Genome Sequencing to Prevent Hospital-Acquired Infections Caused by Carbapenem-Resistant Acinetobacter baumannii Due to Importation and Intra-facility Transmission in a Regional Hospital Network: Study Protocol for Implementation Research.

BACKGROUND AND OBJECTIVES: Carbapenem-resistant Acinetobacter baumannii (CRAb) is among India's leading bacteria responsible for hospital-acquired infections (HAIs). The CRAb causing intra-facility and inter-facility (or importation) HAI transmissions may differ phylogenetically. For control and prevention of CRAb-associated HAIs within and across facilities, information about the phylogenetic lineage characterization and contextual risk factors is critical. To our knowledge, there is no preliminary state-level data available from Odisha state in India regarding the dynamics of CRAb transmission (intra- and inter-facility), phylogenetic lineages, risk factors, and geospatial epidemiology. This study shall document the dynamics of CRAb-associated HAIs, the phylogenetic lineages responsible for intra-facility and inter-facility transmissions, and the risk factors. We shall leverage the CRAb phylogenetic data and risk factors identified through an integrated laboratory-clinical-epidemiological-genomic surveillance for tackling the intra-facility and inter-facility transmissions and outbreaks using implementation research approaches with adoption of contextualized hospital infection control and prevention measures and antibiotic stewardship efforts in a hospital network in Odisha state, India. METHODS: This study adopts an integrated prospective facility-based surveillance with a quasi-experimental design using the plan-do-study-act (PDSA) implementation research cycles with mixed-methods data collection approaches. The study will be conducted over three years at six tertiary care medical institutions in Odisha. Prospective surveillance over 24 months at these hospitals will monitor the CRAb isolates to identify HAI outbreaks and intra- and inter-facility transmissions. The metagenomic and genome-wide sequencing (GWS) shall document CRAb phylogenetic lineages for outbreaks and intra- and inter-facility transmissions. Geospatial mapping shall document the spatial characterization of CRAb transmission for the index cases. Formative research shall identify potential risk factors at various levels for HAIs, outbreaks, intra- and inter-facility CRAb transmissions, hospital infection prevention, surveillance, and antibiotic stewardship efforts, using the Consolidated Framework for Implementation Research (CFIR). Based on this information, contextualized strategies and interventions to strengthen hospital infection prevention, surveillance, and antibiotic stewardship efforts shall be implemented at these facilities using incremental PDSA cycles. Data from these PDSA cycles shall be compared to document the impact on CRAb outbreaks and process indicators. The practices' and interventions' feasibility, acceptability, and sustainability shall be documented. RESULTS: We do not have any observations, as we have not started the study yet. CONCLUSION: The study shall generate evidence on genoepidemiology, transmission dynamics of HAIs due to CRAb in Odisha, India, and the associated risk factors. The lessons from context-specific implementation strategies (covering infection surveillance, prevention strategies, and antibiotic stewardship domains) to tackle CRAb-associated HAIs outbreaks and the feasibility, acceptability, and sustainability shall inform the policy and practices. The geographic signatures of horizontal CRAb-associated HAIs will generate a new knowledge base to design future intervention measures.