The Impact of COVID-19 on Healthcare-Associated Infections

A practical approach to preparing your ICU for epidemics and pandemics

PURPOSE OF REVIEW

Major outbreaks of infectious diseases, including epidemics and pandemics, are increasing in scope and frequency, threatening public health and straining the capacity of health systems worldwide. High-consequence infectious diseases (HCIDs), including highly pathogenic respiratory viruses and viral hemorrhagic fevers, are both contagious and virulent, and these pathogens thus are topics of special concern for pandemic planning.

RECENT FINDINGS

The COVID-19 pandemic demonstrated how a major disease outbreak can negatively impact all aspects of hospital functioning. Identification of patients with HCIDs needs careful clinical evaluation and coordination with public health authorities. Staff safety and patient care require appropriate infection prevention precautions, including personal protective equipment. Surges of ill patients may lead to significant strain, with increased ICU patient mortality. Strategies to reduce the impact of surge appear to reduce mortality, such as tiered staffing models and load-leveling across health systems.

SUMMARY

Pandemics and HCIDs are a significant threat to global health, and ICUs play a major role in the care of affected patients. Critical care professionals must work to ensure that our hospitals are prepared to identify and care for these patients in advance of the next emergency.

Characteristics of Enterococcus species bloodstream infections among adults with and without onco-hematological malignancies: Experiences from the national center of Hungary

Introduction

Over the past decade, enterococcal bloodstream infection (BSI) shows increasing incidence globally among the elderly and in patients with comorbidities. In this study, we aimed to assess microbiological and clinical characteristics and long-term outcomes of BSIs caused by Enterococcus spp. in adult patients with and without active onco-hematological malignancies hospitalized at a national referral institute.

Methods

A prospective analysis of consecutive enterococcal BSI cases was conducted in the National Institute of Hematology and Infectious Diseases (Budapest, Hungary) between December 2019 and April 2022. We compared characteristics and outcomes at 30-days and 1 year after diagnosis among patients with and without onco-hematological malignancies.

Results

In total, 141 patients were included (median age 68 ± 21 years, female sex 36.9%), 37% (52/141) had active onco-hematological malignancies. The distribution of species was as follows: 50.4% Enterococcus faecalis, 46.1% Enterococcus faecium, 1.4% Enterococcus avium and Enterococcus gallinarum, and 0.7% Enterococcus raffinosus. No statistically significant differences in all-cause mortality rates were observed between patient subgroups at 30 days (32.7 vs. 28.1%; P = 0.57) and 1 year (75.0 vs. 60.7%; P = 0.09).

Conclusion

Enterococcal bloodstream infections yielded a relevant burden of morbidity, but with no statistical difference in long-term outcomes of adult patients with and without active onco-hematological malignancies.

Pneumonia Characteristics in an Intensive Care Unit Setting during and after the COVID-19 Pandemic-A Single-Center Prospective Study

Background: During and after the COVID-19 pandemic, there was a suspicion of varying rates of respiratory tract infections (RTIs), particularly pneumonia (PN). Methods: This research evaluated epidemiological indicators of community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP) in the COVID-19 pandemic and post-pandemic period, including pathogens, ventilator-associated pneumonia (VAP), selected risk factors, and PN mortality. Results: At 1740 patients, throughout the 22,774 patient-days (Pt-D) and 18,039 ventilation days (Vt-D), there were 681 PN cases (39.14%): CAP 336 (19.31%) and HAP 345 (19.83%). CAP caused by SARS-CoV-2 was diagnosed in 257/336 (76.49%) patients. The clinical manifestations of PNs were CAP with 336/681 (49.34%), VAP with 232/681 (34.07%), and non-ventilator HAP (NV-HAP) with 113/681 cases (16.59%). The incidence rate of CAP/1000 Pt-D has been over 3 times higher in the pandemic period of 2020-2021 (20.25) than in the post-pandemic period of 2022 (5.86), p = 0.000. Similarly, higher incidence rates of VAP/1000 Pt-D were found in the pandemic period (p = 0.050). For NV-HAP, this difference was not statistically significant (p = 0.585). VAP occurred more frequently in the group of patients with PN in the course of COVID-19 compared to patients without COVID-19 (52/234 [22.2%] vs. 180/1506 [11.95%]); (p = 0.000). The most common CAP pathogen (during the pandemic) was SARS CoV-2 234/291 (80.4%), followed by MSSA/MRSA 8/291 (2.75%), whereas the most common VAP/NV-HAP pathogen was Acinetobacter baumannii XDR/MDR. The highest PN mortality was found in the patients with CAP caused by SARS-CoV-2 159/257 (61.87%). Conclusions: Pneumonias were diagnosed in nearly 40% of Intensive Care Unit (ICU) patients. Surveillance of pneumonias during the specific observation period was beneficial in the epidemiological and microbiological analysis of the ICU patients.

A Trial of Automated Outbreak Detection to Reduce Hospital Pathogen Spread

BACKGROUND

Detection and containment of hospital outbreaks currently depend on variable and personnel-intensive surveillance methods. Whether automated statistical surveillance for outbreaks of health care-associated pathogens allows earlier containment efforts that would reduce the size of outbreaks is unknown.

METHODS

We conducted a cluster-randomized trial in 82 community hospitals within a larger health care system. All hospitals followed an outbreak response protocol when outbreaks were detected by their infection prevention programs. Half of the hospitals additionally used statistical surveillance of microbiology data, which alerted infection prevention programs to outbreaks. Statistical surveillance was also applied to microbiology data from control hospitals without alerting their infection prevention programs. The primary outcome was the number of additional cases occurring after outbreak detection. Analyses assessed differences between the intervention period (July 2019 to January 2022) versus baseline period (February 2017 to January 2019) between randomized groups. A post hoc analysis separately assessed pre-coronavirus disease 2019 (Covid-19) and Covid-19 pandemic intervention periods.

RESULTS

Real-time alerts did not significantly reduce the number of additional outbreak cases (intervention period versus baseline: statistical surveillance relative rate [RR]=1.41, control RR=1.81; difference-in-differences, 0.78; 95% confidence interval [CI], 0.40 to 1.52; P=0.46). Comparing only the prepandemic intervention with baseline periods, the statistical outbreak surveillance group was associated with a 64.1% reduction in additional cases (statistical surveillance RR=0.78, control RR=2.19; difference-in-differences, 0.36; 95% CI, 0.13 to 0.99). There was no similarly observed association between the pandemic versus baseline periods (statistical surveillance RR=1.56, control RR=1.66; difference-in-differences, 0.94; 95% CI, 0.46 to 1.92).

CONCLUSIONS

Automated detection of hospital outbreaks using statistical surveillance did not reduce overall outbreak size in the context of an ongoing pandemic. (Funded by the Centers for Disease Control and Prevention; ClinicalTrials.gov number, NCT04053075. Support for HCA Healthcare's participation in the study was provided in kind by HCA.).

Impact of active surveillance and decolonization strategies for methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit

OBJECTIVE

To assess the impact of active surveillance and decolonization strategies on methicillin-resistant Staphylococcus aureus (MRSA) infection rates in a NICU.

STUDY DESIGN

MRSA infection rates were compared before (2014-2016) and during (2017-2022) an active surveillance program. Eligible infants were decolonized with chlorohexidine gluconate (CHG) bathing and/or topical mupirocin. Successful decolonization and rates of recolonization were assessed.

RESULTS

Fifty-two (0.57%) of 9 100 hospitalized infants had invasive MRSA infections from 2014 to 2022; infection rates declined non-significantly. During the 6-year surveillance program, the risk of infection was 16.9-times [CI95 8.4, 34.1] higher in colonized infants than uncolonized infants. Those colonized with mupirocin-susceptible MRSA were more likely successfully decolonized (aOR 9.7 [CI95 4.2, 22.5]). Of 57 infants successfully decolonized who remained hospitalized, 34 (60%) became recolonized.

CONCLUSIONS

MRSA infection rates did not significantly decline in association with an active surveillance and decolonization program. Alternatives to mupirocin and CHG are needed to facilitate decolonization.

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.

When Infections Are Found: A Qualitative Study Characterizing Best Management Practices for Central Line-Associated Bloodstream Infection and Catheter-Associated Urinary Tract Infection Performance Monitoring and Feedback

Healthcare-associated infections (HAIs) remain a significant patient safety problem that can lead to illness and death, despite the implementation of clinical bundles to prevent HAIs. Management practices can support HAI prevention, but their role in HAI performance monitoring and feedback is not well understood. To address this knowledge gap, we previously conducted semi-structured interviews with staff at 18 hospitals to examine the role of management practices around the prevention of central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). Interview transcripts were analyzed to identify themes related to HAI performance monitoring and feedback. The current analysis focuses on 10 higher-performing hospitals that were successful in preventing CLABSIs and CAUTIs. These institutions had robust practices including timely event analysis, leadership engagement, and multidisciplinary participation in HAI reviews. Across these sites, we found common goals including investigating HAIs without blame and identifying opportunities for improvement. Management practices such as timely analysis of HAIs, collaboration between facility leadership and multidisciplinary team members, and a focus on identifying the failure of a procedure or protocol, rather than the failure of staff members, are all approaches that can support infection prevention efforts. These management practices may be especially important as hospitals attempt to address increases in CLABSI and CAUTI rates that may have occurred during the coronavirus pandemic.

Novel preventive bundle for multidrug-resistant organisms in intensive care setting; tertiary care experience

Background

A widely-accepted standardized preventive bundle targeting multidrug-resistant organisms (MDROs) is lacking. The objective was to describe the components, implementation, compliance, and impact of a novel MDROs bundle in intensive care units (ICUs).

Methods

Cohort study of surveillance activities on the components of MDROs bundle (July 2019 to June 2022) and the incidence of MDROs (April 2016 to June 2022). The implementation of MDROs bundle were preceded by ICPs-led education of the staff working in target ICUs about the importance and components of the MDROs bundle. These included the overall use of antimicrobials, appropriate environmental cleaning, appropriate contact precautions, and hand hygiene compliance.

Results

During implementation, the overall use of antimicrobials was 57.8 days of therapy per 100 patient-days (44,492/76,933). It was higher in adult compared with pediatric/neonatal ICUs (p < 0.001). Appropriate environmental cleaning was 74.8% (12,409/16,582), appropriate contact precautions was 83.8% (10,467/12,497), and hand hygiene compliance was 86.9% (27,023/31,096). The three components were significantly higher in pediatric/neonatal compared with adult ICUs (p = 0.027, p < 0.001, p = 0.006, respectively). The MDROs rates per 10,000 patient-days were 71.8 before (April 2016 to June 2019) and 62.0 during (July 2019 to June 2022) the bundle implementation (858/119,565 versus 891/143,649 p = 0.002). The reduction in MDROs rates were replicated in adult (p = 0.001) but not pediatric/neonatal ICUs (p = 0.530).

Conclusions

The finding of this study indicate that the implementation of the current bundle was associated with a modest decrease in MDROs rates in adult ICUs. The provided detailed definitions and methodology will facilitate its use by other healthcare facilities.

Quantifying racial disparities in risk of invasive Staphylococcus aureus infection in Metropolitan Atlanta, Georgia, during the 2020-2021 coronavirus disease 2019 (COVID-19) pandemic

We estimated the racial disparity in rates of invasive S. aureus infections based on community coronavirus disease 2019 (COVID-19) rates at the county level. Our data suggest that COVID-19 infection burden (1) affects not only hospital-onset MRSA invasive infection risk but also community-onset S. aureus invasive infection risk and (2) affects Black residents ∼60% more than White residents.

Prevalence of hospital-associated infections and its association with discharge destinations and hospital readmissions in Brussels, Belgium, from 2008 to 2020: A hospital-based, cross-sectional study

OBJECTIVES

To examine time trends of hospital-associated infections (HAIs) in people living in the Brussels-Capital Region, and to evaluate the consequences for hospitals and long-term care facilities (LTCFs).

DESIGN

Cross-sectional analyses of yearly hospital administrative data.

SETTING

All Belgian hospitals and discharge destinations, focusing on LTCFs.

PARTICIPANTS

All individuals from the Brussels-Capital Region hospitalized for >1 day throughout Belgium between 2008 and 2020 (N = 1,915,572).

METHODS

We calculated HAI prevalences and then, adjusting for confounders, the odds of being discharged to a LTCF or being readmitted within 30 days postdischarge after an HAI. HAIs included hospital-associated bloodstream infections, hospital-associated urinary tract infections, hospital-associated pneumonia, ventilator-associated pneumonia, and surgical-site infections.

RESULTS

Between 2008 and 2020, we identified 77,004 HAIs. Changes in time trends occurred. We observed a decrease of all HAIs from 2012 to 2014 from 5.17% to 2.19% (P < .001) and an increase from 2019 to 2020 from 3.38% to 4.06% (P < .001). Among patients with HAIs, 24.36% were discharged to LTCFs and 13.51% underwent early readmission. For stays ≥4 days, HAIs were associated with higher odds of LTCF discharge (adjusted odds ratio [aOR], 1.25; 95% confidence interval [CI], 1.22-1.28), but with lesser odds of early readmission (aOR, 0.88; 95% CI, 0.85-0.90).

CONCLUSIONS

Administrative data can be useful to detect HAIs trends, but they seem to underestimate the burden compared to surveillance systems. Risk factors of readmission should be identified during hospital stays to ensure continuity of care. Considering the results from 2020 coinciding with the COVID-19 pandemic, monitoring the impact of HAIs should continue.

Transition of care interventions to manage severe COVID-19 in the ambulatory setting: a systematic review

BACKGROUND

Severe COVID-19, with the need in supplemental oxygen and hospitalization, leads to major burden on patients and healthcare systems. As a result, safe and effective ambulatory treatment strategies for severe COVID-19 are of urgent need. In this systematic review, we aimed to evaluate interventions to transition care to the ambulatory setting for patients with active severe COVID-19 that required supplemental oxygen.

METHODS

We searched Medline, Scopus, Web of Science, and DOAJ databases to identify articles with original data published until the 1st of April 2023. Characteristics and outcomes of interventions to transition care to home management were reviewed. Given the heterogeneous settings and outcomes studied, a meta-analysis was not performed.

RESULTS

Of the 235 studies identified, 11 observational studies, with 2645 patients, were included. The interventions were initiated from the emergency department, observation units or inpatient units, and included continuous home telemonitoring (n = 8), mobile applications (n = 2), and patient-initiated medical contact (n = 3). Included patients had an overall short length of hospital stay, high readmission rates, and positive patients' feedback. There was a lack of prospective controlled data and cost-effectiveness analyses.

CONCLUSION

Our findings highlight the potential in treating severe COVID-19 at the ambulatory setting and the lack of high-quality data in this field. Dedicated medical teams, adjusted monitoring methods, improving clinical trajectory, and correct inclusion settings are needed for safe and effective transition of care.

The impact of the COVID-19 pandemic on longitudinal trends of surgical mortality and inpatient quality of care in Ontario, Canada

AIMS

Previous studies have shown the COVID-19 pandemic was associated with reductions in volume across a spectrum of non-SARS-CoV-2 hospitalizations. In the present study, we examine the impact of the pandemic on patient safety and quality of care.

DESIGN

This is a retrospective population-based study of discharge abstracts.

METHODS

We applied a set of nationally validated indicators for measuring the quality of inpatient care to hospitalizations in Ontario, Canada between January 2010 and December 2022. We measured 90-day mortality after selected types of higher risk admissions (such as cancer surgery and cardiovascular emergency) and the rate of patient harm events (such as delirium, pressure injuries and hospital-acquired infections) occurring during the hospital stay.

RESULTS

A total 13,876,377 hospitalization episodes were captured. Compared with the pre-pandemic period, and independent of SARS-CoV-2 infection, the pandemic period was associated with higher rates of mortality after bladder cancer resection (adjusted risk ratio [aRR] 1.20 (1.07-1.34)) and open repair for abdominal aortic aneurysm (aRR 1.45 (1.06-1.99)). The pandemic was also associated with higher rates of delirium (adjusted odds ratio [aOR] 1.04 (1.02-1.06)), venous thromboembolism (aOR 1.10 (1.06-1.13)), pressure injuries (aOR 1.28 (1.24-1.33)), aspiration pneumonitis (aOR 1.15 (1.12-1.18)), urinary tract infections (aOR 1.02 (1.01-1.04)), Clostridiodes difficile infection (aOR 1.05 (1.02-1.09)), pneumothorax (aOR 1.08 (1.03-1.13)), and use of restraints (aOR 1.12 (1.10-1.14)), but was associated with lower rates of viral gastroenteritis (aOR 0.22 (0.18-0.28)). During the pandemic, SARS-CoV-2-positive admissions were associated with a higher likelihood of various harm events.

CONCLUSION

The COVID-19 pandemic was associated with higher rates of patient harm for a wide range of non-SARS-CoV-2 inpatient populations.

IMPACT

Understanding which quality measures are improving or deteriorating can help health systems prioritize quality improvement initiatives.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

The impact of an intervention to reduce dispersal from wastewater drain sites on carbapenem-resistant Pseudomonas aeruginosa colonization and bloodstream infection on a hematopoietic cell transplant and hematologic malignancy unit

OBJECTIVE

To evaluate the impact of an intervention to limit dispersal from wastewater drain (WWD) sites on meropenem-nonsusceptible Pseudomonas aeruginosa patient and environmental colonization and bloodstream infection (BSI) on a hematopoietic cell transplant (HCT) and hematologic malignancy (HM) unit.

DESIGN

This quasi-experimental study included pre/postintervention point-prevalence surveys in July 2019 and June 2020, respectively. The retrospective cohort included HCT/HM patients with P. aeruginosa BSI between 2012 and 2022.

SETTING

Adult HCT/HM unit at an academic center.

PARTICIPANTS

This study included consenting HCT/HM patients on the unit at the time of the point-prevalence surveys. HCT/HM patients with P. aeruginosa BSI between 2012 and 2022.

METHODS

A quality improvement intervention targeting WWD sites was conceived and implemented on a HCT/HM unit. Pre and postintervention colonization samples were obtained from patients and environmental sites, cultivated on selective media, then characterized by susceptibility testing. Whole-genome sequencing and phylogenetic analysis were performed on select isolates. The impact of the intervention on colonization and BSI was evaluated, as was relatedness among isolates.

RESULTS

Although colonization of WWD sites with meropenem-nonsusceptible P. aeruginosa was widespread before and after this intervention, we observed a substantial decline in patient colonization (prevalence rate ratio, 0.35; 95% confidence interval [CI], 0.04-3.12) and BSI (incidence rate ratio, 0.67; 95% CI, 0.31-1.42) after the intervention. Among 3 predominant sequence types (ST-111, ST-446, and ST-308), there was striking genetic conservation within groups and among environmental colonization, patient colonization, and BSI isolates.

CONCLUSIONS

An intervention targeting WWD sites on a HCT/HM unit had a meaningful impact on meropenem-nonsusceptible P. aeruginosa patient colonization and BSI.

Antimicrobial Resistance in Qatar: Prevalence and Trends before and Amidst the COVID-19 Pandemic

Antimicrobial resistance (AMR) is a global healthcare challenge with substantial morbidity, mortality, and management costs. During the COVID-19 pandemic, there was a documented increase in antimicrobial consumption, particularly for severe and critical cases, as well as noticeable travel and social restriction measures that might influenced the spectrum of AMR. To evaluate the problem, retrospective data were collected on bacterial infections and antimicrobial susceptibility patterns in Qatar before and after the pandemic from 1 January 2019 to 31 December 2021, covering 53,183 pathogens isolated from reported infection episodes. The findings revealed a significant resistance pattern for extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-EBC), carbapenem-resistant Enterobacteriaceae (CR-EBC), and carbapenem-resistant Pseudomonas aeruginosa (CRPA), ciprofloxacin-resistant Salmonella and methicillin-resistant Staphylococcus aureus (MRSA). For correlation with social restrictions, ESBL-EBC and MRSA were positively correlated with changing patterns of international travel (ρ = 0.71 and 0.67, respectively; p < 0.05), while CRPA was moderately correlated with the number of COVID-19 hospitalized patients (ρ = 0.49; p < 0.05). CREBC and CRPA respiratory infections were associated with hospitalized patients (OR: 3.08 and 2.00, respectively; p < 0.05). The findings emphasize the challenges experienced during the COVID-19 pandemic and links to international travel, which probably will influence the local epidemiology of AMR that needs further surveillance and control strategies.

Asymptomatic Testing of Hospital Admissions for SARS-CoV-2: Is it OK to Stop?

Universal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing of all persons admitted to acute care hospitals has become common practice. We describe why 1 hospital discontinued this practice after weighing potential benefits against known harms. Considerations around the benefits shifted as we saw a decline in SARS-CoV-2 community transmission and coronavirus disease 2019 (COVID-19) severity of illness, increased availability of vaccines and treatments, and better understood the many other transmission pathways in the healthcare environment. Considerations around harms included the additional strain on laboratory and infection prevention resources, and several unintended adverse consequences of admission screening for patients, including unnecessary isolation, antiviral treatments, and delays in care delivery. Poor test performance for detection of infectiousness also played a significant role in determining to stop universal screening. No increase in hospital-onset COVID-19 has been documented since discontinuation of admission testing. We continue to apply other established layers of prevention while monitoring for any change in incidence of within-facility transmission of SARS-CoV-2.

UVC Box: An Effective Way to Quickly Decontaminate Healthcare Facilities' Wheelchairs

Disinfection in the hospital environment remains challenging, especially for wide and structurally complex objects such as beds or wheelchairs. Indeed, the regular disinfection of these objects with chemicals is manually carried out by healthcare workers and is fastidious and time-consuming. Alternative antibacterial techniques were thus proposed in the past decades, including the use of naturally antimicrobial UVC. Here, the antibacterial efficiency of a large UVC box built to accommodate wheelchairs was investigated through testing bacterial burden reductions on various parts of a wheelchair, with various support types and with several treatment durations. The results demonstrate a time-dependent antibacterial effect, with a strong burden reduction at only five minutes of treatment (>3-log median reduction in Escherichia coli and Staphylococcus epidermidis). The UVC flux and residual bacterial burden both significantly varied depending on the spatial location on the wheelchair. However, the nature of the support impacted the antibacterial efficiency even more, with residual bacterial burdens being the lowest on rigid materials (steel, plastics) and being the highest on tissue. On metallic samples, the nature of the alloy and surface treatment had various impacts on the antibacterial efficiency of the UVC. This study highlights the efficiency of the tested UVC box to efficiently and quickly decontaminate complex objects such as wheelchairs, but also gives rise to the warning to focus on rigid materials and avoid porous materials in the conception of objects, so as to ensure the efficiency of UVC decontamination.

Impact of the COVID-19 pandemic on the incidence and type of infections in hospitalized patients with cirrhosis: a retrospective study

Infections are a major cause of morbidity and mortality in cirrhosis, especially those caused by multi-drug resistant bacteria. During the COVID-19 pandemic, the incidence and type of infection in these patients may have been influenced by the restrictive measures implemented. We aimed to compare the infections in patients with cirrhosis hospitalized before the COVID-19 pandemic versus those hospitalized during the pandemic. We retrospectively compared infections in patients with cirrhosis hospitalized in the hepatology unit during the pre-pandemic period (3/2019-2/2020) with infections in patients hospitalized during the pandemic (3/2020-2/2021). Baseline characteristics, type of infections, type of bacteria, antimicrobial resistance and mortality were evaluated. There were 251 hospitalizations in 170 patients during the pre-pandemic period and 169 hospitalizations in 114 patients during the pandemic period. One or more infections were identified in 40.6% of hospitalizations during the pre-pandemic period and 43.8% of hospitalizations during the pandemic, P = 0.52. We found 131 infections in the pre-pandemic period and 75 infections during the pandemic. The percentage of nosocomial infections decreased in the pandemic period (25.3% vs. 37.4% in the pre-pandemic period, P = 0.06). We found a non-significant trend to a higher incidence of infections by multi-drug resistant organisms (MDRO) in the pandemic period than in the pre-pandemic period (6.5% vs. 4%). The incidence of infections was similar in both periods. However, during the pandemic, we observed a trend to a lower incidence of nosocomial infections with a higher incidence of MDRO infections.

Implementation of a multi-modal intervention adopting new technologies, clinical services, and feedback improves catheter-associated urinary tract infections

OBJECTIVES

Catheter-associated urinary tract infections (CAUTI) are a significant cause of morbidity and financial burden to healthcare systems. The aim of this study was to develop and implement a program designed to reduce Foley catheter use days and associated CAUTI rates.

METHODS

A retrospective evaluation of a multi-modal program aimed toward reducing Foley catheter use days and associated CAUTI rates across the Indiana University Health (IUH) system was conducted. IUH is comprised of 16 hospitals and 2,703 available beds. The program included the adoption of new technologies with evidence-based clinical training materials based on change management and feedback from clinicians. National Healthcare Safety Network Standardized Infection Ratio (SIR), Standardized Utilization Ratio (SUR), and Incidence Density Ratio (IDR) rates were assessed.

RESULTS

Implementation of the multi-modal program resulted in a significant reduction in SIR, SUR, and IDR in the post-implementation compared to the baseline periods.

CONCLUSIONS

Through CAUTI bundle workflow assessments, education, and interventions designed to standardize practice variation, the program was successfully implemented and resulted in a significant decrease in Foley Catheter use days, and associated CAUTI rates.

How COVID-19 impacted CAUTI and CLABSI rates in Alabama

BACKGROUND

The study objective was to quantify infection rate trends for central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) in 89 Alabama hospitals from 2015 to 2021 to analyze how the COVID-19 pandemic impacted health care delivery.

METHODS

Retrospective analysis of CLABSI and CAUTI rates, from 89 Alabama hospitals via data from the Alabama Department of Public Health from 2015 to 2021.

RESULTS

Based on our modeling strategies, there was a statistically significant decrease in rates of CAUTIs from 2015 to 2019 at an estimated rate of 7% per year (P = 0.0167) and CLABSIs from 2015 to 2018 at an estimated rate of 13% per year (P < .001) in these hospitals. In 2020, the CAUTI and CLABSI rates began increasing at a modeled rate of 29% per year (P = .001) and 35% per year (P < .001) respectively.

DISCUSSION

A review of potential causes for the elevated rate of health care-associated infections illustrated that certain practices may have contributed to increased CAUTI and CLABSI rates. Utilizing staff from noncritical care areas with less experience in health care-associated infection prevention, batching of tasks to conserve personal protective equipment, and a nationwide mental health crisis could have affected infection prevention bundle compliance.

CONCLUSIONS

An increase in CAUTIs and CLABSIs was observed during the pandemic, likely due to the large volume of patients requiring advanced medical care and subsequent depleted resources.

Incidence, antimicrobial resistance and mortality of Pseudomonas aeruginosa bloodstream infections among hospitalized patients in China: a retrospective observational multicenter cohort study from 2017 to 2021

Background

Pseudomonas aeruginosa (P. aeruginosa) accounts for high antimicrobial resistance and mortality rates of bloodstream infections (BSIs). We aim to investigate incidence, antimicrobial resistance and risk factors for mortality of P. aeruginosa BSIs among inpatients.

Methods

A retrospective cohort study were conducted at two tertiary hospitals in 2017-2021. Medical and laboratory records of all inpatients diagnosed with P. aeruginosa BSIs were reviewed. A generalized linear mixed model was used to identify risk factors for mortality.

Results

A total of 285 patients with P. aeruginosa BSIs were identified. Incidence of P. aeruginosa BSIs fluctuated between 2.37 and 3.51 per 100,000 patient-days over the study period. Out of 285 P. aeruginosa isolates, 97 (34.04%) were carbapenem-resistant (CR) and 75 (26.32%) were multidrug-resistant (MDR). These isolates showed low resistance to aminoglycosides (9.51-11.62%), broad-spectrum cephalosporins (17.19-17.61%), fluoroquinolones (17.25-19.43%), and polymyxin B (1.69%). The crude 30-day mortality rate was 17.89% (51/285). Healthcare costs of patients with MDR/CR isolates were significantly higher than those of patients with non-MDR/CR isolates (P < 0.001/=0.002). Inappropriate definitive therapy [adjusted odds ratio (aOR) 4.47, 95% confidence interval (95% CI) 1.35-14.77; P = 0.014], ICU stay (aOR 2.89, 95% CI: 1.26-6.63; P = 0.012) and corticosteroids use (aOR 2.89, 95% CI: 1.31-6.41; P = 0.009) were independently associated with 30-day mortality.

Conclusion

Incidence of P. aeruginosa BSIs showed an upward trend during 2017-2020 but dropped in 2021. MDR/CR P. aeruginosa BSIs are associated with higher healthcare costs. Awareness is required that patients with inappropriate definitive antimicrobial therapy, ICU stay and corticosteroids use are at higher risk of death from P. aeruginosa BSIs.

Community Antibiotic Consumption in Cyprus for the Period 2015 to 2022

BACKGROUND

Cyprus currently reports to ESAC-Net the total consumption of antimicrobials, without distinguishing between hospital and community-based antibiotic use. As a result, these data can only provide generalized insights into antimicrobial trends in the country.

AIM

This study is a first attempt to retrospectively analyze community antibiotic consumption in Cyprus for the period of 2015 to 2022.

MATERIAL AND METHODS

Data on community antimicrobial consumption between 2015 and 2022 were extracted from Pharmatrack's database. Orally administered dispensed antibiotics were categorized under the J01 group of the WHO Anatomical Therapeutic Chemical (ATC) classification and by the WHO's AWaRe classification of antibiotics. Antibiotic consumption was calculated in both packages consumed and per 1000 inhabitants, overall, by year of consumption and districts.

RESULTS

During the period of 2015-2022, there was variability in the mean outpatient antibiotic consumption per 1000 inhabitants among the five districts in Cyprus. Community consumption increased by 38% throughout the study period. Additionally, a decrease of 3% in the consumption of WHO 'Access' antibiotics was observed, accompanied with a concurrent increase of 3% in the 'Watch' group. Specifically, in 2022 the WHO 'Access' group consumption in the Cypriot community was 48%, significantly lower than the WHO's goal of 60% and the EU's goal of 70% for 'Access' antibiotic consumption.

CONCLUSIONS

Antibiotic consumption in the community of Cyprus between 2015 and 2022 demonstrated substantial variability among districts, with higher consumption in less populated areas. There was an increasing trend in community consumption over the years and a decreasing trend in the percentage of 'Access' antibiotics prescribed.

Increased Peripheral Venous Catheter Bloodstream Infections during COVID-19 Pandemic, Switzerland

Studies suggest that central venous catheter bloodstream infections (BSIs) increased during the COVID-19 pandemic. We investigated catheter-related BSIs in Switzerland and found peripheral venous catheter (PVC) BSI incidence increased during 2021-2022 compared with 2020. These findings should raise awareness of PVC-associated BSIs and prompt inclusion of PVC BSIs in surveillance systems.

Impact of coronavirus disease 2019 (COVID-19) on antimicrobial resistance among major pathogens causing healthcare-associated infection

BACKGROUND

Coronavirus disease 2019 (COVID-19) has caused great impact on healthcare systems, including antibiotic usage and multi-drug resistant (MDR) bacterial infections at hospitals. We aim to investigate the trends of antimicrobial resistance among the major pathogens causing healthcare-associated infection (HAI) at intensive care units (ICU).

MATERIAL AND METHODS

The demographic characteristics of hospitalization, usage of antimicrobial agents, counted by half-an-year DID (defined daily dose per 1000 patient-days), and HAI density of five major MDR bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), carbapenem-resistant Acinetobacter baumannii (CRAB), carbapenem-resistant Klebsiella pneumoniae (CRKP), and carbapenem-resistant Pseudomonas aeruginosa (CRPA), of ICU patients at a medical center in Taiwan during January 2017 to December 2021 were collected and analyzed.

RESULTS

The total antibiotic usage, counted by DID, had a significant increasing trend, before COVID-19 occurrence in 2017-2019, but no further increase during the pandemic period in 2020-2021. However, comparing the two time periods, antibiotics consumption was significantly increased during pandemic period. There was no significant change of HAI density in MRSA, VRE, CRAB, CRKP, and CRPA, comparing the pandemic to the pre-pandemic period. Although, CRKP and CRPA infection rates were increasing during the pre-pandemic period, there was no further increase of CRKP and CRPA HAI rates during the pandemic period.

CONCLUSION

During COVID-19 pandemic, there was no significant increase in HAI density of five major MDR bacteria at ICU in Taiwan, despite increased antibiotic usage. Strict infection prevention measures for COVID-19 precautions and sustained antimicrobial stewardship probably bring these effects.

Deployment of nursing students to assist in CLABSI and CAUTI prevention bundle audits and interventions during the COVID-19 pandemic

The COVID-19 pandemic exacerbated previously existing health care challenges related to hospital-acquired infections. Nursing students were deployed to augment staffing shortages and mitigate incidences of catheter-associated urinary tract infections and catheter-associated bloodstream infections. Nursing students' use as an adjunct to infection prevention measures facilitated success in sustaining low rates of catheter-associated bloodstream infections and catheter-associated urinary tract infections.

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.

Machine learning-based clinical decision support for infection risk prediction

Background

Healthcare-associated infection (HAI) remains a significant risk for hospitalized patients and a challenging burden for the healthcare system. This study presents a clinical decision support tool that can be used in clinical workflows to proactively engage secondary assessments of pre-symptomatic and at-risk infection patients, thereby enabling earlier diagnosis and treatment.

Methods

This study applies machine learning, specifically ensemble-based boosted decision trees, on large retrospective hospital datasets to develop an infection risk score that predicts infection before obvious symptoms present. We extracted a stratified machine learning dataset of 36,782 healthcare-associated infection patients. The model leveraged vital signs, laboratory measurements and demographics to predict HAI before clinical suspicion, defined as the order of a microbiology test or administration of antibiotics.

Results

Our best performing infection risk model achieves a cross-validated AUC of 0.88 at 1 h before clinical suspicion and maintains an AUC >0.85 for 48 h before suspicion by aggregating information across demographics and a set of 163 vital signs and laboratory measurements. A second model trained on a reduced feature space comprising demographics and the 36 most frequently measured vital signs and laboratory measurements can still achieve an AUC of 0.86 at 1 h before clinical suspicion. These results compare favorably against using temperature alone and clinical rules such as the quick sequential organ failure assessment (qSOFA) score. Along with the performance results, we also provide an analysis of model interpretability via feature importance rankings.

Conclusion

The predictive model aggregates information from multiple physiological parameters such as vital signs and laboratory measurements to provide a continuous risk score of infection that can be deployed in hospitals to provide advance warning of patient deterioration.

Trends in the epidemiology of Clostridioides difficile infection in Germany

PURPOSES

Despite reports of a declining incidence over the last decade, Clostridioides difficile infection (CDI) is still considered the most important healthcare-associated causes of diarrhea worldwide. In Germany, several measures have been taken to observe, report, and influence this development. This report aims to analyze the development of hospital coding for CDI in Germany over the last decade and to use it to estimate the public health burden caused by CDI.

METHODS

Reports from the Institute for Hospital Remuneration Systems, German Federal Statistical Office (DESTATIS), the Robert-Koch-Institute (RKI), Saxonian authorities and hospital quality reports during 2010-2021 were examined for CDI coding and assessed in a structured expert consultation. Analysis was performed using 2019 versions of Microsoft Excel® and Microsoft Access®.

RESULTS

Peaks of 32,203 cases with a primary diagnosis (PD) of CDI and 78,648 cases with a secondary diagnosis (SD) of CDI were observed in 2015. The number of cases had decreased to 15,412 PD cases (- 52.1%) and 40,188 SD cases (- 48.9%) by 2021. These results were paralleled by a similar decline in notifiable severe cases. However, average duration of hospitalization of the cases remained constant during this period.

CONCLUSIONS

Hospital coding of CDI and notification to authorities has approximately halved from 2015 to 2021. Potential influential factors include hospital hygiene campaigns, implementation of antibiotic stewardship programs, social distancing due to the COVID-19 pandemic, and a decrease in more pathogenic subtypes of bacteria. Further research is necessary to validate the multiple possible drivers for this development.

Addressing an increase in surgical site infections during the COVID-19 pandemic-Identifying opportunities during a chaotic time

BACKGROUND

Health care systems saw increases in device-associated infections and decreases in surgical site infections (SSI) during the COVID-19 pandemic. However, following an increase in SSIs, an acute care hospital assessed the risk and preventative factors of SSIs among patients.

METHODS

A retrospective cohort study on surgeries performed between January 2020 and September 2021 analyzed associations of SSI with risk and preventive factors utilizing χ2, t-tests, and odds ratios. A secondary analysis was utilized to determine the association of case urgency and prevention practice performance.

RESULTS

There was a significant difference in the administration of correct perioperative antibiotic selection between SSI (78.1%) and non-SSI (86.2%) along with 2.9 greater odds of developing an SSI with incorrect perioperative antibiotics. Patients who had urgent cases were significantly less likely than elective to receive preoperative chlorhexidine gluconate wipes (81.6%, 61.5%, respectively), correct antibiotic selection and timing (93.2%, 70.8%, respectively) and chlorhexidine and alcohol skin preparation (81.6%, 67.5%, respectively).

DISCUSSION

Disruption of perioperative workflow during the COVID-19 pandemic likely resulted in an increase in SSI. Numerous opportunities were identified for focused prevention efforts.

CONCLUSIONS

The next steps include implementing strategies to improve SSI prevention and establish a culture that can withstand workflow disruptions to maintain a safe environment during significant changes.

What US hospitals are doing to prevent common device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: Results from a national survey in the United States

OBJECTIVE

The ways that device-associated infection prevention practices changed during the coronavirus disease 2019 (COVID-19) pandemic remain unknown. We collected data mid-pandemic to assess the use of several infection prevention practices and for comparison with historical data.

DESIGN

Repeated cross-sectional survey.

SETTING

US acute-care hospitals.

PARTICIPANTS

Infection preventionists.

METHODS

We surveyed infection preventionists from a national random sample of 881 US acute-care hospitals in 2021 to estimate the current use of practices to prevent catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated events (VAE). We compared the 2021 results with those from surveys occurring every 4 years since 2005.

RESULTS

The 2021 survey response rate was 47%; previous survey response rates ranged from 59% to 72%. Regular use of most practices to prevent CLABSI (chlorhexidine gluconate for site antisepsis, 99.0%, and maximum sterile barrier precautions, 98.7%) and VAE (semirecumbent positioning, 93.4%, and sedation vacation, 85.8%) continued to increase or plateaued in 2021. Conversely, use of several CAUTI prevention practices (portable bladder ultrasound scanner, 65.6%; catheter reminders or nurse-initiated discontinuation, 66.3%; and intermittent catheterization, 37.3%) was lower in 2021, with a significant decrease for some practices compared to 2017 (P ≤ .02 for all comparisons). In 2021, 42.1% of hospitals reported regular use of the newer external urinary collection devices for women.

CONCLUSIONS

Although regular use of CLABSI and VAE preventive practices continued to increase (or plateaued), use of several CAUTI preventive practices decreased during the COVID-19 pandemic. Structural issues relating to care during the pandemic may have contributed to a decrease in device-associated infection prevention practices.

The impact of the COVID-19 pandemic on hospital-acquired infections at a comprehensive cancer center

BACKGROUND

Robust infection prevention and control (IPC) measures were deployed across health care institutions at the start of the COVID-19 pandemic, resulting in increased use of personal protective equipment, enhanced contact precautions, and an emphasis on hand hygiene. Here, we evaluate the effect of enhanced IPC practices on the occurrence of various hospital-associated infections (HAIs) in a comprehensive cancer center.

METHODS

From September 2016 through March 2022, we calculated the incidence rates (IRs) of HAIs for C. difficile infection, multidrug-resistant organisms, respiratory viral infections (RVIs), and device-related infections. We analyzed the incidence rate ratios for all HAIs during the periods before the pandemic, during the pandemic, at the time of the surges, and in COVID-19-designated wards.

RESULTS

When comparing the prepandemic to the pandemic period, the IR across all MRDOs was similar. We observed a decrease in the IR of central line-associated bloodstream infections and a stable IR of catheter-associated urinary tract infections. A significant decrease was observed in the IR of C. difficile infection. The total IR of nosocomial RVIs decreased, as did for each respiratory virus. A similar IR of nosocomial RVIs between COVID-19 community surge versus nonsurge periods was observed except for SARS-CoV-2, RSV, and influenza. multidrug resistant organisms were 5 times more likely to occur on the COVID-19 wards compared with the non-COVID-19 wards.

CONCLUSIONS

Implementing strict IPC measures during the COVID-19 pandemic in a cancer hospital led to a significant decrease in many HAIs and a reduction in nosocomial RVIs.

Impact of the COVID-19 pandemic on Clostridioides difficile infection in a tertiary healthcare institution in Belgium

OBJECTIVES

Clostridioides difficile infection (CDI) causes the greatest number of healthcare-associated infectious diarrhoea. CDIs are transmitted by direct and indirect patient-to-patient contact and risk increases with the use of antibiotics. Since early 2020, the COVID-19 pandemic has affected healthcare systems in many ways including substantial changes in hygiene behaviour. The aim of this study was to assess whether CDI incidence differed during the COVID-19 pandemic compared to a year before.

METHODS

All tests for suspected CDI cases were recorded for a hospital in Brussels, Belgium. The percentage of CDI-positive results and incidences (total and healthcare-associated (HA)-CDI)) for years 2019, 2020, 2021, and 2022 were calculated. Antibiotic consumption was analysed for years 2019 and 2020.

RESULTS

Since the COVID-19 pandemic struck, a significant reduction of up to 39% was observed in the number of Clostridioides difficile stool tests in our hospital. A significant decrease in the percentage of positive tests and a 50% decrease in the incidence of CDI (total and HA-CDI) was found for 2020 compared with 2019 and confirmed for years 2021 and 2022. The decrease in CDI incidence was mostly marked in haematology, nephrology, and gastroenterology units. No significant change in the use of antibiotics was found.

CONCLUSION

The global decrease in CDI incidence observed in our hospital was not associated with a change in the use of antibiotics. The control measures implemented to prevent COVID-19 transmission may explain a reduction in CDI incidence. An underdiagnosis of CDI cannot be excluded.

Coronavirus disease 2019 (COVID-19) impact on central-line-associated bloodstream infections (CLABSI): a systematic review

Introduction

Central line-associated bloodstream infections (CLABSI) are an important clinical and public health issue, impacted by the purported increase in healthcare-associated infections (including CLABSI) during the COVID-19 pandemic. This review evaluates the impact of COVID-19 on CLABSI at a global level, to determine risk factors, effective preventive measures and microbiological epidemiology.

Methods

A systematic literature review was performed using a PECO framework, with COVID-19 infection as the exposure measure and CLABSI rates as the main outcome of interest, pre- and during the pandemic.

Results

Overall, most studies (17 of N=21) found a significant increase in CLABSI incidence/rates during the pandemic. Four studies showed a reduction (N=1) or no increase (N=3). High workload, redeployment, and 'overwhelmed' healthcare staff were recurrent risk-factor themes, likely to have negatively influenced basic infection control practices, including compliance with hand hygiene and line care bundles. Microbiological epidemiology was also impacted, with an increase in enterococcal infections and other pathogens.

Conclusion

The COVID-19 pandemic significantly impacted CLABSI incidence/rates. Observations from the different studies highlight significant gaps in healthcare associated infections (HCAI) knowledge and practice during the pandemic, and the importance of identifying preventive measures effective in reducing CLABSI, essential to health system resilience for future pandemics. Central to this are changes to CLABSI surveillance, as reporting is not mandatory in many healthcare systems. An audit tool combined with regular assessments of the compliance with infection control measures and line care bundles also remains an essential step in the prevention of CLABSI.

Epidemiology of vancomycin-resistant enterococci in the United Arab Emirates: a retrospective analysis of 12 years of national AMR surveillance data

Introduction

Enterococci are usually low pathogenic, but can cause invasive disease under certain circumstances, including urinary tract infections, bacteremia, endocarditis, and meningitis, and are associated with peritonitis and intra-abdominal abscesses. Increasing resistance of enterococci to glycopeptides and fluoroquinolones, and high-level resistance to aminoglycosides is a concern. National antimicrobial resistance (AMR) surveillance data for enterococci from the Middle East and North Africa (MENA) and the Gulf region is scarce.

Methods

A retrospective 12-year analysis of N = 37,909 non-duplicate diagnostic Enterococcus spp. isolates from the United Arab Emirates (UAE) was conducted. Data was generated by routine patient care during 2010-2021, collected by trained personnel and reported by participating surveillance sites to the UAE National AMR Surveillance program. Data analysis was conducted with WHONET.

Results

Enterococcus faecalis was the most commonly reported species (81.5%), followed by Enterococcus faecium (8.5%), and other enterococci species (4.8%). Phenotypically vancomycin-resistant enterococci (VRE) were found in 1.8% of Enterococcus spp. isolates. Prevalence of VRE (%VRE) was highest for E. faecium (8.1%), followed by E. faecalis (0.9%). A significant level of resistance to glycopeptides (%VRE) for these two species has been observed in the majority of observed years [E. faecalis (0-2.2%), 2010: 0%, 2021: 0.6%] and E. faecium (0-14.2%, 2010: 0%, 2021: 5.8%). Resistance to fluoroquinolones was between 17 and 29% (E. faecalis) and was higher for E. faecium (between 42 and 83%). VRE were associated with higher patient mortality (RR: 2.97), admission to intensive care units (RR: 2.25), and increased length of stay (six excess inpatient days per VRE case), as compared to vancomycin-susceptible Enterococcus spp.

Discussion

Published data on Enterococcus infections, in particular VRE-infections, in the UAE and MENA region is scarce. Our data demonstrates that VRE-enterococci are relatively rare in the UAE, however showing an increasing resistance trend for several clinically important antibiotic classes, causing a concern for the treatment of serious infections caused by enterococci. This study also demonstrates that VRE were associated with higher mortality, increased intensive care unit admission rates, and longer hospitalization, thus poorer clinical outcome and higher associated costs in the UAE. We recommend the expansion of current surveillance techniques (e.g., local VRE screening), stricter infection prevention and control strategies, and better stewardship interventions. Further studies on the molecular epidemiology of enterococci are needed.

Navigating a Pandemic: Leadership Dynamics and Challenges within Infection Prevention and Control Units in Israel

This study investigates the impact of the coronavirus disease 2019 (COVID-19) pandemic on leadership within infection prevention and control (IPC) units across public hospitals in Israel. Through qualitative interviews with ten IPC managers from nine hospitals, equivalent to 30% of the country's acute care facilities, the research uncovers significant changes in managerial approaches due to the health crisis. The results reveal four main themes: (1) Enhanced managerial autonomy and leadership skills, with a noted rise in self-efficacy against the pandemic's backdrop; (2) Shifted perceptions of IPC units by upper management, recognizing their strategic value while identifying the need for a more profound understanding of IPC operations; (3) The increased emphasis on adaptability and rapid decision-making for effective crisis management; (4) The dual effect on job satisfaction and well-being, where greater commitment coincides with risks of burnout. The study underscores the essential nature of effective IPC leadership during emergencies, highlighting the need for clear communication, prompt action, and empathetic leadership. The conclusions point to the necessity for continuous research into IPC leadership, promoting strategic advancements in management to bolster IPC units against future health threats.

Decreased incidence of late-onset sepsis during the SARS-CoV-2 pandemic in Italy: a multicentric study on a cohort of infants requiring major surgery

Changes in the organization of the clinical care wards, requested by the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic, have influenced the environmental circulation of other pathogens. The implementation of prevention procedures may have led to a decrease in the incidence of healthcare-associated infections. We aimed to investigate the impact of prevention and control measures for preventing the COVID-19 spread on the incidence of bacterial sepsis and invasive fungal infections in neonates and infants requiring major surgery. We compared the incidence of bacterial and fungal sepsis and their risk factors observed before the SARS-CoV-2 pandemic (from 01/10/2018 to 29/02/2020) with those observed during the pandemic (from 01/03/2020 to 07/05/2021) in 13 level III Neonatal Intensive Care Units in Italy, through a secondary analysis of data, collected during a prospective multicenter study (REF). The patients enrolled were infants within three months of life, hospitalized in the two periods in the participating centers to undergo major surgery. Among 541 enrolled patients, 324 (59.9%) were born in the pre-pandemic period and 217 (40.1%) during the pandemic. The incidence density (ID) of any infection in the pre-pandemic period was 16.0/1000 patient days versus 13.6/1000 patient days in the pandemic period (p < 0.001). One hundred and forty-five (145/324; 44.8%) patients developed at least one episode of bacterial sepsis in the pre-pandemic period, versus 103/217 (31.8%) patients, during the pandemic (p = 0.539). Concerning fungal sepsis, 12 (3.7%) patients had one episode in the pre-pandemic period versus 11 (5.1%) patients during the pandemic (p = 0.516). The most significant differences observed in the use of healthcare procedures were the reduction of CVC days, the reduced use of antibiotics pre-surgery, and that of proton pump inhibitors during the SARS-CoV-2 pandemic compared with the previous period.

CONCLUSIONS

In our cohort of patients with major surgical needs, the reduction of CVC days, pre-surgery antibiotics administration, and current use of proton pump inhibitors, during the SARS-CoV-2 pandemic, led to a decrease in the incidence of late-onset sepsis.

WHAT IS KNOWN

• Most cases of late-onset sepsis in neonates are referred to as central line-associated bloodstream infections. • In adults, the COVID-19 outbreak negatively influenced healthcare-associated infection rates and infection clusters within hospitals.

WHAT IS NEW

• In neonates and infants undergoing major surgery the incidence density of infections was lower in the pandemic period than before. • The most significant differences observed in the use of healthcare procedures were the reduction of CVC days, the reduced use of antibiotics before surgery, and that of proton pump inhibitors during the pandemic compared with previously.

Outbreak of Candida parapsilosis fungemia in an intensive care unit during a COVID surge: an epidemic within a pandemic

We sought to investigate epidemiology, risk factors, clinical features, and outcome of the C. parapsilosis blood stream infection (BSI) outbreaks observed during the first surges of COVID-19 pandemic in our population. Retrospective, monocentric observational study in the 24 bed intensive care unit (ICU) of a tertiary care medical center in northern Italy, from 2019 to 2021 first 5 months. 2030 patients were enrolled, of whom 239 were COVID-19 positive. The total incidence of Candida-BSI was 41.9 per 1000 admissions, with two outbreaks during 2020 spring and winter's COVID surges. The total numbers of C. parapsilosis BSI cases are 94, of which 21 during the first outbreak and 20 during the second. In our population, COVID-19 was strongly associated with C. parapsilosis BSI (OR 4.71, p < 0.001), as well as continuous renal replacement therapy (CRRT) (OR 3.44, p = 0.001), prolonged antibiotic therapy (OR 3.19, p = 0.004), and delayed infusion sets replacements (OR 2.76, p = 0.015). No statistically significant association was found between Candida-BSI episodes and mortality, when adjusted for other known outcome risk factors. COVID surges undermined the infectious control measures in our ICU, leading to two outbreak of C. parapsilosis BSI. A stricter, thorough management of intravascular devices and infusion set is crucial in prevention of catheter related BSI, and awareness must be kept high, especially in emergencies circumstances, such as the ongoing COVID-19 pandemic.

Prevalence of Hospital-Onset Bacteremia Pre- and Post-Implementation of a Needleless Blood Sampling Device From Existing Peripheral Catheters

Repeated access of peripheral intravenous (IV) devices theoretically increases the risk of bacterial exposure. PIVO™ (VelanoVascular) is a needleless, single-use device that enables blood sampling from an existing peripheral IV. The goal of this retrospective observational exploratory study was to evaluate the influence of PIVO use on rates of hospital-onset bacteremia and fungemia (HOB) by comparing HOB rates in the year before and after PIVO introduction in hospitals implementing PIVO and over similar time periods in "control" hospitals with no PIVO. Two hospitals implementing PIVO (Hospital 1, a large community hospital; Hospital 2, a tertiary oncology center), and 71 control hospitals were included. During the 1-year period before and after PIVO introduction, HOB rates decreased in hospitals 1 and 2 by 31.9% and 41.8%, respectively. Control hospitals that did not use PIVO had a 12.4% decrease in HOB rates. Multivariable logistic regression analyses found that PIVO was associated with a lower risk (Hospital 1 odds ratio [OR]: 0.63; 95% CI, 0.42-0.94) or no change (Hospital 2 OR: 1.05; 95% CI, 0.72-1.52) in HOB rates. Control hospitals also showed no change in HOB rates between the 2 time periods. These data do not support concerns about increased risk of bacteremia with PIVO.

Distribution and Drug Resistance of Bacterial Infection in Hospitalized Patients at the Respiratory Department before and after the COVID-19 Pandemic in Guangzhou, China

Since COVID-19 might have a lasting impact on global public health, it is crucial to analyze its effect on drug-resistant bacterial infections in the respiratory system for the prevention and control of hospital infections. This work aimed to investigate the impact of the COVID-19 outbreak on the clinical distribution and antibiotic resistance of bacterial infection among hospitalized patients in the respiratory unit in order to establish strategies to control antibiotic-resistant infections. Electronic clinical data registry records from 2018 to 2022 were retrospectively analyzed. A total of 36,829 clinical specimens, including sputum, bronchoalveolar lavage fluid, blood, and urine, were collected from 16,073 patients admitted to the Guangzhou First People's Hospital from January 2018 to December 2022. Among them, 2209 samples were culture-positive. The bacterial isolation rates of different types of samples showed a similar trend from 2019 to 2022, with an increase in 2020 and 2022 and a decrease in 2021. Different bacterial species were separated from different types of samples. The most reported pathogens were identified in sputum samples. Gram-positive isolates were prevalent in urine samples, while Gram-negative bacilli were the predominant pathogenic bacteria isolated from respiratory tract and blood samples. Pseudomonas aeruginosa (P. aeruginosa), Acinetobacter baumannii (A. baumannii) complex, and Klebsiella pneumoniae (K. pneumoniae) were the most abundant Gram-negative bacteria in sputum samples, of which A. baumannii complex had the highest resistance to all tested antibiotics except colistin. Notably, there has been a substantial prevalence of carbapenem-resistant P. aeruginosa, A. baumannii, and K. pneumoniae in the past five years. This alarming situation calls for greater attention and precaution with prescribed antibiotics to limit the generation and spread of new multidrug-resistant bacteria and improve therapeutic management.

Nasal Iodophor Antiseptic vs Nasal Mupirocin Antibiotic in the Setting of Chlorhexidine Bathing to Prevent Infections in Adult ICUs: A Randomized Clinical Trial

Importance

Universal nasal mupirocin plus chlorhexidine gluconate (CHG) bathing in intensive care units (ICUs) prevents methicillin-resistant Staphylococcus aureus (MRSA) infections and all-cause bloodstream infections. Antibiotic resistance to mupirocin has raised questions about whether an antiseptic could be advantageous for ICU decolonization.

Objective

To compare the effectiveness of iodophor vs mupirocin for universal ICU nasal decolonization in combination with CHG bathing.

Design, Setting, and Participants

Two-group noninferiority, pragmatic, cluster-randomized trial conducted in US community hospitals, all of which used mupirocin-CHG for universal decolonization in ICUs at baseline. Adult ICU patients in 137 randomized hospitals during baseline (May 1, 2015-April 30, 2017) and intervention (November 1, 2017-April 30, 2019) were included.

Intervention

Universal decolonization involving switching to iodophor-CHG (intervention) or continuing mupirocin-CHG (baseline).

Main Outcomes and Measures

ICU-attributable S aureus clinical cultures (primary outcome), MRSA clinical cultures, and all-cause bloodstream infections were evaluated using proportional hazard models to assess differences from baseline to intervention periods between the strategies. Results were also compared with a 2009-2011 trial of mupirocin-CHG vs no decolonization in the same hospital network. The prespecified noninferiority margin for the primary outcome was 10%.

Results

Among the 801 668 admissions in 233 ICUs, the participants' mean (SD) age was 63.4 (17.2) years, 46.3% were female, and the mean (SD) ICU length of stay was 4.8 (4.7) days. Hazard ratios (HRs) for S aureus clinical isolates in the intervention vs baseline periods were 1.17 for iodophor-CHG (raw rate: 5.0 vs 4.3/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 4.1 vs 4.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 18.4% [95% CI, 10.7%-26.6%] for mupirocin-CHG, P < .001). For MRSA clinical cultures, HRs were 1.13 for iodophor-CHG (raw rate: 2.3 vs 2.1/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 2.0 vs 2.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 14.1% [95% CI, 3.7%-25.5%] for mupirocin-CHG, P = .007). For all-pathogen bloodstream infections, HRs were 1.00 (2.7 vs 2.7/1000) for iodophor-CHG and 1.01 (2.6 vs 2.6/1000) for mupirocin-CHG (nonsignificant HR difference in differences, -0.9% [95% CI, -9.0% to 8.0%]; P = .84). Compared with the 2009-2011 trial, the 30-day relative reduction in hazards in the mupirocin-CHG group relative to no decolonization (2009-2011 trial) were as follows: S aureus clinical cultures (current trial: 48.1% [95% CI, 35.6%-60.1%]; 2009-2011 trial: 58.8% [95% CI, 47.5%-70.7%]) and bloodstream infection rates (current trial: 70.4% [95% CI, 62.9%-77.8%]; 2009-2011 trial: 60.1% [95% CI, 49.1%-70.7%]).

Conclusions and Relevance

Nasal iodophor antiseptic did not meet criteria to be considered noninferior to nasal mupirocin antibiotic for the outcome of S aureus clinical cultures in adult ICU patients in the context of daily CHG bathing. In addition, the results were consistent with nasal iodophor being inferior to nasal mupirocin.

Trial Registration

ClinicalTrials.gov Identifier: NCT03140423.

Assessing the Impact of 2-Step Clostridioides difficile Testing at the Healthcare Facility Level

BACKGROUND

Two-step testing for Clostridioides difficile infection (CDI) aims to improve diagnostic specificity but may also influence reported epidemiology and patterns of treatment. Some providers fear that 2-step testing may result in adverse outcomes if C. difficile is underdiagnosed.

METHODS

Our primary objective was to assess the impact of 2-step testing on reported incidence of hospital-onset CDI (HO-CDI). As secondary objectives, we assessed the impact of 2-step testing on C. difficile-specific antibiotic use and colectomy rates as proxies for harm from underdiagnosis or delayed treatment. This longitudinal cohort study included 2 657 324 patient-days across 8 regional hospitals from July 2017 through March 2022. Impact of 2-step testing was assessed by time series analysis with generalized estimating equation regression models.

RESULTS

Two-step testing was associated with a level decrease in HO-CDI incidence (incidence rate ratio, 0.53 [95% confidence interval {CI}, .48-.60]; P < .001), a similar level decrease in utilization rates for oral vancomycin and fidaxomicin (utilization rate ratio, 0.63 [95% CI, .58-.70]; P < .001), and no significant level (rate ratio, 1.16 [95% CI, .93-1.43]; P = .18) or trend (rate ratio, 0.85 [95% CI, .52-1.39]; P = .51) change in emergent colectomy rates.

CONCLUSIONS

Two-step testing is associated with decreased reported incidence of HO-CDI, likely by improving diagnostic specificity. The parallel decrease in C. difficile-specific antibiotic use offers indirect reassurance against underdiagnosis of C. difficile infections still requiring treatment by clinician assessment. Similarly, the absence of any significant change in colectomy rates offers indirect reassurance against any rise in fulminant C. difficile requiring surgical management.

The intertwining of healthcare-associated infections and COVID-19 in Italian intensive care units: an analysis of the SPIN-UTI project from 2006 to 2021

BACKGROUND

Although healthcare-associated infections (HAIs) pose an extraordinary burden on public health, the impact of coronavirus disease 2019 (COVID-19) is still a matter of debate.

AIM

To describe trends of HAIs in Italian intensive care units (ICUs) from 2006 to 2021, and to compare characteristics and outcomes of patients with or without COVID-19.

METHODS

We evaluated patients participating in the 'Italian Nosocomial Infections Surveillance in Intensive Care Units' (SPIN-UTI) project, who were admitted to ICUs for more than 48 h. Data regarding diagnosis, clinical conditions, therapies, treatments and outcomes of COVID-19 patients were also collected.

FINDINGS

From a total of 21,523 patients from 2006 to 2021, 3485 (16.2%) presented at least one HAI. We observed an increasing trend for both the incidence of patients with HAI and the incidence density of HAIs (P-trend <0.001). Compared with the pre-pandemic period, the incidence density of HAIs increased by about 15% in 2020-2021, with pneumoniae being the greatest contributors to this increase (P-trend <0.001). Moreover, incidence of HAIs was higher in ICUs dedicated to COVID-19 patients (P<0.001), who showed a greater risk of HAIs and death than patients without COVID-19 (P-values <0.001). Accordingly, the mortality in ICUs increased over the years and doubled during the pandemic (P-trend <0.001). Notably, co-infected patients had higher mortality (75.2%) than those with COVID-19 (66.2%) or HAI (39.9%) alone, and those without any infection (23.2%).

CONCLUSIONS

Our analysis provides useful insight into whether and how the COVID-19 pandemic influenced HAI incidence and death in Italian ICUs, highlighting the need for evaluation of the long-term effects of the pandemic.

Healthcare workers' experiences of patient safety in the intensive care unit during the COVID-19 pandemic: A multicentre qualitative study

AIM

To describe healthcare workers' experiences of preconditions and patient safety risks in intensive care units during the COVID-19 pandemic.

BACKGROUND

Healthcare workers' ability to adapt to changing conditions is crucial to promote patient safety. During the COVID-19 pandemic, healthcare workers' capacity to maintain safe care was challenged and a more in-depth understanding on frontline experiences of patient safety is needed.

DESIGN

A qualitative descriptive design.

METHODS

Individual interviews were conducted with 29 healthcare workers (nurses, physicians, nurse assistants and physiotherapists) from three Swedish hospitals directly involved in intensive care of COVID-19 patients. Data were analysed with inductive content analysis. Reporting followed the COREQ checklist.

RESULTS

Three categories were identified. Hazardous changes in working conditions describes patient safety challenges associated with the extreme workload with high stress level. Imperative adaptations induced by changed preconditions for patient safety which include descriptions of safety risks following adaptations related to temporary intensive care facilities, handling shortage of medical equipment and deviations from routines. Safety risks triggered by reorganisation of care describe how the diluted skill-mix and team disruptions exposed patients to safety risks, and that safety performance mostly relied on individual healthcare worker's responsibility.

CONCLUSIONS

The study suggests that healthcare workers experienced an increase in patient safety risks during the COVID-19 pandemic mainly because the extremely high workload, imperative adaptations, and reorganisation of care regarding skill-mix and teamwork. Patient safety performance relied on the individuals' adaptability and responsibility rather than on system-based safety.

RELEVANCE TO CLINICAL PRACTICE

This study provides insights on how healthcare workers' experiences can be used as a source of information for recognition of patient safety risks. To improve detection of safety risks during future crises, guidelines on how to approach safety from a system perspective must include healthcare workers' perceptions on safety risks.

PATIENT AND PUBLIC CONTRIBUTION

None in the conceptualisation or design of the study.

Impact of COVID-19 pandemic on the rates of central line...associated bloodstream infection and catheter-associated urinary tract infection in an.ßintensive care setting:.ßNational experience

BACKGROUND

COVID-19 is believed to increase the risk of secondary health care...associated infections. The objective was to estimate the impact of COVID-l9 pandemic on the rates of central line...associated bloodstream infection (CLABSI) and catheter-associated urinary tract infections (CAUTIs) in the.ßMinistry of Health hospitals across Saudi Arabia.

METHODS

A retrospective analysis of prospectively collected CLABSI and CAUTI data over a period of 3 years (2019-2021) was done. The data were obtained from the Saudi Health Electronic Surveillance Network. All adult intensive care units in 78 Ministry of Health hospitals that contributed CLABSI or CAUTI data before (2019) and during (2020-2021).ßthe pandemic were included.

RESULTS

During the study, 1440 CLABSI events and 1119 CAUTI events were identified. CLABSI rates significantly increased in 2020-2021 compared with 2019 (2.50 versus 2.16 per 1000 central line days, P.ß=.ß.010). CAUTI rates significantly decreased in 2020-2021 compared with 2019 (0.96 versus 1.54 per 1000 urinary catheter days, P.ß<.ß.001).

CONCLUSIONS

COVID-19 pandemic is.ßassociated with increased CLABSI rates and reduced CAUTI rates. It.ßis believed to have negative impacts on several infection control practices and surveillance accuracy. The opposite impacts of COVID-19 on CLABSI and CAUTI probably reflect.ßthe nature of their case definitions.

Investigating potential drivers of increased central line...associated bloodstream infections during the coronavirus disease 2019 (COVID-19) Omicron surge

Central line...associated bloodstream infection rates increased during the Omicron surge at our rural academic medical center. To identify potential drivers of this increase, we investigated period- and patient-specific factors associated with the increase in central line...associated bloodstream infection. Increased central line utilization, decreased central line bundle compliance monitoring, increased proportion of traveling nurses, increased short-term venous catheter use in the internal jugular vein, increased multilumen catheter use, decreased port...associated infection, and increased patient acuity were significantly associated with the surge. Our results helped us target our local infection prevention efforts.

Typing of Candida spp. from Colonized COVID-19 Patients Reveal Virulent Genetic Backgrounds and Clonal Dispersion

Advances in the knowledge of the pathogenesis of SARS-CoV-2 allowed the survival of COVID-19 patients in intensive care units. However, due to the clinical characteristics of severe patients, they resulted in the appearance of colonization events. Therefore, we speculate that strains of Candida spp. isolated from COVID-19 patients have virulent genetic and phenotypic backgrounds involved in clinical worsening of patients. The aim of this work was to virutype Candida spp. strains isolated from colonized COVID-19 patients, analyze their genomic diversity, and establish clonal dispersion in care areas. The virulent potential of Candida spp. strains isolated from colonized COVID-19 patients was determined through adhesion tests and the search for genes involved with adherence and invasion. Clonal association was done by analysis of intergenic spacer regions. Six species of Candida were involved as colonizing pathogens in COVID-19 patients. The genotype analysis revealed the presence of adherent and invasive backgrounds. The distribution of clones was identified in the COVID-19 care areas, where C. albicans was the predominant species. Evidence shows that Candida spp. have the necessary genetic tools to be able colonize the lungs, and could be a possible causal agent of coinfections in COVID-19 patients. The detection of dispersion of opportunistic pathogens can be unnoticed by classical epidemiology. Epidemiological surveillance against opportunistic fungal pathogens in COVID-19 patients is an immediate need, since the findings presented demonstrate the potential virulence of Candida spp.

Surveillance of Multidrug-Resistant Pathogens in Neonatal Intensive Care Units of Palermo, Italy, during SARS-CoV-2 Pandemic

BACKGROUND

Antimicrobial resistance (AMR) is a topic of concern, especially in high-level care departments like neonatal intensive care units (NICUs). The systematic use of an "active" epidemiological surveillance system allows us to observe and analyze any changes in microbial distribution, limiting the risk of healthcare-associated infection (HAI) development.

METHODS

We have conducted a longitudinal observational study in the five NICUs of Palermo, comparing the "pre-pandemic period" (March 2014-February 2020) with the "pandemic" one (March 2020-February 2022). The primary aim of the study was to evaluate the cumulative prevalence of carriage from multi-drug resistant (MDR) bacteria in the cumulative NICUs (NICU C).

RESULTS

During the "pre-pandemic period", 9407 swabs were collected (4707 rectal, 4700 nasal); on the contrary, during the "pandemic period", a total of 2687 swabs were collected (1345 rectal, 1342 nasal). A statistically significant decrease in MDR-Gram-negative bacteria (GNB) carriage prevalence was detected during the pandemic. At the same time, there was a general worsening of the carriage of carbapenemase-forming MDR-GNB (CARBA-R+) and methicillin-resistant Staphylococcus aureus (MRSA) during the pandemic period. A significant reduction in methicillin-susceptible Staphylococcus aureus (MSSA) carriage was detected too.

CONCLUSIONS

The surveillance of MDRO carriage in NICUs is fundamental for limiting the social and economic burden of HAIs.

Environmental approaches to controlling Clostridioides difficile infection in healthcare settings

As today's most prevalent and costly healthcare-associated infection, hospital-onset Clostridioides difficile infection (HO-CDI) represents a major threat to patient safety world-wide. This review will discuss how new insights into the epidemiology of CDI have quantified the prevalence of C. difficile (CD) spore contamination of the patient-zone as well as the role of asymptomatically colonized patients who unavoidable contaminate their near and distant environments with resilient spores. Clarification of the epidemiology of CD in parallel with the development of a new generation of sporicidal agents which can be used on a daily basis without damaging surfaces, equipment, or the environment, led to the research discussed in this review. These advances underscore the potential for significantly mitigating HO-CDI when combined with ongoing programs for optimizing the thoroughness of cleaning as well as disinfection. The consequence of this paradigm-shift in environmental hygiene practice, particularly when combined with advances in hand hygiene practice, has the potential for significantly improving patient safety in hospitals globally by mitigating the acquisition of CD spores and, quite plausibly, other environmentally transmitted healthcare-associated pathogens.

Hospital-acquired bacterial infections in coronavirus disease 2019 (COVID-19) patients in Israel

BACKGROUND

We sought to determine incidence of common hospital-acquired bacteria among coronavirus disease 2019 (COVID-19) patients in Israeli general hospitals during the first year of the pandemic.

METHODS

We analyzed routinely collected incidence data to determine hospital acquisition of the following sentinel bacteria: Klebsiella pneumoniae, Escherichia coli, Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium, Pseudomonas aeruginosa, Acinetobacter baumannii, and Clostridioides difficile. We examined 3 acquisition measures: (1) sentinel bacteria, (2) sentinel bacteremia, and (3) antimicrobial-resistant sentinel bacteremia. The study period was March 1, 2020, through January 31, 2021.

RESULTS

Analysis of pooled data from the 26 hospitals surveyed revealed that rates were higher for all 3 acquisition measures among COVID-19 patients than they were among patients on general medical wards in 2019, but lower than those among patients in intensive care units in 2019. The incidence rate was highest during the first COVID-19 wave, despite a lower proportion of severe COVID-19 cases among total hospitalized during this wave. Wide variation in incidence was evident between hospitals.

CONCLUSIONS

Hospitalized COVID-19 patients experienced nosocomial bacterial infection at rates higher than those of patients on pre-pandemic general medical wards, adding to the complexity of their care. Lower rates of nosocomial infection after the first wave, despite higher proportions of severely ill patients, suggest that healthcare worker practices, rather than patient-related factors, were responsible for most of these infections.

Random variation drives a critical bias in the comparison of healthcare-associated infections

OBJECTIVE

To evaluate random effects of volume (patient days or device days) on healthcare-associated infections (HAIs) and the standardized infection ratio (SIR) used to compare hospitals.

DESIGN

A longitudinal comparison between publicly reported quarterly data (2014-2020) and volume-based random sampling using 4 HAI types: central-line-associated bloodstream infections, catheter-associated urinary tract infections, Clostridioides difficile infections, methicillin-resistant Staphylococcus aureus infections.

METHODS

Using 4,268 hospitals with reported SIRs, we examined relationships of SIRs to volume and compared distributions of SIRs and numbers of reported HAIs to the outcomes of simulated random sampling. We included random expectations into SIR calculations to produce a standardized infection score (SIS).

RESULTS

Among hospitals with volumes less than the median, 20%-33% had SIRs of 0, compared to 0.3%-5% for hospitals with volumes higher than the median. Distributions of SIRs were 86%-92% similar to those based on random sampling. Random expectations explained 54%-84% of variation in numbers of HAIs. The use of SIRs led hundreds of hospitals with more infections than either expected at random or predicted by risk-adjusted models to rank better than other hospitals. The SIS mitigated this effect and allowed hospitals of disparate volumes to achieve better scores while decreasing the number of hospitals tied for the best score.

CONCLUSIONS

SIRs and numbers of HAIs are strongly influenced by random effects of volume. Mitigating these effects drastically alters rankings for HAI types and may further alter penalty assignments in programs that aim to reduce HAIs and improve quality of care.