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

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.