Healthcare is meant to cure and care for patients, but unfortunately invasive devices and procedures also form a risk for patients to acquire infections. This type of infection is termed nosocomial or healthcare‐associated infections (HAI) and they increase morbidity and mortality. In this thesis, HAI will usually refer more specifically to hospital‐associated infections. Time spent in a hospital can itself be a risk factor for HAI, as certain pathogens are more concentrated than in the community and may have evolved resistance to antibiotics due to antibiotic selection pressure. The aim of this thesis is to describe achievements in HAI prevention over the last two decades, as measured through surveillance, and the role of the promotion of best practices. In the latter the emphasis is on central venous catheter‐related bloodstream infection (CRBSI) – prevention bundles, and hand hygiene. 1.1 Prevention of hospital infections in historical perspective During millennia of human history, in times of conflict or peace, people have suffered injuries and diseases that needed medical attention. In medieval Europe, treatment in infirmaries and sick‐houses was often a death sentence, with gastroenteritis and louse‐ borne typhus (“hospital fever”) infesting the crowded wards, where beds were usually shared. Neither surgical tools nor hands or gowns were cleaned or changed, and postsurgical mortality rates of 60‐80% were common, mostly due to infectious gangrene [1]. The second half of the 19th century was, however, an era of many scientific achievements. Even before the exact nature of infections was understood or accepted, the importance of hygiene (“cleanliness”) became increasingly acknowledged and led to improvements [2, 3]. The discovery of the role of micro‐organisms laid the foundations of “germ‐theory”, which led to sterilisation of surgical tools and bandages and, consequently, decreasing rates of infection and mortality [1, 3]. Semmelweis, Pasteur, Koch, Lister and Nightingale were the well‐known pioneers in the field of infection prevention. Other advances in health technology that ensured safer healthcare and surgery were the introduction of X‐ray units in hospitals, intravenous fluid therapy and clinical thermometry [1], and anaesthesia in surgery (although initially it increased risk as it allowed surgery to last longer) [6]. While infection prevention improved, infection treatment did not progress until the first half of the last century, when penicillin, discovered in 1928, was introduced in patient care and other antibiotics followed [4]. Despite the hope of some that this would spell the end for infectious diseases, antimicrobial resistance evolved almost instantaneously. Hospital outbreaks and indeed a pandemic of a single lineage of penicillin‐resistant Staphylococcus aureus followed within a single decade after the widespread introduction of penicillin. This set the stage for professional hospital 1 9 Introduction
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