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Critical Care Nurse. 2008;28: 15-25
Copyright © 2008 by the American Association of Critical-Care Nurses.
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Cover Article
CE Article

Acinetobacter baumannii: An Emerging Multidrug-Resistant 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

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.

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{at}aacn.org.

Financial Disclosures
None reported.

This 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

Corresponding author: Kerry Montefour, RN, BSN, CIC, Banner Good Samaritan Medical Center, 1111 E McDowell Rd, Phoenix, AZ 85006 (e-mail: Kerry.montefour{at}bannerhealth.com).

Acinetobacter baumannii is a troublesome and increasingly problematic healthcare-associated pathogen, especially in critical care.1–4 It may be associated with hospital-acquired infections with considerable clinical and economic costs. In physiologically compromised patients, morbidity and mortality are common sequelae of hospital-acquired infections.4–7 Hence, multiple professional organizations have identified multidrug-resistant (MDR) pathogens as a critical target that requires intervention (Tables 1Go and 2Go).


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  		Table 1 Actions of professional organizations and recommended interventions for outbreaks of infections caused by multidrug-resistant organisms

 

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  		Table 2 Centers for Disease Control and Prevention: 12 steps to prevent antimicrobial resistance among hospitalized adults8

 
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
Top
 Literature Review
An Outbreak of MDR...
 Clinical Recommendations
 Conclusion
 References
 
Characteristics of A baumannii and A baumannii Infections
Acinetobacter baumannii is a non-fermentive, 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 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 3Go). 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.


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

 
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 4Go) 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 4Go appear to be improbable sources of 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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  		Table 4 Potential hospital environmental sources of Acinetobacter baumanii1,3,4,6,12,17,18

 
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 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


   An Outbreak of MDR A baumannii
Top
 Literature Review
 An Outbreak of MDR...
Clinical Recommendations
 Conclusion
 References
 
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 antimicrobial resistance.5 Some of the genes are inherited, some emerge from random DNA mutations in bacteria, and others are imported from related bacteria33 (Figure 1Go). Evidence of A baumannii antimicrobial resistance may be a harbinger, or indication, of transmission of the organism among patients and may be predictive of an impending outbreak of A baumannii infections.4


Figure 1
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  		Figure 1 Bacterial acquisition of resistance genes. Bacteria gain resistance genes by 3 major methods: (a) donor cells transmit whole plasmids containing one or more genes into bacteria, (b) a virus acquires a resistance gene from a bacterium and injects it into a different bacterial cell, and (c) bacteria assimilate gene-bearing components of DNA within their immediate vicinity.
Reprinted from Levy,8 with permission from Tomo Narashima/Tane+1.LLC.

 
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 originate from a single source with widespread environmental contamination or where no reservoir for the contamination can be verified.4,33–37

Most MDR A baumannii outbreaks occur in critical care settings and involve resistance to multiple classes of antimicrobial agents.4,18 Potential sources of A baumannii in the ICU have received close scrutiny. Dust has been identified as a potential vehicle. In one investigation,17 the outbreak strain of A baumannii was recovered from dust within pneumatic and electronic equipment, in air filters of continuous veno-veno hemodialysis machinery, ventilators, and air conditioner parts despite filters placed at air inlets and outlets. Because of the scope of technological equipment within critical care, this potential source of A baumannii should receive further investigation.

Antimicrobial Management
Historically, carbapenems have resulted in the best therapeutic response in infections caused by MDR A baumannii.5,25,36 Currently, carbapenems, such as imipenem and meropenem, remain the widely recognized drug of choice for A baumannii infections.5,13,25,38 Nevertheless, susceptibility testing is still required when this pathogen is identified.

During the time of our outbreak, testing resulted in an unprecedented 38% resistance rate to imipenem (Table 5Go). Resistance to meropenem for the MDR isolates was close to 100%.


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  		Table 5 Susceptibility of Acinetobacter baumannii isolates to antimicrobials at Banner Good Samaritan Medical Center and in the United States, January 2005–April 2006

 
Tests for susceptibility to colistin and tigecycline were also performed. For carbapenem-resistant A baumannii, tigecycline and colistimethate are 2 of the most frequently used alternative agents. The Clinical and Laboratory Standards Institute did 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 Administration’s 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 B–resistant 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 rapidly 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 gram-negative 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 µg/mL for 739 isolates of Acinetobacter, indicating the potential clinical effectiveness of tigecycline. Tigecycline’s 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 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, 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, 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 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 health-care 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 unit’s functioning. As a result, an "Acinetobacter update" flyer (Figure 2Go) 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.


Figure 2
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  		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.

 
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 unit’s 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 patient’s 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 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 comprehensively 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 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" 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
Top
 Literature Review
 An Outbreak of MDR...
 Clinical Recommendations
Conclusion
 References
 
The first and foremost clinical recommendation for preventing outbreaks of MDR A baumannii infection 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 pre-treated 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 "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 6Go).


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  		Table 6 Recommendations for control of Acinetobacter baumanii outbreaks

 
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 7Go).


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  		Table 7 Costs of an outbreak

 
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 nurse-sensitive indicator of quality care,45 personnel from numerous health-care 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:

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
Top
 Literature Review
 An Outbreak of MDR...
 Clinical Recommendations
 Conclusion
References
 
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.


   References
Top
 Literature Review
 An Outbreak of MDR...
 Clinical Recommendations
 Conclusion
 References
 

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