key: cord-1007335-np8vv8ib
authors: Sturdy, Ann; Basarab, Marina; Cotter, Meaghan; Hager, Kristina; Shakespeare, David; Shah, Nirav; Randall, Paul; Spray, Dominic; Arnold, Amber
title: Severe COVID-19 and Healthcare Associated Infections on the ICU: Time to Remember the Basics?
date: 2020-06-23
journal: J Hosp Infect
DOI: 10.1016/j.jhin.2020.06.027
sha: ac0f3e42690e3463573be1ec2af70ed25c3a5377
doc_id: 1007335
cord_uid: np8vv8ib

nan

Coronavirus disease 2019 (COVID-19) has posed a significant health care challenge globally, with intensive care unit (ICU) provision being of particular consequence [1] . In the UK, where ICU beds are already lower per head of population than in much of the rest of Europe [2] , there has been a requirement to rapidly expand ICU bed capacity in response. St George's Hospital is a 1000 bedded tertiary care hospital in South West London. From an initial ICU capacity of 60 beds spread over three purpose-built units, ICU beds expanded at peak surge in April 2020 to 83 COVID-19 beds and 13 non-COVID-19 beds (96 in total) involving additional space on two medical wards, a day unit and surgical theatres. Key differences to ICU provision during this time are summarised in table I, and encompass changes in the environment, staffing and personal protective equipment (PPE), which combined to present a substantial infection control challenge. Patients have also had long average stays on ICU over this period, with multiple central venous catheters (CVC), and a high proportion requiring additional access for renal replacement therapy. All of these contributed to an increased risk of infection from both cross-contamination of organisms between patients and within an individual patient.

During a 16 day period in April, 20 Gram-negative bloodstream infections were identified in patients across all of the COVID ICUs. Line days were not recorded, however this equated to 17.95 Gramnegative bloodstream infections per 1000 bed days on the COVID ICUs over this 16 day period. This contrasted to 1.04 Gram-negative bloodstream infections per 1000 bed days over the same 16 day period in the preceding year (2019). Eleven of these were wild type Klebsiella pneumoniae species, with three demonstrating identical typing patterns. Eighteen of 20 patients had ICU stays in excess of 7 days at time of bacteraemia and half had been transferred from other hospitals. The source of bacteraemia was felt to be the CVC in all cases -either due to the same organism growing from a line tip or to the lack of another clear focus. This indicates a higher than expected number of bloodstream infections with a variety of organisms -suggesting that infection was largely caused by organisms from patients' endogenous flora. Given that three of the Klebsiella species however were indistinguishable, this also suggests some transmission between patients -though these patients were all treated on different ICUs.

On identification of the first four Klebsiella pneumoniae bloodstream infections, an outbreak meeting was convened. All issues in Table I were discussed and addressed systematically. With ICU bed requirements beginning to decrease, a decision was made to relocate one of the new ICUs to a larger repurposed ward, and to condense the smaller new ICUs onto the existing units as soon as possible. Staffing ratios were discussed -addressing both increasing nurse to patient ratios and decreasing unnecessary footfall. PPE practices were simplified and standardised with a requirement to don and doff gloves at the bedside rather than on entry to each bay, double gloving was stopped, and aseptic non-touch technique during line care was re-emphasised -all with the aim of reestablishing basic infection control standards. Following these interventions, absolute numbers of Gram-negative bloodstream infections have decreased (to 5.74 per 1000 patients on the COVID-19 ICUs at time of writing this report), noting that this is also on a background of a slowing of COVID-19 ICU admissions.

Evidence from the literature now suggests that concomitant bacterial infection during early COVID-19 is unusual [7] . However, we highlight our experience of later nosocomial infection in the sickest patients requiring ICU care. This is likely to be multifactorial, including challenges inherent in the rapid upscaling of ICU capacity within existing infrastructure, reduced staff to patient ratios and the increased length of stay and complexity of patients. The correct use of PPE in the new pandemic setting has been a particular challenge. The understandable focus on protecting the health care provider from COVID-19 infection has often obscured the importance of the other role of PPE -as part of a basic infection control package to prevent hospital acquired infection. Of note Yap et al, reached a very similar conclusion in a paper documenting increased rates of meticillin-resistant Staphylococcus aureus (MRSA) transmission during the 2009 Severe Acute Respiratory Syndrome (SARS) pandemic [8] . Infection prevention and control skills need to be seen as core training requirements for all health care workers -with the flexibility to adapt this learning in the face of an emergency pandemic response with new PPE requirements. To neglect infection control going forward in the pandemic risks increasing the morbidity and mortality of the sickest COVID-19 patients. 

Hospital Surge Capacity in a Tertiary Emergency Referral Centre During the COVID-19 Outbreak in Italy

NHS Hospital Bed Numbers: Past, Present

Health Building Note 04-02 Critical care units

Guidelines for the Provision of Intensive Care Services

epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England

World Health Organisation. WHO Guidelines on Hand Hygiene in Health Care

Bacterial and Fungal Co-Infection in Individuals With Coronavirus: A Rapid Review to Support COVID-19 Antimicrobial Prescribing

Increase in Methicillin-Resistant Staphylococcus Aureus Acquisition Rate and Change in Pathogen Pattern Associated With an Outbreak of Severe Acute Respiratory Syndrome

Funding Statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The study was carried out in line with the Declaration of Helsinki. Ethical approval with not required according to the Health Research Authority tool, and the study was registered with the local hospital clinical audit group: reference AUDI000634.