American Journal of Infection Control 52 (2024) 147–151

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American Journal of Infection Control

journal homepage: www.ajicjournal.org

Major Article

How COVID-19 impacted CAUTI and CLABSI rates in Alabama

a,⁎
Melanie Hyte PharmD, BCIDP , Cassidy Clark OMSII , Rishika Pandey OMSII , a a
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David Redden PhD a, Melanie Roderick MPH b, Kenny Brock DVM, PhD a
a
Edward Via College of Osteopathic Medicine-Auburn Campus, Auburn, AL
b
Alabama Department of Public Health, Montgomery, AL

Key Words:
Health care–associated infection (HAI)
Personal Protective Equipment (PPE)
Infection prevention bundle
Background: The study objective was to quantify infection rate trends for central line–associated blood­
stream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) in 89 Alabama hos­
pitals from 2015 to 2021 to analyze how the COVID-19 pandemic impacted health care delivery.
Methods: Retrospective analysis of CLABSI and CAUTI rates, from 89 Alabama hospitals via data from the
Alabama Department of Public Health from 2015 to 2021.
Results: Based on our modeling strategies, there was a statistically significant decrease in rates of CAUTIs
from 2015 to 2019 at an estimated rate of 7% per year (P = 0.0167) and CLABSIs from 2015 to 2018 at an
estimated rate of 13% per year (P < .001) in these hospitals. In 2020, the CAUTI and CLABSI rates began
increasing at a modeled rate of 29% per year (P = .001) and 35% per year (P < .001) respectively.
Discussion: A review of potential causes for the elevated rate of health care–associated infections illustrated
that certain practices may have contributed to increased CAUTI and CLABSI rates. Utilizing staff from non­
critical care areas with less experience in health care–associated infection prevention, batching of tasks to
conserve personal protective equipment, and a nationwide mental health crisis could have affected infection
prevention bundle compliance.
Conclusions: An increase in CAUTIs and CLABSIs was observed during the pandemic, likely due to the large
volume of patients requiring advanced medical care and subsequent depleted resources.
© 2023 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All
rights reserved.

BACKGROUND Despite their association with infection, the use of indwelling

Central line–associated bloodstream infections (CLABSIs) and
catheter-associated urinary tract infections (CAUTIs) are 2 important
health care–associated infections (HAIs) addressed in the National
Action Plan to Prevent Health Care–Associated Infections created by
the US Department of Health and Human Services. Reduction of HAIs
is an Agency Priority Goal given the association with increased
morbidity and mortality.1 In 2016, the United States spent between
$7.2 and $14.9 billion on HAIs.2 Complications from CAUTIs and
CLABSIs during a hospital stay can increase the hospital cost by up to
$896 per patient and $58,614, respectively, with CLABSIs being the
costliest HAI per patient.3 Furthermore, nearly 12%-16% of adults
admitted to the hospital will require an indwelling urinary catheter
at some point during their stay, increasing their risk for a CAUTI via
catheter colonization by 3%-7% each day.1
⁎
Address correspondence to Melanie Hyte, PharmD, BCIDP, Edward Via College of
Osteopathic Medicine-Auburn Campus, 910 South Donahue Drive, Auburn, AL 36832.
E-mail address: mhyte@auburn.vcom.edu (M. Hyte).
Conflicts of interest: None to report.
devices such as urinary catheters and central venous lines is critical
for diagnostic and therapeutic purposes for patients in intensive care
units.4 Prevention of CAUTIs and CLABSIs are addressed in the
Centers for Disease Control’s (CDC) Health Care–Infection Control
Practices Advisory Committee Guidelines for the Prevention of In­
travascular Catheter-Related Infections5 and the Guideline for Pre­
vention of Catheter-Associated Urinary Tract Infections.6 To increase
compliance with evidence-based practices and reduce HAIs, many
hospitals have incorporated a combination of guideline utilization
with a multidisciplinary team approach to implement the perfor­
mance improvement initiatives through bundled checklists.5 Com­
ponents of the CLABSI bundle checklist emphasize providing
appropriate education and training, avoiding routine catheter pla­
cement, using aseptic techniques for insertion when appropriate,
properly applying sterile barriers, and using chlorhexidine sponge
dressings or antiseptic-impregnated catheters.5 One study suggested
that access to infection prevention resources and compliance with
all 5 components of the bundled checklist saw the greatest reduction
in infection rates, yet compliance with at least 1 component was also
seen to reduce CLABSI rates.7 Similar to the CLABSI guidelines,

https://doi.org/10.1016/j.ajic.2023.05.014
0196-6553/© 2023 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
148 M. Hyte et al. / American Journal of Infection Control 52 (2024) 147–151
several hospitals have also incorporated the CDC’s guidelines for
CAUTI prevention into bundled checklists to decrease CAUTI occur­
rences. CAUTI bundle checklists highlight key prevention strategies
including careful assessment of indications for catheter placement,
evaluation of appropriate catheter alternatives, best practices for
aseptic insertion, proper catheter maintenance and surveillance, and
early removal of catheter when warranted.6 Hospitals that im­
plemented appropriate training protocols and bundle checklists saw
CAUTI reductions ranging from 30% to 70%.8
The SARS-CoV-2 virus, commonly known as COVID-19, caused a
global pandemic with negative impacts including loss of life and
shortage of resources.9 Since the first reported case in the United
States in January of 2020, many studies have found statistically
significant increases in HAIs such as CAUTIs and CLABSIs.10–13 Our
objective was to quantify and compare a 5-year trend of prepan­
demic rates for CAUTIs and CLABSIs to their trends during the pan­
demic. Additionally, in 2015 the National Health Care Safety Network
(NHSN) adjusted the way facilities report their HAIs, thus creating an
ideal starting point for data collection. While this data are specific to
the State of Alabama and is especially relevant for its providers, it
also heightens awareness of the impact of COVID-19 on the in­
cidence of CAUTIs and CLABSIs on a state level.
METHODS
We obtained the annual number of reported CAUTIs and CLABSIs
from 2015 to 2021 for 89 hospitals in Alabama from the Alabama
Department of Public Health via the NHSN. NHSN is a secure,
Internet-based national surveillance system used to collect and re­
port HAI data. In Alabama, health care facilities are required by law
to enter HAI data into NHSN no later than the last day of the sub­
sequent month. Health care facilities are defined as general, or
specialized hospitals (including pediatric hospitals, but excluding
psychiatric, rehabilitation, long-term care, and eye hospitals). CAUTI
data are reported from medical wards, surgical wards, medical or
surgical wards, and adult and pediatric critical care units. CLABSIs
are reported from adult, pediatric, and neonatal critical care units.
ANALYSIS
The statistical analysis for this manuscript seeks to address
whether there is statistically significant evidence that CAUTI and
CLASBI rates increased during the COVID-19 pandemic. To identify
the most appropriate model to test this hypothesis, the distribution
of the outcome measure and the statistical consequence of modeling
repeated measurements from the same hospital overtime must be
considered. To test the hypothesis using regression methods, the
typical modeling strategy is a piece-wise regression. A piecewise
regression model typically includes 4 variables, an intercept that
models the average rate within the first observed time period (2015
for this model), a time variable that measures change per year over
the entire study period (2015-2021), a yes or no variable that in­
dicates whether an observation occurred within a period where
disruption is expected to occur (years 2019 and 2020 for this model),
and a final variable that is a time variable for observations within the
period where disruption could occur. This final variable measures
the change in slope that occurred during the COVID-19 pandemic
and is the term we examined for statistical significance. Though we
used this modeling strategy, we could not conduct this model using
ordinary regression approaches. The outcome measure is the count
of infections per hospital each year. Because of the outcome variable,
either Poisson Regression or Negative Binomial Regression is ap­
propriate. We chose to utilize Negative Binomial Regression because
it allows for heterogeneity. Because hospitals were followed long­
itudinally, the nonindependence of observations from the same
hospital had to be modeled using a generalized estimating equation
approach. Therefore, the final model was a Negative Binomial Piece-
wise Regression model within a generalized estimating equations
framework. The models accounted for hospital size by including the
total number of catheter days or the total number of central line days
in the models. All analyses were conducted in SAS 9.4.
RESULTS
For CLASBIs, our modeling strategy indicates that the rate of in­
fections was decreasing annually from 2015 to 2018 at an estimated
rate of 13% per year (P < .001). There was a slight statistically
nonsignificant increase (P = .699) in CLASBI rates observed in 2019.
However, beginning in 2020, we observed a sharp increase in the
CLASBI rate. At this juncture, the model indicates that the rate of
infections started increasing annually at a model rate of 35% per year
(P < .001). We observed a similar pattern in CAUTIs. From 2015 to
2019, the CAUTI rate of infections decreased annually at a model rate
of 7% per year (P = .0167). Beginning in 2020, the CAUTI rate of in­
fections began increasing at a model rate of 29% per year (P = .001)
(Figs. 1 and 2). (Table 1).
DISCUSSION
Our modeling strategy illustrates that there was a statistically
significant decrease in CAUTIs and CLABSIs in Alabama hospitals
prior to the COVID-19 pandemic and a statistically significant in­
crease after the pandemic began. This is troubling given that these
infections increase a patient’s length of stay at the hospital and affect
hospital costs as previously stated.3 Several published studies
document that resource shortages and an increase in high-acuity
patients are the main cause of increased HAIs across the nation.10–13
In these studies, larger hospitals with increased COVID-19 popula­
tions were found to be associated with higher levels of HAIs, which
suggests a correlation between increased COVID-19 burden and in­
creased infection rates.10,11 This correlation may align with hardships
experienced by hospitals and staff resulting from the surge of high
acuity COVID-19 patients requiring longer hospital stays with a
higher level of care, in combination with resource shortages in in­
tensive care unit (ICU) beds, Personal Protective Equipment (PPE),
and hospital personnel. While it is true that the pandemic has been
found to be associated with surges of higher acuity patients and
multiple resource shortages,14 our review of potential causes for the
elevated CAUTI and CLABSI rates across the state of Alabama found
that certain practices may have also contributed dramatically. Spe­
cifically, utilizing staff from noncritical care areas with less experi­
ence in HAI prevention, batching of tasks to conserve PPE which
affected time-dependent tasks and influenced medical decision-
making, and a mental health crisis could have affected compliance
with infection prevention bundles.
The surge of COVID-19 patients led to decreased availability of ICU
beds; therefore, hospitals were encouraged to prepare alternative
sites capable of ICU-level care, such as step-down units and post
anesthesia care units, to accommodate the increased volume of
COVID-19 patients.15 The creation of new makeshift ICUs helped to
 M. Hyte et al. / American Journal of Infection Control 52 (2024) 147–151 149

Fig. 1. Observed rates of central line–associated bloodstream infections.

resolve space limitations, but subsequently placed a huge burden on
the nursing workforce, given that most ICUs utilize a 1:2 or a 1:1
nurse-to-patient ratio staffing model.·This model is essential for the
intensified needs of critical care patients and facilitates close mon­
itoring for the rapid deterioration of ill patients. Notwithstanding,
critical care patients more often require central venous lines (CVLs)
and foley catheters for care and diagnostic purposes than patients on
a traditional medical-surgical floor·More CVL and catheter
placement translates to more central line and catheter days, re­
sulting in a greater potential for CAUTIs and CLABSIs. The CDC’s
guidelines and infection prevention bundled checklists help prevent
these HAIs, but as previously stated, work best when strictly adhered
to while reassigning nursing staff to work in the makeshift ICUs was
essential to manage the large influx of patients requiring care during
the pandemic, utilizing staff from noncritical care areas to work in
these units most likely played a role in increased CAUTI and CLABSI

Fig. 2. Observed rates of catheter-associated urinary tract infections.

150 M. Hyte et al. / American Journal of Infection Control 52 (2024) 147–151

rates because these staff have less experience than a critical care Table 1
Infection rates with 95% confidence intervals from 2015 to 2021
nurse in HAI prevention.16
Catheter associated urinary tract infections
Furthermore, the pandemic affected the global supply chain of
materials17 and led to an increased discrepancy in available PPE. Year Events Days Rate per 1,000 days 95% confidence interval

With an inability to import PPE products such as respirators, gloves, 2015 413 442,185 0.934 (0.846, 1.029)
face shields, gowns, and hand sanitizer, many hospitals were unable 2016 391 447,012 0.875 (0.790, 0.966)
2017 374 436,461 0.857 (0.772, 0.948)
to meet the needs of health care workers.18 In an effort to mitigate
2018 318 408,082 0.779 (0.696, 0.870)
the shortage of face masks, the CDC recommended limiting N95 2019 306 405,072 0.755 (0.673, 0.845)
masks for use during aerosol-generating procedures only and re­ 2020 385 445,945 0.863 (0.779, 0.954)
using surgical masks and other items intended for single use.18 This 2021 494 480,237 1.029 (0.940, 1.123)
led to health care workers “batching tasks” (ie, performing multiple Central line–associated bloodstream infections
Year Events Days Rate per 1,000 days 95% confidence interval
tasks during 1 visit within a patient room), reducing PPE volume 2015 314 213,199 1.473 (1.314,1.645)
while also limiting exposure.16 Batching practices could lead to 2016 272 216,452 1.257 (1.112,1.415)
rushing certain time-dependent tasks and influence medical deci­ 2017 208 210,446 0.988 (0.859,1.132)
sion-making in the care of patients. Specifically, 1 COVID-19 study 2018 154 198,701 0.775 (0.657,0.908)
2019 170 204,674 0.831 (0.710,0.965)
from a tertiary care center in Detroit found there were lapses in
2020 276 231,468 1.192 (1.056,1.342)
infection control practices stemming from hurrying time-dependent 2021 367 258,368 1.42 (1.279,1.573)
tasks. Such lapses were reported by survey and included not using
skin disinfectant for the manufacturer’s recommended time, col­
lecting serial cultures either from the same site or through central
line access, and spending less time on handwashing.12,16 Batching of line–maintenance bundles. This single intervention resulted in a
tasks due to limitations in PPE also influenced medical decision- decrease in their CLABSI rate from 3.3 to 0 per 1,000 central line
making regarding CVL placement. A study reported that more cen­ days.22 While the study was limited by sample size, the results il­
tral lines were placed at the femoral site relative to the subclavian or lustrate that certain HAIs could potentially be decreased with ad­
internal jugular despite a known association with higher infection ditional personnel specifically committed to HAI reduction and CVL
rates at the femoral site. This site was speculated to be chosen more maintenance through strict compliance with infection prevention
frequently due to a shorter placement time and the location of line bundles. This information further supports the idea that increased
placement being farther away from a patient’s head and neck, both rates of HAIs during the COVID-19 pandemic could have been sec­
of which help limit the provider’s exposure to aerosolized particles ondary to increased nursing workload and/or staffing shortages.
while at the bedside.12 Despite efforts to improve resource While pandemic-related patient surges and shortages in ICU and
shortages, the Federal Drug Administration did not remove PPE from non-ICU beds, ventilators, and PPE have abated, the continued
the Medical Device Shortage List until mid-2022, and this shortage staffing shortages and impending nursing burnout are most likely to
potentially affected HAI rates during 2020 and 2021. continue contributing to increased CAUTI and CLABSI rates. The
Moreover, with the substantial burdens placed on hospitals and pandemic’s disruption of HAI prevention efforts resulted in a failure
health care workers, a mental health crisis ensued. A large national to meet the United States Department of Health and Human Services
cross-sectional study conducted from May 28, to October 1, 2020, target to reduce 2015 HAI numbers by 25% by the year 2020.23 In­
evaluated how health care workers were “coping with COVID’’ and creased quantities of observed CLABSIs and CAUTIs can have a ne­
found that “61% reported fear of exposure or transmission, 38% re­ gative impact on the Centers for Medicare and Medicaid Services
ported anxiety/depression, 43% suffered work overload, and 49% had calculated total health care–association conditions score, which is
burnout.”19 While there is no literature specifically evaluating the utilized in determining reimbursement reductions. The Inpatient
extent to which work overload could affect HAIs, there are indis­ Prospective Payment System/Long-Term Care Hospital Prospective
putable implications for how work overload could have affected Payment System final rule for the fiscal year 2023 designated that
compliance with infection prevention bundle checklists and there­ Centers for Medicare and Medicaid Services will not be calculating
fore indirectly lead to a rise in CAUTI and CLABSI rates. The intense total health care–association conditions scores for any hospital data
hospital work environment associated with the pandemic was most collected for the performance period of January 1, 2021, to December
likely exacerbated by a national decrease in nursing staff and sub­ 31, 2021. Therefore, no hospital will receive a payment reduction for
sequent nursing shortage. An analysis from 2022 found that the total said performance period, but the potential implication of continued
number of registered nurses in the United States from 2020 to 2021 health care worker burnout on HAI rates warrants further in­
decreased by over 100,000; most of those who left the workforce vestigation.24
had been practicing in hospitals.20 The exact cause of this exodus is
speculative but could have been due to physical illness from COVID- CONCLUSIONS
19. Efforts to attenuate staffing shortages secondary to COVID-19
illness resulted in vaccine recommendations or requirements, ro­ This retrospective analysis showed that an increase in central-
tating staffing schedules, quarantine, and even expectations to line–associated bloodstream infections (CLABSIs) and catheter-as­
continue working in extreme circumstances of personnel sociated urinary tract infections (CAUTIs) was observed during the
shortages.21 While demanding situations required drastic changes to COVID-19 pandemic, likely due to the large volume of patients re­
ensure hospitals were able to continue to remain open, it is rea­ quiring advanced medical care and subsequent depleted resources.
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