Infection preventionists and colleagues struggled against a global pandemic for more than two years in apparent futility, watching healthcare-associated infections (HAIs) increase despite their best efforts. Their perseverance paid off. HAIs fell in 2022 and signs look favorable thus far for 2023, the Centers for Disease Control and Prevention (CDC) reports.1
When the first cases of COVID-19 began appearing in United States in January and February 2020, the coronavirus seemed — dare we say it, in retrospect — almost manageable. As of Feb. 23, 2020, there were a total of 14 cases of SARS-CoV-2 diagnosed in six U.S. states. People continued to travel and attend social and entertainment events.
There were some warnings of what was coming — none more dire nor accurate than that of CDC official Nancy Messonnier, MD, who said at a press conference on Feb. 26, 2020, that “we need to be preparing for significant disruption of our lives.” Then director of CDC’s National Center for Immunization and Respiratory Diseases, Messonnier became a political casualty of a presidential administration that was playing down the pandemic in an election year.2 Messonnier left the CDC in May 2021 to become dean of the Gillings School of Global Public Health at the University of North Carolina.
For the record, she was right. By April 21, 2020, 793,669 confirmed COVID-19 cases had been reported in the United States, the majority resulting from widespread community transmission. The siege of U.S. hospitals by COVID-19 patients was underway.
Infection preventionists found their priorities redirected and their departments overwhelmed. “At the height of the pandemic, we couldn’t really do our normal jobs because we were concentrating so much on the guidance for COVID,” said Pat Jackson, RN, MA, CIC, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology. “Now we are able to do more of what we need to do to help us prevent infections.”
Infection preventionists, healthcare epidemiologists, and antibiotic stewards should be credited with standing fast as vaccines, hybrid immunity, and new medications gradually began to blunt the effect of the worst pandemic in a century. What looked like an unfolding disaster in real time became the finest hour for those who held the line.
“I would give them all the credit — all of it,” says Arjun Srinivasan, MD, an infectious disease physician and deputy director in the CDC Division of Healthcare Quality Promotion. “There was unbelievable work done by healthcare epidemiologists, infection preventionists, antibiotic stewardship programs. They all did tremendous work to manage this pandemic across the board.”
A Shock to the System
The 2020 HAI report was about as subtle as a gut punch. The rate of central line-associated bloodstream infections (CLABSIs) was 47% higher than 2019 in the third and fourth quarters of 2020.3 The CDC also found that catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), and methicillin-resistant Staphylococcus aureus (MRSA) infections rose sharply in 2020. MRSA infections increased 34% from 2019. With surging use of ventilators for COVID-19 patients, VAEs increased 45% in 2020 compared to 2019. Although the increases generally were smaller in 2021, the rates for many important HAIs still increased. For example, CLABSIs increased 7% between 2020 and 2021, there was a 5% increase in CAUTIs, and VAEs spiked another 12%.4
Then, in 2022, the rates fell off, in some cases precipitously — CLABSIs in intensive care units (ICUs) dropped 21%.
Highlights of the HAI declines between 2021 and 2022 include:
• A 9% overall decrease in CLABSIs, with the largest drop being a 21% decline in ICUs;
• A 12% overall decline in CAUTIs, with the largest decrease in ICUs at 27%;
• A 19% decrease in VAEs between 2021 and 2022, with 37% observed in non-ICUs;
• Hospital-onset MRSA bacteremia reduced by 16%;
• Hospital-onset Clostridioides difficile infections (CDIs) fell 3%.
“It’s very encouraging,” Jackson says. “I think it probably indicates that the COVID patients really affected our infection rates.”
Jackson cites a study of 182 hospitals that suggests the COVID-19 patients primarily were responsible for the increase in HAIs, and, thus, as treatment improved, hospitalizations dropped, and more people with vaccine or natural immunity had less severe cases and attendant HAIs.
In a nutshell, the researchers concluded, “In a cross-sectional analysis of more than 5 million hospitalizations between 2020 and 2022, the occurrence of CLABSIs, CAUTIs, and MRSA was between 2.7- and 3.7-fold higher in the COVID-19 population. Occurrence of these HAIs among patients hospitalized without COVID-19 did not increase significantly from baseline during this same time frame. Despite the strain on the healthcare system, the increase in HAIs was not observed in the non-COVID-19 population.”5
Jackson underscores this key point: “The [HAI] rates in patients without COVID were steady. My feeling is there are a lot less COVID patients in the hospital now and we know how to treat them better. If they are hospitalized, they have a lesser length of stay, and then hospitals aren’t overwhelmed with COVID patients.”
The study was done by the Hospital Corporation of America (HCA), which is based in Nashville.
“The study was done by very good people, and they may have a valid observation in that now we are substantially past COVID, we have fewer of those really high-risk patients,” says William Schaffner, MD, a professor at Vanderbilt University, who was not involved in the study. “But I can’t but believe that many of those [COVID] patients have been replaced by traditionally high-risk patients. Our population is aging, we are living longer with more complex underlying illnesses, and that results in hospitalization of older patients with chronic underlying conditions. I would think that the patient population in hospitals continues to be at high risk.”
The CDC did not cite the HCA study in the most recent report, but Srinivasan said the research provided a critical piece of information the agency did not have. Srinivasan added that the COVID data existed, but he and his colleagues did not know which patients had both HAIs and COVID. “It was not unexpected that the majority of those excess HAIs were in patients who had COVID,” he says. “That’s good, because that means that as COVID cases decline, hospitalizations for those infections will go down. The corollary also holds true if we see more surges in COVID, if there are new variants, if vaccination rates drop. If we lower our guard with infection control, we could see hospitalizations go up, and we would again be vulnerable to rates of HAIs going up.”
To Srinivasan’s point, as of Dec. 2, 2023, there was an average of 22,513 hospitalizations in the week preceding — a 17.6% increase. The morality rate was seven per 100,000 cases. COVID is not forgotten — it’s not even gone.6
Chaos Theory
Other factors that could explain the HAI increase, particularly in the first year of the pandemic, was that there was confusion about a mutating virus and its modes of transmission, a national shortage of personal protective equipment, and perceived disinformation about the COVID vaccines.
“True, when you’re dealing with a pandemic of a novel pathogen, there were lots of issues that created a number of challenges,” Srinivasan said. “The good news is that a lot of the initial challenges — the uncertainty and chaos that occurred in the beginning — we have learned so much about. We have kind of figured out how to take care of COVID patients within a normal workflow. The safety systems have come back on line, which is what we really needed.”
Still, there is much that is not known about COVID-19, including why settings like inpatient rehabilitation facilities and long-term acute care hospitals did not see the levels of HAI reductions that acute care hospitals did.
“That’s a good question, and I don’t know that we fully know enough to really explain what has happened in some of those other types of settings,” Srinivasan says.
The overall CDC goal now is to reduce COVID-related HAIs down to the pre-pandemic levels of 2019.
“With this report, we see the data of 2022 and the primary data for the early months of 2023 does continue to show that these solid, steady declines in HAIs are carrying us back much closer to pre-pandemic levels,” Srinivasan says. “I’m optimistic that, when we see the data for the full year of 2023, that will be across the board back to pre-pandemic levels or even maybe a little bit below.”
Hold the champagne — there is a caveat that involves lost time and accumulated progress. “Getting back to pre-pandemic levels is a win but it is also a loss because we lost basically three years when we would have been making more progress,” he says, reminding that years of incremental gains against HAIs vanished in the path of the pandemic.
The CDC HAI national reduction plan established a 2015 baseline of infections that was to be updated with a new 2020 baseline. That did not happen for obvious reasons, so the CDC is holding to the 2015 baseline for ongoing comparisons, such as how many states fared better or worse in HAI metrics. (See Table 1.)
Table 1. Data from the 2022 National and State Healthcare-Associated Infections Progress Report |
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The number of states and territories performing better than the 2015 national baseline, by infection and facility type: |
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Acute Care Hospitals |
Inpatient Rehabilitation Facilities (IRFs) |
Long-Term Acute Care Hospitals (LTACHs) |
|
|
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The number of states and territories that performed worse than the 2015 national baseline, by infection type: |
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Acute Care Hospitals |
Inpatient Rehabilitation Facilities (IRFs) |
Long-Term Acute Care Hospitals (LTACHs) |
|
|
|
CLABSI: central line-associated bloodstream infection; CAUTI: catheter-associated urinary tract infections; VAE: ventilator-associated event; SSI: surgical site infection; MRSA: methicillin-resistant Staphylococcus aureus; C. difficile: Clostridioides difficile Source: Centers for Disease Control and Prevention. 2022 national and state healthcare-associated infections progress report. Last reviewed Dec. 1, 2023. https://www.cdc.gov/hai/data/portal/progress-report.html#Tables |
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With COVID-19 known to be devastating to the lungs, it is not that surprising that 29 states had higher rates of VAEs compared to the 2015 deadlines. However, C. diff had lower infection rates in all 50 states and two territories compared to the 2015 baseline. This was followed by CAUTIs, with 41 states reporting rates below baseline.
“The year 2022 showed U.S. progress in preventing several important HAIs in acute care hospitals,” the CDC report concluded. “This progress is the first of its kind since the emergence of the COVID-19 global pandemic in 2020. The 2022 HAI Progress Report showed little progress in reducing HAIs in other healthcare settings.”
REFERENCES
- Centers for Disease Control and Prevention. 2022 National and State Healthcare-Associated Infections Progress Report. Last reviewed Dec. 1, 2023. https://www.cdc.gov/hai/data/portal/progress-report.html
- Stanley-Becker I, Sun LH. Senior CDC official who met Trump’s wrath for raising alarm about coronavirus to resign. The Washington Post. Published May 7, 2021. https://www.washingtonpost.com/health/2021/05/07/cdc-official-resigns/
- Centers for Disease Control and Prevention. 2020 national and state healthcare-associated infections progress report. Last reviewed Oct. 26, 2021. https://www.cdc.gov/hai/data/archive/2020-HAI-progress-report.html
- Centers for Disease Control and Prevention. 2021 National and State Healthcare-Associated Infections Progress Report. https://www.cdc.gov/hai/pdfs/progress-report/2021-Progress-Report-Executive-Summary-H.pdf
- Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: A summary of data reported to the National Healthcare Safety Network. Infect Control Hosp Epidemiol 2022;43:12-25.
- Centers for Disease Control and Prevention. United States COVID-19 hospitalizations, deaths, emergency department (ED) visits, and test positivity by geographic area. Dec. 2, 2023. https://covid.cdc.gov/covid-data-tracker/#maps_new-admissions-rate-county
Infection preventionists and colleagues struggled against a global pandemic for more than two years in apparent futility, watching healthcare-associated infections (HAIs) increase despite their best efforts. Their perseverance paid off. HAIs fell in 2022 and signs look favorable thus far for 2023, the Centers for Disease Control and Prevention reports.
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