Impact of COVID-19 pandemic on the rates of central line–associated bloodstream infection and catheter-associated urinary tract infection in an intensive care setting: National experience

Abstract

Background

COVID-19 is believed to increase the risk of secondary health care–associated infections. The objective was to estimate the impact of COVID-l9 pandemic on the rates of central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infections (CAUTIs) in the Ministry of Health hospitals across Saudi Arabia.

Methods

A retrospective analysis of prospectively collected CLABSI and CAUTI data over a period of 3 years (2019-2021) was done. The data were obtained from the Saudi Health Electronic Surveillance Network. All adult intensive care units in 78 Ministry of Health hospitals that contributed CLABSI or CAUTI data before (2019) and during (2020-2021) the pandemic were included.

Results

During the study, 1440 CLABSI events and 1119 CAUTI events were identified. CLABSI rates significantly increased in 2020-2021 compared with 2019 (2.50 versus 2.16 per 1000 central line days, P = .010). CAUTI rates significantly decreased in 2020-2021 compared with 2019 (0.96 versus 1.54 per 1000 urinary catheter days, P < .001).

Conclusions

COVID-19 pandemic is associated with increased CLABSI rates and reduced CAUTI rates. It is believed to have negative impacts on several infection control practices and surveillance accuracy. The opposite impacts of COVID-19 on CLABSI and CAUTI probably reflect the nature of their case definitions.

Background

Health care–associated infections (HAIs) are a major health care challenge due to their negative impact on patient outcomes and additional pressure on health care resources.1, 2, 3 For example, intensive care unit (ICU) patients with central line–associated bloodstream infection (CLABSI) have between 5% and 30% excess mortality and on average 2 weeks of extra length of stay.2, 3 Similarly, ICU patients with catheter-associated urinary tract infections (CAUTIs) have between 1% and 13% excess mortality and on average 2 weeks of extra length of stay.2, 3

COVID-19 pandemic has tremendously affected all components of the health care system, including reduced utilization of health care services.⁴ Although COVID-19 pandemic raised the public and professional attention to infection control,⁵ it had a negative impact on some infection control activities, such as surveillance and antimicrobial stewardship activities.6, 7, 8 Additionally, COVID-19 patients experienced a higher risk of secondary bacterial infections and HAIs due to prolonged illness, prolonged hospital stay, use of immunosuppressive medication, and increased device utilization.9, 10 Despite the strict implementation of infection control practices in most health care settings, some types of HAIs continued to rise in these facilities.¹¹ This was especially important in HAIs caused by resistant bacteria.¹²

A number of studies compared the rates of CLABSI and CAUTI before and during the COVID-19 pandemic. The majority of these studies showed a significant increase in CLABSI rates13, 14, 15, 16 and nonsignificant decrease in CAUTI rates.13, 15 Other studies did not find a significant impact of the pandemic on the rates of device-associated HAIs.17, 18 There is a lack of national data determining the impact of COVID-19 pandemic on the HAI rates in Saudi Arabia and the Middle East. The objective of the current study was to estimate the impact of COVID-l9 pandemic on CLABSI and CAUTI rates in adult ICUs of Ministry of Health (MOH) hospitals across Saudi Arabia.

Methods

Setting

The study was conducted in the adult critical care units of MOH hospitals. MOH financially funds and administratively controls 284 hospitals with a total bed capacity of more than 43,000 beds. The rate of hospital beds in Saudi Arabia was 22.5 beds per 10,000 population at the start of the study.

Population

For the study, we obtained the data from the Saudi Health Electronic Surveillance Network (HESN) of MOH. For the sake of standardization and as per MOH policy, hospitals with more than 100 beds that have at least a critical care unit, and a microbiology laboratory with a full-time microbiologist were eligible to submit surveillance data to HESN. Therefore, 78 MOH hospitals that were submitting CALBSI and/or CAUTI data from adult ICUs to HESN during the study duration were included in the study. These hospitals were distributed in 20 regions of the Kingdom of Saudi Arabia. Hospitals that were not submitting surveillance data to HESN were not included. Hospitals that were submitting only pediatric and/or neonatal data were excluded (28 hospitals).

Design

A retrospective analysis of prospectively collected CLABSI and CAUTI data over a period of 3 years was done. The data were divided into 2 periods: before the start of the pandemic (2019) and during COVID-19 pandemic (2020 and 2021). This study includes all types of ICUs that conducted CLABSI and/or CAUTI surveillance before and during the pandemic. The outcomes studied were the numbers and rates of CLABSI and CAUTI.

Methods

The surveillance methodology was similar to the methods suggested by the US National Healthcare Safety Network (NHSN)¹⁹ and the Gulf Cooperation Council Center for Infection Control.²⁰ The surveillance was an active, patient-based, prospective targeted surveillance that was done in specific ICUs for specific durations after a local infection risk assessment.

Data collection methods

The data were obtained from HESN, which is an integrated national electronic surveillance system that has several domains to uniformly monitor communicable diseases, disease epidemics, immunization, and HAIs across Saudi Arabia.²¹ It allows users at different hospitals to continually and uniformly report HAIs to the General Directorate of Infection Prevention and Control at Riyadh, Saudi Arabia. Infection preventionists collected the data on HAIs occurring in all patients admitted to the adult ICUs. The corresponding denominator data, consisting of specific patient days and device days, were collected and validated. The number of patients with a central line and/or urinary catheter inserted for any duration at the time of daily counting was considered central line days or urinary catheter days, respectively.

Statistical analysis

CLABSI rates (expressed per 1000 central line days) and CAUTI rates (expressed per 1000 urinary catheter days) were calculated for different types of ICUs by dividing the number of events by the device days of the same year and location. CLABSI and CAUTI rates were compared between 2020 and 2021 (individually and combined) and 2019 using the Z-test for event-time data. Additionally, standardized infection ratios (SIRs) and their 95% confidence intervals were calculated for each year separately after adjusting for differences in ICU types between the Saudi HESN and the US NHSN. SIRs were calculated by dividing the number of observed CLABSI or CAUTI events by their expected values.¹⁹ The expected values for CLABSI and CAUTI events were calculated using the published reports of NHSN.²² Additionally, the impacts of COVID-19 pandemic on CALBSI and CAUTI rates in large benchmarking datasets were graphically presented (Fig. 2). P values were two-tailed. P value<.05 was considered as significant. SPSS software (release 25.0, IBM Corp) was used for all statistical analyses.

Fig. 2.

Impact of COVID-19 on central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates in the main benchmarking reports. Note: Benchmarking reports included reports published by the US National Healthcare Safety Network (NHSN), the International Nosocomial Infection Control Consortium (INICC) of developing countries, German National Reference Center for Surveillance of Nosocomial Infections (KISS), and Brazilian hospitals.

Results

During the 3 years of surveillance covering 601,079 central line days, a total of 1440 CLABSI events were identified: 395 in 2019, 522 in 2020, and 523 in 2021. As shown in Table 1, the overall CLABSI rates per 1000 central line days were 2.16 in 2019, 2.75 in 2020, and 2.29 in 2021. During the 3 years of surveillance covering 980,186 urinary catheter days, a total of 1119 CAUTI events were identified: 470 in 2019, 332 in 2020, and 317 in 2021. As shown in Table 2, the overall CAUTI rates per 1000 urinary catheter days were 1.54 in 2019, 1.07 in 2020, and 0.87 in 2021.

Table 1.

Rates of central line–associated bloodstream infection for different types of intensive care units between 2019 and 2021

	2019			2020			2021
	CL days	Events	Rate	CL days	Events	Rate	CL days	Events	Rate
Burn	1097	4	3.65	2054	5	2.43	1523	6	3.94
Medical	20,013	67	3.35	18,720	63	3.37	22,138	60	2.71
Medical cardiac	6663	15	2.25	7248	17	2.35	7439	13	1.75
Medical surgical	138,756	281	2.03	147,835	417	2.82	179,100	416	2.32
Neurological	30	0	0.00	169	0	0.00	365	0	0.00
Neurosurgical	2293	1	0.44	848	1	1.18	1245	2	1.61
Respiratory	1562	0	0.00	3107	17	5.47	3625	21	5.79
Surgical	2259	0	0.00	2542	0	0.00	3050	0	0.00
Surgical cardiothoracic	4304	6	1.39	3772	0	0.00	5129	5	0.97
Trauma	5894	21	3.56	3732	2	0.54	4567	0	0.00
Total	182,871	395	2.16	190,027	522	2.75	228,181	523	2.29
95% Confidence			1.96-2.38			2.52-2.99			2.10-2.50

CL, central line.

Table 2.

Rates of catheter-associated urinary tract infections for different types of intensive care units between 2019 and 2021

	2019			2020			2021
	UC days	Events	Rate	UC days	Events	Rate	UC days	Events	Rate
Burn	1782	3	1.68	2706	2	0.74	2669	2	0.75
Medical	35,549	77	2.17	31,459	26	0.83	36,734	23	0.63
Medical cardiac	11,038	11	1.00	11,613	12	1.03	11,503	9	0.78
Medical surgical	234,752	346	1.47	244,898	284	1.16	289,506	267	0.92
Neurological	131	0	0.00	139	1	7.19	2	0	0.00
Neurosurgical	3470	5	1.44	1182	0	0.00	2421	1	0.41
Respiratory	2204	0	0.00	4736	5	1.06	5986	8	1.34
Surgical	3703	0	0.00	4177	0	0.00	4518	0	0.00
Surgical cardiothoracic	3908	2	0.51	3418	0	0.00	4473	1	0.22
Trauma	9089	26	2.86	5409	2	0.37	7011	6	0.86
Total	305,626	470	1.54	309,737	332	1.07	364,823	317	0.87
95% Confidence			1.40-1.68			0.96-1.19			0.78-0.97

UC, urinary catheter.

As shown in Figure 1, the rates of CLABSI increased during the pandemic. Compared with the 2019 CLABSI rate (2.16 per 1000 central line days), the 2020 and 2021 rates increased (2.75 and 2.29 per 1000 central line days, respectively). The difference was significant in 2020 (P < .001) but not 2021 (P = .316). The same finding was observed using the 95% confidence intervals. The combined 2020-2021 CLABSI rate was significantly higher than the 2019 rate (2.50 versus 2.16 per 1000 central line days, P = .010). The rates of CAUTI decreased during the pandemic. Compared with the 2019 CAUTI rate (1.54 per 1000 urinary catheter days), the rates for 2020, 2021, and combined 2020-2021 were significantly lower (1.07, 0.87, and 0.96 per 1000 urinary catheter days, respectively, P < .001 for each). The same finding was observed using the 95% confidence intervals.

Fig. 1.

Rates of central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infections (CAUTI) in all types of intensive care units between 2019 and 2021. Note: The P value of the Z-test was the testing rate difference relative to 2009.

Table 3 shows the yearly SIRs of CLABSI and CAUTI. During the 3 years of the study, the CLABSI SIRs in HESN were 2.3-2.9 times higher as compared with NHSN while the CAUTI SIRs in HESN were 23%-56% lower as compared with NHSN. Similar to the crude CLABSI rates shown above, the CLABSI SIRs were higher in 2020, 2021, and combined 2020-2021 compared with 2019 (3.16, 2.67, and 2.82, respectively, versus 2.52). As shown in the confidence intervals, the increased CLABSI SIRs were significant (no overlap of confidence intervals) only in 2020. Similar to the crude CAUTI rates shown above, the CAUTI SIRs were lower in 2020, 2021, and combined 2020-2021 compared with 2019 (0.61, 0.50, and 0.53, respectively, versus 0.84). As shown in the confidence intervals, the reduced CAUTI SIRs were significant in 2020, 2021, and combined 2020-2021. Overall, the pandemic SIRs of CLABSI increased by 16% while the pandemic SIRs of CAUTI decreased by 36% after adjusting for the type of ICU relative to NHSN.

Table 3.

Standardized infection ratios (SIRs)^* of central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infections (CAUTI) between 2019 and 2021

	Observed events	Expected events	SIR	95% LCI	95% UCI
CLABSI
2019	395	173.1	2.28	2.07	2.52
2020	522	179.9	2.90	2.66	3.16
2021	523	213.8	2.45	2.25	2.67
2020-2021	1045	393.7	2.65	2.50	2.82
CAUTI
2019	470	614.3	0.77	0.70	0.84
2020	332	604.2	0.55	0.49	0.61
2021	317	713.2	0.44	0.40	0.50
2020-2021	649	1317.4	0.49	0.46	0.53

LCI, lower confidence interval; UCI, upper confidence interval.

^*Adjusted for the difference in the type of intensive care unit between the Saudi Health Electronic Surveillance Network and the US National Healthcare Safety Network.

Figure 2 shows the impact of COVID-19 on CLABSI and CAUTI rates in the main benchmarking reports.13, 14, 15, 16, 18 CLABSI rates increased during the pandemic in the studies of the International Nosocomial Infection Control Consortium of developing countries, the US NHSN, and Brazilian hospitals. The CLABSI increase was much higher in INICC (86%) and Brazilian hospitals (76%) than in NHSN hospitals (37% and 51%). CAUTI rates decreased during the pandemic in the International Nosocomial Infection Control Consortium and German National Reference Center for Surveillance of Nosocomial Infections hospitals (−6% to −13%), while the results were mixed in the NHSN hospitals (−10% and 9%).

Discussion

We report the impact of COVID-19 pandemic on CLABSI and CAUTI surveillance rates during the first 2 years of the pandemic in 78 MOH hospitals in Saudi Arabia. As far as we know, these national data are considered the first to examine such a topic in Saudi Arabia and the Middle East. The current findings showed that CLABSI rates were significantly increased by approximately 16% in 2020-2021 compared with the 2019 rates, before and after adjusting for the type of ICU. The current findings were consistent with previous studies done in multihospital systems.13, 14, 15, 16 For example, the increase in CLABSI rates in 2020/2021 compared with 2019 was 37%-51% in>3400 NHSN hospitals in the United States,13, 14 86% in 7 hospitals in 7 INNIC developing countries,¹⁵ and 76% in 21 Brazilian hospitals.¹⁶ With the exception of German hospitals,¹⁸ studies that failed to detect such increase in CLABSI rates were single-center studies, such as those done in Tunisia²³ and Saudi Arabia.¹⁷

Several possible explanations have been reported in relation to the increase of CLABSI rates, including reduction of catheter care during insertion and maintenance by overwhelmed staff.6, 8, 24 For example, infection control staff experienced up to 500% increase in the number of infection control consultations during the pandemic, which primarily focused on COVID-19 isolations and exposures with marked reduction in the time allocated for surveillance or central line care.6, 8 Additionally, to meet the increasing care demands, quickly trained nurses were deployed to assist in the ICU care of COVID-19 patients.²⁵ Moreover, the excess use of immunosuppressive drugs such as tocilizumab and steroids among patients with COVID-19 increased their susceptibility to infection including CLABSI.9, 26 Furthermore, as COVID-19 pandemic changed hospital admission policies with limited access to less severe cases, the increase of CLABSI rates could be due to the decrease in the denominator, which is primarily composed of patients with lower CLABSI risk.²⁷ Furthermore, the preference of using the more-risky femoral catheter may have increased due to the fear of catheter insertion close to the mouth and respiratory secretions of the patients.²⁷ Finally, COVID-19 patients may have had higher central line utilization due to the increased risk of acute renal injury that required dialysis and a prolonged ICU stay.²⁷ Interestingly, the increasing impact of the pandemic on the CLABSI rates in the current study was higher in the first compared with the second year, which probably reflects the actual burden of the pandemic on an unprepared health care system in the first year.

The current finding showed that CAUTI rates were significantly decreased by approximately 37% in 2020-2021 compared with the 2019 rates unlike CLABSI. Similar to the current findings but to a less extent, COVID-19 pandemic was associated with 6%-13% reduction in CAUTI rates in multicentered studies in the United States, Germany, and 7 developing countries.13, 15, 18 On the other hand, some studies reported no change17, 23 or even an increase²⁸ in CAUTI during the COVID-19 pandemic. Interestingly, the increase and decrease in these studies did not reach statistical significance. The decrease in CAUTI rates observed in the current study may be explained by several reasons. For example, several hospitals limited surgical and elective admissions during the first year of the pandemic, which may have reduced the number of CAUTI-susceptible patients.¹³ As COVID-19 patients are more susceptible to develop secondary infections, they were prescribed more antibiotics, which may have masked the required CAUTI threshold for bacteriuria.13, 29 Additionally, the rate of urine culture may have been reduced to minimize the exposure to COVID-19 patients.¹³ Interestingly, the opposite impacts of COVID-19 on CLABSI and CAUTI probably reflect the nature of their case definitions. Unlike CLABSI, developing CAUTI is dependent on culturing practices and the level of preexisting bacteriuria rather than catheter maintenance.13, 30

Our study has several strengths and some limitations. The main strength is the fact that we used standardized national data obtained from different ICUs in 78 MOH hospitals covering all the 20 regions of Saudi Arabia over a period of 3 years. We presented the results using both rates and SIR. However, because of using standardized surveillance data collection tools, there was a lack of data to adjust the finding for disease severity and other risk factors of HAIs. Using a retrospective design, causal relationship cannot be confirmed. Nevertheless, these limitations are inherent in surveillance design and unlikely to significantly impact the current study findings.

Conclusions

In conclusion, we report increased CLABSI rates and reduced CAUTI rates during the first 2 years of the COVID-19 pandemic as compared with the prepandemic year. COVID-19 pandemic is believed to have negative impacts on several infection control practices and surveillance accuracy. The opposite impacts of COVID-19 on CLABSI and CAUTI probably reflect the nature of their case definitions. Unlike CLABSI, developing CAUTI is dependent on culturing practices and the level of preexisting bacteriuria rather than catheter maintenance. These national data are thought to be the first to elaborate on such a topic in Saudi Arabia and the Middle East.