Striving for zero traditional and non-traditional healthcare-associated infections (HAI): a target, vision, or philosophy

Abstract

Healthcare-associated infections (HAIs) are a major global health concern, affecting millions of patients each year across a variety of healthcare settings. Originally known as nosocomial infections, HAIs now include infections acquired during medical care other than acute-care hospital admissions. These infections, which range from traditional (eg, CLABSI, CAUTI, SSI, VAP) to non-traditional (eg, outbreaks, EIDs, MDROs), pose a variety of challenges and have a significant impact on patient care outcomes. According to studies, patients with HAIs have longer hospital stays, higher mortality rates (ranging from 7% to 64.6%), and higher healthcare costs as a result of their extended care needs. This review will delve into the prevalence, consequences, and management strategies for both traditional and non-traditional HAIs.

Introduction

Healthcare-associated infections (HAIs) are infections acquired by patients during medical treatment, and previously were known as nosocomial infections, which referred specifically to acute-care hospital admissions. This definition now encompasses infections occurring in various healthcare settings. ¹ HAIs develop during care in a facility and were not present at admission. ¹ They can be categorized into traditional types, such as central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), surgical site infections (SSI), and ventilator-associated pneumonia (VAP), and non-traditional types, including outbreaks, emerging infectious diseases (EIDs), and multidrug-resistant organisms (MDROs) (Table 1). ²

Table 1.

Traditional and non-traditional healthcare associated infections

Type of HAI	Definition	Examples	Additional Thoughts
Traditional HAIs	during medical treatment or procedures associated with healthcare settings.	CLABSI CAUTI VAE SSI	arise from invasive procedures and devices can be prevented through proper hand hygiene and protocols.
Non-Traditional HAIs	may not be directly tied to standard medical procedures significantly impact hospital settings.	- Hospital transmissions of MERS, SARS-CoV-2, Influenza	- importance of infection control measures beyond routine protocols, especially during outbreaks.

*Abbreviations:.- CLABSI: Central Line-Associated Bloodstream Infection.

- CAUTI: Catheter-Associated Urinary Tract Infection.

- VAE: Ventilator-Associated Event.

- SSI: Surgical Site Infection.

- MERS: Middle East Respiratory Syndrome.

- SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus 2.

HAIs are a significant global health concern, affecting millions annually and posing substantial challenges to healthcare systems. Patients with HAIs experience 2–20 more days of hospitalization than those without infections. The mortality rate among infected patients ranges from 7% to 64.6%, and the economic burden includes extended hospital stays, additional tests, and invasive procedures, ^3,4 for example traditional HAIs are associated with a case-fatality rate of 2.3–14.4%. ⁵

This review examines both traditional and non-traditional HAIs, focusing on their prevalence, impact, and management strategies. By addressing these elements, the aim is to enhance healthcare professionals’ understanding of HAIs and effective prevention methods. Ultimately, we will explore the “Striving for Zero” initiative to determine if it serves as a target, vision, or guiding philosophy in combating these infections.

Traditional healthcare-associated infections (HAIs)

Traditional HAIs remain a significant challenge in healthcare settings mainly for CLABSI, CAUTI, VAP, and SSI.

Burden of traditional HAIs

Based on the 2011 World Health Organization (WHO) Report on the Burden of Endemic HAIs, there is a variation in the burden among high-income countries (HICs) and low- and middle-income countries (LMICs). The prevalence of HAI in HICs is typically lower, typically less than 10%. The prevalence of HAI in LMICs is much higher there than in HICs; there is a lack of data because of surveillance resource limitations. ⁶ In addition, there is regional variations with a rate of 11.8% in the Eastern Mediterranean Region, 10% in South East Asia and 4.6–9.3% in the European Region. ¹ According to data from 55 countries, the overall prevalence of HAI is estimated to be 8.7%. ⁷ Prevalence is lower in the Western Pacific Region than in other regions. ⁷ A most recent report from the WHO in 2024 also shows variable HAIs in different countries (Table 2). ⁸ The data highlights the significant disparity in HAI prevalence between high-income countries and low- and middle-income countries, particularly in intensive care units. The high rates of healthcare-associated sepsis cases, especially in adult ICUs, underscore the critical need for improved infection prevention and control measures globally, with a particular focus on resource-limited settings. ⁸

Table 2.

A summary of the key statistics on healthcare-associated infections (HAIs) across different healthcare settings and regions. Data from WHO 2024 report [8]

Category	High-Income Countries (HICs)	Low- and Middle-Income Countries (LMICs)	Global/Other
HAI prevalence in acute-care hospitals	7%	15%	–
EU/EEA and Western Balkan territories (2022–2023 survey)	8%	–	–
ICU HAI prevalence	Up to 30%	2–20 times the HICs rate	Up to 30% overall
Hospital-treated sepsis cases that are healthcare-associated	–	–	23.6%
Adult ICU sepsis cases with organ dysfunction acquired in hospital	–	–	48.7%

CLABSI rates vary across healthcare settings, with a reported baseline rate of 2.1 per 1,000 catheter days in a study of 250 hospitals in the USA. ⁹ Risk factors for the development of CLABSI include: immunocompromised or neutropenic patients, severe burns or malnutrition, prolonged central line catheterization, femoral site insertion and multiple catheter lumens. One study examined factors were associated with CLABSI and were the duration of ICU stay; duration of catheter insertion; and APACHE II score. ¹⁰

CAUTIs are a significant concern, with varying rates reported. In Saudi Arabia, the CAUTI rate was 1.68 per 1,000 catheter-days across 99 hospitals and 15 ICUs, with the highest rates in pediatric medical (5.73) and adult medical (2.02) ICUs. ¹¹ Another study found a slightly lower rate of 1.64 per 1,000 catheter-days from 47,926 patients and 61,047 catheterizations, noting a higher pediatric rate of 2.08 compared to 1.61 in adults. ¹² SSI rates range from .5% to 3% of surgical procedures. ¹³ Risk factors include patient conditions (eg, diabetes, obesity), surgical complexity, procedure duration, and preoperative preparation.

Prevention of traditional HAIs

Guidelines for preventing CLABSI include evidence-based strategies such as a comprehensive bundle approach, proper hand hygiene, maximal sterile barrier precautions, and Chlorhexidine skin antisepsis, which reduces CLABSI risk by 49% compared to povidone-iodine. ¹⁴ Other measures involve avoiding femoral site insertion, daily catheter necessity assessments, adequate staffing, and bundle implementation. ¹⁵

The AHRQ reports significant progress in reducing CAUTI rates through initiatives like the Comprehensive Unit-based Safety Program. A study of 926 hospital units showed a 32% decrease in CAUTI rates in non-ICUs, from 2.28 to 1.54 infections per 1,000 catheter-days, though rates in ICUs remained unchanged. ¹⁶ CAUTI prevention strategies include limiting catheter use, proper insertion techniques, maintaining a closed drainage system, and regular necessity assessments. ¹⁷

To reduce SSI rates, evidence-based interventions include avoiding razors for hair removal, using chlorhexidine gluconate with alcohol, maintaining normothermia, and ensuring perioperative glycemic control. ^13,18–20 Implementing these practices can significantly lower HAIs, enhancing patient outcomes and reducing healthcare costs.

Non-traditional healthcare-associated infections

Multi-drug-resistant organisms (MDROs)

Non-traditional HAIs present significant challenges beyond typical infectious diseases in healthcare settings, with MDRO outbreaks being a major concern. These MDRO complicate treatment, leading to longer hospital stays, increased costs, and higher mortality rates. ²¹ MDROs include pathogens like methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and carbapenem-resistant Enterobacteriaceae (CRE), which can cause severe and hard-to-treat infections. ^22,23 The rise of plasmid-mediated colistin resistance (mcr-1) raises alarms about widespread drug resistance among gram-negative bacteria ^22,23 and complicates treatment and control efforts. ²⁴ Of importance, the emergence of Candidozyma (Candida) auris has raised concerns due to its persistence in healthcare environments and outbreak potential. ^25,26 Factors contributing to MDRO emergence include antibiotic overprescription, poor infection control practices, and global interconnectedness. ^27,28 Key strategies for prevention of MDROs include antimicrobial stewardship, strict hand hygiene, environmental cleaning, and appropriate isolation precautions. ²⁹ Collaborative efforts among infection control specialists, microbiologists, clinicians, and public health authorities are crucial as well. ³⁰

Emerging infectious diseases (EIDs)

In parallel, the rise of EIDs poses additional challenges to healthcare settings. In the recent years, the 2009 H1N1 influenza pandemic, the Ebola outbreaks in West Africa (2013–2015) and the Democratic Republic of the Congo (2018–2020), poliomyelitis (2014–present), Zika (2016), and COVID-19 (2020–2023), the 2022–2023 and 2024 Mpox outbreaks were designated public health events of international concern by the World Health Organization (WHO). ^31–35 The Middle East Respiratory Syndrome Coronavirus (MERS-CoV) had caused multiple healthcare associated outbreaks and were related to multiple factors (Table 3). ³⁶ Healthcare workers (HCWs) are at high risk of acquiring and spreading emerging infections within healthcare facilities. ³⁷ Studies have shown that healthcare-associated COVID-19 outbreaks can be substantial. In Taiwan, a nationwide study reported 54 healthcare-associated COVID-19 outbreaks involving 512 confirmed cases between January 2020 and July 2021. The median number of affected cases per outbreak was six, with a median outbreak duration of 12 days. ³⁸

Table 3.

Main infection control issues and their prevalence in relation to middle east respiratory syndrome coronavirus outbreaks [36]

Infection Control Issue	Prevalence	Affected Regions
Hospital Design	High	Middle East (Jordan, Saudi Arabia), South Korea
Healthcare Worker Adherence	Very High	Middle East (Jordan, Saudi Arabia, UAE), South Korea
Patient Flow Management	Moderate	South Korea, Saudi Arabia
Aerosol-Generating Procedures	Moderate	South Korea, Saudi Arabia
Social and Cultural Factors	Low	South Korea

In a PCR study of SARS-CoV-2, 326 HCWs had COVID-19, with ten infection clusters identified; HCWs were the index case in nine clusters and a patient in one. ³⁹ Transmission dynamics in healthcare settings are complex, with HCW-to-HCW transmission being significant. A Swedish study found that 78% of HCW cases during an outbreak were linked to co-workers. ⁴⁰ Key risk factors for HCWs included direct care of COVID-19 patients and positive family contacts, with adjusted odds ratios of 8.4 and 9.0, respectively. ⁴⁰ COVID-19 rates among HCWs often mirrored community cases, suggesting that strict infection control in non-clinical areas may not always be necessary. ⁴¹

The potential for nosocomial spread of EIDs is concerning due to delayed recognition of novel pathogens, which can hinder early infection control measures. ²⁴ Close contact with infected patients increases HCWs’ risk of acquiring and spreading infections, especially in facilities housing immunocompromised individuals. Resource-limited settings may lack adequate personal protective equipment (PPE) or isolation capabilities during outbreaks. ⁴²

Effective management of EIDs requires understanding the pathogens, modes of transmission, and treatment strategies. Surveillance and response protocols are essential for early detection and containment as well. ⁴³ Awareness, preparedness, and collaboration across sectors are vital to mitigate EID impacts. ^44,45

The CDC has developed a strategic plan focusing on surveillance, research, prevention, and strengthening public health infrastructure to address emerging infectious disease threats Effective response strategies depend on collaboration among healthcare providers, microbiologists, and public health professionals. ⁴⁵ Healthcare facilities must implement policies for early identification of highly communicable diseases, immediate isolation, and proper management to prevent transmission. ³⁵ Additionally, protocols for early identification and isolation of suspected EIDs, ensuring adequate PPE supplies, training staff in infection control, and developing surge capacity plans are crucial . ⁴⁰ Designating entire units with dedicated HCWs for SARS-CoV-2 patients may also be beneficial. ⁴² As new threats emerge, healthcare systems must remain vigilant and adaptable to protect patients and HCWs.

The interactions between traditional and non-traditional healthcare-associated infections (HAIs)

The interaction between traditional and non-traditional HAIs is a complex and continually evolving within healthcare settings and can significantly worsen patient outcomes and complicate infection control efforts. For instance, certain non-traditional HAIs, such as viral infections, can suppress the immune system, rendering patients more susceptible to traditional bacterial HAIs. ^46,47

Moreover, non-traditional HAIs, particularly those that necessitate broad-spectrum antimicrobial treatment, can disrupt the patient’s normal microbiome. This disruption may increase the risk of traditional HAIs, such as Clostridioides difficile infections. ⁴⁸ In one study, carbapenem resistant Acinetobacter baumannii and C. auris were the most common causes of reported MDRO outbreaks during the COVID-19 pandemic. ⁴⁹ In addition, CAUTIs caused by a carbapenem-resistant Enterobacteriaceae (CRE) are significantly more challenging to treat than one caused by a susceptible organism. ⁵⁰ Pathogens, like C. auris, have a propensity for biofilm formation. This can enhance the colonization of medical devices, potentially increasing the risk of traditional device-associated infections like CLABSI. ⁵¹ Outbreaks of non-traditional HAIs can strain healthcare resources, potentially leading to lapses in standard infection control practices that prevent traditional HAIs. ⁵² The presence of non-traditional pathogens can create opportunities for synergistic interactions with traditional HAI-causing organisms, potentially leading to more severe or persistent infections. ⁵¹ One such interaction is an increase in antimicrobial consumption as seen during the first wave of the COVID-19 pandemic, especially in ICUs. ⁵³

To address these complex interactions, healthcare facilities must adopt comprehensive infection prevention strategies that consider both traditional and non-traditional HAIs. This includes robust surveillance systems, judicious use of antimicrobials, and innovative approaches to infection control that can adapt to emerging threats. ^49,54

Achieving Zero Healthcare-Associated Infections

HAIs continue to pose a significant challenge in clinical settings, yet many can be prevented through evidence-based interventions. ^55,56 They can be divided into two categories: potentially preventable HAIs, which can be avoided by following infection prevention protocols, and potentially unpreventable HAIs, which occur despite adherence to recommended measures. ⁵⁷ Addressing modifiable risk factors is essential for prevention and involves both vertical and horizontal strategies. Vertical strategies target specific pathogens, such as actively detecting and isolating MRSA and VRE, while horizontal strategies focus on reducing the transmission of multiple pathogens through strict hand hygiene, thorough disinfection, skin decolonization with chlorhexidine, appropriate PPE use, and antibiotic stewardship. ^1,57

The investigation process is critical for determining the preventability of HAIs and identifying areas for improvement. This process aims for zero potentially preventable infections, aligning with the healthcare principle of “primum non nocere” (first, do no harm). ⁵⁸ Effective implementation requires a multifaceted approach involving patients, healthcare systems, and workers. ⁵⁵ Evidence-based strategies may prevent 30% to 70% of HAIs. ⁵⁶ However, the law of diminishing returns applies; as prevention efforts intensify, additional benefits may decrease over time . ⁵⁶

The concept of “zero tolerance” for HAIs emerged in the early 2000s, evolving into a “targeting zero” approach that acknowledges the complexities of healthcare systems while striving for zero preventable infections. ⁵⁹ This“zero harm” philosophy represents a paradigm shift in how healthcare organizations address preventable infections, challenging the notion that some HAIs are inevitable. It sets an aspirational goal of eliminating all preventable harm to patients. ^59,60

Implementing comprehensive HAI prevention programs is crucial for achieving the goal of zero HAIs. These programs typically involve multi-faceted interventions including systemic changes and strong support from hospital administrators and clinical leaders. ⁶¹ Fostering a culture of safety where all healthcare workers are empowered to prioritize infection prevention is essential. ⁵⁹ To effectively prevent infections, it is crucial to implement and consistently follow proven measures, such as proper hand hygiene and device management protocols. Additionally, establishing strong data collection systems can help identify areas for improvement and track progress. ⁶² An integrated approach that addresses multiple aspects of infection prevention simultaneously is also essential for achieving better outcomes. ⁶²

Achieving “zero-target” of HAIs is a challenging but potentially attainable goal, as demonstrated by several healthcare organizations (Table 4). For instance, the American University of Beirut Medical Center’s NICU achieved zero CLABSIs for over 23 months by implementing a comprehensive safety bundle, anonymous auditing, and staff training. ⁶³ Riverside Methodist Hospital eliminated CLABSI through a multidisciplinary team approach, securing stakeholder support and providing continuous feedback, resulting in zero CLABSI rates for 12 months. ⁶⁴ The Community Based Medical Center implemented a targeted nursing practice with specific product technologies in their CLABSI prevention bundle, leading to 15 months without infections through a well-defined educational program. ⁶⁵ In a UK ICU, infection surveillance and insertion/maintenance bundles, along with educational interventions, sustained a reduction in CLABSI rates for 19 months. ⁶⁶

Table 4.

Examples of published studies of achieving zero healthcare-associated infections (HAIs)

Facility	Type of HAI Eliminated	Strategies Implemented	Results	Reference
The American University of Beirut Medical Center NICU	CLABSIs in Neonatal ICU	Comprehensive insertion and maintenance bundle; anonymous auditing; and staff training.	Sustained zero CLABSI rates for 23 consecutive months.	[63]
Riverside Methodist Hospital	CLABSI	multidisciplinary team approach, support from persons with a stake in the process, and provision of continuous feedback	Sustained zero CLABSI rates for 12 consecutive months.	[64]
Community Based Medical Center	CLABSI	focused nursing practice and product technologies were selected for the bundle and implemented through a defined educational program	15 months	[65]
a UK ICU	CLABSI	established infection surveillance and introduced bundles related to insertion and maintenance and educational intervention	19 months	[66]

These examples highlight the importance of evidence-based practices, multidisciplinary collaboration, and a culture of safety in combating HAIs. Common strategies include comprehensive infection control protocols, ongoing staff education, strict hand hygiene adherence, and thorough environmental cleaning. By tailoring interventions to specific HAIs and patient populations while maintaining strong surveillance and accountability, healthcare facilities can significantly lower infection rates and enhance patient outcomes. These success stories serve as valuable models for institutions aiming for zero HAIs. However, some initiatives, like the Spanish Zero Surgical Infection Project (ZSIP) from 2017–2021, did not achieve zero targets. ⁶⁷

Achieving zero HAIs requires persistent and rigorous monitoring and evaluation at all times. This involves setting clear, measurable goals for reducing HAIs across various types of infections, such as CLABSI, CAUTI, and SSI. ⁶¹ It is also essential to implement systems for timely reporting and analysis of infection data, allowing for real-time tracking. Conducting thorough investigations of any HAIs that do occur to identify and address systemic issues. ⁶⁸ Regularly communicating progress and challenges to all stakeholders, including frontline staff. ⁶¹

Additionally, prevention strategies should be continuously refined and updated based on new evidence and emerging best practices. ⁶² While the goal of zero HAIs is ambitious, evidence suggests that significant reductions are achievable. For example, one healthcare system reported a 34% decrease in CLABSI after implementing a zero harm initiative. ⁶⁸

Implementing “Target zero” initiatives

Implementing “Target Zero” initiatives for HAIs requires a multifaceted approach. Successful programs feature strong leadership that prioritizes HAI prevention and actively supports infection control initiatives by allocating resources, motivating staff, and fostering a culture of safety. ⁶⁰ In contrast, unsuccessful programs often lack this commitment . ^69,70 Transforming hospital culture to prioritize patient safety and securing steadfast leadership support are essential for a successful “Target Zero” program. ^71–74 Table 5 outlines a roadmap with a structured framework for implementing these initiatives, promoting a culture of safety and measurable improvements in patient outcomes.

Table 5.

Striving for zero: reducing healthcare-associated infections (HAI) - a target, vision, or philosophy

	Target	Vision	Philosophy	Comprehensive Approach
Definition	Specific, measurable goal (SMART)	Aspirational ideal of infection-free care	Fundamental shift in patient safety approach	Integration of target, vision, and philosophy
Key Features	- Drives continuous improvement	- Guides long-term planning	- Views all HAIs as preventable	- Implements evidence-based practices
	- Sets clear benchmarks	- Fosters a culture of safety	- Promotes continuous learning	- Cultivates safety-first culture
	- Encourages data-driven decisions	- Engages all stakeholders	- Empowers all healthcare workers	- Ensures multi-level engagement
Examples	- Annual HAI reduction goals	- Comprehensive prevention programs	- Ongoing infection prevention education	- Evidence-based practices
	- Regular HAI rate monitoring	- Leadership and staff training initiatives	- Root cause analysis/learn from defect tool for HAIs	- Stakeholder engagement at all levels
Challenge	Achieving absolute zero infections may be unrealistic	Maintaining consistent engagement across all levels	Overcoming resistance to change	Coordinating diverse strategies and stakeholders
Impact	Drives continuous focus on infection prevention and control	Aligns organizational efforts toward a common goal	Transforms organizational culture and individual mindsets	Creates a comprehensive, multi-faceted approach
Outcome	Significant reduction in HAI rates over time	Development of a pervasive safety culture	Increased accountability and proactive prevention efforts	Sustainable, long-term improvements in patient safety and care quality

Leadership must promote open communication, encourage questioning of assumptions, and prioritize safety over productivity. Education and training are critical for effective HAI reduction, with successful programs investing in continuous training for HCWs on hand hygiene, appropriate PPE use, and protocol adherence. Conversely, programs that neglect staff education often see increased infection rates. Ongoing education covering fundamental knowledge, skills, and regulatory compliance is essential for HAI prevention. ^75–77

Successful programs utilize robust data collection and analysis to monitor infection rates and identify patterns, allowing healthcare facilities to pinpoint areas for improvement and assess intervention effectiveness. Inadequate surveillance in unsuccessful programs hinders performance evaluation and necessary adjustments. By addressing avoidable factors and implementing effective infection prevention and control strategies, healthcare systems can significantly reduce HAIs and enhance patient safety. As the World Health Organization (WHO) states, “No one should get sick seeking care,” yet millions are affected by avoidable HAIs each year, highlighting that no health system can claim to be free of them. ⁷⁸

Effective HAI reduction also requires collaboration among departments and stakeholders within healthcare facilities. ⁷⁹ Open communication fosters a team approach to infection control and enables the sharing of best practices, while poor communication can lead to siloed operations and fragmented prevention efforts. Successful programs recognize the importance of involving patients in infection prevention, enhancing awareness and compliance through education and encouraging active participation in their care. Ineffective programs often overlook patient education, diminishing their overall impact.

Education and training are crucial in preventing both traditional and non-traditional HAIs. Continuous education for HCWs is essential to uphold high infection prevention standards, keeping them updated on the latest advancements in practices, treatments, and diagnosis. ^80,81 This is especially important for addressing emerging infectious diseases and multidrug-resistant organisms.

Competency-based training ensures HCWs are proficient in infection prevention practices, with measurable skills that can be regularly assessed. Tools like the Infection Control Assessment and Response (ICAR) help identify competency gaps. ⁸² A study during the MERS outbreak highlighted that following established procedures reduces cross-infection risks, prioritizes safety, and expedites patient treatment. ⁸³ Training on recognizing, containing, and managing MERS-CoV cases was crucial for nurse educators. ⁸³

Simulation-based training has proven effective for HAI prevention, enhancing HCWs’ competence, confidence, and compliance with infection measures, ultimately reducing HAI rates and healthcare costs. ⁸⁴ National initiatives like the CDC’s STRIVE program emphasize education in improving infection prevention practices through multimodal strategies that include educational materials and guided facilitation. ^85,86

Hand hygiene is a cornerstone of infection prevention and requires ongoing educational reinforcement. Despite its importance, compliance rates are low, averaging around 40% in hospitals. Educational materials, such as training films and visual posters, effectively promote hand hygiene practices. ^83,87

Challenges and limitations of the “Target zero” approach

Achieving zero HAIs requires a comprehensive commitment to patient safety. While absolute zero may be difficult, striving for this goal can significantly enhance infection prevention practices. Effective HAI reduction programs rely on evidence-based methods, including checklists, bundles, and regular training for HCWs. One study included 116 intensive care units and showed a significant reduction of 43.5%, 52.1%, and 65.8%, for CLABSI, VAP and CAUTI, respectively. ⁸⁸ The reduction was linked to the VAP prevention bundle, CAUTI and CLABSI insertion and maintenance bundles, all showing inverse correlations with HAI incidence densities. ⁸⁸ Pursing Zero HAIs serves as a goal, a vision, and guiding philosophy encompassing the interconnected elements of healthcare quality improvement. As a goal, it is a clear, quantifiable objective. Even though it might be difficult to achieve, establishing this ambitious goal motivates ongoing efforts for improvement. As a vision, it represents a perfect scenario in which patients receive treatment without contracting avoidable infections. Long-term planning and decision-making are guided by this aspirational perspective. As a philosophy, it indicates a significant change in the way medical facilities handle patient safety. Prioritizing infection prevention as a fundamental element of high-quality care with multiple elements such as encouraging a culture of continuous improvement and learning from defects and to assume responsibility for infection prevention (Table 5).

Achieving the ambitious goal of “zero HAIs” requires a strategic approach with several steps ⁸⁹ (Table 6).

Table 6.

Roadmap to achieve zero healthcare-associated infections (HAIs)

Step	Key Actions	Details
1. Leadership Commitment	- Secure leadership buy-in to prioritize zero HAIs as a strategic initiative and a philosophy.	- Leaders must actively support initiatives and allocate resources for infection prevention.
2. Strategic Planning	- Adapt “zero target”; as part of the organizational strategy.	- Incorporate the goal into mission statements and operational plans.
3. Goal Setting	- Set SMART (Specific, Measurable, Achievable, Relevant, Time-bound) goals for HAIs reduction.	- Gradually raise the bar to inspire teams while maintaining achievable milestones.
4. Cultural Integration	- Embed the “zero target” strategy into organizational culture.	Foster a culture where infection prevention is everyone’s responsibility.
5. Data-Driven Prioritization	- Use surveillance data to identify high-risk areas and prioritize interventions.	Leverage best practices from literature to guide targeted efforts in critical areas.
6. Open Communication	- Create a safe environment for healthcare workers (HCWs) to report adverse processes or outcomes without fear of retribution.	Transparency encourages proactive problem-solving and continuous improvement.
7. Treat Every Infection as Preventable	- Investigate every infection to determine preventability and root causes.	Use interprofessional teams to analyze cases and implement corrective actions.
8. Accountability	- Require every HCW to take ownership of infection prevention practices.	Accountability ensures adherence to protocols and fosters collective responsibility.
9. Education and Training	- Provide unit-specific or area-specific education on infection prevention protocols and practices.	Continuous education keeps HCWs updated on best practices and emerging risks.
10. Evidence-Based Interventions	- Implement proven interventions like CLABSI bundles, surgical safety checklists, etc.	Utilize technology (e.g., electronic health records, alert systems) for monitoring progress.
11. Monitoring and Feedback	- Regularly track compliance metrics and infection rates; establish feedback loops for improvement.	Monitoring ensures accountability and identifies gaps in implementation strategies.
12. Sustainability	- Embed infection prevention into daily operations; continuously update practices based on new evidence.	Long-term success requires adaptability and integration into routine workflows.

Securing leadership commitment is crucial for prioritizing infection reduction and integrating it into the organization’s strategic plan. Setting an inspirational goal enables initial achievements, with expectations for gradual increases over time. This strategy should become part of the organizational culture, making infection prevention a shared value. Priorities must be based on surveillance data and best practices. Creating a safe environment for HCWs to report adverse processes is essential. Each infection should be viewed as potentially preventable, prompting investigations into prevention failures. An interprofessional/multidisciplinary team should analyze infection cases to foster collaboration. Every HCW must be held accountable for preventing HAIs, with unit-specific education to enhance knowledge and skills. Infection prevention should be seen as a comprehensive system, considering all components in care processes. The ultimate goal should be the lowest possible infection rate, ideally a ‘zero target,’ driving continuous improvement and patient safety. Healthcare leaders must receive thorough education on infection prevention strategies, their impact on patient outcomes, and the economic implications of HAIs. This knowledge empowers leaders to make informed decisions on resource allocation and budget prioritization, ensuring support for effective infection prevention initiatives. ⁸⁹

In conclusion, achieving zero HAIs is a priority, even though reaching absolute zero might be difficult, it encourages ongoing advancements in patient safety and stems from its capacity to encourage a culture of alertness, creativity, and cooperation. The emphasis is on data analysis, cutting-edge technologies, and evidence-based practices. Closing the gaps in patient safety will require staff engagement, unwavering leadership commitment, and the integration into daily workflows. By sticking to this objective, healthcare systems can continue to lower the morbidity, mortality, and financial burden related to HAIs. Maintaining the goal of zero HAIs does not only enhances patient outcomes for each individual but also advances the general objectives of public health and healthcare quality improvement. ^90,91

Data availability statement

Not applicable.

Financial support

None to declare.

Competing interests

None to declare.