Bloodstream Infection Risk, Incidence, and Deaths for Hospitalized Patients during Coronavirus Disease Pandemic

Impact of central-line-associated bloodstream infections and catheter-related bloodstream infections: a systematic review and meta-analysis

BACKGROUND

Accurate effect estimates are needed to inform input parameters of health economic models. Central-line-associated bloodstream infections (CLABSIs) and catheter-related bloodstream infections (CRBSIs) are different definitions used for central-line bloodstream infections and may represent dissimilar patients, but previous meta-analyses did not differentiate between CLABSIs/CRBSIs.

AIM

To determine outcome effect estimates in CLABSI and CRBSI patients, compared to uninfected patients.

METHODS

PubMed, Embase, and CINAHL were searched from January 2000 to March 2024 for full-text studies reporting all-cause mortality and/or hospital length of stay (LOS) in adult inpatients with and without CLABSI/CRBSI. Two investigators independently reviewed all potentially relevant studies and performed data extraction. Odds ratio for mortality and mean difference in LOS were pooled using random-effects models. Risk of study bias was assessed using ROBINS-E.

FINDINGS

Thirty-six studies were included. Sixteen CLABSI and 12 CRBSI studies reported mortality. The mortality odds ratios of CLABSIs and CRBSIs, compared to uninfected patients, were 3.19 (95% CI: 2.44, 4.16; I2 = 49%) and 2.47 (95% CI: 1.51, 4.02; I2 = 82%), respectively. Twelve CLABSI and eight CRBSI studies reported hospital LOS; only three CLABSI studies and two CRBSI studies accounted for the time-dependent nature of CLABSIs/CRBSIs. The mean differences in LOS for CLABSIs and CRBSIs compared to uninfected patients were 16.14 days (95% CI: 9.27, 23.01; I2 = 91%) and 16.26 days (95% CI: 10.19, 22.33; I2 = 66%), respectively.

CONCLUSION

CLABSIs and CRBSIs increase mortality risk and hospital LOS. Few published studies accounted for the time-dependent nature of CLABSIs/CRBSIs, which can result in overestimation of excess hospital LOS.

Incidence of catheter-related thrombosis and its association with outcome in critically ill patients: A prospective observational study

BACKGROUND

Incidence of central venous catheter (CVC)-related thrombosis in critically ill patients remains ambiguous and its association with potential hazardous sequelae unknown. The primary aim of the study was to evaluate the epidemiology of CVC-related thrombosis; secondary aims were to assess the association of catheter-related thrombosis with catheter-related infection, pulmonary embolism and mortality.

METHODS

This was a single-center, prospective observational study conducted at a tertiary intensive care unit (ICU) in the Netherlands. The study population consisted of CVC placements in adult ICU patients with a minimal indwelling time of 48 h. CVC-related thrombosis was diagnosed with ultrasonography. Primary outcomes were prevalence and incidence, incidence was reported as the number of cases per 1000 indwelling days.

RESULTS

173 CVCs in 147 patients were included. Median age of patients was 64.0 [IQR: 52.0, 72.0] and 71.1 % were male. Prevalence of thrombosis was 0.56 (95 % CI: 0.49, 0.63) and incidence per 1000 indwelling days was 65.7 (95 % CI: 59.0, 72.3). No association with catheter-related infection was found (p = 0.566). There was a significant association with pulmonary embolism (p = 0.022). All 173 CVCs were included in the survival analysis. Catheter-related thrombosis was associated with a lower 28-day mortality risk (hazard ratio: 0.39, 95 % CI: 0.17, 0.87).

CONCLUSION

In critically ill patients, prevalence and incidence of catheter-related thrombosis were high. Catheter-related thrombosis was not associated with catheter-related infections, but was associated with pulmonary embolism and a decreased mortality risk.

Bloodstream Coinfections and Antimicrobial Resistance in Hospitalized COVID-19 Patients: A Single-center Retrospective Study

BACKGROUND/AIM

Bloodstream infections in patients with COVID-19 are linked to higher mortality rates, whilst data on epidemiology and resistance patterns remains scarce to guide management and prevent antibiotic resistance. This research focuses on the prevalence, clinical features, causative microorganisms, and antimicrobial susceptibility of bacterial and fungal secondary bloodstream co-infections in hospitalized patients with COVID-19.

PATIENTS AND METHODS

In this retrospective study analysis of 230 patients with COVID-19 from Central Taiwan (June 2021 to June 2022), pathogens were identified via MALDI-TOF MS and Vitek 2 system with Clinical & Laboratory Standards Institute (CLSI) standards.

RESULTS

In the cohort, 17.8% experienced bloodstream infections, resulting in a total of 45 isolates from the 41 bloodstream infection patients: predominantly gram-positive bacteria (Staphylococcus and Enterococcus) at 69%, gram-negative at 29% (Escherichia coli and Klebsiella pneumoniae), and fungi at 2%. Infected patients showed significantly elevated levels of white blood count (WBC), C-reactive protein (CRP) and procalcitonin (PCT). Of note, resistance to common antibiotics, such as fluoroquinolones, cephalosporins, and oxacillin was significant, especially in K. pneumoniae, Acinetobacter species, and S. aureus infections.

CONCLUSION

Our study highlights the influence of bacterial infections in hospitalized patients with COVID-19. The bacterial infections were discovered to impact the clinical trajectory of COVID-19, potentially exacerbating or mitigating its symptoms, severity and fatality. These insights are pivotal to addressing clinical challenges in COVID-19 management and underscoring the need for tailored medical interventions. Understanding these co-infections is thus essential for optimizing patient care and improving overall outcomes in the post COVID-19 pandemic era.

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.

Development of a novel integrated isothermal amplification system for detection of bacteria-spiked blood samples

Bloodstream infection (BSI) caused by bacteria is highly pathogenic and lethal, and easily develops whole-body inflammatory state. Immediate identification of disease-causing bacteria can improve patient prognosis. Traditional testing methods are not only time-consuming, but such tests are limited to laboratories. Recombinase polymerase amplification combined with lateral flow dipstick (RPA-LFD) holds great promise for rapid nucleic acid detection, but the uncapping operation after amplification easily contaminates laboratories. Therefore, the establishment of a more effective integrated isothermal amplification system has become an urgent problem to be solved. In this study, we designed and fabricated a hermetically sealed integrated isothermal amplification system. Combining with this system, a set of RPA-LFD assays for detecting S. aureus, K. peneumoniae, P. aeruginosa, and H. influenza in BSI were established and evaluated. The whole process could be completed in less than 15 min and the results can be visualized by the naked eye. The developed RPA-LFD assays displayed a good sensitivity, and no cross-reactivity was observed in seven similar bacterial genera. The results obtained with 60 clinical samples indicated that the developed RPA-LFD assays had high specifcity and sensitivity for identifying S. aureus, K. peneumoniae, P. aeruginosa, and H. influenza in BSI. In conclusion, our results showed that the developed RPA-LFD assay is an alternative to existing PCR-based methods for detection of S. aureus, K. peneumoniae, P. aeruginosa, and H. influenza in BSI in primary hospitals.

Impact of the COVID-19 Pandemic on the Epidemiology of Bloodstream Infections in Hospitalized Patients-Experience from a 4th Military Clinical Hospital in Poland

Bloodstream infections (BSIs) are associated with high mortality and inappropriate or delayed antimicrobial therapy. The purpose of this study was to investigate the impact of the COVID-19 pandemic on the epidemiology of BSIs in hospitalized patients. The research aimed to compare the incidence of BSIs and blood culture results in patients hospitalized before and during the COVID-19 pandemic.

METHODS

Retrospective and prospective data were collected from blood cultures obtained from 4289 patients hospitalized between June 2018 and July 2022. Two groups of patients were distinguished: those with BSIs admitted during the pre-COVID-19 period and those admitted during the COVID-19 surge. Demographic and clinical data, blood cytology, and biochemistry results were analyzed, and the usefulness of PCT was assessed in patients with COVID-19.

RESULTS

The study showed a significant increase in the incidence of BSIs during the pandemic compared to the pre-COVID-19 period. Positive blood cultures were obtained in 20% of patients hospitalized during the pandemic (vs. 16% in the pre-COVID-19 period). The incidence of BSIs increased from 1.13 to 2.05 cases per 1000 patient days during COVID-19, and blood culture contamination was more frequently observed. The mortality rate was higher for patients hospitalized during the COVID-19 pandemic. An increased frequency of MDRO isolation was observed in the COVID-19 period.

CONCLUSIONS

The incidence of BSIs increased and the mortality rate was higher in the COVID-19 period compared to the pre-COVID-19 period. The study showed limited usefulness of procalcitonin in patients with COVID-19, likely due to the administered immunosuppressive therapy.

Central Line Associated Bloodstream Infections in Critical Ill Patients during and before the COVID-19 Pandemic

(1) Background: The purpose of this study was to evaluate the impact of the COVID-19 pandemic on the rates of central line-associated bloodstream infections (CLABSI), its etiology, and risk factors in critically ill patients, because Slovakia was one of the countries experiencing a high burden of COVID-19 infections, and hospitals faced greater challenges in preventing and managing CLABSI; (2) Methods: A retrospective analysis of CLABSI data from all patients admitted to adult respiratory intensive care units before and during COVID-19 pandemic was conducted. We followed the guidelines of the Center for Disease Control surveillance methodology for CLABSI. Data were analyzed using STATISTICA 13.1; (3) Results: We analyzed the data of 803 ICU patients hospitalized for 8385 bed days, with 7803 central line days. Forty-five CLABSI events were identified. The CLABSI rate significantly increased during the COVID-19 pandemic compared to before the COVID-19 pandemic (2.81 versus 7.47 events per 1000 central line days, (p < 0.001). The most frequently identified pathogens causing CLABSI were Gram-negative organisms (60.20%). The risk factors found to increase the probability of developing CLABSI were length of stay (OR = 1.080; 95% Cl: 1.057-1.103; p < 0.001) and COVID-19 (OR = 5.485; 95% Cl: 32.706-11.116; p < 0.001). (4) Conclusions: The COVID-19 pandemic was associated with increases in CLABSI in ICUs. These data underscore the need to increase efforts in providing surveillance of CLABSI and implementing infection prevention measures.

Impact of COVID-19 on healthcare-associated infections: Antimicrobial consumption does not follow antimicrobial resistance

BACKGROUND

This study aimed to analyze the Healthcare-Associated Infections (HAI) rates and antimicrobial consumption in Intensive Care Units (ICU) in São Paulo city during the COVID-19 pandemic and compare them with the pre-pandemic period.

METHODS

This cohort included all hospitals that reported HAI rates (Central-Line-Associated Bloodstream Infection ‒ CLABSI and Ventilator-Associated Pneumonia ‒ VAP), the proportion of microorganisms that caused CLABSI, the proportion of resistant microorganisms, and antimicrobial consumption from January 2017 ‒ December 2020. Hospitals were stratified by the number of beds, Central Venous Catheter (CVC) utilization rate, Mechanical-Ventilation (MV) utilization rate, and type of funding. Statistical analyses were based on time-series plots and regression models.

RESULTS

220 ICUs were included. The authors observed an abrupt increase in CLABSI rates after the pandemic onset. High CLABSI rates during the pandemic were associated with hospital size, funding (public and non-profit private), and low CVC use (≤ 50%). An increase in VAP rates was associated with public hospitals, and high MV use (> 35%). The susceptibility profile of microorganisms did not differ from that of the pre-pandemic period. polymyxin, glycopeptides, and antifungal use increased, especially in COVID-19 ICUs.

CONCLUSIONS

HAI increased during COVID-19. The microorganisms' susceptibility profile did not change with the pandemic, but the authors observed a disproportionate increase in large-spectrum antimicrobial drug use.

Antimicrobial resistance in patients with COVID-19: a systematic review and meta-analysis

BACKGROUND

Frequent use of antibiotics in patients with COVID-19 threatens to exacerbate antimicrobial resistance. We aimed to establish the prevalence and predictors of bacterial infections and antimicrobial resistance in patients with COVID-19.

METHODS

We did a systematic review and meta-analysis of studies of bacterial co-infections (identified within ≤48 h of presentation) and secondary infections (>48 h after presentation) in outpatients or hospitalised patients with COVID-19. We searched the WHO COVID-19 Research Database to identify cohort studies, case series, case-control trials, and randomised controlled trials with populations of at least 50 patients published in any language between Jan 1, 2019, and Dec 1, 2021. Reviews, editorials, letters, pre-prints, and conference proceedings were excluded, as were studies in which bacterial infection was not microbiologically confirmed (or confirmed via nasopharyngeal swab only). We screened titles and abstracts of papers identified by our search, and then assessed the full text of potentially relevant articles. We reported the pooled prevalence of bacterial infections and antimicrobial resistance by doing a random-effects meta-analysis and meta-regression. Our primary outcomes were the prevalence of bacterial co-infection and secondary infection, and the prevalence of antibiotic-resistant pathogens among patients with laboratory-confirmed COVID-19 and bacterial infections. The study protocol was registered with PROSPERO (CRD42021297344).

FINDINGS

We included 148 studies of 362  976 patients, which were done between December, 2019, and May, 2021. The prevalence of bacterial co-infection was 5·3% (95% CI 3·8-7·4), whereas the prevalence of secondary bacterial infection was 18·4% (14·0-23·7). 42 (28%) studies included comprehensive data for the prevalence of antimicrobial resistance among bacterial infections. Among people with bacterial infections, the proportion of infections that were resistant to antimicrobials was 60·8% (95% CI 38·6-79·3), and the proportion of isolates that were resistant was 37·5% (26·9-49·5). Heterogeneity in the reported prevalence of antimicrobial resistance in organisms was substantial (I2=95%).

INTERPRETATION

Although infrequently assessed, antimicrobial resistance is highly prevalent in patients with COVID-19 and bacterial infections. Future research and surveillance assessing the effect of COVID-19 on antimicrobial resistance at the patient and population level are urgently needed.

FUNDING

WHO.

Risk stratification for selecting empiric antibiotherapy during and after COVID-19

PURPOSE OF REVIEW

SARS-CoV-2 deeply modified the risk of bacterial infection, bacterial resistance, and antibiotic strategies. This review summarized what we have learned.

RECENT FINDINGS

During the COVID-19 pandemic, we observed an increase in healthcare-acquired infection and multidrug-resistant organism-related infection, triggered by several factors: structural factors, such as increased workload and ongoing outbreaks, underlying illnesses, invasive procedures, and treatment-induced immunosuppression. The two most frequently healthcare-acquired infections described in patients hospitalized with COVID-19 were bloodstream infection, related or not to catheters, health-acquired pneumonia (in ventilated or nonventilated patients). The most frequent species involved in bacteremia were Gram-positive cocci and Gram-negative bacilli in health-acquired pneumonia. The rate of Gram-negative bacilli is particularly high in late-onset ventilator-associated pneumonia, and the specific risk of Pseudomonas aeruginosa- related pneumonia increased when the duration of ventilation was longer than 7 days. A specificity that remains unexplained so far is the increase in enterococci bacteremia.

SUMMARY

The choice of empiric antibiotimicrobials depends on several factors such as the site of the infection, time of onset and previous length of stay, previous antibiotic therapy, and known multidrug-resistant organism colonization. Pharmacokinetics of antimicrobials could be markedly altered during SARS-CoV-2 acute respiratory failure, which should encourage to perform therapeutic drug monitoring.

Epidemiology and outcomes of culture-positive bloodstream pathogens prior to and during the SARS-CoV-2 pandemic: a multicenter evaluation

Background

Bloodstream infections (BSIs) are an important cause of morbidity and mortality in hospitalized patients. We evaluate incidence of community- and hospital-onset BSI rates and outcomes before and during the SARS-CoV-2 pandemic.

Methods

We conducted a retrospective cohort study evaluating patients who were hospitalized for ≥ 1 day with discharge or death between June 1, 2019, and September 4, 2021, across 271 US health care facilities. Community- and hospital-onset BSI and related outcomes before and during the SARS-CoV-2 pandemic, including intensive care admission rates, and overall and ICU-specific length of stay (LOS) was evaluated. Bivariate correlations were calculated between the pre-pandemic and pandemic periods overall and by SARS-CoV-2 testing status.

Results

Of 5,239,692 patient admissions, there were 20,113 community-onset BSIs before the pandemic (11.2/1000 admissions) and 39,740 (11.5/1000 admissions) during the pandemic (P ≤ 0.0062). Corresponding rates of hospital-onset BSI were 2,771 (1.6/1000 admissions) and 6,864 (2.0/1000 admissions; P < 0.0062). Compared to the pre-pandemic period, rates of community-onset BSI were higher in patients who tested negative for SARS-CoV-2 (15.8/1000 admissions), compared with 9.6/1000 BSI admissions among SARS-CoV-2-positive patients. Compared with patients in the pre-pandemic period, SARS-CoV-2-positive patients with community-onset BSI experienced greater ICU admission rates (36.6% vs 32.8%; P < 0.01), greater ventilator use (10.7% vs 4.7%; P < 0.001), and longer LOS (12.2 d vs 9.1 d; P < 0.001). Rates of hospital-onset BSI were higher in the pandemic vs the pre-pandemic period (2.0 vs 1.5/1000; P < 0.001), with rates as high a 7.3/1000 admissions among SARS-CoV-2-positive patients. Compared to the pre-pandemic period, SARS-CoV-2-positive patients with hospital-onset BSI had higher rates of ICU admission (72.9% vs 55.4%; P < 0.001), LOS (34.8 d vs 25.5 d; P < 0.001), and ventilator use (52.9% vs 21.5%; P < 0.001). Enterococcus species, Staphylococcus aureus, Klebsiella pneumoniae, and Candida albicans were more frequently detected in the pandemic period.

Conclusions and relevance

This nationally representative study found an increased risk of both community-onset and hospital-onset BSI during the SARS-CoV-2 pandemic period, with the largest increased risk in hospital-onset BSI among SARS-CoV-2-positive patients. SARS-CoV-2 positivity was associated with worse outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07810-8.

Epidemiology of Candidemia and Fluconazole Resistance in an ICU before and during the COVID-19 Pandemic Era

The objectives of this study were to investigate the incidence of candidemia, as well as the factors associated with Candida species distribution and fluconazole resistance, among patients admitted to the intensive care unit (ICU) during the COVID-19 pandemic, as compared to two pre-pandemic periods. All patients admitted to the ICU due to COVID-19 from March 2020 to October 2021, as well as during two pre-pandemic periods (2005–2008 and 2012–2015), who developed candidemia, were included. During the COVID-19 study period, the incidence of candidemia was 10.2%, significantly higher compared with 3.2% and 4.2% in the two pre-pandemic periods, respectively. The proportion of non-albicans Candida species increased (from 60.6% to 62.3% and 75.8%, respectively), with a predominance of C. parapsilosis. A marked increase in fluconazole resistance (from 31% to 37.7% and 48.4%, respectively) was also observed. Regarding the total patient population with candidemia (n = 205), fluconazole resistance was independently associated with ICU length of stay (LOS) before candidemia (OR 1.03; CI: 1.01–1.06, p = 0.003), whereas the presence of shock at candidemia onset was associated with C. albicans (OR 6.89; CI: 2.2–25, p = 0.001), and with fluconazole-susceptible species (OR 0.23; CI: 0.07–0.64, p = 0.006). In conclusion, substantial increases in the incidence of candidemia, in non-albicansCandida species, and in fluconazole resistance were found in patients admitted to the ICU due to COVID-19, compared to pre-pandemic periods. At candidemia onset, prolonged ICU LOS was associated with fluconazole-resistant and the presence of shock with fluconazole-susceptible species.

Delayed mortality among solid organ transplant recipients hospitalized for COVID-19

INTRODUCTION

Most studies of solid organ transplant (SOT) recipients with COVID-19 focus on outcomes within one month of illness onset. Delayed mortality in SOT recipients hospitalized for COVID-19 has not been fully examined.

METHODS

We used data from a multicenter registry to calculate mortality by 90 days following initial SARS-CoV-2 detection in SOT recipients hospitalized for COVID-19 and developed multivariable Cox proportional-hazards models to compare risk factors for death by days 28 and 90.

RESULTS

Vital status at day 90 was available for 936 of 1117 (84%) SOT recipients hospitalized for COVID-19: 190 of 936 (20%) died by 28 days and an additional 56 of 246 deaths (23%) occurred between days 29 and 90. Factors associated with mortality by day 90 included: age > 65 years [aHR 1.8 (1.3-2.4), p =<0.001], lung transplant (vs. non-lung transplant) [aHR 1.5 (1.0-2.3), p=0.05], heart failure [aHR 1.9 (1.2-2.9), p=0.006], chronic lung disease [aHR 2.3 (1.5-3.6), p<0.001] and body mass index ≥ 30 kg/m 2 [aHR 1.5 (1.1-2.0), p=0.02]. These associations were similar for mortality by day 28. Compared to diagnosis during early 2020 (March 1-June 19, 2020), diagnosis during late 2020 (June 20-December 31, 2020) was associated with lower mortality by day 28 [aHR 0.7 (0.5-1.0, p=0.04] but not by day 90 [aHR 0.9 (0.7-1.3), p=0.61].

CONCLUSIONS

In SOT recipients hospitalized for COVID-19, >20% of deaths occurred between 28 and 90 days following SARS-CoV-2 diagnosis. Future investigations should consider extending follow-up duration to 90 days for more complete mortality assessment.

The effect of the COVID-19 pandemic on the epidemiology of positive blood cultures in Swiss intensive care units: a nationwide surveillance study

BACKGROUND

Evidence about the impact of the pandemic of COVID-19 on the incidence rates of blood cultures contaminations and bloodstream infections in intensive care units (ICUs) remains scant. The objective of this study was to investigate the nationwide epidemiology of positive blood cultures drawn in ICUs during the first two pandemic waves of COVID-19 in Switzerland.

METHODS

We analyzed data on positive blood cultures among ICU patients, prospectively collected through a nationwide surveillance system (ANRESIS), from March 30, 2020, to May 31, 2021, a 14-month timeframe that included a first wave of COVID-19, which affected the French and Italian-speaking regions, an interim period (summer 2020) and a second wave that affected the entire country. We used the number of ICU patient-days provided by the Swiss Federal Office of Public Health as denominator to calculate incidence rates of blood culture contaminations and bloodstream infections (ICU-BSI). Incidence rate ratios comparing the interim period with the second wave were determined by segmented Poisson regression models.

RESULTS

A total of 1099 blood culture contaminations and 1616 ICU-BSIs were identified in 52 ICUs during the study. Overall, more episodes of blood culture contaminations and ICU-BSI were observed during the pandemic waves, compared to the interim period. The proportions of blood culture contaminations and ICU-BSI were positively associated with the ICU occupancy rate, which was higher during the COVID-19 waves. During the more representative second wave (versus interim period), we observed an increased incidence of blood culture contaminations (IRR 1.57, 95% CI 1.16-2.12) and ICU-BSI (IRR 1.20, 95% CI 1.03-1.39).

CONCLUSIONS

An increase in blood culture contaminations and ICU-BSIs was observed during the second COVID-19 pandemic wave, especially in months when the ICU burden of COVID-19 patients was high.