Preventing the spread of antibiotic resistance compels us to use antimicrobials judiciously, but it also requires us to implement infection prevention and control (IPC) practices to prevent resistant organisms from spreading in the first place. Cohorting, handwashing, environmental cleaning, and using personal protective equipment (PPE) appropriately are all examples of IPC practices that can help prevent the spread of multidrug resistant organisms (MDROs).

The COVID-19 pandemic has introduced a number of unique challenges for implementing life-saving IPC practices including shortages of PPE and environmental cleaning products, lack of sufficient staff, and unprecedented hospital admission rates. The focus on COVID-19 and stresses related to the pandemic have meant that some facilities have struggled to maintain ideal IPC practices and are experiencing a resurgence of some MDROs.

To learn more about MDRO resurgence during COVID-19, the importance of IPC, and the activities local health departments can conduct as they lead this response, NACCHO spoke with Matt Zahn, the Medical Director for Orange County Healthcare Agency’s Communicable Disease Control Division.

What are you seeing in Orange County as it relates to MDRO transmission?

We first identified an outbreak of Candida auris (C. auris) in Orange County in February of 2019. With assistance from a team from the California Department of Public Health and the CDC, we embarked on a major local response to identity cases and work with healthcare facilities to improve IPC and prevent C. auris’ spread. We had made a lot of progress in slowing spread by the beginning of 2020…and then COVID-19 hit and changed the environment entirely in healthcare facilities. We have seen multiple C. auris outbreaks in facilities that previously had it contained. We are also seeing it introduced into facilities that did not have it before.

How did you identify this issue?

Since C. auris was first identified in Orange County, we have been conducting regular point prevalence surveys in all facilities with patient populations that are at risk, such as long term acute care hospitals and subacute units of nursing homes (units that provide care for ventilated patients). We ask these facilities to swab all residents that are not already known to have C. auris and we coordinate laboratory testing performed by the CDC’s the National Antimicrobial Resistance Laboratory Network. These surveys are conducted every few weeks to every few months, depending on each facility’s level of risk, and allow us to monitor the presence of C. auris and the impact of IPC efforts. This process allowed us to identify an increased number cases that really began in May, which coincided with an increase of COVID-19 risk in the county.

What are some of the factors you identify as contributing to MDRO resurgence during COVID-19?

Some practices for preventing the spread of COVID-19 are different than those for preventing transmission of C. auris and other MDROs. COVID-19 is primarily transmitted through respiratory droplets while C. auris is spread through contact with a person who has C. auris on them or a surface (such as a gown or medical device) with C. auris on it.

With shortages of personal protective equipment (PPE), facilities adjusted how staff used PPE. For example, many facilities established a COVID-19 unit and staff assigned to that unit were allowed to keep wearing the same gown to care for multiple patients. This strategy helped mitigate PPE burn rates and was also perceived to reduce opportunities for staff to acquire COVID-19 during doffing. The problem is, if one of these COVID-19 patients also has C. auris, then this strategy can lead to healthcare workers carrying it from patient to patient.

In addition, the stress of the increased number of cases, and stress of COVID-19 itself, presents a risk that individuals are not going to think about other IPC practices because they are so focused on COVID-19 prevention. For example, in any facility with C. auris, proper environmental cleaning is critically important. High touch surfaces should be cleaned really frequently. It is human nature to want to spend as little time in a COVID-19 patient’s room as possible, because individuals do not want to be exposed to the virus. This stress, in addition to high patient loads, can make it more challenging for folks to spend the appropriate time on environmental cleaning and other IPC practices.

What is your health department doing to address the issue?

We have a COVID-19 response team that is working with these facilities on COVID-19 and we have leveraged this team to address C. auris issues. We review IPC practices and environmental cleaning practices and make recommendations and will continue conducting point prevalence surveys to monitor the situation and see if this is working. We have used this event to remind local healthcare providers of the continuing threat of MDROs, even in the COVID-19 era, and the continued need to maintain good infection control measures. The recommendations we provide need to be realistic and able to be implemented in the case of a COVID-19 resurgence.

COVID-19 is at the top of everyone’s mind, but we need to keep MDROs in the back of our mind to help improve IPC practices long term. This is a real opportunity.

What recommendations do you have for other health departments? What are the lessons learned from your experience?

If you are conducting outreach to skilled nursing facilities in your county related to COVID-19, look at it as an opportunity to establish long-term relationships with these facilities and to help educate them about MDRO prevention and ways they can establish practices to prevent MDROs in their facilities. COVID-19 is at the top of everyone’s mind, but we need to keep MDROs in the back of our mind to help improve IPC practices long term. This is a real opportunity.

More information:

The Centers for Disease Control and Prevention recently released an MMWR on another MDRO outbreak related to COVID-19: Increase in Hospital-Acquired Carbapenem-Resistant Acinetobacter baumannii Infection and Colonization in an Acute Care Hospital During a Surge in COVID-19 Admissions — New Jersey, February–July 2020. Read the full report here .

Visit NACCHO’s COVID-19 webpage to learn about NACCHO’s response efforts and access featured resources.