.

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Mechanized equipment
Air conditioners
Hemodialysis machinery
Infusion pumps
Key panels of monitors, computers,
continuous venovenous hemodialysis
machinery
Mattresses with pneumatic pumps
Ventilators, respiratory equipment
Liquids
Blood products
Enteral formulas
Saline
Soaps and detergents
Water
Distilled
In humidifers
Nonsterile

Despite the diversity of host sites

of A baumannii, inadequate hand
hygiene remains a significant factor
in the transmission of this pathogen.18
Cross-transmission of MDR A baumannii occurs via direct contact from
hands (especially in persons with
damaged skin from chronic dermatitis) and gloves from healthcare
professionals to patients.3,4,6,12,18
Colonization on the skin and contamination on glove surfaces may be
direct or indirect as the healthcare
provider touches the patient and/or

In mid-December of 2005, the

microbiology specialist at Banner
Good Samaritan Medical Center,
Phoenix, Arizona, reported that 5
extremely resistant isolates of A baumannii had been cultured during a
2-week period. This number was a
dramatic increase. In the previous 6
months, resistant A baumannii had
been isolated from only 11 specimens. All of the December isolates
were from 5 patients in medical
ICUs, and all 5 patients were receiving mechanical ventilation.
Development of Antimicrobial
Resistance
Antimicrobial resistance has
become a national problem.24-26 An
organism is considered resistant
when its growth in vitro is not inhibited by an antimicrobial agent that
has been associated with eradication
of the organism in vivo. Causes of
resistance vary but are often linked
to inappropriate initial antimicrobial
therapy,16 including administration
of subtherapeutic doses of antimicrobial agents, drug overuse, abbreviated or interrupted courses of
treatment, and poor tissue penetration by the antimicrobial agent.9,25,28
In A baumannii, antimicrobial
resistance probably originated from
resistance genes that are transferred
between bacterial species.5,30-33 These
genes are acquired rapidly and
contribute to the development of

CRITICALCARENURSE Vol 28, No. 1, FEBRUARY 2008 17

and air conditioner parts despite filoriginate from a

ters placed at air inlets and outlets.
single source
a Plasmid
Because of the scope of technological
with widespread
transfer
Resistance gene
equipment within critical care, this
environmental
Resistance
potential source of A baumannii
contamination
gene
should receive further investigation.
or where no
c Transfer of
free DNA
reservoir for the
Antimicrobial Management
contamination
Historically, carbapenems have
can be veriDead
b Transfer by
4,33-37
resulted in the best therapeutic
fied.
viral delivery
bacterium
response in infections caused by
Most MDR
MDR A baumannii.5,25,36 Currently,
A baumannii
Bacterium
Resistance
receiving
carbapenems, such as imipenem
outbreaks occur
gene
resistance
genes
and meropenem, remain the widely
in critical care
Bacterium
infected
recognized drug of choice for A bausettings
and
by a virus
mannii infections.5,13,25,38 Nevertheless,
involve resistsusceptibility testing is still required
Figure 1 Bacterial acquisition of resistance genes. Bacteria gain ance to multiple
resistance genes by 3 major methods: (a) donor cells transmit
when this pathogen is identified.
classes of
whole plasmids containing one or more genes into bacteria, (b)
During the time of our outbreak,
antimicrobial
a virus acquires a resistance gene from a bacterium and injects
4,18
testing resulted in an unpreceagents. Potenit into a different bacterial cell, and (c) bacteria assimilate genebearing components of DNA within their immediate vicinity.
dented 38% resistance rate to
tial sources of A
Reprinted from Levy, with permission from Tomo Narashima/Tane+1.LLC.
imipenem (Table 5). Resistance to
baumannii in
meropenem for the MDR isolates
the ICU have
5
antimicrobial resistance. Some of
was close to 100%.
received close scrutiny. Dust has
the genes are inherited, some emerge
Tests for susceptibility to colistin
been identified as a potential vehi17
from random DNA mutations in
and tigecycline were also performed.
cle. In one investigation, the outbacteria, and others are imported
For carbapenem-resistant A baubreak strain of A baumannii was
33
from related bacteria (Figure 1).
mannii, tigecycline and colistimethrecovered from dust within pneuEvidence of A baumannii antimicroate are 2 of the most frequently used
matic and electronic equipment, in
bial resistance may be a harbinger,
alternative agents. The Clinical and
air filters of continuous veno-veno
or indication, of transmission of the
Laboratory Standards Institute did
hemodialysis machinery, ventilators,
organism among patients and may
be predictive of an impending outTable 5 Susceptibility of Acinetobacter baumannii isolates to antimicrobials at Banner
break of A baumannii infections.4
Good Samaritan Medical Center and in the United States, January 2005-April 2006
Plasmid donor

Plasmid

Susceptibility of isolates, %

Outbreak Potential
The evolution of A baumannii
infections and their associated relationship with outbreaks correlate
with the virulence of the strain. Inherent, unknown mechanisms appear to
impede desiccation of this pathogen.
Resistant A baumannii often become
apparent as a cluster of infections
caused by the bacterium.4 Cases are
often aggregated by time and place
within settings. An outbreak may

Antimicrobial
Amikacin
Ampicillin/sulbactam
Aztreonam
Cefepime
Ceftazidime
Ciprofloxacin
Gentamicin
Imipenem
Levofloxacin
Piperacillin/tazobactam
Trimethoprim/
sulfamethoxazole
Tobramycin

18 CRITICALCARENURSE Vol 28, No. 1, FEBRUARY 2008

Medical center (18 isolates)

National39 (>8000 isolates)

25.5
47.8
0.0
16.3
16.8
15.2
19.6
62.0
16.8
20.2
16.4

80.4
67.1
6.2
41.8
39.6
42.0
52.3
72.1
Not available
47.0
52.7

23.9

70.1

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not provide interpretation of susceptible, intermediate, and resistant for susceptibility to tigecycline
because of a lack of correlating clinical data. Without an interpretation,
only the size of the area of growth
inhibition could be reported. Hence,
the interpretation of these findings
was left up to individual physicians.
In mid-February 2006, the use of
tigecycline E-test strips was implemented by our microbiology laboratory. (E-test strips are impregnated
with a predefined antibiotic gradient.
They are placed on agar culture plates
that have been inoculated with the
organism. The goal is to determine
the in vitro minimum inhibitory
concentration.) Results and interpretations of the E-tests were provided to clinicians according to the
Food and Drug Administrations
interpretive guidelines to provide
more standardized and informational guidance to physicians. Colistimethate was used clinically because
of its proven ability to treat infections
caused by MDR A baumannii and
other MDR organisms.38,40 According
to The Surveillance Network,37 the
susceptibility of A baumannii isolates
to polymyxin B in the United States
is 95.4%. During the outbreak, no
polymyxin Bresistant organisms
were identified. Tigecycline, a new
broad-spectrum minocycline derivative, received approval from the
Food and Drug Administration in
June 2005.39
We subsequently used tigecycline
because of the reported in vitro susceptibility of A baumannii to this
drug. By the E-test strip method,
the susceptibility of MDR A baumannii at the medical center February through June 2006 was 71%.
Susceptibility to tigecycline has rap-

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idly declined; only 39% of isolates

obtained from July through December 2006 were susceptible, and 22%
of those obtained from January
through June 2007. Of note, this
resistance pattern has emerged
despite restriction of tigecycline to
treatment of MDR organisms that
were sensitive only to colistin and
tigecycline. The combination of colistimethate and tigecycline was prescribed for many of our patients
because the severity of illness, limited
susceptibility information, and lack of
clinical outcome data for tigecycline.
Colistimethate Colistimethate is an

antimicrobial produced by Bacillus

colistinus. It became commercially
available in 1959. Use of this agent
has been limited because of its
nephrotoxicity and the availability
of less toxic agents. It is approved by
the Food and Drug Administration
for treatment of acute or chronic
infections due to susceptible gramnegative bacteria. Colistimethate is
hydrolyzed to colistin, also known
as polymyxin E. Colistin acts as a
cationic detergent to damage the
bacterial cell wall, resulting in leakage of intracellular substances and
cell death. Colistin is eliminated via
the kidneys and has a half-life of 1.5
to 8 hours.41
The most common dose of colistimethate is 2.5 mg/kg intravenously
every 12 hours for patients with
normal renal function. Nephrotoxic,
neurotoxic, and pulmonary toxic
effects are significant adverse events
associated with this drug. Dose and
interval adjustments are recommended for patients with creatinine
clearance less than 75 mL/min.
However, dosing modifications for
patients with renal impairment are

not well established. Colistin is

poorly removed by hemodialysis.
Patients with renal impairment
require monitoring of renal function,
and dose and interval adjustments
of the drug are recommended. No
commercial method for monitoring
the therapeutic level of colistin is
available in the United States.
Tigecycline Tigecycline, a parenteral

broad-spectrum bacteriostatic agent,

is approved for treatment of complicated skin and skin structure infections and intra-abdominal infections
caused by susceptible organisms.39
In one study,38 in susceptibility testing, the minimum inhibitory concentration required to inhibit the
growth of 90% of organisms in vitro
was 2.0 g/mL for 739 isolates of
Acinetobacter, indicating the potential clinical effectiveness of tigecycline. Tigecyclines mechanism of
action involves binding to the 30S
ribosomal subunit and blocking
protein synthesis.
Tigecycline has a 7 to 9 L/kg volume of distribution and a half-life of
approximately 42 hours. A loading
dose of 100 mg is recommended,
with a maintenance dose of 50 mg
every 12 hours. No dose adjustment
is required for patients with renal
impairment or mild to moderate
hepatic impairment. Major side
effects include nausea (29.5%), vomiting (19.7%), and diarrhea (12.7%).36
Infection Control Measures
Once the cluster of MDR A baumannii was recognized, discussions
occurred between personnel in infection control and the nurse managers
of the affected ICUs. Contact precautions were implemented for the
patients who had infections caused

CRITICALCARENURSE Vol 28, No. 1, FEBRUARY 2008 19

by MDR A baumannii, as per hospital policy for any patient with an

MDR organism. As new patients
continued to be identified, it became
apparent that contact precautions
were not controlling the outbreak.
Nursing staff reported that some
colleagues, particularly physicians,
but also other staff working on and
off the units, had not been following
strict contact precautions.
Cohorting or keeping patients
who have the same illness together,
is a strategic intervention to limit
outbreaks of infections caused by
MDR organisms.42 The patients were
moved to a single ICU, and the unit
was closed to other patients. Nursing and respiratory staff were dedicated to that unit: they did not
respond to code calls or assist in
other units during their shift. Equipment was dedicated to that unit as
well (eg, portable x-ray machine). In
order to verify that the isolates were
related, isolates from 4 patients were
sent to the Arizona state laboratory
for ribotyping and pulse field gel
electrophoresis (PFGE). Results confirmed that the isolates were identical.
Recent reports of PFGE testing to
prove clonal spread is useful in
determining the appropriate actions
to control an outbreak.43
The results of our request for
PFGE testing prompted the state
health department to investigate the
prevalence of MDR A baumannii
throughout Phoenix. The investigation indicated some unrecognized
endemicity of this organism in the
greater Phoenix area. Of the Phoenix
isolates tested, 80% were the same
type, and a quarter of those had indications of single point mutations,
indicating that although the isolates
appeared to come from a single

source, this organism had been circulating in the area for a while.
We investigated environmental
sources of contamination at the
medical center. It was verified that
our hospital disinfectant (a quaternary ammonium compound) was
effective against Acinetobacter. Random specimens for culturing were
taken in patients rooms from frequently touched surfaces, including
beds, bed rails, intravenous pumps,
and ventilator faces. Of 13 cultures,
7 were positive for A baumannii.
Extensive education was done
with the environmental services staff
about the importance of attention to
detail in room cleaning. Additional
education was done with clinical
staff (nurses, physicians, and respiratory therapists); data on the positive environmental cultures were
used to reinforce the need for strict
contact precautions with gowns, hand
hygiene, and so on. Later, specimens
were obtained from vacant cleaned
rooms in the cohort nursing unit and
at the nurses station (ie, automatic
medication-dispensing machines,
telephones, and computers). All
specimens were negative for A baumannii, verifying that the cleaning
with our disinfectant was effective.
Of the first 9 cases at the medical
center, 6 occurred in patients receiving mechanical ventilation, so attention was focused on the ventilators.
It was verified that when mechanical
ventilation was discontinued, the
circuits on the machine were discarded and the outside of the machine
was disinfected. The ventilators used
on patients who had A baumannii
infections were, in addition, sent to
the decontamination department
for extensive cleaning. Exhalation
filters on several random ventilators,

20 CRITICALCARENURSE Vol 28, No. 1, FEBRUARY 2008

ready for use, were cultured; all

were negative for A baumannii.
The respiratory therapy department
created a spreadsheet to track specific ventilator use on individual
patients. Ventilator use did not
explain patient transmission.
Transmission via bronchoscopes
was also investigated. Cleaning procedures were reviewed. No new
technicians were cleaning the bronchoscopes, and all the technicians
were well trained and had received
updated annual in-service education.
The bronchoscopes were tracked,
and their use in patients affected by
the outbreak was determined. Only
2 bronchoscopes were used on more
than a single patient with MDR A
baumannii, and in both instances,
use of the bronchoscope in patients
who became infected with A baumannii was separated by at least a
2-week period, and the instrument
was used in between on other
patients who did not become infected.
A new procedure for active surveillance was initiated. Each time
MDR A baumannii was isolated from
a new patient receiving mechanical
ventilation, contact precautions were
implemented empirically for all
patients in that nursing unit who
were receiving mechanical ventilation. The use of the precautions was
continued until a sputum specimen
negative for MDR A baumannii was
obtained from each patient. Additionally, for any patient admitted
from an outside facility who was
receiving mechanical ventilation or
had a tracheostomy, contact precautions were implemented empirically
until a sputum specimen negative
for A baumannii was obtained. This
precaution has continued. Cohorting
was discontinued on March 1, 2006,

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when only 2 patients remained in

the unit and no new patients had
been identified for 3 weeks.
A second cohort unit was started
at the end of May 2006, nearly 3
months after the first cohort unit
had closed. Intermittent cases of
MDR A baumannii infections had
been identified, but when 8 patients
in different ICUs with such infections were identified during the
same time frame, the decision was
made to open a cohort unit. After 3
weeks, 3 patients remained, and the
unit was opened up to patients who
did not have A baumannii infections. The latter patients had to be
at low risk for infection: no mechanical ventilation, no tracheostomies,
and no surgical or open wounds. No
new clusters of patients infected
with this organism have occurred
since that time.
Staffing Impact
Staffing needs of a cohort unit
vary from the usual. As might be
expected, challenges during the use
of a cohort unit included matching
the number and types of staff required
with available resources. Most of the
patients required a 1 to 1 nurse to
patient ratio because of the frequency
of treatments, tests, and drug therapies. As isolation precautions
intensified, so did patient acuity.
Additionally, with this model of
cohorting infectious patients, members of the nursing staff were required
to assume additional responsibilities. Of note was their need to coach
all healthcare workers, including
physicians, who interacted with
patients to ensure that proper contact precautions were being adhered
to during patient contact. The staffing
implications also affected respiratory

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therapy staff, because they were

restricted to the cohort unit for the
duration of a shift, and often that
ICU did not require a respiratory
therapist full time. Staffing these
cohort units increased the variance
between budgeted and actual costs.
Information: Getting Out a
Consistent Message
During the cohort experience,
we used multiple strategies to quickly
bring the most current information
about the cohorting procedure to
the nursing staff. First, the nursing
management and infection control
teams made rounds at least daily,
and at times more often, to update
the staff about the situation and to
address questions. These rounds
provided a time for day and night
nursing staff to speak with infection
control staff and to inform managerial staff of the nurses needs. Second,
it was necessary to update all healthcare providers around the clock.
Because the members of the nursing
staff were the liaisons and primary
educators for what was transpiring
in the units, these personnel needed
more resources to provide ongoing,
timely, and accurate information to
a variety of colleagues involved in
the units functioning. As a result, an
Acinetobacter update flyer (Figure 2)
was created. The flyer was updated
periodically to keep the staff informed
of any new issues or pertinent clinical changes related to Acinetobacter.
In addition, extensive education
was done, on a continuing basis, to
increase compliance with contact
precaution measures.
Staff Responses to the Outbreak
At the beginning of the outbreak,
a general sense of fear and uncertainty

existed in the unit. Acinetobacter

baumannii was an unknown organism to the staff, and most of the
nurses were unfamiliar with the
threat it posed to themselves and
their families. The initial days were
characterized by questions about
what to wear, what not to touch,
how often to wash hands, and how
long the unit would remain
cohorted. One staff nurse said the
following:
I remember working on the
A baumannii unit for the first
time: gowns, gloves, booties,
and isolation signs covered
the entire unit. Everyone
seemed to have a fear of
working here. Some would
refuse. Nurses feared for
their health and that of their
families. Questions and
uncertainties filled the day:
Should I shower at work?
Should I change my scrubs
before going home? Will I
become infected?
News of the units cohorting status quickly spread throughout the
hospital. The unit became known as
the quarantine or the bug unit.
These names created an even deeper
sense of isolation for the nursing
staff working there. The staff were
stigmatized and characterized as
being different. Some staff members
asked to be transferred. The nurses
who remained felt an overwhelming
sense of exhaustion as each day the
requirement to gown and glove
upon entering a patients room
seemed increasingly burdensome.
As the outbreak continued and
core staff began to understand the
need and purpose for cohorting,
fear dissipated and the staff
assumed ownership of this special

CRITICALCARENURSE Vol 28, No. 1, FEBRUARY 2008 21

Critical Care Nursing News

Acinetobacter Update
March 24, 2006

Due to the newness of this pathogen and the evolving nursing care requirements associated with this patient population, a periodic
newsletter will be sent to critical care areas to ensure all staff have access to updated, timely information. This is the second newsletter in this series of updates.
Definition:

Acinetobacter baumanii is a gram-negative bacteria, often found in soil and water and can be
isolated readily from many sources in the environment. It can survive for long periods of time
in the environment and tolerates both moist and dry conditions. Resistant strains of this
bacteria have developed recently throughout the United States and are difficult to treat.

In hospitals, Acinetobacter baumannii is most common in ICU and burn patients. It poses very
little risk to healthy people. Patients at highest risk are very ill, on ventilators, have open
wounds and/or have many invasive devices.
As of March 1st, we are no longer cohorting patients. Strict adherence to Contact Precautions and optimum hand
hygiene remain the standard of care. We are continuing to screen all patients being transferred to us from long
term care facilities if they are vented, have a trach, or have large or draining wounds. Such patients are placed
into Contact Precautions upon admission, and remain so until screening cultures are finalized.
These resistant organisms have been found in many hospitals around our valley. The Arizona Department of
Health Services has been collecting isolates from hospitals around Arizona and most have turned out to be identical strains. In the long term, this may be an organism that is here to stay. The most recent nosocomial isolates of
resistant Acinetobacter were in sputum specimens from 2 of our patients, both collected on 3/22/06. It had been
a month since the last one was identified on 2/26/06.
For patients admitted from LTC with a trach, draining wound, or who are vented:
Immediately upon Admission, place the patient in Contact Precautions;
Obtain a culture of the site (i.e., trach, draining wound, or ET tube);
Notify Infection Control x 34390; may leave a message.
Question of the Week
What kind of patient can be paired with an Acinetobacter patient?
Ideally, for a patient in an ICU, a 1:1 assignment is preferred. If that is not possible, the nurse should be
assigned to a non-vented/non-trached patient, one who has not had recent surgery, and one with few invasive
devices or draining wounds.
Please call ***** (x 34390 or page 555-5555) if you have any concerns and please refer to these evolving
updates for continued information.
Figure 2 Example of an Acinetobacter update flyer.
Abbreviations: ET, endotracheal tube; ICU, intensive care unit; LTC, long-term care; trach, tracheostomy; vent, mechanical ventilation.
Reprinted with permission of Banner Good Samaritan Medical Center, Phoenix, Arizona.

population of patients. One nurse

remarked as follows:
Core staff became comfortable with the isolated unit. I
remember working on the A
baumannii outbreak unit for
3 months straight. I became
an advocate for proper education to doctors, nurses, and
other healthcare providers,

compiling education posters

for display throughout our
hospital so that others could
understand more about this
bacterial outbreak.
The initial struggle evolved into
a shared ownership between the
critical care nursing staff, infection
control specialists, and nursing
management. The need to compre-

22 CRITICALCARENURSE Vol 28, No. 1, FEBRUARY 2008

hensively educate the hospital and

public became a joint venture. For
example, the routine process of
sending a patient for a medical imaging procedure became a seemingly
unyielding event because of the
increased demands for preparation,
planning, transportation, and performing the procedure. An added
burden was also imposed on staff

http://ccn.aacnjournals.org

Table 6 Recommendations for control of Acinetobacter baumanii outbreaks

Action

Recommendations

Rationale

Organize response Start a time line: include all actions, meetings, education,
to outbreak
consultations (eg, health departments)
Save emails
Start a sequential list of patients

Actions can be reviewed in an organized

manner to help determine next steps
Organization facilitates financial assessment
of outbreak if required at a later date

Cohort patients,
staff, and
equipment

Cohorting assists in containing organism

Cohorting helps nursing staff enforce
meticulous attention to hand hygiene and
contact precautions
Use of active surveillance cultures facilitates
earlier use of contact precautions for
colonized and infected patients
Use of active surveillance cultures and
empiric precautions while awaiting
results, when done on inpatients, facilitates
earlier uses of contact precautions for
colonized and infected patients

Cohort patients, close unit to noninfected and noncolonized patients

Cohort staff: respiratory therapists and nurses remain in the cohort
unit, do not respond to code calls during shift
Cohort equipment (eg, portable x-ray machine)
Use active surveillance cultures on admission of high-riska patients
throughout hospital
If cohort unit is discontinued, consider active surveillance cultures
on all high-risk patients in a nursing unit each time a new patient
with resistant A baumannii is identified

Ensure that staff Ventilators: determine cleaning used, type of filters

Often an outbreak ends without an
are all in
Contact precautions: verify that staff have enough personal
identified culprit
compliance with protective equipment, are following procedures, have tools to
Attention to detail is what is needed
preventive
educate and coach other colleagues in complying with precautions
procedures
Environmental cleaning: verify procedures and education of
housekeeping staff; check disinfectant, how it is mixed, and so on
Environmental culturing: can be done if for no other reason than to
reassure staff
Bronchoscopes (if implicated by culture sites): review cleaning and
sterilization process, track patient use
Educate and
communicate
with staff

Develop educational programs for all departments: respiratory

therapy, medical imaging, environmental services, transport,
dietary/nutrition
Develop a newsletter or other communication tool to address
concerns or information needs
Create a question box and post the questions and answers daily

Knowledge equals power

All staff must be included to ensure
comprehensive team effort
Information in writing avoids pitfalls of
misinterpretation of answers and missed
instructions, giving all staff the benefit of
others questions
Emotionally healthy staff can change the
experience for patients, physicians and
visitors; it can be the difference between
success and failure

Provide emotional Anticipate emotional needs of cohort staff: provide food, use
support for
chaplaincy or music therapy in-house teams, arrange for times to
professional
vent/share frustrations on a regular basis
caregivers

a During the outbreak at Banner Good Samaritan Medical Center, patients from long-term care facilities who were receiving mechanical ventilation or had a
tracheotomy and any patient with draining wounds were high risk.

who remained in the unit to oversee

patient care in the absence of the
nurse deemed responsible for care
during this time.
Finally, as the decrease in the
number of infected patients became
obvious, staff realized how the
combination of cohorting, effective
hand hygiene, and institutional
education had worked together to
combat the spread of MDR A baumannii. Although staff nurses were
obviously approaching burnout

http://ccn.aacnjournals.org

near the culmination of this experience, the support of nursing management and the infection control
specialists sustained the core nursing
staff by providing daily effective
communication and listening to staff
members concerns about and reactions to this intense experience.

Clinical Recommendations
The first and foremost clinical
recommendation for preventing outbreaks of MDR A baumannii infec-

tion is early recognition: develop a

method to track the incidence and
resistance patterns of all Acinetobacter
isolates in your critical care areas.4
By the time a patient arrives in the
ICU, he or she is often heavily pretreated and highly compromised
and thus vulnerable to a number of
potentially fatal sequelae. Patients
with known clinical infection most
likely represent only a small percentage of microbial colonization/
contamination, signifying the

CRITICALCARENURSE Vol 28, No. 1, FEBRUARY 2008 23

iceberg phenomenon.6 Prevalence

of infection in the setting may be
only partially realized.
Our list of recommendations for
facilities that must address the management of A baumannii infections
fall into 5 categories (Table 6).
Consideration of Cost
The costs associated with a
hospital-acquired infection are significant.2,44 In the United States, an
estimated 250000 episodes of
hospital-acquired infection occur
annually, with a total cost of nearly
$5 billion, associated mortality rates
of 35%, an extended mean length of
hospitalization of 24 days, and
added costs exceeding $40000 per
survivor.7,10,45 The cost of treating
resistant hospital-acquired infections is staggering, particularly in
critical care.24 ICU beds account for
5% to 10% of inpatient beds, yet
account for more than 30% of hospital budgets and 8% of healthcare
costs45-47 (Table 7).
According to one estimate,48 the
overall cost to contain an outbreak

was $220000 per patient. Additionally, the hospital may lose more
than $2 million in potential revenue
because of the loss of nearly 300
hospital-bed days because of room
closings. Although our review did
not include quantification of cost, we
recommend the integration of cost
data in future analyses of outbreaks.

Quality Improvement and Nursing

Research Indices
Although infection is a nursesensitive indicator of quality care,45
personnel from numerous healthcare disciplines interact with
patients in the ICU. In order to
improve outcomes in patients with
MDR and potentially fatal infections, nurse-promoted multidisciplinary inquiries could target the
following areas:
Proactive planning to anticipate
the emergence of MDR organisms
Ongoing collaboration with
infection control practitioners
regarding trends of outbreaks of
infections caused by MDR organisms and prevention strategies
Providing a
forum to enhance
Table 7 Costs of an outbreak
staff nurses critical thinking
Direct
Prolonged length of stay
Identifying
Consumption of supplies (eg, personal protective
the
interrelationequipment, disposal of supply cart contents after patient
is discharged)
ship of host factors
Use of professional services (eg, consultations with
(eg, type, number
physicians, dedicated respiratory personnel)
and severity of
Dedicated equipment for the unit (eg, portable electrocardiographic and x-ray machines)
comorbid condi Pay for nursing full-time equivalents
tions, age, and
Laboratory services (eg, additional surveillance cultures,
effect of antibiotic
environmental and patient screening, pulse field gel
electrophoresis testing)
polypharmacy)
Staff comIndirect
Onsite time for chaplain, psychologist unit manager,
pliance with stanintensive care nurses
dard precaution
Loss of intensive care unit bed days
requirements (ie,
Outbreak containment
hand hygiene,
$220 000 per patient
gown use)
48

24 CRITICALCARENURSE Vol 28, No. 1, FEBRUARY 2008

Investigation of intervention
timing (eg, cohorting patients, staff,
equipment) and its impact on the
magnitude of the outbreak
Variations in nursing care interventions for ICU patients infected
with MDR organisms have not been
identified. Frequency of culturing,
types of cohorting, communication
strategies, prevalence, and intensity
of adverse reactions to multiple
drug therapies remain unknown.
Preventive interventions are difficult
to measure, and most researchers did
not describe the monitoring of
infection control practices.4 We
make no recommendations about
staffing for patients with MDR
pathogens; however, high work load
can be a contributing factor for the
acquisition of antimicrobial-resistant
organisms.18

Conclusion
A new class of patient has unintentionally evolved in healthcare:
the chronically critically ill.22
Increases in the number of such
patients will require added nursing
resources and expertise. These complex patients also require fine-tuned
teams with respect for specialty
knowledge. In our experience with
an outbreak of infections caused by
MDR A baumannii, a high-quality
team effort was responsible for a
timely, interdisciplinary, and ultimately successful effort to contain a
potentially widespread outbreak.
Acknowledgments
We wish to acknowledge significant contributions for
this article from Michael A. Saubolle, PhD, Medical Director, Infectious Disease Division, Laboratory Sciences of
Arizona, Banner Health; Adarsh Khalsa, Microbiology
Technical Specialist, Banner Health; Mark F. Rudinsky,
MD, Chairman, Infection Control Committee, Banner
Good Samaritan Medical Center; and ICU staff and
physicians at Banner Good Samaritan Medical Center.

Financial Disclosures
None reported.

http://ccn.aacnjournals.org

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Sader HS, Verhoef J. Emerging importance
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17. Bernards AT, Harinck HI, Dijkshoorn L,

van der Reijden TJ, van den Broek PJ. Persistent Acinetobacter baumannii? Look
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35-40.
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after contact with environmental surfaces
near hospitalized patients. Infect Control
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22. Cardoso CL, Pereira H, Zequin JC, Guilhermetti M. Effectiveness of hand-cleansing
agents for removing Acinetobacter baumannii strain from contaminated hands. Am J
Infect Control. 1999;27(4):327-331.
23. Denton M, Wilcox MH, Parnell P, et al.
Role of environmental cleaning in controlling an outbreak of Acinetobacter baumannii
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27. Dzidic S, Bedekovic V. Horizontal gene
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29. Levy SB. The challenge of antibiotic resistance. Sci Am. 1998;278:46-53.
30. Landman D, Quale JM, Mayorga D, et al.
Citywide clonal outbreak of multiresistant
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31. Aygun G, Demirkian O, Utku T, et al. Environmental contamination during a carbapenem-resistant Acinetobacter baumannii
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antimicrobial with activity against resistant
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;27:12-22.
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National Academy Press; 1998.
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nosocomial outbreak of multiresistant
Acinetobacter baumannii originating from
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Epidemiol. 2001;22(1):48-49.
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Agents in Healthcare Settings 2007.
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Wells P. Emergence of resistant Acinetobacter baumannii in critically ill patients within
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CRITICALCARENURSE Vol 28, No. 1, FEBRUARY 2008 25

CE Test

Test ID C081: Acinetobacter baumannii: An Emerging Multidrug-Resistant Pathogen in Critical Care

Learning objectives: 1. Identify factors that contribute to the emergence and significance of Acinetobacter baumannii in healthcare environments
2. Describe the characteristics of A baumannii and the associated risk factors for development of A baumannii infections 3. Discuss nursing interventions,
infection control measures, and clinical recommendations for prevention and/or containment A baumannii infections

1. Acinetobacter baumannii is a normal inhabitant in which area of the

body?
a. Gastrointestinal tract
b. Plasma
c. Lungs
d. Skin and mucous membranes
2. What is the most significant factor in the transmission of A baumannii?
a. Widespread overuse of broad-spectrum antibiotics
b. Direct contact with persons who have contact dermatitis
c. Inadequate hand hygiene among healthcare providers
d. The organisms resistance to multiple hand-cleansing agents
3. How many strains of A baumannii have been identified thus far?
a. 19
b. 15
c. 21
d. 14
4. Which of the following drugs associated nephrotoxicity requires that
doses and intervals be adjusted for patients with renal impairment?
a. Tigecycline
b. Imipenem
c. Colistimethate
d. Aztreonam
5. The term cohorting refers to which of the following?
a. Colonization of A baumannii on the skin of susceptible persons
b. Concurrent use of a combination of 1 or more antimicrobial agents
c. Implementation of strict contact isolation procedures for patients at high
risk for development of multidrug-resistant (MDR) infections
d. Placement of patients who have the same illness together
6. What is the first and foremost recommendation made by the authors
for preventing outbreaks of MDR A baumannii infections?
a. The use of a multidisciplinary team to establish infection control measures for each healthcare facility
b. Paying attention to the infection rates specific to critical care settings
c. Implementation of contact precautions for patients who have infections
caused by MDR A baumannii
d. Extensive education for environmental services staff about the importance
of attention to detail in room cleaning
7. Acinetobacter baumannii is what kind of bacteria?
a. Gram-negative, coccobacillary rod
b. Gram-positive, opportunistic fungi
c. Gram-negative, nonfermentive spirochete
d. Gram-positive, anaerobic mycobacteria

8. Which of the following statements about A baumannii is true?

a. The organism cannot survive on moist surfaces for long periods.
b. The organism is inconsequential to hosts with intact immune systems.
c. Infections caused by this organism are most prevalent in extended-care and
rehabilitation settings.
d. Eradication of the organism from hospital surfaces requires specially formulated
cleaning solutions and particular cleaning techniques.
9. What is an expected outcome of establishing a cohort/isolation unit?
a. Improved productivity of nursing and respiratory therapy staff
b. Increased ease of matching the number and types of staff required with available
resources
c. Increased variance between budgeted and actual costs
d. Rapid understanding and acceptance of the need for cohorting
10. Successful prevention of the spread of MDR A baumannii infections includes
which of the following combinations?
a. Improved staffing, cohorting, and enhanced infection control practices
b. Increased interdisciplinary involvement, standardized antibiotic therapy, and
review of cleaning procedures
c. Contact precautions on all mechanically ventilated patients, tracking of specific
ventilator use on individual patients, and additional education with all clinical staff
d. Institutional education, effective hand hygiene, and cohorting
11. Which of the following is a recommendation of the Centers for Disease
Control and Preventions 12 Steps to Prevent Antimicrobial Resistance Among
Hospitalized Adults?
a. Begin antimicrobial treatment with multiple agents at first and eliminate as soon
as possible when susceptibility results are available.
b. Treat the infection, not colonization of the bacteria.
c. Treat the infection according to the most recent national data.
d. Use antimicrobial-treated catheters.
12. Risk factors for acquiring A baumannii include which of the following?
a. Male sex
b. Fall or winter season
c. Depression
d. Mechanical ventilation
13. What is a recommendation to aid in cohorting patients, staff, and equipment?
a. Post flyers and informational literature throughout the facility.
b. Ensure proper cleaning of ventilators and bronchoscopes.
c. Require that staff on the cohort unit do not respond to code calls during shifts.
d. Sterilize and disinfect all ventilator circuits used on the cohort unit between patients.
14. What is the estimated cost of outbreak containment per patient?
a. $40 000
b. $220 000
c. $510 000
d. $730 000

Test answers: Mark only one box for your answer to each question. You may photocopy this form.

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Test ID: C081 Form expires: February 1, 2010 Contact hours: 1.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 10 correct (71%) Category: A, Synergy
CERP A Test writer: Ann Lystrup, RN, BSN, CEN, CFRN, CCRN

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