ABSTRACT
Background. Increases in central line-associated bloodstream infection (CLABSI) rates have been reported in association with the COVID-19 pandemic, particularly among Candida species and coagulase-negative Staphylococcal species (CoNS). We sought to further validate the impact of the COVID-19 pandemic on CLABSI trends and perform a microbiologic analysis. Methods. This is an IRB-approved retrospective analysis of CLABSIs across a network of 38 community hospitals in southeastern United States. CLABSI rates were compared between pre-pandemic (1/1/2018-3/30/2020) and pandemic periods (4/1/2020-12/31/2021). Regression models were developed to evaluate CLABSI incidence over time. Likelihood ratio tests were used to compare models that were exclusively time-dependent to segmented regression models that also accounted for the COVID-19 pandemic. Results. A total of 1,167 CLABSIs over 1,345,062 central line days were analyzed (Table 1). The mean monthly CLABSI rate per hospital increased from 0.63 to 1.01 per 1,000 central line days (p< 0.001) in the pandemic period (Table 1). CLABSIs secondary to Candida (0.16 to 0.33, p< 0.001), CoNS (0.09 to 0.22, p< 0.001), and Enterococcal species (0.06 to 0.18, p=0.001) increased, while Escherichia coli CLABSIs decreased (0.04 to 0.01, p< 0.001). Upon regression modeling, the COVID-19 pandemic was associated with increases in monthly CLABSI rates by Candida and Enterococcus species (Figure 1). In contrast, the changes in CoNS and Escherichia coli CLABSI rates were better explained by exclusively timedependent models (Figure 1;Table 2). Non-sustained changes in Staphylococcus aureus and Klebsiella pneumoniae CLABSI rates were also noted (Table 2). Gray areas denote COVID-19 pandemic period. Statistically significant level changes in CLABSI rates were observed among Candida and Enterococcus spp. (RR=1.92, CI 1.16-3.20 and 2.42, CI 1.09-5.38). Staphylococcus aureus CLABSI rates had a non-sustained but significant increase at the onset of COVID-19 (RR 2.20, CI 1.16-4.20). CoNS and E. coli rate changes occurred independent of COVID-19 (see Table 2). Conclusion. The COVID-19 pandemic was associated with substantial increases in CLABSIs, driven in part by Candida and Enterococcus species across this network of hospitals. However, the observed increase in CoNS CLABSIs and decrease in Escherichia coli CLABSIs appear to have occurred independently of COVID-19, which only became apparent upon regression analysis. Interpretation of pre-post statistics without assessment of pre-existing trends should be done cautiously. Additional analyses may help elucidate other factors influencing these CLABSI trends by organism.
ABSTRACT
Background. The COVID pandemic shifted antimicrobial stewardship resources at community hospitals. One reason for this shift was new COVID treatments, the first of which was remdesivir, which received initial emergency use authorization (EUA) for the treatment of COVID-19 in May 2020. The UNC Health Southeastern (UNC SEH) pharmacy director stewarded remdesivir by reviewing patients to ensure they met emergency use authorization (EUA) and guideline-based appropriateness criteria. The infectious diseases physician resolved any disputes regarding patient candidacy for remdesivir. The goal of remdesivir stewardship was to optimize care;however, the shift in workflow presented an unrecognized opportunity for stewards to reduce remdesivir costs. Methods. The percentage of COVID patient admissions receiving remdesivir at UNC SEH for calendar years 2020 and 2021 was benchmarked against 32 community hospitals in the Duke Antimicrobial Stewardship Outreach Network (DASON) (Figure 1). UNC SEH purchasing data were used to calculate remdesivir expenditures for 2020 and 2021. Next, the anticipated cost if the hospital had prescribed remdesivir to the same percentage of admissions as the DASON mean was calculated. The difference was calculated to determine the cost avoidance achieved by having below average use of remdesivir (Table 1). Results. At UNC SEH, 28.1% of COVID admissions received remdesivir in 2020 and annual remdesivir expenditures were $693,680. In 2021, 47.45% of COVID-19 admissions received remdesivir and drug expenditures were $1,248,000. The DASON mean % of COVID admissions receiving remdesivir in 2020 was 44.08% and 60.07% in 2021. A total cost avoidance of $726,407 was calculated based on the hospital's below-benchmark use of remdesivir (Table 1). Conclusion. UNC SEH achieved significant cost-savings in 2020 and 2021 due to active remdesivir stewardship. The team created a patient-centered model that focused on using drugs for the right patients and the organization realized cost-savings while ensuring that patients received therapy in accordance with remdesivir EUAs and published guidelines.
ABSTRACT
Background. COVID-19 shifted antibiotic stewardship program resources and changed antibiotic use (AU). Shifts in patient populations with COVID surges, including pauses to surgical procedures, and dynamic practice changes makes temporal associations difficult to interpret. Our analysis aimed to address the impact of COVID on AU after adjusting for other practice shifts. Methods. We performed a longitudinal analysis of AU data from 30 Southeast US hospitals. Three pandemic phases (1: 3/20-6/20;2: 7/20-10/20;3: 11/20-2/21) were compared to baseline (1/2018-1/2020). AU (days of therapy (DOT)/1000 patient days (PD)) was collected for all antimicrobial agents and specific subgroups: broad spectrum (NHSN group for hospital-onset infections), CAP (ceftriaxone, azithromycin, levofloxacin, moxifloxacin, and doxycycline), and antifungal. Monthly COVID burden was defined as all PD attributed to a COVID admission. We fit negative binomial GEE models to AU including phase and interaction terms between COVID burden and phase to test the hypothesis that AU changes during the phases were related to COVID burden. Models included adjustment for Charlson comorbidity, surgical volume, time since 12/2017 and seasonality. Results. Observed AU rates by subgroup varied over time;peaks were observed for different subgroups during distinct pandemic phases (Figure). Compared to baseline, we observed a significant increase in overall, broad spectrum, and CAP groups during phase 1 (Table). In phase 2, overall and CAP AU was significantly higher than baseline, but in phase 3, AU was similar to baseline. These phase changes were separate from effects of COVID burden, except in phase 1 where we observed significant effects on antifungal (increased) and CAP (decreased) AU (Table). Conclusion. Changes in hospital AU observed during early phases of the COVID pandemic appeared unrelated to COVID burden and may have been due to indirect pandemic effects (e.g., case mix, healthcare resource shifts). By pandemic phase 3, these disruptive effects were not as apparent, potentially related to shifts in non-COVID patient populations or ASP resources, availability of COVID treatments, or increased learning, diagnostic certainty, and provider comfort with avoiding antibacterials in patients with suspected COVID over time. (Figure Presented).
ABSTRACT
Background. The COVID-19 pandemic had a considerable impact on US healthcare systems, straining hospital resources, staff, and operations. Our objective was to evaluate the impact of COVID-19 pandemic on incidence and trends of healthcare-associated infections (HAIs) in a network of hospitals. Methods. This was a retrospective review of central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), C. difficile infections (CDI), and ventilator-associated events (VAE) in 51 hospitals from 2018 to 2021. Descriptive statistics were reported as mean hospital-level monthly incidence rates (IR) and compared using Poisson regression GEE models with period as the only covariate. Segmented regression (SR) analysis was performed to estimate changes in monthly IR of CAUTIs, CLABSIs and CDI in the baseline period (01/2018 - 02/2020) and the Pandemic period (03/2020 -03/2021). SR model was not appropriate for VAE based on the plot. All models were constructed using SAS v.9.4 (SAS Institute, Cary NC). Results. Compared to the baseline period, CLABSIs increased significantly by 50% from 0.6 to 0.9/ 1000 catheter days (P< 0. 001). In contrast, no significant changes were identified for CAUTI (P=0.87). Similar trends were seen in SR models for CLABSI and CAUTI (Figures 1, 2 and Table 1). While overall CDIs decreased significantly from 3.5 to 2.5/10,000 patient days in the pandemic period (P< 0.001), SR model showed increasing pandemic trend change (Figure 3). VAEs increased > 700% from 6.9 to 59.7/1000 ventilator days (P=0.15), but displayed considerable variation during the pandemic period (Figure 4). Compared to baseline period, there was a significant increase in central line days (647 vs 677, P=0.02), ventilator days (156 vs 215, P< 0.001), but no change in urinary catheter days (675 vs 686, P=0.32) during the pandemic period. Conclusion. The COVID-19 pandemic was associated with substantial increases in CLABSIs and VAEs, no change in CAUTIs, and an increasing trend in CDI incidence. These variations in trends of different HAIs are likely due, in part, to unique characteristics of the underlying infection, resource shortages, staffing concerns, increased device use, changes in testing practices, and the limitations of surveillance definitions.
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Background. The COVID-19 pandemic placed a strain on inpatient clinical and hospital programs due to increased patient volume and rapidly evolving data on best COVID-19 management strategies. However, the impact of the pandemic on ASPs has not been well described. Methods. We performed a cross-sectional electronic survey of stewardship pharmacy and physician leaders in 37 hospitals within the Duke Antimicrobial Stewardship Outreach Network (DASON) (community) and Duke/UNC Health systems (academic) in April-May 2021. The survey included 60 questions related to staffing changes, use of COVID-targeted therapies, related restrictions, and medication shortages. Results. Twenty-seven facilities responded (response rate of 73%). Pharmacy personnel was reduced in 17 (63%) facilities by an average of 16%. Impacted pharmacy personnel included the stewardship lead in 15/17 (88.2%) hospitals. Converting to remote work was rare and only reported in academic institutions (n=2, 7.4%). ASP personnel were reassigned to non-stewardship duties in 12 (44%) hospitals with only half returning to routine ASP work as of May 2021. Respondents estimated that 62% of routine ASP activities were diverted during the time of the pandemic. Non-traditional, pandemic-related ASP activities included managing multiple drug shortages, of which ventilator support medications (91%) were most common affecting patient care at 52% of facilities. Steroid and hydroxychloroquine shortages were less frequent (44% and 22%, respectively). Despite staff reductions, pharmacists often served as primary contact for remdesivir approvals either using a criteria-based checklist at dispensing or as part of a dedicated phone approval team (Figure). Most (77%) hospitals used a criteria-based pharmacist review strategy after remdesivir FDA approval. Restriction processes for other COVID-19 therapies such as tocilizumab, hydroxychloroquine, and ivermectin were reported in 64% of hospitals. Proportion of facilities implementing specific remdesivir allocation strategies from the time of the first US Food and Drug Administration (FDA) Emergency Use Authorization (EUA) through FDA approval Conclusion. Pandemic response diverted routine ASP work and has not yet returned to baseline. Despite the reduction in pharmacy personnel due to the pandemic, the ASP pharmacy lead took on a novel and critical stewardship role throughout the pandemic exemplified by their involvement in novel treatment allocation for COVID patients.
ABSTRACT
Background. Early assessments of COVID19 preparedness reported resource shortages, use of crisis capacity strategies, variations in testing, personal protective equipment (PPE), and policies in US hospitals. One year later, we performed a follow-up survey to assess changes in infection prevention practice and policies in our diverse network of community and academic hospitals. Methods. This was a cross-sectional electronic survey of infection preventionists in 58 hospitals within the Duke Infection Control Outreach Network (community) and Duke/UNC Health systems (academic) in April-May 2021 to follow-up our initial survey from April 2020. The follow-up survey included 26 questions related to resource availability, crisis capacity strategies, procedures, changes to PPE and testing, and staffing challenges. Results. We received 54 responses (response rate, 93%). Facilities reported significantly fewer PPE and resource shortages in the follow-up survey compared to our initial survey (Figure 1, P< 0.05). Only 32% of respondents were still reprocessing N95 respirators (compared to 73% in initial survey, P< 0.05). All hospitals performed universal masking, universal symptom screening on entry, and 30% required eye protection. In 2020, most hospitals suspended elective surgical procedures in March-April, and restarted in May-June. Approximately 92% reported in-house testing for SARS-COV-2 by April 2020, at least a third of which had a weekly capacity of >100 tests. Almost 80% performed universal pre-operative testing, while 61% performed universal preadmission testing for SARS-COV-2. Almost all hospitals switched from test-based to time-based strategy for discontinuing isolation precautions, majority in August-September 2020. Twenty-five percent hospitals reported infection prevention furloughs, staffing cuts, and or reassignments, while 81% reported increased use of agency nursing during the pandemic. Conclusion. Our follow-up survey reveals improvement in resource availability, evolution of PPE guidance, increase in testing capacity, and burdensome staffing changes. Our serial surveys suggest increasing uniformity in infection prevention policies, but also highlight the increase in staff turnover and infection prevention staffing shortages.
ABSTRACT
Background. The COVID-19 pandemic has brought vaccination to the forefront of discourse on public health. The rapid speed of COVID-19 vaccine development, utilization of novel technology, and an atmosphere of politicized misinformation have created a perfect storm for vaccine hesitancy. As early adopters of vaccination, HCWs set an example for the general population;as trusted sources of medical information, they educate and inform. However, comparatively little work has investigated HCWs' attitudes toward vaccination and how those attitudes drive their recommendation behavior. Methods. We surveyed hospital employees about their personal reasons for hesitancy and beliefs about patient hesitancies and randomly assigned them to see one of three messages aimed at increasing vaccine confidence. Message themes included an appeal to return to normal life (Normalcy), a risk comparison between vaccinating or not (SDT), and an explanation of the speed of safe and effective vaccine development (Process). Results. Of the 674 NC hospital employees who completed our survey in February 2021, 98% had been offered the COVID-19 vaccine, and 80% had already accepted. For the 20% who had not received the vaccine, the top reasons for hesitancy involved the speed of development and testing, and concerns of vaccine safety and effectiveness. We also found differences in susceptibility to misinformation and vaccine hesitancy across political affiliation, which was higher in Republicans compared to Democrats. HCWs were generally very comfortable recommending the COVID-19 vaccine to patients and supported the idea of sharing the message they read. Although the risk comparison message was most trusted personally, the process message was rated as both the most helpful to patients and the most likely to be shared with them (see Figure 1). This suggests that what is most appealing on a personal level is not necessarily what a HCW would recommend to their patients. Rating of personal opinions of the passages. On a scale from 1 to 7 with 1 = Strongly Disagree and 7 = Strongly Agree. This chart shows the average message ratings across the board when answering whether they thought the passages were understandable, helpful, correct, believable, and trustworthy. (Error bars are 95% CI) There was no significant difference across the messages. The Process message is seen as most helpful and is most likely to be shared with patient than the other messages On left, the average answer on a scale from 1 to 5 for "Do you think the passage you just read would help your patients feel more comfortable about getting the vaccine?" and on right, the average answer for "Would you share this passage with your patients?" Conclusion. HCWs' high uptake and minimal hesitancy in recommending the COVID-19 vaccine is encouraging and merits further exploration for how to increase confidence in HCW who are hesitant to discuss and recommend vaccines to patients, as several highlighted the importance of respecting patient autonomy.