Inequities in healthcare-associated infections across North America: a systematic review of U.S.-based studies

Abstract Background Healthcare-associated infections (HAIs) remain a major concern in North America, with an estimated 687,000 HAIs and nearly 72,000 associated deaths. Studies show that social determinants of health (SDOH), including socioeconomic status, insurance, poverty, and race/ethnicity, have been associated with HAI risk, severity and outcomes. However, these disparities have not been systematically synthesized. Therefore, this review aims to examine how SDOH are associated with HAI incidence, severity, and outcomes. Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed, MEDLINE, and CINAHL were searched for studies published between 2014 and 2024 using HAI terms, including methicillin-resistant Staphylococcus aureus (MRSA), Clostridioides difficile infection (CDI), catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and surgical site infection (SSI), as well as SDOH (race, income, insurance, poverty, area deprivation). Eligible studies were conducted in the United States or Canada and examined at least one HAI and one SDOH. A single reviewer conducted study selection, data extraction, and assessed risk of bias using the Joanna Briggs Institute critical appraisal tools, which may have introduced selection or interpretation bias despite the partial second-rater verification. Of 3,068 records, 21 studies met inclusion criteria. Results Twenty-one studies met the inclusion criteria, all of which were based in the United States; no Canadian studies met the final eligibility criteria. SDOH were consistently associated with differences in HAI incidence, readmission, and mortality. Medicaid insurance was strongly associated with increased CDI and SSI burden; low-income neighborhoods were associated with higher pediatric CLABSI rates; 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 surveillance and prevention strategies. Longitudinal studies are needed to explore HAI outcomes among socially disadvantaged populations.