higher. This is in line with the study of Arcilla et al., who showed the highest carriage rates for ESBL-E upon returning from Southern Asia, central and eastern Asia, and Northern Africa among healthy volunteers (23). Additionally, Voor in ‘t holt et al. showed the highest carriage rates of multidrug resistant Enterobacterales after travel to Southern Asia and Northern Africa (25). While more research into the burden of travel-related MDRO carriage and possible consequences within the hospital environment, our results show that including questions regarding recent travel to Asia or Africa could be an addition to the universal risk assessment. According to our study, the majority of patients (90.9%) would support a screening strategy based on travel history. Therefore, we conclude that adding a question regarding recent travel behavior to the universal risk-assessment would be accepted by patients and would be beneficial in identifying ESBL-E carriers. While adding questions to the universal risk assessment might increase the identification of MDRO carriers, implementing this would not be without consequences. Van Hout et al. determined that the universal risk-assessment currently is associated with a high workload (20). They estimated that during the four-and-a-half years of their study, 160 working weeks of 36h were spent on performing and administration of the risk assessment. Adding questions to the risk assessment would only add to the current workload. Additionally, the question remains if it is necessary to ask about all risk factors. Besides increasing the workload for healthcare workers, the questions could also become a burden for patients. For example, Lekkerkerk et al. identified that having at least one foreign parent is a risk factor for MRSA carriage (26). This type of personal questions could be an imposition for patients. Furthermore, the yield of an improved risk assessment still needs to be determined. It is an illusion that a risk-based screening strategy could be 100% effective in identifying all carriers, as not all carriers will have a risk factor. Moreover, it is debatable if it is necessary to identify all MDRO carriers. As stated before, the majority of ESBL-E carriers identified in Chapter 2.1 were and remained unidentified through clinical cultures and were not regularly screened for carriage. Therefore, it could be concluded that identifying these carriers was not of clinical importance. However, we also showed acquisition in 19 patients. Consequently, transmission within the hospital occurs, also if identification was not of clinical importance for the index patients. As a hospital, you aim to provide a microbial safe environment for your patients, and as part of this, it is important to have a screening strategy with the highest possible yield, but with a balanced outcome and effort. Therefore, if we want to increase the yield of screening strategies upon admission, other screening strategies should also be considered. These strategies could potentially lead to a decrease in workload and pose less of a burden for patients. We were in the unique position to have admission cultures from a large group of patients, independent from the universal risk assessment combined with risk-based screening. Consequently, we were able to compare the yield of universal screening strategy with the yield of the universal risk assessment combined with risk-based screening, of which the results were presented in Chapter 2.3. We found that a universal screening strategy identified more MDRO compared to the universal risk assessment, although the risk-based 4 189 Summarizing discussion
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