Healthcare-associated infections (HAIs) are infections that occur in the process of patients receiving care. (If the infection occurs at a hospital, it is also called a nosocomial infection) (Bardi et al, 2021). The National Healthcare Safety Network (NHSN) tracks rates of six HAIs: central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated events, antibiotic resistant staph infections, surgical site infections and Clostridioides Difficile (C. diff) infection (SHEA, 2021). Understanding the effects of the COVID-19 pandemic on metrics of typical healthcare-associated infections and analyzing the rates of healthcare-acquired SARS-CoV-2 infection are important areas of research and reflection.
Of the six measures tracked by the NHSN for 2020, only surgical site infections and C. diff infections did not increase. It has been suggested that surgical site infection rates were unaffected because operating room infection control processes were uninterrupted and largely separate from COVID wards. Additionally, fewer elective surgeries took place (SHEA, 2021). C. diff infection rates actually decreased; it has been suggested that the increased focus on handwashing, patient isolation, environmental cleaning and personal protective equipment (PPE) during the pandemic contributed to this (SHEA, 2021).
In contrast, rates of central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated events and antibiotic resistant staph infections all increased during 2020. The largest increase was seen in the rate of bloodstream infections related to central lines, catheters which are placed in large blood vessels for the long term provision of fluids or medications (SHEA, 2021). Ventilator associated infections were also notable, as the infection rate increased more sharply than what could be expected with the increased frequency and duration of ventilator use required by the pandemic (SHEA, 2021).
In addition to the NHSN measurements, it has also become important to assess the healthcare-associated spread of SARS-CoV-2. According to one UK study from early in the pandemic (around March 2020), 7.1% of COVID-19 cases seen within the hospital were nosocomial infections (Khonyongwa et al, 2020). Patients with hospital-acquired COVID-19 tended to be older and have more pre-existing conditions than those who were infected in the community, likely related to the typical inpatient demographic. Despite these demographic differences, both groups had a similar 30 day mortality rate (Khonyongwa et al, 2020).
In a US-based study from March to August 2020, 3.7% of patients hospitalized with COVID-19 in a community hospital developed an identifiable HAI (Kumar et al, 2021). “Identifiable” is related to whether or not providers were able to obtain a positive culture from the patient; however, some HAIs can be culture-negative, so this may have been an undercount. The study notes that the center where it was performed was successfully able to increase capacity for treating COVID-19 patients and that the results may not be representative of hospitals which were more overwhelmed (Kumar et al, 2021).
This study also found that certain COVID-19 treatments were associated with an increased risk of a patient developing an HAI. For example, patients given antibiotics vancomycin and cefepime at admission for pneumonia had increased rates of HAI’s, especially fungal infections (Kumar et al, 2021). The study also examined some of the first attempted treatments for COVID-19, immunomodulatory medications like tocilizumab and hydroxychloroquine. (One theory of the mechanism underlying severe COVID-19 is a dysregulated immune response, called a cytokine storm; these medications were used in response to that) (Kumar et al, 2021). Tocilizumab is known to increase risk of bacterial infection in other contexts, and some studies have found that the percentage of COVID-19 patients treated with tocilizumab who developed an HAI is 27-32% (Kumar et al, 2021).
Overall, the sicker a patient was upon entering the hospital, the more likely they were to acquire a second infection, which then significantly increased mortality (Kumar et al, 2021). This can be seen especially with patients in the ICU. A different study from around the same time period found that 40.7% of COVID-19 patients in the ICU developed an HAI (Bardi et al, 2021). This was significantly associated with longer stays in the ICU and with death (Bardi et al, 2021).
Certain stresses that the pandemic caused on the healthcare system may have contributed to the increased risk of HAIs, including shortages of personal protective equipment and staffing shortages (SHEA, 2021). A robust supply chain and pool of healthcare workers can help to mitigate these problems in the event of a future pandemic.
References
Khonyongwa K, Taori SK, Soares A, et al. Incidence and outcomes of healthcare-associated COVID-19 infections: significance of delayed diagnosis and correlation with staff absence. J Hosp Infect. Dec 2020;106(4):663-672. doi:10.1016/j.jhin.2020.10.006
Kumar G, Adams A, Hererra M, et al. Predictors and outcomes of healthcare-associated infections in COVID-19 patients. Int J Infect Dis. Mar 2021;104:287-292. doi:10.1016/j.ijid.2020.11.135
Society for Healthcare Epidemiology of America (SHEA). “COVID-19 cited in significant increase in healthcare-associated infections in 2020: CDC analysis of National Healthcare Safety Network data compares infection rates before and during pandemic.” ScienceDaily. Sept 2021. <www.sciencedaily.com/releases/2021/09/210902124943.htm>
Bardi T, Pintado V, Gomez-Rojo M, et al. Nosocomial infections associated to COVID-19 in the intensive care unit: clinical characteristics and outcome. Eur J Clin Microbiol Infect Dis. Mar 2021;40(3):495-502. doi:10.1007/s10096-020-04142-w
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