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May 24, 2026Open Access

Root Cause Analysis for Outbreaks of Carbapenem-Resistant Acinetobacter baumannii and Pseudomonas aeruginosa in a Pediatric Intensive Care Unit: A Retrospective Study

Key Points

This study investigates the causes of carbapenem-resistant Acinetobacter baumannii and Pseudomonas aeruginosa outbreaks in a pediatric intensive care unit.
Retrospective analysis of five MDR infection cases in the PICU from January to February 2024.
Applied root cause analysis to identify causes and develop interventions.
Conducted environmental sampling for detection of bacteria in healthcare settings.
Identified four CRAB strains and three CRPA strains among five patients during the outbreak period.
Environmental sampling showed CRAB at four sites and CRPA at two sites, including healthcare workers' hands.
Post-intervention, no further multidrug-resistant clusters were observed in 2024, indicating effective control measures.

Abstract

Objective: Children in the pediatric intensive care unit (PICU) are inherently susceptible to multidrug-resistant (MDR) bacterial infections due to physiological vulnerabilities and clinical management-related factors. Such infections are prone to outbreaks and confer substantial harm. This study aims to investigate the etiologies of carbapenem-resistant Acinetobacter baumannii (CRAB) and carbapenem-resistant Pseudomonas aeruginosa (CRPA) infection outbreaks in the PICU and develop targeted prevention and control strategies using the root cause analysis (RCA) approach. Methods: A retrospective analysis was conducted on five cases (n=5) of MDR infection clusters admitted to the PICU of a large comprehensive hospital from January to February 2024. RCA was applied to identify underlying causes, develop targeted interventions, and evaluate their effectiveness. Results: From 31 January to 18 February 2024, four CRAB strains and three CRPA strains were detected among five patients (n = 5). Environmental sampling (145 specimens) revealed CRAB in four sites (crane tower, handwashing basin wall, healthcare workers’ hands, and PDA devices) and CRPA in two sites (fiberoptic bronchoscopes and healthcare workers’ hands). Post-intervention, no further MDR clusters were observed in 2024, indicating effective control. Conclusion: RCA facilitates systematic identification of root causes for MDR outbreaks, enabling targeted interventions to curb transmission and strengthen infection control practices. Keywords: root cause analysis, pediatric intensive care unit, multidrug-resistant bacteria, carbapenem-resistant Acinetobacter baumannii , carbapenem-resistant Pseudomonas aeruginosa , outbreak

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