Impact of Personal Protective Equipment usage and hand washing due to COVID-19 on the rate of HA-CDI

Background: Clostridium difficile infection (CDI) is one of the most common healthcare-associated (HA) infections. Advanced age, use of proton pump inhibitors, concomitant antibiotics, steroids, prolonged hospital stay, and gastrointestinal surgeries are associated with increased incidence of disease. CDI is transmissible via the fecal-oral route by ingestion of spores and is readily transmitted in the hospital between patients and caregivers. Strict contact precautions and handwashing are implemented in health care settings to prevent its transmission. The current pandemic of Coronavirus disease (COVID-19) has led to imposing restrictions on patient admission, visitor visit and implementing extra measures on handwashing along with the use of personal protective equipment (PPE). Therefore, the main objective of this study is to identify if additional preventive measures for COVID-19 have any impact on the rate of HA-CDI. Methods: A retrospective study was conducted on patients diagnosed with HA-CDI during the COVID-19 year (2020) and compared with patients of the pre-COVID-19 year (2019) from March to October. A comparison of baseline characteristics, risk factors and patient hospitalization were compared. Results: During the study period, a total of 148 cases were diagnosed with HA-CDI of which 75 cases were in the pre-COVID-19 and 73 cases in COVID-19 year accounting for a total of 149,092 and 136,982 inpatient bed days respectively. The rate of HA-CDI was 5.03 vs 5.33 per 10,000 hospitalized patients in the pre-COVID-19 year vs COVID-19 year. No significant differences in baseline demographic characteristics, (age, sex, race and BMI); comorbidities (diabetes and hypertension) and risk factors like cancer and steroid use were observed between the two groups. Factors associated with CDI like antibiotic use (p=0.001) and proton pump inhibitor use (p= 0.005) was significantly lower in COVID-19 year. However, there was a significantly high number of patients that had undergone gastrointestinal (GI) surgery (22.6% vs 6.6%, p=0.01) during COVID-19 year. Almost half of the patients in each group stayed in the intensive care unit (ICU) and the mean length of ICU stay was significantly higher in COVID-19 year (20.4± 34.3 days vs 11.6± 16.9 days, p= 0.03). The mortality rate was higher (20.5% vs 12%, p= 0.23) during COVID-19 period. A sub-analysis was done with 2020 data to identify if there lies any contributing factors to the increase CDI rate. 21 cases were positive for COVID-19, of which 28.5% underwent GI surgery; 19% received steroids (Dexamethasone), 76.1% stayed in ICU with median LOS (16± 20.2) and 52.3% died. Conclusions: Based on our observations, a slightly higher rate of symptomatic HA-CDI was observed during COVID-19 year when compared with pre-COVID-19 year. Implementation of measures to prevent the spread of COVID-19 e.g., use of PPE, handwashing, environmental cleaning, visitor restriction etc. were expected to help decrease HA-CDI, which was not observed in our study. We did observe longer ICU stay and higher rate of GI surgery among patients who had HA-CDI in 2020. Higher acuity patients and increased rate of these risk factors amongst patients admitted in year 2020 might have offset the expected benefit of COVID-19 prevention strategies.