Impact of the COVID-19 Pandemic on Antibiotic Resistant Infection Burden in U.S. Hospitals : Retrospective Cohort Study of Trends and Risk Factors

Christina Yek, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, and Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, Rockville, Maryland (C.Y.).
Alex G. Mancera, Critical Care Medicine Department, National Institutes of Health Clinical Center, and Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland (A.G.M., M.W., M.N., E.A.C., R.A., M.E.R., B.S., S.R.W., S.S.K.).
Guoqing Diao, Department of Biostatistics and Bioinformatics, George Washington University, Washington, DC (G.D.).
Morgan Walker, Critical Care Medicine Department, National Institutes of Health Clinical Center, and Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland (A.G.M., M.W., M.N., E.A.C., R.A., M.E.R., B.S., S.R.W., S.S.K.).
Maniraj Neupane, Critical Care Medicine Department, National Institutes of Health Clinical Center, and Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland (A.G.M., M.W., M.N., E.A.C., R.A., M.E.R., B.S., S.R.W., S.S.K.).
Emad A. Chishti, Critical Care Medicine Department, National Institutes of Health Clinical Center, and Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland (A.G.M., M.W., M.N., E.A.C., R.A., M.E.R., B.S., S.R.W., S.S.K.).
Roxana Amirahmadi, Critical Care Medicine Department, National Institutes of Health Clinical Center, and Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland (A.G.M., M.W., M.N., E.A.C., R.A., M.E.R., B.S., S.R.W., S.S.K.).
Mary E. Richert, Critical Care Medicine Department, National Institutes of Health Clinical Center, and Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland (A.G.M., M.W., M.N., E.A.C., R.A., M.E.R., B.S., S.R.W., S.S.K.).
Chanu Rhee, Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, and Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (C.R., M.K.).
Michael Klompas, Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, and Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (C.R., M.K.).
Bruce Swihart, Critical Care Medicine Department, National Institutes of Health Clinical Center, and Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland (A.G.M., M.W., M.N., E.A.C., R.A., M.E.R., B.S., S.R.W., S.S.K.).
Sarah R. Warner, Critical Care Medicine Department, National Institutes of Health Clinical Center, and Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland (A.G.M., M.W., M.N., E.A.C., R.A., M.E.R., B.S., S.R.W., S.S.K.).
Sameer S. Kadri, Critical Care Medicine Department, National Institutes of Health Clinical Center, and Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland (A.G.M., M.W., M.N., E.A.C., R.A., M.E.R., B.S., S.R.W., S.S.K.).

Document Type

Journal Article

Publication Date

4-29-2025

Journal

Annals of internal medicine

DOI

10.7326/ANNALS-24-03078

Abstract

BACKGROUND: In 2022, the U.S. Centers for Disease Control and Prevention reported increases in antimicrobial resistance (AMR) across U.S. hospitals during the COVID-19 pandemic. The key drivers and lasting effects of this phenomenon remain unexplored. OBJECTIVE: To determine the incidence of AMR infections in U.S. hospitals during and beyond the pandemic and identify factors contributing to AMR. DESIGN: Retrospective cohort study. SETTING: 243 U.S. hospitals. PARTICIPANTS: Adult hospitalizations, excluding inpatient transfers. INTERVENTION: Prepandemic (January 2018 to December 2019), peak pandemic (March 2020 to February 2022), and waning pandemic (March to December 2022). MEASUREMENTS: Incidence of methicillin-resistant Staphylococcus aureus; vancomycin-resistant Enterococci; extended-spectrum cephalosporin-resistant Enterobacterales; and carbapenem-resistant Enterobacterales, Acinetobacter baumannii, and Pseudomonas aeruginosa infections was evaluated among 120 continuously reporting hospitals. Infections detected more than 3 days after admission were classified as hospital-onset. Antibiotic exposure was estimated using a duration- and spectrum-weighted index. A competing risks analysis was done in 243 hospitals to identify risk factors for resistance. RESULTS: During the peak of the COVID-19 pandemic, AMR infections increased from 182 to 193 per 10 000 hospitalizations (6.5% [95% CI, 5.1% to 8.0%]). Hospital-onset AMR infections increased from 28.9 to 38.0 per 10 000 hospitalizations (31.5% [CI, 27.3% to 35.8%]). Factors associated with hospital-onset AMR included illness severity (intensive care unit admission, mechanical ventilation, vasopressors, COVID-19 diagnosis), comorbidities (Elixhauser Comorbidity Index), and prior exposure to antibiotics, but not hospital factors. Prevalence of AMR returned to prepandemic levels as the pandemic waned (182 to 182 per 10 000 hospitalizations; 0.4% [CI, -1.4% to 2.2%]), however, hospital-onset AMR remained above baseline (28.9 to 32.3 per 10 000 hospitalizations; 11.6% [CI, 6.8% to 16.7%]). LIMITATION: Residual confounding; unknown appropriateness of antibiotics. CONCLUSION: Sustained increases in hospital-onset AMR infections occurred in U.S. hospitals during the pandemic and were strongly associated with antibiotic exposure. PRIMARY FUNDING SOURCE: National Institutes of Health Clinical Center; National Heart, Lung, and Blood Institute; and National Institute of Allergy and Infectious Diseases Intramural Research Programs.

Department

Biostatistics and Bioinformatics

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