key: cord-0723328-pkhq1pjx authors: Shinohara, Danielle Rosani; dos Santos Saalfeld, Silvia Maria; Martinez, Hilton Vizzi; Altafini, Daniela Dambroso; Costa, Bruno Buranello; Fedrigo, Nayara Helisandra; Tognim, Maria Cristina Bronharo title: Outbreak of endemic carbapenem-resistant Acinetobacter baumannii in a coronavirus disease 2019 (COVID-19)–specific intensive care unit date: 2021-03-09 journal: Infection control and hospital epidemiology DOI: 10.1017/ice.2021.98 sha: 4aa892a61979359a6809d4e5178c00cca67f3fc2 doc_id: 723328 cord_uid: pkhq1pjx nan In total, 14 cases were included in the study (Fig. 1) . The mean patient age was 60 years, with male patients predominating (64%). The median duration of the ICU stay was 24 days (interquartile range [IQR], 14-34), duration of invasive mechanical ventilation was 25 days (IQR, 11-32), and Sequential Organ Failure Assessment score on admission to ICU was 4 (IQR, [3] [4] [5] [6] [7] [8] [9] . Overall, 19 CRAb isolates were recovered from blood, endotracheal aspirates, and/or rectal swabs of 14 patients. Of these patients, 13 received invasive mechanical ventilation, 9 were diagnosed with VAP and 1 with bacteremia. Among the 9 patients with a CRAb-positive rectal swabs, 5 also had CRAb-positive endotracheal aspirate (>1.0×10 6 CFU/mL). Of the 4 patients only colonized with CRAb (not infected), 2 survived. A colonized patient can serve as a source or reservoir and thus can increase the spread of CRAb. CRAb colonization may prolong the hospital stay and increase medical costs and the ICU mortality rate. 6 Of the 10 patients with VAP or bacteremia, 7 died. Our findings support a previous report associating CRAb infection in COVID-19 patients with worse outcomes. 3 All isolates proved to be resistant to penicillins, cephalosporins, aminoglycosides, fluoroquinolones, and carbapenems, greatly limiting options for treatment. All patients with CRAb infection were previously treated with azithromycin, ceftriaxone, and piperacillin/tazobactam. Of these, 1 (patient 5) died before starting appropriate antibiotic treatment, 5 (patients 1, 3, 6, 11 and 14) received polymyxin monotherapy, and 4 received combination therapy. Of the 4 patients treated with combination therapy, 2 (patients 8 and 13) received polymyxin B plus meropenem; 1 (patient 4) received polymyxin B, meropenem, and vancomycin; and 1 (patient 9) received meropenem and vancomycin. Only 1 (20%) of 5 patients treated with polymyxin monotherapy survived; 2 (50%) of 4 patients who received combination therapy recovered. The best treatment for CRAb infections is a matter of debate. Although polymyxin monotherapy is widely used against CRAb infections, combination therapy has been associated with higher probabilities of therapeutic success. 7 Our results suggest that combination therapy may be more effective in treating COVID-19 patients with CRAb infection, although further studies are needed to evaluate this possibility. ERIC-PCR results showed a monoclonal spread of CRAb in the COVID-19 ICU within a short period, characterizing an outbreak. The band profile of these isolates showed 100% similarity to representatives of an endemic CRAb clone (previously reported). 8, 9 This CRAb clone has been a persistent problem in our region since 2004, and although the newly opened ICU may have initially been contamination free, the clone spread rapidly in this unit. A. baumannii can survive for long periods on surfaces, including dry surfaces and human skin, which could facilitate its persistence and spread in ICUs. 7 CRAb cross transmission between equipment (eg, ventilators, infusion pumps, and hemodialysis machines) and COVID-19 patients may also partly explain the onset of this outbreak. Furthermore, in several countries, including Brazil, health personnel were hired on an emergency basis to respond to the COVID-19 pandemic, impeding adequate training in infection prevention and control. In our hospital, stricter barrier measures were implemented, increasing the effectiveness of screening and surveillance for CRAb. The active surveillance culture and efficient performance of a multidisciplinary team were highly important in detecting and controlling the CRAb outbreak in the COVID-19 ICU. In conclusion, constant infection-control measures are necessary to stop the spread of CRAb in the hospital environment, prevent outbreaks, and lower mortality rates, especially in this time of the SARS-CoV-2 pandemic. With overloaded health systems and shortages of health workers trained in infection management, as well as medical consumables and equipment, the best preventive measure remains changing gloves and hand washing. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region Ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Acinetobacter baumannii in patients with COVID-19: two problems, one solution? Evaluation of bacterial coinfections of the respiratory tract in COVID-19 patients admitted to ICU An outbreak of carbapenem-resistant Acinetobacter baumannii in COVID-19 dedicated hospital Evaluation of three molecular typing techniques for nonfermentative gram-negative bacilli male; F, female; SOFA, sequential organ failure assessment score calculated on admission to COVID-19 ICU; ERIC, Enterobacterial Repetitive Intergenic Consensus Polymerase Chain Reaction HT, hypothyroidism; MetS, metabolic syndrome; CRAb, carbapenem-resistant Acinetobacter baumannii; ICU, COVID-19 intensive care unit Clinical and economic evaluation of multidrug-resistant Acinetobacter baumannii colonization in the intensive care unit Control and management of multidrug resistant Acinetobacter baumannii: a review of the evidence and proposal of novel approaches Endemic carbapenem-resistant Acinetobacter baumannii in a Brazilian intensive care unit Dissemination of Acinetobacter baumannii OXA-23 in old and new intensive care units without transfer of colonized patients Acknowledgments. The authors thank Dr Janet W. Reid for her English text review.Financial support. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, Brazil (CAPES), Finance Code 001. These government funds covered only the cost of laboratory materials and had no role in the study design or the decision to submit the work for publication.Conflicts of interest. All authors report no conflicts of interest relevant to this article.