Central line-associated blood stream infection during COVID-19 pandemic.

A considerable number of patients with coronavirus disease 2019 (COVID-19) require intensive care management. The COVID-19 pandemic required clinicians to adopt new treatments and practices that could help critically ill patients in the face of unprecedented challenges. In this short report, we adressed the possible impact of these treatments and practices on the rate of central line-associated bloodstream infection (CLABSI). It is defined as a laboratory-confirmed bloodstream infection not related to an infection at another site that develops within 48 h of central line placement [1]. The majority of CLABSI cases are preventable if the recommended central line insertion bundle and maintenance guidelines were followed [2]. Neverthless, CLABSI still contribute to increased hospital mortality, stay, and cost [3].

To assess the impact of COVID-19 on CLABSI rates, we compared the CLABSI rates and associated patient characteristics before and during the COVID-19 pandemic. CLABSI surveillance using National Healthcare Safety Network criteria [1] was conducted in trauma critical care unit dedicated to treat adult patients with COVID-19, in King Abdulaziz Medical City, Riyadh (KAMC-R), Kingdom of Saudi Arabia, during the period from April 2020 to October 2020. During the study period, 9 CLABSI events were diagnosed and 981 central line days were recorded (9.2 versus per 1000 central line days). The CLABSI rate was higher during the study period compared with pre-pandemic period (Zero cases between October 2019 and March 2020). The rate was highest during the peak of COVID-19 cases (June and July, Fig. 1 ). The peak of CLABSI rate was consistent with the peak of hospital admission of COVID-19 cases. As shown in Fig. 2 , there were 1553 confirmed COVID-19 patients admitted to the KAMC-R during the study period with 334 (21.5%) required ICU care. The majority (8 out of 9) of organisms identified were Candida species (4 Candida glabrata, 3 Candida auris, and one Candida albicans).

Fig. 1

CLABSI cases before and during the COVID-19 pandemic at trauma intensive care unit.

Fig. 2

Number COVID-19-related hospital and ICU admissions at King Abdulaziz Medical City, Riyadh between March and October 2020.

Several practices can probably explain the increase of candidemia during the COVID-19 pandemic. All the patients with CLABSI in this study received antibiotics to treat community-acquired pneumonia which can flare up intestinal candida [4]. The median number of antibiotics used during hospitalization was 4.5 antibiotics (inter-quartile range 3–7.5). Three patients with CLABSI received tocilizumab, an immunosuppressive drug used for the treatment of COVID-19 patients with severe pneumonia and cytokine storm. The median time between administering the drug and development of candidemia was two days. Tocilizumab has been shown to increase the risk of bowel perforation and severe neutropenia [5]. A decrease in the number of patients with candidemia was noticed after stopping this approach in July. This suggest that some of the bloodstream infection (BSI) detected may be of an endogenous origin. However, criterion-1 mucosal barrier injury laboratory-confirmed BSI could not be met as the patients did not develop severe neutropenia. Moreover, infusion pumps were kept outside the patient room to minimize staff exposure to COVID-19. While this intervention can limit the exposure, the multiple extensions used to connect the infusion to the central line may carry the risk of contamination [6]. Furthermore, the connection points were not always protected properly. Although it is not recommended to insert central-line in the femoral vein as it has been linked to increased risk of candidemia [7]. This was unavoidable in some critically ill patients. Finally, infection control measures were strictly implemented throughout the pandemic period and the staff were further trained on use of personal protective equipment (PPE). Nevertheless, the local guidelines were also following the international guidelines that allowed resue and extended use of PPE in response to PPE shortage.

In conclusion, CLABSI rates may increase during the current COVID-19. The sudden decrease of CLABSI rates after stopping tocilizumab may point to the presence of an association between tocilizumab and candidemia. Such an association has to be confirmed in larger prospective multicenter studies. The current findings underscore the importance of continuously monitoring COVID-19 therapy for early detection of adverse events including CLABSI.

No conflict of interest