Prevalence of healthcare-associated infections in developing and developed countries: a systematic review

Abstract

Introduction

In the global context, healthcare-associated infections (HCAIs) are the most prevalent outcome of substandard patient care. There is a lack of data from developing regions, except for developing countries such as China and India, where reports from the World Health Organization (WHO) demonstrate a more substantial presence. This systematic review aims to investigate geographical disparities in HCAI occurrence in developing and developed countries. It also focuses on healthcare-associated infections, especially infectious endocarditis (IE) from implantable cardiac devices in high-income countries.

Methods

A literature review was conducted according to a pre-designed protocol. A search was performed in Embase, Ovid Medline, and PubMed for reports published between 2000 and 2024. No language restrictions were applied, and older, highly cited studies were retained. The search process retrieved 6,928 abstracts, of which 263 met eligibility criteria. The primary endpoint was to ascertain extant empirical research on the epidemiology of HCAIs in developing countries, with a focus on bacterial infections. The secondary endpoint investigated infections associated with transcatheter aortic valve replacement (TAVR) and cardiac implantable electronic devices (CIED) in developed countries.

Results

The primary endpoint revealed a HCAI rate in adult ICUs that is at least three times the USA rate. Surgical site infections were the most prevalent type of infection, with rates significantly higher than in developed countries. Gram-negative bacilli caused the most hospital infections. Methicillin-resistant Staphylococcus aureus was detected in many cases. The secondary endpoint demonstrated that Staphylococcus aureus is responsible for approximately one-third of healthcare-associated IE cases. In the United States, the percentage increased from 24% to 32%. Healthcare-associated IE carries a higher in-hospital mortality rate than community-acquired IE (31.1% vs. 20.3%; p < 0.01). Comparisons between TAVR and surgical aortic valve replacement are few and mixed. Large national registries and pooled PARTNER-trial data show comparable IE rates for both procedures. CIEDs-IE have a lower three-year survival rate (53.8% vs. 33% for pacemakers, 47.7% vs. 31.6% for implantable cardioverter-defibrillators, and 50.8% vs. 36.5% for cardiac resynchronization therapy).

Conclusion

Surveillance HCAIs is essential for tracking disease and evaluating interventions. Focusing on key procedural steps can improve adherence and intervention impact. IE after TAVR and CIED is rare but severe, with high in-hospital mortality.

Introduction

Healthcare-associated infections are the most prevalent infections in healthcare settings. Adverse events are frequently observed, and they pose a clear threat to patient safety [1], [2–6]. The overall impact of disease is challenging to calculate due to a lack of data on endemic infections, particularly in regions with limited financial support [7, 8]. In countries where less than 5% of the national wealth is allocated to healthcare, and the healthcare sector employs fewer than five professionals per 1,000 inhabitants, the primary focus is on addressing other prevailing healthcare challenges and illnesses. [9, 10] The absence of reliable global infection statistics stems from the complexity inherent in epidemiological monitoring. Surveillance for healthcare-associated infections (HCAIs) is a time-consuming process that requires significant resources and expertise in study conception, data acquisition, evaluation, and elucidation. A significant number of low- and middle-income countries have yet to implement national public health monitoring frameworks for these specific infectious diseases.

Data from the International Nosocomial Infection Control Consortium [11, 12], highlights this gap. As demonstrated in the research conducted by the International Nosocomial Infection Control Consortium [11, 12], this discrepancy is clearly illustrated. Systematic reviews of the literature on the subject have shown a significantly higher prevalence of healthcare-associated infections in developing nations, as indicated by the presence of hospital-acquired neonatal infections [13, 14] and ventilator-associated pneumonia (VAP) [15, 16]. The impact on patients and healthcare systems is considerable, yet often underestimated. As documented by Allegranzi et al. [17], there has been a notable decline in healthcare-associated infections over time. This decline encompasses a variety of infection categories, including overall infections (p < 0.0001), catheter-related bloodstream infections (p = 0.0230), and catheter-related urinary tract infections (p = 0.0008). This observation was made in relation to the publication year of the studies included in the meta-analysis. The authors conducted an extensive analysis of various infection types from 101 published sources, highlighting a predominant focus on surgical site infections, which constituted 56% of the reviewed studies. The documented frequency of surgical site infections (SSIs) varied between 0.4 and 30.9 per 100 patients undergoing surgery. This range includes the procedure-based incidence, which ranged from 1.2 to 23.6 per 100 surgical operations [17].

In high-income countries around the world during the twenty-first century, there has been a notable epidemiological shift in the profile of infective endocarditis (IE). The prevalence of HCAIs has now surpassed 25% [18]. At the same time, progress in cardiology has led to new developments in the patient population and the way the condition presents itself. The introduction of cardiac implantable electronic devices (CIEDs) has had a substantial impact on the field. The prevalence of CIEDs and the subsequent impact on complex devices has increased significantly [19]. Transcatheter aortic valve replacement (TAVR) has shown comparable effectiveness in treating valvular heart disease. However, it is associated with a range of potential adverse consequences. As indicated in the relevant literature, there appears to be a higher incidence of IE in cases involving surgically implanted bioprosthetic valves when compared to cases involving mechanical valves [20–36].

The aim of this systematic review is a thorough analysis of the existing literature on healthcare-associated infections. The objective of this review is to assess the scale of the burden caused by endemic healthcare-associated conditions. The conclusions presented are based on an analysis of infection data from developing countries, derived from published epidemiological studies. Moreover, for developed countries, the present review delineates the persistent evolution of the IE in two patient groups, which encompass several of the pivotal challenges: those with TAVR-endocarditis and those with CIED infection. The investigation will also encompass constraints associated with the surveillance of healthcare-associated infections. When resources are limited, it becomes essential to identify and consider a range of perspectives. The objective is twofold: first, to enhance the quality and efficacy of the process; and second, to ensure the seamless integration of technology into the business operations.

Methods

Search strategy and selection criteria

A systematic literature search and review was conducted in accordance with a pre-defined protocol established prior to data collection. The study’s objective was to identify empirical research on the epidemiology of HCAIs in developing countries, with a focus on bacterial infections such as urinary tract infections, surgical-site infections, bloodstream infections, hospital-acquired pneumonia, and ventilator-associated pneumonia. The study’s scope was expanded to include infections associated with TAVR and CIEDs in high-income countries.

A comprehensive search was conducted in Embase, Ovid Medline, and PubMed for reports published between January 2000 and March 2024. No language restrictions were initially applied, and older, highly cited studies were retained. A comprehensive examination of reference lists was conducted to identify relevant sources and ensure comprehensive coverage. In instances where further elaboration was deemed necessary, review articles were cited to provide additional context.

Extraction and summary of data from prevalence and incidence studies were conducted using consistent units of measurement. Prevalence was defined as the number of infection episodes or infected patients per 100 hospital or ward patients at a given time. Cumulative incidence refers to the number of new infection episodes or newly infected patients per 100 individuals over a specified period. For SSIs, this period is 30 days post-surgery, while for other infections, it is the duration of hospital or ward stay. Incidence density was reported as cases per 1,000 patient-days or device-days. This data were available only from intensive care unit (ICU) studies.

The search process yielded 6,928 abstracts, of which 263 met the established eligibility criteria. Full texts of 20 studies could not be accessed, and 27 were excluded due to language restrictions. Of the remaining articles, only those published in English were selected for final analysis (see Fig. 1 and Table 1). The protocol for the systematic review was registered at the Open Science Framework (OSF) under ID 9JK85 on June 1, 2025. A comprehensive list of search terms is provided for reference.

Fig. 1.

Flow diagram for selection of articles

Table 1.

Prisma Checklist

Send Topic	Item #	Checklist item	Location where item is reported
TITLE
Title	1	Identify the report as a systematic review.	Title
ABSTRACT
Abstract	2	See the PRISMA 2020 for Abstracts checklist.	Abstract
INTRODUCTION
Rationale	3	Describe the rationale for the review in the context of existing knowledge.	Introduction
Objectives	4	Provide an explicit statement of the objective(s) or question(s) the review addresses.	Introduction
METHODS
Eligibility criteria	5	Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses.	Methods
Information sources	6	Specify all databases, registers, websites, organisations, reference lists and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted.	Methods
Search strategy	7	Present the full search strategies for all databases, registers and websites, including any filters and limits used.	Methods
Selection process	8	Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.	Methods
Data collection process	9	Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.	Methods
Data items	10a	List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect.	Methods
	10b	List and define all other variables for which data were sought (e.g. participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information.	Methods
Study risk of bias assessment	11	Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.	Methods
Effect measures	12	Specify for each outcome the effect measure(s) (e.g. risk ratio, mean difference) used in the synthesis or presentation of results.	N/A
Synthesis methods	13a	Describe the processes used to decide which studies were eligible for each synthesis (e.g. tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)).	N/A
	13b	Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.	N/A
	13c	Describe any methods used to tabulate or visually display results of individual studies and syntheses.	Tables
	13d	Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.	Tables
	13e	Describe any methods used to explore possible causes of heterogeneity among study results (e.g. subgroup analysis, meta-regression).	N/A
	13f	Describe any sensitivity analyses conducted to assess robustness of the synthesized results.	N/A
Reporting bias assessment	14	Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases).	N/A
Certainty assessment	15	Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome.	N/A
RESULTS
Study selection	16a	Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.	Results
	16b	Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.	PRISMA Diagram/Methods
Study characteristics	17	Cite each included study and present its characteristics.	Tables
Risk of bias in studies	18	Present assessments of risk of bias for each included study.	N/A
Results of individual studies	19	For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g. confidence/credible interval), ideally using structured tables or plots.	Tables
Results of syntheses	20a	For each synthesis, briefly summarise the characteristics and risk of bias among contributing studies.	N/A
	20b	Present results of all statistical syntheses conducted. If meta-analysis was done, present for each the summary estimate and its precision (e.g. confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect.	N/A
	20c	Present results of all investigations of possible causes of heterogeneity among study results.	N/A
	20d	Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results.	N/A
Reporting biases	21	Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed.	N/A
Certainty of evidence	22	Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed.	N/A
DISCUSSION
Discussion	23a	Provide a general interpretation of the results in the context of other evidence.	Discussion
	23b	Discuss any limitations of the evidence included in the review.	N/A
	23c	Discuss any limitations of the review processes used.	N/A
	23d	Discuss implications of the results for practice, policy, and future research.	Discussion
OTHER INFORMATION
Registration and protocol	24a	Provide registration information for the review, including register name and registration number, or state that the review was not registered.	Methods
	24b	Indicate where the review protocol can be accessed, or state that a protocol was not prepared.	Methods
	24c	Describe and explain any amendments to information provided at registration or in the protocol.	N/A
Support	25	Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review.	Other Information
Competing interests	26	Declare any competing interests of review authors.	Other Information
Availability of data, code and other materials	27	Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review.	N/A

Key PubMed terms included “cross infection” (161,045 results), “infection control” (498,184 results), “infective endocarditis” (48,824 results), and “developing countries” (172,880 results). The specific queries included “infective endocarditis in developing countries” (134 results), “TAVR infections”/“TAVR endocarditis” (250 results), “CIED healthcare-associated infections”/“CIED endocarditis” (68 results), and “CIED infection” (878 results).

FN conducted the preliminary literature review, during which they screened abstracts from developing countries for studies reporting HAIs (UTIs, SSIs, BSIs, VAP, and their microbiology). The screening concentrated on patients undergoing TAVR and CIED procedures at high-volume medical centers. The following were excluded from the study: duplicates, outbreak reports, community-acquired infections, and studies with overlapping data. FN and SSAS independently reviewed the full texts of selected studies. A structured screening process was implemented to identify studies eligible for analysis, and the final reference list includes all of them.

Data extraction

The following data were extracted: the authors of the publication and the year of publication. The information to be supplied includes details such as the country(s) where the study was conducted, the time frame, the context and extent of the study, the number of subjects included, demographic characteristics of the subjects (adult, neonatal, and pediatric), the level of risk (high-risk patients, patients admitted to intensive care units, burn patients, and transplant patients). The survey’s objective was to gather exhaustive infection-related data, with a particular focus on healthcare-associated infections. The four most prevalent types were prioritized: urinary tract infections, surgical site infections, bloodstream infections, and hospital-acquired or ventilator-associated infections.

Key factors considered in the analysis included pneumonia; surveillance methods; diagnostic criteria; reported infection prevalence or cumulative incidence data with corresponding denominators; microbiological samples; wound contamination; the classification and type of surgical site infection; and antimicrobial resistance. The validity of microbiological evidence used for assessment depends on providing quantitative metrics for the bacterial strains in question.

A variety of terms were used in the studies, including “central venous catheter-associated” (992 items to date), “central venous catheter-related” (4,860 items to date), “central line-associated” (2,200 items to date), and “catheter-related bloodstream infection” (5,350 items to date). Throughout this document, the term “catheter-related bloodstream infection” is used to refer to all of these classifications.

Demographics of studies included

The present analysis involved the retrieval of three additional systematic reviews, the focus of which was neonatal health care-associated infection [13] and ventilator-associated infection [15, 16]. A total of five studies (5/95)—originating from four developing countries—were undertaken at the national level [37–41]. Furthermore, 11 multicenter, country-specific studies were conducted, with three of these focusing on healthcare-associated infections [42–44]. Eight studies have documented the occurrence of general infections as well as surgical-site infections (8/28) [45–52]. Please refer to Table 2.

Table 2.

Health-care-associated infections in developing countries*^‡ according to WHO region, patient population, and type of infection (2000–2024)

HCAI	Developing Countries*	Developing Countries‡	Total
Surgical-site infection	20	24	44
Ventilator associated pneumonia	5	13	18
General health care-associated infection	58	42	100
Bloodstream infection	3	7	10
Health-care associated pneumonia	4	3	7
Urinary-tract infection	3	2	5
Total†	93	91	184

* The data for developing countries was obtained from the Americas and Europe. ^‡ Data for developing countries was obtained from the Africa, Eastern Mediterranean, Southeast Asia, and ^{†# †} Western Pacific regions. The data are expressed as the number of publications. ^#Thirty-two manuscripts report data on pediatric patients

Results

Primary endpoint. Results from healthcare-associated infections in low-income or middle-income countries

Prevalence and incidence studies

An analysis of 18 studies on infections in healthcare settings in developing countries indicates significant variation in the prevalence [53–60] incidence of these infections [37, 39, 42–44, 61–66]. It also emphasizes the most prevalent types of infections and demonstrates how the quality of the studies influences the reported rates. These studies documented the proportions of overall healthcare-associated cases. The presence of infection was also observed in patient groups with various conditions [37, 39, 42–44, 53–66]. The prevalence of healthcare-associated infections ranged from 5.7% to 19.1%, with a pooled estimate of 10.1% (95% CI 8.4–12.2). The incidence of the condition ranged from 1.7% to 23.6%, resulting in a pooled rate of 7.4% (95% CI 4.4–12.2). The overall infection rate among patients was documented at 10.6% (95% CI 8.1–13.9) across the studies. According to the findings of studies in which 10% or more of the patient population was infected [53–60], surgical-site infections accounted for 29% of cases, urinary-tract infections for 24%, bloodstream infections for 19%, healthcare-associated pneumonia for 15%, and other infections for 13%.

In this population of patients, the following distribution of healthcare-associated infections was observed. The most prevalent infections were surgical-site infections (29%), followed by urinary tract infections (24%), bloodstream infections (19%), healthcare-associated pneumonia (15%), and other infections (13%). This is based on reports from just over half of the participants. [39, 43, 53–60] (52.6%) met the high-quality criteria. These studies reported a significantly higher pooled prevalence (15.5% vs. 8.5%; p < 0.0001) and proportion of infected patients (13.5% vs. 7.2%; p = 0.0007) compared with lower-quality studies. Table 1

Healthcare and device associated infections

Across 31 studies reporting healthcare- and device-associated infection densities in high-risk adult patients, overall HCAI densities ranged from 9.0 to 91.7 episodes per 1,000 patient-days [67–98]. In intensive care units, the pooled cumulative incidence was 34.7 per 100 patients (95% CI: 23.6–47.7), corresponding to an incidence density of 47.9 per 1,000 patient-days (95% CI: 36.7–59.1). A multinational survey of 55 ICUs across eight countries documented device-associated infection densities as high as 22.5 episodes per 1,000 patient-days. A multicenter ICU study in Argentina^([69]) reported HCAI densities exceeding 80 episodes per 1,000 patient-days. Similarly, studies from oncology and neurology units in Brazil^([94]) and Turkey^([98]) also observed rates above 80 episodes per 1,000 patient-days. Table 3

Table 3.

Comparison of device-associated infection densities in adult ICUs from developed and developing countries, 2000–2008

	Number of ICUs	Catheter-days	Urinary catheter-days	Ventilator-days	CR-BSI (95% CI)	CR-UTI (95% CI)	VAP (95% CI)
Developing countries
INICC (2002–2007), 18 developing	60	132 061	1030	1802	8.9†	6.6†	19;8†
Countries# ‡ [80]
Argentina (2003–2008; current systematic review) [67–70]	15	9458	19 013	5777	24.7 (7.4–4.·0)	17.2 (13.4–21.1)	48 × 0 (42 × 0–54 × 0)
Turkey (2006–2008; current systematic review) [89, 91, 92]	14	23 465	36 275	39 482	10.8 (1.9–24.1)	10 × 3 (3.8–17.2)	25.7 (19.8–31.7)
Current systematic review	224	373 830	427 728	261 146	10.4 (8.0–12.5)	8.7 (6.9–10.5)	22.3 (18.8–25.7)
(2004–2023) [67–70, 72, 73], ‡ [75, 79–83]‡ [85, 87, 89, 91, 92]
Developed countries
NNIS (1995–2003), USA # [99]	85–133*	1 356 490	1 356 490	115 900	5.0†	5 × 3†	5.8†
NHSN (2006–2008), USA # [100]	89–182*	699 300	546 824	383 068	2.1†	3 × 4†	2.9†
KISS (1997–2003), Germany [101]	309	1 993 541	-	1 177 137	1.8†	-	8.0†
KISS (2004–2009), Germany [102]	514–583*	4 002 108	4 757 133	2 391 381	1.3†	2 × 0†	5.1†

The data presented herein refer to the overall mean number of infection episodes per 1000 device-days. Abbreviations; ICUs, intensive care units; CR-BSI, catheter-related bloodstream infection; CR-UTI, catheter-related urinary tract infection; VAP; ventilator-associated pneumonia; NNIS, National Nosocomial Infection Surveillance; NHSN, National Healthcare Safety Network; KISS, Krankenhaus Infektions Surveillance System; INICC, International Nosocomial Infection Control Consortium. The following institutions are to be considered: #medical or surgical intensive care units in major teaching hospitals. *The range is reported due to the variation in the number of ICUs included in the data pooling, which is contingent on the respective type of ICU. The infection is associated with the device. †The 95% confidence interval (CI) was not reported. ‡The following countries are included in the study: Argentina, Brazil, Colombia, Costa Rica, Cuba, El Salvador, India, Kosovo, Lebanon, Macedonia, Mexico, Morocco, Nigeria, Peru, the Philippines, Turkey, and Uruguay. ‡China and India are considered middle-income countries

ICU-acquired device-associated infections

A total of twenty-five studies evaluated adult ICU–acquired device-associated infections, reporting catheter-related bloodstream infection densities ranging from 1.7 to 44.6 episodes per 1,000 catheter-days, catheter-associated urinary tract infection densities ranging from 1.4 to 23.0 episodes per 1,000 urinary catheter-days, and ventilator-associated pneumonia densities ranging from 3.2 to 56.9 episodes per 1,000 ventilator-days. Table 4 compares these findings with benchmarks from the US NNIS/NHSN and the German Hospital Infection Surveillance System [99–102]. Thirty-two studies characterized nosocomial infections in newborns and children, with 14 specifically reporting overall healthcare-associated infection rates [103–116] (Table 2).

Table 4.

Bacterial isolates identified in health-care-associated infections from developing countries, 2000–2008^†

	High-risk patients (17 studies)	Mixed populations (11 studies)	Bloodstream infection (3 studies)	Ventilator-associated and health-care-associated pneumonia (5 studies)	Surgical-site infection (11 studies)
Staphylococcus aureus	158 (11%)	269(21%)	157 (19%)	50 (10%)	225 (20%)
Coagulase-negative staphylococci	151 (11%)	137 (11%)	140 (17%)	18 (3%)	70 (6%)
Enterococcus spp	75 (5%)	3 (<1%)	47 (6%)	1 (<1%)	38 (4%)
Enterobacteriaceae (excluding E coli)	271 (20%)	232 (18%)	128 (15%)	92 (20%)	284 (26%)
Escherichia coli	93 (7%)	116 (9%)	23 (3%)	6 (1%)	193 (18%)
Acinetobacter spp	258 (19%)	111 (9%)	144 (17%)	110 (24%)	14 (1%)
Pseudomonas spp	240 (17%)	215 (17%)	98 (13%)	134 (29%)	180 (17%)
Candida spp	27 (2%)	76 (7%)	44 (5%)	1 (<1%)	6 (1%)
Others	112 (8%)	112 (8%)	46 (6%)	53 (12%)	77 (7%)
Total	1384 (100%)	1271 (100%)	827 (100%)	465 (100%)	1087 (100%)

The data presented herein correspond to the number of isolates (%). Patients considered to be at high risk include those undergoing burn injuries and those receiving transplants, in addition to those receiving intensive care. The presence of a heterogeneous population has been demonstrated to result in a corresponding admission of patients to lower-risk categories. †The inclusion criteria for the present study were limited to studies that reported the number of isolates.

In the context of pediatric wards and hospitals dedicated to treating children, the observed cumulative incidence ranged from 0.9% to 17.7% among patients. For patients admitted to these units, the incidence ranged from 2.7% to 26.9%, yielding an estimated pooled incidence of 5.7% (95% CI: 2.3–13.1) and 10.9% (95% CI: 2.8–34.5). In pediatric ICUs, HCAI densities ranged from 1.6 to 46.1 per 1,000 patient-days, while neonatal units reported densities between 15.2 and 62.0 per 1,000 patient-days [17, 108–116].

The incidence of ventilator-associated pneumonia ranged from 4.4 to 143.0 episodes per 1,000 ventilator-days (median 28.0; IQR 10.9–88.3), and catheter-related bloodstream infections ranged from 10.2 to 60.0 episodes per 1,000 catheter-days (median 18.7; IQR 12.5–43.0) [17, 110, 111, 113, 115, 116]. A total of four studies conducted in Brazilian neonatal intensive care units (ICUs) documented an overall healthcare-associated infection (HCAI) incidence of 40.8 infections per 100 patients (95% confidence interval [CI]: 16.1–71.1) and a density of 30.0 episodes per 1,000 patient-days (25.0–35.0) [108, 109].

A median cumulative incidence of surgical-site infections was determined across the following wound classifications: clean, clean-contaminated, contaminated, and dirty. The incidence of clean wounds was 7.6 per 100 procedures (range 1.3–79.0), clean-contaminated wounds was 13.7 (1.5–81.0), contaminated wounds was 14.3 (0.5–65.5), and dirty wounds was 39.2 (0.2–100.0) per 100 surgical procedures [17, 117–131]. Twenty-six studies reported pathogens responsible for healthcare-associated infections, and 18 of these included detailed microbiological data on surgical-site infections, ventilator-associated and healthcare-associated pneumonia, and bloodstream infections [39, 43, 53–57, 62, 65, 72, 73, 75, 85, 88, 89, 94, 95, 98, 132–139]. Table 3

Gram-negative bacilli were identified most frequently in both the mixed and high-risk patient groups. In mixed populations, Staphylococcus aureus was the most prevalent single pathogen, whereas Acinetobacter species predominated among high-risk groups. Acinetobacter spp. were the leading cause of ventilator-associated pneumonia and bloodstream infections, while Staphylococcus aureus was most commonly recovered from surgical sites and blood cultures. Gram-negative bacilli accounted for nearly half of all surgical-site infections examined. Geographic or regional stratification of pathogen prevalence was not performed due to limited isolate numbers and heterogeneity. There is a limited amount of information available on antimicrobial resistance reporting. According to the findings of eight studies, 54% of S. aureus isolates were noted to be meticillin-resistant, but no comprehensive evaluation of resistance patterns was conducted [54–56, 65, 134, 140–145].

Secondary endpoints. Results from healthcare-associated infections in high-income countries

The prevalence of healthcare-associated IE is on the rise, highlighting a pressing need for effective prevention measures. The condition primarily affects older adults, many of whom have degenerative valve disease or no intrinsic cardiac risk factors. It is associated with haemodialysis, cancer, diabetes mellitus, cardiac implantable electronic devices, and TAVR procedures [18, 146]. In high-income countries, Staphylococcus aureus is responsible for approximately one-third of healthcare-associated IE. In the United States, its share increased from 24% to 32% between 1998 and 2009 [147], and it independently predicts in-hospital mortality [148]. Healthcare-associated IE carries a higher in-hospital mortality rate compared to community-acquired IE (31.1% vs. 20.3%; p < 0.01). [146] (Fig. 2; Table 5).

Fig. 2.

The illustration offers a visual representation of the incidence of infective endocarditis in a French population, with data derived from a study report that encompasses 497 adult subjects. The incidence of cases reached its peak at 194 cases per million within a population of men with IE aged between 75 and 79 years. The blue box is designated for female subjects, while the brown box is intended for male subjects. As cited in the article “from Selton-Suty C et al., Clin Infect Dis 2012;54:1230–9.” [18]

Table 5.

Infective endocarditis in TAVR studies

First Author, Year (Ref. ϕ)	No. of TAVR-IE Patients	Microbiology	1-Yr Incidence of TAVR-IE	In-Hospital Mortality	1-yr-Mortality
*Vahanian et al. EHJ.,2021 [149]	2 (cohort of 179)	Not indicated	1.12%γ	Not indicated	100%
# Otto et al. Circulation., 2020 [150]	3 (cohort of 344)	Not indicated	0.87%γ	Not indicated	33%
Aung et al., 2013 SJID [30]	4 (cohort of 132)	Enterococci (75%), oral streptococci (25%)	3.0%	0%	0%
Latib et al., 2014 JACC [28]	29 (cohort of 2,572)	Enterococci (21%), CoNS (17%), S aureus (14%), oral streptococci (3.4%)	0.89%γ	45%	Not indicated
Olsen et al., 2015 CCI 2015 [31]	18 (cohort of 509)	Enterococci (33%), S aureus (17%), oral streptococci (17%), CoNS (11%)	3.1%	11%	Not indicated
But et al., 2019 JACC [33]	5 (cohort of 180)	Enterococcus (40%), oral streptococci (20%), S aureus (20%), E. coli (20%)	2.78%	40%	40%
Mangner et al., 2016 JACC [26]	55 (cohort of 1,820)	S aureus (38%), enterococci (31%), CoNS (9.1%), oral streptococci (3.6%)	2.25%γ	64%	75%
Amat-Santos et al., 2015 Circulation [27]	53 (cohort of 7,944)	CoNS (24%), Staphylococcus aureus (21%), enterococci (21%), oral streptococci (5.7%)	0.5%	47%	66%
Raguiero et al., 2016 JAMA [25]	250 (cohort of 20,006)	Enterococcus (25%), S aureus (24%), CoNS (17%)	1.1% per person-year	36%	66.7% (2-yr mortality)
del Val et al., 2022 CJC [29]	604 (cohort of 40,345)	Non S. aureus (432) S. aureus (141)	Non S. aureus 6.3 months vs S. aureus 4.7 months	S. aureus group (47.8% vs 26.9%)	S. aureus group (71.5% vs 49.6%)

*data from PARTNER B Investigator; # data from PARTNER A Investigator. Abbreviations: CI, confidence interval; CoNS, coagulase-negative staphylococci; HR, hazard ratio; IE, infective endocarditis; PARTNER, Placement of Aortic Transcatheter Valve; TAVR, transcatheter aortic valve replacement.; TPVR, transcatheter pulmonary valve replacement. * IE in patients undergoing TAVR vs. SAVR; ** Meta-analysis; γ Calculated/estimated

Transcatheter aortic valve replacement infection

Thirty-two studies report infective endocarditis (IE) incidence after TAVR or surgical aortic valve replacement (SAVR) ranging from 0.3 to 2.0 per 100 person-years (Tables 5-6) [20–35, 151–167]. Direct comparisons between TAVR and SAVR are few and yield mixed results. However, large national registries (Danish National Patient Registry, FinnValve, US NRD, French Discharge Database) and pooled PARTNER-trial data show comparable IE rates for both procedures [33, 158, 159, 161, 164]. A meta-analysis of RCTs also found no significant differences in early (≤1 year) or late (>1 year) IE, though intermediate-risk TAVR patients trended toward higher IE (2.3% vs. 1.2%, p = 0.05) [153].

Table 6.

Report on the causative agents in multicentre cohorts: a comparison of Native, Prosthetic and TAVR heart valve infections

	GAMES			*ICE			TVR registry
	Native (n = 2,769)	Prosthetic (n = 1,354)	Overall (N = 4,123)	Native (n = 4,822)	Prosthetic (n = 1,828)	Overall (N = 6,650)	TAVR-IE (N = 250)
Staphylococcus aureus	766 (27.7)	208 (23.6)	974 (23.6)	1,493 (34.1)	381 (22.9)	1,874 (31)	54 (23.3)
CoNS	285 (10.3)	437 (32.3)	722 (17.5)	285 (10.3)	437 (32.3)	722 (17.5)	41 (17.7)
Viridans group streptococci	932 (33.7)	262 (19.4)	1,194 (28.9)	978 (22.3)	266 (16.0)	1,244 (20.6)	16 (6.9)
Streptococcus gallolyticus group	-	-	-	341 (7.8)	119 (7.2)	460 (7.6)	5 (2.2)
Other streptococci	-	-	-	341 (7.8)	85 (5.1)	427 (7.1)	7 (3.0)
Enterococcus species	441 (15.9)	217 (16.0)	658 (15.9)	530 (12.1)	276 (16.6)	806 (13.3)	57 (24.6)
Gram-negative bacilli	91 (3.3)	63 (4.7)	154 (3.7)	186 (3.6)	98 (5.4)	284 (4.2)	-
HACEK	-		-	63 (1.4)	34 (2.0)	97 (1.6)	-
Non-HACEK	-		-	123 (2.8)	64 (3.9)	187 (3.1)	-
Fungi/yeast	41 (1.5)	35 (2.6)	76 (1.8)	68 (1.6)	68 (4.1)	136 (2.2)	2 (0.9)
Polymicrobial	34 (1.2)	18 (1.3)	52 (1.2)	81 (1.8)	34 (2.0)	115 (1.9)	18 (7.7)
Other	62 (2.3)	39 (2.7)	101 (2.4)	115 (2.6)	46 (2.8)	161 (2.7)	-
Negative culture findings	78 (2.8)	37 (2.7)	115 (2.7)	340 (7.8)	100 (6.0)	440 (7.3)	12 (5.2)

The values are expressed as a percentage of the total (n%). Abbreviations; CoNS; coagulase-negative staphylococci; GAMES; Grupo de Apoyo al Manejo de la Endocarditis Infecciosa en España; HACEK; Haemophilus species, Aggregatibacter actinomycetemcomitans, Aggregatibacter aphrophilus (formerly Haemophilus aphrophilus and Haemophilus paraphrophilus), Cardiobacterium hominis, Eikenella corrodens, and Kingella species; ICE; International Collaboration on Endocarditis; TAVR-IE; transcatheter aortic valve replacement infective endocarditis. * Add the following: ICE study from Murdoch et al.; ICE study from Ambrosioni et al. [20, 21, 24, 25, 34, 146, 148].

However, some studies have indicated that lower IE may occur after TAVR. Lanz et al. reported a five-year incidence of adverse events (IE) of 1.01% for TAVR as compared with 1.58% for SAVR. The p-value of this comparison was 0.047 [162]. Moreover, UK administrative data showed a higher incidence of SAVR complications (2.4% as compared with 1.5%, p < 0.001) [156]. In a propensity-matched cohort study, the incidence of early IE was 1.7 per 100 cases for TAVR versus 1.9 per 100 cases for SAVR [159]. The Swiss TAVR registry noted a higher early IE rate (1.48 vs. 0.40 per 100 person-years) and a sixfold risk increase within the first 100 days (2.6 per 100 person-years), with 64% of cases occurring early (Fig. 3) [160, 163].

Fig. 3.

This presentation provides a visual illustration of the clinical outcomes of TAVR international registry endocarditis. The N value is used to denote patients suffering from infective endocarditis involving the aortic prosthesis. [25, 34]

These findings are largely derived from observational registries, non-dedicated RCTs, and administrative databases, methodologies that are susceptible to bias. The heterogeneity of reported incidence rates is attributable to variations in patient risk profiles, device generations, procedural techniques, and IE definitions (definite vs. possible).

Cardiac implantable electronic devices infection

CIED infections—including those of pacemakers, implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy devices—have risen faster than implantation rates. In the United States, device implants grew 12% (199,516→222,940) from 2004 to 2006, while infections surged 57% (8,273→12,979). Between 1996 and 2006, end-organ failure increased from 6.5% to 8.0% and diabetes from 14.5% to 16.5% among new recipients. The share of Caucasian patients fell from 65.6% to 57.6%, and CRT device implants rose sharply, though recipient age remained stable.

Overall infection rates range from 1 to 10 per 1,000 device-years—about 1 for pacemakers and up to 8–9 for other devices [168–171]. In one cohort of 1,524 patients followed for 7,578 device-years, definite infections occurred at 1.9 per 1,000 device-years; rates were higher for defibrillators than pacemakers. Among Staphylococcus aureus bloodstream infections, 54.6% had definite or possible CIED infection versus 12.0% for gram-negative bacteremias. Pacemaker infections occur at 4.82 per 1,000 PM-years after initial implantation and 12.12 after replacement; late (>365 days) rates are 1.02 and 3.26 respectively. Key risk factors include multiple device operations, male sex, younger age, early implantation era, and omission of antibiotic prophylaxis. In CRT-D recipients, the annual infection rate is 1.0%; device replacements double the risk (HR 2.04) without affecting overall mortality.

CIED infections carry a substantial mortality burden lasting years after diagnosis. Three-year survival is lower in infected patients across device types: pacemakers (53.8% vs. 33%), ICDs (47.7% vs. 31.6%), and CRT-D (50.8% vs. 36.5%). After adjusting for demographics and comorbidities, infection-related mortality remains elevated for up to three years post-pacemaker infection and two years post-ICD infection.

Discussion

Epidemiology

Developing countries

The present study emphasizes the widespread nature of HCAI and underscores their disproportionate burden in resource-constrained settings compared with high-income nations. According to the report by the European Centre for Disease Prevention and Control, there was a mean HcAI prevalence of 7.1% among hospitalized patients across Europe [172]. In contrast, U.S. point-prevalence surveys by the CDC’s Emerging Infections Program (EIP) documented a decline in HCAI prevalence from 3.2% (one in 31 patients; >680,000 annual infections) in 2015 to 2.6% in 2023 [173]. A thorough comparison of ICU-HAIs reveals an incidence of 47.9 per 1,000 patient-days in developing-country ICUs [172]. In contrast, U.S. data from 2022 to 2023 show national declines in MRSA (16%), CLABSI (13%), CDI (13%), CAUTI (11%), and VAE (5%), though SSIs following abdominal hysterectomy increased by 8% and colon-surgery SSI rates remained consistent compared to the 2022 SIR [173]. These trends emphasize the importance of strengthened surveillance, particularly in regard to ventilator-associated pneumonia and catheter-related bloodstream infections, among adult and pediatric populations.

In long-term care facilities across nine European countries, over half of residents experienced at least one HAI during a 12-month period. Respiratory tract infections (n = 394, 10.7% [9.6–11.8]) and urinary tract infections (n = 743, 18.7% [17.2–20.3]) accounted for nearly half of all cases [102]. A pooled analysis of low- and middle-income cohorts showed that device-associated infection rates were up to 16–19 times higher than reference rates, particularly catheter-related bloodstream infections and VAP. The analysis identified three key findings: VAP is the most prevalent HAI, co-infections are common, and certain patient populations face higher risk [15].

Zaidi et al. reported that neonatal infection rates in resource-limited countries are three to twenty times higher than in industrialized nations [13]. Our review supports this observation, demonstrating a NICU HCAI incidence in Brazil ranging from 15.2 to 62.0 cases per 1,000 patient-days, which is up to nine times the rate of 6.9 cases per 1,000 patient-days reported in the U.S. [173]. High HAI prevalence is also a concern in pediatric wards and children’s hospitals [103, 106, 174, 175].

SSIs have the most extensive study history and are the most prevalent HAIs in developing-world hospitals. Our analysis revealed a pooled SSI incidence of 5.6 per 100 procedures, which is notably higher than the 2.6% observed in U.S. nationwide data [176] and the range of 1.6–2.9% reported across European countries [101, 177]. The CDC also reported an 8% increase in SSIs following abdominoplasty in 2024 [173] and significant SSI rises across wound classes in the U.S. [178].

However, the scarcity of samples and the paucity of antimicrobial-resistance profiles pose significant challenges in the analysis of these samples. Notably, the prevalence of methicillin resistance in Staphylococcus aureus is of particular concern, as other resistance patterns are underreported. Key factors contributing to high HCAI burdens in developing countries include inadequate infrastructure, poor hygiene, overcrowding, understaffing, insufficient infection-control training, and prolonged or inappropriate use of invasive devices [179, 180]. Resource limitations are a key factor in the reuse of single-use items, which has been identified as a significant source of unsafe practices. According to estimates by the WHO in 2000, 39.3% of injections in these regions involved the reuse of equipment [181].

Developed countries

Advances in technology have led to the development of improved structural valve platforms which have contributed to the significant reduction of healthcare-associated infections following TAVR. There is growing interest in a simplified, less invasive “minimalist approach”, and this has resulted in its widespread adoption as best practice across many centres. A recent study looked at whether TAVR has lowered the incidence of IE compared to previous periods. While the overall incidence of TAVR-associated IE (TAVR-IE) showed no significant change over time, a downward trend was observed (2.3 vs. 4.9 per 1,000 patient-years) [29]. Notably, the incidence of very early TAVR-IE (defined as infections occurring within two months of the procedure) declined in the contemporary cohort [157].

• Transcatheter Aortic Valve Replacement

Technological advances in structural valve platforms have contributed to a reduction in the incidence of following TAVR. The “minimalist approach,” which emphasizes simplicity and less invasiveness, has seen a surge in interest and has been adopted as the standard of care in numerous medical centers. [182–187]

A recent study examined whether TAVR has contributed to a reduction in the incidence of IE compared to previous periods. While the overall incidence of TAVR-IE showed no significant change over time, a downward trend was observed (2.3 vs. 4.9 per 1,000 patient-years) [29]. The contemporary cohort shows a noteworthy decrease in the incidence of very early TAVR-IE (defined as infections occurring within two months of the procedure).

Key TAVR studies have demonstrated a low incidence of IE. Partner 3 had no 30-day cases, and only one patient (0.2%) developed IE at one year [183]. According to the latest statistics, the low-risk trial rates were 0.1% at 30 days and 0.2% at one year [184]. These data suggest that procedural refinements and improved platforms may be reducing the infectious burden in modern TAVR practice. Some patient and procedural factors can lead to IE after TAVR. The procedure itself can cause IE. Numerous studies have sought to identify predictors of death from TAVR-related IE. However, the findings are inconsistent due to the diverse populations included in the studies.

The following patient-related risk factors have been identified: younger age, male sex, elevated BMI, and comorbid conditions such as diabetes, chronic obstructive pulmonary disease, chronic kidney disease, and a prior history of IE. There are additional clinical variables associated with an increased susceptibility, including pulmonary hypertension, coagulopathy, hepatic dysfunction, atrial fibrillation, peripheral vascular disease, critical preoperative status, peri-procedural blood transfusion, and anemia.^([25, 26, 154, 156, 158, 160, 163]) Procedure-specific risk factors encompass residual moderate or severe aortic regurgitation, low prosthesis positioning, vascular and hemorrhagic complications, implantation of multiple prosthetic valves, omission of pre-TAVR balloon valvuloplasty, valve-in-valve procedures, and elevated residual transvalvular gradients [25, 26, 156, 160, 163].

With regard to prosthesis type, the current evidence shows no statistically significant difference in IE risk between balloon-expandable valves (BEVs) and self-expanding valves (SEVs). A direct comparative study reported similar one-year cumulative incidence rates (BEVs: 1.25%; SEVs: 0.95%; p = 0.33) [185]. A subsequent meta-analysis corroborated the absence of statistically significant differences in IE rates between valve platforms [186]. Nonetheless, a recent observational study suggested a potentially elevated risk of TAVR-IE in recipients of mechanically expandable valves [156]. This finding warrants further investigation.

Two studies have examined the risk factors associated with IE in patients undergoing TAVR and SAVR [33, 156]. A Danish registry analysis identified male sex and chronic kidney disease as consistent predictors of IE in both groups, with diabetes mellitus also contributing to risk [33]. Similarly, Cahill et al. [156] found that male sex and younger age were significant risk factors for both modalities. Further analysis revealed that additional variables exhibited a stronger correlation with IE in the SAVR population.

• Microbiology

Today, we are witnessing a paradigm shift in the treatment of structural heart disease, with a transition towards transcatheter procedures. Consequently, there is a heightened risk of infection during the procedure. In high-income countries, studies indicate that Staphylococcus species are the predominant cause of infective endocarditis in native and prosthetic valves [187–189]. However, the microbiological profile of IE following TAVR is distinct. The most prevalent bacteria in TAVR-associated IE cases are Enterococci, Staphylococcus aureus, and coagulase-negative staphylococci. Enterococci have been detected in approximately 10% of SAVR-IE cases. However, certain studies indicate that they may represent more than 25% of documented IE cases following TAVR [25, 155, 157]. Enterococci flourish in warm, moist environments such as the groin [190–192], which may be a contributing factor to the high infection rate associated with these bacteria, potentially due to the utilization of the transfemoral approach in TAVR procedures. Following Enterococci, the second most common isolate is Staphylococcus aureus, which was the most frequently identified microbial species in certain studies [26, 28, 161].

A recent study highlighted the virulence of Staphylococcus aureus in patients with TAVR-IE. The study revealed a nearly twofold increase in in-hospital mortality (47.8% vs. 26.9%) and a two-year mortality rate (71.5% vs. 49.6%) [29]. Coagulase-negative staphylococci are the third most prevalent microorganism in TAVR-IE cases, accounting for over 15% in certain observational series [25, 26, 159]. The TAVR-IE cohort demonstrates a lower likelihood of complications due to Streptococcus spp, exhibiting a prevalence of 6.9% compared to 21.1% in the SAVR-IE cohort. Culture-negative TAVR-IE cases are also uncommon (5%). In contrast to the previously observed rates of native valve endocarditis of 10–20% [187, 188, 193] and surgical prosthetic valve endocarditis of the same range [187, 188, 193], the present study’s findings offer a novel insight.

• Prevention of IE following TAVR

Approximately 50% of TAVR-IE cases are healthcare-associated [25, 28], which is more than double the rate seen in surgical patients [187]. This may be indicative of increased exposure to healthcare interventions, which could elevate bacteremia risk—a hypothesis that warrants further study. Some clinicians advocate for limiting procedures that pose bloodstream infection risks in this population [26, 154, 156, 160–164]. Although prior permanent pacemaker implantation has not been consistently linked to increased TAVR-IE risk, patients with additional cardiac devices often present with more severe symptoms and poorer outcomes [29].

While antibiotic prophylaxis is standard practice for dental procedures, its use for other invasive procedures has declined due to a lack of substantial evidence supporting its effectiveness. Research is needed to assess whether broader prophylaxis could reduce IE risk in TAVR patients. Preventing bacteremia and prosthetic infection remains a key unmet need. Antibacterial biomaterials may reduce the risk of TAVR-IE associated with transfemoral aortic valve replacement procedures. [194] Vaccine development targeting Staphylococcus aureus has shown promising results in preliminary studies [195]. However, the efficacy of these vaccines in reducing IE after cardiovascular surgery remains to be fully demonstrated. [196, 197] Further research in this field is essential.

• Cardiac Implantable Electronic Devices infection

CIEDs-IE present a multifaceted challenge, with associated risks depending on patient, procedure, and device factors. In many cases, these infections necessitate the implementation of a surgical procedure. [198, 199]. Patient factors that contribute to this phenomenon include corticosteroid use, diabetes, end-stage kidney disease, prior device infections, COPD, malignancy, and heart failure. Procedural risks include post-op hematoma (OR 8.46; 95% CI : 4.01–17.86), lead displacement reintervention, prolonged procedures, and dual-lead implantation. The infection risk associated with revision surgeries is 2–5 times higher than the risk associated with initial implant surgeries. Antibiotic prophylaxis has been shown to effectively prevent cardiac device infections in both trials and observational studies [199].

Reducing healthcare-associated bacteremia is critical. According to Danish data, there was a notable increase in Staphylococcus aureus bacteremia cases, rising from 3 to 20 cases per 100,000 person-years from 1957 to 1990. This increase in cases coincided with a rise in hospitalizations and surgical procedures. However, subsequent years have seen a stabilization in these rates. [200, 201] In the U.S., 10–20% of the population is made up of chronic S. aureus carriers. Improved sterile practices have led to a substantial decrease in central line-associated bloodstream infections [202, 203]. Implementing targeted strategies in high-risk groups has the potential to significantly reduce the incidence of infective endocarditis [204, 205]. Table 7

Table 7.

Overall clinical outcomes reported in groups of patients from different centres : a side-by-side look at Native and Prosthetic valves

		#Games study			*ICE study
	Native (n = 2769)	Prosthetic (n = 1354)	Overall (N = 4123)	p-value	Native (n = 4822)	Prosthetic (n = 1828)	Overall (N = 6650)	p-value
In-hospital mortality	709 (25.6)	442 (32.6)	1151 (27.9)	<0.001	875 (20)	449 (27)	1,324 (21.9)	0.17
First year mortality	876 (31.6)	507 (37.4)	1383 (33.5)	<0.001	1,263 (28.8)	607 (36.5)	1,870 (30.9)	““
In-hospital surgical therapy	1,306 (69.2)	650 (64.4)	1,956 (67.5)	0.009	2,408 (54.9)	835 (50.2)	3,243 (53.6)	0.001
Recurrence †	28 (1.3)	21 (2.3)	49 (1.6)	0.063

The values are expressed as a percentage (n). The N value is used to denote patients suffering from infective endocarditis involving the aortic prosthesis. [24, 146, 148]. †During the first year after diagnosis calculated on patients discharged from the hospital (n = 2972). #Seventy cases (5.1%) showed concomitant involvement of native and prosthetic valves. * Add the following: ICE study from Murdoch et al.; ICE study from Ambrosioni et al. [20, 21, 24, 146, 148].

Future perspective

A close look at the evidence indicates significant difficulties in implementing surveillance systems to monitor healthcare-associated infections in developing countries. Limited expertise, resources, and competing healthcare priorities are hindering progress. Standardizing nomenclature is challenging because of unreliable microbiological data and diagnostic procedures, as well as inaccuracies in patient records. The absence of electronic records, along with the lack of dedicated software and databases for HCAI surveillance, poses challenges in the effective management of these systems. The interpretation of accurate data requires specialized knowledge, and leadership must establish guidelines for using surveillance data to raise awareness and encourage action. In certain situations, surveillance interventions are not executed. As outlined in Table 8, the current surveillance constraints and perspectives for improving and researching HCAIs in developing countries are reported.

Table 8.

Surveillance problems and infection research in developing countries

The right limits on monitoring • There are not enough people or money. • There is a lack of expertise in the study of diseases and how to stop them spreading. • Difficulties in using standard definitions         - I didn’t have much experience to tell the difference between infection, colonisation, and something has caused it to become dirty.        - There is a lack of reliable ways to diagnose illnesses using microbes and other methods.        - Information from patients’ records that is not good quality        - A rigorous examination of the extant clinical evidence is imperative. • No ability to understand and use data • Not enough microbiological laboratory capacity • There are different ways to pay.

Prospects for enhancement and further investigation. • The enhancement of the reporting of information in clinical records is of paramount importance. • It is imperative to ensure that there is a clear understanding of the minimum facilities and requirements. • The capacity-building process for clinical microbiological laboratories is to be improved. • It is essential to establish fundamental components for infection control. • It is imperative to promote staff education on infection control and surveillance of healthcare-associated infections. • It is imperative to undertake comprehensive research in order to adapt and validate definitions of healthcare-associated infection and surveillance protocols for such infections, taking into account the particular circumstances prevalent in developing countries. • A programme of research is to be conducted in order to establish the levels of educational attainment and engagement of patients and relatives with regard to identifying and reporting infections associated with healthcare.

Healthcare-associated infections present a significant challenge to healthcare providers and national health infrastructures. A review of studies revealed that the available information on prolonged hospital stays, attributable mortality, and financial impact was frequently limited by inadequate detail, high variability, and incomplete reporting of statistical methods. Reliable, systematically collected, country- and setting-specific data are essential to assess HCAI burden. Research should explore the relationship between infection rates and a nation’s gross national product. A thorough examination of these intricacies will furnish policymakers with the insights necessary to optimize healthcare resource allocation.

Although IE following TAVR is a rare occurrence, as the use of TAVR expands, the number of at-risk patients is expected to rise. As medical procedures become more streamlined and minimally invasive, patients often recover more quickly and have shorter hospital stays. This can lead to a reduction in the incidence of periprocedural infections, such as IE, which can occur as a result of surgical procedures. However, the occurrence of late-onset IE, defined as >1 year post-TAVR, is a concern due to the association with prolonged life expectancy and increased exposure to potential risk factors. Standardized guidelines are imperative for the effective management of TAVR-IE. In order to further clarify the role of surgery in selected patients, it is necessary to conduct additional analysis with detailed operative risk data. To date, only one randomized clinical trial has addressed IE in the TAVR setting, highlighting the challenges of such studies given the low incidence [198]. Until additional data from controlled trials is available, large observational studies will be essential for advancing the clinical understanding in this evolving field.

Conclusion

In the field of healthcare, effective surveillance of healthcare-associated infections is paramount. This is due to the critical importance of HCAIs in tracking disease burden and evaluating interventions. Robust systems have been shown to reduce infection rates on a global scale [101, 206], but standardized, cost-effective protocols still need refinement across diverse settings. HAI definitions depend on clinical criteria, the accuracy of which must be validated against international standards. [207] In environments where resources are scarce, empowering patients and families to report symptoms can improve detection, especially for surgical-site infections [208].

By focusing on key procedural steps, known as process control, we can enhance adherence and intervention impact [209]. Despite improvements in patient profiles, infective endocarditis post-TAVR remains uncommon but severe, with high in-hospital mortality. Surveillance for healthcare-related infections (HAI) on a global scale has the potential to inform epidemiological models utilized by entities such as the World Health Organization (WHO) [210] and other health organizations [149, 150] . Both the European Society of Cardiology [149] and the American College of Cardiology [150] are well-positioned to lead multicenter studies [211–213] using objective endpoints like mortality to drive actionable solutions.

Funding

This research received no external funding.

Data availability

Data is provided within the manuscript

Declarations

Informed consent statement

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Human Ethics and consent to participate declarations

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Institutional review board statement

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Conflicts of interest

The author declares no conflict of interest.