Background:
The SARS-CoV-2 pandemic has increased the use of Personal Protective Equipment (PPE) in hospitals. Within departments with SARS-CoV-2 infected patients, staff often use the same PPE between patients since they are infected with the same microorganism. We present a case report of an Acinetobacter baumanii outbreak that occurred within a COVID-19 department.

Methods:
The case presented is based on an experience in May 2021 in the Intensive Care Unit for COVID-19 patients of Arezzo Hospital, Italy. Within the hospital, there is an active surveillance system for rapidly spreading microorganisms or multi-resistant bacteria to prevent their transmission and reduce the risk of outbreaks. Following the case, an audit was conducted to focus on the problem and prevent it from recurring.

Results:
In the department under consideration, 6 cases of Acinetobacter baumanii infection occurred within 9 days after the first infection. Following the event, a meeting was conducted with all department staff. It was found that due to the shortage of PPE caused by the emergency period and because all patients were admitted for the same infection, the same PPE (coveralls, visor, gloves, mask) was used during care activities; thus, the A. baumannii infection was spread from the first infected but asymptomatic patient to all others.

Conclusion:
When we safeguard ourselves, we let our guard down because we feel “protected”, but the same PPE that makes us feel protected may instead be “dangerous” to others. Hospitalized patients may carry more than one infection. During current or future pandemics, it is critical to implement common contact precautions and change or sanitize PPE even if we are caring for patients with the same ongoing infection because our PPE can act as a vehicle for further over-infection and the spread of multi-resistant bacteria.