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Am Fam Physician. 2022;105(3):262-270

Published online January 26, 2022.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Health care–associated infections (HAIs) are a significant cause of morbidity and mortality in the United States. Common examples include catheter-associated urinary tract infections, central line–associated bloodstream infections, ventilator-associated pneumonia, surgical site infections, and Clostridioides difficile infections. Standardized infection control processes and precautions have been shown to reduce the rate of HAIs, and targeted practices for HAIs have shown further reductions. Patient safety tools have been developed for various HAIs to help guide administrators and are free for public use through the Centers for Disease Control and Prevention STRIVE (States Targeting Reduction in Infections via Engagement) initiative. The Choosing Wisely initiative makes best practice recommendations for physicians to improve quality of care and reduce costs; targeted recommendations were developed to reduce the risk of HAIs. For example, using invasive devices only when indicated and for the shortest time possible reduces the risk of device-related HAIs. The goal of antibiotic stewardship is to reduce C. difficile infections and further development of multidrug-resistant organisms such as vancomycin-resistant Enterococcus and carbapenem-resistant Enterobacteriaceae. Antibiotic stewardship targets physician behaviors such as reviewing antibiotic therapy choices every 48 to 72 hours, reviewing culture results as soon as available, de-escalating antibiotic therapy when appropriate, and documenting the indications for initiating and continuing antibiotic therapy.

Health care–associated infections (HAIs) are a significant source of morbidity and mortality in the United States, with approximately 687,000 infections and 72,000 deaths annually, leading to costs in the billions of dollars.1 The Centers for Disease Control and Prevention (CDC) estimates that up to one in 25 patients will develop an HAI.1,2 The CDC tracks and reports data on the occurrence of catheter-associated urinary tract infections (UTIs), central line–associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP), and surgical site infections through the STRIVE (States Targeting Reduction in Infections via Engagement) initiative, with the goal of reducing HAIs.3 SARS-CoV-2 had a negative impact on rates of HAIs; between 2019 and 2020, CLABSIs, catheter-associated UTIs, and VAPs increased by 47%, 19%, and 45%, respectively, without a significant reduction in surgical site infections.4 Standard practices reduce HAIs, and more targeted practices instituted at the local level further reduce HAIs.3 Free tools are available through the STRIVE initiative and CDC that can be implemented and used to reduce HAIs.3

Clinical recommendationEvidence ratingComments
To reduce health care–associated infections, institutions should establish local infection prevention processes, including ongoing educational programs, checklists and treatment “bundles,” and local reporting and tracking programs.3,5,6 BConsistent evidence from meta-analysis and systematic reviews of randomized controlled trials
Urinary catheters should be used for the shortest duration possible and removed as soon as they are no longer required.13,16 BExpert opinion and consensus guidelines; a small prospective cohort study
Central lines should be used for the shortest duration possible and removed as soon as they are no longer required.17,18 CExpert opinion and consensus guidelines
Noninvasive positive pressure ventilation should be attempted before intubation when clinically appropriate to prevent ventilator-associated pneumonia.22 CExpert opinion and consensus guidelines
Probiotics should be considered to prevent Clostridioides difficile infection in hospitalized, immunocompetent patients at high risk of the infection who are receiving antibiotics.43,47 B [corrected]Consistent evidence from meta-analysis and systematic reviews of randomized controlled trials; expert clinical review
Antibiotics should be used for the shortest possible duration, discontinued when appropriate, and targeted to specific organisms to reduce risk of C. difficile infection and development of multidrug-resistant organisms.39 CExpert opinion and consensus guidelines
RecommendationSponsoring organization
Catheter-associated urinary tract infection
Do not place or maintain an indwelling urinary catheter in a patient unless there is a specific indication to do so.
Do not place an indwelling urinary catheter to manage urinary incontinence.
Do not place, or leave in place, urinary catheters for incontinence, convenience, or monitoring of output for noncritically ill patients (acceptable indications: critical illness, obstruction, hospice, in perioperative period for fewer than two days for urologic procedures); use daily weights instead to monitor diuresis.
American Academy of Nursing
Society for Post-Acute and Long-Term Care Medicine
Society of Hospital Medicine (Adult)
Central line–associated bloodstream infection
Avoid invasive devices (including central lines, endotracheal tubes, and urinary catheters) and, if required, use them no longer than necessary.
Do not place, or leave in place, peripherally inserted central lines for patient or clinician convenience.
Society for Healthcare
Epidemiology of America
Society of General Internal Medicine
Surgical site infection
Do not continue antibiotics used for surgical prophylaxis after the patient has left the operating room.
Do not routinely use topical antibiotics on a surgical wound.
Society for Healthcare
Epidemiology of America
American Academy of Dermatology
Clostridioides difficile infections/multidrug-resistant organisms
Do not use antibiotics in patients without convincing evidence of need.
Do not continue antibiotics beyond 72 hours in hospitalized patients unless patient has clear evidence of infection.
Society for Healthcare Epidemiology of America
Society for Healthcare Epidemiology of America
C. difficile infections/ventilator-associated pneumonia
Do not prescribe medications for stress ulcer prophylaxis to medical inpatients unless they are at high risk of gastrointestinal complications (e.g., high risk of gastrointestinal ulcer bleeding).
Do not continue hospital-prescribed stress ulcer prophylaxis with proton pump inhibitor therapy in the absence of an appropriate diagnosis in the postacute and long-term care population.
For pharmacologic treatment of patients with gastroesophageal reflux disease, long-term acid suppression therapy (proton pump inhibitors or histamine H2 blockers) should be titrated to the lowest effective dose to achieve therapeutic goals.
Society of Hospital Medicine (Adult)
Society for Post-Acute and Long-Term Care Medicine
American Gastroenterological Association

The health care environment increases the risk of the development and spread of multidrug-resistant bacteria, leading to increased difficulty in treating HAIs.3 Targeted practices should be aimed at reducing HAIs and the development of multidrug-resistant pathogens.2

General Recommendations

Health care institutions should establish local infection prevention processes, including ongoing educational programs, institutional checklists and treatment “bundles” (a combination of developed interventions that help reduce HAIs),3 and local reporting and tracking programs.5,6 Multiple professional organizations have made specific and targeted recommendations to reduce HAIs. Good hand hygiene and proper use of personal protective equipment are necessary.7 Guidelines for preventing HAIs are available from the CDC at https://www.cdc.gov/hai/prevent/prevention.html. The Society for Healthcare Epidemiology of America offers further recommendations and resources at https://shea-online.org/compendium-of-strategies-to-prevent-healthcare-associated-infections-in-acute-care-hospitals/.

SARS-CoV-2

Current evidence supports social distancing, masking, and vaccination to prevent or reduce HAIs related to SARS-CoV-2.8 The CDC recommends adhering to prevention practices for airborne diseases, which include having all individuals wear a face mask while in any indoor clinical space, placing the infected patient in an airborne infection isolation room if available, limiting visitation, and having health care workers use additional appropriate personal protective equipment (e.g., N95 respirator, goggles, gown, hair coverings, gloves).8 If an airborne infection isolation room is not available, private rooms can also reduce the spread of airborne diseases.8 Personal protective equipment should be donned and doffed using appropriate techniques before and after each patient encounter to reduce the risk of HAIs caused by SARS-CoV-2.8 A CDC educational video on a donning technique is available at https://youtu.be/H4jQUBAlBrI. Health care workers should also be immunized against COVID-19 and other vaccine-preventable communicable diseases to prevent or reduce spread.9

Mask wearing by health care workers has been demonstrated to reduce the spread of airborne diseases in health care environments.10,11 Effectiveness of cloth masks is unclear given the variability of material and construction of the masks, and they should not be worn during patient care when appropriate medical masks or N95 respirator masks are available.10,11

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