HAIs Didn’t Go Away When COVID-19 Came Along

By last December, the rates of some hospital-acquired infections (HAIs) were on the way down. For instance, by 2016, central line-associated bloodstream infections (CLABSIs) had declined 10%, catheter-associated urinary tract infections (CAUTIs) 6%, hospital-onset methicillin-resistant Staphylococcus aureus 6%, hospital-onset Clostridium difficile infections, 7%.¹

But for the time being that’s pretty much all we’ll know. Because shortly after the 2019 results were posted, COVID-19 was beginning to suck all the oxygen out of the room as far as tabulating infections went. So much so that, in March, CMS “announced unprecedented relief” for the clinicians and providers participating in Medicare quality reporting programs: They would not have to report data on HAIs from January 1 through June 30, the first two quarters of 2020. Announcing the suspension, CMS administrator Seema Verma said CMS was “supporting clinicians fighting Coronavirus on the front lines” and the administration was “cutting bureaucratic red tape so the healthcare delivery system can direct its time and resources toward caring for patients.”²

Infection prevention resources have necessarily been diverted to outbreak management, but the impacts on traditional HAI surveillance and prevention efforts “remain concerning,” say clinicians from the Hospital Infection Prevention Program at Virginia Commonwealth University Health System in Richmond. ³ They conducted an informal Twitter poll in April 2020, asking the infection prevention and hospital epidemiology community what percentage of their traditional infection prevention time had been diverted to COVID-19 response efforts. Of the 220 respondents, 79% said they were spending more than 75% of their time.

The potential impacts of the diversion, the authors suggest, are numerous. Surveillance efforts, process measure data collection, and mitigation efforts may be compromised. Moreover, shortages in traditional PPE resources have led the CDC to recommend, for instance, that hospitals with gown shortages stop using isolation gowns for endemic pathogens such as MRSA and vancomycin-resistant Enterococci. Antimicrobial stewardship programs may also divert their attention to Covid-19, meaning that an influx of critically ill patients could drive suboptimal antibiotic uses, putting patients at risk for antibiotic resistance and CDI.³

Only 28 states have passed laws to provide the public with hospital infection “report cards,” and it’s only been about six years since CMS began penalizing hospitals that have poor records on hospital-acquired conditions.^4,5 But those are factors in the downward trend for HAIs. The information at Hospital Compare, for example, which is Medicare’s database on quality of care at more than 4,000 Medicare-certified hospitals, “encourages hospitals to improve the quality of care they provide.”⁶ The teeth in the “encouragement” are the reduced Medicare payments for hospitals that rank in the worst-performing quartile with respect to hospital-acquired conditions, including CAUTI, CLABSI, MRSA bacteremia, CDI, and surgical site infections.⁵ (CMS’s temporary suspension of penalties, Stevens suggests, is an acknowledgment of the challenges facing the IP community and should be considered and copied by other quality programs.)³

Watchdog organizations that allow customers to compare hospitals by ratings have made infection control measures more transparent. The Leapfrog Group, a nonprofit organization that collects, analyzes, and disseminates data on quality and safety of the healthcare system, assigns bi-annual letter grades to general acute-care hospitals to bring patient safety “into the sunlight” and “prove transparency can save lives.” Leapfrog says its safety grade is the nation’s only rating focused entirely on patient safety, including infections.⁷ According to the 2019 Hospital Safety Grade, 33% of more than 2,600 hospitals earned an “A.”

HAIs are still a serious problem, of course: 1 in 31 hospital patients has at least one.⁸ And just because hospitals were given a reprieve from reporting for (so far) the first half of 2020 doesn’t mean someone isn’t paying attention. Healthcare providers, infection control experts, and hospital administrators are still noting patterns and doing studies.

Kathleen McMullen, the manager of infection prevention at Christian Hospital and Northwest Healthcare, St. Louis, and lead author on an article about HAIs during the Covid-19 pandemic, writes that the greatest impact is expected to be on CLABSI rates.⁹ COVID-19 patients are at higher risk for many reasons, she notes, including increased use of femoral lines for central access (away from the mouth and respiratory tract). She and her co-authors, Barbara Smith and Teri Rebman, say two of their hospitals have seen dramatic jumps already: One hospital had a 420% increase; a second had a 327% increase. They also saw a jump in CAUTI for similar reasons: a 179% increase at one hospital, a 57% increase at the other.

One beneficial aspect of COVID-19 is the enhanced environmental cleaning, which reduces organisms spread via contact, like C difficile. McMullen et al say C difficile rates dropped 51% and 45% in the two hospitals. They add, however, that some PPE conservation practices may be concerning, such as reuse of isolation gowns and reduced focus on contact isolation precautions in lower-risk patients.

Although a low number of studies have been published so far, the rates of bacterial infection in COVID-19 patients are “considerable and probably underestimated,” says Patrizia Spigaglia, from the Istituto Superiore di Sanità, the leading technical-scientific body of the Italian National Health Service that’s located in Rome. In part, this is due to the complexity of bacterial infection diagnosis during the current health emergency. She also warns about a higher risk of C difficile infections, because of the connection with antibiotics. She cites estimates that 72% of COVID-19 patients have been treated with broad-spectrum antibiotics, and about 75% of residents in long-term-care facilities (LTCFs, and hardest hit by COVID-19) receive at least one course of antibiotics during 6 or more months.¹⁰

The mid-pandemic studies have the immediacy of ongoing research, because the patients who survive usually have only recently had COVID-19, or still have it. And the findings vary—not surprising since the studies are often observational, in individual hospitals, with small patient populations.

For instance, a single-center study in northern Italy found a high incidence of bloodstream infections in the study group of 78 critically ill patients with COVID-19.¹¹ The cumulative risk of developing BSI was almost 25% after 15 days in the ICU, potentially surpassing 50% after 30 days. On the other hand, researchers who analyzed 88,201 blood cultures from 28,011 patients at New York-Presbyterian hospitals found the rate of bacteremia, which can lead to bloodstream infections, low among COVID-19 patients.¹² In fact, bloodstream infections, the researchers said, are “very rare” in COVID-19 patients.

All the usual suspects of HAI are now compounded by this new one—COVID-19 itself. Zhou et al conducted a meta-analysis of 40 studies and found the proportions of nosocomial Covid-19, SARS and MERS were relatively similar: 44%, 36% and 56%, respectively. Of the confirmed patients, the medical staff and other HAIs accounted for 33% and 2% of Covid-19 cases, 37% and 24% of SARS cases, and 19% and 36% of MERS cases.¹³

Despite the heavier workload of dealing with COVID-19, it’s more important than ever to provide data feedback by surveillance on Enterococcus, S aureus, Klebsiella, Acinetobacter, Pseudomonas and Enterobacter spp., according to Dexter et al. Cleaning and other processes, these physicians write, significantly reduce the transmission of pathogenic bacteria and viruses—particularly important for a virus like SARS-CoV-2, which can survive for at least three days on a variety of materials, including stainless steel and plastic.¹⁴

Two categories—patients with hospital-acquired COVID-19 infection and healthcare personnel with occupationally acquired COVID-19—are new metrics that require monitoring, say McMullen and her co-authors. The definitions are not clear yet, they add, due to the mass of unknowns swirling around COVID-19, but determining the definitions should be a priority for the infection prevention field. Infection preventionists should take action now, they urge, to prevent some of these anticipated health outcomes. They should encourage continual focus on proven best practices for CLABSI and CAUTI prevention, and prioritize IP observation of invasive procedures.

As the pandemic seems not to abate, patients will start to present to the hospital after delaying crucial primary and preventive care visits, meaning sicker non– COVID-19 infected patients, with the potential for increased CLABSI and CAUTI rates. Patients selected for the first non-emergent surgeries will also be at higher risk of infection, which may lead to higher rates of SSIs.⁹

In other words, despite this new threat, and despite the reprieve from data reporting, now is not the time to let surveillance of the “old familiar” HAIs slip.

JAN DYER is a writer and editor specializing in clinical topics. She lives in Suffern, New York.

References

1. US Department of Health and Human Services. National HAI targets & metrics. HHS website. https://health.gov/our-work/health-care-quality/health-care-associated-infections/targets-metrics. Accessed 07-20-20.
2. Centers for Medicare and Medicaid Services. CMS announces relief for clinicians, providers, hospitals and facilities participating in quality reporting programs in response to COVID-19. CMS website. https://www.cms.gov/newsroom/press-releases/cms-announces-relief-clinicians-providers-hospitals-and-facilities-participating-quality-reporting. Accessed 07-20-20.
3. Stevens MP, Doll M, Pryor R, et al. Commentary: Impact of COVID-19 on traditional healthcare-associated infection prevention efforts. Infect Control Hosp Epidemiol 2020; 1–2. doi:10.1017/ice.2020.141.
4. Committee to Reduce Infection Deaths. Hospital Infection Reporting. https://hospitalinfection.org/resources/state-infection-laws/state-law-summary/. Accessed 07-20-20.
5. Centers for Medicare and Medicaid Services. Hospital-Acquired Condition Reduction Program (HACRP). CMS website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program. Accessed 07-20-20.
6. 6. Medicare.gov. Hospital Compare CMS website. https://www.medicare.gov/hospitalcompare/About/What-Is-HOS.html. Accessed 07-20-20.
7. Leapfrog Group. 20 years after “To Err Is Human,” Leapfrog Hospital Safety Grades prove transparency can save lives. Leapfrog Group website. https://www.hospitalsafetygrade.org/about-our-movement/newsroom/display/807485. Accessed 07-20-20.
8. Centers for Disease Control and Prevention. HAI Data. CDC website. https://www.cdc.gov/hai/data/index.html. Accessed 07-20-20.
9. McMullen KM, Smith BA, Rebman T. Impact of SARS-CoV-2 on hospital-acquired infection rates in the United States: Predictions and early results. Am J Infect Control. 2020 Jul 2 doi:10.1016/j.ajic.2020.06.209 [Epub ahead of print].
10. Spigliaga P. COVID-19 and Clostridioides difficile infection (CDI): Possible implications for elderly patients. Anaerobe. 2020;64. Published online 2020 Jun 25. doi:10.1016/j.anaerobe.2020.102233.
11. Giacobbe DR, Battaglini D, Ball L, et al. Bloodstream infections in critically ill patients with COVID-19. Eur J Clin Invest. 2020;46(2): 266–284. doi.org/10.1111/eci.13319.
12. Sepulveda J, Westblade LF, Whittier S, et al. Bacteremia and blood culture utilization during COVID-19 surge in New York City. J Clin Microbiol. doi:10.1128/JCM.00875-20.
13. Zhou Q, Gao Y, Wang X, and others. Nosocomial infections among patients with COVID-19, SARS and MERS: A rapid review and meta-analysis. Ann Transl Med. 2020; 8(10): 629. doi:10.21037/atm-20-3324.
14. Dexter F, Elhakim M, Loftus RW, Seering MS, Epstein RH. Strategies for daily operating room management of ambulatory surgery centers following resolution of the acute phase of the COVID-19 pandemic. J Clin Anesth. 2020;64 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188624/pdf/main.pdf. Accessed 07-20-20.