key: cord-0828712-arxv1l1c
authors: Elliott, Thomas M.; Hurst, Cameron; Doidge, Michelle; Hurst, Trish; Harris, Patrick NA.; Gordon, Louisa G.
title: Unexpected benefit of COVID-19 hospital restrictions: reduction in patients isolating with multidrug resistant organisms after restrictions were lifted
date: 2021-08-18
journal: Infect Dis Health
DOI: 10.1016/j.idh.2021.08.001
sha: f98dd5b66c7963797009e4a44479ece62824cb76
doc_id: 828712
cord_uid: arxv1l1c

BACKGROUND: During the COVID-19 pandemic, measures to prevent microorganism transmission were implemented across hospitals, including wearing compulsory surgical masks, minimising non-urgent procedures and restricting visitors. Previously, concerns have been raised that MRO-associated deaths could rise during a future pandemic through superimposed bacterial infections, inappropriate antibiotic use and reduced focus on preventing MRO infections. METHODS: In the state of Queensland, Australia with a population of 5 million, only a short first wave of coronavirus cases occurred and restrictions were quickly scaled back. This presented a natural experiment of pre-, during and post-COVID-19 restriction timings to evaluate the effectiveness of heightened prevention measures on multidrug resistant organism (MRO) infections. Patient isolation days and MRO types were collected weekly from routine infection control reports, at a large public hospital, from 28(th) January 2020 to 24(th) July 2020. In this interrupted time series design, we employed Poisson mixed effect regression modelling to evaluate the difference in incidence of patient isolation days between time periods. RESULTS: Compared to pre-COVID, patient isolation days reduced during COVID restrictions (incidence rate ratio 0.65, 95%CI: 0.59, 0.70; p<0.001) and increased again post-COVID restrictions, but did not return to pre-COVID levels (0.87, 95%CI: 0.80, 0.95; p=0.001). The efficiency of isolating patients improved after COVID-19 with fewer bed closures required. CONCLUSION: Heightened infection control awareness, hand sanitation and mask wearing after COVID-19 restrictions were lifted appear to effectively prevent common hospital-acquired MRO infections.

Termed an 'invisible pandemic', multidrug resistant organisms (MRO) causing infections in 2 healthcare settings are a growing problem worldwide and result in 700,000 deaths globally each 3

year [1] . Infections with MROs are more difficult to treat, and are associated with poorer outcomes 4 for patients such as increased morbidity, length of stay, additional treatment and increased costs to 5 the health care system [1] . Managing MRO aims to minimise MRO transmission through surveillance 6 and by creating barriers between contacts. Hospitals enact this through targeted measures such as 7 alerts and notification systems, isolating patients, hand hygiene practices and wearing personnel 8 protective equipment. During the Coronavirus Disease 2019 (COVID-19) pandemic, several additional 9 infection control measures were implemented across hospitals to prevent viral transmission. These 10 included compulsory surgical masks, delaying surgeries and increasing the use of telehealth. 11

In Queensland Australia the first COVID-19 wave peaked in late March with around 78 cases per day. 12

The wave was small compared with elsewhere in the world with Queensland only having 10+ cases 13 per day for 28 days from mid-March 2020 [2] . On 23 rd March 2020, Brisbane hospitals elevated their 14 response by reducing hospital service capacity [3] . During the height of the COVID-19 response, 67% 15 of outpatient appointments were conducted via phone or videoconferencing [4] and 50% of all 16 elective surgery activity was suspended [5] . Due to international and interstate border closures 17 along with 'stay at home' orders, the surge of COVID-19 patients in Brisbane was avoided. On the 1 st 18

June 2020, reduced patient capacity orders were reversed but universal mask wearing and hand 19 sanitation stations across all facilities remained [5] . 20 Previously, concerns have been raised that MRO-associated deaths could rise during a future 21 pandemic through superimposed bacterial infections, inappropriate antibiotic use and reduced focus 22 on preventing MRO infections [6] . However, a study during the COVID-19 pandemic showed the 23 prolonged use of intensive preventive measures could decrease MRO burden [7] . To inform this 24 further, here we describe a natural experiment, based on the COVID-19 experience in Brisbane, Data were collected on 'patient isolation days' defined as the number of days where a patient was 15 isolated due to harbouring one or more of the MROs of concern. Ward locations were collected for 16 each patient in isolation from 28 th January to 24 th July 2020 (129 days), excluding weekends and 17 public holidays. In each ward, the number of single-bed isolation rooms vary between 2 and 6, and 18 when filled, patients are isolated in multi-bed rooms (hereafter called non-isolation rooms). 19

Prioritising patients with viral pathogens limits the single-bed isolation rooms available to patients 20 with MROs. 'Patient isolation days' include patients isolated in either dedicated single rooms or non-21 isolation rooms. Monthly occupied bed day reports were used to assess patient capacity. 22

Analysis: 23 J o u r n a l P r e -p r o o f In this interrupted time-series design, a Poisson mixed-effect regression analysis was employed to 1 evaluate the difference in patient isolation days between the pre-, during and post-COVID-19 2 restriction time periods. Ward was used as the random effect in the Poisson mixed effect regression 3 to account for potential clustering effect at this level, and isolation events were offset by the 4 occupied bed days to calculate incidence rate ratios (IRR). We also assessed the subset of non- We identified an overall decrease in the number of patients isolating with MROs during the COVID-3 19 restrictions that subsequently rose after the restrictions were lifted but did not return to pre-4 COVID-19 levels. This decrease was evident across all but one MRO type. We highlight improved 5 isolation efficiency with the continued decrease in non-isolation room use for isolating patients with 6

MROs. If maintained post pandemic, this improved isolation efficiency could save AU$54,692 per 7 month in hospital costs [8] through reducing closure of multi-bed rooms. 8

Three studies have investigated the heightened precautions associated with COVID-19 and its impact 9 on incidence of MROs. An Italian study found a significant reduction in the incidence of total MRO 10 infections during the pandemic compared to previous years [7] . Similar to our study, no changes in 11 detection of Enterococcus faecium infections were identified during COVID-19 restrictions. Also 12 similar to our findings, in a Belgian study, no differences in the acquisition rate of MROs in the 13 intensive care unit (ICU) were found before and during the COVID-19 pandemic [9] . This may be 14 explained by the heightened prevention measures already occurring for patients within an ICU. 15

Within an Italian geriatric population, increased MRO bloodstream infections and mortality were 16 identified in a post COVID-19 outbreak period [10] . However, the small selective sample size (83 17 cultures) and incomplete screening limits the generalizability of these results. We conclude from 18 these studies that a holistic approach is required to understand the impact of COVID-19 precaution 19 measures, rather than within a specific ward. 20

The limitations of this study were the lack of patient-level data and brevity of data collection to 21 further explore this topic. We cannot rule out the impact of changes in patient case mix or other 22 service-line factors (e.g, volume of transplants) that may affect the susceptibility of patients to 23 should be minimal with influenza season not occurring. Balanced against these limitations, was 1 access to patient isolation data before, during and after a COVID-19 wave at a large public hospital. 2 We have shown a hospital committed to reduced microorganism transmission, as occurred during 3 COVID-19 pandemic, can immediately reduce the MRO burden, with potential ongoing 4 improvements in MRO prevention and patient isolation efficiency. J o u r n a l P r e -p r o o f Figure 1 : Incidence rate ratios for MRO isolation days and isolation days in non-isolation rooms (pre-COVID is the referent)

Note: The Incidence rate ratio of isolation days is represented in blue and the subset non-isolation room patient days in orange. The incidence rate ratio was estimated from the interrupted time series analysis. Pre COVID-period is between 28 th of January to 22 nd of March 2020. The During COVID-19 restriction period is between 26 th March and 1 st June 2020. The post COVID-19 restrictions period was between 7 th June to 24 th July 2020.

J o u r n a l P r e -p r o o f

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Queensland COVID-19 statistics

-COVID-19 (coronavirus) Message from the Chief Executive In: Metro North Hospital and Health Service

The Metro North Hospital and Health Service. Metro North Hospital and Health Service Annual Report

Quarter of a billion dollar elective surgery blit

Collateral damage of the COVID-19 pandemic: Exacerbation of antimicrobial resistance and disruptions to antimicrobial stewardship programmes? South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 2020

Martelletti P Reduction of Multidrug-Resistant (MDR) Bacterial Infections during the COVID-19 Pandemic: A Retrospective Study

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The Acquisition of Multidrug-Resistant Bacteria in Patients Admitted to COVID-19 Intensive Care Units: A Monocentric Retrospective Case Control Study

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