single-occupancy rooms on outbreaks in the hospital is lacking. We recommend that a retrospective study determining the number of outbreaks in the old hospital building and the number of outbreaks in the new hospital building. This data could show if the relocation impacted transmission of MDRO. It should also be considered to determine the differences in the number and the size of contact tracing investigations that needed to be performed after identifying a MDRO carrier. This data could be used to determine the costs and workload associated with the outbreaks, to determine the cost-effectiveness of the relocation from an infection prevention and control point of view. Thirdly, our results show the impact of 100% single-occupancy rooms in a country with a low prevalence of MDRO. Due to the variability in prevalence of MDRO, we recommend to evaluate the impact of 100% single-occupancy rooms in countries with a difference MDRO prevalence. And fourth, our results show the effect for an adult population. We recommend that the impact of 100% single-occupancy rooms on acquisition, environmental contamination, and on outbreaks, should also be evaluated in a children’s hospital. As stated before, we recommend that architects design future hospitals with 100% singleoccupancy rooms. To reach this, it is important that architects work together with medical microbiologists, epidemiologists, infection prevention and control practitioners, and other healthcare workers. In current practice, this is not (yet) occurring. Combining the expertise of these professions with the expertise of architects would increase the microbial safety of future hospitals. Additionally, including the people who will work in the building (e.g., nurses, health and safety officers, supportive staff) other bottlenecks could be identified early in the design phase, making adaptations more feasible. To quickly start the collaborations, a network proposal to the EU-COST program (Hospital Preparedness for Epidemics: network for designing safe and healthy healthcare environments (HoPE)) has been submitted. The purpose of this network is to create an international multidisciplinary research network with a focus of improving safety of hospital by design. This could be a first step in improving collaborations between architects and healthcare workers. On conclusion, given the results of this thesis, we recommend that new hospital buildings should be built with 100% single-occupancy rooms, to maximize microbial safety. We had two parameters for microbial safety. The first was met: Environmental contamination in the 100% single-occupancy rooms was significantly lower. The second was partially met: While we did not show a decrease in acquisition, we showed that patients are transferred less in a hospital with 100% single-occupancy rooms. This decreased the exposure to the hospital environment and was associated with lower odds on ESBL-E acquisition, and potentially other MDRO. Consequently, we believe that our hospital with 100% single-occupancy rooms provides a microbial safer hospital. Given the results in our low endemic setting, the impact of introducing 100% single-occupancy rooms might even be more substantial in countries with a higher prevalence of MDRO. Regarding the screening methods upon admission, a universal screening strategy seems to be a good strategy in theory. However, adding questions, such as about recent travel history, to the risk assessment is more feasible and will improve the detection of carriers upon admission. 4 199 Summarizing discussion
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