A case report from a New Jersey hospital highlights how drug-resistant pathogens can take advantage of COVID-related disruptions to standard infection prevention and control (IPC) practices.
In a paper published yesterday in Morbidity and Mortality Weekly Report, researchers from the Centers for Disease Control and Prevention (CDC), the New Jersey Department of Health (NJDOH), and Rutgers University report on an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) at an unnamed 500-bed hospital that occurred during the spring surge of coronavirus infections in the state.
A total of 34 patients were found to be infected or colonized with the multidrug-resistant pathogen, which frequently contaminates healthcare surfaces and is considered an urgent health threat by the CDC. An investigation revealed that the surge in cases at the hospital, which peaked on Apr 9, resulted in deviance from routine IPC measures that may have continued to the outbreak.
"The occurrence of this cluster underscores the potential for multidrug-resistant organisms (MDROs) to spread during events when standard hospital practices might be disrupted," the authors of the paper wrote.
Routine practices disrupted
The hospital notified NJDOH of an increase in CRAB isolates from weekly intensive care unit (ICU) point-prevalence surveys and from clinical infections on May 8. A subsequent review of hospital microbiology records and laboratory results dating back to November 2019 identified 20 patients with hospital-acquired CRAB infection and 14 who were colonized with the pathogen from February through July 2020.
Twenty-eight of the 34 patients were infected or colonized with CRAB during the COVID-19 surge at the hospital, which occurred from March to June, and 17 also had confirmed infection with SARS-CoV-2, the virus that causes COVID-19. Ten of the patients died.
An NJDOH investigation of the outbreak revealed that pandemic-related resource challenges resulted in necessary changes to the hospital's IPC measures. For example, the hospital's respiratory therapy unit instituted a policy to extend the use of ventilator circuits and suctioning catheters unless they were malfunctioning or visibly soiled, rather than replace them at specific intervals, as was done before the pandemic.
To conserve personal protective equipment (PPE), gown use was suspended for patients with the endemic MDROs Enterococcus spp and methicillin-resistant Staphylococcus aureus. There was also a 43% reduction in ICU CRAB screening tests.
COVID-19 caused other disruptions to standard practice that likely contributed to the outbreak. A multidisciplinary team responsible for guiding MDRO prevention efforts was suspended, along with biweekly bedside central venous catheter and indwelling urinary catheter maintenance rounds. Routine audits of appropriate PPE use, hand hygiene compliance, and environmental cleaning were temporarily discontinued. Illnesses among staff and quarantines led to shortages of nursing and environmental services personnel.
"During COVID-19 preparations and the ensuing surge in cases, decreased vigilance for control of CRAB transmissions, including suspension of the MDRO workgroup, reduced surveillance cultures, reduced personnel numbers (which decreased capacity for overall auditing practices), and both intentional and unintentional changes in IPC practice likely contributed to this CRAB cluster," the authors said.
CRAB decline seen after surge
In June the hospital reported fewer CRAB cases after the peak of the surge had passed, the hospital's IPC leaders had notified physicians and staff of the outbreak, environmental services had terminally cleaned and infected COVID-19 ICUs, and routine compliance audits resumed. That trend continued through July, and in August no CRAB cases were reported.
"This outbreak highlights that MDROs can spread rapidly in hospitals experiencing surges in COVID-19 cases and cause serious infections in this setting," the authors concluded. "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."