Bloodstream Infection Risk, Incidence, and Deaths for Hospitalized Patients During Coronavirus Disease Pandemic

Bhavarth S. Shukla; Prem R. Warde; Eric Knott; Sebastian Arenas; Darryl Pronty; Reinaldo Ramirez; Arely Rego; Miriam Levy; Martin Zak; Dipen J. Parekh; Tanira Ferreira; Hayley B. Gershengorn

Disclosures

Emerging Infectious Diseases. 2021;27(10):2588-2594.

Abstract and Introduction

Abstract

Hospital-acquired infections are emerging major concurrent conditions during the coronavirus disease (COVID-19) pandemic. We conducted a retrospective review of hospitalizations during March–October 2020 of adults tested by reverse transcription PCR for severe acute respiratory syndrome coronavirus 2. We evaluated associations of COVID-19 diagnosis with risk for laboratory-confirmed bloodstream infections (LCBIs, primary outcome), time to LCBI, and risk for death by using logistic and competing risks regression with adjustment for relevant covariates. A total of 10,848 patients were included in the analysis: 918 (8.5%) were given a diagnosis of COVID-19, and 232 (2.1%) had LCBIs during their hospitalization. Of these patients, 58 (25%) were classified as having central line–associated bloodstream infections. After adjusting for covariates, COVID-19–positive status was associated with higher risk for LCBI and death. Reinforcement of infection control practices should be implemented in COVID-19 wards, and review of superiority and inferiority ranking methods by National Healthcare Safety Network criteria might be needed.

Introduction

The incidence of co-infection with either bacterial or fungal pathogens in patients hospitalized because of coronavirus disease (COVID-19) during the ongoing pandemic has become a topic of great interest. Hospitalized COVID-19 patients have shown co-infection rates as low as 7%^[1]and as high as 15%, and as many as 27% of those who ultimately die are co-infected.

Abstract and Introduction
Methods
Results
Discussion
References

Table 1. Patients characteristics by outcome on bloodstream infection risk, incidence, and deaths for hospitalized patients during coronavirus disease pandemic, Miami, Florida, USA, March 25–October 27, 2020*
Characteristic	Full cohort for LCBI analyses, no. (%)						Central line cohort for CLABSI analyses, no. (%)
	NHSN LCBI			NHSN LCBI (HAI)			Central line cohort for CLABSI analyses, no. (%)
	No LCBI	LCBI	p value†	No LCBI	LCBI	p value†	No CLABSI	CLABSI	p value†
Patient admissions	10,616 (97.9)	232 (2.1)		10,694 (98.6)	154 (1.4)		2,840 (98.0)	58 (2.0)
COVID-19 RT-PCR positive	854 (8.0)	64 (28)	<0.001	857 (8.0)	61 (40)	<0.001	365 (13)	32 (55)	<0.001
Age, y	63 (52–73)	66 (55–74)	0.093	63 (52–73)	66 (54–74)	0.4	66 (55–76)	66 (56–72)	0.3
Sex‡			0.094			0.001			0.016
M	5,479 (52)	134 (58)	0.094	5,512 (52)	101 (66)	0.001	1,343 (47)	37 (64)	0.016
F	5,136 (48)	98 (42)		5,181 (48)	53 (34)		1,497 (53)	21 (36)
Race/ethnicity			0.041			0.053			<0.001
Non-Hispanic White	2,318 (22)	33 (14)		2,330 (22)	21 (14)		553 (19)	7 (12)
Non-Hispanic Black	280 (2.6)	3 (1.3)		281 (2.6)	2 (1.3)		76 (2.7)	1 (1.7)
Hispanic White	5,152 (49)	123 (53)		5,188 (49)	87 (56)		1,338 (47)	33 (57)
Hispanic Black	1,952 (18)	49 (21)		1,976 (18)	25 (16)		647 (23)	4 (6.9)
Other	577 (5.4)	17 (7.3)		581 (5.4)	13 (8.4)		154 (5.4)	8 (14)
Unknown	337 (3.2)	7 (3.0)		338 (3.2)	6 (3.9)		72 (2.5)	5 (8.6)
Payer			<0.001			<0.001			0.077
Commercial	3,849 (36)	59 (25)		3,869 (36)	39 (25)		741 (26)	15 (26)
Government	73 (0.7)	4 (1.7)		74 (0.7)	3 (1.9)		17 (0.6)	2 (3.4)
Medicaid	1,248 (12)	35 (15)		1,254 (12)	29 (19)		407 (14)	12 (21)
Medicare	4,964 (47)	130 (56)		5,014 (47)	80 (52)		1,597 (56)	27 (47)
Other	482 (4.5)	4 (1.7)		483 (4.5)	3 (1.9)		78 (2.7)	2 (3.4)
BMI, kg/m²§	27 (23–31)	26 (23–30)	0.2	27 (23–31)	27 (23–31)	0.7	26 (22–31)	28 (25–33)	0.028
Elixhauser comorbidity index	15 (4–29)	27 (15–40)	<0.001	15 (4–29)	26 (15–39)	<0.001	23 (11–36)	22 (12–34)	>0.9
Urethral catheter	3,406 (32)	126 (54)	<0.001	3,430 (32)	102 (66)	<0.001	1,249 (44)	45 (78)	<0.001
Central line	2,690 (25)	208 (90)	<0.001	2,754 (26)	144 (94)	<0.001	NA	NA	NA
Mechanical ventilation	750 (7.1)	97 (42)	<0.001	767 (7.2)	80 (52)	<0.001	569 (20)	39 (67)	<0.001
Steroid treatment	3,094 (29)	127 (55)	<0.001	3,119 (29)	102 (66)	<0.001	1,155 (41)	49 (84)	<0.001
ICU admission	2,043 (19)	135 (58)	<0.001	2,067 (19)	111 (72)	<0.001	1,118 (39)	48 (83)	<0.001
Dialysis	657 (6.2)	82 (35)	<0.001	682 (6.4)	57 (37)	<0.001	312 (11)	29 (50)	<0.001
SOFA score¶	1 (0–3)	3 (2–5)	<0.001	1 (0–3)	3 (2–5)	<0.001	2 (1–4)	3 (2–4)	0.055
Central line duration, d	0.0 (0.0–0.3)	14.2 (5.0–28.0)	<0.001	0.0 (0.0–0.4)	20.8 (10.2–34.3)	<0.001	5 (3–11)	28 (15–54)	<0.001
Hospital LOS, d	3.5 (1.9–6.9)	18.8 (9.4–30.9)	<0.001	3.5 (1.9–6.9)	24.9 (14.3–36.7)	<0.001	8 (5–14)	29 (20–50)	<0.001
Deaths in hospital	258 (2.4)	50 (22)	<0.001	267 (2.5)	41 (27)	<0.001	201 (7.1)	21 (36)	<0.001

*Values are no. (%) or median (IQR). BMI, body mass index; CLABSI, central line–associated bloodstream infection; COVID-19, coronavirus disease; HAI, healthcare associated infection; IQR, interquartile range; LCBI, laboratory-confirmed bloodstream infection; LOS, length of stay; NA, not applicable; NHSN, National Healthcare Safety Network; RT-PCR, reverse transcription PCR; SOFA. sequential organ failure assessment.
†Statistical tests performed: Fisher exact test; Wilcoxon rank-sum test; χ² test of independence.
‡One patient of an unknown sex in the full cohort (did not have an LCBI).
§Eight patients had missing BMIs in the full cohort (3 in the CLABSI cohort); none had a bloodstream infection.
¶Indicates patients who had missing SOFA scores: 4,815 (55%) of no LCBI full cohort, 104 (55%) of LCBI full cohort, 4,851 (55%) of no LCBI-HAI full cohort, 68 (56%) of LCBI-HAI full cohort, 1,355 (52%) of no CLABSI, and 25 (57%) of CLABSI patients.

Table 2. Adjusted association for virus positivity with outcomes for patients during the coronavirus disease pandemic, Miami, Florida, USA, March 25–October 27, 2020*
Cohort	Primary outcome	OR/HR (95% CI)
Full	Risk for LCBI†	3.88 (2.70–5.51)
	Time to LCBI‡	2.35 (1.77–3.13)
	Risk for death,§ adjusted for LCBI	6.68 (4.94–9.01)
	Risk for LCBI-HAI†	5.58 (3.67–8.43)
	Time to LCBI-HAI‡	2.73 (1.94–3.85)
	Risk for death,§ adjusted for LCBI-HAI	6.64 (4.91–8.96)
Central line	Risk for CLABSI†	5.68 (2.94–11.1)
	Time to CLABSI‡	2.86 (1.75–4.65)
	Risk for death§	5.30 (3.68–7.64)

*All p values were <0.001. BMI, body mass index; CLABSI: central line–associated bloodstream infection; HR, hazard ratio; ICU, intensive care unit; LCBI, laboratory-confirmed bloodstream infection; OR, odds ratio; SOFA, sequential organ failure assessment.
†Modeled with logistic regression including age, sex, race/ethnicity, payer, BMI, no. comorbidities, previous urethral catheter use, previous central line use, previous mechanical ventilation, previous steroid treatment, previous ICU admission, previous dialysis, previous prone positioning, previous remdesivir treatment, tocilizumab treatment, and imputed SOFA score as covariates. OR is reported.
‡Modeled with proportional hazards model including age, sex, race/ethnicity, payer, BMI, no. comorbidities, previous urethral catheter use, previous central line use, previous mechanical ventilation, previous steroid treatment, previous ICU admission, previous dialysis, and imputed SOFA score as covariates. HR is reported.
§Modeled with logistic regression including age, sex, race/ethnicity, payer, BMI, no. comorbidities, urethral catheter days, central line days, previous mechanical ventilation days, steroid treatment days, ICU days, dialysis days, imputed SOFA score, and LCBI as covariates; OR is reported.

Table 3. Subgroup analysis of clinical variables in patients who had COVID-19 and bloodstream infection risk, incidence, and deaths for hospitalized patients during coronavirus disease pandemic, Miami, Florida, USA, March 25–October 27, 2020*
Characteristic	LCBI		LCBI HAI		CLABSI
Characteristic	OR (95% CI)	p value	OR (95% CI)	p value	OR (95% CI)	p value
Sex
M	1.84 (0.96–3.61)	0.068	2.09 (1.07–4.23)	0.034	3.50 (1.29–10.7)	0.019
F	0.54 (0.28–1.04)	0.068	0.48 (0.24–0.93)	0.034	0.29 (0.09–0.77)	0.019
Age, y	0.97 (0.94–1.00)	0.03	0.97 (0.94–1.00)	0.029	0.99 (0.94–1.03)	0.6
BMI, kg/m²	0.99 (0.94–1.04)	0.7	0.99 (0.95–1.05)	0.8	0.98 (0.91–1.05)	0.5
Comorbidity index	1.00 (0.98–1.03)	0.9	1.00 (0.97–1.02)	0.8	0.97 (0.93–1.00)	0.094
Previous urethral catheter	1.96 (0.75–5.18)	0.2	1.99 (0.74–5.41)	0.2	1.60 (0.28–10.2)	0.6
Previous central line	8.11 (2.40–37.3)	0.002	11.7 (2.94–78.2)	0.002	NA	NA
Previous mechanical ventilation	2.82 (0.91–9.89)	0.086	2.18 (0.70–7.44)	0.2	∞ (0.00–∞)	>0.9
Previous steroid treatment	0.91 (0.40–2.14)	0.8	0.91 (0.39–2.21)	0.8	1.42 (0.35–6.73)	0.6
Previous ICU admission	2.47 (0.74–7.61)	0.12	3.56 (1.07–11.5)	0.034	0.00 (0.00–∞)	>0.9
Previous dialysis	1.01 (0.46–2.14)	>0.9	0.95 (0.43–2.07)	>0.9	0.59 (0.20–1.68)	0.3
Prone positioning	1.09 (0.49–2.37)	0.8	1.21 (0.55–2.69)	0.6	2.02 (0.64–6.97)	0.2
Remdesivir treatment	1.58 (0.78–3.24)	0.2	1.58 (0.76–3.32)	0.2	1.29 (0.45–3.77)	0.6
Tocilizumab treatment	1.29 (0.42–3.77)	0.6	1.23 (0.39–3.62)	0.7	1.10 (0.25–4.44)	0.9
SOFA score imputed	1.00 (0.86–1.14)	>0.9	0.96 (0.82–1.10)	0.6	0.083 (0.63–1.03)	0.12

*Model also adjusted for race/ethnicity and payer (these variables had no major association with outcomes). BMI, body mass index; CLABSI, central line–associated bloodstream infection; ICU, intensive care unit; LCBI, laboratory–confirmed bloodstream infection; NA, not applicable; SOFA, sequential organ failure assessment.

processing....

Bloodstream Infection Risk, Incidence, and Deaths for Hospitalized Patients During Coronavirus Disease Pandemic

Abstract and Introduction

Abstract

Introduction

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

Most Popular Articles

Email This

Feedback