infection control programmes, which were first initiated in the 1950s in the UK and the USA [1, 5]. In the Netherlands, the Dutch government asked the Health Council for advice on this matter and, starting with the Council’s report in 1966, infection prevention and control in hospitals acquired a legal basis through several laws and guidelines [6]. In the 1960s the Centers for Disease Control (CDC) in the USA recommended hospitals to perform surveillance of HAI, to inform the development of control measures. Since 1970 the CDC has coordinated surveillance of HAI in a group of voluntarily cooperating hospitals known as the National Nosocomial Infections Surveillance (NNIS) system [7]. In the 1970s, the CDC‐initiated study on the efficacy of nosocomial infection control (SENIC) concluded that organised surveillance and control activities in a multimodal infection prevention and control programme could reduce HAI rates by one third [5]; since then, surveillance of healthcare‐associated infections is considered a cornerstone of prevention and control [8]. The monitoring of HAI rates has increased awareness and improved insight into patients at increased risk, enabling targeted interventions. Subsequently, interventions could also be evaluated for their effectiveness. To this day, continuous surveillance initiatives facilitate feedback and have improved institutionalised healthcare (Plan‐Do‐ Check‐Act). Moreover, sufficiently standardised surveillance programmes allow for the benchmarking of institutions as an incentive and a means of quality assessment. 1.2 HAI: current incidence and etiology At present, the most frequently diagnosed HAI in the Netherlands are surgical site infections (SSI), lower respiratory tract infections including pneumonia, bacteraemia, and urinary tract infections (UTI). Clostridioides difficile infection (CDI) is the dominant type of gastrointestinal HAI and can severely affect hospitalised patients [9, 10]. In point prevalence surveys during 2017‐2019, the three years preceding the COVID‐19 pandemic, the prevalence of SSI was 1.7% (95% confidence interval (CI) 1.6‐1.8), of pneumonia 1.1% (1.0‐1.2), of bacteraemia 0.9% (0.8‐1.0) and of symptomatic UTI 0.8% (0.7‐0.9). C. difficile was the responsible micro‐organism in 37% of the hospital‐associated gastrointestinal infections [11]. The acquisition of HAI is influenced by endogenous and exogenous risk factors. Advanced age, acute or chronic illness, impairment of organ functions, or metabolic disturbances, as well as disruption of individual microbiomes or reduced immunity are endogenous factors that additionally increase exposure to exogenous risk factors. The latter includes frequent hospital admissions, diagnostic and/or therapeutic interventions and repeated antibiotic therapy. Institutional factors such as ‐ but not limited to ‐ infection prevention practices and behaviour of healthcare workers (HCW) add 10 Chapter 1
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