Structured sterile pathway and reduced hospital-acquired infections in resource-constrained oncology care: A pre-post study

Abstract

Objective: To evaluate whether a structured sterile pathway incorporating portable dual-mechanism HEPA-ionization devices can achieve equivalent protective environment standards and reduce healthcare-associated infections (HAIs) in an oncology unit lacking fixed HEPA infrastructure.

Methodology: A single-centre, pre-post quasi-experimental study was carried out at Ittefaq Hospital Trust, Lahore (January to December 2025).  A four-component pathway was implemented in a seven-bed oncology unit: zone-based controls using portable Plasmacluster devices (True HEPA H13 plus ion-mediated inactivation), staff education, WHO Five Moments hand-hygiene auditing, and PPE monitoring. Phase one (n=142) used standard air-conditioned rooms without purification; Phase two (n=138) added the full pathway. The primary outcome was HAI rate per 1,000 patient-days (CDC/NHSN); air and surface colony counts were sampled on days 1, 7, 14, 30 and 60 of each phase.

Results: Across 280 admissions, the HAI rate fell sharply from 8.4 to 2.6 per 1,000 patient-days—a 69.0% reduction (RR 0.31, 95% CI 0.19–0.51; p<0.001). CLABSI fell from 3.2 to 0.8 per 1,000 line-days (p=0.003) and CAUTI from 2.1 to 1.1 (p=0.012). Mean air changes per hour rose from 5.2 to 13.8, reaching the ASHRAE 170-2021 benchmark, and median PM2.5 fell from 44.8 to 7.3 µg/m³. Air and surface colony counts dropped by 89.1% and 91.5% (both p<0.001), with airborne Aspergillus eliminated by the second month.

Conclusions:Implementation of the four-component sterile pathway was associated with attainment of the ASHRAE 170-2021 minimum air-change threshold, a 69% lower HAI rate and no recovery of clinically significant environmental pathogens, at a total implementation cost of US$2,030. Because the components were introduced together in an uncontrolled pre-post design, these findings support the pathway as a whole rather than any single component, and need confirmation in controlled studies.