Last month, a 46-year-old military veteran in Houston died of pancreatitis, an urgent but treatable condition, while waiting to be admitted to a hospital overwhelmed with unvaccinated Covid patients. Last week, the governor of Hawaii signed an executive order releasing the state’s hospitals from liability if they turn away sick patients because they have no room. On Monday, the Idaho state health department declared “crisis standards of care,” a triage system that allows hospitals with no spare beds to decide which patients they will accept.
Simultaneously, a Florida high school teacher went viral after describing how he took his 12-year-old to an emergency room that turned out to be overwhelmed with Covid patients. They waited six hours, while his child’s appendix ruptured, a potentially life-threatening event. His son survived—after what the dad described as five days in the hospital, and an initial $5,000 bill.
Stories of patients unable to get into hospitals—stuck in waiting rooms, lingering in ambulances, life-flighted to other states where there might be an open bed—have been an awful constant during this hot-spot summer. Overcrowding is an obvious threat to their health. But it poses a more subtle threat to already admitted patients: It creates conditions, and demands on hospital staff, that allow dangerous infections to spread.
Now a new study shows how real that threat is, based on infection statistics from hospitals that battled the first waves of Covid in 2020. An analysis published last week by the Centers for Disease Control and Prevention in the journal Infection Control and Hospital Epidemiology shows that the pressure of caring for Covid patients has erased years of progress in preventing hospital infections. In 2020, according to a federal registry that collects data from thousands of hospitals, urgent care centers, and outpatient facilities, there were sharp, consistent increases in bloodstream and urinary tract infections related to catheters and pneumonias caused by being put on ventilators—including infections caused by drug-resistant staph, better known as MRSA.
Health-care-associated infections, as they’re known, arise from a collision of factors. Patients become vulnerable to infections when severe illness undermines their immune systems, or requires them to be treated in ICUs in proximity to other sick people. Health care staff can unwittingly carry pathogens from one patient to another, and lifesaving equipment such as catheters and breathing tubes can also allow those pathogens to enter the body.
Those infections are some of the most serious consequences of being hospitalized, especially in intensive care; they can kill up to one in five patients unlucky enough to develop them. In the 2000s, citizen advocates exposed that as many as one in 20 patients developed one of those infections every year, causing more than 1 million unnecessary illnesses and deaths annually and costing health care and the federal reimbursement system billions of dollars in excess spending. Their pressure on state legislatures and Congress led to mandatory reporting laws and a national action plan, created in 2013, which forced health care providers to work on reducing the conditions—staff behavior, treatment algorithms, equipment types—that let infections occur. Real progress was made. Since 2015, rates of the most prevalent and deadly ones, including ventilator-related pneumonias, infections linked to catheters, and infections in surgical incisions, have been trending down.
Until Covid hit. The pandemic brought overloads of desperately ill patients who needed lifesaving equipment into ICUs, to be treated by overtaxed health care workers deprived of adequate protective equipment—in other words, creating exactly the conditions in which hospital infections can surge. Between the end of 2019 and the end of 2020, according to the CDC, catheter-related bloodstream infections, known as CLABSIs, rose 47 percent. Ventilator-associated pneumonias and other infections rose 44.8 percent. Catheter-related urinary tract infections bounced up 18.8 percent.
The news is dismaying, but not surprising to officials who have been watching waves of patients swamp hospitals—in 2020, because there were no vaccines and few effective treatments; in 2021, because vaccines are being refused. “We really had a perfect storm when it comes to health-care-associated infections and Covid,” says Arjun Srinivasan, a physician and associate director of the CDC’s program for preventing those infections.
During the first waves, he points out, the patients most likely to come into hospitals with severe Covid were older, with chronic illnesses, possibly immunocompromised—and as a result, more likely to end up in an ICU and need ventilation tubes to take over breathing and ports into their bloodstreams to deliver medications. With so many patients, health care workers were stretched thin, more at risk of skipping preventive tasks—and with PPE in such short supply, more at risk of unknowingly carrying pathogens between patients. “So at the same time you have more patients than you've ever had before, you have fewer staff than you would normally have to take care of them,” Srinivasan says. “Normal systems of care delivery break down, because you've just got too much demand for care, and not enough health care providers to provide it.”
There was an uneasy expectation last year that this might happen. In November, a team of researchers from New York and St. Louis predicted in the American Journal of Infection Control that as Covid advanced, people with less acute illnesses or postponable surgeries would be less likely to check into hospitals. They forecast that that would lead to an increase in patients with severe illness who would need the kind of interventions that lead to hospital infections. They based that prediction on early signals from their own institutions: In the first three months of the US pandemic, central-line-associated bloodstream infections rose by 420 percent in one hospital and 327 percent in another, compared to the previous 15 months.
“In my institution, Covid came to us in mid-March 2020, and April was the worst month of hospital infections in the history of our hospital,” says Kathleen M. McMullen, senior manager of infection prevention and occupational health at Christian Hospital and Northwest Healthcare in St. Louis and first author of that study. “Talking to colleagues nationally, we heard they were dealing with it also, and thought ‘We need to get this out.’”
The team also foresaw that some categories of infections, such as ones that take hold in surgical incisions, would diminish as elective surgeries were postponed. Their instincts were solid. The CDC’s new data shows that the only types of hospital infections to decline last year were surgical-site infections following colon surgery or hysterectomy (the kind that requires an open incision, not those done by laparoscopy), and also C. difficile, the pernicious intestinal infection that surges when broad-spectrum antibiotics disrupt the balance of intestinal bacteria.
All of that made sense, given the conditions hospitals were enduring in that first wave, McMullen says: “There were so many patients, not many more health care workers, and so much fear—of not being comfortable, of wanting to get in and out of a patient’s room quickly.”
The data the CDC uncovered matches what McMullen and her colleagues observed and then predicted. But she says it may actually underrepresent hospital infections across the country, because the labor of caring for patients in that first wave was so intense that the federal Center for Medicare and Medicaid Services allowed hospitals to suspend mandatory reporting between April and June.
There’s an especially foreboding signal within the CDC’s data. One of the infections that spiked, rising by a third between the end of 2019 and the end of last year, was bacteremia—dissemination of infectious bacteria throughout the bloodstream, which can lead to sepsis and septic shock—caused by MRSA. It was the only drug-resistant infection appearing in their data because it is among the infections that CMS requires to be reported. (MRSA and all staph bacteria live on the skin, so piercing it with a catheter or incision can conduct the bacterium inside the body.)
But MRSA bacteremia isn’t the only drug-resistant infection that health workers have been concerned about. At the start of the pandemic, researchers worried that empiric use of antibiotics—given on a presumption of what’s wrong, rather than a lab test—was increasing, a hedge against the possibility that Covid patients might develop bacterial pneumonias while on ventilators or in ICUs. Antibiotics do not treat Covid, of course; but their presence in the body of a patient receiving them might allow other bacteria to develop resistance against the drugs.
Those concerns have now been backed up by data. The Pew Charitable Trusts reported in March, based on a database of 6,000 admission records, that more than half of patients hospitalized in the first months of the pandemic received at least one antibiotic; a third received multiple prescriptions. And almost all of them, 96 percent, received their first antibiotic faster than a lab test on any bacterial pathogen could be completed, reinforcing concerns that the prescriptions were empiric and thus possibly unnecessary. Simultaneously, the rise in telehealth, which can also enable empiric prescribing, led to higher numbers of outpatient prescriptions.
Meanwhile, drug-resistant infections began erupting in hospitals. In a presentation to a federal panel last winter, Srinivasan reported that the CDC investigated 20 outbreaks in Covid treatment units between April 2020 and February 2021. Those included outbreaks of the bacterium Acinetobacter baumanii in New Jersey and the fungus Candida auris in Florida, which both had become resistant to even last-resort drugs.
Those investigations, and the data set the CDC reported last week, all predate the rise of the Delta variant. There are places in the US where case rates are higher now than they have been at any point in the pandemic. And even with protective PPE supplies replenished, the pressure to care for so many very sick people is intense; the crowding in ICUs and the emotional toll of the fourth wave creates conditions where hospital infections can continue to spread.
“The strain is insidious,” says Cornelius J. Clancy, a hospital physician and associate professor of medicine at the University of Pittsburgh. “Health care workers have been working full-throttle for 18 months. Staffing is tight. People are run-down. And we’re moving into what normally is the busiest time of the year in a hospital.”
The solution to the problem of hospital infections, and to burgeoning antibiotic resistance, may turn out to be the same as the solution to the pandemic itself: vaccination. The fewer seriously ill patients there are in intensive care, and the less harried the staff is, the lower the risks will be.
“We have to focus on doing everything that can be done to get people vaccinated, because it will keep them out of the hospital and reduce the strain on the system, so we can get back to implementing all of the procedures that we know work,” Srinivasan says. “We wouldn’t usually think of a Covid vaccine as a hospital-infection prevention, but it is the most important tool we have right now.”