Discussion Through our survey, we sought to gain insight into current environmental sampling practices. The results indicate that there is great variability in sampling practices, both within and between countries. Whereas the literature is focused mainly on sampling to identify the source of an ongoing outbreak, specifically for outbreaks caused by multidrug resistant microorganisms, respondents also indicated that routine environmental sampling takes place. Eighty-nine respondents filled in the survey, but response rates differed with each question. The highest sampling rates were found for CPE, with the exception of the Netherlands, perhaps because CPE is less prevalent there than in other countries (6). Though it was to be expected that, without current guidelines, there would be differences in sampling procedures between countries, there was still a lot of diversity even within countries, specifically for which sample sites to be assessed. Although there was some consensus within countries on which sites were never sampled (e.g. the privacy curtain), there was no consensus on which sites needed to be sampled. A possible explanation could be that the majority of respondents decided on locations to be sampled prior to entering the area, but also then changed some of these or added others while in that area. Consequently, sampling practices may differ with each sampling occasion. It may be that for this survey, respondents only reported locations that are determined prior to entering the area. Flocked and cotton swabs were the most preferred sampling method, which is unsurprising, since they are the most frequently used sampling method in the literature (5). This could be explained by the fact that they can be used to sample every type of surface, their affordability, and because they are readily available in most hospitals. However, standardization of sampling methods is difficult, leading to variations in recovery rates and non-comparable results (7). Sampling was most common for CPE, and this may be explained by national epidemiology, e.g. in Ireland, a national public health emergency was declared in 2017 to address CPE and acute hospitals undertake a nationally mandated programme of extensive patient screening to prevent CPE becoming endemic (8, 9). However, sampling rates in the Netherlands were highest for VRE. This could be explained by the low prevalence of VRE in the Netherlands compared to other countries. In 2020, 0.5% of Enterococcus faecium isolates were resistant to vancomycin, compared to 35.9% in Ireland (10). Additionally, outbreaks with VRE have occurred in the Netherlands, whereas outbreaks with CPE are less common. Therefore, VRE is a greater priority for IPC measures in the Netherlands to maintain a low prevalence compared to other countries. For CPE, the prevalence throughout Europe is of concern, and consequently a priority for IPC teams (10). We observed a distinct difference between self-reported knowledge and objective knowledge. The majority of respondents claimed good to excellent knowledge at the start of the survey, but a substantial proportion of these respondents were not able to answer the relevant questions. This could indicate that the respondents expected different questions, or that the respondents were not aware about gaps in their knowledge regarding environmental sampling processes. 134 Chapter 3.1
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