general and/or with MDRO is lower, and/or when acquisition and/or transmission of MDRO is lower compared to the old hospital. This overarching hypothesis could be divided into several sub-hypotheses; first, 100% single-occupancy rooms will decrease the risk on the acquisition of MDRO during hospitalization as direct patient to patient transmission between roommates cannot occur in single-occupancy rooms. Research has indicated that there is a significant relation between being exposed to roommates and acquisition of microorganisms, especially for the same microorganism the roommate was colonized with (15, 16). Although a number of studies have been performed on the effect of single-occupancy rooms on acquisition of MDRO, and consequently the impact on HAI, literature is conflicted on the added benefit of single-occupancy rooms on IPC (14). While several studies showed a significant reduction in healthcare-associated colonization with MDRO after transitioning to mainly or only singleoccupancy rooms (17-22), some studies showed no effect (23-25). The majority of the studies were performed on pediatric or adult ICUs or on a neonatology department (17-19, 21, 22, 24). Furthermore, only four studies studied the transition to 100% single-occupancy rooms (18-21). A recent study of McDonald et al., looked at the effect of relocating to a newly constructed building with only single-occupancy rooms on colonization and infection rates (26). They identified a decrease in colonization and infection rates with VRE and MRSA colonization, but not for MRSA and Clostridioides difficile infections. Overall, the effect of single-occupancy rooms on general wards on acquisition is lacking, specifically for ESBL-E and CPE. Besides the elimination of transmission from roommates and the shared environment, introducing single-occupancy rooms eliminates specific reasons for intra-hospital patient transfers (i.e., transferring patients from one patient room to another patient room in the same hospital). For example, intra-hospital patient transfers for small procedures, social circumstances, or for contact isolation will no longer be essential (27). The number of intrahospital patient transfers on an ICU after transitioning to single-occupancy rooms was reduced by 90% (12). The hypothesis is that the number of intra-hospital patient transfers will decrease by the transition to 100% single-occupancy rooms. Limiting the number of intra-hospital patient transfers leads to less exposure of the patient to different hospital environments or in short; the patient is exposed to less square meters of the hospital environment. This potential reduction of exposure to different hospital environments, could also lead to a reduced risk of MDRO acquisition and transmission (28). In this thesis (chapter 2.1), we aim to determine the effect of transitioning to 100% singleoccupancy rooms on the odds on acquiring an ESBL-E during hospitalization. Additionally, we aim to determine the effect on the number of intra-hospital patient transfer. A second hypothesis is that implementation of 100% single-occupancy rooms could lead to lower environmental contamination rates. This is based on the assumption that, since there 1 13 General introduction
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