Skip to main content Accessibility help

Nosocomial Outbreak of Infection With Pan–Drug-Resistant Acinetobacter baumannii in a Tertiary Care University Hospital

  • Raquel Valencia (a1) (a2), Luis A. Arroyo (a3), Manuel Conde (a1) (a2), Josefa M. Aldana (a1), María-José Torres (a4), Felipe Fernández-Cuenca (a4), José Garnacho-Montero (a5), José M. Cisneros (a6), Carlos Ortiz (a5), Jerónimo Pachón (a6) (a7) and Javier Aznar (a3) (a4)...



TO describe what is, to our knowledge, the first nosocomial outbreak of infection with pan–drug-resistant (including colistin-resistant) Acinetobacter baumannii, to determine the risk factors associated with these types of infections, and to determine their clinical impact.


Nested case-control cohort study and a clinical-microbiological study.


A 1,521-bed tertiary care university hospital in Seville, Spain.


Case patients were inpatients who had a pan-drug-resistant A. baumannii isolate recovered from a clinical or surveillance sample obtained at least 48 hours after admission to an intensive care unit (ICU) during the time of the epidemic outbreak. Control patients were patients who were admitted to any of the “boxes” (ie, rooms that partition off a distinct area for a patient's bed and the equipment needed to care for the patient) of an ICU for at least 48 hours during the time of the epidemic outbreak.


All the clinical isolates had similar antibiotic susceptibility patterns (ie, they were resistant to all the antibiotics tested, including Colistin), and, on the basis of repetitive extragenic palindromic-polymerase chain reaction, it was determined that all of them were of the same clone. The previous use of quinolones and glycopeptides and an ICU stay were associated with the acquisition of infection or colonization with pan-drug-resistant A. baumannii. To control this outbreak, we implemented the following multicomponent intervention program: the performance of environmental decontamination of the ICUs involved, an environmental survey, a revision of cleaning protocols, active surveillance for colonization with pan-drug-resistant A. baumannii, educational programs for the staff, and the display of posters that illustrate contact isolation measures and antimicrobial use recommendations.


We were not able to identify the common source for these cases of infection, but the adopted measures have proven to be effective at controlling the outbreak.


Corresponding author

Preventive Medicine and Public Health Services, Virgen del Rocío Hospital, Avenida Manuel Siurot s/n, Seville 41013, Spain(


Hide All
1.Fournier, PE, Richet, H. The epidemiology and control of Acinetobacter baumannii in health care facilities. Clin Infect Dis 2006;42:692699.
2.Bergogne-Berezin, E, Towner, KJ. Acinetobacter spp. as nosocomial pathogens: microbiological, clinical, and epidemiological features. Clin Microbiol Rev 1996;9:148165.
3.Jawad, A, Seifert, H, Snelling, AM, Heritage, J, Hawkey, PM. Survival of Acinetobacter baumannii on dry surfaces: comparison of outbreak and sporadic isolates. J Clin Microbiol 1998;36:19381941.
4.Wendt, C, Dietze, B, Dietz, E, Rüden, H. Survival of Acinetobacter baumannii on dry surfaces. J Clin Microbiol 1997;35:13941397.
5.Roberts, SA, Findlay, R, Lang, SDR. Investigation of an outbreak of multidrug resistant Acinetobacter baumannii in an intensive care burns unit. J Hosp Infect 2001;48:228232.
6.Fierobe, L, Lucet, JC, Decré, D, et al.An outbreak of imipenem-resistant Acinetobacter baumannii in critically ill surgical Patients. Infect Control Hosp Epidemiol 2001;22:3540.
7.Wang, SH, Sheng, WH, Chang, YY, et al.Healthcare-associated outbreak due to pan-drug resistant Acinetobacter baumannii in a surgical intensive care unit. J Hosp Infect 2003;53:97102.
8.Blot, S, Vandewoude, K, Colardyn, F. Nosocomial bacteremia involving Acinetobacter baumannii in critically ill patients: a matched cohort study. Intensive Care Med 2003;29:471475.
9.Manikal, VM, Landman, D, Saurina, G, Oydna, E, Lal, H, Quale, J. Endemie carbapenem-resistant Acinetobacter species in Brooklyn, New York: ci-tywide prevalence, interinstitutional spread, and relation to antibiotics usage. Clin Infect Dis 2000;31:101106.
10.Corbella, X, Montero, A, Pujol, M, et al.Emergence and rapid spread of carbapenem resistance during a large and sustained hospital outbreak of multiresistant Acinetobacter baumannii. J Clin Microbiol 2000;38:40864095.
11.Fluit, AC, Jones, ME, Schmitz, FJ, Acar, J, Gupta, R, Verhoef, J. Antimicrobial susceptibility and frequency of occurrence of clinical blood isolates in Europe from the SENTRY antimicrobial surveillance program, 1997 and 1998. Clin Infect Dis 2000;30:454460.
12.Go, ES, Urban, C, Burns, J, et al.Clinical and molecular epidemiology of Acinetobacter infections sensitive only to polymyxin B and sulbactam. Lancet 1994;344:13291332.
13.Evans, ME, Feola, DJ, Rapp, RP. Polymyxin B sulfate and Colistin: old antibiotics for emerging multiresistant gram-negative bacteria. Ann Phar-macother 1999;33:960967.
14.Catchpole, CR, Andrews, JM, Brenwald, N, Wise, R. A reassessment of the in vitro activity of Colistin sulphomethate. J Antimicrob Chemother 1997;39:255260.
15.Appleman, MD, Beizberg, H, Citron, DM, et al.In vitro activities of nontraditional antimicrobials against multiresistant Acinetobacter baumannii strains isolated in an intensive care unit outbreak. Antimicrob Agents Chemother 2000;44:10351040.
16.Fernandez-Viladrich, P, Corbella, X, Corral, L, Tubau, F, Mateu, A. Successful treatment of ventriculitis due to carbapenem-resistant Acinetobacter baumannii with intraventricular Colistin sulfomethate sodium. Clin Infect Dis 1999;28:916917.
17.Vasen, W, Desmery, P, Ilutovich, S, Di Martino, A. Intrathecal use of Colistin. J Clin Microbiol 2000;38:3523.
18.Garnacho-Montero, J, Ortiz-Leyva, C, Jiménez-Jiménez, FJ, et al.Treatment of multidrug-resistant Acinetobacter baumannii ventilator-associated pneumonia (VAP) with intravenous Colistin: a comparison with imipenem-susceptible VAP. Clin Infect Dis 2003;36:11111118.
19.Jimenez-Mejias, ME, Pichardo-Guerrero, C, Márquez-Rivas, FJ, Martin-Lozano, D, Prados, T, Pachón, J. Cerebrospinal fluid penetration and pharmacokinetic/pharmacodynamic parameters of intravenously administered Colistin in a case of multidrug-resistant Acinetobacter baumannii meningitis. Eur J Clin Microbiol Infect Dis 2002;21:212214.
20.Rodriguez-Hernandez, MJ, Jimenez-Mejias, ME, Pichardo, C, Cuberos, L, Garcia-Curiel, A, Pachón, J. Colistin efficacy in an experimental endocarditis model caused by Acinetobacter baumannii. Clin Microbiol Infect 2004;10:581584.
21.Hsueh, PR, Teng, LJ, Chen, CY, et al.Pandrug-resistant Acinetobacter baumannii causing nosocomial infections in a university hospital, Taiwan. Emerg Infect Dis 2002;8:827832.
22.Reis, AO, Luz, DA, Tognim, MC, Sader, HS, Gales, AC. Polymyxin-resistant Acinetobacter spp. isolates: what is next? Emerg Infect Dis 2003;9:10251027.
23.Urban, C, Mariano, N, Rahal, JJ, et al.Polymyxin B-resistant Acinetobacter baumannii clinical isolate susceptible to recombinant BPI21 and cecropin PI. Antimicrob Agents Chemother 2001;45:994995.
24.Souli, M, Kontopidou, FV, Koratzanis, E, et al.In vitro activity of tige-cycline against multiple-drug-resistant, including pan-resistant, gram-negative and gram-positive clinical isolates from Greek hospitals. Antimicrob Agents Chemother 2006;50:31663169.
25.Delgado, M, Llorca, J, Doménech, JM. Estudio de casos y controles. Barcelona, Spain: Signo; 2005.
26.Garner, JS, Jarvis, WR, Emori, TG, Horan, TC, Hughes, JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988;16:128140.
27.Horan, TC, Gaynes, RP, Martone, WJ, Jarvis, WR, Emori, TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606608.
28.Pittet, D, Thiévent, B, Wenzel, RP, Li, N, Gurman, G, Suter, PM. Importance of pre-existing co-morbidities for prognosis of septicemia in critically ill Patients. Intensive Care Med 1993;19:265272.
29.WHO Collaborating Centre for Drug Statistics Methodology. November 17, 2004. Available at: Accessed September 23, 2004.
30.Vaneechoutte, M, Dijkshoorn, L, Tjernberg, I, et al.Identification of Acinetobacter genomic species by amplified ribosomal DNA restriction analysis. J Clin Microbiol 1995;33:1115.
31.Gales, AC, Reis, AO, Jones, RN. Contemporary assessment of antimicrobial susceptibility testing methods for polymyxin B and Colistin: review of available interpretative criteria and quality control guidelines. J Clin Microbiol 2001;39:183190.
32.Arroyo, LA, Garcia-Curiel, A, Pachon-Ibaflez, ME, et al.Reliability of the E-test method for detection of Colistin resistance in clinical isolates of Acinetobacter baumannii. J Clin Microbiol 2005;43:903905.
33.CLSI. Performance standards for antimicrobial susceptibility testing: 16th informational supplement. CLSI document. Wayne, PA: CLSI, 2006: M100S16.
34.Snelling, AM, Gerner-Smidt, P, Hawkey, PM, et al.Validation of use of whole-cell repetitive extragenic palindromic sequence-based PCR (REP-PCR) for typing strains belonging to the Acinetobacter calcoaceticus-Acinetobacter baumannii complex and application of the method to the investigation of a hospital outbreak. J Clin Microbiol 1996;34:11931202.
35.De Vegas, EZ, Nieves, B, Araque, M, Velasco, E, Ruiz, J, Vila, J. Outbreak of infection with Acinetobacter strain RUH 1139 in an intensive care. Infect Control Hosp Epidemiol 2006;27:397403.
36.Ayats, J, Corbella, X, Ardanuy, C, et al.Epidemiological significance of cutaneous, pharyngeal, and digestive tract colonization by multiresistant Acinetobacter baumannii in ICU Patients. J Hosp Infect 1997;37:287295.
37.Cisneros, JM, Rodriguez-Baño, J, Fernandez-Cuenca, F, et al.; Spanish Group for Nosocomial Infection (GEIH), for the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC). Risk-factors for the acquisition of imipenem-resistant Acinetobacter baumannii in Spain: a nationwide study. Clin Microbiol Infect 2005;11:874879.
38.Martín-Lozano, D, Cisneros, JM, Becerril, B, et al.Comparison of a repetitive extragenic palindromic sequence-based PCR method and clinical and microbiological methods for determining strain sources in cases of nosocomial Acinetobacter baumannii bacteremia. J Clin Microbiol 2002;40:45714575.
39.Paterson, DL. The epidemiological profile of infections with multidrug-resistant Pseudomonas aeruginosa and Acinetobacter species. Clin Infect Dis 2006;43:S43S48.
40.Garcia-Garmendia, JL, Ortiz-Leyba, C, Garnacho-Montero, J, Jimenez-Jimenez, FJ, Monterrubio-Villar, J, Gilli-Miner, M. Mortality and the increase in length of stay attributable to the acquisition of Acinetobacter in critically ill Patients. Crit Care Med 1999;27:17941799.
41.D'Agata, AM, Thayer, V, Schaffner, W. An outbreak of Acinetobacter baumannii: the importance of cross-transmission. Infect Control Hosp Epidemiol 2000;21:588591.


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed