installed risk-assessment and transfer to a system where (previously) known MDRO carriers are cared for in isolation. However, we feel that more research is needed before such a drastic change in policy is made. For this, we advocate to improve the risk assessment or to consider the possibility of different screening strategies. This could be done by adding questions about risk factors to the risk-assessment, or by evaluating other screening strategies, such as a universal screening strategy upon admission (Table 1). Table 1. Overview of current risk assessment and proposed improvements and other screening strategies Current risk-assessment of the Erasmus MC 1) Is the patient a known carrier of a MDRO? 2) Has the patient recently been treated in or admitted to a healthcare institution abroad? 3) Did the patient stay in a healthcare facility known with a MDRO outbreak in the past two months, and if yes, was the patient approached for screening? 4) Has the patient lived in an institution for asylum seekers in the past two months? 5) Does the patient live or work where pigs, veal calves or broilers are kept commercially? 6) Is the patient a partner, housemate or caregiver of someone who is MRSA positive? 7) Is the patient a professional seafarer? Proposal for additional questions in the risk-assessment 8) Did you recently travel to South East Asia? 9) Did you recently consume antibiotics, and if yes, what types? 10) …. Alternative strategy Universal screening upon admission Screening of specific patient population upon admission The universal risk assessment does not ask about all known risk factors, such as antibiotic usage in the last 90 days, specifically use of fluoroquinolones and beta-lactams (6, 21, 22), or recent travel history (6, 23-25). However, studies determining MDRO colonization after travel are often performed in healthy volunteers and cannot be directly extrapolated to patients admitted to our hospital. In Chapter 2.2, we determined if patients admitted to our hospital recently traveled, and if yes, if they were colonized with a MDRO upon admission (5). We observed that almost 47.4% of patients travelled in the year before hospitalization, the majority of which within Europe and only a small number of patients outside of Europe. Colonization rates among travelers was 6.0%, compared to 6.2% among non-travelers. Although numbers were small and differences were non-significant, carriage rates were lower among travelers inside of Europe (3.4%) compared to travelers outside of Europe (13.3%). Our results indicate that the carriage rate increased when we looked at patients who travelled outside Europe <3 months before hospitalization (29%), <2 months (40%), and <1 month (67%). For patients who travelled to Asia or Africa, carriage rates were even 188 Chapter 4
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