year. Outside the ICU, the CRBSI risk decreased with increasing compliance but was not additionally reduced with ongoing participation or calendar time. Evaluation of all hospitals in the surveillance, with the above‐mentioned reservation as to the variable pool of participants, found apparent reduction outside the ICU as well (figure 1 in chapter 9). In 2019 the average risk in the ICU of the 21 participating hospitals was 0.5/1000 CVC days and outside the ICU it was 2.7/1000 CVC days. The DHPSP not only advocated a CRBSI bundle but also an SSI bundle. Higher SSI bundle adherence appeared to lead to declining SSI rates as well [28]. VAP rates likewise seem to have improved, as the average incidence density was 25/1000 ventilator days in the ICU surveillance and 10.3/1000 in the VAP surveillance (8.6% of the patients). Firm conclusions cannot be based on these results, as few hospitals participated in VAP surveillance, and pneumonias were considered ventilator‐associated only when a patient was ventilated for at least 48 hours versus 24 hours in the ICU surveillance. Of patients in eight Dutch hospitals, admitted in 2017‐2019, without acute respiratory distress syndrome and expected to be ventilated for at least 24 hours, 2.1% developed “suspected” VAP (1.3% when restricted to microbiologically confirmed VAP), which suggests further improvement [29]. The point prevalence surveys (PPS) conducted since 2007 also suggest a decrease in patients with VAP, notwithstanding the less specific denominator data: from 0.7% and 0.5% in 2007 and 2008, to 0.2% and 0.1% in 2018 and 2019 (prevalence of all patients, unpublished data). Hopmans et al. reported an unadjusted OR per calendar year of 0.97 (95%CI [0.95‐0.99]) in the period 2007‐2016 for the total of lower respiratory tract infections [30]. With a reduction in SSI, CRBSI and VAP, it comes as no surprise that the overall prevalence of HAI decreased too. The prevalence of patients with HAI onset during hospitalisation decreased from 6.1% in 2007 (when the PPS was first organised) to 3.6% in 2016 [30]. The adjusted OR for yearly reduction until 2016 was 0.97 (95% CI [0.96 ‐ 0.98]). The most prominent trends were seen for UTIs from 2.1% to 0.6% (unadjusted OR per year 0.85 [0.83‐0.97]); CRBSIs from 0.3% to 0.1% (OR 0.90 [0.87‐0.94]) and SSI from 1.6% to 0.8% (OR 0.91 [0.90‐0.93]) [30]. As explained by Hopmans et al., the decrease in HAI prevalence may in part be attributed to the simultaneous decrease in length of stay (until the survey day) and to the declining percentage of patients undergoing surgery. The mean length of stay has since then not decreased further (yearly mean range 7.2‐7.8 days in 2013‐2019). The percentage having surgery remained stable too (around 30% overall). Obviously one can only go so far in discharging patients earlier during their convalescence, and this and the stable percentage of surgery patients may in part explain why HAI prevalence did not decrease further but remained approximately 5% [31]. 10 241 General Discussion
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