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When an 850-bed urban hospital fought off COVID-19 in part by having to relax infection prevention protocols, the opportunistic and deadly carbapenem-resistant Acinetobacter baumannii (CRAB) struck.
Infection preventionists and other healthcare providers have exhibited incredible courage and competency during the coronavirus disease 2019 (COVID-19) pandemic. They’re only human, however, and these heroes are not superheroes. Fighting off COVID-19 is one thing. Fighting off COVID-19 along with another deadly superbug is something most of those even in the thick of the pandemic battle haven’t had to deal with. But that’s exactly the situation healthcare providers at an unnamed New Jersey hospital found themselves in from March to June when they had to suspend the usual infection prevention and control (IPC) protocols to fight COVID-19, according to a study in Morbidity and Mortality Weekly Report (MMWR), a publication of the US Centers for Disease Control and Prevention (CDC).
Carbapenem-resistant Acinetobacter baumannii (CRAB) is not much seen in the United States now, but it has begun to emerge as a deadly pathogen where it does strike, with a 55% mortality rate and an ability to resist most antibiotics thrown its way. Whenever and wherever it strikes in the US, healthcare officials take notice and take no chances. CRAB invaded a skilled nursing facility in February 2018 and both the Utah Department of Health and the CDC were all over it. This is 2020, a year anyone living through will never forget. It’s the year when healthcare resources were focused on the viral COVID, with not much left over to fight off a bacteriological invasion from something like CRAB. IPC strategies suffer from a lack of equipment and personnel and that leaves hospitals vulnerable to outbreaks of multidrug-resistant organism (MDRO) infections.
The 500-bed acute care hospital in the study managed to get COVID under control in late May, and reactivate its usual IPC practices. When that happened CRAB cases returned to a pre-COVID-19 level, which is usually about 2 cases a month.
From March to August, the urban hospital admitted about 850 COVID-19 patients. That peaked on April 9, when the hospital admitted 36 new patients, with 61% having a confirmed diagnosis of COVID-19
“Before the pandemic, ventilator circuits and suctioning catheters were changed at specified intervals of every 14 days and every 3 days, respectively, unless malfunctioning or visibly soiled,” the study states. “To conserve equipment during the surge, the hospital’s respiratory therapy unit instituted a policy to extend the use of ventilator circuits and suctioning catheters for individual patients, replacing them only if they were visibly soiled or malfunctioning. To conserve PPE, gown use as part of contact precautionswas suspended for care of patients with the endemic MDROs vancomycin-resistant Enterococcus spp. and methicillin-resistant Staphylococcus aureus but was maintained for nonendemic MDROs such as CRAB.”
As was the case with hospitals throughout the US, the hospital in the MMWR study also adjusted the IPC rules for use of personal protective equipment (PPE) by, for instance, allowing the reuse of N95s and face shields.
A MDRO workgroup at the hospital was shifted to the COVID fight and maintenance rounds for bedside central venous catheter and indwelling urinary catheter maintenance were suspended. Auditing of hand hygiene, PPE use, and environmental services were also suspended during the COVID surge.
“IPC leadership noted less frequent patient bathing with chlorhexidine gluconate and a 43% reduction in ICU CRAB screening tests,” the study states. “These changes resulted from competing clinical priorities, challenges in personnel availability, and an effort to minimize staff members’ interaction time with patients. The facility experienced critical shortages in personnel for nursing and environmental services, resulting from staff members’ illness, quarantine, and a surge in the number of patients with COVID-19. Nursing resources were supplemented through agency and government entities; however, increased patient-to-staff member ratios and the need to minimize patient contact might have led to unidentified IPC breaches.”
The CDC investigators appreciate that hospitals have had to take unusual steps during the pandemic. However, they should never underestimate the ability of MDROs to strike.
“To reduce spread of MDROs and the risk of infection for patients, hospitals should remain vigilant to prevent and detect clusters of unusual infections and respond promptly when they are detected,” the study states. “Facilities should prioritize continuity of core IPC practices (e.g., training for and auditing of hand hygiene, PPE use, and environmental cleaning) to the greatest extent possible during surges in hospitalizations and make every effort to return to normal operating procedures as soon as capacity allows.”