An important role of public health agencies is to define the unacceptable. This concept has particular relevance for healthcare-associated infections. Evidence indicates that, with focused efforts, these once-formidable infections can be greatly reduced in number, leading to a new normal for healthcare-associated infections as rare, unacceptable events.

The past decade has witnessed an intense interest in healthcare-associated infections as well as increases in legislation and reporting requirements aimed at decreasing the number of these costly infections. In the next decade, healthcare epidemiology must address major gaps in understanding of the epidemiology and pathogenesis of healthcare-associated infections and in knowledge of the efficacy of interventions for healthcare-associated infections and the efficacy in implementing such interventions.

The ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) are responsible for a substantial percentage of nosocomial infections in the modern hospital and represent the vast majority of isolates whose resistance to antimicrobial agents presents serious therapeutic dilemmas for physicians. Over the years, improved molecular biology techniques have led to detailed information about individual resistance mechanisms in all these pathogens. However, there remains a lack of compelling data on the interplay between resistance mechanisms and between the bacteria themselves. In addition, data on the impact of clinical interventions to decrease the prevalence of resistance are also lacking. The difficulty in identifying novel antimicrobial agents with reliable activity against these pathogens argues for an augmentation of research in the basic and population science of resistance, as well as careful studies to identify optimal strategies for infection control and antimicrobial use.

During the past 2 decades, Europe has made substantial progress in the prevention and control of hospital-acquired infections and antimicrobial resistance (eg, through multicenter trials, international surveillance networks, and hand hygiene initiatives). This short overview highlights recent advances and future priorities in infection prevention research, including methodological challenges to be addressed.

Implementing evidence-based infection prevention practices is challenging. Implementation science, which is the study of methods promoting the uptake of evidence into practice, addresses the gap between theory and practice. Just as healthcare epidemiology has emerged as a paradigm for patient safety, infection prevention may serve as a clinical model for implementation researchers.

Multidrug resistant organisms (MDROs) and healthcare-associated infections (HAIs) are associated with increased lengths of hospital stay, increased costs, and increased mortality. We explore the scope of MDRO HAIs in children, current MDRO HAI prevention practices and data to support these practices, and we propose research topics targeting MDRO HAI prevention in children.

Viral respiratory infections pose a significant challenge to pediatric infection prevention programs. We explore issues regarding the prevention of viral respiratory infections by discussing transmission of influenza A virus, isolation of infected patients, and hospital programs for influenza vaccination.

Central line–associated bloodstream infections cause morbidity and mortality in children. We explore the evidence for prevention of central line–associated bloodstream infections in children, assess current practices, and propose research topics to improve prevention strategies.

The past decade has been characterized by an epidemic of Clostridium difficile infection in North America and Europe that threatens to extend to the rest of the world. The epidemic is due in part to the emergence of a previously rare and now more lethal C. difficile strain variously named group BI, ribotype 027, and North American pulsed-field gel electrophoresis type 1.

There has been a recent surge of interest in Clostridium difficile infection, which reflects an impressive increase in the number and severity of these infections. This review addresses some of the newer methods for detection of C. difficile infection at the bedside and in the laboratory. Particularly important are the new rapid diagnostic tests that detect toxigenic C. difficile using polymerase chain reaction and the combination tests that, either simultaneously or sequentially, screen for C. difficile and test for toxins A and B. It is expected that these new testing methods will largely supplant the enzyme immunoassays for toxins, which are used by most laboratories, departments, and divisions. The present goal is to combine clinical, laboratory, and animal research related to C. difficile that reflects issues that are considered to be major contemporary challenges. Among this work is the pursuit of studies of immune mechanisms to better control this disease.

Prevention of Clostridium difficile infection has become extremely important because of increases in its incidence and severity. Unfortunately, efforts at C. difficile infection prevention are hampered by lack of data to support optimal prevention methods, especially for endemic C. difficile infection. Studies are needed to define the optimal prevention practices and to investigate novel prevention methods.

Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of disease across Europe, except for Scandinavian countries and the Netherlands. Recently, MRSA incidence has decreased in many European countries following national interventions, including structural and regulatory changes in health care, promotion of hand hygiene, antibiotic stewardship, and targeted screening, isolation, and decolonization of hospitalized carriers of MRSA.

Development of an effective vaccine against Staphylococcus aureus would provide great potential public health benefit. We present a brief overview of the current knowledge in this field, with emphasis on present challenges and lessons learned, together with a summary of vaccines and immunoglobulin preparations currently under investigation.

How the media communicate and how the scientific community influences the media are important factors to consider in the public health response to emerging pathogens, including methicillin-resistant Staphylococcus aureus. Social representation theory suggests that the media link “the threatening” to commonplace “anchor representations,” which can serve to educate or to create fear.

Gram-negative bacilli are an important cause of infection in healthcare and community settings. Antimicrobial resistance, including resistance to multiple antimicrobial classes, is an ongoing problem among gram-negative bacilli. This synopsis reviews the incidence of multidrug resistance among gram-negative bacilli in the United States and describes emerging issues in their epidemiology.

Development of antibiotics to treat infections caused by multidrug-resistant gram-negative bacilli has lagged significantly behind development of antibiotics to treat infections with gram-positive pathogens. Although a few promising drugs have entered early clinical development, more must be done to preserve the utility of currently available antibiotics and to ensure a pipeline of efficacious, safe antibacterials.

The H1N1 influenza pandemic provided a real-world test of hospital disaster plans. Challenges to hospitals included inconsistent use of isolation precautions; changing and conflicting guidelines; lack of available supplies, including N95 respirators and medications; and overwhelming amounts of information that required sifting. Further research is needed regarding pandemic planning.

My experience as a hospital epidemiologist at the National Institutes of Health Clinical Center has underscored the importance of aggressively managing infection with opportunistic pathogens and of taking advantage of opportunities as they arise (most often as crises). I review selected aspects of my career and use these as examples of the opportunists and opportunities now facing healthcare epidemiology.

Outbreaks of healthcare-associated infections have long played a critical role in both identification and mitigation of emerging challenges in health care. This article describes some of the most influential outbreaks of healthcare-associated infections in the past decade that serve as excellent illustrations of this point.