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Healthcare-associated infections (HAI), also referred to as hospital-acquired infections, are infections that are acquired in the course of treatment that did not exist prior to admission. HAI can affect healthcare staff, patients, visitors, and can occur in hospitals, nursing homes, or any other health care facility with regular patient contact. Such an infection can also appear after discharge or in the home setting.
HAI represents a significant burden and risk to healthcare systems globally, with hundreds of millions of patients affected each year. It results in unnecessary illness and death, increased antibiotic resistance of microorganisms, prolonged length of care, and a resulting increase in cost to hospitals, facilities, patients and families, as well as healthcare systems globally.
HAI occurs in all countries regardless of Human Development Index, but appears to affect patients in low-income and middle-income countries two- to three-fold higher than high-income countries. Additionally, the WHO reports that the true impact of HAI is not well-understood due to limited data reliability and lack of surveillance systems for detecting HAI in developing regions.
It is a global priority to address HAI, and effective infection prevention and control (IPC) instituted at the level of governments and healthcare systems is one potential solution.
Global Burden and Incidence
Overall, HAI occurs more frequently in developing regions than in developed countries. According to a 2011 WHO report, HAI occurs at a rate of 7.6 per 100 individuals in high-income countries and a rate of 15.5 per 100 patients in developing countries. In Europe, with an HAI prevalence of 7.1 per 100 patients, that equates to 4.13 million patients every year impacted by an HAI, based on a 2011 Lancet meta-analysis. Hospital-wide prevalence in developing countries ranges from 5.7% to 19.1% (pooled, 10.1%). Urinary tract infections are the most common type of HAI in Europe and the U.S., whereas surgical site infections are the most frequent HAI hospital-wide in developing countries.
HAI incidence rates, based on the 2011 WHO report and Lancet meta-analysis, are shown below:
|Region Category||Cases per 100 patients|
*Developing: low- and middle-income according to World Bank classification 2009
ICU-Acquired Infection (Adult)
|Region Category||Cases per 1000 patient-days|
*Developed: high-income country, defined according to World Bank classification 2009
Surgical Site Infection
|Region Category||Cases per 100 surgical procedures|
|Developing countries||1.2 to 23.6 (pooled = 11.8)|
Paediatric and Neonatal Infection
|Type of Setting||Cases per 1000 patient-days|
|Paediatric ICU (Developing countries)||1.6 to 46.1|
|Neonatal ICU (Developing countries)||15.2 to 62|
|Neonatal ICU (USA)||6.9|
HAI in the ICU Setting
In particular, HAIs occur most frequently in the ICU setting, where various factors including use of invasive medical devices and lines, prolonged bed rest, multiple comorbidities, and high exposure risk predispose patients to transmission. Additionally, data suggest that 30% of patients in the ICU are affected by at least one episode of HAI. The mean cumulative incidence of infection in adult critically-ill patients is 17.0 episodes per 1000 patient-days. The most common type of HAI among these patients is ventilator-associated pneumonia. High frequencies of infection also occur in association with use of central lines and urinary catheters.
Physiotherapy and HAI
Due to the broad role of physiotherapists and involvement in the continuum of patient care, including hospitals, ambulatory clinics, nursing homes, rehabilitation hospitals, and homes, HAIs are a growing area of concern in physiotherapy. Physiotherapists routinely work in close proximity among patients presenting with a range of illnesses, interact with a variety of healthcare staff, and frequently provide hands-on and physical assist to patients. Physiotherapists often work with older adult patients, who are more prone to infection. Additionally, the comparatively long length of treatment sessions (30 to 60 minutes) and course of care among settings make both patients and physiotherapists particularly susceptible to HAIs.
Due to these factors, it is especially important for physiotherapists to practice effective IPC and hand hygiene, regardless of clinical setting. According to the World Health Organization's "My 5 Moments of Hand Hygiene" approach, healthcare workers including physiotherapists should clean their hands before touching a patient, before clean/ aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings.
Global Impact of HAIs
Although the full picture of the impact of HAIs is yet to be elucidated, there is strong evidence from existing published studies that hundreds of millions of patients are effected globally each year, with the highest impact occurring in low- and middle-income countries.
- The burden of health care-associated infection worldwide [Internet]. World Health Organization. 2020 [cited 27 March 2020]. Available from: https://www.who.int/infection-prevention/publications/burden_hcai/en/
- Health care-associated infections Key facts [Internet]. [cited 2020]. Available from: https://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf
- Allegranzi B, Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. The Lancet. 2011;377(9761):228-241.
- World Health Organization. (2011). Report on the burden of endemic health care-associated infection worldwide. World Health Organization.
- Ibeneme S, Maduako V, Ibeneme G, Ezuma A, Ettu T, Onyemelukwe N et al. Hand Hygiene Practices and Microbial Investigation of Hand Contact Swab among Physiotherapists in an Ebola Endemic Region: Implications for Public Health. BioMed Research International. 2017;2017:1-13.