Infection prevention and control programme and COVID-19 measures: Effects on hospital-acquired infections in patients with cirrhosis

Abstract

Background & aims: Bacterial infections affect survival of patients with cirrhosis. Hospital-acquired bacterial infections present a growing healthcare problem because of the increasing prevalence of multidrug-resistant organisms. This study aimed to investigate the impact of an infection prevention and control programme and coronavirus disease 2019 (COVID-19) measures on the incidence of hospital-acquired infections and a set of secondary outcomes, including the prevalence of multidrug-resistant organisms, empiric antibiotic treatment failure, and development of septic states in patients with cirrhosis.

Methods: The infection prevention and control programme was a complex strategy based on antimicrobial stewardship and the reduction of patient's exposure to risk factors. The COVID-19 measures presented further behavioural and hygiene restrictions imposed by the Hospital and Health Italian Sanitary System recommendations. We performed a combined retrospective and prospective study in which we compared the impact of extra measures against the hospital standard.

Results: We analysed data from 941 patients. The infection prevention and control programme was associated with a reduction in the incidence of hospital-acquired infections (17 vs. 8.9%, p <0.01). No further reduction was present after the COVID-19 measures had been imposed. The impact of the infection prevention and control programme remained significant even after controlling for the effects of confounding variables (odds ratio 0.44, 95% CI 0.26-0.73, p = 0.002). Furthermore, the adoption of the programme reduced the prevalence of multidrug-resistant organisms and decreased rates of empiric antibiotic treatment failure and the development of septic states.

Conclusions: The infection prevention and control programme decreased the incidence of hospital-acquired infections by nearly 50%. Furthermore, the programme also reduced the prevalence of most of the secondary outcomes. Based on the results of this study, we encourage other liver centres to adopt infection prevention and control programmes.

Impact and implications: Infections are a life-threatening problem for patients with liver cirrhosis. Moreover, hospital-acquired infections are even more alarming owing to the high prevalence of multidrug-resistant bacteria. This study analysed a large cohort of hospitalised patients with cirrhosis from three different periods. Unlike in the first period, an infection prevention programme was applied in the second period, reducing the number of hospital-acquired infections and containing multidrug-resistant bacteria. In the third period, we imposed even more stringent measures to minimise the impact of the COVID-19 outbreak. However, these measures did not result in a further reduction in hospital-acquired infections.

Keywords: ALD, alcoholic liver disease; Antibiotic resistance; Antimicrobial stewardship; BB, beta-blockers; Bacterial infections; C19MC, COVID-19 measures cohort; CA, community acquired; COVID-19, coronavirus disease 2019; CRP, C-reactive protein; EATF, empiric antibiotic treatment failure; Empiric antibiotic failure; HAI, hospital-acquired infection; HCA, healthcare-associated; IPCC, infection prevention and control cohort; IPCP, infection prevention and control programme; Liver cirrhosis; MAP, mean arterial pressure; MDR, multidrug-resistant; MELD, model for end-stage liver disease; Multidrug-resistant bacteria; NASH, non-alcoholic steatohepatitis; Nosocomial infections; OR, odds ratio; PDR, pandrug-resistant; PPI, proton pump inhibitor; SARS-CoV-2; SBP, spontaneous bacterial peritonitis; SMC, standard measures cohort; UTI, urinary tract infection; WBC, white blood cell; XDR, extensively drug-resistant.

Graphical abstract

Fig. 1

The proportion of patients suffering from hospital-acquired infections in all three cohorts. The χ² test was used to evaluate the significance of distribution differences. Values of p <0.05 are significant. C19MC, COVID-19 measures cohort; IPCC, infection prevention and control cohort; SMC, standard measures cohort.

Fig. 2

The incidence of secondary outcomes among patients with hospital-acquired infections. MDR and XDR/PDR proportions are calculated only from populations of patients with successful bacterial isolation. The χ² test was used to evaluate the significance of distribution differences. Values of p <0.05 are significant. C19MC, COVID-19 measures cohort; EATF, empiric antibiotic treatment failure; IPCC, infection prevention and control cohort; MDR, multidrug resistance; SMC, standard measures cohort; XDR/PDR, extreme drug resistance/pandrug resistance.