considered to only install universal screening for specific patient populations, such as surgical or intensive care patients, next to implementing the extended risk assessment as described above. Carefully checking the compliance to this assessment is highly recommended to ensure optimal detection. The contamination of the innate hospital environment Pathogens can survive on surfaces for longer periods, ranging from a few hours up to several months (36). Therefore, surfaces can be a lasting source for transmission when they are not appropriately cleaned and/or disinfected. Consequently, it is not surprising that the hospital environment plays an important role in transmission and outbreaks. The importance of the hospital environment in outbreaks has been shown in several studies (37-39). When an outbreak has no clear source, and or cannot be controlled, environmental sampling can be performed to identify the source. To perform environmental sampling, direct (e.g., contact plates, dip slides, petri film) and indirect (e.g., sponges, wipes, cotton swabs, flocked swabs, cotton swabs) sampling methods exist. However, currently, no guidelines on how and when (indication) to perform environmental sampling exist. In Chapter 3.1 we aimed to determine current environmental sampling practices by performing an online survey (40). Our results show that currently, there is no consensus on how to perform environmental sampling, even within countries. While sampling practices depend on the target microorganism and the nature of the outbreak, it was surprising that differences in locations sampled for specific microorganisms within countries. Additionally, some locations were never sampled for specific target microorganisms, while these locations are reported in other studies. For example, the Netherlands did not report sampling the shower drain for VRE, while in Chapter 3.2 of this study we reported identifying vancomycin resistant E. faecium on the shower chair (41). This highlights the need for guidelines, while tailoring of these guidelines will remain necessary for specific situations. Regarding sampling method, the respondents mainly reported the use of swabs, either flocked or cotton. This was as expected, as swabs are readily available in the healthcare environment, are low in cost, and can be used to sample all types and shapes of surfaces (42). However, sampling with swabs is difficult to standardize (e.g., pressure on the swab during sampling, the sampling pattern, the angle of the swab during sampling), which causes variability in recovery rates (43). This again indicates to the need for sampling guidelines. Interestingly, our results indicated a difference between the self-reported knowledge of the respondents and the objective knowledge. While over-estimation of knowledge is to be expected (44, 45), the respondents to our survey were mainly infection prevention and control practitioners and clinical microbiologists. These are the professionals that are responsible for either performing environmental sampling, or evaluating the results and deciding how to proceed. It is worrisome that these professionals are not aware of the gaps in their knowledge, and again highlights the need for standardization and guidelines. We conclude that guidelines for how and when to perform environmental sampling are necessary, both on a national and an international level. These guidelines could help standardize sampling, provide a focus on what to sample and why, 4 191 Summarizing discussion
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