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2020-10-08

Impact of COVID-19 pandemic on healthcare-associated infections

Hospitals around the world are fighting the COVID-19 pandemic. Their efforts are led by hospital epidemiologists, experts trained in infection prevention and control. The hospital epidemiologists are responsible for making tough decisions including complete visitor restrictions, universal masking despite lack of sufficient personal protective equipment and quarantining of employees despite lack of a sufficient work force [1].

In April, Michael P. Stevens from Virginia Commonwealth University initiated an informal Twitter poll asking the expert community what percentage of their traditional infection prevention time had been diverted to COVID-19 response efforts [2]. Seventy-nine percent of 220 respondents indicated spending more than 75% of their time on COVID-19.

However, COVID-19 was first identified in December 2019. What were the responsibilities of hospital epidemiologist before the pandemic? They performed surveillance of healthcare-associated infections, ran complex hygiene audits, analyzed device-associated infections, fine-tuned antimicrobial stewardship, and created and maintained appropriate infection control policies. It was a full-time job, but these tasks have been neglected or abandoned due to the recent pandemic.

HAIs didn’t go away. In fact, rates of HAIs have risen during the COVID-19 pandemic.

Many hospitals postponed surveillance of healthcare-associated infections, but the infections did not go away. Quite the opposite, actually. Sturdy et al. [3] reported a staggering increase in gram-negative bloodstream infections at St George’s Hospital in London: 17.95 bloodstream infections per 1000 bed-days on the COVID-19 ICUs over a 16-day period in April 2020. This was contrasted with 1.04 bloodstream infections per 1000 bed-days over the same 16-day period the preceding year. The same phenomenon occurred, according to McMullen et al. [4], in two American hospitals. A hospital in New York City, New York saw a 420% increase to a rate of 5.38 cases of central-line-associated bloodstream infections per 1000 central line days, while a St. Louis, Missouri hospital saw a 327% increase to a rate of 3.79 cases per 1000 central line days (comparing several months of COVID-19 to the prior 15 months).

What could be the cause? McMullen et al. [4] state that COVID-19 patients have longer average ICU stays with multiple invasive devices. The disease also leads to an increased incidence of acute kidney injury, requiring high numbers of patients to have central access for dialysis. There is also a decreased provider focus on removing central lines, and a reluctance to try to manage patients with lower-risk venous access, such as midlines or peripheral catheters.

Sturdy et al. [3] argue that the understandable focus on protecting healthcare providers from COVID-19 has often obscured the importance of the other role of personal protective equipment as part of a basic infection control package to prevent healthcare-associated infections. For example, St George’s Hospital stopped the practice of double gloving, because the gelling of gloves between patients did not provided adequate hand hygiene. Instead, they reemphasized the aseptic non-touch technique during central line care.

As the pandemic does not seem to be subsiding, hospital epidemiologists will need to redesign existing infection prevention processes. Delayed primary and preventive care visits will result in sicker non-COVID-19 patients whose admissions cannot be postponed any further. These patients will be at even greater risk of acquiring healthcare-associated infections. Therefore, it is not feasible for hospital epidemiologists to focus solely on COVID-19 and neglect the surveillance of healthcare-associated infections any longer.

References:
[1] Teena Chopra, Phillip Levy, Glenn Tillotson & Jack Sobel (2020) COVID-19 corollary: the changing role of a hospital epidemiologist in the new world, Expert Review of Anti-infective Therapy, DOI: 10.1080/14787210.2020.1807941
[2] Stevens, M. P., Doll, M., Pryor, R., Godbout, E., Cooper, K., & Bearman, G. (2020). Impact of COVID-19 on traditional healthcare-associated infection prevention efforts. Infection control and hospital epidemiology, 41(8), 946–947. https://doi.org/10.1017/ice.2020.141
[3] Sturdy, A., Basarab, M., Cotter, M., Hager, K., Shakespeare, D., Shah, N., Randall, P., Spray, D., & Arnold, A. (2020). Severe COVID-19 and healthcare-associated infections on the ICU: time to remember the basics?. The Journal of hospital infection, 105(4), 593–595. https://doi.org/10.1016/j.jhin.2020.06.027
[4] McMullen, K. M., Smith, B. A., & Rebmann, T. (2020). Impact of SARS-CoV-2 on hospital acquired infection rates in the United States: Predictions and early results. American journal of infection control, S0196-6553(20)30634-9. Advance online publication. https://doi.org/10.1016/j.ajic.2020.06.209
[5] Jan Dyer (2020). HAIs Didn’t Go Away When COVID-19 Came Along. Infection Control Today.

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