.  She has been a writer and editor for over 30 years. She has an MA and BA in English Composition/Literature from the University of Akron in Akron, OH, and lives in Ohio with her fiance; her 2 tiny dogs, Sally and Doctor Danger Dog; and a big black cat, Freya. She loves reading, writing, gardening, and spending time with her loved ones.

Tori L. Whitacre

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread. The pathogen profiles will span bacterial, viral, fungal and parasitic species. We encourage you to use Bug of the Month as a teaching tool to help educate healthcare personnel and start a dialogue about microbiology-related imperatives.

Click here to guess the June Bug of the Month

Articles

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in health care facilities today. 

Bug of the Month: I Am Hiding in the Dirt

Despite the increase of infection control and prevention protocols during the COVID-19 pandemic, during the first two years, several health care-acquired infections (HAIs) continued and most increased according to a study recently published, “Continued Increases in HAI Incidence During the Second Year of the COVID-19 Pandemic.”

“For most HAIs, our results are representative of most acute care hospitals in the U.S. and provide a national picture of the impact of COVID-19 on HAI incidence,” the investigators noted in the study. “Our findings describe the increases in HAIs that occurred during the 2021 COVID-19 pandemic year and underscore the continued challenges experienced in infection prevention. Resilient approaches are needed to reduce HAIs in 2022 and beyond.”

Central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), select surgical site infections (SSIs), and laboratory-identified (LabID) methicillin resistant 

 (MRSA) bacteremia increased during 2021, especially during the first and third quarters of the year. However, 

, Lindsey Lastinger, MPH, health scientist with the Centers for Disease Control and Prevention (CDC) and published by CambridgeCore, answered questions for 

). She summarizes the study, what are the practical applications for infection preventionists, and what research is coming on this topic.

): Please give a summary of the key findings and why they are important.

U.S. hospitals continued to face challenges with infection prevention and control during the second year of the pandemic. We found that the incidence of certain types of health care-associated infections (HAIs) in U.S. hospitals remained significantly higher in 2021 compared to the pre-pandemic time period. Within 2021, HAIs appeared to be highest during the first and third quarters of the year, coinciding with COVID-19 surges in the U.S. and the resulting high volume of COVID-19 hospitalizations.

: What is the practical application for the key findings for infection preventionists from this study?

 Infection preventionists should regularly review their HAI surveillance data to identify any gaps in infection prevention practices, paying particular attention to CLABSIs, VAEs, and MRSA bacteremia infections, which all appeared to have significant and substantial increases on the national-level during 2021. Health system leaders and infection prevention staff should explore building resiliency into their programs so that future efforts may better withstand public health emergencies.

 The heightened HAI incidence during 2021 is consistent with the results that were observed during 2020, the initial year of the pandemic. Unfortunately, the COVID-19 pandemic has presented numerous and unprecedented operational challenges in hospitals, particularly for those facilities experiencing high system stress as a result of an increasing caseload, the effects of which we are continuing to see during COVID-19 surges.

: What, if any, future research will there be related to this study?

 CDC will continue to monitor national HAI incidence throughout the pandemic and continue to identify new ways to improve HAI prevention efforts.

: Is there anything else that you would like to add?

 Previous efforts in health care settings to prevent HAIs were working effectively to decrease HAIs in the years prior to the onset of the COVID-19 pandemic. However, despite the utility of these efforts, our findings demonstrate the difficulty of HAI mitigation in times of severe strain on the health care system. Our report highlights this reality in the context of the COVID-19 pandemic which continues to take a significant toll on health care systems in the United States. It may also have implications for future instances of severe strain upon the health care system.

Device-associated HAIs were likely impacted by the continued alteration of hospital practices that occurred throughout the pandemic.


Some HAI Incident Increases Continued Into Second Year of COVID-19

Daily and regular use of hydrogen peroxide (HP) as an antiseptic is demonstrated to give protection against COVID-19 curtails health care-acquired spread of SARS-CoV-2.

in health care workers (HCW) in 2 hospitals, the Shai-Osudoku Hospital (SODH), Dodowa, and the Mount Olives Hospital (MOH), Techiman, Ghana, between May 2020 and December 2021. The study, “Further observations on hydrogen peroxide antisepsis (HPA) and COVID-10 cases among healthcare workers and inpatients” was recently published in the 

“The significant clinical evidence of HP protection against COVID-19, and likewise considering that it is also quite safe, inexpensive, and readily available, makes it a valuable prophylaxis to be recommended to protect HCW, inpatients, and all vulnerable groups against COVID-19,” the investigators noted in the study. “These vulnerable groups might include the unvaccinated, the elderly, those in long term care facilities or homes, sportsmen and sportswomen, teachers, students, front-line security service personnel, airline crew, pregnant and lactating women.”

The investigators’ observations indicated that daily and regular use for 1 minute duration of HP in low concentrations as a 1% mouthwash and throat gargle, and 0.5% for nasal rinse for the same amount of time, effectively protects against SARS-CoV-2 infections. This imitates HP’s mode of action when used on inanimate surfaces to inactivate coronaviruses. The investigators say that HP, therefore, has the potential to mitigate this pandemic, a solution simpler than had been imagined when it had been proposed previously.

“HP could further mitigate the pandemic when used by both symptomatic and asymptomatic COVID-19 patients, by inactivating the viruses these patients shed,” the investigators wrote.

The numbers are clear in the study: HPA demonstrated protection against SARS-CoV-2. At SODH from May to December 2020, 62 (13.5%) COVID-19 cases were noted among 458 HCW not on HPA, but none among 8 on HPA (

= 0.622). Between January and March 2021, 10 (2.7%) of 372 HCW had COVID-19, but none among 94 HCW on HPA (

At MOH, prior to HPA, 17 (20.2%) of 84 HCW and 5 (1.4%) of 370 inpatients had COVID-19 in July 2020. From August 2020 to March 2021, 2 of 54 (3.7%) who discontinued HPA had COVID-19; 0 of the 32 staff not on HPA contracted it. At SODH from April to December 2021, none of 23 unvaccinated HCW on HPA had COVID-19; 35 (64%) of 55 not on HPA contracted it (

< 0.0001). None of 34 vaccinated HCW on HPA contracted COVID-19, compared with 53 (13.6%) of 390 not on HPA who had it (

= 0.015). No inpatient on HP prophylactic antisepsis (total 7736) contracted COVID-19.

The investigators describe this study as “real-world observational study,” and they collected no personal data, such as age, gender, co-morbidities, or clinical information from HP-HCW, NHP-HCW, vaccinated, unvaccinated, or in inpatients. They did not consider the influence of co-variates nor was the HPA randomized, as the decision to use HPA was personal at SODH and persuaded by management and not the investigative team at MOH.

“The study, nevertheless, provides useful information of evidential value to fill a knowledge gap of clinical evidence that HPA protects against SARS-CoV-2 infections,” the investigators noted in the article.

Regardless of vaccination status, health care workers were protected with daily and regular hydrogen peroxide antisepsis. 


Does Daily Hydrogen Peroxide Antisepsis Protect Against COVID-19? 

Even though health care-associated rhinovirus infections incidences were reduced, they were still reported during the COVID-19 pandemic, despite amplified infection control and prevention practices according to a recent 

, “Dodging the Bundle: Persistent Healthcare-Associated Rhinovirus Infection Throughout the Pandemic” in the 

 (AJIC). The investigators reviewed medical records and applied the National Health Safety Network (NHSN) surveillance criteria for upper respiratory infections (URIs) with pre-determined incubation periods for unit attribution.

The investigators observed an overall decrease in the pandemic period (P < 0.01) in respiratory HAVI of 68%, with pre-pandemic rates of 0.19 infections per 1000 patient significantly decreased to a rate of 0.06 per 1000 patient days. Rhinovirus made up proportionally more of the respiratory HAVI in the pandemic period (64% vs 53%), with respiratory HAVI secondary only to rhinovirus identified during 8 of 16 months in the pandemic period. During the pandemic period, compliance with HAVI prevention bundle significantly improved.

Eimear Kitt, MD, program director, Infectious Diseases Fellowship Program; associate medical director, Infection Prevention and Control, Division of Infectious Diseases, Children’s Hospital of Philadelphia, and lead author for the study, answered key questions for 

): Please give a brief summary of the key findings and why they are important.

: Health care-associated viral infections (HAVI) are a preventable cause of harm, particularly in the pediatric population. The pandemic provided opportunity to measure the effectiveness of HAVI prevention measures when followed consistently by staff. Throughout the pandemic period, we noted a sustained and significant decrease in respiratory HAVI of 68%; however, rhinovirus infection persisted. This is important as it suggests that even when current prevention practices are optimized, transmission dynamics of rhinovirus in the nosocomial settings are not completely addressed.

: The main practical application is that despite robust public health and in hospital infection prevention and control (IPC) measures, we did not prevent rhinovirus HAVI, as transmission persisted throughout pandemic months. Heightened awareness should exist around the risk for rhinovirus HAVI and the potential for clusters, particularly in the immunocompromised and vulnerable populations.

 The persistence of rhinovirus seemed initially surprising given our strict prevention practices, yet this has been described in both community and other hospital settings throughout the pandemic where similar mitigation measures were in place.

 Further research should focus on the unique transmission dynamics of rhinovirus that may require different prevention measures to be implemented.

 With any preventative measure, the benefits should be weighed against the potential risks. Throughout the study period, we had restrictive visitation policies and strict screening of all staff and visitors, thus we suspect a substantial proportion of our transmission was from asymptomatic employees and/or adult caregivers at the bedside. Both of these groups make up crucial parts of the patient's care team. We, therefore, believe efforts should focus on increasing awareness of asymptomatic transmission particularly to high risk groups like neonates and immunocompromised patients, and reinforcing the importance of consistent hand hygiene, rather than restricting all visitors in pediatric settings.

However, respiratory HAVIs continued to be reported, despite elevated prevention practices, leaving young, susceptible patients threatened. 


Rhinovirus Infections Decreased—But Did Not Vanish—During Pandemic 

The patient with home infusion therapy has an improved outcome when home health care agencies and acute care facilities communicate relevant information on their shared patients.

 called, “A Task Analysis of Central Line-Associated Bloodstream Infection Surveillance and Home Infusion Therapy” was recently published in the 

(AJIC) that highlighted major barriers affecting health care workers’ ability to perform successful central line-associated bloodstream infection (CLABSI) surveillance among patients receiving home infusion therapy. The study was funded by the Agency for Healthcare Research and Quality (AHRQ), and it describes facilitators, strategies, and suggestions for improving CLABSI surveillance, both in the home and health care facilities to better track and monitor infection rates.

“Although we focus a lot on certainly CLABSI prevention and acute care hospitals, patients do go frequently go home, with central lines in place for things like central parenteral nutrition, chemotherapy, long term antibiotics, allotropes, and indications,” said Sara C. Keller, MD, MSHP, MPH, associate professor at Johns Hopkins University School of Medicine, Armstrong Institute of Patient Safety and Quality, and lead author on the published study in an exclusive interview with 

“Some patients can have these central lines in place for years, most frequently with support from home infusion therapy agencies.”

The investigators to see what practices and as well as barriers and strategies there are for home infusion therapy agencies trying to monitor for CLABSI.” To do this, the investigators interviewed staff members at five different home infusion agencies covering portions of 14 states across the country.

They began by figuring out what the home infusion agencies’ steps were for CLABSI surveillance. The major steps included first learning who to monitor for CLABSI which was much more difficult for many of the home health agencies’ staff than the investigators expected, according to Keller. The second step was to identify the need to investigate each individual patient who may have a complication and symptoms of CLABSI. The third step is gathering information on those patients who potentially might have a CLABSI, then, fourth, determining whether the patients have had a biopsy, and then fifth, summarizing and examining all their data on each of the patients. The sixth step is sharing this data with stakeholders. Next is seven, identifying an action plan, and then the eighth and final step is taking action to prevent future CLABSI.

Keller also discussed how communication is the key to many issues in health care in this 

Videos

Patients with home infusion therapy have improved outcomes when home health care agencies and acute care facilities communicate relevant information on their shared patients.


CLABSI Prevention at Home Starts With Sharing Patient Information  

Hand hygiene is vital to prevent spread of infections. (Adobe Stock) 

Hand hygiene is key to preventing HAIs and SSIs in the health care facility. In fact, it is so important that the World Health Organization (WHO) has a World Hand Hygiene Day for infection preventionists to emphasize the impact of not washing one’s hands or using hand sanitizer. Yet, health care facilities still struggle to 

, lectures, and other various methods to instill the importance of hand hygiene every time a health care worker (HCW) interacts with a patient and throughout the workday, according to recent research by 

, a division of Georgia-Pacific dedicated to helping advance hygiene in health care and other market segments, 5 barriers inhibit HCWs from dependably complying with their facility’s hand hygiene protocol. All the reasons, across the survey results, were due primarily to inconvenience.

“Performing hand hygiene is the single most important step in breaking the chain of infection. The transfer of pathogens from surfaces is largely due to hand contact with surfaces,” 

said Sharon Ward-Fore, MS, MT(ASCP), CIC, FAPIC

, an infection prevention consultant, located in Chicago, and a member of 

about this research. "Touching a contaminated surface can lead to cross contamination of patient care items, other environmental surfaces, self-contamination, and possible infection if you touch your face, mouth, or eyes. That's why we need to perform hand hygiene at every opportunity. HCP know the importance. It's up to everyone to remove barriers like those mentioned, to make hand hygiene as reflexive as breathing.”

, consisting of 100 respondents from November 4, 2021 to November 9, 2021, when HCW were asked why they were unable to comply with their facility’s hand hygiene policy consistently 100% of the time when using an alcohol-based hand rub, the top five ranked reasons included:

emergencies requiring immediate attention (66%);

malfunctioning, broken or empty hand sanitizer dispensers (51%);

hands being full and, therefore, unable to access a dispenser (50%);

and difficulty sanitizing hands during glove-on/glove-off process (50%).

In addition, all of these reasons need managerial buy-in to be addressed and eliminated as Jan Dyer discussed in a recent 

The authors of the study noted that when 1 respondent was asked why he/she believed the policies were not followed 100% of the time, he/she replied, “Short staffing. High patient ratios. Lack of support from admin. Admin asking staff for completion of time sensitive tasks without consideration for employee's time and workload. Burnout.”

 have demonstrated to improve HCW compliance as well; however, none show a 100% observance.

Despite various techniques that health care facilities use to facilitate 100% hand hygiene compliance from their health care workers, barriers still must be overcome. 
