Journal of The Academy of Clinical Microbiologists

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 23  |  Issue : 1  |  Page : 14--17

'Double Trouble' -Antimicrobial resistance and COVID-19 A study on health care associated infections and multidrug resistant organisms in critical care units during the global pandemic


K Raksha1, Poorani Gopinath2,  
1 Central Laboratory, St. Martha's Hospital, Bengaluru, Karnataka, India
2 Department of General Medicine, St. Martha's Hospital, Bengaluru, Karnataka, India

Correspondence Address:
Dr. K Raksha
St. Martha's Hospital, #5, Opposite Reserve Bank of India, Nrupatunga Road, Bengaluru - 560 001, Karnataka
India

Abstract

INTRODUCTION: Healthcare-associated infections (HAIs) contribute to mortality and morbidity in critical care units. The influence of the ongoing coronavirus disease (COVID-19) pandemic on the already existing silent pandemic of antimicrobial resistance, especially in a critical care setting in our experience, is discussed here in this perspective. MATERIALS AND METHODS: In our prospective single-centred study over three months (July to September 2020), 123 COVID-19-positive patients admitted in the medical and surgical intensive care units (ICUs) were enrolled after institutional ethical clearance and informed consent. Patient characteristics and risk factors for HAIs were studied using univariate analysis. Antimicrobial usage was monitored based on high-end antibiotic usage monitoring policy. RESULTS: Of 123 COVID-19 patients, 98 were mechanically ventilated and 47% (46/98) developed ventilator-associated pneumonia (VAP) with predominant strain of multidrug-resistant (MDR) Klebsiella pneumoniae. In patients with central line, 26% (10/38) developed central line-associated bloodstream infection (CLABSI) with coagulase-negative Staphylococcus. In catheterised patients, 51% (23/45) developed catheter-associated urinary tract infection (CAUTI) with predominant MDR K. pneumoniae and Acinetobacter baumannii complex. The significant risk factors for VAP were acute respiratory distress syndrome (ARDS), acute kidney injury, duration of mechanical ventilation, steroid therapy and longer ICU length of stay. Patients with CAUTI had diabetes and chronic kidney disease, were on steroids and had a longer ICU stay. Patients with CLABSI had more ARDS, had diabetes, were mechanically ventilated longer and had longer ICU stay. A 57%–84% increase in consumption of antibiotics was seen in our set-up with Azithromycin, Colistin, Meropenem and newer β-lactam/β-lactamase inhibitor combinations like Ceftazidime/Avibactam. CONCLUSION: HAIs in a critical setting with patients admitted with COVID-19 need special focus in terms of prevention and control. In our study, we highlight the incidence of VAP and a need to monitor these key quality indicators including antimicrobial prescription practices.



How to cite this article:
Raksha K, Gopinath P. 'Double Trouble' -Antimicrobial resistance and COVID-19 A study on health care associated infections and multidrug resistant organisms in critical care units during the global pandemic.J Acad Clin Microbiol 2021;23:14-17


How to cite this URL:
Raksha K, Gopinath P. 'Double Trouble' -Antimicrobial resistance and COVID-19 A study on health care associated infections and multidrug resistant organisms in critical care units during the global pandemic. J Acad Clin Microbiol [serial online] 2021 [cited 2021 Nov 29 ];23:14-17
Available from: https://www.jacmjournal.org/text.asp?2021/23/1/14/326046


Full Text



 Introduction



At the beginning of the last year, there were two pandemics. One was uncurbed, overlooked and silent. The other was new, noticed and notified. The first is antimicrobial resistance (AMR). The second is the ongoing coronavirus disease (COVID-19) pandemic with growing number of cases as hospital admissions increase the risk of healthcare-associated infections and the transmission of multidrug-resistant (MDR) organisms, which in turn lead to increased antimicrobial use.[1] In this study, we report the current challenges in critical care units with regard to issues existing pre-COVID-19 and augmented by COVID-19 with a special focus on healthcare-associated infections (HAIs) and MDR organisms. There is an increasing need to monitor and implement infection control and antimicrobial stewardship strategies in these areas. The aim and objectives of the study were as follows:

To study the occurrence of HAIs in COVID-19-positive patients admitted in critical care unitsTo study the incidence of infections caused by MDR organisms COVID-19-positive patients admitted in critical care unitsTo study the pattern of antimicrobial prescription practice for COVID-19-positive patients.

 Materials and Methods



Our prospective single-centred study involved 123 patients admitted in our medical and surgical intensive care units (ICUs) over a period of three months (July to September 2020) and who were tested positive for COVID-19 by reverse transcription–polymerase chain reaction. All patients or their guardian had an information about the data collection and gave their approval. Ethical clearance from the institutional committee was obtained for the study.

Continuous variables were described as median whereas categorical variables were expressed as frequencies (%), and group comparisons of continuous variables were performed using Student's t-test. Categorical data were compared using Chi-square test for count data. As per the Hospital Infection Control Policy, the HAIs are monitored as key quality indicators on a monthly basis with checklists based on standard definitions, criterions established for HAIs with reporting instructions.[2] Antibiotic usage monitoring was done using high-end antibiotic use monitoring forms.

 Results



Of 123 COVID-19 patients admitted in our critical care units during the study period, 98 had been mechanically ventilated, 45 of them were on Foley's catheter and 38 of them were on central line access [Table 1]. Amongst the mechanically ventilated patients, 47% (46/98) developed ventilator-associated pneumonia (VAP), with predominant strain being MDR Klebsiella pneumoniae. Colonisation was seen in 29% (28/98) patients with Klebsiella, Pseudomonas, Escherichia coli and Acinetobacter baumannii complex. In patients with central line, 26% (10/38) developed central line-associated bloodstream infection (CLABSI) with coagulase-negative Staphylococcus followed by MDR K. pneumoniae. In catheterised patients, 51% (23/45) developed catheter-associated urinary tract infection (CAUTI) with predominant MDR K. pneumoniae and A. baumannii complex [Table 1] and [Table 2].{Table 1}{Table 2}

In univariate analysis, patients with VAP had more acute respiratory distress syndrome (ARDS) and more acute kidney injury, were mechanically ventilated longer, were on steroids and had a longer ICU length of stay similar to a study by Dudoignon et al.[3] Patients with CAUTI had diabetes and chronic kidney disease, were on steroids and had a longer ICU stay. Patients with CLABSI had more ARDS, had diabetes, were mechanically ventilated longer and had longer ICU stay [Table 3].{Table 3}

On monitoring of high-end antibiotic usage using recommended checklists, it was found that majority of them were on Piperacillin / Tazobactam (62%) and Meropenem (28%) which were escalated to high-dose Meropenem and Colistin with Amikacin or alternate antibiotics based on antibiotic susceptibility pattern. A 57%–84% increase in consumption of antibiotics was seen in our set-up with Azithromycin, Colistin, Meropenem and newer β-lactam/β-lactamase inhibitor combinations like Ceftazidime/Avibactam.

Care bundle compliance was assessed for these HAIs in view of the increase in the number of cases by the infection control team A root cause analysis (RCA) was done for the MDR K. pneumoniae outbreak with VAP, CAUTI and CLABSI and increase in colonisation in these COVID-19 patients.

 Discussion



Critical care with COVID-19 has turned out to be nothing less than a battlefield for healthcare professionals in terms of infection control and individual case management. An unprecedented increase in the number of cases has made associated HAIs look like a mammoth of a challenge.[3],[4],[5] To our knowledge, this is the first study from India identifying this problem; we have noticed higher rates of colonisation and infections with MDR K. pneumoniae in our set-up. After RCA, retraining of staff on hand hygiene, infection control protocols, deep cleaning, staffing ratio and rational antibiotic use was done by our infection control team which is being monitored with a 'back-to-basics' approach.[6]

We reported a significant rate of bacterial pneumonia, mostly MDR VAP, in critically ill patients with COVID-19 in our critical care units. Our study highlights the role of set processes with case definitions, routine surveillance, case tracking and retraining. The role of microbiological cultures in early diagnosis to decide antimicrobial therapy in these high-risk patients is another issue as opposed to earlier impression of lesser microbiological tests. The limitations of our study was that it was a single centre study, also there was no comparative data from previous studies. Policy changes in admission and discharge based on national, state, or local guidelines during the course of the COVID-19 pandemic were also important factors which would have an effect on the patient's course of treatment and recovery in the critical care unit. The higher mortality rates in our study can be attributed to secondary bacterial infections which are a part of the already existing larger and silent pandemic, AMR.[7],[8] Lest we forget, our efforts need to be collaborative and innovative.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1McMullen KM, Smith BA, Rebmann T. Impact of SARS-CoV-2 on hospital acquired infection rates in the United States: Predictions and early results. Am J Infect Control 2020;48:1409-11.
2Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309-32.
3Dudoignon E, Caméléna F, Deniau B, Habay A, Coutrot M, Ressaire Q, et al. Bacterial pneumonia in COVID-19 critically ill patients: A case series. Clin Infect Dis 2021;72:905-6.
4Clancy CJ, Nguyen MH. Coronavirus disease 2019, superinfections, and antimicrobial development: What can we expect? Clin Infect Dis 2020;71:2736-43.
5Getahun H, Smith I, Trivedi K, Paulin S, Balkhy HH. Tackling antimicrobial resistance in the COVID-19 pandemic. Bull World Health Organ 2020;98:442-2A.
6Nieuwlaat R, Mbuagbaw L, Mertz D, Burrows LL, Bowdish DME, Moja L, et al. Coronavirus disease 2019 and antimicrobial resistance: Parallel and interacting health emergencies. Clin Infect Dis 2021;72:1657-9.
7Yam ELY. COVID-19 will further exacerbate global antimicrobial resistance. J Travel Med. 2020 Sep 26;27(6).
8Clancy CJ, Buehrle DJ, Nguyen MH. PRO: The COVID-19 pandemic will result in increased antimicrobial resistance rates. JAC-Antimicrob Res 2020;2:dlaa049.