Horizontal versus vertical strategies for infection prevention: current practices and controversies

Healthcare-associated infections (HAIs) represent a major burden on healthcare facilities. Effective infection prevention strategies are essential to prevent the spread of HAIs. These can be broadly classified as vertical and horizontal interventions. Through this review, we aim to assess the merits of these strategies.

Vertical strategies include active surveillance testing and isolation for patients infected or colonized with a particular organism. These strategies are beneficial to curb the spread of emerging pathogens and during outbreaks. However, the routine use of contact precautions for organisms such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus remains controversial. Horizontal interventions are larger-scale and reduce HAIs by targeting a common mode of transmission shared by multiple organisms. Among these, hand hygiene, chlorhexidine gluconate bathing of select patients and environmental decontamination are the most high-yield and must be incorporated into infection prevention programs. As antimicrobial stewardship is also an effective horizontal strategy, antimicrobial stewardship programs must operate in synergy with infection prevention programs for maximal impact.

Overall, horizontal interventions are considered more cost-effective and have a broader impact. Infection control programs may opt for a combination of vertical and horizontal strategies based on local epidemiology and available resources.