Bloodstream Infection Risk, Incidence, and Deaths for Hospitalized Patients During Coronavirus Disease Pandemic

Bhavarth S. Shukla; Prem R. Warde; Eric Knott; Sebastian Arenas; Darryl Pronty; Reinaldo Ramirez; Arely Rego; Miriam Levy; Martin Zak; Dipen J. Parekh; Tanira Ferreira; Hayley B. Gershengorn


Emerging Infectious Diseases. 2021;27(10):2588-2594. 

In This Article

Abstract and Introduction


Hospital-acquired infections are emerging major concurrent conditions during the coronavirus disease (COVID-19) pandemic. We conducted a retrospective review of hospitalizations during March–October 2020 of adults tested by reverse transcription PCR for severe acute respiratory syndrome coronavirus 2. We evaluated associations of COVID-19 diagnosis with risk for laboratory-confirmed bloodstream infections (LCBIs, primary outcome), time to LCBI, and risk for death by using logistic and competing risks regression with adjustment for relevant covariates. A total of 10,848 patients were included in the analysis: 918 (8.5%) were given a diagnosis of COVID-19, and 232 (2.1%) had LCBIs during their hospitalization. Of these patients, 58 (25%) were classified as having central line–associated bloodstream infections. After adjusting for covariates, COVID-19–positive status was associated with higher risk for LCBI and death. Reinforcement of infection control practices should be implemented in COVID-19 wards, and review of superiority and inferiority ranking methods by National Healthcare Safety Network criteria might be needed.


The incidence of co-infection with either bacterial or fungal pathogens in patients hospitalized because of coronavirus disease (COVID-19) during the ongoing pandemic has become a topic of great interest. Hospitalized COVID-19 patients have shown co-infection rates as low as 7%[1] and as high as 15%, and as many as 27% of those who ultimately die are co-infected.[1–5] Although some COVID-19 patients have bacterial or fungal co-infections, it appears that nosocomial origins for co-infection might be a major factor. One study found that only 3.2% of hospitalized COVID-19 patients were co-infected at the time of hospital admission,[3] and another study demonstrated a cumulative risk of 25% of developing a bloodstream infection in critically ill COVID-19 patients, but only after 48 hours in the intensive care unit (ICU).[6]

Sparse evidence exists that directly compares nosocomial incidence of bloodstream infection in those having COVID-19 with other hospitalized populations. A multicenter study in New York, New York, USA, found bloodstream infections in only 3.8% of hospitalized patients who had COVID-19 but in 8.0% of patients who did not have COVID-19.[7] When comparing with patients who had influenza, Hughes et al. found a 1.8-fold increased rate of bloodstream infection in COVID-19 patients (2.5% vs. 1.4%) hospitalized in the United Kingdom.[3] However, differences in the types of case-patients by COVID-19 status were not considered in either study. Moreover, the generalizability of these differences by COVID-19 status to other geographic regions remains unknown.

Little evidence exists for risk factors for nosocomial infection in COVID-19. A single-center study from Wuhan, China, identified an association related to use of invasive devices and combination antimicrobial drugs, as well as having diabetes mellitus, with an increased risk for developing a hospital-acquired infection (HAI).[8] However, the external validity of these associations has not been explored.

In this study, we sought to investigate whether being infected with COVID-19 was independently associated with an increase in odds of developing a laboratory-confirmed bloodstream infection (LCBI). We also aimed to identify other potential risk factors for LCBI in hospitalized COVID-19 patients. We hypothesized that COVID-19 patients would have greater odds of acquiring an LCBI than hospitalized patients without COVID-19 after adjusting for relevant confounders, and that other risk factors might also be identified, which might serve as targets for interventions to reduce co-infection rates in this vulnerable group.