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How Did COVID-19 Affect Healthcare-Associated Infections?

  • Authors: News Author: Lucy Hicks; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 10/15/2021
  • Valid for credit through: 10/15/2022
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Target Audience and Goal Statement

This activity is intended for primary care physicians, infectious disease specialists, hospitalists, critical care specialists, nurses, physicians, pharmacists and other members of the healthcare team who care for hospitalized patients.

The goal of this activity is to analyze trends in the prevalence of healthcare-associated infections (HAIs) during the COVID-19 pandemic.

Upon completion of this activity, participants will:

  • Assess prepandemic trends in the epidemiology of HAIs in the United States
  • Analyze the prevalence of HAIs in the United States during the COVID-19 pandemic
  • Outline implications for the healthcare team


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New Author

  • Lucy Hicks

    Freelance writer, Medscape


    Disclosure: Lucy Hicks has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/CE Reviewer

  • Esther Nyarko, PharmD

    Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

CME Reviewer/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

None of the nonfaculty planners for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients.

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How Did COVID-19 Affect Healthcare-Associated Infections?

Authors: News Author: Lucy Hicks; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 10/15/2021

Valid for credit through: 10/15/2022


Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to COVID-19 vaccines may be provided in this activity to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

Efforts to reduce the rates of healthcare-associated infection (HAI) in the United States have continued for decades, and the authors of the current study describe that they have had some success. From 2015 to 2019, there were consistent reductions in the rates of central-line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and Clostridium difficile infection (CDI). Reductions in the rates of methicillin-resistant Staphylococcus aureus (MRSA) infection have been present in certain years, with less of a consistent downward trend. In contrast, ventilator-associated event (VAE) rates have generally remained stable from 2015 to 2019.

COVID-19 placed a tremendous amount of pressure on hospitals because of the large numbers of critically ill patients, along with staff shortages resulting from illness and quarantine. Hospitals also suffered from a lack of resources, including personal protective equipment (PPE). Could this severe stress result in a rebound in the rate of HAI? The current study by Weiner-Lastinger and colleagues assesses this issue.

Study Synopsis and Perspective

Several HAIs in US hospitals spiked in 2020 compared with the previous year, according to a Centers for Disease Control and Prevention (CDC) analysis published online September 3 in Infection Control and Hospital Epidemiology. Soaring hospitalization rates, sicker patients who required more frequent and intense care, and staffing and supply shortages caused by the COVID-19 pandemic are thought to have contributed to this increase.

This is the first increase in HAIs since 2015.

These findings "are a reflection of the enormous stress that COVID has placed on our healthcare system," Arjun Srinivasan, MD (Captain, US Public Health Service), the associate director of the Healthcare-Associated Infection Prevention Programs of the Centers for Disease Control and Prevention (CDC), in Atlanta, Georgia, told Medscape Medical News.

He was not an author of the article, but he supervised the research.

"We don't want anyone to read this report and think that it represents a failure of the individual provider or a failure of healthcare providers in this country in their care of COVID patients," he said. He noted that healthcare professionals have provided "tremendously good care to patients under extremely difficult circumstances.

"People don't fail -- systems fail -- and that's what happened here," he said. "Our systems that we need to have in place to prevent [HAI] simply were not as strong as they needed to be to survive this challenge."

In the study, researchers used data reported to the National Healthcare Safety Network, the CDC's tracking system for HAIs. The team compared national standard infection ratios -- calculated by dividing the number of reported infections by the number of predicted infections -- between 2019 and 2020 for 6 routinely tracked events:

  • Central line-associated bloodstream infections (CLABSIs)
  • Catheter-associated urinary tract infections (CAUTIs)
  • Ventilator-associated events (VAEs)
  • Infections associated with colon surgery and abdominal hysterectomy
  • Clostridioides difficile infections
  • Methicillin-resistant Staphylococcus aureus (MRSA) infections

Researchers used regression models created with baseline data from 2015 to estimate infections.

"The new report highlights the need for healthcare facilities to strengthen their infection prevention programs and support them with adequate resources so that they can handle emerging threats to public health, while at the same time ensuring that gains made in combating HAIs [healthcare-associated infections] are not lost," said the Association for Professionals in Infection Control and Epidemiology in a statement.

The analysis revealed significant national increases in CLABSIs, CAUTIs, VAEs, and MRSA infections in 2020 compared with 2019. Among all infection types, the greatest increase was in CLABSIs, which were 46% to 47% higher in the third quarter (Q3) and fourth quarter (Q4) of 2020 relative to the same periods in the previous year. Ventilator-associated events rose by 45%, MRSA infections increased by 34%, and CAUTIs increased by 19% in Q4 of 2020 compared with 2019.

The influx of sicker patients in hospitals throughout 2020 led to more frequent and longer use of medical devices such as catheters and ventilators. The use of these devices increases risk for infection, David P. Calfee, MD, chief medical epidemiologist at the NewYork-Presbyterian/Weill Cornell Medical Center, in New York, New York, told Medscape. He is an editor of Infection Control and Hospital Epidemiology and was not involved with the study. Shortages in PPE and crowded intensive care units could also have affected how care was delivered, he said. These factors could have led to "reductions in the ability to provide some of the types of care that are needed to optimally reduce the risk of infection."

There was either no change or decreases in infections associated with colon surgery or abdominal hysterectomy, likely because there were fewer elective surgeries performed, said Srinivasan. C difficile-associated infections also decreased throughout 2020 compared with the previous year. Common practices to prevent the spread of COVID-19 in hospitals, such as environmental cleaning, use of PPE, and patient isolation, likely helped to curb the spread of C difficile. Although these mitigating procedures do help protect against MRSA infection, many other factors -- notably, the use of medical devices, such as ventilators and catheters -- can increase the risk for MRSA infection, Srinivasan added.

Although more research is needed to identify the reasons for these spikes in infection, the findings help quantify the scope of these increases across the United States, Calfee said. The data allow hospitals and healthcare professionals to "look back at what we did and then think forward in terms of what we can do different in the future," he added, "so that these stresses to the system have less of an impact on how we are able to provide care."

Srinivasan and Calfee report no relevant financial relationships.

Infect Control Hosp Epidemiol. Published online September 3, 2021.

Study Highlights

  • Study data came from the National Healthcare Safety Network. Researchers compared data on HAIs reported from US hospitals in 2019 and 2020. They measured trends in HAIs using an observed-to-predicted ratio called the "standardized infection ratio."
  • Researchers broke down national data for reports on HAIs at the state level.
  • > 3000 hospitals reported on the study variables, with little decline from 2019 to 2020. The largest drop-off in reporting in 2020 was for VAEs and surgical site infections (SSIs).
  • Central line and catheter use increased in 2020 vs 2019, as did ventilator use.
  • There was an initial decline of 12% in the rate of CLABSI in comparing data from the first quarter (Q1) of 2020 with 2019; however, this trend reversed by Q3 to Q4 of 2020, with increases in the rates of CLABSI of 46% to 47%.
  • The higher rate of CLABSI was driven by an increase in the numerator of the standardized infection ratio, meaning that there were more cases of CLABSI reported.
  • The increase in CLABSI during 2020 was particularly notable in Massachusetts and Arizona.
  • CAUTIs increased steadily over 2020 compared with 2019, with an increase of 19% in Q4 2020 vs Q4 2019.
  • Ventilator usage was significantly higher overall in 2020 compared with 2019, and VAEs were higher in all 4 quarters of 2020. The biggest increase of 45% was recorded during Q4, and Georgia was the state with the biggest increase in VAE in Q4.
  • There were substantially fewer outpatient and inpatient encounters for MRSA bacteremia in 2020 vs 2019, resulting in a small increase in the overall rate of patient encounters in the inpatient setting in 2020. The increase in MRSA bacteremia in the outpatient domain was more pronounced in 2020.
  • In contrast, the rate of CDI remained stable in comparing data from 2020 and 2019. Rates of SSI declined in 2020 vs 2019, with lower rates of surgical procedures overall in 2020.

Clinical Implications

  • From 2015 to 2019, there were consistent reductions in the rates of CLABSI, CAUTI, and CDI in the United States. In contrast, the rates of VAEs generally remained stable.
  • The current study by Weiner-Lastinger and colleagues reports higher rates of CLABSI, CAUTI, and VAE in comparing hospital data from 2020 and 2019; however, rates of CDI were stable in 2019-2020.
  • Implications for the healthcare team: Hospital infection control practices for nonrespiratory pathogens likely suffered in 2020. The healthcare team should reengage with these practices. Members of the healthcare team must reengage with and adhere to evidence-based infection control practices to reduce the rates of HAIs.


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