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COVID-19 Inpatients Drove Increase in Healthcare-Acquired Infections, Study Finds

Analysis  |  By Christopher Cheney  
   April 14, 2023

Previous research had found an increase in healthcare-acquired infections at hospitals during the coronavirus pandemic.

Hospital inpatients with COVID-19 have had much higher rates of healthcare-acquired infections (HAIs) than hospital inpatients without COVID-19, a new research article shows.

Previous research that compared data from 2019 to 2020 found that there was an increase in HAIs at hospitals. That research found higher infection rates for central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.

The new research article, which was published by JAMA Network Open, features data collected from more than 5 million hospitalizations between 2020 and 2022 at 182 inpatient facilities operated by the HCA Healthcare health system. The researchers documented cases of CLABSI, CAUTI, MRSA, and Clostridioides difficile (Cdiff) among COVID-19 inpatients and inpatients without COVID-19.

The study includes several key findings:

  • The incidence of CLABSI was nearly 4-fold higher among the COVID-19 inpatients than the non-COVID-19 inpatients
  • The incidence of CAUTI was 2.7-fold higher among the COVID-19 inpatients than the non-COVID-19 inpatients
  • The incidence of MRSA was 3.0-fold higher among the COVID-19 inpatients than the non-COVID-19 inpatients
  • For Cdiff, there was no significant difference in infection rates for COVID-19 inpatients and non-COVID-19 inpatients
  • COVID-19 inpatients had a mean 8.2-day length of stay compared to a mean 4.7-day length of stay for non-COVID-19 inpatients  

"In this cross-sectional study of hospitals during the pandemic, HAI occurrence among inpatients without COVID-19 was similar to that during 2019 despite additional pressures for infection control and healthcare professionals. The findings suggest that patients with COVID-19 may be more susceptible to HAIs and may require additional prevention measures," the study's co-authors wrote.

Interpreting the data

A key finding of the study is that HAI rates for non-COVID inpatients did not increase at HCA Healthcare during the pandemic, the lead author of the research article told HealthLeaders.

"There have been some prior publications that say, 'Hospital infection rates have gone up since COVID.' The inference is that hospitals took their eye off the ball, or they were not as safe as they used to be. Until this study, no one had looked to see whether it was true that everybody was getting more infections or whether it was the introduction of a new population of patients that caused the infection rate to go up. In fact, our paper shows that for the non-COVID population, infection rates have been stable. It turns out that COVID patients are at high risk for hospital-acquired infections," says Kenneth Sands, chief epidemiologist at HCA Healthcare.

It would not be fair to say that COVID patients got worse care, he says. "They are just a new patient population, and the risks of infection had never been documented before. Now that they are documented, it provides the opportunity to start being aware of the higher risk and taking the appropriate extra steps."

The next step for researchers is to determine why COVID patients are at higher risk for hospital-acquired infections, Sands says.

COVID-19 inpatients drove the increase of HAIs during the pandemic, the study's coauthors wrote. "Our findings are consistent with previous reports that the occurrence of HAIs increased during the COVID-19 pandemic, reversing a multiyear national trend of improving performance regarding hospital infection. However, our subanalysis revealed that this increase in the overall infection rate appeared to be entirely due to the occurrence of HAIs in the COVID-19 population. Patients without COVID-19 had rates of HAIs that would be expected based on the incidence observed before the pandemic."

Three factors could have accounted for higher rates of HAIs among COVID-19 inpatients compared to non-COVID-19 inpatients, the study's co-authors wrote:

  • The COVID-19 inpatients had a longer length of stay, which is associated with higher risk of developing a HAI
  • Healthcare workers assigned to COVID-19 units may have had reduced resources and altered workflows
  • A decrease in infection prevention performance among COVID-19 inpatients could have been due to risks associated with this high-risk population

HAI rates among COVID-19 inpatients improved over time, the study's co-authors wrote. "While HAI rates were higher in the COVID-19 population, the occurrence of CLABSI, MRSA, and CAUTI in this population decreased over the course of the pandemic from 2020 to 2022. This is likely reflective of both improving practice in the management of COVID-19 as well as the decreasing acuity and length of stay in this population over time."

Related: Coronavirus Pandemic Drives Growth of Hospital at Home Programs

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


Between 2020 and 2022, the incidence of central line-associated bloodstream infection was nearly 4-fold higher among COVID-19 inpatients than non-COVID-19 inpatients.

The incidence of catheter-associated urinary tract infection was 2.7-fold higher among COVID-19 inpatients than non-COVID-19 inpatients.

The incidence of methicillin-resistant Staphylococcus aureus was 3.0-fold higher among COVID-19 inpatients than non-COVID-19 inpatients.

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