Health Care-Associated Infections Among Hospitalized Patients With COVID-19, March 2020-March 2022

Impact of COVID-19 on healthcare-associated infections and antimicrobial use in Italy, 2022

BACKGROUND

It is unknown whether COVID-19 patients are at higher risk due to demographic and clinical characteristics associated with higher COVID-19 infection risk and severity of infection, or due to the disease and its management.

AIM

To assess the impact of COVID-19 on healthcare-associated infection (HAI) transmission and antimicrobial use (AMU) prevalence during the later stages of the pandemic.

METHODS

A point-prevalence survey (PPS) was conducted among 325 acute care hospitals of 19 out of 21 Regions of Italy, during November 2022. Non-COVID-19 patients were matched to COVID-19 patients according to age, sex, and severity of underlying conditions. HAI and AMU prevalence were calculated as the percentage of patients with at least one HAI or prescribed at least one antimicrobial over all included patients, respectively.

FINDINGS

In total, 60,403 patients were included, 1897 (3.14%) of which were classified as COVID-19 patients. Crude HAI prevalence was significantly higher among COVID-19 patients compared to non-COVID-19 patients (9.54% vs 8.01%; prevalence rate ratio (PRR): 1.19; 95% confidence interval (CI): 1.04-1.38; P < 0.05), and remained higher in the matched sample; however, statistical significance was not maintained (odds ratio (OR): 1.25; 95% CI: 0.99-1.59; P = 0.067). AMU prevalence was significantly higher among COVID-19 patients prior to matching (46.39% vs 41.52%; PRR: 1.21; 95% CI: 1.11-1.32; P < 0.001), and significantly lower after matching (OR: 0.77; 95% CI: 0.66-0.89; P < 0.001).

CONCLUSION

COVID-19 patients could be at higher HAI risk due to underlying clinical conditions and the intensity of healthcare needs. Further efforts should be dedicated to antimicrobial stewardship among COVID-19 patients.

Impact of discontinuation of contact precautions on surveillance- and whole genome sequencing-defined methicillin-resistant Staphylococcus aureus healthcare-associated infections

Objective

Prior studies evaluating the impact of discontinuation of contact precautions (DcCP) on methicillin-resistant Staphylococcus aureus (MRSA) outcomes have characterized all healthcare-associated infections (HAIs) rather than those likely preventable by contact precautions. We aimed to analyze the impact of DcCP on the rate of MRSA HAI including transmission events identified through whole genome sequencing (WGS) surveillance.

Design

Quasi experimental interrupted time series.

Setting

Acute care medical center.

Participants

Inpatients.

Methods

The effect of DcCP (use of gowns and gloves) for encounters among patients with MRSA carriage was evaluated using time series analysis of MRSA HAI rates from January 2019 through December 2022, compared to WGS-defined attributable transmission events before and after DcCP in December 2020.

Results

The MRSA HAI rate was 4.22/10,000 patient days before and 2.98/10,000 patient days after DcCP (incidence rate ratio [IRR] 0.71 [95% confidence interval 0.56-0.89]) with a significant immediate decrease (P = .001). There were 7 WGS-defined attributable transmission events before and 11 events after DcCP (incident rate ratio 0.90 [95% confidence interval 0.30-2.55]).

Conclusions

DcCP did not result in an increase in MRSA HAI or, in WGS-defined attributable transmission events. Comprehensive analyses of the effect of transmission prevention measures should include outcomes specifically measuring transmission-associated HAI.

COVID-19 Admission Rates and Changes in Care Quality in US Hospitals

Importance

Unprecedented increases in hospital occupancy rates during COVID-19 surges in 2020 caused concern over hospital care quality for patients without COVID-19.

Objective

To examine changes in hospital nonsurgical care quality for patients without COVID-19 during periods of high and low COVID-19 admissions.

Design, Setting, and Participants

This cross-sectional study used data from the 2019 and 2020 Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project State Inpatient Databases. Data were obtained for all nonfederal, acute care hospitals in 36 states with admissions in 2019 and 2020, and patients without a diagnosis of COVID-19 or pneumonia who were at risk for selected quality indicators were included. The data analysis was performed between January 1, 2023, and March 15, 2024.

Exposure

Each hospital and week in 2020 was categorized based on the number of COVID-19 admissions per 100 beds: less than 1.0, 1.0 to 4.9, 5.0 to 9.9, 10.0 to 14.9, and 15.0 or greater.

Main Outcomes and Measures

The main outcomes were rates of adverse outcomes for selected quality indicators, including pressure ulcers and in-hospital mortality for acute myocardial infarction, heart failure, acute stroke, gastrointestinal hemorrhage, hip fracture, and percutaneous coronary intervention. Changes in 2020 compared with 2019 were calculated for each level of the weekly COVID-19 admission rate, adjusting for case-mix and hospital-month fixed effects. Changes during weeks with high COVID-19 admissions (≥15 per 100 beds) were compared with changes during weeks with low COVID-19 admissions (<1 per 100 beds).

Results

The analysis included 19 111 629 discharges (50.3% female; mean [SD] age, 63.0 [18.0] years) from 3283 hospitals in 36 states. In weeks 18 to 48 of 2020, 35 851 hospital-weeks (36.7%) had low COVID-19 admission rates, and 8094 (8.3%) had high rates. Quality indicators for patients without COVID-19 significantly worsened in 2020 during weeks with high vs low COVID-19 admissions. Pressure ulcer rates increased by 0.09 per 1000 admissions (95% CI, 0.01-0.17 per 1000 admissions; relative change, 24.3%), heart failure mortality increased by 0.40 per 100 admissions (95% CI, 0.18-0.63 per 100 admissions; relative change, 21.1%), hip fracture mortality increased by 0.40 per 100 admissions (95% CI, 0.04-0.77 per 100 admissions; relative change, 29.4%), and a weighted mean of mortality for the selected indicators increased by 0.30 per 100 admissions (95% CI, 0.14-0.45 per 100 admissions; relative change, 10.6%).

Conclusions and Relevance

In this cross-sectional study, COVID-19 surges were associated with declines in hospital quality, highlighting the importance of identifying and implementing strategies to maintain care quality during periods of high hospital use.

Level of implementation of multimodal strategies for infection prevention and control interventions and prevalence of healthcare-associated infections in Northern Italy

BACKGROUND

In November 2022, Italy participated in the third edition of the European Centre for disease prevention and control (ECDC) point prevalence survey (PPS) of healthcare-associated infections (HAIs) in acute-care hospitals. A questionnaire based on the WHO infection prevention and control assessment framework (IPCAF) was included, which aims to investigate multimodal strategies for the implementation of IPC interventions.

METHODS

A PPS was conducted using the ECDC PPS protocol version 6.0. The Regional health authority of the region of Piedmont, in north-western Italy, chose to enlist all public acute-care hospitals. Data were collected within one day per each ward, within 3 weeks in each hospital, at hospital, ward and patient level. A score between 0-1 or 0-2 was assigned to each of the 9 items in the IPCAF questionnaire, with 14 points representing the best possible score. HAI prevalence was calculated at the hospital-level as the percentage of patients with at least one HAI over all included patients. Relations between HAI prevalence, IPCAF score, and other hospital-level variables were assessed using Spearman's Rho coefficient.

RESULTS

In total, 42 acute-care hospitals of the region of Piedmont were involved, with a total of 6865 included patients. All participant hospitals reported they employed multimodal strategies to implement IPC interventions. The median IPCAF overall score was 11/14 (interquartile range, IQR: 9.25-12). The multimodal strategy with the highest level of adherence was education and training, followed by communication and reminders. Strategies with the lowest level of adherence were safety climate and culture of change, and system change. Overall HAI prevalence was 8.06%. A weak to moderate inverse relation was found between IPCAF score and HAI prevalence (Spearman's Rho -0.340, p 0.034). No other significant correlation was found.

CONCLUSIONS

This study found a high self-reported overall level of implementation of multimodal strategies for IPC in the region. Results of this study suggest the relevance of the multimodal approach and the validity of the IPCAF score in measuring IPC programs, in terms of effectiveness of preventing HAI transmission.

Descriptive epidemiology of central line-associated bloodstream infections at an academic medical center in Iowa, 2019-2022

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) increased nationally during the COVID-19 pandemic. We described CLABSIs at our institution during 2019 to 2022.

METHODS

This retrospective observational study examined CLABSIs among adult inpatients at an 866-bed teaching hospital in the Midwest. CLABSI incidence was trended over time and compared to monthly COVID-19 admissions. Manual chart review was performed to obtain patient demographics, catheter-associated variables, pathogens, and clinical outcomes.

RESULTS

We identified 178 CLABSIs. The CLABSI incidence (cases per 1,000 line days) tripled in October 2020 as COVID-19 admissions increased. CLABSIs in 2020 were more frequently caused by coagulase-negative staphylococci and more frequently occurred in the intensive care units 7+ days after central line insertion. The CLABSI incidence normalized in early 2021 and did not increase during subsequent COVID-19 surges. Throughout 2019 to 2022, about half of the nontunneled central venous catheters involved in CLABSI were placed emergently. One-quarter of CLABSIs involved multiple central lines. Chlorhexidine skin treatment adherence was limited by patient refusal.

CONCLUSIONS

The increase in CLABSIs in late 2020 during a surge in COVID-19 admissions was likely related to central line maintenance but has resolved. Characterizing CLABSI cases can provide insight into adherence to guideline-recommended prevention practices and identify areas for improvement at individual institutions.

Ten pillars for the expansion of health system infection prevention capacity

The COVID-19 pandemic has accelerated changes in health care across the nation. Particularly, infection prevention programs have been subjected to pressures and increased responsibilities with no expansion in support. In addition, there is a rapid trend for health systems to merge to ensure long term sustainability. Based on our experience leading infection prevention at one of the largest health systems in the United States, we outline how systems can provide and increase capacity to optimize and enhance the hospital level infection prevention programs and outcomes. In this commentary, "Ten Pillars for the Expansion of Health System Infection Prevention Capacity" we offer 10 categories of what we have found to establish a successful and functioning infection prevention program. The pillars to support the infection prevention programs focus on structure, processes, empowerment, and partnerships, and the elements and strategies that comprise them.

Innovative Approaches to Monitor Central Line Associated Bloodstream Infections (CLABSIs) Bundle Efficacy in Intensive Care Unit (ICU): Role of Device Standardized Infection Rate (dSIR) and Standardized Utilization Ratio (SUR)-An Italian Experience

In several settings, the COVID-19 pandemic determined a negative impact on the occurrence of healthcare-associated infection, particularly for on central lines associated bloodstream infections (CLABSI). In our setting, we observed a significant increase in CLABSI in our intensive care unit (ICU) during 2020 and 2021 vs. 2018 to 2019. A refresher training activity on central venous catheter (CVC) management bundles was carried out in September-October 2021 for the ICU health staff. We assessed the impact of bundle implementation by means of standardized indicators, such as the Device Utilization Ratio (DUR), in this case, the Central Line Utilization Ratio, the Standardized Utilization Ratio (SUR), and the device Standardized Infection Ratio (dSIR). Standardized ratios for device use and infection ratio were computed using data from 2018 and 2019 as expectation data. After bundle implementation, we observed a significant reduction of dSIR (p < 0.001), which dropped from 3.23 and 2.99 in the 2020-2021 biennium to 1.11 in 2022 (CLABSI in the first quarter only); no more CLABSI were observed afterwards. Standardized ratios proved helpful in identify increasing trends of CLABSI in the ICU and monitoring the impact of a simple effective tool, i.e., training on and implementation of a bundle for CVC management.

Healthcare‑associated infections in intensive care unit patients with and without COVID-19: a single center prospective surveillance study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic led to a global increase in healthcare-associated infections (HAI) among intensive care unit (ICU) patients. Whether this increase is directly attributable to COVID-19 or whether the pandemic indirectly (via staff shortages or breaches in infection prevention measures) led to this increase, remains unclear. The objectives of this study were to assess HAI incidence and to identify independent risk factors for HAI in COVID-19 and non-COVID-19 ICU patients.

METHODS

We established a monocentric prospective HAI surveillance in the medical ICU of our tertiary care center from September 1st 2021 until August 31st 2022, during circulation of the SARS-CoV-2 delta and omicron variants. We consecutively included patients ≥ 18 years of age with an ICU length of stay of > 2 calendar days. HAI were defined according to the European Centre for Disease Prevention and Control definitions. HAI rate was calculated per 1,000 patient-days or device-days; risk ratios (RR) and corresponding 95% confidence intervals (CI) for COVID-19 versus non-COVID-19 patients were calculated. We used multivariable Cox regression to identify independent risk factors for HAI. As a proxy for institutional COVID-19 burden, weekly COVID-19 density (i.e. percentage of COVID-19 patients among all ICU patients) was included in the model as time-dependent co-variable.

RESULTS

We included 254 patients, 64 (25.1%) COVID-19 and 190 (74.9%) non-COVID-19 patients; 83 HAI in 72 patients were recorded, thereof 45 ventilator-associated lower respiratory tract infections (VA-LRTI) (54.2%) and 18 blood stream infections (BSI) (21.6%). HAI incidence rate was 49.1/1,000 patient-days in COVID-19 and 22.5/1,000 patient-days in non-COVID-19 patients (RR 2.2, 95%-CI 1.4-3.4). This result was mainly due to different VA-LRTI rates (40.3 vs. 11.7/1,000 ventilator days, p < 0.001), whereas BSI rates were not statistically different (9.4 vs. 5.6/1,000 patient days, p = 0.27). Multivariable analysis identified COVID-19 as main risk factor for HAI development, whereas age, mechanical ventilation and COVID-19 density were not significant.

CONCLUSIONS

These data from the fourth and fifth wave of the pandemic show a higher HAI incidence in COVID-19 than in non-COVID-19 ICU patients, mainly due to an increase in pulmonary infections. A diagnosis of COVID-19 was independently associated with HAI development, whereas institutional COVID-19 burden was not.

Evaluating Healthcare-Associated Infections in Public Hospitals: A Cross-Sectional Study

BACKGROUND

Hospital-acquired infections (HAIs) pose a significant danger to global public health, mainly because their numbers are growing exponentially each year. Additionally, the rise of bacterial strains resistant to current treatment options further exacerbates this threat. This study aimed to examine the occurrences of HAIs identified in public hospitals at the county level.

METHODS

We conducted a cross-sectional study utilizing data provided to the Mures Public Health Directorate from all the public hospitals within the studied county. We examined HAIs reported during the period spanning from 2017 to 2021, which amounted to a total of 4603 cases.

RESULTS

The medical departments reported the highest prevalence of HAIs at 48.25%. The most common infections included enterocolitis with Clostridioides difficile (32.61%), COVID-19 (19.83%), bronchopneumonia (16.90%), sepsis, surgical wound infections, and urinary tract infections. The five most frequently identified pathogens were Clostridioides difficile (32.61%), SARS-CoV-2 (19.83%), Acinetobacter baumannii (11.82%), Klebsiella pneumoniae (9.58%), and Pseudomonas aeruginosa (7.95%). Acinetobacter baumannii was the predominant agent causing bronchopneumonia, while Klebsiella pneumoniae was the leading cause of sepsis cases. Escherichia coli was the primary agent behind the urinary tract infections, and Staphylococcus aureus MRSA was identified as the main etiology for wound infections and central catheter infections. Throughout the study period, there was a significant rise in Clostridioides difficile and Gram-negative bacteria prevalence rates.

CONCLUSIONS

This study identified increased Clostridioides difficile in HAI cases during COVID-19, highlighting the need for careful antibiotic use and emphasizing the growing challenge of multi-resistant strains in post-pandemic state hospitals.

The Assessment of Nursing Staff Knowledge and Barriers Regarding Aseptic Techniques in Khartoum Teaching Hospital, Sudan

Background Aseptic techniques are crucial in preventing healthcare-associated infections, which are an integral part of standard precautions, and encompass a range of practices designed to safeguard patients from healthcare-associated infections. Objective The objective of this study was to evaluate the level of knowledge and identify the barriers faced by nursing staff in implementing aseptic techniques. Methodology This study employed a stratified random sampling technique to ensure the representation of the research sample. A cross-sectional, descriptive research design was used to assess the knowledge and barriers of nursing staff in maintaining aseptic techniques in their medical practice at Khartoum Teaching Hospital, Sudan. The nursing staff members were divided into different units, and a proportionate number of participants were randomly selected from each stratum. A total of 83 nursing staff members were recruited for this study. Data collection was conducted using a structured questionnaire specifically designed for this study. The questionnaire consisted of items that assessed the nursing staff's knowledge and barriers to aseptic technique implementation. Results The study findings revealed that the mean knowledge score of nursing staff was 14.12, with a median score of 15. The knowledge score had a standard deviation of 3.22. Approximately two-thirds of the nurses (66.3%) had an average level of knowledge, while 33.7% had a below-average level of knowledge. The chi-square analysis indicated a significant association between educational level, years of experience, and knowledge scores (P value=0.010) at a significance level of 0.05. Additionally, 65% of the participants reported facing multiple challenges in maintaining aseptic techniques, including insufficient training, limited resources, and inadequate support. Conclusion In conclusion, the evaluation revealed that a significant proportion of participants felt that their unit lacked adequate training and resources for aseptic techniques. Many had observed colleagues not adhering to aseptic practices, and the participants faced multiple challenges in maintaining aseptic techniques, including insufficient training, limited resources, time constraints, and inadequate support.