Hospital COVID-19 Burden Impact on Inpatient Antibiotic Use Rates

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).

Impact of COVID-19 Pandemic on Healthcare-associated Infections (HAIs) in a Large Network of Hospitals

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.

Pandemic Pinch: The Impact of COVID Response on Antimicrobial Stewardship Program (ASP) Resource Allocation

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.

The Impact of COVID-19 Response on Infection Prevention Programs and Practices in Southeastern United States

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.

Healthcare Personnel Perceived Benefit of Infection Prevention Strategies during COVID

Background. During the COVID-19 pandemic, many infection prevention policy and practice changes were introduced to mitigate hospital transmission. Although each change had evidence-based infection prevention rationale, healthcare personnel (HCP) may have variable perceptions of their relative values. Methods. Between October-December 2020, we conducted a voluntary, anonymous, IRB-approved survey of UNC Medical Center HCP regarding their views on personal protective equipment (PPE) and hospital policies designed to prevent COVID acquisition. The survey collected occupational and primary work location data (COVID unit or not) as well as their views on specific infection prevention practices during COVID. Chi squared tests (two tailed) were used to compare differences in the proportions. Results. The overall results are displayed (Figure). Among the 694 HCP who responded to the survey, we found HCP were largely (68%) satisfied that the organization was taking all the necessary measures to protect them from COVID-19. A significantly greater proportion (14% more) of HCP (81.7% compared to 67.6%;95% CI of difference 9.4-18.5%, P< 0.0001) agreed that all PPE was available to them compared to those who were confident that the organization was taking necessary steps for protection, highlighting that safety is more than simply availability of supplies. More than 90% felt that daily screening of patients/visitors and patient/visitor mask requirements were important for protecting them from acquiring COVID in the workplace and that wearing a mask themselves was a key intervention for protecting others. Fewer HCP (72-80%), although still a majority, perceived that eye protection and daily symptom screening for HCP were beneficial. Symptom screening for patients/visitors was perceived by 19% more HCP (90.9% compared to 72.2%;95% CI of difference 15-23%) to be beneficial than symptom screening of HCP (P< 0.0001). Conclusion. Although infection prevention strategies were implemented based on evidence and in alignment with CDC recommendations, it is important to acknowledge that the perception and acceptance of these recommendations varied among our HCP. Compliance can only be optimized with key interventions when we seek to understand the perceptions of our staff.

SARS-CoV-2 Environmental Contamination in Hospitalized COVID-19 Patients' Rooms

Background. The correlation between SARS-CoV-2 RNA and infectious viral contamination of the hospital environment is poorly understood. Methods. housed in a dedicated COVID-19 unit at an academic medical center. Environmental samples were taken within 24 hours of the first positive SARS-CoV-2 test (day 1) and again on days 3, 6, 10 and 14. Patients were excluded if samples were not obtained on days 1 and 3. Surface samples were obtained with flocked swabs pre-moistened with viral transport media from seven locations inside (bedrail, sink, medical prep area, room computer, exit door handle) and outside the room (nursing station computer). RNA extractions and RT-PCR were completed on all samples. RT-PCR positive samples were used to inoculate Vero E6 cells for 7 days and monitored for cytopathic effect (CPE). If CPE was observed, RT-PCR was used to confirm the presence of SARS-CoV-2. Results. We enrolled 14 patients (Table 1, Patient Characteristics) between October 2020 and May 2021. A total of 243 individual samples were obtained - 97 on day 1, 98 on day 3, 34 on day 6, and 14 on day 10. Overall, 18 (7.4%) samples were positive via RT-PCR - 9 from bedrails (12.9%), 4 from sinks (11.4%), 4 from room computers (11.4%) and 1 from the exit door handle (2.9%). Notably, all medical prep and nursing station computer samples were negative (Figure 1). Of the 18 positive samples, 5 were from day 1, 10 on day 3, 1 on day 6 and 2 on day 10. Only one sample, obtained from the bedrails of a symptomatic patient with diarrhea and a fever on day 3, was culture-positive (Figure 2). Conclusion. Overall, the amount of environmental contamination of viable SARS-CoV-2 virus in rooms housing COVID-19 infected patients was low. As expected, more samples were considered contaminated via RT-PCR compared to cell culture, supporting the conclusion that the discovery of genetic material in the environment is not an indicator of contamination with live infectious virus. More studies including RT-PCR and viral cell culture assays are needed to determine the significance of discovering SARS-CoV-2 RNA versus infectious virus in the clinical environment.

Impact of COVID-19 Pandemic on Activity of Other Respiratory Viral Pathogen and Norovirus

Background. The COVID-19 pandemic led to the implementation of several strategies (e.g., masking, physical distancing, daycare/school and business closures, hand hygiene, surface disinfection) intended to mitigate the spread of disease in the community. Our objective was to evaluate the impact of these strategies on the activity of respiratory viral pathogens (other than SARS-CoV-2) and norovirus. Methods. At University of North Carolina (UNC) Hospitals, we compared the percent positivity for respiratory viral pathogens and norovirus by calendar year for 2014-2019 and the first three months of 2020 to the percent positivity in the subsequent months of 2020 and the first quarter of 2021. Patients were included in the study if they had a positive specimen obtained in a clinic, ED or as an inpatient. Three molecular tests were used to detect these viruses: adenoviruses, endemic coronaviruses (OC43, 229E, NL63, HKU1), influenza A (subtypes H3, H1, H1N1pdm), influenza B, metapneumovirus (MPV), parainfluenza viruses 1-4 (PIV), rhinovirus and/or enterovirus (RhV/EV), and respiratory syncytial virus (RSV). Two molecular tests were used to detect norovirus. We calculated point prevalence rates with 95% confidence intervals to assess statistical differences in percent positivity. Results. There was a statistically significant decline in percent positivity for endemic coronaviruses, influenza, MPV, PIV, RSV and norovirus during the time-periods after March 2020 when compared to all other time-periods (Figure). RhV/EV, followed by adenovirus were the most prevalent types of respiratory viruses circulating during height of COVID-19. There was a statistically significant decline seen in RhV/ EV in April-Dec 2020, but activity increased in 2021. There was no difference seen in adenovirus activity across time-periods. Percent Positivity of Respiratory Viral Pathogens and Norovirus by Time Period Conclusion. Our study demonstrated statistically significant decreases in the percent positivity of several respiratory viral pathogens, as well as norovirus, during the time-period of high community prevalence of SARS-CoV-2. Strategies put in place to mitigate SARS-CoV-2 transmission likely contributed to these differences. Non-enveloped viruses like rhinovirus and adenoviruses may have been less impacted by these strategies since they are more resistant to disinfection.