achieved risk reductions over 1990‐2002 and estimated that 20% of HAI were preventable, peaking up to 70% for catheter‐related bacteraemia [70]. Later reviews of intervention studies often came up with similar or even higher proportions [25] [71, 72]. A more recent meta‐analysis by Schreiber et al., including papers from 2005‐2016 concluded that 35‐55% may be preventable[73]. A drawback of this approach, especially when a long time‐period is evaluated, is that it ignores the fact that medical knowledge advances in time, and with this the possibilities to prevent HAI and the associated morbidity and mortality. Therefore, this retrospective assessment may lead to an overestimation of the preventable proportion of HAI and its consequences. With best practices implemented in a growing number of hospitals, the proportion of preventable HAI may decrease over time [74]. Endogenous factors contributing to HAI remain and are more difficult to influence. Another aspect evaluated during the HAI‐Net mortality review was the contribution of antimicrobial resistance (AMR), if present. For micro‐organisms with the AMR phenotypes under surveillance, AMR “possibly” or “definitely” contributed to death in 65% cases. AMR increased the risk of inappropriate empirical antibiotic therapy, which is associated with worse patient outcomes [75]. In a large US database of patients with BSIs (not necessarily hospital‐onset), 19% received discordant empirical antibiotic therapy. The odds of receiving discordant therapy was 9.1 (95% CI [7.7‐10.8]) in cases of infection with an antibiotic‐resistant pathogen. Inappropriate therapy was associated with increased mortality [76]. This increased mortality risk was not affected by resistance in itself. None of the Dutch cases in chapter 6 were caused by one of the AMR phenotypes in the protocol (data not shown in the paper). In a Dutch study in eight hospitals, the attributable mortality of resistant and susceptible gram‐negative infections was comparable [77]. The number of people dying of AMR each year in the Netherlands is considered low [78], but may be underestimated as this is not systematically reported. In 2015 the Dutch Ministry of Public health, Welfare and Sports initiated an extensive programme to contain antimicrobial resistance [79]. Does the limited number of deaths warrant the huge effort and cost that has since been invested in initiatives to prevent antimicrobial resistance in human healthcare in the Netherlands? Certainly, the predicted number of deaths on a global scale is of a different order [80], but infections with AMR pathogens in the Netherlands are relatively rare and trends with most pathogens are now stable [81, 82]. Developments in AMR have, however, shown clearly that AMR is not solely a problem of hospitals and other aspects of human healthcare. Large‐scale antibiotic use in animal husbandry increased the prevalence of AMR in this sector, including the persons working in it and further in the food chain[80]. So far, the 246 Chapter 10
RkJQdWJsaXNoZXIy MTk4NDMw