A new study by researchers with the Centers for Disease Control and Prevention (CDC) illustrates the impact that the COVID-19 pandemic had on infection control (IC) practices in US hospitals, even in parts of the country that experienced lower SARS-CoV-2 transmission.
The study, published yesterday in the American Journal of Infection Control, describes outbreaks of emerging multidrug-resistant organisms (eMDROs) in 18 healthcare facilities in 10 states over the course of the pandemic. Survey results from the facilities indicate that changes in IC practices linked to the pandemic—along with shortages of and strategies to conserve personal protective equipment (PPE) —may have contributed to eMDRO transmission.
The study is the latest to link the pandemic's impact on US hospital staffing and PPE to increases in multidrug-resistant hospital infections documented over the past several years.
Changes in IC practices, PPE conservation strategies
The findings are based on an analysis of outbreak report forms submitted to the CDC by health departments in 11 states by March 12, 2021. The forms collected facility and cluster characteristics, the number of patients associated with each cluster, patient outcomes, IC practices, changes in IC practices and in frontline healthcare personnel (HCP) staffing due to the pandemic, and the local epidemiology of eMDROs and SARS-CoV-2.
Overall, 18 clusters of carbapenem-resistant Enterobacterales (CRE, 10), carbapenem-resistant Pseudomonas aeruginosa (CRPA, 1), carbapenem-resistant Acinetobacter baumannii (CRAB, 1), and Candida auris (6) were reported by facilities in 10 states. The clusters affected 345 patients in 11 acute care hospitals and 52 patients in 6 post-acute care facilities. A cluster reported in a long-term acute care hospital did not have information available on the number of affected patients.
Among the 17 clusters with information available, 5 (29%) were first recognized in a non-COVID unit, 7 (41%) occurred in facilities located in communities with moderate to substantial SARS-CoV-2 transmission, and 10 (59%) in jurisdictions where the eMDRO was considered endemic or regional. The pooled proportion of patients co-infected with SARS-CoV-2 was 54%.
Among the facilities with available information on HCP staffing, 10 (71%) of 15 said they increased the use of contracted or agency HCP relative to pre-pandemic practices, 8 (53%) of 15 reassigned HCP to units with a different patient acuity than where they typically worked, and 7 (58%) of 12 reassigned cleaning duties to HCP who were also providing direct patient care.
Of the facilities with information about PPE availability, 9 (60%) of 15 reported a shortage of isolation gowns, and 11 (69%) of 16 reported extended use of gowns (HCPs wearing the same gown when interacting with more than one patient), irrespective of an actual shortage. And although only 1 (7%) of 15 facilities reported a glove shortage, 3 (19%) of 16 reported extended use of gloves without changing them between patients.
"Although nearly half of reported clusters occurred in healthcare facilities in communities experiencing lower levels of community SARS-CoV-2 transmission, a far greater proportion indicated implementing contingency and crisis capacity strategies to manage actual or anticipated shortages of PPE," the study authors wrote. "Together, these results suggest that changes in PPE practices in outbreak units including extended use and reuse of isolation gowns were common and were not limited to facilities facing SARS-CoV-2 surges."
In addition, shortages of or difficulty obtaining preferred disinfectants were reported in 8 (67%) of 12 facilities, while 5 (31%) of 16 reported shortages of alcohol-based sanitizer or soap. Compared with pre-pandemic practices in similar units, hand hygiene audit frequency decreased in 85% of affected units during the cluster period.
Although nearly half of reported clusters occurred in healthcare facilities in communities experiencing lower levels of community SARS-CoV-2 transmission, a far greater proportion indicated implementing contingency and crisis capacity strategies to manage actual or anticipated shortages of PPE.
Facilities reported that even in the absence of an active COVID-19 surge, practices to conserve PPE had become habitual since the beginning of the pandemic and were employed in anticipation of future surges. They also said competing priorities from other activities, such as SARS-CoV-2 testing, impeded them from implementing measures to prevent eMDRO transmission
Nationwide increases in MDROs during COVID
The authors note that while their study was limited to a small number of healthcare facilities, the pathogens documented in the outbreak reports are among those that saw substantial nationwide increases during the pandemic. A 2022 CDC report found that hospital-onset CRAB cases increased by 78% in 2020 compared with 2019, CRE cases by 35%, multidrug-resistant P aeruginosa by 32%, and combined hospital and community-onset C auris by 60%.
"These nationwide increases in MDROs that were realized during the pandemic have the potential for long-term negative impact on the prevention and control of antimicrobial-resistant organisms in the United States," they wrote.
And although they acknowledge that surges in COVID-19 patients, overcrowding, increased antibiotic use, and actual shortages of HCP and PPE likely played a role in these increases, they suggest changes in staffing practices and PPE conservation strategies may have also contributed. Extended use of gowns and gloves, for example, could have facilitated MDRO transmission among patients.
The authors say that while acute PPE shortages have been alleviated, staffing problems remain in many US hospitals, and that could affect efforts to address the pandemic-era increases in multidrug-resistant infections.
"Now more than ever due to increasing prevalence of eMDROs, healthcare facilities require strong, well-supported IC programs to reverse the MDRO trends seen in recent years," they wrote.
