Open research questions in Nosocomial Infections in ICU

What the literature leaves open

• Background The incidence of nosocomial candidemia has increased in recently years, however, the epidemiological data remain insufficient in China.

  Nineteen years retrospective analysis of epidemiology, antifungal resistance and a nomogram model for 30-day mortality in nosocomial candidemia patients · 2025 · DOI

• Background/purpose: Complications, such as postoperative pneumonia, can occur after pediatric cardiac surgery; however, studies on related changes in perioperative oral bacterial counts are scarce.

  Oral care methods to reduce salivary bacteria in infants undergoing cardiac surgery: A randomized controlled trial · 2024 · DOI

• The limited literature has demonstrated higher rates of recurrence for non-glucose fermenting gram-negative bacilli with short course therapy, raising the concern of optimal treatment duration for these pathogens.

  Duration of antibiotic therapy for multidrug resistant Pseudomonas aeruginosa pneumonia: is shorter truly better? · 2024 · DOI

• Further studies can investigate the long-term effects of structured oral care on patient outcomes. Research can explore the cost-effectiveness of implementing structured oral care in ICU settings.

  Impact of Adjuvant Oral Care on Clinical Outcomes in Mechanically Ventilated ICU Patients: A Randomized Controlled Trial · 2026 · DOI

• The study does not investigate the relationship between structured oral care adherence and patient outcomes, nor does it address barriers to implementing and sustaining oral care regimens in routine ICU nursing practice. Qualitative and implementation science studies are needed to understand compliance challenges and optimize integration of oral care into ICU protocols.

  Impact of Adjuvant Oral Care on Clinical Outcomes in Mechanically Ventilated ICU Patients: A Randomized Controlled Trial · 2026 · DOI

• There is a need to identify clinical risk factors and microbial profiles associated with VAP. Prior studies have reported inconsistent findings on the predictive value of inflammatory markers for VAP.

  Risk factors, predictive biomarkers, and microbial profile of ventilator-associated pneumonia in critically ill patients: a retrospective cohort Study · 2026 · DOI

• Clinician uncertainty remains about the effectiveness of SDD in reducing mortality in mechanically ventilated patients. There is a need for evidence on the effectiveness of SDD in reducing mortality in mechanically ventilated patients.

  Selective Decontamination of the Digestive Tract during Ventilation in the ICU · 2026 · DOI

• include mortality and long-term outcomes as key indicators - adopt robust grouping protocols to ensure balanced baseline characteristics - utilize multicenter prospective designs with larger sample sizes

  Process Improvement of In-Hospital Critical and Life-Threatening Patient Resuscitation: A Quality Improvement Project in a China Otolaryngology Hospital · 2026 · DOI

• The low resuscitation success rate in the hospital. The lack of standardized procedures for monitoring, identifying, and activating the emergency system. The need for improved emergency resuscitation capabilities.

  Process Improvement of In-Hospital Critical and Life-Threatening Patient Resuscitation: A Quality Improvement Project in a China Otolaryngology Hospital · 2026 · DOI

• There is a need for a comprehensive summary of the latest evidence on the prevention and management of nosocomial infections in patients undergoing extracorporeal membrane oxygenation. The current evidence on the prevention and management of nosocomial infections in ECMO patients is limited and fragmented.

  Prevention and management of nosocomial infections in patients undergoing extracorporeal membrane oxygenation: a summary of best evidence · 2026 · DOI

• X u e t a l. 2 3 5 3 4 5 5 5 A B A B B B A A. 1 0 3 3 8 9 / f. m e d 2 0 2 6. 1 8 1 9 1 3 4 Xu et al. 10.3389/fmed.2026.1819134 mentioned above (such as particular dressing types or extubation timeframes), and many recommendations are based on clinical experience and observational data. This reflects the significant challenges in conducting prospective randomized controlled studies to evaluate the independent effectiveness of single infection prevention and control measures within the complex intervention that is ECMO. Cannulation itself compromises the integrity of the skin barrier, and the risk of infection correlates directly with the duration of catheterization (2). The application of transparent semipermeable film dressings over puncture sites provides an effective microbial barrier while enabling continuous visual assessment for early detection of infection signs. ELSO guidelines recommend avoiding unnecessary circuit access to maintain system integrity. All essential connections should utilize needleless connectors, with interfaces securely sealed using aseptic techniques to effectively block microbial invasion pathways (24, 33). Manerikar et al. (34) demonstrated that central venous catheter indwelling exceeding 8 days in ECMO patients was associated with higher rates of bloodstream infection and oxygenator secondary colonization. Therefore, daily assessment and prompt removal of non-essential lines are crucial for reducing potential infection portals at the source. Comprehensive skin management remains equally indispensable. Prophylactic dressings (such as hydrocolloid or foam dressings) should be placed beneath ECMO cannulas and monitoring devices to maintain clean, dry skin. This approach not only prevents pressure injuries but also serves as a critical measure for preserving the body’s natural barrier function. In refined skin and mucosal decolonization strategies, chlorhexidine serves as a critical broad-spectrum antiseptic agent. Systematic reviews indicate that chlorhexidine bathing can reduce the incidence of bloodstream infections by approximately 29% (IRR = 0.71, 95% CI 0.51–0.9) (35). A cluster-randomized trial published in JAMA demonstrated that combining chlorhexidine bathing with nasal mupirocin decolonization effectively reduced clinical culture positivity for staphylococcus aureus and methicillin-resistant staphylococcus aureus among ICU patients (36). However, evidence applicability to ECMO patients remains unclear, and existing results are conflicting. One study found that chlorhexidine plus mupirocin failed to reduce bloodstream infections in ECMO patients but unexpectedly increased enterococcal infections (11). Conversely, another study reported that a multi-site decontamination regimen including topical antibiotics significantly reduced infections (31).

  Prevention and management of nosocomial infections in patients undergoing extracorporeal membrane oxygenation: a summary of best evidence · 2026 · DOI

• Multidrug-resistant (MDR) Gram-negative organisms are a significant challenge in treating patients with VAP. The development of new antibiotics cannot keep up with the rate of emerging resistance. Inhaled antibiotics may have limited efficacy and safety profiles in VAP.

  To Give or Not to Give Inhaled Antibiotics: Heterogeneous Effects of Inhaled Antibiotics in Ventilated Patients in the Intensive Care Unit · 2026 · DOI

• Further studies are needed to establish the optimal dosage and frequency of inhaled antibiotics in VAP. Research is needed to evaluate the long-term effects of inhaled antibiotics on patients with VAP. Studies should investigate the use of inhaled antibiotics in combination with other therapies for VAP.

  To Give or Not to Give Inhaled Antibiotics: Heterogeneous Effects of Inhaled Antibiotics in Ventilated Patients in the Intensive Care Unit · 2026 · DOI

• The study identifies a gap in healthcare professionals' knowledge of HAI management. The study highlights the importance of addressing systemic deficiencies in healthcare delivery systems.

  Scaling up improvement: the drive to reduce healthcare-associated infections in public Brazilian intensive care units across all patient ages · 2026 · DOI

• This nationwide study has significant limitations. As in other HAIprevention initiatives, adjudication of VAP and the measured incidence of CLABSI and CAUTI may be influenced by local diagnostic and surveillance practices, including the frequency of culture ordering and how definitions are applied; culture stewardship alone can reduce reported CAUTI rates.36 To mitigate this, the study used a pre–post design in which each ICU served as its own control, established a complete one-year baseline, https://doi.org/10.1017/ice.2026.10434 Published online by Cambridge University Press Infection Control & Hospital Epidemiology 7 Table 1.

  Scaling up improvement: the drive to reduce healthcare-associated infections in public Brazilian intensive care units across all patient ages · 2026 · DOI

• The study identifies a knowledge gap on nosocomial infections among healthcare professionals in low-resource settings. The study highlights the need for targeted training programs to address this gap.

  Analyse des besoins en formation continue de professionnels de santé sur la lutte contre les infections nosocomiales : Résultats d’une enquête menée à l'Hôpital Général de Référence de Nsona-Nkulu, dans la Province du Kongo Central. · 2026 · DOI

• Further studies are needed to investigate the emergence and dissemination of antimicrobial-resistant microorganisms in ICUs. Research on the epidemiological relevance of ESKAPE pathogens in healthcare-associated infections is necessary. Studies on the resistance patterns of Gram-positive and Gram-negative bacteria in ICUs should be conducted.

  Microbiological Profile and Antimicrobial Resistance Patterns in an Intensive Care Unit: Emphasis on ESKAPE Pathogens · 2026 · DOI

• The study identifies a gap in the understanding of antimicrobial resistance patterns in ICU settings, particularly in Brazil. The study highlights the need for monitoring antimicrobial resistance in ICU settings to guide infection control and antimicrobial stewardship programs.

  Microbiological Profile and Antimicrobial Resistance Patterns in an Intensive Care Unit: Emphasis on ESKAPE Pathogens · 2026 · DOI

• Promoting adherence to prevention bundles is a complex challenge. Healthcare organizations face challenges in implementing and sustaining effective prevention strategies. Nurses may face barriers to adherence, such as lack of training or resources.

  Factors influencing nurses’ adherence to ventilator-associated pneumonia prevention bundles: a scoping review · 2026 · DOI

• There is a lack of research on the factors influencing nurses' adherence to ventilator-associated pneumonia prevention bundles. There is a need for further studies on the effectiveness of integrated strategies for promoting adherence.

  Factors influencing nurses’ adherence to ventilator-associated pneumonia prevention bundles: a scoping review · 2026 · DOI

• There is a need for robust, locally calibrated surveillance data to inform context-specific antimicrobial policy. The epidemiology of bacterial pathogens has shifted markedly over the past two decades.

  Bacterial Profile and Antimicrobial Resistance Patterns in the Pediatric Intensive Care Unit of Rajshahi Medical College Hospital: A Prospective Observational Study · 2026 · DOI

• This meta-analysis has several limitations. Despite the consistent inclusion of multivariable-adjusted estimates, retrospective, single- center studies remain predominant, which may introduce selection bias and information bias. Because of the lack of standardized infec- tion definitions and the heterogeneity of ECMO populations, substan- tial residual heterogeneity persists for several factors. The limited number of studies within each infection-type subgroup restricted the power to detect subtle effect modifications. Moreover, the included studies span more than two decades, and ECMO technology has advanced rapidly, particularly after 2020; this may introduce temporal bias due to developments in extracorporeal membrane oxygenation technology and critical care practices. Prospective, multicenter studies using consensus infection definitions are essential to validate these findings.

  Risk factors for nosocomial infections in ECMO patients: a systematic review and meta-analysis · 2026 · DOI

• Clinical heterogeneity among patients with bacterial pneumonia. Difficulty in identifying pathological markers that predict therapeutic response and disease progression. Need for a comprehensive systematic review and meta-analysis of the existing literature.

  A Systematic Review and Meta-analysis on Correlation Between Histopathological Lung Findings and Antibiotic Response in Bacterial Pneumonia · 2026 · DOI

• There is a need for a comprehensive systematic review and meta-analysis of the association between histopathological lung findings and antibiotic response in bacterial pneumonia. Prior studies have reported inconsistent findings, and a comprehensive review is needed to synthesize the existing literature.

  A Systematic Review and Meta-analysis on Correlation Between Histopathological Lung Findings and Antibiotic Response in Bacterial Pneumonia · 2026 · DOI

• The incidence and microbiological characteristics of COVID-19 associated VAP remain a clinical concern. The exact impact of VAP on mortality remains controversial.

  Ventilator-associated pneumonia in an intensive care unit: A comparative analysis of clinical and microbiological characteristics of COVID-19 and non-COVID-19 patients · 2026 · DOI

Most-cited papers in Nosocomial Infections in ICU

• An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU · New England Journal of Medicine · 2006 · 3,451 citations
• Multistate Point-Prevalence Survey of Health Care–Associated Infections · New England Journal of Medicine · 2014 · 3,404 citations
• International Study of the Prevalence and Outcomes of Infection in Intensive Care Units · JAMA · 2009 · 2,850 citations
• Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002 · Public Health Reports · 2007 · 2,240 citations
• The Prevalence of Nosocomial Infection in Intensive Care Units in Europe · JAMA · 1995 · 2,231 citations
• THE EFFICACY OF INFECTION SURVEILLANCE AND CONTROL PROGRAMS IN PREVENTING NOSOCOMIAL INFECTIONS IN US HOSPITALS · American Journal of Epidemiology · 1985 · 1,530 citations
• Comparison of 8 vs 15 Days of Antibiotic Therapy for Ventilator-Associated Pneumonia in Adults · JAMA · 2003 · 1,143 citations
• Prevalence and Outcomes of Infection Among Patients in Intensive Care Units in 2017 · JAMA · 2020 · 834 citations
• Oral Care Reduces Pneumonia in Older Patients in Nursing Homes · Journal of the American Geriatrics Society · 2002 · 644 citations
• Timing of Antibiotic Administration and Outcomes for Medicare Patients Hospitalized With Community-Acquired Pneumonia · Archives of Internal Medicine · 2004 · 610 citations

Most recent work

• Selective Decontamination of the Digestive Tract during Ventilation in the ICU · New England Journal of Medicine · 2026
• Effectiveness of oral care for the prevention of non-ventilator hospital-acquired pneumonia (HAPPEN): a multicentre, stepped-wedge, cluster-randomised trial in Australia · The Lancet Infectious Diseases · 2026
• Ventilator-associated pneumonia and prior antibiotic exposure in intubated patients due to depressed consciousness · Medicina Intensiva · 2026
• Racial and Ethnic Disparities in Length of Stay for Pediatric Bacterial Tracheostomy-Associated Infections · Hospital Pediatrics · 2026
• Bayesian network model for identification of factors associated with ventilator-associated pneumonia in mechanically ventilated patients in the ICU: retrospective cohort study · BMC Pulmonary Medicine · 2026
• Azithromycin for Preschoolers with Wheezing in the Emergency Department · New England Journal of Medicine · 2026
• Questions and issues of nonventilated hospital-acquired pneumonia: an opinion document · Clinical Microbiology and Infection · 2026
• Integrating Oral Care Into Nurse‐Led Models: A Critical Step to Reduce Pneumonia in Older Adults · Journal of the American Geriatrics Society · 2026
• Impact of Adjuvant Oral Care on Clinical Outcomes in Mechanically Ventilated ICU Patients: A Randomized Controlled Trial · Medical Forum Monthly · 2026
• Risk factors, predictive biomarkers, and microbial profile of ventilator-associated pneumonia in critically ill patients: a retrospective cohort Study · BMC Pulmonary Medicine · 2026

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