Inequities in Healthcare-Associated Infections Across North America- A Systematic Review

Inequities in Healthcare-Associated Infections Across North America- A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Inequities in Healthcare-Associated Infections Across North America- A Systematic Review Chandni Shahdev, ScD(c), MPH, BDS This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8419140/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Healthcare-associated infections (HAIs) remain a major concern in North America, with an estimated 687,700 HAIs and nearly 72,000 associated deaths. Studies show that social determinants of health (SDOH), including socioeconomic status, insurance, poverty, and race/ethnicity substantially influence HAI risk, severity and outcomes. However, these disparities have not been systematically synthesized. Therefore, this review aims to examine how SDOH shape HAIs incidence, severity, and outcomes. Methods Following PRISMA guidelines, PubMed, MEDLINE, and CINAHL were searched for studies published between 2014 and 2024 using HAIs terms (MRSA, C. difficile, CAUTI, CLABSI, SSI) and SDOH (race, income, insurance, poverty, area deprivation). Studies conducted in the U.S. or Canada and included at least one HAI and one SDOH. Of 3,068 records, 21 studies met inclusion criteria. Results Across 21 studies, SDOH consistently predicted higher HAI incidence, readmission, or mortality. Medicaid insurance was strongly associated with increased CDI and SSI burden; low-income neighborhoods predicted greater pediatric CLABSI; and higher MRSA odds were observed in areas of greater deprivation. Multiple studies documented racial inequities, with Black patients experiencing higher MRSA risk and postoperative morbidity. Conclusions Findings highlight the need to integrate SDOH into HAI surveillance and prevention strategies. Longitudinal studies are needed to explore HAI outcomes among socially disadvantaged populations. healthcare-associated infections Social determinants of health health disparities infection prevention health equity Figures Figure 1 1. Introduction Healthcare-associated infections (HAIs) remain a major threat to patient safety in North America. In the United States, the Centers for Disease Control and Prevention (CDC) estimates that about 687,000 HAIs occur each year, leading to nearly 72,000 hospital-associated deaths[ 1 ]. Despite decades of prevention efforts, conditions such as surgical site infections (SSIs), central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), ventilator-associated pneumonia (VAP), methicillin-resistant Staphylococcus aureus (MRSA), and Clostridioides difficile infection (CDI) remain persistent[ 2 , 3 ], These conditions cause morbidity, mortality, longer hospital stays, and increased healthcare costs [ 4 ]. While clinical risk factors and hospital practices are central to prevention, there is growing evidence that HAIs do not occur uniformly across populations [ 5 , 6 ]. Several studies have documented the role of social determinants of health, including socioeconomic status, insurance type, race and ethnicity, poverty level, household condition, neighborhood deprivation, which significantly influence HAI risk, severity and outcomes. These disparities contribute to patient access to care, exposure to the healthcare environment, timely diagnosis and quality of treatment [ 7 – 9 ]. Moreover, public health reports have documented that marginalized communities in the U.S. and Canada face a disproportionate burden of HAIs. They intersect with healthcare environment exposure, contributing to systematic differences in HAI incidence and severity [ 10 , 11 ]. Despite efforts to achieve equity in infection prevention and healthcare quality [ 5 ], evidence linking SDOH and HAI remains scattered across study designs, populations, and infection types. Although one recent study has begun to examine how social and structural factors contribute to differences in HAI type and severity, however, the evidence has not been comprehensively synthesized [ 12 ]. A systematic understanding of these relationships is essential for developing infection prevention strategies that address not only clinical and procedural risks but also the upstream social factors that shape patients’ vulnerability to acquiring HAIs. Such insights are critical for strengthening health system equity efforts, informing targeted prevention initiatives, and guiding policies aimed at improving outcomes among socially disadvantaged populations disproportionately affected by HAIs. To our knowledge, no systematic review has evaluated the influence of social determinants on HAIs across North America. Hence, the objective of this systematic review is to synthesize current evidence on the association between social determinants of health and healthcare-associated infections in North America. The review aims to recognize consistent patterns of disparities, methodological gaps, and policy recommendations to strengthen infection prevention strategies and equity-focused efforts to reduce HAIs. 2. Methods A review protocol was conducted in line with recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines​ [ 13 ]. 2.1 Literature search strategy Three databases were searched to explore the relationship between different types of HAI infection and SDOH indicators in North America, in collaboration with a university librarian. The database included were PubMed, MEDLINE and CINHAL PLUS with full text. The search keywords included MeSH terms and text were used related to HAI infection: “hospital acquired infection" OR "hospital-acquired infection" OR "healthcare associated infection" OR "healthcare-associated infection” OR "nosocomial infection" OR "surgical site infection” OR "central line-associated bloodstream infection” OR "catheter-associated urinary tract infection" OR "ventilator-associated pneumonia” OR "methicillin-resistant Staphylococcus aureus" OR "clostridioides difficile" OR "c difficile"; and related to SDOH indicators: "social determinants of health” OR “socioeconomic” OR "socio-economic" OR “SES” OR “income” OR “poverty” OR “deprivation” OR "area deprivation index" OR "social vulnerability index" OR "health disparities" OR "healthcare disparities" OR "racial disparities" OR “race” OR “racial” OR “ethnicity” OR “minority” OR “insurance” OR “Medicaid” OR “uninsured.” 2.2. Eligibility Criteria Inclusion We included peer-reviewed articles that examined the relationship between at least one HAI and one SDOH, conducted in the United States or Canada, and were published in English in a last ten years (January 2014- December 2024). Eligible study designs included quantitative or mixed-methods analysis, such as retrospective cohorts, cross-sectional studies, case-control as well as qualitative studies that explored association between HAI and SDOH. Exclusion Systematic reviews, narrative reviews, scoping reviews, and meta-analyses were excluded; however, their reference lists were screened to identify additional eligible primary studies. Studies conducted outside the United States were excluded, as were those published in languages other than English. Non-peer reviewed publications including unpublished manuscripts, conference abstracts or presentations, dissertations, news articles, and organizational reports were also excluded from the review. 2.3 Study Selection As this is a single-author review study, all titles, abstracts and full text were independently screened and selected by reviewer based on predefined eligibility criteria. EndNote reference manager was used to export all references from the databases and duplicates were removed. First, titles and abstracts were screened to identify potentially eligible studies based on inclusion and exclusion criteria. Then full texts of these studies were reviewed. 2.4 Data Extraction and Synthesis Data was extracted on study design, setting, population, HAI type, SDOH variables and key findings. Due to heterogeneity in outcome and measures, a narrative synthesis was conducted. 3. Results The search yielded 3,068 records, of which 1,355 duplicates were removed, leaving 1,713 records for screening. After title and abstract review, 1,633 records were excluded. 80 full-text articles were assessed, and 59 were excluded for reasons including non–North American setting, review design, lack of HAI outcomes, or evaluation of only clinical (non-SDOH) risk factors. A total of 21 studies met the inclusion criteria and were included in this review. The included studies evaluated a range of HAIs (MRSA, CDI, CLABSI, CAUTI, VAP, and SSI); and examined SDOH indicators (race/ethnicity, insurance type, neighborhood deprivation, and poverty). Data sources included hospital surveillance systems, statewide datasets, pediatric registries, and large national databases from the United States and Canada (Fig. 1 ). 4. Discussion This systematic review synthesizes 21 studies examining how social determinants of health (SDOH) influence healthcare-associated infections (HAIs) across North America. Across HAI types including CDI, MRSA, CLABSI, CAUTI, VAP, and SSI, the findings consistently show that structural and social inequities significantly impact HAI risk, severity and outcomes (Table 1). Racial and Ethnic Disparities Several studies in this review show racial disparities across various types of HAIs, with Black people remain the most common affected groups among others [8,18,20,23,24,28]. In CDI, Black patients had significantly higher mortality (aOR 1.12; 95% CI 1.09-1.15) and greater odds of severe disease (aOR 1.09; 95% CI 1.07-1.11) compared to Whites, despite White patients having a higher crude incidence rate of CDI-related hospitalizations [8]. CDI testing patterns also reflected inequities: White patients had more CDI tests per 1,000 patient-days than Black or non-White patients, although positivity rates were similar, this suggests potential differences in diagnostic access for clinical decisions [18]. Similarly, device associated infections also show pronounced disparities. Non- Hispanic Black patients had significantly higher CLABSI rates (IRR 1.27; 95% CI 1.02-1.58) and higher CAUTI rates (IRR 1.42; 95% CI 1.05-1.92) compared to non-Hispanic White patients [20]. Pediatric studies also revealed that multiracial Hispanic and Hispanic- pacific Islander children experienced higher CLABSI rates above reference values for race, whereas White children consistently had lower risk [7]. Racial disparities were also dominant in MRSA and MSSA. Hispanic children with cystic fibrosis had a 19% higher risk of MSSA (HR 1.19; 95% CI 1.10-1.28) and a 13% higher risk of MRSA (HR 1.13; 95% CI 1.02-1.26) and acquired these infections earlier than non- Hispanic White children.[22] At a population level analysis by Freeman et al, the author found that proportion of African American residents were the strongest predictor of hospital-onset MRSA bloodstream infections in multivariable models [23]. Disparities in SSI was also found higher in African American demonstrating higher risk of SSI in orthopedic, vascular and gynecological surgical procedures [28]. These findings collectively indicate that racial disparities in HAIs reflect structural inequities in healthcare access, environmental exposure, diagnostic procedure and socioeconomic conditions rather than biological factors. A study by Sood and colleagues also found that when neighborhood deprivation was included in MRSA models, the previously observed racial disparities were no longer significant [24]. This suggests that the higher level of MRSA burden among Black patients may be driven by underlying structural inequalities rather than race itself. Insurance Status Insurance type was also one of the most consistent predictors of emerging HAI incidence and severity. In CDI, Medicaid-insured individuals experienced elevated risk: dual-eligible patients gad more than threefold higher incidence (3.1 times) compared to Medicare-only patients, and younger adults on Medicaid had 2.7 times higher CDI incidence than other private insurance types. Even among Medicaid beneficiaries without chronic comorbidities, CDI remained significantly higher (67.5 vs 45.6 per 100,00 person-years) [9]. Moreover, in VAP lack of insurance more than doubled the odds of mortality (aOR 2.13; 95% CI 1.49-3.06) than insured groups, suggesting the critical role of financial burden in acute infection outcomes [31]. Several surgical complication studies also indicate similar effects. Medicaid and Medicare were independently associated with higher SSI risk following abdominal surgery [26]. In cesarean deliveries, Medicaid coverage increases SSI risk by 40% (aOR 1.40; 95% CI 1.20-1.60), and Medicaid accounted for nearly half of all cesarean birth, highlighting substantial population-level implications [29]. Medicaid also reported higher odds of SSI-related readmission at both 30 and 90 days [30]. These findings indicate that insurance-based disparities reflect broader financial as well as socioeconomic burden, including delayed treatment, limited perioperative care and challenges with follow-up. Poverty, Neighborhood Deprivation and Area- Level Social Disparities Neighborhood-level indicators of deprivation were strongly and consistently associated with increased HAI risk and worse outcomes. Patients living in the most disadvantaged neighborhood had significantly higher CDI readmission rates (26% vs 21%), even after adjusting for comorbidities (aOR 1.16; 95% CI 1.04-1.28) [16]. Similarly, in pediatric care, children from low-income neighborhoods had significantly elevated CLABSI risk (RR 1.43; 95% CI 1.10-1.84) [19]. A study on MRSA risk also found that higher-deprivation neighborhood (ADI>5) was linked to double the odds of MRSA infections (OR 2.26; 95%CI 1.14-4.45) [32], while state-level ecological analysis found that poverty, income inequality and the proportion of African American residents were all correlated with increased hospital-onset MRSA rates [23]. Conversely, higher community education levels and improved housing quality were associated with lower MRSA rates [21]. In surgical populations, pediatric patients in high SVI neighborhood had nearly 10-fold higher SSI rates (3.9% vs 0.4%), suggesting the profound impact of structural barriers such as overcrowded house, limited transportation and inadequate access to routine care [27]. These findings indicate that housing quality, income level and neighborhood significantly influence HAI risks across various infection types and healthcare settings. Collectively all domains related to SDOH suggest the need for expanding infection prevention efforts beyond patient-level clinical factors and include social and structural determinants. Hence, this review has several strengths. It is first, to our knowledge, to systematically synthesize evidence across North America on the relationship between social determinants of health and a wide range of healthcare-associated infections, including MRSA, CLABSI, CAUTI, VAP and SSI. The review follows the structured PRISMA protocol to conduct this study and includes multiple large national datasets (e.g. NIS, Medicare, SPS) as well as hospital surveillance data. By integrating findings across diverse populations and infection types, the review highlights consistent and critical inequities among population. Furthermore, the narrative analysis allowed for the meaningful interpretation of heterogenous study designs, SDOH measures, contributing to valuable insights for infection prevention and health equity efforts. Limitations However, several limitations also exist in this study. First, the heterogeneity of study designs, data sources, HAI definitions and SDOH measures limited direct comparison and precluded meta-analysis. Many studies relied on administrative datasets, which may contain misclassification of both outcomes and social variables such as race or insurance type. Several studies also lack control of potential confounders, raising the possibility of potential residual confounding. Finally, this review was conducted by single author, there is potential risk of selection or interpretation bias despite adherence to a structured protocol. 5. Conclusions This systematic review highlights the SDOH play critical role in shaping the risks and outcomes of HAIs across North America. Evidence consistently shows that racial and ethnic inequities, insurance status, neighborhood deprivation, and poverty are associated with higher HAI incidence, severity, readmissions, and mortality. These disparities persist even as overall HAI rates have declined, which suggests that improvements in infection prevention have not been applied equitably. The findings highlight the need for infection prevention efforts and policies to move beyond a narrow focus on clinical risk factors and incorporate social and structural contexts into surveillance, risk stratification and quality improvement initiatives. Hospitals in low-income areas may require additional resources, enhanced screening and modified quality of care metrics to address structural inequities. Infection prevention team can integrate neighborhood-level indices, insurance status, and racial inequities quality markers into HAI dashboards to facilitate earlier detection of racial disparities and support tailored prevention efforts for patient safety. Future research is needed to include more longitudinal and prospective studies to better understand casual pathways linking social disparities to HAI risks. Abbreviations ADI – Area Deprivation Index BAA – Black or African American CAUTI – Catheter-Associated Urinary Tract Infection CDI – Clostridioides difficile Infection CI – Confidence Interval CLABSI – Central Line-Associated Bloodstream Infection HCUP – Healthcare Cost and Utilization Project HAI – Healthcare-Associated Infection IRR – Incidence Rate Ratio LOS – Length of Stay MRSA – Methicillin-Resistant Staphylococcus aureus MSSA – Methicillin-Susceptible Staphylococcus aureus NIS – National Inpatient Sample NSQIP – National Surgical Quality Improvement Program OR – Odds Ratio PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses SDI – Social Deprivation Index SDOH – Social Determinants of Health SSI – Surgical Site Infection SVI – Social Vulnerability Index VAP – Ventilator-Associated Pneumonia WNH – White Non-Hispanic Declarations Ethical approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials All data generated or analyzed using this study are included in the manuscript. Competing interests The author declares that there is no competing interest. Funding Statement This research received no specific grant from any funding agency. Author’s contributions The author solely conducted the study, designed the search strategy, screened articles, extracted and synthesized data and revised the manuscript. Acknowledgments The author thanks the university librarian for assistance with refining the search strategy. Author’s Information CS is a doctoral student in Public Health Infectious Disease Epidemiology at the University of Massachusetts Lowell with research interest in Infectious diseases, Occupational health and safety and prevention of HIV disease. References CDC. Current HAI Progress Report [Internet]. Healthcare-Associated Infections (HAIs). 2025 [cited 2025 Dec 8]. Available from: https://www.cdc.gov/healthcare-associated-infections/php/data/progress-report.html Weiner-Lastinger LM, Abner S, Edwards JR, Kallen AJ, Karlsson M, Magill SS, et al. Antimicrobial-resistant pathogens associated with adult healthcare-associated infections: Summary of data reported to the National Healthcare Safety Network, 2015-2017. Infect Control Hosp Epidemiol. 2020 Jan;41(1):1–18. Magill SS, O’Leary E, Janelle SJ, Thompson DL, Dumyati G, Nadle J, et al. Changes in Prevalence of Health Care-Associated Infections in U.S. Hospitals. N Engl J Med. 2018 Nov 1;379(18):1732–44. AHRQ’s Healthcare-Associated Infections Program [Internet]. [cited 2025 Dec 8]. Available from: https://www.ahrq.gov/hai/index.html McGrath CL, Logan LK, Deloney VM, Rubin LG, Ravin KA, Muller M, et al. Monitoring health disparities in healthcare-associated infection surveillance: A Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN) Survey. Infect Control Hosp Epidemiol. 45(4):526–9. Chen J, Khazanchi R, Bearman G, Marcelin JR. Racial/Ethnic Inequities in Healthcare-associated Infections Under the Shadow of Structural Racism: Narrative Review and Call to Action. Curr Infect Dis Rep. 2021 Aug 27;23(10):17. Lyren A, Haines E, Fanta M, Gutzeit M, Staubach K, Chundi P, et al. Racial and ethnic disparities in common inpatient safety outcomes in a children’s hospital cohort. BMJ Qual Saf. 2024 Jan 19;33(2):86–97. Argamany JR, Delgado A, Reveles KR. Clostridium difficile infection health disparities by race among hospitalized adults in the United States, 2001 to 2010. BMC Infect Dis. 2016 Aug 27;16(1):454. Olsen MA, Stwalley D, Tipping AD, Keller MR, Yu H, Dubberke ER. Trends in the incidence of Clostridioides difficile infection in adults and the elderly insured by Medicaid compared to commercial insurance or Medicare only. Infect Control Hosp Epidemiol. 2023 July;44(7):1076–84. Addressing Health Inequities in Canada | Canadian Public Health Association [Internet]. [cited 2025 Dec 8]. Available from: https://www.cpha.ca/health-inequities kffdrishtip. Disparities in Health and Health Care: 5 Key Questions and Answers [Internet]. KFF. 2024 [cited 2025 Dec 8]. Available from: https://www.kff.org/racial-equity-and-health-policy/disparities-in-health-and-health-care-5-key-question-and-answers/ Tarabay J, Nix CD, Doline K, McClusky J, Catalfumo F, Lewin CA, et al. Exploring the connection of health disparities and inequities with health care-acquired infections in North America: A scoping review of the literature. Am J Infect Control. 2025 July;53(7):778–84. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29;372:n71. Shaka H, El-amir Z, Akhtar T, Wani F, Raghavan S, Khamooshi P, et al. A nationwide retrospective analysis of ventilator-associated pneumonia in the US. Proc Bayl Univ Med Cent. 35(4):410–4. Ramai D, Dang-Ho KP, Lewis C, Fields PJ, Ofosu A, Barakat M, et al. Clostridioides difficile infection in US hospitals: a national inpatient sample study. Int J Colorectal Dis. 2020 Oct;35(10):1929–35. Scaria E, Powell WR, Birstler J, Alagoz O, Shirley D, Kind AJH, et al. Neighborhood disadvantage and 30-day readmission risk following Clostridioides difficile infection hospitalization. BMC Infect Dis. 2020 Oct 16;20(1):762. Vader DT, Weldie C, Welles SL, Kutzler MA, Goldstein ND. Hospital-acquired Clostridioides difficile infection among patients at an urban safety-net hospital in Philadelphia: Demographics, neighborhood deprivation, and the transferability of national statistics. Infect Control Hosp Epidemiol. 2021 Aug;42(8):948–54. Warren BG, Burch CD, Barrett A, Graves A, Gettler E, Turner NA, et al. Racial disparities in Clostridioides difficile testing in three southeastern US hospitals. Infect Control Hosp Epidemiol. 2024 Apr;45(4):429–33. Gutierrez SA, Chiou SH, Raghu V, Cole CR, Rhee S, Lai JC, et al. Associations between hospital-level socioeconomic patient mix and rates of central line-associated bloodstream infections in short bowel syndrome: A retrospective cohort study. JPEN J Parenter Enteral Nutr. 2024 Aug;48(6):678–85. Gettler EB, Kalu IC, Okeke NL, Lewis SS, Anderson DJ, Smith BA, et al. Disparities in central line-associated bloodstream infection and catheter-associated urinary tract infection rates: An exploratory analysis. Infect Control Hosp Epidemiol. 44(11):1857–60. Andreatos N, Shehadeh F, Pliakos EE, Mylonakis E. The impact of antibiotic prescription rates on the incidence of MRSA bloodstream infections: A county-level, US-wide analysis. Int J Antimicrob Agents. 2018 Aug;52(2):195–200. McGarry ME, Huang CY, Ly NP. Ethnic differences in staphylococcus aureus acquisition in cystic fibrosis. J Cyst Fibros Off J Eur Cyst Fibros Soc. 2023 Sept;22(5):909–15. Freeman JT, Blakiston MR, Anderson DJ. Hospital-Onset MRSA Bacteremia Rates Are Significantly Correlated With Sociodemographic Factors: A Step Toward Risk Adjustment. Infect Control Hosp Epidemiol. 2018 Apr;39(4):479–81. Sood G, Dougherty G, Martin J, Beranek E, Landrum BM, Qasba S, et al. Is neighborhood deprivation index a risk factor for Staphylococcus aureus infections? Am J Infect Control. 2023 Dec 1;51(12):1314–20. Arsoniadis EG, Ho YY, Melton GB, Madoff RD, Le C, Kwaan MR. African Americans and Short-Term Outcomes after Surgery for Crohn’s Disease: An ACS-NSQIP Analysis. J Crohns Colitis. 2017 Apr 1;11(4):468–73. Qi AC, Peacock K, Luke AA, Barker A, Olsen MA, Joynt Maddox KE. Associations Between Social Risk Factors and Surgical Site Infections After Colectomy and Abdominal Hysterectomy. JAMA Netw Open. 2019 Oct 2;2(10):e1912339. Stevens J, Reppucci ML, Pickett K, Acker S, Carmichael H, Velopulos CG, et al. Using the Social Vulnerability Index to Examine Disparities in Surgical Pediatric Trauma Patients. J Surg Res. 2023 July;287:55–62. Welter M, Grosh K, Jose J, Khalil S, Muharraq A, Elian A, et al. Are There Racial Differences in the Rate of Surgical Site Infection Based on Surgical Subspecialty? Surg Infect. 2023 Dec;24(10):860–8. Yi SH, Perkins KM, Kazakova SV, Hatfield KM, Kleinbaum DG, Baggs J, et al. Surgical site infection risk following cesarean deliveries covered by Medicaid or private insurance. Infect Control Hosp Epidemiol. 2019 June;40(6):639–48. Taree A, Mikhail CM, Markowitz J, Ranson WA, Choi B, Schwartz JT, et al. Risk Factors for 30- and 90-Day Readmissions Due To Surgical Site Infection Following Posterior Lumbar Fusion. Clin Spine Surg. 2021 May 1;34(4):E216–22. Cai Y, Booraphun S, Li AY, Kayastha G, Tambyah PA, Cooper BS, et al. Cost-effectiveness of a short-course antibiotic treatment strategy for the treatment of ventilator-associated pneumonia: an economic analysis of the REGARD-VAP trial. Lancet Glob Health. 2024 Dec;12(12):e2059–67. Oates GR, Harris WT, Rowe SM, Solomon GM, Dey S, Zhu A, et al. Area Deprivation as a Risk Factor for Methicillin-resistant Staphylococcus aureus Infection in Pediatric Cystic Fibrosis. Pediatr Infect Dis J. 2019 Nov;38(11):e285–9. Table Table 1 is available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files Table.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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00:58:44","extension":"html","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":118735,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8419140/v1/fc97e45785ae5809a5d246e9.html"},{"id":99191660,"identity":"605ea228-dc83-4f07-804e-09034a99a556","added_by":"auto","created_at":"2025-12-30 00:58:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":31014,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA Flow Diagram of Study Selection\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8419140/v1/1e9f7da44293fb5b8fa9cd69.png"},{"id":99788472,"identity":"5c77d692-43f7-4f08-ac3c-3bb6ea86c4a1","added_by":"auto","created_at":"2026-01-08 12:46:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":494468,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8419140/v1/07a5930b-f226-4c63-9b47-2396e04e7271.pdf"},{"id":99191661,"identity":"ccf3c735-78ff-4dfb-bddd-d1a077d43a9d","added_by":"auto","created_at":"2025-12-30 00:58:44","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":48889,"visible":true,"origin":"","legend":"","description":"","filename":"Table.docx","url":"https://assets-eu.researchsquare.com/files/rs-8419140/v1/4a0f4d59747c83ce6b814862.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eInequities in Healthcare-Associated Infections Across North America- A Systematic Review\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eHealthcare-associated infections (HAIs) remain a major threat to patient safety in North America. In the United States, the Centers for Disease Control and Prevention (CDC) estimates that about 687,000 HAIs occur each year, leading to nearly 72,000 hospital-associated deaths[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite decades of prevention efforts, conditions such as surgical site infections (SSIs), central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), ventilator-associated pneumonia (VAP), methicillin-resistant Staphylococcus aureus (MRSA), and Clostridioides difficile infection (CDI) remain persistent[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], These conditions cause morbidity, mortality, longer hospital stays, and increased healthcare costs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile clinical risk factors and hospital practices are central to prevention, there is growing evidence that HAIs do not occur uniformly across populations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Several studies have documented the role of social determinants of health, including socioeconomic status, insurance type, race and ethnicity, poverty level, household condition, neighborhood deprivation, which significantly influence HAI risk, severity and outcomes. These disparities contribute to patient access to care, exposure to the healthcare environment, timely diagnosis and quality of treatment [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMoreover, public health reports have documented that marginalized communities in the U.S. and Canada face a disproportionate burden of HAIs. They intersect with healthcare environment exposure, contributing to systematic differences in HAI incidence and severity [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Despite efforts to achieve equity in infection prevention and healthcare quality [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], evidence linking SDOH and HAI remains scattered across study designs, populations, and infection types.\u003c/p\u003e \u003cp\u003eAlthough one recent study has begun to examine how social and structural factors contribute to differences in HAI type and severity, however, the evidence has not been comprehensively synthesized [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A systematic understanding of these relationships is essential for developing infection prevention strategies that address not only clinical and procedural risks but also the upstream social factors that shape patients\u0026rsquo; vulnerability to acquiring HAIs. Such insights are critical for strengthening health system equity efforts, informing targeted prevention initiatives, and guiding policies aimed at improving outcomes among socially disadvantaged populations disproportionately affected by HAIs.\u003c/p\u003e \u003cp\u003eTo our knowledge, no systematic review has evaluated the influence of social determinants on HAIs across North America. Hence, the objective of this systematic review is to synthesize current evidence on the association between social determinants of health and healthcare-associated infections in North America. The review aims to recognize consistent patterns of disparities, methodological gaps, and policy recommendations to strengthen infection prevention strategies and equity-focused efforts to reduce HAIs.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eA review protocol was conducted in line with recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines​ [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Literature search strategy\u003c/h2\u003e \u003cp\u003eThree databases were searched to explore the relationship between different types of HAI infection and SDOH indicators in North America, in collaboration with a university librarian. The database included were PubMed, MEDLINE and CINHAL PLUS with full text. The search keywords included MeSH terms and text were used related to HAI infection: \u0026ldquo;hospital acquired infection\" OR \"hospital-acquired infection\" OR \"healthcare associated infection\" OR \"healthcare-associated infection\u0026rdquo; OR \"nosocomial infection\" OR \"surgical site infection\u0026rdquo; OR \"central line-associated bloodstream infection\u0026rdquo; OR \"catheter-associated urinary tract infection\" OR \"ventilator-associated pneumonia\u0026rdquo; OR \"methicillin-resistant Staphylococcus aureus\" OR \"clostridioides difficile\" OR \"c difficile\"; and related to SDOH indicators: \"social determinants of health\u0026rdquo; OR \u0026ldquo;socioeconomic\u0026rdquo; OR \"socio-economic\" OR \u0026ldquo;SES\u0026rdquo; OR \u0026ldquo;income\u0026rdquo; OR \u0026ldquo;poverty\u0026rdquo; OR \u0026ldquo;deprivation\u0026rdquo; OR \"area deprivation index\" OR \"social vulnerability index\" OR \"health disparities\" OR \"healthcare disparities\" OR \"racial disparities\" OR \u0026ldquo;race\u0026rdquo; OR \u0026ldquo;racial\u0026rdquo; OR \u0026ldquo;ethnicity\u0026rdquo; OR \u0026ldquo;minority\u0026rdquo; OR \u0026ldquo;insurance\u0026rdquo; OR \u0026ldquo;Medicaid\u0026rdquo; OR \u0026ldquo;uninsured.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Eligibility Criteria\u003c/h2\u003e \u003cp\u003e \u003cb\u003eInclusion\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe included peer-reviewed articles that examined the relationship between at least one HAI and one SDOH, conducted in the United States or Canada, and were published in English in a last ten years (January 2014- December 2024). Eligible study designs included quantitative or mixed-methods analysis, such as retrospective cohorts, cross-sectional studies, case-control as well as qualitative studies that explored association between HAI and SDOH.\u003c/p\u003e \u003cp\u003e \u003cb\u003eExclusion\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSystematic reviews, narrative reviews, scoping reviews, and meta-analyses were excluded; however, their reference lists were screened to identify additional eligible primary studies. Studies conducted outside the United States were excluded, as were those published in languages other than English. Non-peer reviewed publications including unpublished manuscripts, conference abstracts or presentations, dissertations, news articles, and organizational reports were also excluded from the review.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Study Selection\u003c/h2\u003e \u003cp\u003eAs this is a single-author review study, all titles, abstracts and full text were independently screened and selected by reviewer based on predefined eligibility criteria. EndNote reference manager was used to export all references from the databases and duplicates were removed. First, titles and abstracts were screened to identify potentially eligible studies based on inclusion and exclusion criteria. Then full texts of these studies were reviewed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Extraction and Synthesis\u003c/h2\u003e \u003cp\u003eData was extracted on study design, setting, population, HAI type, SDOH variables and key findings. Due to heterogeneity in outcome and measures, a narrative synthesis was conducted.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe search yielded 3,068 records, of which 1,355 duplicates were removed, leaving 1,713 records for screening. After title and abstract review, 1,633 records were excluded. 80 full-text articles were assessed, and 59 were excluded for reasons including non\u0026ndash;North American setting, review design, lack of HAI outcomes, or evaluation of only clinical (non-SDOH) risk factors. A total of 21 studies met the inclusion criteria and were included in this review.\u003c/p\u003e \u003cp\u003eThe included studies evaluated a range of HAIs (MRSA, CDI, CLABSI, CAUTI, VAP, and SSI); and examined SDOH indicators (race/ethnicity, insurance type, neighborhood deprivation, and poverty). Data sources included hospital surveillance systems, statewide datasets, pediatric registries, and large national databases from the United States and Canada (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis systematic review synthesizes 21 studies examining how social determinants of health (SDOH) influence healthcare-associated infections (HAIs) across North America. Across HAI types including CDI, MRSA, CLABSI, CAUTI, VAP, and SSI, the findings consistently show that structural and social inequities significantly impact HAI risk, severity and outcomes (Table 1). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRacial and Ethnic Disparities\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral studies in this review show racial disparities across various types of HAIs, with Black people remain the most common affected groups among others [8,18,20,23,24,28]. In CDI, Black patients had significantly higher mortality (aOR 1.12; 95% CI 1.09-1.15) and greater odds of severe disease (aOR 1.09; 95% CI 1.07-1.11) compared to Whites, despite White patients having a higher crude incidence rate of CDI-related hospitalizations [8]. CDI testing patterns also reflected inequities: White patients had more CDI tests per 1,000 patient-days than Black or non-White patients, although positivity rates were similar, this suggests potential differences in diagnostic access for clinical decisions [18]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilarly, device associated infections also show pronounced disparities. Non- Hispanic Black patients had significantly higher CLABSI rates (IRR 1.27; 95% CI 1.02-1.58) and higher CAUTI rates (IRR 1.42; 95% CI 1.05-1.92) compared to non-Hispanic White patients [20]. Pediatric studies also revealed that multiracial Hispanic and Hispanic- pacific Islander children experienced higher CLABSI rates above reference values for race, whereas White children consistently had lower risk [7]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRacial disparities were also dominant in MRSA and MSSA. Hispanic children with cystic fibrosis had a 19% higher risk of MSSA (HR 1.19; 95% CI 1.10-1.28) and a 13% higher risk of MRSA (HR 1.13; 95% CI 1.02-1.26) and acquired these infections earlier than non- Hispanic White children.[22] At a population level analysis by Freeman et al, the author found that proportion of African American residents were the strongest predictor of hospital-onset MRSA bloodstream infections in multivariable models [23]. Disparities in SSI was also found higher in African American demonstrating higher risk of SSI in orthopedic, vascular and gynecological surgical procedures [28].\u003c/p\u003e\n\u003cp\u003eThese findings collectively indicate that racial disparities in HAIs reflect structural inequities in healthcare access, environmental exposure, diagnostic procedure and socioeconomic conditions rather than biological factors. A study by Sood and colleagues also found that when neighborhood deprivation was included in MRSA models, the previously observed racial disparities were no longer significant [24]. This suggests that the higher level of MRSA burden among Black patients may be driven by underlying structural inequalities rather than race itself.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInsurance Status\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInsurance type was also one of the most consistent predictors of emerging HAI incidence and severity. In CDI, Medicaid-insured individuals experienced elevated risk: dual-eligible patients gad more than threefold higher incidence (3.1 times) compared to Medicare-only patients, and younger adults on Medicaid had 2.7 times higher CDI incidence than other private insurance types. Even among Medicaid beneficiaries without chronic comorbidities, CDI remained significantly higher (67.5 vs 45.6 per 100,00 person-years) [9].\u003c/p\u003e\n\u003cp\u003eMoreover, in VAP lack of insurance more than doubled the odds of mortality (aOR 2.13; 95% CI 1.49-3.06) than insured groups, suggesting the critical role of financial burden in acute infection outcomes [31]. Several surgical complication studies also indicate similar effects. Medicaid and Medicare were independently associated with higher SSI risk following abdominal surgery [26]. In cesarean deliveries, Medicaid coverage increases SSI risk by 40% (aOR 1.40; 95% CI 1.20-1.60), and Medicaid accounted for nearly half of all cesarean birth, highlighting substantial population-level implications [29]. Medicaid also reported higher odds of SSI-related readmission at both 30 and 90 days [30].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese findings indicate that insurance-based disparities reflect broader financial as well as socioeconomic burden, including delayed treatment, limited perioperative care and challenges with follow-up.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePoverty, Neighborhood Deprivation and Area- Level Social Disparities\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNeighborhood-level indicators of deprivation were strongly and consistently associated with increased HAI risk and worse outcomes. Patients living in the most disadvantaged neighborhood had significantly higher CDI readmission rates (26% vs 21%), even after adjusting for comorbidities (aOR 1.16; 95% CI 1.04-1.28) [16]. Similarly, in pediatric care, children from low-income neighborhoods had significantly elevated CLABSI risk (RR 1.43; 95% CI 1.10-1.84) [19].\u003c/p\u003e\n\u003cp\u003eA study on MRSA risk also found that higher-deprivation neighborhood (ADI\u0026gt;5) was linked to double the odds of MRSA infections (OR 2.26; 95%CI 1.14-4.45) [32], while state-level ecological analysis found that poverty, income inequality and the proportion of African American residents were all correlated with increased hospital-onset MRSA rates [23]. Conversely, higher community education levels and improved housing quality were associated with lower MRSA rates [21].\u003c/p\u003e\n\u003cp\u003eIn surgical populations, pediatric patients in high SVI neighborhood had nearly 10-fold higher SSI rates (3.9% vs 0.4%), suggesting the profound impact of structural barriers such as overcrowded house, limited transportation and inadequate access to routine care [27].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese findings indicate that housing quality, income level and neighborhood significantly influence HAI risks across various infection types and healthcare settings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCollectively all domains related to SDOH suggest the need for expanding infection prevention efforts beyond patient-level clinical factors and include social and structural determinants. Hence, this review has several strengths. It is first, to our knowledge, to systematically synthesize evidence across North America on the relationship between social determinants of health and a wide range of healthcare-associated infections, including MRSA, CLABSI, CAUTI, VAP and SSI. The review follows the structured PRISMA protocol to conduct this study and includes multiple large national datasets (e.g. NIS, Medicare, SPS) as well as hospital surveillance data. By integrating findings across diverse populations and infection types, the review highlights consistent and critical inequities among population. Furthermore, the narrative analysis allowed for the meaningful interpretation of heterogenous study designs, SDOH measures, contributing to valuable insights for infection prevention and health equity efforts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHowever, several limitations also exist in this study. First, the heterogeneity of study designs, data sources, HAI definitions and SDOH measures limited direct comparison and precluded meta-analysis. Many studies relied on administrative datasets, which may contain misclassification of both outcomes and social variables such as race or insurance type. Several studies also lack control of potential confounders, raising the possibility of potential residual confounding. Finally, this review was conducted by single author, there is potential risk of selection or interpretation bias despite adherence to a structured protocol.\u0026nbsp;\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThis systematic review highlights the SDOH play critical role in shaping the risks and outcomes of HAIs across North America. Evidence consistently shows that racial and ethnic inequities, insurance status, neighborhood deprivation, and poverty are associated with higher HAI incidence, severity, readmissions, and mortality. These disparities persist even as overall HAI rates have declined, which suggests that improvements in infection prevention have not been applied equitably.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe findings highlight the need for infection prevention efforts and policies to move beyond a narrow focus on clinical risk factors and incorporate social and structural contexts into surveillance, risk stratification and quality improvement initiatives. Hospitals in low-income areas may require additional resources, enhanced screening and modified quality of care metrics to address structural inequities. Infection prevention team can integrate neighborhood-level indices, insurance status, and racial inequities quality markers into HAI dashboards to facilitate earlier detection of racial disparities and support tailored prevention efforts for patient safety. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFuture research is needed to include more longitudinal and prospective studies to better understand casual pathways linking social disparities to HAI risks.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eADI – Area Deprivation Index\u003cbr\u003eBAA – Black or African American\u003cbr\u003eCAUTI – Catheter-Associated Urinary Tract Infection\u003cbr\u003eCDI –\u0026nbsp;\u003cem\u003eClostridioides difficile\u003c/em\u003e Infection\u003cbr\u003eCI – Confidence Interval\u003cbr\u003eCLABSI – Central Line-Associated Bloodstream Infection\u003cbr\u003eHCUP – Healthcare Cost and Utilization Project\u003cbr\u003eHAI – Healthcare-Associated Infection\u003cbr\u003eIRR – Incidence Rate Ratio\u003cbr\u003eLOS – Length of Stay\u003cbr\u003eMRSA – Methicillin-Resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e\u003cbr\u003eMSSA – Methicillin-Susceptible \u003cem\u003eStaphylococcus aureus\u003c/em\u003e\u003cbr\u003eNIS – National Inpatient Sample\u003cbr\u003eNSQIP – National Surgical Quality Improvement Program\u003cbr\u003eOR – Odds Ratio\u003cbr\u003ePRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses\u003cbr\u003eSDI – Social Deprivation Index\u003cbr\u003eSDOH – Social Determinants of Health\u003cbr\u003eSSI – Surgical Site Infection\u003cbr\u003eSVI – Social Vulnerability Index\u003cbr\u003eVAP – Ventilator-Associated Pneumonia\u003cbr\u003eWNH – White Non-Hispanic\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed using this study are included in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares that there is no competing interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author solely conducted the study, designed the search strategy, screened articles, extracted and synthesized data and revised the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author thanks the university librarian for assistance with refining the search strategy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCS is a doctoral student in Public Health Infectious Disease Epidemiology at the University of Massachusetts Lowell with research interest in Infectious diseases, Occupational health and safety and prevention of HIV disease.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCDC. Current HAI Progress Report [Internet]. Healthcare-Associated Infections (HAIs). 2025 [cited 2025 Dec 8]. Available from: https://www.cdc.gov/healthcare-associated-infections/php/data/progress-report.html\u003c/li\u003e\n\u003cli\u003eWeiner-Lastinger LM, Abner S, Edwards JR, Kallen AJ, Karlsson M, Magill SS, et al. Antimicrobial-resistant pathogens associated with adult healthcare-associated infections: Summary of data reported to the National Healthcare Safety Network, 2015-2017. Infect Control Hosp Epidemiol. 2020 Jan;41(1):1\u0026ndash;18. \u003c/li\u003e\n\u003cli\u003eMagill SS, O\u0026rsquo;Leary E, Janelle SJ, Thompson DL, Dumyati G, Nadle J, et al. Changes in Prevalence of Health Care-Associated Infections in U.S. Hospitals. N Engl J Med. 2018 Nov 1;379(18):1732\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eAHRQ\u0026rsquo;s Healthcare-Associated Infections Program [Internet]. [cited 2025 Dec 8]. Available from: https://www.ahrq.gov/hai/index.html\u003c/li\u003e\n\u003cli\u003eMcGrath CL, Logan LK, Deloney VM, Rubin LG, Ravin KA, Muller M, et al. Monitoring health disparities in healthcare-associated infection surveillance: A Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN) Survey. Infect Control Hosp Epidemiol. 45(4):526\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eChen J, Khazanchi R, Bearman G, Marcelin JR. Racial/Ethnic Inequities in Healthcare-associated Infections Under the Shadow of Structural Racism: Narrative Review and Call to Action. Curr Infect Dis Rep. 2021 Aug 27;23(10):17. \u003c/li\u003e\n\u003cli\u003eLyren A, Haines E, Fanta M, Gutzeit M, Staubach K, Chundi P, et al. Racial and ethnic disparities in common inpatient safety outcomes in a children\u0026rsquo;s hospital cohort. BMJ Qual Saf. 2024 Jan 19;33(2):86\u0026ndash;97. \u003c/li\u003e\n\u003cli\u003eArgamany JR, Delgado A, Reveles KR. Clostridium difficile infection health disparities by race among hospitalized adults in the United States, 2001 to 2010. BMC Infect Dis. 2016 Aug 27;16(1):454. \u003c/li\u003e\n\u003cli\u003eOlsen MA, Stwalley D, Tipping AD, Keller MR, Yu H, Dubberke ER. Trends in the incidence of Clostridioides difficile infection in adults and the elderly insured by Medicaid compared to commercial insurance or Medicare only. Infect Control Hosp Epidemiol. 2023 July;44(7):1076\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eAddressing Health Inequities in Canada | Canadian Public Health Association [Internet]. [cited 2025 Dec 8]. Available from: https://www.cpha.ca/health-inequities\u003c/li\u003e\n\u003cli\u003ekffdrishtip. Disparities in Health and Health Care: 5 Key Questions and Answers [Internet]. KFF. 2024 [cited 2025 Dec 8]. Available from: https://www.kff.org/racial-equity-and-health-policy/disparities-in-health-and-health-care-5-key-question-and-answers/\u003c/li\u003e\n\u003cli\u003eTarabay J, Nix CD, Doline K, McClusky J, Catalfumo F, Lewin CA, et al. Exploring the connection of health disparities and inequities with health care-acquired infections in North America: A scoping review of the literature. Am J Infect Control. 2025 July;53(7):778\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29;372:n71. \u003c/li\u003e\n\u003cli\u003eShaka H, El-amir Z, Akhtar T, Wani F, Raghavan S, Khamooshi P, et al. A nationwide retrospective analysis of ventilator-associated pneumonia in the US. Proc Bayl Univ Med Cent. 35(4):410\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eRamai D, Dang-Ho KP, Lewis C, Fields PJ, Ofosu A, Barakat M, et al. Clostridioides difficile infection in US hospitals: a national inpatient sample study. Int J Colorectal Dis. 2020 Oct;35(10):1929\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eScaria E, Powell WR, Birstler J, Alagoz O, Shirley D, Kind AJH, et al. Neighborhood disadvantage and 30-day readmission risk following Clostridioides difficile infection hospitalization. BMC Infect Dis. 2020 Oct 16;20(1):762. \u003c/li\u003e\n\u003cli\u003eVader DT, Weldie C, Welles SL, Kutzler MA, Goldstein ND. Hospital-acquired Clostridioides difficile infection among patients at an urban safety-net hospital in Philadelphia: Demographics, neighborhood deprivation, and the transferability of national statistics. Infect Control Hosp Epidemiol. 2021 Aug;42(8):948\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eWarren BG, Burch CD, Barrett A, Graves A, Gettler E, Turner NA, et al. Racial disparities in Clostridioides difficile testing in three southeastern US hospitals. Infect Control Hosp Epidemiol. 2024 Apr;45(4):429\u0026ndash;33. \u003c/li\u003e\n\u003cli\u003eGutierrez SA, Chiou SH, Raghu V, Cole CR, Rhee S, Lai JC, et al. Associations between hospital-level socioeconomic patient mix and rates of central line-associated bloodstream infections in short bowel syndrome: A retrospective cohort study. JPEN J Parenter Enteral Nutr. 2024 Aug;48(6):678\u0026ndash;85. \u003c/li\u003e\n\u003cli\u003eGettler EB, Kalu IC, Okeke NL, Lewis SS, Anderson DJ, Smith BA, et al. Disparities in central line-associated bloodstream infection and catheter-associated urinary tract infection rates: An exploratory analysis. Infect Control Hosp Epidemiol. 44(11):1857\u0026ndash;60. \u003c/li\u003e\n\u003cli\u003eAndreatos N, Shehadeh F, Pliakos EE, Mylonakis E. The impact of antibiotic prescription rates on the incidence of MRSA bloodstream infections: A county-level, US-wide analysis. Int J Antimicrob Agents. 2018 Aug;52(2):195\u0026ndash;200. \u003c/li\u003e\n\u003cli\u003eMcGarry ME, Huang CY, Ly NP. Ethnic differences in staphylococcus aureus acquisition in cystic fibrosis. J Cyst Fibros Off J Eur Cyst Fibros Soc. 2023 Sept;22(5):909\u0026ndash;15. \u003c/li\u003e\n\u003cli\u003eFreeman JT, Blakiston MR, Anderson DJ. Hospital-Onset MRSA Bacteremia Rates Are Significantly Correlated With Sociodemographic Factors: A Step Toward Risk Adjustment. Infect Control Hosp Epidemiol. 2018 Apr;39(4):479\u0026ndash;81. \u003c/li\u003e\n\u003cli\u003eSood G, Dougherty G, Martin J, Beranek E, Landrum BM, Qasba S, et al. Is neighborhood deprivation index a risk factor for Staphylococcus aureus infections? Am J Infect Control. 2023 Dec 1;51(12):1314\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eArsoniadis EG, Ho YY, Melton GB, Madoff RD, Le C, Kwaan MR. African Americans and Short-Term Outcomes after Surgery for Crohn\u0026rsquo;s Disease: An ACS-NSQIP Analysis. J Crohns Colitis. 2017 Apr 1;11(4):468\u0026ndash;73. \u003c/li\u003e\n\u003cli\u003eQi AC, Peacock K, Luke AA, Barker A, Olsen MA, Joynt Maddox KE. Associations Between Social Risk Factors and Surgical Site Infections After Colectomy and Abdominal Hysterectomy. JAMA Netw Open. 2019 Oct 2;2(10):e1912339. \u003c/li\u003e\n\u003cli\u003eStevens J, Reppucci ML, Pickett K, Acker S, Carmichael H, Velopulos CG, et al. Using the Social Vulnerability Index to Examine Disparities in Surgical Pediatric Trauma Patients. J Surg Res. 2023 July;287:55\u0026ndash;62. \u003c/li\u003e\n\u003cli\u003eWelter M, Grosh K, Jose J, Khalil S, Muharraq A, Elian A, et al. Are There Racial Differences in the Rate of Surgical Site Infection Based on Surgical Subspecialty? Surg Infect. 2023 Dec;24(10):860\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eYi SH, Perkins KM, Kazakova SV, Hatfield KM, Kleinbaum DG, Baggs J, et al. Surgical site infection risk following cesarean deliveries covered by Medicaid or private insurance. Infect Control Hosp Epidemiol. 2019 June;40(6):639\u0026ndash;48. \u003c/li\u003e\n\u003cli\u003eTaree A, Mikhail CM, Markowitz J, Ranson WA, Choi B, Schwartz JT, et al. Risk Factors for 30- and 90-Day Readmissions Due To Surgical Site Infection Following Posterior Lumbar Fusion. Clin Spine Surg. 2021 May 1;34(4):E216\u0026ndash;22. \u003c/li\u003e\n\u003cli\u003eCai Y, Booraphun S, Li AY, Kayastha G, Tambyah PA, Cooper BS, et al. Cost-effectiveness of a short-course antibiotic treatment strategy for the treatment of ventilator-associated pneumonia: an economic analysis of the REGARD-VAP trial. Lancet Glob Health. 2024 Dec;12(12):e2059\u0026ndash;67. \u003c/li\u003e\n\u003cli\u003eOates GR, Harris WT, Rowe SM, Solomon GM, Dey S, Zhu A, et al. Area Deprivation as a Risk Factor for Methicillin-resistant Staphylococcus aureus Infection in Pediatric Cystic Fibrosis. Pediatr Infect Dis J. 2019 Nov;38(11):e285\u0026ndash;9. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"healthcare-associated infections, Social determinants of health, health disparities, infection prevention, health equity","lastPublishedDoi":"10.21203/rs.3.rs-8419140/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8419140/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHealthcare-associated infections (HAIs) remain a major concern in North America, with an estimated 687,700 HAIs and nearly 72,000 associated deaths. Studies show that social determinants of health (SDOH), including socioeconomic status, insurance, poverty, and race/ethnicity substantially influence HAI risk, severity and outcomes. However, these disparities have not been systematically synthesized. Therefore, this review aims to examine how SDOH shape HAIs incidence, severity, and outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFollowing PRISMA guidelines, PubMed, MEDLINE, and CINAHL were searched for studies published between 2014 and 2024 using HAIs terms (MRSA, C. difficile, CAUTI, CLABSI, SSI) and SDOH (race, income, insurance, poverty, area deprivation). Studies conducted in the U.S. or Canada and included at least one HAI and one SDOH. Of 3,068 records, 21 studies met inclusion criteria.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAcross 21 studies, SDOH consistently predicted higher HAI incidence, readmission, or mortality. Medicaid insurance was strongly associated with increased CDI and SSI burden; low-income neighborhoods predicted greater pediatric CLABSI; and higher MRSA odds were observed in areas of greater deprivation. Multiple studies documented racial inequities, with Black patients experiencing higher MRSA risk and postoperative morbidity.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eFindings highlight the need to integrate SDOH into HAI surveillance and prevention strategies. Longitudinal studies are needed to explore HAI outcomes among socially disadvantaged populations.\u003c/p\u003e","manuscriptTitle":"Inequities in Healthcare-Associated Infections Across North America- A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-30 00:58:39","doi":"10.21203/rs.3.rs-8419140/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"32503dd0-3f6b-41ba-bcc4-943f079618b1","owner":[],"postedDate":"December 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-30T00:58:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-30 00:58:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8419140","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8419140","identity":"rs-8419140","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}