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As healthcare continues to evolve, economic forces and technological advancements have facilitated the transition of healthcare delivery from acute care hospitals to a myriad of different outpatient care settings such as ambulatory surgery centers, physician offices, dialysis centers, home care, and other specialized settings (Friedman C, Barnette M, Buck AS et al, Infect Control Hosp Epidemiol 20(10):695–705. doi:10.1086/501569, 1999). The number of outpatient visits and procedures continues to rise, with 929 million physician office visits occurring in the United States in 2012, or 301 visits per 100 persons (Ashman J, Hing E, Talwalkar A, NCHS data brief: variation in physician office visit rates by patient characteristics and state, 2012. http://www.cdc.gov/nchs/data/databriefs/db212.htm. Updated 2015. Accessed 01/14, 2016). Surgical procedures occurring in ambulatory surgical centers rose threefold between 1999 and 2005 and now represent 75% of all surgical procedures performed (Barie PS, JAMA 303(22):2295–2297. doi:10.1001/jama.2010.760, 2010). Outpatient oncologic care is also significant, with an estimated 1.1 million cancer patients per year receiving outpatient chemotherapy or radiation (Halpern MT, Yabroff KR, Cancer Investig 26(6):647–651. doi:10.1080/07357900801905519, 2008). Approximately 500,000 patients per year receive infusion therapy for maintenance hemodialysis, nutritional support, home intravenous antimicrobial therapy, or cancer chemotherapy in the outpatient setting (Williams DN, Rehm SJ, Tice AD, Bradley JS, Kind AC, Craig WA, Clin Infect Dis 25(4):787–801, 1997). While healthcare in the outpatient setting is on the rise, the overall number of inpatient hospital admissions is decreasing (35,522,000 in 2008 to 34,217,000 in 2012) (American Hospital Association. Fast facts on US hospitals. http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. Updated 2015. Accessed 01/14, 2016. n.d.). These pivotal trends provide a major impetus to develop sound infection control processes and practices in the outpatient setting.

The use of personal protective equipment (PPE) to provide care to patients on “contact” isolation precautions is a standard infection prevention practice. This is despite the fact that limited data exists to show such practices are effective in preventing transmission of organisms from patient to patient (Lopez-Alcalde J, Mateos-Mazon M, Guevara M et al, Cochrane Database Syst Rev (7):CD007087, 2015; Cohen CC, Cohen B, Shang J, J Hosp Infect 90:275–284, 2015; De Angelis G, Cataldo MA, De Waure C et al, J Antimicrob Chemother 69:1185–1192, 2014). Yet contamination of healthcare providers after interaction with the patient care environment has been well documented in the ICU setting, where multidrug-resistant organisms similar to those colonizing patients can be found on the gloves and gowns of healthcare workers after providing care (Morgan DJ, Liang SY, Smith CL et al, Infect Control Hosp Epidemiol 31:716–721, 2010; Snyder GM, Thom KA, Furuno JP et al, Infect Control Hosp Epidemiol 29:583–589, 2008). Several human factors presumably limit effectiveness of contact precautions as they are currently practiced including poor adherence (Dhar S, Marchaim D, Tansek R et al, Infect Control Hosp Epidemiol 35:213–221, 2014). More recently, technique in PPE donning and doffing has become recognized as a widespread opportunity for improvement among healthcare providers (Doll M, Bearman GB, JAMA Intern Med 175(12), 2015).

Interest in technologies to assist infection prevention efforts is increasing. The basic science literature contains an abundance of novel ideas at varying stages of development. A few of these technologies have been developed beyond preclinical testing and have been used in the healthcare setting with the goal of reducing bioburden and interrupting the transmission paths of healthcare-associated organisms. New technologies are assisting in cleaning of surfaces and devices. Other technologies endeavor to insert bactericidal materials into healthcare center furnishings and garments. Additional technologies capable of tracking and monitoring have been developed to assess hand hygiene of healthcare workers. These products are attractive to infection prevention departments and hospital administrators given the difficulties inherent in achieving and maintaining desired staff behaviors; they promise to bypass the human element and deliver automated infection prevention. Yet effectiveness of these often expensive interventions is uncertain, and incremental benefit over traditional infection prevention best practices may be scant. Nevertheless, as infection prevention programs are tasked with more activities than ever (Morgan DJ, Deloney VM, Bartlett A et al, Infect Control Hosp Epidemiol 36:605–608, 2015), they will continue to look for innovative strategies to improve the effectiveness of existing efforts.

Healthcare-associated infections are a major burden on a nation’s healthcare system, and prevention has been an area of major focus. Several strategies have been used to target transmission risks and various organisms including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), carbapenem-resistant Enterobacteriaceae (CRE), and carbapenem-resistant Acinetobacter baumannii (CRAB). Vertical strategies target a specific organism and include measures such as active surveillance cultures which may be followed by isolation or decolonization. In contrast, horizontal strategies aim to reduce infections caused by all microorganisms sharing a common means of transmission. Examples of horizontal measures include implementation of hand hygiene, universal decolonization, selective digestive tract decolonization, antimicrobial stewardship, and environmental cleaning. While there is no clear consensus over which strategies are most optimal in different settings, horizontal strategies are more likely to have a broader impact and are more cost-effective.