For years, U.S. hospitals were making steady progress in reducing health care-associated infections (HAIs). But when COVID-19 hit, HAIs had their chance to hit back.
In 2019, the latest data available from the CDC showed overall decreases in central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and hospital-onset Clostridioides difficile infections by 7%, 8%, and 18%, respectively, compared to 2018. During that time, use of central lines and urinary catheters also decreased by 3% and 7%, respectively. Most states were reporting lower rates of these infections in hospitals than they had in 2015.
This progress is largely due to public reporting and financial ramifications required by the Hospital-Acquired Condition Reduction Program, as well as increased awareness about the preventability of these infections, said Marci Drees, MD, MS, FACP, chief infection prevention officer and hospital epidemiologist for ChristianaCare, a Delaware-headquartered health system with three hospitals.
“Most of it, honestly, is culture and training and education of staff,” she said. “And I think because it's been such a priority, we've been chipping away at it bit by bit over the years, and the end result is a significantly decreased rate of infections.”
But now hospitals seem to be losing ground on one infection in particular. For CLABSIs, the national standardized infection ratio was 28% higher in the second quarter of 2020 than in the same period of 2019, according to an analysis of data reported to the CDC's National Healthcare Safety Network, which was published online in March by Infection Control & Hospital Epidemiology.
Increases in CLABSI rates may be even more pronounced at the individual hospital level. Two hospitals saw CLABSI rate increases of 420% and 327% during early months of the pandemic compared to the prior 15 months, according to a paper published online in July 2020 by the American Journal of Infection Control.
“CLABSI really does appear to be the problem associated with COVID,” said Kathleen M. McMullen, MPH, CIC, lead author of the study and interim director of quality and analytics at Christian Hospital in St. Louis and Northwest HealthCare in Florissant, Mo.
Since the pandemic started, Christian Hospital has seen a 20% decrease in C. difficile infection rates and a 10% decrease in CAUTI rates, reported Ms. McMullen. “But at the same time, the flipside really is CLABSI,” she said. “It has surprised everybody how quickly it went backwards, how quickly all that work we've done over all of these years seemed to slide away.”
There's something about CLABSI
At Ascension, a large St. Louis-based health care system, infection preventionists first noted some increases in CLABSI rates during the first wave of the pandemic in March through May 2020, said Mohamad Fakih, MD, MPH, chief quality officer at Ascension.
A study of the system's 78 hospitals in 12 states, published online in February by Infection Control & Hospital Epidemiology, confirmed that CLABSI is the HAI to watch during the pandemic. Compared with the 12 months before COVID-19, CLABSI rates significantly increased during six months of the pandemic from 0.56 to 0.85 per 1,000 line-days (a 51.0% rise) and from 1.00 to 1.64 per 10,000 patient-days (a 62.9% increase). The findings were driven mainly by ICUs, where rates rose by 71.0% from 0.68 to 1.16 per 1,000 line-days and by 90.7% from 2.95 to 5.63 per 10,000 patient-days during the pandemic period. In addition, the proportion of patients with a CLABSI was five times higher among COVID-19 patients than those hospitalized for another reason.
The results were not surprising to the study's lead author, Dr. Fakih, who noted that the pandemic led to an abrupt drop in admissions for most common conditions and a selective increase in severity of illness among hospitalized patients. “With the work on reducing the risk of exposure of health care workers to COVID-19 and the increased severity of illness of the patients, who more than a third of them require intensive care support, the risk of CLABSI increased,” he said.
The study did not assess the factors contributing to the increases in CLABSI, but feedback from infection preventionists provided some clues. They reported changes to several routine CLABSI prevention practices in ICUs, such as less universal decolonization (e.g., mupirocin administration and chlorhexidine bathing), alterations in line care due to IV pumps placed in hallways (e.g., extension tubing used and fewer bedside checks on lines), and challenges in line site care due to prone positioning of patients, said Dr. Fakih.
There was also the constant flurry of changes for clinicians, Ms. McMullen noted. “Many of us were so hungry for frontline health care workers, we were moving people who didn't normally care for central lines to frontline health care worker duties for critically ill patients,” she said. “A lot of the daily work of the infection preventionists wasn't happening, so we weren't doing line audits, nor was nursing doing line audits.”
Changes to nursing practices to keep staff safe, such as “batching” tasks in the patient's room instead of making multiple visits, likely also contributed to the increase, Ms. McMullen said.
“When they would go into the room, they would have five or seven things to do, and there was fear,” she said. “Things like scrub-the-hub [of the central line] were probably not as ideal as we would have wanted them to be. . . . Nurses on a good day don't like to spend 30 seconds sitting there rubbing a piece of plastic with an alcohol swab, but in this environment, we can understand why some of that went to the wayside.”
Urinary catheters could have been affected by some of the same factors, but the Ascension study did not find a significant change in CAUTI events during the pandemic. The lack of change is likely because the National Healthcare Safety Network definition of CAUTI is more dependent on culturing practices and the pre-existing prevalence of bacteriuria and is less susceptible to device maintenance than CLABSI, Dr. Fakih noted.
Data on health care-associated C. difficile infection are also limited. However, the available data suggest that C. difficile rates were stable or even decreased during the pandemic, according to a review of the evidence published as a letter to the editor online in March by Infection Control & Hospital Epidemiology.
“This is surprising, given the concern for an increase in antibiotic use,” said senior author Michael P. Stevens, MD, MPH, FACP, who is a professor of internal medicine, the associate chair of the division of infectious diseases, and the associate hospital epidemiologist at VCU Health in Richmond, Va. “These findings may be related to optimization of PPE [personal protective equipment] use, isolation, and decreased transit of patients within health systems.”
Going forward, there “will be a giant asterisk in the data” on all these infections for the first six months of 2020, since CMS has made data reporting on HAIs for the first two quarters optional, said Ms. McMullen. “But I think there's enough people who are going to publish their own results that are pretty generalizable that we'll know.”
What hospitalists can do
As was true before the pandemic, physicians can help combat HAIs by becoming more aware of which patients have lines or catheters, choosing to order the devices wisely, and taking them out when possible, experts said.
All hospitalists should be able to avoid devices that are more likely to cause HAIs if alternatives are safe, effective, and available as well as to encourage removal of invasive devices when clinically safe, according to the Society of Hospital Medicine's Core Competencies in Hospital Medicine, published as a supplement to the April 2017 Journal of Hospital Medicine. But multiple studies have shown gaps in this area.
More than 20% of hospital clinicians were unaware of the presence of a central venous catheter in one multicenter study. Hospitalists and teaching attendings were more frequently unaware of the presence of central venous catheters than interns/residents (31% and 26%, respectively, vs. 16%), according to results published in October 2014 by Annals of Internal Medicine.
These findings echoed those of a study published in October 2000 by the American Journal of Medicine, which also found differences in the awareness of indwelling urinary catheters by physicians' level of training. Rates of unawareness of an indwelling catheter were 38% for attending physicians, 27% for residents, 22% for interns, and 21% for students.
In more recent years, hospital clinicians have become more aware of device placement, Dr. Drees said. “One of the things we try to hardwire into our daily rounds is whatever lines, tubes, or drains that patient has, those should be reviewed every single day to see if it is really essential that the patient still has this device,” she said. “And if they don't really need the Foley and it's just there for convenience, can we get it out and do a straight cath? Can we get away with a peripheral IV instead of a central line?”
This kind of device scrutiny is key for hospitalists to help prevent HAIs, Dr. Drees said. “From a physician standpoint, that is the most important thing: that they're hyperaware of what devices their patients have and that they're very aggressive at getting them out,” she said. “You can't get a [device-associated] infection if you don't have a device.”
On a systems level, having a structure to address infection prevention and widely adopted, consistent hospital processes also help, especially during a pandemic, said Dr. Fakih. “We always talk about hardwiring infection prevention practices so they would be resilient to such events,” he said, adding that close evaluation of patient outcomes and engagement across disciplines are key to success.
Dr. Drees added that while nurses provide the bulk of line and catheter care, physicians should remember that the care team is all in this together. “I think just remembering we're on the same team, which is the patient's team, and minimizing their exposure, whether it's to an antibiotic or a central line or a Foley or whatever the case may be, generally will be better for the patient,” she said.
Individual hospitalists can also help the cause by doubling down on optimal hand hygiene and PPE use, as well as asking every day whether their patient still needs that antibiotic, Dr. Stevens said.
He noted that with good infection prevention strategies, at least one health system in Singapore saw a decrease in CLABSI during last year's COVID-19 surge. Clinicians' prior experience with SARS-CoV-1 in 2003 meant that local hospitals knew the benefits of quickly implementing multimodal infection prevention and control bundles for COVID-19, including universal masking policies, improved segregation of patients with respiratory symptoms, visitor screening, and adequate PPE, according to a paper published in the April American Journal of Infection Control.
Now U.S. hospitals can take their own lessons learned from the current pandemic to inform their HAI-prevention efforts, Dr. Stevens said. “It's understandable that attention was diverted during COVID-19 surges, but hospitals should regroup and double down on preventing HAIs like CLABSI, CAUTI, and [C. difficile infection] . . . We need to learn from the pandemic and position ourselves to be able to nimbly and robustly respond in the future,” he said.