Community-acquired in name only: A cluster of carbapenem-resistant in a burn intensive care unit and beyond.

OBJECTIVE

To describe an investigation into 5 clinical cases of carbapenem-resistant Acinetobacter baumannii (CRAB).

DESIGN

Epidemiological investigation supplemented by whole-genome sequencing (WGS) of clinical and environmental isolates.

SETTING

A tertiary-care academic health center in Boston, Massachusetts.

PATIENTS OR PARTICIPANTS

Individuals identified with CRAB clinical infections.

METHODS

A detailed review of patient demographic and clinical data was conducted. Clinical isolates underwent phenotypic antimicrobial susceptibility testing and WGS. Infection control practices were evaluated, and CRAB isolates obtained through environmental sampling were assessed by WGS. Genomic relatedness was measured by single-nucleotide polymorphism (SNP) analysis.

RESULTS

Four clinical cases spanning 4 months were linked to a single index case; isolates differed by 1-7 SNPs and belonged to a single cluster. The index patient and 3 case patients were admitted to the same room prior to their development of CRAB infection, and 2 case patients were admitted to the same room within 48 hours of admission. A fourth case patient was admitted to a different unit. Environmental sampling identified highly contaminated areas, and WGS of 5 environmental isolates revealed that they were highly related to the clinical cluster.

CONCLUSIONS

We report a cluster of highly resistant Acinetobacter baumannii that occurred in a burn ICU over 5 months and then spread to a separate ICU. Two case patients developed infections classified as community acquired under standard epidemiological definitions, but WGS revealed clonality, highlighting the risk of burn patients for early-onset nosocomial infections. An extensive investigation identified the role of environmental reservoirs.