screening identified a vancomycin-resistant Enterococcus faecium that was missed through the universal screening. An explanation for this could be that we used perianal samples instead of rectal samples, which have a higher recovery rate (27). That universal screening identified more carriers was expected and in agreement with other studies. Phee et al. even showed that a universal screening strategy for carbapenemase-producing organisms identified a higher local incidence than the reported average in the United Kingdom (28). When conducting the administration of the universal risk assessment, healthcare workers can select “the previous risk assessment is still up to date”. This is associated with several challenges. Within our study, the electronic health records (EHR) of 16 patients (1.7%) referred to a previous risk assessment, while no previous risk assessment was taken. Consequently, for these patients the risk on MDRO colonization was not determined. Another challenge is when a previous risk assessment was performed, and that the patient was deemed at risk. When the consequent risk assessment refers to the risk assessment where a patient was at risk, the patient should again be screened for MDRO colonization. However, in this situation the patient is often not screened. An added benefit of a universal screening strategy is that this method will also identify patients who acquired a MDRO from transmission in the community, thus without risk-factors. We did not determine if a universal screening strategy would be a cost-effective strategy, however, several studies have been performed. Regarding the identification of MRSA, some studies reported that a universal screening strategy is not effective, or only effective when there is a high prevalence (29-31). On the other hand, it has been reported that universal screening decreased the incidence and prevalence of MRSA, and even to be cost-effective in the study of Borg et al. (30, 32). For carbapenemase-producing organisms, universal screening to reduce transmission appeared to be a cost-effective strategy (28, 33, 34). The costeffectiveness of a universal screening strategy for MDRO in general still needs to be determined. Considering the number of unidentified carriers (n=49) and the number of unidentified acquisitions (n=19) within the hospital identified in Chapter 2.1, there is a need for improved screening for MDRO colonization upon admission. The yield of the currently installed universal risk assessment combined with risk-based screening is low. Additionally, the current screening is time consuming, not complete in asking about known risk factors, consequently not complete in identifying MDRO carriers upon admission, and at last prone to administrative mistakes. It is possible to adapt the risk assessment, but this could increase the burden for both healthcare workers and patients. Therefore, we conclude that in theory a universal screening strategy including rectal and nose swabs appears to be an effective method to increase the yield of the current screening strategy. However, it is importance to note that this strategy would not only be labor intensive, but also could be a financial burden for the hospital, at least on the short-term. Such a strategy would not only increase the number of microbiological cultures, but also the number of patients that need to be cared for in isolation. This is associated with an average price between 28 and 41 euros per day per patient (35). Additionally, an increase in the number of isolated patients is associated with an added workload for healthcare workers. Consequently, it should be 190 Chapter 4
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