1 INTRODUCTION

Infection prevention and control (IPC) is the taking of effective measures and nonpharmaceutical interventions to reduce the spread of illnesses such as coronavirus disease 2019 (COVID-19) and is an essential prerequisite for general medical treatment [1, 2]. Infection prevention and control professionals (IPCPs) have dual managerial and operational responsibilities [3]. The World Health Organization (WHO) publication, “Minimum requirements for infection prevention and control programmes” describes the minimum requirements for IPC programs at the national level [4]. However, despite this publication, significant gaps remain in practice around the world. A survey of 106 countries about the national minimum standards for IPC showed that only four countries met the WHO requirements [5]. In another survey, only five (45.45%) of the 11 nations studied had IPC physician training programs [6]. In a separate study of 20 low-income countries, only nine countries (45%) had a national IPC program, only four (20%) reported the existence of documents on implementing IPC strategies, and only one (5%) monitored adherence to IPC practices, highlighting deficits in IPC management systems and leadership [7]. A study of 65 hospitals found that 17 (26.15%) showed insufficient microbiological and surveillance capability for IPC [8]. The same situation exists in China. For example, a study there found that only 24.03% of IPCPs had enough knowledge to be prepared to face the COVID-19 pandemic, indicating deficiencies in education and training resources [9]. The Chinese IPC program has advanced significantly, but further training and educational resources are still needed. Other gaps include insufficient functioning IPC programs with annual work plans, lack of expertise in conducting IPC monitoring, inadequate IPC training, need for construction of a COVID-19-safe environment, and need to secure adequate IPC supplies, particularly personal protective equipment (PPE) [4].

COVID-19 no longer constitutes a public health emergency of international concern, but the pandemic provided insights into where current IPC efforts are working or insufficient. We conducted a systematic scoping review of lessons from the pandemic and carried out cluster analysis to provide practice recommendations for IPCP training and core competencies.

2 METHODS

3 RESULTS

3.1 Literature search

The initial database search yielded 383 unique citations, of which nine were from PubMed, 10 from Embase, two from the Cochrane Library, 193 from Web of Science, 158 from CNKI, five from WanFang Data, and six from CBM. Fifteen duplicates were removed. After excluding studies whose titles and abstracts suggested that they did not meet the inclusion criteria, 58 publications remained. Of these, 10 had limited data and two were inappropriate types of paper. The final meta-analysis therefore included 46 eligible studies. The list of excluded studies and the reasons for their exclusion are shown in Figure 1.

3.3 Technical terms related to IPCPs' core competencies

Overall, 39 technical terms related to IPCPs' core competencies were extracted in this study, including four words with a frequency of two and six words with a frequency of one. Using the Donohue formula, the threshold of the high-frequency terms was defined as 3 (T  =  3), indicating that the high-frequency terms should occur more than twice. This gave a total of 29 high-frequency technical terms. Some of these had similar meanings, and we therefore added them together. Other terms were not included because of their relatively low frequency but were still considered.

Figure 2 shows that “IPC training” occurred with the highest frequency (184 times, 17.3%), followed by “hand hygiene” (172 times, 16.2%). The least common phrase was “pre-checking and triage” (three times, 0.3%). The core competency category “IPC in clinical practice” contained the highest number of high-frequency terms (13), and “education” contained the lowest number (one). A higher frequency suggests that this competency is more valued. The importance of these low-frequency competencies should thus be strengthened in future research and clinical practice.

The innermost blue part of the circular Manhattan plot indicates the five core competencies of IPCPs. The multicolored middle layer shows all the high-frequency terms categorized into the five core competencies. The numbers show the total frequency and proportion of the total of each high-frequency term. The legends top to bottom and left to right correspond to the frequency data from most to least.

Figure 3 shows that the core competency “IPC in clinical practice” had the highest frequency (367 times, 34.5%), followed by “Microbiology and surveillance” (292 times, 27.5%). The frequency of “Patient safety and occupational health” was the lowest (99 times, 9.3%). The maximum frequency (“IPC in clinical practice”) was 73% higher than the minimum frequency (“Patient safety and occupational health”). This suggests that IPC in clinical practice is widely understood, and a focus. However, patient safety and occupational health are of less concern, and may even be ignored. The lower the frequency, the less that competence is discussed, indicating areas for development. We found significant differences among the five core competencies of IPCPs, highlighting varying levels of attention on these competences.

3.4 Cluster analysis

The results of the cluster analysis are shown in Figure 4 and Supporting Information S1: Table S3. With a distance threshold of 20, the cluster analysis identified two core competency categories: Category 1: IPC program management and leadership, Patient safety and occupational health, Education, and Microbiology and surveillance; and Category 2: IPC in clinical practice. The clustering coefficient was 5669.

A detailed explanation of the competences is shown in Table 3.

Table 3. A detailed explanation of the five core competencies.

Category	IPCPs' core competencies	Detailed explanation
Category 1	IPC program management and leadership	Use management strategies and leadership to plan and operationalize an IPC program, develop evidence-based IPC guidelines, standard operating protocols, training resources and monitoring tools, and undertake monitoring and feedback of adherence to guidelines and recommendations. Support the achievement of adequate infrastructure for water, sanitation and hygiene and IPC and procurement of supplies. Assess the infection risks related to building design, construction and renovation, and provide guidance based on IPC principles. Use communication skills to interact with teams, senior management, patients and families, and other audiences [55].
	Microbiology and surveillance	A coherent set of actions to promote the responsible use of antimicrobials. The primary goal of antimicrobial stewardship is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms (such as Clostridium difficile), and the emergence of resistance [56]. Facility-based healthcare-acquired infection (HAI) surveillance should be performed to guide IPC interventions and detect outbreaks, including antimicrobial resistance surveillance, with timely feedback of results to healthcare workers and stakeholders and through national networks [4].
	Education	IPC education should be in place for all healthcare workers by using team- and task-based strategies that are participatory and include bedside and simulation training to reduce the risk of HAI and antimicrobial resistance [4].
	Patient safety and occupational health	Demonstrate an understanding of the key principles of quality and patient safety and of the epidemiology, burden of risk factors and causes of adverse events, near-misses, accidents, and dangerous incidents in healthcare. Contribute to designing, developing, implementing, and evaluating quality improvement and patient safety programs. Understand the infection risks related to employment and support the implementation of appropriate preventive measures to provide a safe environment and healthy workforce [11].
Category 2	IPC in clinical practice	Standard precautions	A set of activities designed to prevent the transmission of organisms between patients/staff for the prevention of HAI. They must be applied to all patients who require healthcare, by all healthcare workers in all healthcare settings. They include hand hygiene; use of PPE; handling and disposal of waste and sharps; handling and management of clean and used linen; environmental cleaning; and decontamination of equipment [57].
		Transmission-based precautions	Additional measures focused on the specific mode of transmission of the microorganism and always used in addition to standard precautions. They are grouped into categories according to the route of transmission of the infectious agent. Transmission-based precautions should be applied when caring for patients with known infections, patients who are colonized with an infectious organism and asymptomatic patients who are suspected of/under investigation for colonization or infection with an infectious microorganism [58].
		Decontamination and reprocessing of medical devices and equipment	All steps that are necessary to make a contaminated reusable medical device ready for its intended use. These steps may include cleaning, functional testing, packaging, labeling, disinfection, and sterilization [59].
		Catheter-associated blood-stream infection prevention	Understand the epidemiology, risk factors, burden, clinical presentation, and complications of catheter-associated bloodstream infections, catheter-associated urinary tract infections, surgical site infections, and healthcare-associated pneumonia, use evidence-based guidelines for prevention, and monitor the implementation of IPC measures [60].
		Catheter-associated urinary tract infection prevention
		Surgical site infection prevention
		Prevention of healthcare-associated pneumonia
		Healthcare-associated outbreak prevention and management	Prevent, detect, manage, and control healthcare-associated outbreaks. Conduct IPC training activities and develop effective communications during outbreaks in healthcare facilities [61].
		COVID-19 blood tests	COVID-19 blood tests and related treatments are more effective when the budget, IPCP education level, and national development level are high [62].

• Abbreviations: COVID-19, coronavirus disease 2019; HAI, healthcare-associated infection; IPC, infection prevention and control; PPE, personal protective equipment.

4 DISCUSSION

Among the core competencies of IPCPs, it is particularly important to focus on IPC program management and leadership, microbiology and surveillance, education, and patient safety and occupational health. To enable IPCPs to cope with emerging infectious diseases with unknown causes or to prevent and control infections in hospitals, they should preferentially conduct microbiological surveillance backed up by multiple means, and ensure that they keep learning and attending training.

IPC in clinical practice is a comprehensive and highly regarded skill with many facets, including recognizing the risk of healthcare-acquired infections (HAIs), combining multiple approaches to IPC in clinical practice, and appraisal of outcomes. A prospective study found that a comprehensive hospital infection control strategy could successfully prevent infection among IPCPs, suggesting the importance of IPC program management and leadership [43]. Risk stratification models used in clinical practice can identify high-risk patients and assist nursing teams to manage resources including interventions, hospital beds, and staffing [63]. The clinical practice element of IPC, including but not limited to PPE usage guidelines and antimicrobial stewardship, patient monitoring, environmental surveillance, environmental cleaning and disinfection, and hand hygiene, plays an important role [43, 64].

We also found that the five core competencies are tightly linked. A cross-sectional study in four community hospitals in ‎California found that the number of multidrug-resistant organisms could be decreased by providing additional education to IPCPs about appropriate PPE usage and the importance of hand hygiene, highlighting the capacity of education to improve microbiological surveillance [25]. A large-scale London hospital group developed the “PPE Helper Program”, which provided IPCPs with PPE support and education [54]. Enrolled workers had higher skills than their non-enrolled peers in using PPE appropriately (82.5% vs. 56.5%) [54]. A multicountry survey of 262 IPCPs of 10 nationalities showed that those who had received antimicrobial resistance training had significantly higher scores than those who had not [37].

This study has some limitations. First, this article focuses on the priorities for developing core competencies during the COVID-19 pandemic. The literature from before the pandemic was not included in the analysis, and thus the conclusion has time limitations. Further research is needed to combine our findings with the literature from before the pandemic. Second, the study did not consider factors such as the varying levels of medical resources in different areas, different educational backgrounds, or the job tenure of IPCPs. For example, different countries and regions have different levels of medical resources, and the equipment and health conditions provided during the pandemic were very different. The education level of IPCPs in different medical institutions is also inconsistent, resulting in different response speeds to disease prevention and COVID-19. IPCPs with greater experience may be better able to make quick judgments about the severity of an outbreak [65]. In future studies, these factors should be examined in different cases to expand the results. Nevertheless, the identified core competencies could provide a development path for junior IPCPs to rapidly improve their competencies. They could also enable advanced IPCPs to improve their capabilities.

5 CONCLUSION

Our study summarized the five core competencies of IPCPs during the pandemic and divided them into two categories. We identified four competences in particular for prioritization. These were IPC program management and leadership, microbiology and surveillance, education, and patient safety and occupational health. We suggest that the future training of IPCP personnel should take these four competences as a clear entry point for improving abilities. It is particularly important to focus on the leadership role of senior managers, strengthening communication with patients and their families, correctly using antibacterial drugs, and focusing on patients and their health, especially to reduce the rate of HAIs.

AUTHOR CONTRIBUTIONS

Nuo Chen: Conceptualization and writing—original draft. Shunning Li: Writing—original draft and methodology. Zhengling Kuang: Writing—original draft and software. Ting Gong: Writing—original draft and data curation. Weilong Zhou: Formal analysis and supervision. Ying Wang: Writing—review and editing and supervision.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ETHICS STATEMENT

Ethics approval was waived for this study because no patient data were reported.

INFORMED CONSENT

The need for informed consent was waived for this study because no new patient data were reported.