A new year and new infection prevention and control opportunities from the COVID-19 legacy

The new year is a time for reflection, hope and resolutions for self-improvement in the year ahead. If we were to take this approach to our professional lives, what would this mean for the practice of infection prevention and control (IPC) going forward?

The community is recovering from the COVID-19 pandemic and the lessons learnt have been well documented. If we were to take a ‘strengths, weaknesses, opportunities and threats’ analysis to our current position, then now is the time to ensure any ‘opportunities’ afforded by the COVID-19 legacy are capitalised on. The ‘strength’ analysis would encourage us to review our new assets and resources, skills acquired by staff, relationships forged, knowledge learned and experience gained. It is our responsibility to ensure none of these are wasted.

In the past twelve months the infection community has faced numerous challenges from seasonal and re-emerging infections such as mpox, influenza, Corynebacterium diptheriae and scarlet fever. How can we best take our COVID-19 legacy assets and re-purpose them to tackle these issues? Many hospitals and laboratories acquired new diagnostic platforms, invested in point of care testing (POCT) and employed new staff to cope with the laboratory and IPC demands of COVID-19. Barriers to POCT have historically included training and maintenance of competency records of POCT staff, validation and verification of tests outside a laboratory environment, IT connectivity and maintaining appropriate quality control. However, many of these were overcome during the COVID-19 pandemic. Therefore harvesting these rapid diagnostics at short notice in response to emerging threats is now a viable, cost effective and realistic option for many. The focus for 2023 should be capitalising on new capabilities and pivoting resources to new and existing IPC challenges, at local, national and international levels.

Unseasonal spikes in scarlet fever and invasive Group A streptococcus (iGAS) [1] have placed huge demands on primary care and emergency departments (ED), including high demand for penicillin and macrolide antibiotics, adding to existing winter healthcare pressures in northern hemisphere countries. Utilising existing commercial POCT platforms in ED to rapidly detect GAS from throat swabs can dramatically reduce turnaround times, assist clinicians to differentiate bacterial from viral infection and potentially increase test sensitivity (molecular tests vs. culture) when used alongside clinical algorithms. [2] This has the potential to reduce inappropriate prescribing and ED re-attendance rates.

At present there is little evidence that rapid POCT for GAS reduces healthcare-associated outbreaks, but GAS are important healthcare-associated pathogens, and it is logical that early detection of symptomatic or asymptomatic GAS carriers can reduce the risk of patient-to-patient transmission, especially in higher-risk settings such as paediatric and maternity services. Moreover, rapid testing could enable earlier and more efficient prophylaxis of contacts and might also facilitate case detection in the event of an outbreak in hospital. The potential drawback of relying solely on the use of commercial POCT platforms is the lack of antibiotic sensitivity data (which is particularly relevant for penicillin allergic patients and surveillance of resistance trends) and emm typing data.

Many hospitals have previously utilized rapid POCT for influenza and RSV, but not necessarily using accurate molecular-based test methods. The need to triage patients with viral respiratory infections during the first season when SARS-CoV-2, RSV and influenza have been prevalent, has likely resulted in many more hospitals adding molecular-based POCT for influenza and RSV to their test repertoires, often using multiplexed tests that are now widely commercially available. Undoubtedly hospitals that have adopted these tests will be using different approaches to testing, and there is still much to learn on the most clinically- and cost-effective approaches to testing.

It is also worth noting that NHS England has pledged to explore the use of POCT in community pharmacies in the Community Pharmacy Contractual Framework (2019–2024). [3] Therefore the role of POCT could extend to admission avoidance and earlier signposting to public health guidance. Healthcare workers and the general public have become familiar with the use of POCT (for example, lateral flow devices or rapid molecular tests). With an appropriate understanding of their limitations, their role is being extended (to, for example, influenza and GAS) within community settings. Evidence demonstrates they have a role in improving surveillance of infectious diseases, promoting appropriate antimicrobial use and signposting to appropriate healthcare. [4] By utilising care pathways designed during the pandemic and optimising communication between community and secondary care, hospital admissions with recent community diagnoses of viral respiratory infections could be risk assessed by IPC to optimise patient flow and placement at the front door.

Initially, antimicrobial stewardship (AMS) was considered a ‘COVID casualty’ [5], but rapid multiplex molecular, serological and biochemical diagnostics have more recently been demonstrated to have a valuable role in AMS during the pandemic. [[6], [7], [8]] Clinicians have developed experience and confidence in using these tools to risk-stratify patients and determine when antimicrobials are required. As infection specialists, we have a role in ensuring the utilisation of diagnostic stewardship is now built upon. Encouragingly, total antibiotic consumption in England has fallen pre- and post-pandemic, whilst the burden of antimicrobial resistance (AMR) decreased by 4.2% from 2017-2021. [9] However, we must not become complacent: over 40% of E. coli bacteraemia isolates were resistant to co-amoxiclav, and only 50% of English hospitals met their target to reduce total antimicrobial consumption by 2%. We need to use the diagnostic stewardship tools developed and relationships built during the pandemic to educate and influence colleagues and ensure prudent decisions are being made about AMS at the patient level. Although diagnostic stewardship is key to reducing the burden of AMR, authors of the 2022 Gram report concisely concluded that ‘ … the principles of infection prevention and control remain a foundation for preventing infections broadly and a cornerstone in combating the spread of AMR.’ [10] Robust IPC and diagnostic stewardship are inextricably linked in the fight against AMR.

Many of the ‘strengths’ developed since 2020 are closer to home, within the laboratory. The opportunities for laboratories during the COVID-19 pandemic may have included new molecular testing platforms, increased molecular expertise amongst staff, a move to 24-hour working or a chance to repatriate testing that was previously sent to reference laboratories. Many laboratories evolved to become more resilient, patient-pathway focused and are now recognised for the vital role they play (and have always played) within the larger healthcare system. The legacies left from COVID-19 diagnostics could now be pivoted appropriately to improve IPC locally, for instance CPE gene detection by PCR, rapid molecular detection of MRSA amongst high-risk groups or rapid multiplex respiratory PCR panels for ITU patients. This will be vital during a period of ‘catch-up’ for elective hospital treatment and to assist with annual winter pressures in the northern hemispheres.

At national and international levels the infrastructures developed around diagnostics, vaccine development and delivery, and contact tracing during the pandemic were implemented during the international mpox outbreak last year. [11] This allowed for a prompt, reflexive public health response to managing the outbreak in many countries. The observed benefits of technologies, such as whole genome sequencing, in better understanding the spread of SARS-CoV-2 is also facilitating its introduction into routine practice within clinical diagnostic laboratories. This will undoubtedly assist with better understanding of pathogen cross-transmission and earlier detection of outbreaks. Furthermore, there is increasing focus on metagenomics to detect organisms causing infection and their resistance profiles to facilitate focused treatment and strengthen AMS approaches.

Global warming, [12] globalisation and immigration caused by war and political unrest [13] will lead to further emergence and re-emergence of infectious pathogens going forward. The increase in cases of diphtheria in migrant reception centres in England and across Europe during 2022 is a prime example. [14,15] Added to that, we are facing the challenges of increasingly complex and ageing patient groups, increased demands upon healthcare systems and higher levels of scrutiny. As a community we have learnt a vast amount in the last three years and are much better placed to react to these threats to IPC. But we must harness our new strengths and capitalise on new technologies and relationships in order to do this to the best of our abilities.

The Journal of Hospital Infection and Infection Prevention in Practice would therefore urge readers to consider submitting work that ties into the broad theme of opportunities borne from the legacy of COVID-19, and anticipating the impacts of other global events on IPC in your local healthcare settings – wherever that may be in the world.

Funding

None received.

Conflict of Interest

Gemma Winzor, Martyn Wilkinson, Pauline Jumaa, Jim Gray and Nikunj Mahida are on the editorial teams of The Journal of Hospital Infection and Infection Prevention in Practice, the official journals of the Healthcare Infection Society. The authors have no conflicts of interest to declare.

Ethical statement

N/A.