Hospital Infection Prevention: How Much Can We Prevent and How Hard Should We Try?

  • Gonzalo BearmanEmail author
  • Michelle Doll
  • Kaila Cooper
  • Michael P. Stevens
Healthcare Associated Infections (G. Bearman and D. Morgan)
Part of the following topical collections:
  1. Topical Collection on Healthcare Associated Infections


Purpose of Review

To summarize the extent to which hospital-acquired infections (HAIs) are preventable and to assess expectations, challenges, and barriers to improve patient outcomes.

Recent Findings

HAIs cause significant morbidity and mortality. Getting to zero HAIs is a commonly stated goal yet leads to unrealistic expectations. The extent to which all HAIs can be prevented remains debatable and is subject to multiple considerations and barriers. Current infection prevention science is inexact and evolving. Evidence-based infection prevention practices are often incompletely implemented and at times controversial. Highly sensitive surveillance results in overdiagnosis, calling into question the real incidence of HAIs. Perceived reductions in HAIs by gaming the system lead to false conclusions about preventability and may cause harm. Successful HAI reduction programs require executive oversight yet keeping hospital leaders engaged in infection prevention is a challenge given competing priorities. Medicine is not a physical science with precisely defined laws; thus, infection prevention interventions are subject to variable outcomes.


Perhaps up to 55–70% of HAIs are potentially preventable. This is subject to a law of diminishing returns as the preventable proportion of HAIs may reduce over time with improvements in patient safety. As the principle tenet of medicine is first do no harm, infection prevention programs should relentlessly pursue reliable, sustainable, and practical strategies for heightened patient safety.


Infection prevention Patient safety Implementation science Hospital epidemiology Public health Healthcare quality 



Authors would like to recognize Ms. Tina Olkonen for her assistance with preparing the final manuscript.

Compliance with Ethical Standards

Conflict of Interest

Gonzalo Bearman, Michelle Doll, Kaila Cooper, and Michael Stevens declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Klevens RM, Edwards JR, Richards CL, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122:160–6.CrossRefGoogle Scholar
  2. 2.
    Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173:2039–46.CrossRefGoogle Scholar
  3. 3.
    •• Magill SS, O’Leary E, Janelle SJ, et al. Changes in prevalence of health care-associated infections in US hospitals. N Engl Med. 2018;379:1732–44 Most up to date assessment of the burden of HAIs in the USA.CrossRefGoogle Scholar
  4. 4.
    •• Leapfrog Group. Healthcare associated infections. In: reports on hospital performance: 2018 report series. Available at: Accessed November 1st 2018. Up to date assessment of HAI prevention performance.
  5. 5.
    Pronovost P, Needham D, Berenoltz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–32.CrossRefGoogle Scholar
  6. 6.
    Edmond MB. Getting to zero: is it safe? Infect Control Hosp Epidemiol. 2009;30:74–6.CrossRefGoogle Scholar
  7. 7.
    Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32:2014–20.CrossRefGoogle Scholar
  8. 8.
    Timsit JF, Schwebel C, Geffroy A, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA. 2009;25(301):1231–41.CrossRefGoogle Scholar
  9. 9.
    Climo MW, Yokoe DS, Warren DK, Perl TM, Bolon M, Herwaldt LA, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368:533–42.CrossRefGoogle Scholar
  10. 10.
    Daneman N, Guttmann A, Wang X, Ma X, Gibson D, Stukel TA. The association of hospital prevention process and patient risk factors with the risk of clostridium difficile infection: a population-based cohort study. BMJ Qual Saf. 2015;24:435–43.CrossRefGoogle Scholar
  11. 11.
    Fakih MG, Heavens M, Ratcliffe CJ, Hendrich A. First step to reducing infection risk as a system: evaluation of infection prevention processes for 71 hospitals. Am J Infect Control. 2013;41:950–4.CrossRefGoogle Scholar
  12. 12.
    Dhar S, Marchaim D, Tansek R, Chopra T, Yousuf A, Bhargava A, et al. Contact precautions: more is not necessarily better. Infect Control Hosp Epidemiol. 2014;35:213–21.CrossRefGoogle Scholar
  13. 13.
    Bearman G, Stevens MP. Control of drug-resistant pathogens in endemic settings: contact precautions, controversies and a proposal for a less restrictive alternative. Curr Infect Dis Rep. 2012;14:620–6.CrossRefGoogle Scholar
  14. 14.
    Harris AD, Pineles L, Belton B, Johnson JK, Shardell M, Loeb M, et al. Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial. JAMA. 2013;310:1571–80.PubMedPubMedCentralGoogle Scholar
  15. 15.
    •• Edmond MB, Bearman G, Masroor N, Steven M, Ober J. The impact of discontinuing contact precautions for VRE and MRSA on device-associated infections. Infect Control Hosp Epidemiol. 2015;36:978–80 Important publication on the controversy of discontinuing contact precautions for endemic pathogens: MRSA and VRE.CrossRefGoogle Scholar
  16. 16.
    •• Martin EM, Russell D, Rubin Z, Humphries R, Grogan TR, Elashoff D, et al. Elimination of routine contact precautions for endemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: a retrospective quasi-experimental study. Infect Control Hosp Epidemiol. 2016;37:1323–30 Important publication on the controversy of discontinuing contact precautions for endemic pathogens: MRSA and VRE.CrossRefGoogle Scholar
  17. 17.
    •• Bearman G, Abbas S, Masroor N, et al. Impact of discontinuing contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: an interrupted time series analysis. Infect Control Hosp Epidemiol. 2018;39:676–82 First interrupted time series analysis published on discontinuing contact precautions for endemic pathogens: MRSA and VRE.CrossRefGoogle Scholar
  18. 18.
    • Morgan DJ, Bearman G, Murthy R, et al. Reconsidering contact precautions for endemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Infect Control Hosp Epidemiol. 2015;36:1163–72 Important summary of contact precautions controversy and evidence.CrossRefGoogle Scholar
  19. 19.
    • Morgan DJ, Wenzel RP, Bearman G. Contact precautions for endemic MRSA and VRE time to retire legal mandates. JAMA. 2017;318:329–30 Editorial advocating the retirement of legal mandates for MRSA and VRE control.CrossRefGoogle Scholar
  20. 20.
    •• Madden GR, Weinstein RA, Sifri CD. Diagnostic stewardship for healthcare-associated infections: opportunities and challenges to safely reduce test use. Infect Control Hosp Epidemiol. 2018;39:214–8 Important paper that highlights the evolving role of diagnostic stewardship in infection prevention.CrossRefGoogle Scholar
  21. 21.
    Burnham CA, Carroll KC. Diagnosis of clostridium difficile infection: an ongoing conundrum for clinicians and clinical laboratories. Clin Microbiol Rev. 2013;26:604–30.CrossRefGoogle Scholar
  22. 22.
    Morgan DJ, Leekha S, Croft L, et al. The importance of colonization with clostridium difficile on infection and transmission. Curr Infect Dis Rep. 2015;17:499.CrossRefGoogle Scholar
  23. 23.
    •• Leekha S, Preas MA, Hebden J. Association of national healthcare safety network--defined catheter-associated urinary tract infections with alternate sources of fever. Infect Control Hosp Epidemiol. 2015;36:1236–8 Paper highlights the potential inaccuracies of national surveillance definitions.CrossRefGoogle Scholar
  24. 24.
    Ider BE, Adams J, Morton A, Whitby M, Clements A. Gaming in infection control: a qualitative study exploring the perceptions and experiences of health professionals in Mongolia. Am J Infect Control. 2011;39:587–94.CrossRefGoogle Scholar
  25. 25.
    •• Horowitz HW. Infection control II: a practical guide to getting to zero. Am J Infect Control. 2016;44:1075–7 Important editorial highlighting potential mechanisms to game HAI surveillance.CrossRefGoogle Scholar
  26. 26.
    Klompas M, Berra L. Should ventilator-associated events become a quality indicator for ICUs? Respir Care. 2016;61:723–36.CrossRefGoogle Scholar
  27. 27.
    • Mullin KM, Kovacs KS, Fatica C, et al. A multifaceted approach to reduction of catheter-associated urinary tract infections in the intensive care unit with an emphasis on “stewardship of culturing”. Infect Control Hosp Epidemiol. 2017;38:186–8 Paper highlights diagnostic stewardship to reduce catheter associated urinary tract infections.CrossRefGoogle Scholar
  28. 28.
    Ives, Crystal, Human beings as chaotic systems. . Accessed 10.23.18.
  29. 29.
    Bowen DJ. Leading quality and safety. Getting to zero harm must start at the top. Healthcare Executive. 2015;30:8.PubMedGoogle Scholar
  30. 30.
    • Vokes RA, Bazzoli GJ, Bearman G. Hospital-acquired infections under pay-for-performance systems: as administrative perspective on management and change. Curr Infect Dis Rep. 2018;20:35 Editorial underscores the importance of executive leadership to reach safety goals.CrossRefGoogle Scholar
  31. 31.
    Dellinger EP. Prevention of hospital-acquired infections. Surg Infect. 2016;17:422–6.CrossRefGoogle Scholar
  32. 32.
    Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: an overview of published reports. J Hosp Infect. 2003;54:258–66258-66.CrossRefGoogle Scholar
  33. 33.
    Umscheid CA, Mitchell MD, Doshi JA, Agarqal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011;32:101–14.CrossRefGoogle Scholar
  34. 34.
    •• Schreiber PW, Sax H, Wolfensberger A, Clack L, Kuster SP, Swissnoso. The preventable proportion of healthcare-associated infections 2005–2016: systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2018;39:1277–95 Most up-to-date assessment of proportion of preventable healthcare-associated infections.CrossRefGoogle Scholar
  35. 35.
    The Sveriges Riksbank prize in economic sciences in memory of Alfred Nobel 1978. Accessed October 27, 2018.
  36. 36.
    Wenzel RP, Edmond MB. Infection control: the case for horizontal rather than vertical interventional programs. Int J Infect Dis. 2010;14:S3–5.CrossRefGoogle Scholar
  37. 37.
    • Dellinger EP. Prevention of hospital-acquired infections. Surg Infect. 2016:17422–6 Publication defines and distinguishes potentially preventable vs apparently unpreventable HAIs.Google Scholar
  38. 38.
    McChesney C, Covey S, Huling J. The 4 disciplines of execution: achieving your wildly important goals. New York: Free Press; 2012.Google Scholar
  39. 39.
    Richards C. Getting to zero: an emergency policy framework for the elimination of hospital-associated infections. Infect Control Hosp Epidemiol. 2009;30:71–3.CrossRefGoogle Scholar
  40. 40.
    • Gray J. Infection control: beyond the horizon. J Hosp Infect. 2015;89:237–40 Publication highlights critical next steps in infection prevention science.CrossRefGoogle Scholar
  41. 41.
    Kahn KL, Mendel P, Baker DP. Lessons learned and future directions: the national response for preventing health-care associated infections. Med Care. 2014;52:385.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Gonzalo Bearman
    • 1
    Email author
  • Michelle Doll
    • 1
  • Kaila Cooper
    • 1
  • Michael P. Stevens
    • 1
  1. 1.Virginia Commowealth University Hospital Infection Prevention ProgramRichmondUSA

Personalised recommendations