By Betty Tran, MD, MSc
Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago
SYNOPSIS: The COVID-19 pandemic was associated with increases in hospital-onset bloodstream infections, mainly in patients with COVID-19.
SOURCE: Sturm LK, Saake K, Roberts PB, et al. Impact of COVID-19 pandemic on hospital onset bloodstream infections (HOBSI) at a large health system. Am J Infect Control 2022;50:245-249.
In a single health system consisting of 69 hospitals, Sturm et al used an infection prevention surveillance system to identify all blood cultures positive for five organisms commonly seen in healthcare-associated infections: Staphylococcus aureus, Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa, and Candida sp. They compared their findings between two periods: 14 months before COVID-19 (Jan. 1, 2019, to Feb. 28, 2020) and 14 months during the pandemic (March 1, 2020, to April 30, 2021).
A community-onset bloodstream infection (COBSI) was defined within the first three days of admission; a hospital-onset bloodstream infection (HOBSI) occurred more than three days after admission. They reported overall rates of COBSI and HOBSI per 10,000 patient-days before the pandemic vs. during the pandemic, stratified by COVID-19 infection vs. others, as well as by infecting organism.
The mean length of stay for non-COVID-19-infected patients was similar between the pre-pandemic (4.65 days) and pandemic (4.68 days) periods and was overall lower when compared to COVID-19-infected patients (7.54 days; P < 0.0001). Patients with HOBSIs stayed longer overall (pre-pandemic, 29.55 days; pandemic non-COVID-19, 26.44 days; pandemic COVID-19, 24.65 days; P < 0.0001).
The rate of COBSI did not change in the pre-pandemic compared to pandemic periods for all organisms (21.12 vs. 20.98 per 10,000 patient-days; P = 0.68). Patients without COVID-19 were twice as likely to be admitted with a COBSI vs. patients with COVID-19 during the pandemic (22.35 vs. 10.85; P < 0.0001). Overall, the rate of HOBSI for all patients was higher during the pandemic period compared to pre-pandemic (3.56 vs. 2.78 per 10,000 patient days; P < 0.0001). This finding was mainly attributable to patients with COVID-19. There was no significant difference in HOBSI rates pre-pandemic compared to during the pandemic for patients not infected with SARS-CoV-2 (2.78 vs. 2.74 per 10,000 patient days; P = 0.75). In contrast, the HOBSI rate in COVID-19 patients was 3.5 times higher compared to those without COVID-19 (P < 0.0001); higher rates were seen across all five organisms analyzed. During the pandemic, patients with COVID-19 constituted fewer than 12% of total patient days, but more than 30% of the HOBSI events in that time.
COMMENTARY
This report aligns with prior descriptions of high rates of hospital-acquired infections among patients with COVID-19. In an Italian eight-hospital system, Grasselli et al reported bloodstream infections accounting for 25% of all hospital-acquired infections in the critically ill COVID-19 population, with findings of 11.7 bloodstream infections per 1,000 ICU patient-days and 4.7 catheter-related bloodstream infections per 1,000 ICU patient-days.1 The variables associated with infection included age, positive end-expiratory pressure, and treatment with broad-spectrum antibiotics on admission.1
When considering several clinical and systems-based factors associated with the COVID-19 pandemic, results from this study are not surprising. HOBSI risk is higher among patients with longer hospital stays.2 In the study by Sturm et al, the mean length of stay for non-COVID-19 patients was 4.6 days both before the pandemic and during the pandemic period, vs. 7.5 days for COVID-19 patients (P < 0.0001). To the extent COVID-19 patients were more likely to require ICU-level care for acute hypoxic respiratory failure, the increase in HOBSIs likely was associated not only with extended ICU stays, but also with the need for invasive devices (e.g., central line placement, endotracheal intubation). Using steroids in addition to other immunomodulators, particularly interleukin-6 inhibitors (e.g., tocilizumab, sarilumab), to treat severe COVID-19 further increases the risk of invasive infections. Although not reported in this study, high rates of multidrug-resistant (MDR) organisms1 in this population likely are a reflection of all these factors. Another avenue of exploration would be biologic factors unique to SARS-CoV-2 that may increase the risk of MDR bacterial or other atypical (e.g., Aspergillus) superinfections.
Factors related to hospital culture and system-level practice also likely played a role. Early in the pandemic, when little was known regarding the degree of SARS-CoV-2 infectivity, it was common to see behaviors, such as placement of IV pumps in hallways, extending dwell times for IVs and central lines, and changes in line and dressing care, to reduce healthcare worker exposure risk and potentially in response to practices such as proning for extended periods. Routine infection prevention practices also likely were affected by staffing changes related to personnel working in wards outside their usual environment, increased patient acuity, and higher patient volume during pandemic surges. Considering the high burden of healthcare-associated infections pre-pandemic to both patient safety (i.e., morbidity, mortality, length of stay) and healthcare costs (with central line-associated bloodstream infections the costliest on a per-case basis of $45,814 [95% confidence interval, $30,919 to $65,245]), we probably have yet to grasp the full extent of the pandemic’s effect on this issue. As our management of COVID-19 evolves, a return to implementing protocols for infection prevention and surveillance is warranted.3
REFERENCES
- Grasselli G, Scaravilli V, Mangioni D, et al. Hospital-acquired infections in critically ill patients with COVID-19. Chest 2021;160:454-465.
- Jeon CY, Neidell M, Jia H, et al. On the role of length of stay in healthcare-associated bloodstream infection. Infect Control Hosp Epidemiol 2012;33:1213-1218.
- Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: A meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med 2013;173:2039-2046.
The COVID-19 pandemic was associated with increases in hospital-onset bloodstream infections, mainly in patients with COVID-19.
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