Multi-drug-resistant infections in the COVID-19 era: a framework for considering the potential impact

Abstract

The recent report by Jolivet et al. highlights the progress being made on multi-drug-resistant (MDR) infections [[1]Jolivet S. Lolom I. Bailly S. Bouadma L. Lortat-Jacob B. Montravers P. et al.Impact of colonisation pressure on acquisition of extended-spectrum β-lactamase-producing Enterobacteriaceae and meticillin-resistant Staphylococcus aureus in two intensive care units: a 19-year retrospective surveillance.J Hosp Infect. 2020; 105: 10-16Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar]. However, this report predates the coronavirus disease 2019 (COVID-19) pandemic and it is unclear what the impact will be on MDR infections globally. There are reports of high use of broad-spectrum antibiotics in the hospital setting, recognized as a risk factor for hospital-acquired infections (HAIs) with MDR organisms [2Zhou F. Yu T. Du R. Fan G. Liu Y. Liu Z. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062Abstract Full Text Full Text PDF PubMed Scopus (15774) Google Scholar, 3Phua J. Weng L. Ling L. Egi M. Lim C.M. Divatia J.V. et al.Asian Critical Care Clinical Trials GroupIntensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.Lancet Respir Med. 2020; 8: 506-517Abstract Full Text Full Text PDF PubMed Scopus (862) Google Scholar, 4Siegel J.D. Rhinehart E. Jackson M. Chiarello L. Healthcare Infection Control Practices Advisory CommitteeManagement of multidrug-resistant organisms in health care settings 2006.Am J Infect Control. 2007; 35: S165-S193Abstract Full Text Full Text PDF PubMed Scopus (609) Google Scholar]. Recent data have also highlighted significant rates of hospital-acquired pneumonia [[2]Zhou F. Yu T. Du R. Fan G. Liu Y. Liu Z. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062Abstract Full Text Full Text PDF PubMed Scopus (15774) Google Scholar]. High rates of admission, shortages of staff and personal protective equipment (PPE), and high-acuity patients with prolonged stays in overcrowded facilities may also affect the rates of HAI with MDR pathogens [[2]Zhou F. Yu T. Du R. Fan G. Liu Y. Liu Z. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062Abstract Full Text Full Text PDF PubMed Scopus (15774) Google Scholar,[3]Phua J. Weng L. Ling L. Egi M. Lim C.M. Divatia J.V. et al.Asian Critical Care Clinical Trials GroupIntensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.Lancet Respir Med. 2020; 8: 506-517Abstract Full Text Full Text PDF PubMed Scopus (862) Google Scholar]. Moreover, severe COVID-19, which particularly affects elderly patients with multiple comorbidities, may be an important factor in determining changes in colonization pressure [2Zhou F. Yu T. Du R. Fan G. Liu Y. Liu Z. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062Abstract Full Text Full Text PDF PubMed Scopus (15774) Google Scholar, 3Phua J. Weng L. Ling L. Egi M. Lim C.M. Divatia J.V. et al.Asian Critical Care Clinical Trials GroupIntensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.Lancet Respir Med. 2020; 8: 506-517Abstract Full Text Full Text PDF PubMed Scopus (862) Google Scholar, 4Siegel J.D. Rhinehart E. Jackson M. Chiarello L. Healthcare Infection Control Practices Advisory CommitteeManagement of multidrug-resistant organisms in health care settings 2006.Am J Infect Control. 2007; 35: S165-S193Abstract Full Text Full Text PDF PubMed Scopus (609) Google Scholar]. Equally, wider recognition of the importance of HAIs, with stricter hygiene policies, high use of PPE, and patients being cared for in new temporary hospitals, could all mitigate against this threat [[2]Zhou F. Yu T. Du R. Fan G. Liu Y. Liu Z. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062Abstract Full Text Full Text PDF PubMed Scopus (15774) Google Scholar,[3]Phua J. Weng L. Ling L. Egi M. Lim C.M. Divatia J.V. et al.Asian Critical Care Clinical Trials GroupIntensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.Lancet Respir Med. 2020; 8: 506-517Abstract Full Text Full Text PDF PubMed Scopus (862) Google Scholar]. Table I summarizes the potential relative impact of these various factors to provide a conceptual framework for determining the overall impact [2Zhou F. Yu T. Du R. Fan G. Liu Y. Liu Z. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062Abstract Full Text Full Text PDF PubMed Scopus (15774) Google Scholar, 3Phua J. Weng L. Ling L. Egi M. Lim C.M. Divatia J.V. et al.Asian Critical Care Clinical Trials GroupIntensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.Lancet Respir Med. 2020; 8: 506-517Abstract Full Text Full Text PDF PubMed Scopus (862) Google Scholar, 4Siegel J.D. Rhinehart E. Jackson M. Chiarello L. Healthcare Infection Control Practices Advisory CommitteeManagement of multidrug-resistant organisms in health care settings 2006.Am J Infect Control. 2007; 35: S165-S193Abstract Full Text Full Text PDF PubMed Scopus (609) Google Scholar, 5Liu Y. Li J. Feng Y. Critical care response to a hospital outbreak of the 2019-nCoV infection in Shenzhen, China.Crit Care. 2020; 24: 56Crossref PubMed Scopus (62) Google Scholar, 6Kaier K. Mutters N.T. Frank U. Bed occupancy rates and hospital-acquired infections – should beds be kept empty?.Clin Microbiol Infect. 2012; 18: 941-945Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar].Table IPotential impact of coronavirus disease 2019 (COVID-19) on hospital transmission of multi-drug-resistant organisms (MDROs)Factors that may favour MDRO transmissionFactors that may prevent MDRO transmissionInfection prevention and control practices and use of PPEShortage of PPE due to the rapid increase in people admitted with COVID-19 [3Phua J. Weng L. Ling L. Egi M. Lim C.M. Divatia J.V. et al.Asian Critical Care Clinical Trials GroupIntensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.Lancet Respir Med. 2020; 8: 506-517Abstract Full Text Full Text PDF PubMed Scopus (862) Google Scholar, 4Siegel J.D. Rhinehart E. Jackson M. Chiarello L. Healthcare Infection Control Practices Advisory CommitteeManagement of multidrug-resistant organisms in health care settings 2006.Am J Infect Control. 2007; 35: S165-S193Abstract Full Text Full Text PDF PubMed Scopus (609) Google Scholar, 5Liu Y. Li J. Feng Y. Critical care response to a hospital outbreak of the 2019-nCoV infection in Shenzhen, China.Crit Care. 2020; 24: 56Crossref PubMed Scopus (62) Google Scholar]Isolation of patients with COVID-19, application of enhanced standard precautions (hand hygiene policy and respiratory hygiene), use of PPE (when available) and appropriate environmental disinfection procedures [3Phua J. Weng L. Ling L. Egi M. Lim C.M. Divatia J.V. et al.Asian Critical Care Clinical Trials GroupIntensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.Lancet Respir Med. 2020; 8: 506-517Abstract Full Text Full Text PDF PubMed Scopus (862) Google Scholar, 4Siegel J.D. Rhinehart E. Jackson M. Chiarello L. Healthcare Infection Control Practices Advisory CommitteeManagement of multidrug-resistant organisms in health care settings 2006.Am J Infect Control. 2007; 35: S165-S193Abstract Full Text Full Text PDF PubMed Scopus (609) Google Scholar, 5Liu Y. Li J. Feng Y. Critical care response to a hospital outbreak of the 2019-nCoV infection in Shenzhen, China.Crit Care. 2020; 24: 56Crossref PubMed Scopus (62) Google Scholar]Hospital overcrowdingThe need for large-scale medical assistance exceeds the availability of hospital beds, resulting in overcrowded facilities [[3]Phua J. Weng L. Ling L. Egi M. Lim C.M. Divatia J.V. et al.Asian Critical Care Clinical Trials GroupIntensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.Lancet Respir Med. 2020; 8: 506-517Abstract Full Text Full Text PDF PubMed Scopus (862) Google Scholar,[6]Kaier K. Mutters N.T. Frank U. Bed occupancy rates and hospital-acquired infections – should beds be kept empty?.Clin Microbiol Infect. 2012; 18: 941-945Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar]Lack of beds in ICUs has led to new facilities being developed both within and outside current hospital ICU settings, many with existing colonization with MDROs [[3]Phua J. Weng L. Ling L. Egi M. Lim C.M. Divatia J.V. et al.Asian Critical Care Clinical Trials GroupIntensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.Lancet Respir Med. 2020; 8: 506-517Abstract Full Text Full Text PDF PubMed Scopus (862) Google Scholar,[5]Liu Y. Li J. Feng Y. Critical care response to a hospital outbreak of the 2019-nCoV infection in Shenzhen, China.Crit Care. 2020; 24: 56Crossref PubMed Scopus (62) Google Scholar]HCWsHigh rates of staff sickness and nosocomial acquisition of COVID-19, leading to low HCW:patient ratios [[3]Phua J. Weng L. Ling L. Egi M. Lim C.M. Divatia J.V. et al.Asian Critical Care Clinical Trials GroupIntensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.Lancet Respir Med. 2020; 8: 506-517Abstract Full Text Full Text PDF PubMed Scopus (862) Google Scholar,[5]Liu Y. Li J. Feng Y. Critical care response to a hospital outbreak of the 2019-nCoV infection in Shenzhen, China.Crit Care. 2020; 24: 56Crossref PubMed Scopus (62) Google Scholar,[6]Kaier K. Mutters N.T. Frank U. Bed occupancy rates and hospital-acquired infections – should beds be kept empty?.Clin Microbiol Infect. 2012; 18: 941-945Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar]COVID-19-designed ICUs with dedicated HCWs may have decreased cross-transmission of nosocomial infections [[3]Phua J. Weng L. Ling L. Egi M. Lim C.M. Divatia J.V. et al.Asian Critical Care Clinical Trials GroupIntensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.Lancet Respir Med. 2020; 8: 506-517Abstract Full Text Full Text PDF PubMed Scopus (862) Google Scholar,[4]Siegel J.D. Rhinehart E. Jackson M. Chiarello L. Healthcare Infection Control Practices Advisory CommitteeManagement of multidrug-resistant organisms in health care settings 2006.Am J Infect Control. 2007; 35: S165-S193Abstract Full Text Full Text PDF PubMed Scopus (609) Google Scholar]Demographic features of patients affected by COVID-19Elderly patients with comorbidities require prolonged hospitalization with mechanical ventilation support with high use of broad-spectrum antibiotics [2Zhou F. Yu T. Du R. Fan G. Liu Y. Liu Z. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062Abstract Full Text Full Text PDF PubMed Scopus (15774) Google Scholar, 3Phua J. Weng L. Ling L. Egi M. Lim C.M. Divatia J.V. et al.Asian Critical Care Clinical Trials GroupIntensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.Lancet Respir Med. 2020; 8: 506-517Abstract Full Text Full Text PDF PubMed Scopus (862) Google Scholar, 4Siegel J.D. Rhinehart E. Jackson M. Chiarello L. Healthcare Infection Control Practices Advisory CommitteeManagement of multidrug-resistant organisms in health care settings 2006.Am J Infect Control. 2007; 35: S165-S193Abstract Full Text Full Text PDF PubMed Scopus (609) Google Scholar]Lower rates of admission to hospital from long-term care facilities may lead to fewer transmission cycles between long-term care facilities and hospitals [2Zhou F. Yu T. Du R. Fan G. Liu Y. Liu Z. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062Abstract Full Text Full Text PDF PubMed Scopus (15774) Google Scholar, 3Phua J. Weng L. Ling L. Egi M. Lim C.M. Divatia J.V. et al.Asian Critical Care Clinical Trials GroupIntensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.Lancet Respir Med. 2020; 8: 506-517Abstract Full Text Full Text PDF PubMed Scopus (862) Google Scholar, 4Siegel J.D. Rhinehart E. Jackson M. Chiarello L. Healthcare Infection Control Practices Advisory CommitteeManagement of multidrug-resistant organisms in health care settings 2006.Am J Infect Control. 2007; 35: S165-S193Abstract Full Text Full Text PDF PubMed Scopus (609) Google Scholar]PPE, personal protective equipment; HCW, healthcare worker; ICU, intensive care unit. Open table in a new tab PPE, personal protective equipment; HCW, healthcare worker; ICU, intensive care unit. Novel cost-effective surveillance programmes of MDR HAIs in both high- and low/middle-income countries will be even more important in the post-COVID-19 era, combined with enhanced stewardship interventions. These need to be planned for now, to facilitate future integration with any future pandemic surveillance. None declared.