Impact of the COVID-19 pandemic on the incidence and type of infections in hospitalized patients with cirrhosis: a … – Nature.com

To our knowledge, this is the first comprehensive study analyzing the impact of the COVID-19 pandemic on the incidence and type of infections in patients with cirrhosis hospitalized in a non-intensive care unit setting. The main finding of this study was the similar incidence of infections in both periods (pre-pandemic vs pandemic) although we found a trend to a lower incidence of nosocomial infections and to a higher incidence of MDRO infections during the pandemic.

During the COVID-19 pandemic, strict measures were implemented to prevent the spread of SARS-CoV-2. These measures, such as greater awareness of hand hygiene, are also recommended to prevent infections in general and MDRO infections specifically19. We could therefore have expected a decrease in the incidence of all types of non-COVID-19 infections during the pandemic, as has been reported in the general population in outpatient medical care in Germany20 and in hospitalizations in the US21.

In the present study in hospitalized patients with cirrhosis, the incidence of all infections was similar in the pandemic to that in the pre-pandemic period, but there was a trend to a decreased incidence of nosocomial infections during the pandemic. This finding is in agreement with a report from the US that evaluated nosocomial infections in cirrhotic patients admitted to the intensive care unit22, as well as a report from China that evaluated nosocomial infections in a neurosurgery unit23, and could be attributed to the measures implemented in hospitals to fight the pandemic. However, during the first and second year of the COVID-19 pandemic, the National Healthcare Safety Network in the US described an increase in HCA infections and a high incidence in device-related infections (bloodstream, urinary tract and ventilator-associated infections)24,25. One possible explanation for these findings is that, in parallel to practices intended to prevent and control the spread of SARS-CoV-2, usual medical care was compromised due to the overall pressure on health systems: higher patient volumes and severity as well as shortages of staff and supplies. Focusing resources on SARS-CoV-2 may have reduced the attention given to traditional programs for prevention of nosocomial infections, such as venous and urinary catheter care, leading to an increase in nosocomial infections26,27.

Interestingly, as other authors have observed, we too found a (non-significant) increase in urinary tract infections during the pandemic22,23. This increase could be related to deficient urinary catheter care due to the pressure on health-care systems. We also found a non-significant decrease in SBP and lower respiratory tract infections. The latter might be explained by the measures taken to reduce contact transmission and aerosol spread23. The low rate of COVID-19 infections in our study during the pandemic can be explained by the fact that all patients diagnosed with COVID-19 were admitted to specific COVID-19 hospitalization areas. The three patients with nosocomial-acquired COVID-19 identified during the pandemic period were diagnosed during hospitalization in the hepatology department.

Like in other studies, we also found infection rates of Clostridioides difficile decreased during the COVID-19 pandemic24,25,27,28. This finding is most likely linked to the general preventive measures undertaken during the pandemicmeasures beyond the use of alcohol-based hand sanitizer to which the Clostridioides difficile spores are resistant.

Regarding MDRO infections, it is of note that although their incidence remained low (4% in the pre-pandemic and 6.5% in the pandemic group), it increased both in the community-acquired infections and the nosocomial infections during the pandemic period, as reported by Jeon et al in hospitalized patients in Korea11. In contrast, Park et al found that the rate of infections caused by MRSA and ESBL producers was significantly lower in patients with cirrhosis admitted to the intensive care unit during the pandemic. Bentivegna et al also describe a decrease in MDRO among the total numbers of infections in the general population in Rome during the pandemic10. Other authors in hospitals in Taiwan and the US have also described a reduction of MDRO among nosocomial infections during this period8,9. These contradictory findings between countries could be related to differences in antibiotic policies and/or in infection prevention measures.

We consider the low incidence of MDRO in our population in both periods is a relevant finding. Probably, the reason is that our study was performed in the hepatology unit at a hospital without liver transplant, while most of the previous studies evaluating infections by MDRO in cirrhosis were performed in an intensive-care setting and in hospitals with liver transplant program3,5,6. Therefore, it is important to emphasize the need for monitoring antimicrobial resistance at each centre to adapt the empiric antibiotic therapy. This would contribute to a more rational use of antibiotics in order to prevent further progression of antibiotic resistance.

In our study, the admission rate was statistically lower in the pandemic group. One hypothesis might be that patients chose to stay at home rather than seek medical care due to fear of exposing themselves to SARS-CoV-2 and/or to reduce the pressure on health care system. This hypothesis is further supported by the finding that liver function was more severely impaired in hospitalized patients during the pandemic. A possible reason for this could be that in view of the pandemic only the most seriously ill sought hospital care.

While some studies also report a decrease in the overall hospital admission rate for non-covid-19 conditions during the pandemic29, still others found the admission rate for alcohol-related liver events increased30,31. In our study, we observed a significant increase in the alcoholic etiology of cirrhosis during the pandemic. These data are in agreement with the increase in alcohol abuse during this period32. We observed an increase in the number of women hospitalized during the pandemic, likely related to the increase in the rate of alcohol consumption reported among women at this time and higher susceptibility to the effects of alcohol32.

The main limitation of this study is its retrospective design. Data reliability is not the same as in a prospective design in a non-pandemic situation. Second, we focused only on the two periods we considered could best show the impact of the pandemic on infections: the first year of the pandemic and the previous year. This provided a relatively low sample size that could have contributed to the lack of a statistical significance in some differences observed between the two periods. Finally, we did not include patients with cirrhosis admitted for COVID-19, so we do not have data about their eventual episodes of infection.

To conclude, we observed a trend towards a lower incidence of nosocomial infections and a higher incidence of MDRO infections during the pandemic as compared to the pre-pandemic period. Such findings indicate that even in a crisis like a pandemic, standard infection prevention practices must be maintained in order to avoid the increase of nosocomial infections and the spread of MDRO infections.

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Impact of the COVID-19 pandemic on the incidence and type of infections in hospitalized patients with cirrhosis: a ... - Nature.com