Pandemic strains resources for HAI prevention and surveillance
The COVID-19 pandemic has brought about numerous challenges and a strain on processes in health care systems, including in the prevention of hospital-acquired infections, or HAIs.
An informal Twitter poll on April 4, 2020, received 220 responses from the infection prevention and hospital epidemiology community, including 79.1% of participants who indicated they spent more than 75% of their time on COVID-19 response efforts. An additional 13.2% of participants said they spent more than 50% to 75% of their time on COVID-19 response efforts. This resulted in fewer resources for traditional HAI surveillance and prevention, along with potentially decreased antimicrobial stewardship resources that augment infection prevention efforts for HAIs.
The pandemic’s impact on traditional infection prevention efforts include:
- decreased surveillance;
- reduced data collection for process measures (compliance with hand hygiene, chlorhexidine bathing, etc.);
- less real-time data reporting and unit feedback usually provided during infection prevention or line rounds; and
- stock issues for personal protective equipment (PPE), which may lead to compromised PPE for traditional HAIs with risk for increased cross-transmission.
The impact on antimicrobial stewardship efforts include:
- reduced prospective audit and feedback of antibiotics;
- influx of critically ill patients, potentially driving suboptimal antibiotic use and resistance; and
- increased antibiotic use to treat possible secondary bacterial infections, which may increase rates of Clostridioides difficile infection (CDI).
Outside of traditional infection prevention efforts, there was a shift in the patient population to those with a higher case mix index in many hospitals because of postponement of elective procedures and avoidance of admission, if possible. Admitted patients with COVID-19 were more likely to require critical care support with increased use of central lines and urinary catheters, often for an extended period, increasing the risk for developing an HAI. Patients with COVID-19 are often placed in a prone position, leading to line and dressing integrity gaps and placement of IV pumps (with extended tubing) in hallways, resulting in fewer bedside line checks. Patients may have experienced less frequent contact to reduce health care worker exposure and preserve PPE.
The need to quickly expand the number of ICU beds during peak patient volume could have reduced space for staff and equipment, restraining quick access to PPE supplies, and led to an inability to perform adequate environmental cleaning. Staffing changes during surge periods also might have impacted HAI prevention because traveling clinicians, unfamiliar with institutional practices, were often used, or nurses unfamiliar with critical care patients were shifted into the ICU. Staffing shortages possibly led to increased patient-to-nurse ratios, reducing time for routine central line care, universal decolonization with mupirocin and chlorhexidine bathing and hand hygiene.
Impact on HAIs
A retrospective study of 78 U.S. hospitals comparing 12 months before and 6 months during the COVID-19 pandemic showed a 51% increase in central line-associated bloodstream infections (CLABSIs) from 0.56 to 0.85 per 1,000 lines. A greater COVID-19 burden correlated with increased CLABSI rates. The standardized infection ratio was 2.38 times higher in months with COVID-19 patients representing more than 10% of admissions compared with those with less than 5% prevalence. Those with COVID-19 experienced greater than five times the number of CLABSIs and higher associated mortality compared with those without COVID-19 (53.8% vs. 24%). The trend was most prominent in ICUs and hospitals with more than 300 beds. The rate of coagulase-negative Staphylococcus CLABSIs increased by 130% and Candida species by 56.9%, whereas gram-negative rates remained stable. The rates of catheter-associated UTIs (CAUTIs) increased 7% during the pandemic period but was not a statistically significant change.
A Detroit academic tertiary center evaluated the CLABSI rate before the COVID-19 outbreak (January to May 2019) and during the COVID-19 outbreak (January to May 2020) in a retrospective cohort study. A total of 36 patients had developed CLABSIs: six (17%) pre-COVID-19 and 30 (83%) in the COVID-19 cohort, with the average monthly rate increasing from 0.4 to 1.7 per 10,000 central line days. The increased CLABSI rate correlated with COVID-19 case load, with the highest CLABSI rate occurring during April 2020, which had the highest incidence of COVID-19. Patients with COVID-19 accounted for 60% of the CLABSIs in the COVID-19 period, but even when these were excluded, an increase from 0.4 to 0.77 per 10,000 central line days still existed. The blood culture contamination rates were 19% higher during the COVID-19 period due to using skin disinfectant for less time than recommended, collecting serial cultures from the same site, failing to collect multiple cultures and often obtaining specimens from the central line for faster collection.
A Singapore hospital evaluated HAI rates during COVID-19 (February to August 2020) after the introduction of enhanced infection prevention and control (IPC), and rates in the 2 years before (January 2018 to January 2020). The enhanced IPC measures included universal masking, visitor restrictions, use of droplet and contact precautions for patients with respiratory symptoms and re-emphasis on hand hygiene. CLABSI rates decreased in the COVID-19 period to 0.2 incidents per 1,000 device days compared with 0.83 per 1,000 device days in the pre-pandemic period. CAUTI rates remained stable at 1.8 incidents per 1,000 device days in both cohorts. CDI did not significantly increase, with a rate of 3.47 per 10,000 patient days vs. 3.65 per 10,000 patient days pre-pandemic. There was increased compliance with the CAUTI and CLABSI prevention bundles, likely due to increased hand hygiene during COVID-19. They contributed previous experience with the severe acute respiratory syndrome outbreak in 2003 to a faster and more robust response of enhanced infection prevention and PPE efforts in the COVID-19 pandemic.
Elsewhere, researchers evaluated the implementation of enhanced infection prevention bundles during the COVID-19 pandemic on hospital-acquired CDI rates in two studies. The incidence of CDI decreased in both studies, including from 0.066 per 100 discharges in 2019 to 0.033 per 100 discharges in 2020 at one Rome hospital. A study conducted in Spain also showed a reduction in CDI incidence to 2.68 per 10,000 patient days compared with 8.54 per 10,000 patient days in the control period. These data suggest increased focus on infection prevention basics — like hand hygiene and environmental cleaning, along with decreased patient and visitor movement — may decrease CDI rates.
Based on the limited amount of currently available literature, CLABSI rates appear to be the HAI with the largest increase during the COVID-19 pandemic. However, CAUTI rates remained stable and CDI rates decreased where enhanced infection prevention bundles were implemented.
Tactics for HAI prevention during a pandemic
It is important to maintain basic infection prevention efforts during a pandemic, such as CLABSI prevention bundles, chlorhexidine bathing, hand hygiene and adequate PPE supplies. Close monitoring of processes and outcomes related to device use with regular feedback to frontline staff are also critical to maintain infecti on prevention efforts.
Institutions should create plans and infrastructure to quickly respond to future pandemic threats and have a mechanism to bolster infection prevention programs through personnel or technology during the pandemic. Fast implementation of increased infection prevention efforts was evident during COVID-19 to decrease the rate of HAIs. Additionally, local, regional and national organizations and governments should invest in resources to ensure that there is an adequately trained workforce and sufficient infrastructure to improve response during future pandemics.
CMS allowed for voluntary reporting and submission of HAI measure data for the fourth quarter of 2019 and the first two quarters of 2020, which will limit ability to see the full effect of the COVID-19 pandemic on HAIs. An important consideration for future pandemics is to maintain public reporting while exempting hospitals from penalties.
Although the full impact of this pandemic on HAIs remains unknown, it has already exposed many areas of vulnerability in the prevention of HAIs, allowing institutions to refocus infection prevention efforts now and incorporate critical changes into future pandemic response plans.
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- For more information:
- Kelly M. Percival, PharmD, BCPS-AQ ID, is a clinical pharmacy specialist in infectious diseases at University of Iowa Hospitals & Clinics. Percival can be reached at firstname.lastname@example.org.