Secondary gains of strategies to prevent COVID 19 infection in neonatal intensive care unit: has the frequency of healthcare-associated infections decreased?

doi:10.21203/rs.3.rs-2590536/v1

Purpose

We aimed to compare the frequency and distribution of healthcare associated infections (HAI) in the neonatal intensive care unit at two different times (during pre-COVID-19 period and during COVID-19 period). Our hypothesis as infection control measures taken due to COVID-19 infection have a positive effect on reducing the frequency of HAIs in the neonatal intensive care unit.

Method

Our study was conducted between March - September 2019 (pre-COVID-19 period) and March - September 2020 (during COVID-19 period). All cases with HAIs were included. Demographic characteristics, interventional procedures, feeding style, morbidity and mortality and infection foci were recorded in the case follow-up form. The data obtained in the two periods were compared.

Results

During the determined study period, 427 babies in the pre-COVID-19 period and 530 babies in the COVID-19 period were evaluated. HAIs were determined in 47 patients (60 attack) and 39 patients (44 attack) in the pre-COVID-19 period and during the COVID-19 period, respectively. HAIs incidence density were found 5.43 in pre-COVID-19 period and 4.87 in COVID-19 period. During the COVID-19 period, there was a significant decrease in the healthcare-associated infection incidence density, hospital-associated infection rate and bloodstream infection (p:0.009). No statistical difference was found in catheter-related infection rate (p:0.35) and ventilator associated pneomonia rate (p:0.19).

Conclusions

It has been determined that COVID-19 infection prevention strategies reduce the frequency of healthcare associated infection especially in bloodstream infection in neonatal intensive care units.

Healthcare associated infection

neonatal intensive care unit

COVID-19

The frequency of hospital-acquired infections during the COVID-19 period in neonatal intensive care units is unknown. Bloodstream infections are less common in hospitals where hand hygiene compliance is higher.

what is new

COVID-19 infection prevention strategies reduce the frequency of HAI in NICUs.

In the period of COVID-19, the rate of blood-related infections has decreased significantly

Healthcare-associated infection (HAI); It is the most important factor that increases mortality, morbidity and treatment costs in neonatal intensive care units (NICU) [1]. Newborn babies are in the high risk group for the development of HAI [2, 3]. According to the distribution and frequency of HAIs developing in the neonatal period; bloodstream infections, catheter-related and ventilator-associated infections, urinary tract infections, meningitis, and skin infections are reported [4, 5]. It has been reported that the distribution of HAI incidence rates in NICU is quite different according to countries, and the incidence of HAI varies between 4.8–22 per 1000 hospitalization days [6]. It has been shown that when the rate of compliance with HAI prevention policies is increased, the rates of developing HAI in the neonatal period decrease [7, 8].

The World Health Organization named the disease developed by the severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) agent as coronavirus disease 2019 (COVID-19). The epidemic was classified as an "international public health emergency" on January 30, 2020 and defined as a pandemic on March 11, 2020 [9, 10]. The disease is highly contagious, and all people are susceptible to the disease so extensive measures were taken to prevent the spread of the disease at the community and hospitals. All over the world and in our country, strategies to prevent COVID-19 infection have been developed for the neonatal period [11, 12]. All of these strategies overlap with HAI prevention strategies.

The widespread and rapid outbreak of COVID- 19 is a major challenge for healthcare centers, for prevention and control of nosocomial infections. Recent studies have reported the impact of COVID-19 outbreak on the development of HIA [13–15]. Studies usually include adult intensive care units (ICU), some include NICU [13, 16, 17]. It is reported that the total rate of nosocomial infections decreased by 19.5% in a study involving adult intensive care units (ICU) during the covid-19 period in Iran. However, a 12.5 point increase was observed in the rate of BSI during the COVID-19 outbreak [13]. In a study comparing the pre- and post-COVID-19 periods with a wide range of cases in China reported that the prevalence of nosocomial infection did not differ significantly between 2019 and 2020 in the ICU, but in the neonatal department, the percentages of patients with a nosocomial infection were lower (1.75% vs. 3.11%) [16]. Additionally, a study to determine the impact of COVID-19 on the incidence of healthcare-associated infection (HAI) in US hospitals reported significant increases in Central–line–associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and ventilator-associated events (VAEs) in 2020 [18].

In our study, we aimed to compare the frequency and factors of HAI detected in the NICU during the period before COVID-19 infection and during the period of COVID-19 infection; and we also aimed to examine the effects of healthcare professionals' implementation of infection prevention strategies on the development of HAIs. To the best of our knowledge, similar data on the NICU prevalence of nosocomial infections influenced by the COVID-19 pandemic has not been presented previously. We hypothesize that infection control measures taken due to COVID-19 infection have a positive effect on reducing the frequency of HAIs in the NICU.

Design, setting, and participants

The study was conducted between 1 March − 1 September 2019 (6-month period before COVID-19 pandemic) and 1 March − 1 September 2020 (during COVID-19 pandemic, 6-month period), in University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital, NICU. All of the health care-associated infections detected during the specified periods were included in the study. Ethical approval of our study (2975/2020 number) was obtained from the ethics committee of our hospital. Ministry of Health scientific publication application and approval (2020-09-03T14_25_32) has been made.

Centers for Disease Control and Prevention (CDC) diagnostic criteria, National Hospital Infections Surveillance Network (NHISN) diagnostic criteria and Turkish Neonatology Society's diagnosis and treatment guidelines for neonatal infections were used for diagnosis of HAIs [1, 19–21].

The diagnosis of healthcare-associated bloodstream infection (HA-BSI) and CLABSIs and CAUTIs and VAEs and central nervous system (CNS) infection and necrotizing enterocolitis (NEC) made according to CDC recommendations [19, 20, 22]. Standard surveillance definitions and exclusion rules are described elsewhere for each HAI type [22].

Clinical sepsis: It is a clinical condition in which clinical and laboratory findings are compatible with sepsis, but the pathogen cannot be produced in cultures [21].

Culture-Proven sepsis: A condition in which clinical and laboratory findings are compatible with sepsis, and the pathogen is produced in cultures taken from sterile areas [21].

Babies with pathogen growth in cultures taken within 48 hours of hospitalization or admission to the unit and the group that were determined as intrauterine/transplacental were excluded. In our hospital, bundle compliance in infection prevention strategy is actively followed by the Hospital Infection Control Committee, and hand hygiene and glove use compliance surveillance is performed on a weekly basis. All sink faucets in our NICU are equipped with automatic sensors and hands are dried with disposable towels after hand washing. Alcohol-based hand sanitizer is used at the bedside of each patient. During their duties, healthcare professionals comply with the rules such as hygienic hand washing, not using jewelry such as watches, rings, bracelets, and using appropriate clothing and barrier materials.

During the COVID-19 period, the shift system was started with specialist physicians, neonatal fellows, pediatric assistants, nurses and staff working in the NICU. Care was taken to ensure that the shift teams were always the same people. Care was taken not to use the common areas in the hospital and not to go out of the clinic. The personnel working in the clinic and the personnel who bring the pharmacy, consumables and food of the clinic were kept separate. In the pre-COVID-19 period, mothers and fathers were visiting the baby in the clinic twice a day, mothers were actively participating in feeding every three hours, and 10 mothers were staying at the mother hotel, which was arranged next to the ward to prepare the babies for discharge. In the COVID-19 period, only one of the parents visited the baby twice a week. The mother’s hotel was evacuated, and the mothers of the babies who were eligible for discharge were taken to care at least 2 time/day, 2 days before the planned discharge. Infants whose mother-infant adaptation was achieved in nutrition and care were discharged. As part of the COVID-19 measures for infants hospitalized in the NICU, breast milk was expressed and given to the infants. Information about the baby's health status was conveyed by the baby's doctor by calling the families daily by phone.

Data collection

All cases with HIAs within the two specified periods were included in the study. Demographic characteristics, morbidity and mortality and infection foci of the babies included in the study were recorded in the case follow-up form. Prenatal and natal period information of infants (gestational age, diagnosis, sex, weight, mode of delivery), interventional procedures (mechanical ventilation, central catheter, urinary catheter and its durations), feeding style (breast milk, formula, total parenteral nutrition and its durations). The use of antibiotics and antifungals, the time of detection of HAI, the focus of infection, the type of pathogenic microorganisms grown in the culture, the hospitalization period of the infants, mortality and early morbidity results were recorded in the study form. In both periods, the rate of compliance of the healthcare professionals with the infection prevention rules and the results of the surveillance reports were added to the study form.

Statistical analysis

All data obtained from the infants' study form were recorded in the SPSS 22.0 for Windows program. Descriptive statistics; mean standard deviation was given as minimum-maximum for numerical variables, and as numbers and percentages for categorical variables. The rates detected before and during COVID were compared with chi-square analysis. Statistical significance level was accepted as p < 0.05.

Ethical Issues

The study was approved by both The Ethical Committee of University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital (No:2975/2020) and The Scientific Study Group of The Ministry of Health (No: 2020-09-03T14_25_32). The study was conducted in accordance with the principles stated in the Declaration of Helsinki.

During the determined study period, it was determined that a total of 957 babies were hospitalized, including 427 babies in the pre-COVID-19 period and 530 babies in the COVID-19 period. It was determined that a total of 60 HAIs occurred in 47 patients in the pre-COVID-19 period, and 44 HAIs in 39 patients during the COVID-19 period. There was no difference between gestational week, delivery type, birth weight and sex between babies who developed HAI in both periods. The distribution and comparison of the demographic characteristics of the cases are presented in Table 1.

Among the HAIs, culture-proven sepsis diagnosis was 63.4% in the pre-COVID-19 period, and the clinical sepsis diagnosis was 52.2% in the COVID-19 period. The detailed distribution and comparison of HAI rates in both periods are presented in Table 2.

During the COVID-19 period, there was a significant decrease in the HAI incidence density, hospital-associated infection rate, catheter-related infection rate, and VAEs-related infection rate in the NICU unit compared to the pre-COVID-19 period. The distribution of infection rates detected in both periods are presented in Table 3.

In the pre-COVID-19 period, the distribution of HAI pathogens were: 47.5% gram positive bacteria, 42.5% gram negative bacteria and 10% Candida sp. During the COVID-19 period, the distribution of HAI agents were 56.2% gram negative bacteria, 31.2% gram positive bacteria and 12.5% Candida sp. The most common pathogen produced in culture in the pre-COVID-19 period was coagulase-negative staphylococcus (CONS) (32.5%) and during COVID-19 period, E. coli (25%). There was no statistically significant difference in terms of the distribution of microorganisms grown between the periods (p: 0.539).

When the risk factors affecting the formation of HAIs were examined, it was found that the number of days of hospitalization, the time to start breast milk, the transition to full enteral nutrition, the total parenteral feeding time and the frequency of fluconazole prophylaxis were high in the pre-COVID-19 period (p:0.03, p:0.09, p:0.09, p:0.04, p:0.08, respectively). However, only length of hospitalization and total parenteral feeding time were found to be statistically lower in the COVID-19 periods. The distribution and comparison of the risk factors that are effective in the development of HAI in both periods are presented in Table 4.

In the surveillance study conducted in our NICU, the hand hygiene compliance rates of the healthcare professionals working in both periods and the comparison of these rates are presented in Table 5. There was no significant difference in the ratio between the two periods.

In NICU, the chance of survival of extremely preterm and low-birth-weight babies has increased with innovations in treatment and practices and the increase in the experienced workforce. As a result of the prolongation of hospitalizations of infants with new developments, infections are emerging as an important health problem. HAIs are very important because they cause prolongation of hospital stay, increase in mortality, deterioration in quality of life, loss of workforce and productivity, and increase in costs [23, 24]. In our study, a significant decrease was found in the frequency of HAIs and culture-proven sepsis during the COVID-19 period compared to the pre-COVID-19 period. Hygiene compliance rates of health professionals were found to be similar in both periods.

The incidence of HAI in developed countries is reported as 4.8–22/1000 hospitalization days [6, 25]. In developing countries, it is known that the frequency of healthcare associated infection is 3–20 times higher and it is responsible for 4–56% of neonatal deaths [26]. In a multicenter study conducted by the Turkish Neonatology Society, the frequency of healthcare associated infection was reported as 2.6–17% and the sepsis-related mortality rate was 24.4% in infants hospitalized in the NICU [27]. In our NICU, the nosocomial infection incidence density was reported as 5.1/1000 hospitalization days between 2006–2007 and 10.3/1000 hospitalization days between 2008–2009 [28, 29]. In our study, it was determined as 5.43/1000 patient days in the pre-COVID-19 period and 4.87/1000 patient days in the COVID-19 period. The incidence of healthcare associated infection in both periods was similar to the rates of developed countries. During the COVID-19 era, the incidence of HAIs attacks has decreased. Although a decrease was detected in the mortality rates due to hospital infections during the COVID-19 period, the rates were not statistically significant.

The most common HAIs in NICUs are healthcare-associated bloodstream infection (HA-BSI). In developed countries, the frequency of HA-BSI in neonatal units has been reported as 7-16.7% [30, 31]. The incidence of HA-BSI was reported as 12–14% in Turkey [29, 32]. In our study, it was determined that the frequency of HA-BSI, which was high in the pre-COVID-19 period, decreased significantly during the COVID-19 period. Similarly, it was determined that the pathogen growth rate in blood culture was statistically higher in the pre-COVID-19 period than during the COVID-19 period.

In a multicenter point prevalence study, the rate of clinical sepsis was found to be 40% in patients with healthcare associated infection in NICUs [33]. In our study, it was observed that the rate of clinical sepsis was higher in the COVID-19 period. Despite the increase in the rate of clinical sepsis diagnosis during the COVID-19 pandemic period, culture growths were observed less frequently. We think that the increased the frequency of clinical sepsis diagnosis because of both She/he was more sensitive to the risk of infection in any negative change and the fear of developing infection of the only physician working due to the shift system during the COVID period.

Peripherally inserted central venous catheter and umbilical venous catheter are frequently used in newborn units in low birth weight infants. Healthcare associated infection are frequently associated with the use of central catheters in NICUs [34]. In developed countries, the rate of catheter-related infection has been reported as 3.5–13% and in studies conducted in our country, it has been reported as 9.6–14.3% [29, 32, 35, 36]. In our study, the rate of catheter-related infection was found to be similar to literature studies in the pre-COVID-19 period and the rate of catheter-related HAI was found decreased in the COVID-19 period. VAE is the second most common HAI in NICUs [37, 38]. Its incidence has been reported as 2.7–10.9 per 1000 ventilator days in developed countries [39]. VAEs-associated healthcare associated infection rate was reported as 1.4–3.5% in the United States National Nosocomial Surveillance study, 3.2–8.5% in the study of Yapıcıoğlu et al. and 13.8% in the study of Bolat et al. [29, 32, 35]. In our study, the rate of VAEs-related HAI was found similar in both periods and to be consistent with the literature.

Microorganisms causing bloodstream infection in NICUs can vary over time and from center to center. Today, while gram-negative agents are generally detected in developing countries, it has been reported that coagulase-negative staphylococcus (CONS) are more common in developed countries. In the study of the Turkish Neonatalogy Society, which included 22 centers, it was reported that 45.5% of healthcare associated infection were caused by gram-positive bacteria and 42.9% by gram-negative bacteria [27]. Yalaz et al. reported the most common cause of healthcare associated infection as coagulase-negative staphylococci with a rate of 31.3% [40]. In our study, gram-positive bacteria were the most common factor in the pre-COVID-19 period, while gram-negative bacteria were found to be more common in the COVID-19 period. It was thought that this situation developed as a result of a proportional change due to the decrease in CONS, which are known to be the most common cause of healthcare associated infection in our units. We think that regulating staff work patterns (nurse, assistant physician, and specialist doctor) reduce the frequency of CONS naturally found in the skin flora by reducing multi-person contact.

Patients diagnosed with HAIs generally have a longer hospital stay [41, 42]. It has been shown that the hospitalization period of patients diagnosed with HAI in the NICU is two weeks longer than those who do not [43]. The average hospitalization day of patients diagnosed with HAI was reported than between 27 days and 67 days in the NICU [33]. Newly reported that the length of stay in the pediatric intensive care unit decreased during the COVID-19 period [16]. In our study, the average hospitalization time during the COVID-19 period was significantly reduced compared to the pre-COVID-19 period. The shortening of the transition time to full enteral nutrition and the reduction of total parenteral nutrition time were attributed to the decrease in HAI. We believe that the decrease in the frequency of HAI prevents the prolongation of the hospitalization day.

It has been reported during COVID-19 that training on donning and doffing of personal protective equipment was enhanced, and many hospitals saw increased compliance with contact precautions. It is possible that increased attention to standard infection prevention practices and the use of personal protective equipment impacted HAI rates in a beneficial direction [15]. Bloodstream infections are less common in hospitals where hand hygiene compliance is higher [20]. Multiple factors such as training of healthcare professionals, performance feedback, use of automatic faucets, use of alcohol-based hand sanitizers are required to increase compliance with hand hygiene. In both periods of our study, the rate of hand hygiene was found similarly to be quite high. However, we think that the awareness and continuity of compliance with hand hygiene has increased due to the COVID-19 pandemic outbreak.

Limitations of the study

Retrospective screening of patients in the pre-covid period may not fully reflect the data in this period. Subgroups according to gestational age and birth weight could not be performed because insufficient number of patients.

In our study, we found that COVID-19 infection prevention strategies reduce the frequency of HAI in NICUs. In the period of COVID-19, the rate of blood-related infections has decreased significantly and the frequency of gram positive growth among pathogenic microorganisms has decreased.

CAUTI

Catheter-associated urinary tract infections

CDC

Centers for Disease Control and Prevention

CLABSI

Central–line–associated bloodstream infections

CNS

Central nervous system

COVID-19

Coronavirus disease 2019

HAI

Healthcare associated infections

HA-BSI

Healthcare-associated bloodstream infection

ICU

Intensive care units

NICU

Neonatal intensive care units

VAEs

Ventilator-associated events

Acknowledgments: None

Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Conflict of interest: None to declare

Competing Interests: The authors have no relevant financial or non-financial interests to disclose

Author Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by AB and HA. The first draft of the manuscript was written by AB. All co-authors (EKB and GA) contributed to the review and critically reviewed the revised manuscript. All authors read and approved the final manuscript.

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University Healt Science Sisli Hamidiye Etfal Education and Research Hospital (09/03/2020/No 2975).

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Table 1 Demographic characteristics and comparison of patients with healthcare-associated infections in two periods during the study.

	Pre COVID-19 period n=47	COVID-19 era n=39	p
Gestational age, week^*	30.8±5.5 (23-41)	31.5± 4.7 (23-38)	0.51
Sex, n (%) Male Female	24 (51) 23 (49)	22(50) 22(50)	0.2
Birth weight, g*	1582±994 (446-3600)	1615±938 (600-3500)	0.4
Type of birth , n (%) C/S NSD	35 (74) 12 (26)	32 (82) 7 (18)	0.35
Mortality, n (%)	3 (8.3)	2 (6.6)	0.39

*: mean ±standard deviation (range), C/S: C-section, NSD: Normal spontaneous delivery.

Table 2 Distribution and comparison of healthcare-associated infections detected in newborn babies before and during COVID-19 period*.

	The pre-COVID-19 period Number of patients: 47 Number of attacks: 60	COVID-19 era Number of patients: 39 Number of attacks: 44	p
		n(%)
Clinical Sepsis	22 (36.6)	23 (52.2)	0.45
Culture-Proven Sepsis	38 (63.4)	21 (47.8)	0.47
HA-BSI	22 (36.6)	6 (13.6)	0,009
CLABSIs	24 (40)	13 (29.5)	0.35
VAEs	4 (6.6)	6 (13.6)	0.19
CAUTIs	10 (16.6)	8 (18.1)	0.52
Central nervous system infection	4 (6.6)	4 (10.2)	0.1
Necrotizing enterocolitis	14 (23.3)	11 (25)	0.19
Other (eye, ear, nose, throat, skin infections)	4 (6.6)	2 (4.5)	0.19

CAUTIs: catheter-associated urinary tract infections. CLABSIs: Central–line–associated bloodstream infections, HA-BSI: healthcare-associated bloodstream infection, VAEs: Ventilator-associated events.

*Because there may be multiple foci in cases with HAI, statistical values were given according to the detected infection focus.

Table 3: Healthcare-associated infection rates.

	Pre-COVID-19 period	COVID-19 era
Healthcare-associated infections (HAI), attacks	60	44
NICU HAI incidence density*¹	5,43	4,87
NICU HAI rate*²	8,43	5,66
CLABSIs rate*³	10,76	8,11
HA-BSI rate*⁴	11,27	3,74
VAEs rate*⁵	4,83	4,51

CLABSIs: Central–line–associated bloodstream infections, HA-BSI: healthcare-associated bloodstream infection, VAEs: Ventilator-associated events.

*1: HAI incidence density: (Number of hospital acquired infections / hospitalization days) x 1000

*2: HAI rate: (Number of hospital acquired infections / patient number) x 100

*3: CLABSIs rate: (Catheter related bacteremia number/total catheter days) x 1000

*4: HA-BSI rate: (Number of patients with growth in blood culture / number of inpatients) x 100

*5: VAEs rate: (VAE number / ventilator days) x 1000

Table 4: Comparison of the effective risk factors in the development of healthcare-associated infections in both periods of the study.

	Pre COVID-19 period	COVID-19 era	p
Length of hospitalization, days*	41.2±30.8 (13-153)	39.2±23.7(14-137)	0.03
Mechanical ventilation duration, days*	21.9±38.3 (1-150)	28.9± 38.5(1-130)	0.37
Umbilical catheter duration, days*	5.3 ± 2.2(1-8)	4.9±2.9 (1-10)	0.17
PICC duration, days*	21.2±13.7 (1-76)	19.9±15 (5-50)	0.178
Time to start breast milk, day*	2.6±1.6 (1-8)	2.2±1.3 (1-7)	0.09
Transition time to full enteral feeding, days*	34.7±32.7 (1-78)	25.7±19.9 (1-48)	0.09
Total parenteral feeding time, days*	38.7±35.6 (6-135)	20.9±12.3 (5-48)	0.04
Fluconazole prophylaxis, n (%)	27 (45)	13 (30)	0.08

*Values are given as mean±standar deviation (range).

Table 5: Hand hygiene compliance rates in the surveillance study of health professionals working in the neonatal unit in two periods.

Bundle apps	Pre COVID-19 period	COVID-19 era
Hand hygiene compliance	98.56	98.57
Before-contact	97.06	96.61
Post-contact	98.86	99.12
Before aseptic procedures	100	100
After the risk of contamination from body fluids	100	100
After contact with the patient environment	98.41	98.36

No competing interests reported.

Secondary gains of strategies to prevent COVID 19 infection in neonatal intensive care unit: has the frequency of healthcare-associated infections decreased?

Status:

Version 1

Abstract

Purpose

Method

Results

Conclusions

What Is Known

Introduction

Material And Methods

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

Version 1