Strategies for Reducing Nosocomial Infection in Iranian Hospitals: A Scoping Review

Introduction

Hospitals are complex sociotechnical systems that deliver diagnostic, therapeutic, and rehabilitative care through the coordinated use of specialized healthcare professionals, biomedical technologies, and physical infrastructure. Their central mission is to improve population health outcomes by providing cost-effective, evidence-based services (1). However, increasing expectations for high-quality and safe patient care, along with technological advancements, a rise in invasive procedures, and expanded use of immunosuppressive therapies, have collectively led to an increase in the incidence of nosocomial infections (2). Healthcare-associated infections (HAIs) remain a major global public health concern, and despite extensive international efforts, sustained control has yet to be achieved (3).

Hospital-acquired infections, or nosocomial infections, are defined as infections that develop during hospitalization or healthcare delivery and are neither present nor incubating at the time of admission. Generally, an infection is considered hospital-acquired if it appears 48 hours or more after admission or within 72 hours of discharge, provided that it was not evident or latent upon entry (4). These infections can occur while the patient is still hospitalized or after discharge (5). Epidemiological evidence suggests that approximately 7% of patients in developed countries and 10% in developing countries acquire HAI during their hospital stay (6). Multiple factors contribute to the development of HAIs. Major risk factors include advanced age (particularly patients over 65 years or infants under one year), malnutrition, emergency admissions to intensive care units, and prolonged hospital stays (especially longer than seven days). The use of invasive medical devices—such as urinary catheters, intravenous and arterial lines, suction systems, and endotracheal tubes—significantly increases infection risk by bypassing natural body defenses (7, 8). Surgical procedures, particularly recent or repeated operations, also elevate infection susceptibility. Patients receiving immunosuppressive therapy or in a comatose state face additional vulnerability due to impaired immune function. Other contributing factors include chronic underlying diseases (e.g., cardiovascular disorders), prior antibiotic exposure, and poor nutritional status (9). Among the affected organ systems, the urinary tract is most commonly involved, followed by the respiratory and circulatory systems, often in association with medical devices or invasive procedures (9).

According to the European Centre for Disease Prevention and Control (ECDC), the prevalence of HAIs across 947 hospitals in 30 European countries was approximately 5.7% in 2012 (10). In contrast, developing countries report substantially higher rates, with systematic reviews estimating an average prevalence of 15.5% (11). In Iran, reported prevalence rates vary considerably, ranging from 0.32% to 9.4%, depending on study design, hospital characteristics, and surveillance methodology (12). HAIs represent a critical challenge to patient care, as they are associated with extended hospitalization, delayed recovery, increased complications, and diminished quality of life (13). These infections contribute to higher morbidity and mortality rates, and affected patients incur significantly greater healthcare costs compared with uninfected individuals (14). Furthermore, HAIs undermine hospital efficiency and impose substantial economic burdens on healthcare institutions and insurance systems (15). Globally, HAIs are recognized as one of the most common adverse events in clinical care, affecting millions of patients each year (16). For example, the ECDC estimates that HAIs lead to millions of additional hospital days, tens of thousands of preventable deaths, and billions of euros in direct healthcare expenditures annually (17, 18).

In Iran, numerous studies have explored strategies to prevent and control HAIs (19-22). However, most of these investigations are limited in scope and fragmented, preventing a comprehensive understanding of the most effective interventions. To enable evidence-based policymaking and informed managerial decisions, it is essential to synthesize and integrate the available research evidence. Therefore, the present scoping review aims to identify effective strategies for reducing hospital-acquired infections in Iranian hospitals.

Methods

The approach adopted in this scoping review was guided by the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis (23) and followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) as a reporting framework (24). The PRISMA 2020 flow diagram was also used to depict the process of study selection (25). Comprehensive searches were conducted in PubMed, Web of Science, Scopus, Scientific Information Database (SID), Magiran, and Google Scholar.

The search strategy was developed iteratively, beginning with an initial limited search to identify and analyze relevant keywords and index terms from retrieved studies. The search string was first constructed in MEDLINE (via PubMed) and subsequently refined with input from an experienced medical information specialist. The finalized search syntax was translated and adapted for use across other databases using the Systematic Review Accelerator Polyglot Search Translator tool (26), and further reviewed and modified as required. Relevant subject headings (e.g., MeSH and Emtree terms) were manually incorporated to optimize retrieval accuracy. Common keywords included nosocomial infection, hospital infection, healthcare-associated infection, hospital-acquired infection, strategy, solution, Iran, and hospital (Table 1). The final search was conducted on 31 January 2025.

Table 1: The search strategy and number of studies obtained from databases and search engines

The study selection process was conducted in three sequential stages. In the first stage, the titles and abstracts of all retrieved records were independently screened to identify potentially relevant studies. In the second stage, the full texts of the selected articles were assessed for eligibility based on the predefined inclusion and exclusion criteria. In the final stage, a manual search of the reference lists of all included studies was performed to identify any additional eligible publications. The inclusion and exclusion criteria were jointly developed and refined by both reviewers. All screening stages were conducted independently by three reviewers, and any disagreements were resolved by discussion or, when necessary, through consultation with a fourth independent reviewer. Additionally, the corresponding authors of potentially eligible conference abstracts were contacted for clarification when no full-text publication was available.

This review included studies involving professional healthcare providers working in hospital settings. These professionals encompassed individuals across various training and responsibility levels, such as nurses, physicians, hospital administrators, and infection prevention and control personnel. Eligible studies were those that evaluated or assessed infection prevention and control (IPC) strategies, programs, or interventions implemented within hospital environments. The review was limited to the hospital context, encompassing both medical and specialized nursing care delivered to inpatients. All types of primary research designs (including cross-sectional studies, case series, and case studies) were eligible for inclusion. Editorials, commentaries, narrative reviews, guidance documents, and studies lacking sufficient methodological detail relevant to the research question were excluded.

Articles were excluded if they were published in languages other than English or Persian, published after January 31, 2025, books or book chapters, or if full-text access was unavailable. A data extraction form was designed to collect information from the studies, which included sections for the first author's last name, publication year, location of the study, type of hospital, and strategies (Table 2). This study employed the six-stage thematic analysis method developed by Braun and Clarke to analyze qualitative data. The stages include familiarizing oneself with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report (27). For data analysis, version 10 of the MAXQDA software was utilized.

Table 2. Characteristics of studies included in this scoping review

Ethical Consideration

Ethical approval was not required, as it exclusively utilized data available in the public domain.

Results                                                               

A total of 11,899 records were initially identified. After removing duplicates and records without accessible full texts, 8,985 studies remained for title and abstract screening that 8,477 records were excluded due to not meeting the inclusion criteria, leaving 508 articles related to the topic. Then, 469 studies were excluded because they were not relevant. Additional two studies were identified through reference list screening. Ultimately, 41 studies included in the final synthesis (Figure 1).

Figure 1. PRISMA Flowchart of the study process

The studies published between 1999 and 2025 (Table 2) consisted of quantitative research designs (n = 23), followed by review articles (n = 14), qualitative studies (n = 3), and one mixed-method study (n = 1). The year 2021 accounted for the highest number of publications (n = 6) (Figure 2). Geographically, the studies conducted across 15 Iranian provinces, Tehran Province representing the highest concentration of research (n = 18) (Figure 3). The strategies for reducing hospital-acquired infections classified into six overarching domains: governance and leadership, financing, human resources, infrastructure, medical products and equipment, information systems, and service delivery (Table 3). A total of 76 distinct strategies were identified, the largest subset (n = 22) pertaining to governance and leadership (Figure 4).

Figure 2. Frequency distribution of articles on strategies for reducing Nosocomial infection by done year

Figure 3. Frequency distribution of articles on strategies for reducing Nosocomial infection by Province

Figure 4. Frequency distribution of hospital-acquired infections in Iranian hospitals by related domains

Table 3: Strategies to Reduce Hospital-Acquired Infections in Iranian Hospitals

Training of health care personnel, promotion of hand hygiene among healthcare personnel, regular monitoring of the infection control program, providing the desired physical environment, limiting the use of broad-spectrum antibiotics, and developing national guidelines and standards for the control of hospital-acquired infections (HAIs) were the most common strategies for reducing the incidence of hospital infections in Iranian hospitals (Figure 5).

Figure 5. Frequency distribution of the most common strategies for reducing hospital-acquired infections in Iranian hospitals

Discussion

This study aimed to identify effective strategies for reducing the incidence of hospital-acquired infections (HAIs) among hospitalized patients across healthcare facilities in Iran. A total of 76 distinct strategies were identified across the included studies, all targeting the reduction and prevention of HAIs in Iranian hospitals. These strategies were classified into six main domains: governance and leadership, financing, human resources, infrastructure, medical products and equipment, information systems, and service delivery. Among these, healthcare personnel training emerged as one of the most critical and consistently emphasized interventions. Continuous, competency-based education has been shown to enhance healthcare workers’ proficiency in essential infection prevention and control (IPC) practices, including hand hygiene, appropriate use of personal protective equipment (PPE), environmental disinfection, and isolation of infectious patients. Improved staff competency subsequently leads to better patient outcomes and a safer clinical environment by disrupting the chain of infection transmission. The COVID-19 pandemic further highlighted persistent gaps in IPC knowledge and practice among healthcare professionals, emphasizing the urgency of ongoing professional education to strengthen preparedness for emerging and re-emerging infectious threats (28). Clinical trials and observational studies have consistently demonstrated that structured, competency-based training programs significantly enhance healthcare workers’ knowledge and adherence to infection prevention and control (IPC) protocols. For instance, periodic in-service education, particularly when delivered through face-to-face modular sessions, has been shown to markedly improve knowledge retention and compliance with IPC practices among healthcare personnel. However, these improvements tend to decline over time in the absence of refresher courses, highlighting the need for regular reinforcement—ideally every six months—to maintain sustainable behavioral compliance and effective infection control (29, 30). This continuous education approach is crucial for sustaining behavioral changes and adherence to IPC protocols.

Training methods that utilize active learning strategies, multimedia-enhanced instruction, and hands-on practical demonstrations have been shown to be more effective than conventional lecture-based formats, as they enhance participant engagement, knowledge acquisition, and long-term skill retention. Evidence further indicates that nurses often receive more IPC training than physicians, despite the critical role of physicians in infection prevention. This disparity underscores the importance of designing training programs that inclusively target all healthcare professionals, ensuring optimal hospital-wide infection control (29). Moreover, patient- and family-centered education on infection prevention and control (IPC) measures has been shown to reduce hospital-acquired infections (HAIs). Evidence indicates that educating patients and their caregivers on hand hygiene and adherence to IPC protocols contributes to reduced surgical site infections and enhanced compliance with hospital infection control guidelines, ultimately supporting a safer healthcare environment (30, 31).

Hand hygiene among healthcare personnel is a cornerstone in reducing hospital-acquired infections (HAIs). Improved hand hygiene compliance is consistently associated with substantial reductions in HAIs, particularly bloodstream and respiratory infections. Proper hand hygiene practices can prevent up to 50% of avoidable healthcare-associated infections, representing a simple, effective, and cost-efficient preventive strategy (32). However, compliance remains suboptimal worldwide, especially in low-income countries where lack of basic water and hand hygiene facilities at the point of care leads to compliance rates as low as 9% (32, 33). This contributes to healthcare-associated infection (HAI) rates that are two to three times higher than in developed countries. In contrast, high-income countries typically achieve compliance rates up to 70%, resulting in lower infection burdens. The transmission of pathogens via contaminated healthcare workers’ hands is a primary route for HAIs, including resistant organisms such as MRSA, and improving hand hygiene compliance has been linked to reductions in these infections (34). While hand hygiene alone cannot eliminate all risk factors for HAIs, it remains a cornerstone of infection prevention strategies supported by education, monitoring, and organizational commitment.

Regular monitoring of infection control programs is essential for reducing hospital-acquired infections (HAIs). Evidence consistently demonstrates that electronic hand hygiene monitoring systems enhance healthcare worker compliance by providing real-time, objective feedback, mitigating the bias inherent in direct observation. For instance, an interventional study reported that the implementation of an electronic monitoring system, combined with individual and group feedback, resulted in a marked improvement in hand hygiene compliance and a significant reduction in hospital-acquired bloodstream infections (35). This contrasts with traditional direct observation methods, which may overestimate hand hygiene adherence due to the Hawthorne effect, a phenomenon in which healthcare workers temporarily alter their behavior when aware of being observed, thereby producing less reliable compliance data (36). Furthermore, educational interventions integrated with monitoring have proven effective in sustaining improvements. A study in a respiratory disease hospital showed that hand hygiene training raised compliance rates from 66% to 88.3% and significantly improved healthcare workers’ knowledge and attitudes toward infection control practices (37). These findings align with the evidence that combining training with continuous monitoring, especially electronic systems, enhances both adherence and infection prevention outcomes. Regular, technology-assisted monitoring of infection control programs has been shown to be more effective than traditional observation methods alone. It provides accurate compliance data, reduces observer bias, and, when combined with targeted education and feedback, facilitates sustained improvements in hand hygiene practices and a reduction in hospital-acquired infections (HAIs). Such integrated monitoring strategies should be considered a core component of effective infection prevention programs in healthcare settings. Ensuring a safe and hygienic physical environment is equally essential for preventing HAIs. The design and maintenance of hospital infrastructure—including layout, airflow, ventilation, and antimicrobial materials—play a critical role in controlling infection transmission. Proper ventilation and air conditioning systems help limit airborne pathogens, while thoughtful spatial arrangements minimize cross-contamination by segregating infectious patients and managing the flow of staff, equipment, and waste.

Effective cleaning and disinfection of environmental surfaces is vital, given that pathogens such as MRSA and Clostridium difficile can survive on surfaces for prolonged periods. Ensuring accessible hand hygiene stations and robust hand hygiene infrastructure further supports infection control efforts. Multidisciplinary teams, including infection prevention specialists, facility managers, and healthcare personnel, should collaborate to develop and implement policies and procedures that maintain environmental hygiene and patient safety. By integrating evidence-based design principles with rigorous cleaning protocols, healthcare facilities can create a healing environment that substantially reduces the risk of HAIs (38). Limiting the use of broad-spectrum antibiotics is critical for reducing hospital-acquired infections (HAIs), as overuse contributes to the emergence and dissemination of multidrug-resistant (MDR) pathogens, complicating treatment and increasing morbidity and mortality among hospitalized patients. While broad-spectrum agents may be necessary for initial empiric therapy, especially in critically ill patients or those at high risk for MDR infections, their use should be judicious and guided by pathogen identification and susceptibility patterns. Antimicrobial stewardship programs advocate for the selection of narrow-spectrum agents whenever feasible and the de-escalation of therapy once culture results are available, thereby minimizing unnecessary antibiotic exposure. This strategy reduces selection pressure, prevents difficult-to-treat infections, and ultimately decreases the burden of HAIs in healthcare settings.

Integrating effective infection prevention and control measures with prudent antibiotic use is essential to managing HAIs and preserving the efficacy of antimicrobial agents (39, 40). Developing national guidelines and standards for the control of hospital-acquired infections is critical for reducing their incidence and mitigating their impact. These infections, which typically occur., pose a significant threat to patient safety by increasing morbidity, mortality, prolonging hospitalization, and elevating healthcare costs. National guidelines provide a structured framework for surveillance, prevention, and control measures tailored to healthcare settings, ensuring consistent, evidence-based practices across hospitals. They generally include standardized protocols for key infection control measures, such as hand hygiene, appropriate use of personal protective equipment (PPE), sterilization procedures, and management of invasive devices, which are essential for preventing pathogen transmission. Furthermore, national programs support hospitals by setting objectives aligned with healthcare priorities, promoting staff education, and establishing monitoring systems to evaluate the effectiveness of interventions. Effective implementation of these guidelines reduces the spread of multidrug-resistant organisms and contributes to antimicrobial resistance containment. By fostering collaboration among healthcare workers, hospital management, and public health authorities, national standards create safer healthcare environments, ultimately protecting patients, staff, and the broader community from HAIs (39, 41).

Despite the valuable insights provided by this scoping review, several limitations should be acknowledged. First, the study only included articles published in Persian and English, potentially overlooking relevant research published in other languages and thereby introducing language bias. Second, the review was limited to studies accessible in full text, which may have excluded pertinent data from conference abstracts or unpublished studies, leading to publication bias. Third, the heterogeneity in study designs, settings, and reporting standards among the included articles posed challenges in synthesizing findings and may have affected the comparability of results. Fourth, the reliance on published literature means that the review may not capture recent or ongoing interventions that have not yet been documented in academic sources. Fifth, most of the studies were conducted in certain provinces, such as Tehran, which could limit the generalizability of the findings to other regions with different healthcare infrastructures or resource levels.

Implications for practice

This scoping review systematically synthesized evidence on strategies to prevent and reduce hospital-acquired infections in Iranian hospitals. Analysis of 41 studies indicated that effective infection control necessitates a multifaceted approach, encompassing six key domains: governance and leadership, financing, human resources, infrastructure, medical products and equipment, information systems, and service delivery. Among the 76 identified strategies, the most frequently emphasized and impactful measures included continuous healthcare personnel training, promotion of hand hygiene, regular monitoring and evaluation of infection control programs, enhancement of hospital infrastructure, rational antibiotic use, and the development of national infection prevention guidelines and standards. Governance and leadership interventions, such as establishing infection control committees and ensuring strong managerial support, were the most commonly reported. The findings underscore that ongoing education and practical training—particularly via interactive, modular approaches—are critical to maintaining healthcare workers’ knowledge and adherence to IPC protocols. Furthermore, regular refresher courses and systematic monitoring are essential to sustain high standards of infection control. Reducing HAIs in Iranian hospitals requires an integrated strategy that combines strong leadership, adequate resources, continuous staff training, and evidence-based clinical practices. Policymakers and hospital administrators are urged to implement these multifaceted interventions to enhance patient safety, reduce infection rates, and improve overall healthcare quality across the country.

Acknowledgments

The authors would like to extend their most sincere gratitude and appreciation to the esteemed reviewers of the article.

Conflicts of interest

The authors declare that they have no competing interests.

Funding

None.

Authors' Contributions

MP and PI participated in the design of the study. PI, MA, MS, SZ and AB undertook the literature review process. All authors drafted the manuscript. All authors read and approved the final manuscript. Finally, all authors read and approved the final version for publication.