The impact of the global war on terrorism on healthcare-associated resistant Acinetobacter baumanii

ISSUE: This Army medical center has seen a marked increase in healthcare-associated resistant (r) Acinetobacter baumanii (Acb) acquisitions since mid-2003, due to the volume of colonized military personnel admitted from Iraq and Afghanistan. Since June 2003, there has been a large influx of patients colonized or infected with rAcb. Additionally, there have been 47 healthcare-associated (HA) acquisitions. PROJECT: Since June 2003, prospective surveillance has been conducted on over 800 inpatient military personnel returning from Iraq and Afghanistan. Patients were placed on contact precautions on admission, pending results of surveillance cultures. HA transmission of rAcb was monitored using standard infection control methodology. All cases of patients with rAcb were placed on contact precautions when identified. A large-scale epidemiologic investigation involving cultures of environmental surfaces, providersʹ hands, and patients was conducted as part of a performance improvement initiative. Pulsed-field gel electrophoresis (PFGE) was conducted on a sample of isolates. RESULTS: From June 2003 through January 2004, there were approximately 215 (27%) military personnel identified with rAcb on admission. Forty-seven cases of HA acquisitions were identified. Sites of infection included bloodstream, respiratory tract, urine, and wounds. The mean length of stay until acquisition was 30 days and mean age was 50. The epidemiologic investigation revealed two positive environmental samples, no positive growth on providersʹ hands, and three hemodialysis outpatients not previously identified as colonized. PFGE on patient samples showed no single epidemic strain and no geographically associated strain. LESSONS LEARNED: The presence of a large admission reservoir and in-house reservoir of rAcb resulted in significant HA transmission. As a result of these findings, education was increased to all levels of staff, patients, and families; patient education brochures were developed; surveillance activities were increased; and monitoring of compliance with hand hygiene and contact precautions was initiated. Results of monitoring showed that more assertive action on compliance is needed. These aggressive infection control practices reduced but did not eliminate transmission, probably due to the continued influx of colonized patients.