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<title>A New Instrument for Microbial Epidemiology</title>
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<li><a href="https://doi.org/10.33612/diss.177417131" target="blank"><img src="images/cover.jpg" style="width:90%; margin-left:5%;"></a></li>
<li class="divider"></li>
<li class="chapter" data-level="" data-path="index.html"><a href="index.html"><i class="fa fa-check"></i>Preamble</a>
<ul>
<li class="chapter" data-level="" data-path="index.html"><a href="index.html#short-summary-250-words"><i class="fa fa-check"></i>Short summary (250 words)</a></li>
</ul></li>
<li class="chapter" data-level="" data-path="colophon.html"><a href="colophon.html"><i class="fa fa-check"></i>Colophon</a></li>
<li class="chapter" data-level="" data-path="contents.html"><a href="contents.html"><i class="fa fa-check"></i>Contents</a></li>
<li class="chapter" data-level="1" data-path="ch01-introduction.html"><a href="ch01-introduction.html"><i class="fa fa-check"></i><b>1</b> General Introduction</a>
<ul>
<li class="chapter" data-level="1.1" data-path="ch01-introduction.html"><a href="ch01-introduction.html#microbial-epidemiology"><i class="fa fa-check"></i><b>1.1</b> Microbial epidemiology</a></li>
<li class="chapter" data-level="1.2" data-path="ch01-introduction.html"><a href="ch01-introduction.html#antimicrobial-resistance-in-microorganisms"><i class="fa fa-check"></i><b>1.2</b> Antimicrobial resistance in microorganisms</a>
<ul>
<li class="chapter" data-level="1.2.1" data-path="ch01-introduction.html"><a href="ch01-introduction.html#laboratory-diagnostics"><i class="fa fa-check"></i><b>1.2.1</b> Laboratory diagnostics</a></li>
<li class="chapter" data-level="1.2.2" data-path="ch01-introduction.html"><a href="ch01-introduction.html#interpretation-of-raw-results"><i class="fa fa-check"></i><b>1.2.2</b> Interpretation of raw results</a></li>
<li class="chapter" data-level="1.2.3" data-path="ch01-introduction.html"><a href="ch01-introduction.html#multi-drug-resistant-organisms"><i class="fa fa-check"></i><b>1.2.3</b> Multi-drug resistant organisms</a></li>
<li class="chapter" data-level="1.2.4" data-path="ch01-introduction.html"><a href="ch01-introduction.html#surveillance-programs"><i class="fa fa-check"></i><b>1.2.4</b> Surveillance programs</a></li>
</ul></li>
<li class="chapter" data-level="1.3" data-path="ch01-introduction.html"><a href="ch01-introduction.html#data-analysis-using-r"><i class="fa fa-check"></i><b>1.3</b> Data analysis using R</a></li>
<li class="chapter" data-level="1.4" data-path="ch01-introduction.html"><a href="ch01-introduction.html#setting-for-this-thesis"><i class="fa fa-check"></i><b>1.4</b> Setting for this thesis</a></li>
<li class="chapter" data-level="1.5" data-path="ch01-introduction.html"><a href="ch01-introduction.html#aim-of-this-thesis-and-introduction-to-its-chapters"><i class="fa fa-check"></i><b>1.5</b> Aim of this thesis and introduction to its chapters</a></li>
<li class="chapter" data-level="" data-path="ch01-introduction.html"><a href="ch01-introduction.html#references"><i class="fa fa-check"></i>References</a></li>
</ul></li>
<li class="chapter" data-level="2" data-path="ch02-diagnostic-stewardship.html"><a href="ch02-diagnostic-stewardship.html"><i class="fa fa-check"></i><b>2</b> Diagnostic Stewardship: Sense or Nonsense?!</a>
<ul>
<li class="chapter" data-level="" data-path="ch02-diagnostic-stewardship.html"><a href="ch02-diagnostic-stewardship.html#abstract"><i class="fa fa-check"></i>Abstract</a></li>
<li class="chapter" data-level="2.1" data-path="ch02-diagnostic-stewardship.html"><a href="ch02-diagnostic-stewardship.html#introduction"><i class="fa fa-check"></i><b>2.1</b> Introduction</a>
<ul>
<li class="chapter" data-level="2.1.1" data-path="ch02-diagnostic-stewardship.html"><a href="ch02-diagnostic-stewardship.html#case-1"><i class="fa fa-check"></i><b>2.1.1</b> Case 1</a></li>
<li class="chapter" data-level="2.1.2" data-path="ch02-diagnostic-stewardship.html"><a href="ch02-diagnostic-stewardship.html#case-2"><i class="fa fa-check"></i><b>2.1.2</b> Case 2</a></li>
</ul></li>
<li class="chapter" data-level="2.2" data-path="ch02-diagnostic-stewardship.html"><a href="ch02-diagnostic-stewardship.html#the-general-concept"><i class="fa fa-check"></i><b>2.2</b> The general concept</a>
<ul>
<li class="chapter" data-level="2.2.1" data-path="ch02-diagnostic-stewardship.html"><a href="ch02-diagnostic-stewardship.html#diagnostics"><i class="fa fa-check"></i><b>2.2.1</b> ‘Diagnostics’</a></li>
<li class="chapter" data-level="2.2.2" data-path="ch02-diagnostic-stewardship.html"><a href="ch02-diagnostic-stewardship.html#dsp-in-the-microbiological-laboratory"><i class="fa fa-check"></i><b>2.2.2</b> DSP in the microbiological laboratory</a></li>
<li class="chapter" data-level="2.2.3" data-path="ch02-diagnostic-stewardship.html"><a href="ch02-diagnostic-stewardship.html#dsp-as-process-optimisation"><i class="fa fa-check"></i><b>2.2.3</b> DSP as process optimisation</a></li>
<li class="chapter" data-level="2.2.4" data-path="ch02-diagnostic-stewardship.html"><a href="ch02-diagnostic-stewardship.html#multidisciplinary-aspects-of-dsp-and-infection-management"><i class="fa fa-check"></i><b>2.2.4</b> Multidisciplinary aspects of DSP and infection management</a></li>
</ul></li>
<li class="chapter" data-level="2.3" data-path="ch02-diagnostic-stewardship.html"><a href="ch02-diagnostic-stewardship.html#conclusion"><i class="fa fa-check"></i><b>2.3</b> Conclusion</a></li>
<li class="chapter" data-level="" data-path="ch02-diagnostic-stewardship.html"><a href="ch02-diagnostic-stewardship.html#financing"><i class="fa fa-check"></i>Financing</a></li>
<li class="chapter" data-level="" data-path="ch02-diagnostic-stewardship.html"><a href="ch02-diagnostic-stewardship.html#references-1"><i class="fa fa-check"></i>References</a></li>
</ul></li>
<li class="chapter" data-level="3" data-path="ch03-introducing-new-method.html"><a href="ch03-introducing-new-method.html"><i class="fa fa-check"></i><b>3</b> Introducing a New, Free, and Independent Method for Standardised, Reproducible and Reliable Analyses of Antimicrobial Resistance Data</a>
<ul>
<li class="chapter" data-level="" data-path="ch03-introducing-new-method.html"><a href="ch03-introducing-new-method.html#abstract-1"><i class="fa fa-check"></i>Abstract</a></li>
<li class="chapter" data-level="3.1" data-path="ch03-introducing-new-method.html"><a href="ch03-introducing-new-method.html#background"><i class="fa fa-check"></i><b>3.1</b> Background</a></li>
<li class="chapter" data-level="3.2" data-path="ch03-introducing-new-method.html"><a href="ch03-introducing-new-method.html#standardising-amr-data-analysis"><i class="fa fa-check"></i><b>3.2</b> Standardising AMR data analysis</a></li>
<li class="chapter" data-level="3.3" data-path="ch03-introducing-new-method.html"><a href="ch03-introducing-new-method.html#comparison-with-existing-software-methods"><i class="fa fa-check"></i><b>3.3</b> Comparison with existing software methods</a></li>
<li class="chapter" data-level="3.4" data-path="ch03-introducing-new-method.html"><a href="ch03-introducing-new-method.html#user-feedback"><i class="fa fa-check"></i><b>3.4</b> User feedback</a></li>
<li class="chapter" data-level="3.5" data-path="ch03-introducing-new-method.html"><a href="ch03-introducing-new-method.html#conclusion-1"><i class="fa fa-check"></i><b>3.5</b> Conclusion</a></li>
<li class="chapter" data-level="" data-path="ch03-introducing-new-method.html"><a href="ch03-introducing-new-method.html#references-2"><i class="fa fa-check"></i>References</a></li>
</ul></li>
<li class="chapter" data-level="4" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html"><i class="fa fa-check"></i><b>4</b> <code>AMR</code> - An <code>R</code> Package for Working with Antimicrobial Resistance Data</a>
<ul>
<li class="chapter" data-level="" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#abstract-2"><i class="fa fa-check"></i>Abstract</a></li>
<li class="chapter" data-level="4.1" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#introduction-1"><i class="fa fa-check"></i><b>4.1</b> Introduction</a></li>
<li class="chapter" data-level="4.2" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#antimicrobial-resistance-data"><i class="fa fa-check"></i><b>4.2</b> Antimicrobial resistance data</a></li>
<li class="chapter" data-level="4.3" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#antimicrobial-resistance-data-transformation"><i class="fa fa-check"></i><b>4.3</b> Antimicrobial resistance data transformation</a>
<ul>
<li class="chapter" data-level="4.3.1" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#working-with-taxonomically-valid-microorganism-names"><i class="fa fa-check"></i><b>4.3.1</b> Working with taxonomically valid microorganism names</a></li>
<li class="chapter" data-level="4.3.2" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#working-with-antimicrobial-names-or-codes"><i class="fa fa-check"></i><b>4.3.2</b> Working with antimicrobial names or codes</a></li>
<li class="chapter" data-level="4.3.3" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#working-with-antimicrobial-susceptibility-test-results"><i class="fa fa-check"></i><b>4.3.3</b> Working with antimicrobial susceptibility test results</a></li>
<li class="chapter" data-level="4.3.4" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#interpretative-rules-by-eucast"><i class="fa fa-check"></i><b>4.3.4</b> Interpretative rules by EUCAST</a></li>
<li class="chapter" data-level="4.3.5" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#working-with-defined-daily-doses-ddd"><i class="fa fa-check"></i><b>4.3.5</b> Working with defined daily doses (DDD)</a></li>
</ul></li>
<li class="chapter" data-level="4.4" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#enhancing-antimicrobial-resistance-data"><i class="fa fa-check"></i><b>4.4</b> Enhancing antimicrobial resistance data</a>
<ul>
<li class="chapter" data-level="4.4.1" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#determining-first-isolates"><i class="fa fa-check"></i><b>4.4.1</b> Determining first isolates</a></li>
<li class="chapter" data-level="4.4.2" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#determining-multi-drug-resistant-organisms-mdro"><i class="fa fa-check"></i><b>4.4.2</b> Determining multi-drug resistant organisms (MDRO)</a></li>
</ul></li>
<li class="chapter" data-level="4.5" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#analysing-antimicrobial-resistance-data"><i class="fa fa-check"></i><b>4.5</b> Analysing antimicrobial resistance data</a>
<ul>
<li class="chapter" data-level="4.5.1" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#calculation-of-antimicrobial-resistance"><i class="fa fa-check"></i><b>4.5.1</b> Calculation of antimicrobial resistance</a></li>
</ul></li>
<li class="chapter" data-level="4.6" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#design-decisions"><i class="fa fa-check"></i><b>4.6</b> Design decisions</a></li>
<li class="chapter" data-level="4.7" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#reproducible-example"><i class="fa fa-check"></i><b>4.7</b> Reproducible example</a></li>
<li class="chapter" data-level="4.8" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#discussion"><i class="fa fa-check"></i><b>4.8</b> Discussion</a></li>
<li class="chapter" data-level="" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#computational-details"><i class="fa fa-check"></i>Computational Details</a></li>
<li class="chapter" data-level="" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#acknowledgements"><i class="fa fa-check"></i>Acknowledgements</a></li>
<li class="chapter" data-level="" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#references-3"><i class="fa fa-check"></i>References</a></li>
<li class="chapter" data-level="" data-path="ch04-amr-r-package.html"><a href="ch04-amr-r-package.html#appendix-a-included-data-sets"><i class="fa fa-check"></i>Appendix A: Included Data Sets</a></li>
</ul></li>
<li class="chapter" data-level="5" data-path="ch05-radar.html"><a href="ch05-radar.html"><i class="fa fa-check"></i><b>5</b> Rapid Analysis of Diagnostic and Antimicrobial Patterns in R (RadaR): Interactive Open-Source Software App for Infection Management and Antimicrobial Stewardship</a>
<ul>
<li class="chapter" data-level="" data-path="ch05-radar.html"><a href="ch05-radar.html#abstract-3"><i class="fa fa-check"></i>Abstract</a></li>
<li class="chapter" data-level="5.1" data-path="ch05-radar.html"><a href="ch05-radar.html#introduction-2"><i class="fa fa-check"></i><b>5.1</b> Introduction</a>
<ul>
<li class="chapter" data-level="5.1.1" data-path="ch05-radar.html"><a href="ch05-radar.html#background-1"><i class="fa fa-check"></i><b>5.1.1</b> Background</a></li>
<li class="chapter" data-level="5.1.2" data-path="ch05-radar.html"><a href="ch05-radar.html#objectives"><i class="fa fa-check"></i><b>5.1.2</b> Objectives</a></li>
</ul></li>
<li class="chapter" data-level="5.2" data-path="ch05-radar.html"><a href="ch05-radar.html#methods"><i class="fa fa-check"></i><b>5.2</b> Methods</a></li>
<li class="chapter" data-level="5.3" data-path="ch05-radar.html"><a href="ch05-radar.html#results"><i class="fa fa-check"></i><b>5.3</b> Results</a>
<ul>
<li class="chapter" data-level="5.3.1" data-path="ch05-radar.html"><a href="ch05-radar.html#overview"><i class="fa fa-check"></i><b>5.3.1</b> Overview</a></li>
<li class="chapter" data-level="5.3.2" data-path="ch05-radar.html"><a href="ch05-radar.html#application-design"><i class="fa fa-check"></i><b>5.3.2</b> Application Design</a></li>
<li class="chapter" data-level="5.3.3" data-path="ch05-radar.html"><a href="ch05-radar.html#development-process"><i class="fa fa-check"></i><b>5.3.3</b> Development Process</a></li>
<li class="chapter" data-level="5.3.4" data-path="ch05-radar.html"><a href="ch05-radar.html#workflow"><i class="fa fa-check"></i><b>5.3.4</b> Workflow</a></li>
<li class="chapter" data-level="5.3.5" data-path="ch05-radar.html"><a href="ch05-radar.html#customisation"><i class="fa fa-check"></i><b>5.3.5</b> Customisation</a></li>
</ul></li>
<li class="chapter" data-level="5.4" data-path="ch05-radar.html"><a href="ch05-radar.html#discussion-1"><i class="fa fa-check"></i><b>5.4</b> Discussion</a>
<ul>
<li class="chapter" data-level="5.4.1" data-path="ch05-radar.html"><a href="ch05-radar.html#principal-findings"><i class="fa fa-check"></i><b>5.4.1</b> Principal Findings</a></li>
<li class="chapter" data-level="5.4.2" data-path="ch05-radar.html"><a href="ch05-radar.html#conclusions"><i class="fa fa-check"></i><b>5.4.2</b> Conclusions</a></li>
</ul></li>
<li class="chapter" data-level="" data-path="ch05-radar.html"><a href="ch05-radar.html#acknowledgements-1"><i class="fa fa-check"></i>Acknowledgements</a></li>
<li class="chapter" data-level="" data-path="ch05-radar.html"><a href="ch05-radar.html#conflicts-of-interests"><i class="fa fa-check"></i>Conflicts of interests</a></li>
<li class="chapter" data-level="" data-path="ch05-radar.html"><a href="ch05-radar.html#references-4"><i class="fa fa-check"></i>References</a></li>
</ul></li>
<li class="chapter" data-level="6" data-path="ch06-radar2.html"><a href="ch06-radar2.html"><i class="fa fa-check"></i><b>6</b> Better Antimicrobial Resistance Data Analysis and Reporting in Less Time</a>
<ul>
<li class="chapter" data-level="" data-path="ch06-radar2.html"><a href="ch06-radar2.html#abstract-4"><i class="fa fa-check"></i>Abstract</a></li>
<li class="chapter" data-level="6.1" data-path="ch06-radar2.html"><a href="ch06-radar2.html#introduction-3"><i class="fa fa-check"></i><b>6.1</b> Introduction</a></li>
<li class="chapter" data-level="6.2" data-path="ch06-radar2.html"><a href="ch06-radar2.html#methods-1"><i class="fa fa-check"></i><b>6.2</b> Methods</a>
<ul>
<li class="chapter" data-level="6.2.1" data-path="ch06-radar2.html"><a href="ch06-radar2.html#study-setup"><i class="fa fa-check"></i><b>6.2.1</b> Study setup</a></li>
<li class="chapter" data-level="6.2.2" data-path="ch06-radar2.html"><a href="ch06-radar2.html#amr-data"><i class="fa fa-check"></i><b>6.2.2</b> AMR data</a></li>
<li class="chapter" data-level="6.2.3" data-path="ch06-radar2.html"><a href="ch06-radar2.html#amr-data-analysis-and-reporting"><i class="fa fa-check"></i><b>6.2.3</b> AMR data analysis and reporting</a></li>
<li class="chapter" data-level="6.2.4" data-path="ch06-radar2.html"><a href="ch06-radar2.html#study-participants"><i class="fa fa-check"></i><b>6.2.4</b> Study participants</a></li>
<li class="chapter" data-level="6.2.5" data-path="ch06-radar2.html"><a href="ch06-radar2.html#study-execution-and-data"><i class="fa fa-check"></i><b>6.2.5</b> Study execution and data</a></li>
<li class="chapter" data-level="6.2.6" data-path="ch06-radar2.html"><a href="ch06-radar2.html#evaluation-and-study-data-analysis"><i class="fa fa-check"></i><b>6.2.6</b> Evaluation and study data analysis</a></li>
</ul></li>
<li class="chapter" data-level="6.3" data-path="ch06-radar2.html"><a href="ch06-radar2.html#results-1"><i class="fa fa-check"></i><b>6.3</b> Results</a>
<ul>
<li class="chapter" data-level="6.3.1" data-path="ch06-radar2.html"><a href="ch06-radar2.html#study-participants-1"><i class="fa fa-check"></i><b>6.3.1</b> Study participants</a></li>
<li class="chapter" data-level="6.3.2" data-path="ch06-radar2.html"><a href="ch06-radar2.html#effectiveness-and-accuracy"><i class="fa fa-check"></i><b>6.3.2</b> Effectiveness and accuracy</a></li>
<li class="chapter" data-level="6.3.3" data-path="ch06-radar2.html"><a href="ch06-radar2.html#efficiency"><i class="fa fa-check"></i><b>6.3.3</b> Efficiency</a></li>
<li class="chapter" data-level="6.3.4" data-path="ch06-radar2.html"><a href="ch06-radar2.html#satisfaction"><i class="fa fa-check"></i><b>6.3.4</b> Satisfaction</a></li>
</ul></li>
<li class="chapter" data-level="6.4" data-path="ch06-radar2.html"><a href="ch06-radar2.html#discussion-2"><i class="fa fa-check"></i><b>6.4</b> Discussion</a></li>
<li class="chapter" data-level="" data-path="ch06-radar2.html"><a href="ch06-radar2.html#acknowledgements-2"><i class="fa fa-check"></i>Acknowledgements</a></li>
<li class="chapter" data-level="" data-path="ch06-radar2.html"><a href="ch06-radar2.html#funding"><i class="fa fa-check"></i>Funding</a></li>
<li class="chapter" data-level="" data-path="ch06-radar2.html"><a href="ch06-radar2.html#conflict-of-interest"><i class="fa fa-check"></i>Conflict of interest</a></li>
<li class="chapter" data-level="" data-path="ch06-radar2.html"><a href="ch06-radar2.html#references-5"><i class="fa fa-check"></i>References</a></li>
<li class="chapter" data-level="" data-path="ch06-radar2.html"><a href="ch06-radar2.html#appendix"><i class="fa fa-check"></i>Appendix</a>
<ul>
<li class="chapter" data-level="" data-path="ch06-radar2.html"><a href="ch06-radar2.html#appendix-a1-task-lists-including-correct-results"><i class="fa fa-check"></i>Appendix A1: Task lists including correct results</a></li>
<li class="chapter" data-level="" data-path="ch06-radar2.html"><a href="ch06-radar2.html#appendix-a2-system-usability-scale-sus"><i class="fa fa-check"></i>Appendix A2: System Usability Scale (SUS)</a></li>
<li class="chapter" data-level="" data-path="ch06-radar2.html"><a href="ch06-radar2.html#appendix-a3-task-3-sub-analysis"><i class="fa fa-check"></i>Appendix A3: Task 3 sub-analysis</a></li>
</ul></li>
</ul></li>
<li class="chapter" data-level="7" data-path="ch07-cons.html"><a href="ch07-cons.html"><i class="fa fa-check"></i><b>7</b> Trends in Occurrence and Phenotypic Resistance of Coagulase-Negative Staphylococci (CoNS) Found in Blood in the Northern Netherlands between 2013 and 2019</a>
<ul>
<li class="chapter" data-level="" data-path="ch07-cons.html"><a href="ch07-cons.html#abstract-5"><i class="fa fa-check"></i>Abstract</a></li>
<li class="chapter" data-level="7.1" data-path="ch07-cons.html"><a href="ch07-cons.html#introduction-4"><i class="fa fa-check"></i><b>7.1</b> Introduction</a></li>
<li class="chapter" data-level="7.2" data-path="ch07-cons.html"><a href="ch07-cons.html#materials-methods"><i class="fa fa-check"></i><b>7.2</b> Materials &amp; methods</a>
<ul>
<li class="chapter" data-level="7.2.1" data-path="ch07-cons.html"><a href="ch07-cons.html#study-setting-and-patient-cohort"><i class="fa fa-check"></i><b>7.2.1</b> Study setting and patient cohort</a></li>
<li class="chapter" data-level="7.2.2" data-path="ch07-cons.html"><a href="ch07-cons.html#microbiological-and-demographic-data"><i class="fa fa-check"></i><b>7.2.2</b> Microbiological and demographic data</a></li>
<li class="chapter" data-level="7.2.3" data-path="ch07-cons.html"><a href="ch07-cons.html#species-determination-and-antibiotic-susceptibility-testing-ast"><i class="fa fa-check"></i><b>7.2.3</b> Species determination and antibiotic susceptibility testing (AST)</a></li>
<li class="chapter" data-level="7.2.4" data-path="ch07-cons.html"><a href="ch07-cons.html#selection-of-bacterial-isolates"><i class="fa fa-check"></i><b>7.2.4</b> Selection of bacterial isolates</a></li>
<li class="chapter" data-level="7.2.5" data-path="ch07-cons.html"><a href="ch07-cons.html#eucast-rules-and-antibiotic-resistance-analysis"><i class="fa fa-check"></i><b>7.2.5</b> EUCAST rules and antibiotic resistance analysis</a></li>
<li class="chapter" data-level="7.2.6" data-path="ch07-cons.html"><a href="ch07-cons.html#statistical-analysis"><i class="fa fa-check"></i><b>7.2.6</b> Statistical analysis</a></li>
<li class="chapter" data-level="7.2.7" data-path="ch07-cons.html"><a href="ch07-cons.html#ethical-considerations"><i class="fa fa-check"></i><b>7.2.7</b> Ethical considerations</a></li>
</ul></li>
<li class="chapter" data-level="7.3" data-path="ch07-cons.html"><a href="ch07-cons.html#results-2"><i class="fa fa-check"></i><b>7.3</b> Results</a>
<ul>
<li class="chapter" data-level="7.3.1" data-path="ch07-cons.html"><a href="ch07-cons.html#patients-and-included-isolates"><i class="fa fa-check"></i><b>7.3.1</b> Patients and included isolates</a></li>
<li class="chapter" data-level="7.3.2" data-path="ch07-cons.html"><a href="ch07-cons.html#occurrence-of-cons-species"><i class="fa fa-check"></i><b>7.3.2</b> Occurrence of CoNS species</a></li>
<li class="chapter" data-level="7.3.3" data-path="ch07-cons.html"><a href="ch07-cons.html#definition-of-cons-persistence"><i class="fa fa-check"></i><b>7.3.3</b> Definition of CoNS persistence</a></li>
<li class="chapter" data-level="7.3.4" data-path="ch07-cons.html"><a href="ch07-cons.html#antibiotic-resistance-analysis"><i class="fa fa-check"></i><b>7.3.4</b> Antibiotic resistance analysis</a></li>
</ul></li>
<li class="chapter" data-level="7.4" data-path="ch07-cons.html"><a href="ch07-cons.html#discussion-3"><i class="fa fa-check"></i><b>7.4</b> Discussion</a></li>
<li class="chapter" data-level="" data-path="ch07-cons.html"><a href="ch07-cons.html#supplementary-tables"><i class="fa fa-check"></i>Supplementary tables</a></li>
<li class="chapter" data-level="" data-path="ch07-cons.html"><a href="ch07-cons.html#references-6"><i class="fa fa-check"></i>References</a></li>
</ul></li>
<li class="chapter" data-level="8" data-path="ch08-defining-mdr.html"><a href="ch08-defining-mdr.html"><i class="fa fa-check"></i><b>8</b> Defining Multidrug Resistance of Gram-Negative Bacteria in the Dutch-German Border Region: Impact of National Guidelines</a>
<ul>
<li class="chapter" data-level="" data-path="ch08-defining-mdr.html"><a href="ch08-defining-mdr.html#abstract-6"><i class="fa fa-check"></i>Abstract</a></li>
<li class="chapter" data-level="8.1" data-path="ch08-defining-mdr.html"><a href="ch08-defining-mdr.html#introduction-5"><i class="fa fa-check"></i><b>8.1</b> Introduction</a></li>
<li class="chapter" data-level="8.2" data-path="ch08-defining-mdr.html"><a href="ch08-defining-mdr.html#methods-2"><i class="fa fa-check"></i><b>8.2</b> Methods</a></li>
<li class="chapter" data-level="8.3" data-path="ch08-defining-mdr.html"><a href="ch08-defining-mdr.html#results-3"><i class="fa fa-check"></i><b>8.3</b> Results</a>
<ul>
<li class="chapter" data-level="8.3.1" data-path="ch08-defining-mdr.html"><a href="ch08-defining-mdr.html#number-of-antibiograms-and-patients"><i class="fa fa-check"></i><b>8.3.1</b> Number of Antibiograms and Patients</a></li>
<li class="chapter" data-level="8.3.2" data-path="ch08-defining-mdr.html"><a href="ch08-defining-mdr.html#results-of-mrgn-and-brmo-classification"><i class="fa fa-check"></i><b>8.3.2</b> Results of MRGN and BRMO Classification</a></li>
</ul></li>
<li class="chapter" data-level="8.4" data-path="ch08-defining-mdr.html"><a href="ch08-defining-mdr.html#discussion-4"><i class="fa fa-check"></i><b>8.4</b> Discussion</a></li>
<li class="chapter" data-level="" data-path="ch08-defining-mdr.html"><a href="ch08-defining-mdr.html#acknowledgements-3"><i class="fa fa-check"></i>Acknowledgements</a></li>
<li class="chapter" data-level="" data-path="ch08-defining-mdr.html"><a href="ch08-defining-mdr.html#conflicts-of-interest"><i class="fa fa-check"></i>Conflicts of interest</a></li>
<li class="chapter" data-level="" data-path="ch08-defining-mdr.html"><a href="ch08-defining-mdr.html#references-7"><i class="fa fa-check"></i>References</a></li>
</ul></li>
<li class="chapter" data-level="9" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html"><i class="fa fa-check"></i><b>9</b> Changing Epidemiology of Methicillin-Resistant <em>Staphylococcus aureus</em> in 42 Hospitals in the Dutch-German Border Region, 2012 to 2016: Results of the Search-and-Follow Policy</a>
<ul>
<li class="chapter" data-level="" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#abstract-7"><i class="fa fa-check"></i>Abstract</a></li>
<li class="chapter" data-level="9.1" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#introduction-6"><i class="fa fa-check"></i><b>9.1</b> Introduction</a></li>
<li class="chapter" data-level="9.2" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#methods-3"><i class="fa fa-check"></i><b>9.2</b> Methods</a>
<ul>
<li class="chapter" data-level="9.2.1" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#setting"><i class="fa fa-check"></i><b>9.2.1</b> Setting</a></li>
<li class="chapter" data-level="9.2.2" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#guidelines-for-patients-at-risk-for-mrsa-and-infection-prevention-and-control-measures"><i class="fa fa-check"></i><b>9.2.2</b> Guidelines for patients at risk for MRSA and infection prevention and control measures</a></li>
<li class="chapter" data-level="9.2.3" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#data-collection"><i class="fa fa-check"></i><b>9.2.3</b> Data collection</a></li>
<li class="chapter" data-level="9.2.4" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#ethical-statement"><i class="fa fa-check"></i><b>9.2.4</b> Ethical statement</a></li>
<li class="chapter" data-level="9.2.5" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#data-analysis"><i class="fa fa-check"></i><b>9.2.5</b> Data analysis</a></li>
</ul></li>
<li class="chapter" data-level="9.3" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#results-4"><i class="fa fa-check"></i><b>9.3</b> Results</a>
<ul>
<li class="chapter" data-level="9.3.1" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#trend-and-cross-border-comparison-of-mrsa-rates"><i class="fa fa-check"></i><b>9.3.1</b> Trend and cross-border comparison of MRSA rates</a></li>
<li class="chapter" data-level="9.3.2" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#cross-border-comparison-of-healthcare-utilisation"><i class="fa fa-check"></i><b>9.3.2</b> Cross-border comparison of healthcare utilisation</a></li>
</ul></li>
<li class="chapter" data-level="9.4" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#discussion-5"><i class="fa fa-check"></i><b>9.4</b> Discussion</a></li>
<li class="chapter" data-level="" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#acknowledgements-4"><i class="fa fa-check"></i>Acknowledgements</a></li>
<li class="chapter" data-level="" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#funding-1"><i class="fa fa-check"></i>Funding</a></li>
<li class="chapter" data-level="" data-path="ch09-changing-epidemiology.html"><a href="ch09-changing-epidemiology.html#references-8"><i class="fa fa-check"></i>References</a></li>
</ul></li>
<li class="chapter" data-level="10" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html"><i class="fa fa-check"></i><b>10</b> A Prospective Multicentre MDRO Screening Study on ICUs in the Dutch-German Cross-Border Region (2017-2018): The Importance of Healthcare Structures</a>
<ul>
<li class="chapter" data-level="" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#abstract-8"><i class="fa fa-check"></i>Abstract</a></li>
<li class="chapter" data-level="10.1" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#introduction-7"><i class="fa fa-check"></i><b>10.1</b> Introduction</a></li>
<li class="chapter" data-level="10.2" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#methods-4"><i class="fa fa-check"></i><b>10.2</b> Methods</a>
<ul>
<li class="chapter" data-level="10.2.1" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#study-design"><i class="fa fa-check"></i><b>10.2.1</b> Study Design</a></li>
<li class="chapter" data-level="10.2.2" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#statistical-analysis-software"><i class="fa fa-check"></i><b>10.2.2</b> Statistical Analysis &amp; Software</a></li>
<li class="chapter" data-level="10.2.3" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#ethics"><i class="fa fa-check"></i><b>10.2.3</b> Ethics</a></li>
</ul></li>
<li class="chapter" data-level="10.3" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#results-5"><i class="fa fa-check"></i><b>10.3</b> Results</a>
<ul>
<li class="chapter" data-level="10.3.1" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#healthcare-structure-of-the-participating-hospitals"><i class="fa fa-check"></i><b>10.3.1</b> Healthcare structure of the participating hospitals</a></li>
<li class="chapter" data-level="10.3.2" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#study-population-and-screening-samples-from-icus"><i class="fa fa-check"></i><b>10.3.2</b> Study population and screening samples from ICUs</a></li>
<li class="chapter" data-level="10.3.3" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#prevalence-of-gram-positive-mdros-mrsa-and-vre"><i class="fa fa-check"></i><b>10.3.3</b> Prevalence of Gram-positive MDROs: MRSA and VRE</a></li>
<li class="chapter" data-level="10.3.4" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#prevalence-of-gram-negative-mdro-3gcre-and-cre"><i class="fa fa-check"></i><b>10.3.4</b> Prevalence of Gram-negative MDRO: 3GCRE and CRE</a></li>
<li class="chapter" data-level="10.3.5" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#prevalence-of-gram-negative-mdros-based-on-dutch-and-german-definitions"><i class="fa fa-check"></i><b>10.3.5</b> Prevalence of Gram-negative MDROs based on Dutch and German definitions</a></li>
<li class="chapter" data-level="10.3.6" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#comparison-of-mdro-prevalence-between-nl-br-and-de-br-icus-in-university-and-non-university-hospitals"><i class="fa fa-check"></i><b>10.3.6</b> Comparison of MDRO prevalence between NL-BR and DE-BR ICUs in university and non-university hospitals</a></li>
</ul></li>
<li class="chapter" data-level="10.4" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#discussion-6"><i class="fa fa-check"></i><b>10.4</b> Discussion</a></li>
<li class="chapter" data-level="" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#supplementary-files"><i class="fa fa-check"></i>Supplementary files</a></li>
<li class="chapter" data-level="" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#acknowledgements-5"><i class="fa fa-check"></i>Acknowledgements</a></li>
<li class="chapter" data-level="" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#conflict-of-interest-1"><i class="fa fa-check"></i>Conflict of interest</a></li>
<li class="chapter" data-level="" data-path="ch10-multi-mdro-screening.html"><a href="ch10-multi-mdro-screening.html#references-9"><i class="fa fa-check"></i>References</a></li>
</ul></li>
<li class="chapter" data-level="11" data-path="ch11-summary.html"><a href="ch11-summary.html"><i class="fa fa-check"></i><b>11</b> Summary and Future Perspectives</a>
<ul>
<li class="chapter" data-level="" data-path="ch11-summary.html"><a href="ch11-summary.html#section-i"><i class="fa fa-check"></i>Section I</a></li>
<li class="chapter" data-level="" data-path="ch11-summary.html"><a href="ch11-summary.html#section-ii"><i class="fa fa-check"></i>Section II</a></li>
<li class="chapter" data-level="" data-path="ch11-summary.html"><a href="ch11-summary.html#section-iii"><i class="fa fa-check"></i>Section III</a></li>
<li class="chapter" data-level="" data-path="ch11-summary.html"><a href="ch11-summary.html#future-perspectives"><i class="fa fa-check"></i>Future perspectives</a></li>
<li class="chapter" data-level="" data-path="ch11-summary.html"><a href="ch11-summary.html#references-10"><i class="fa fa-check"></i>References</a></li>
</ul></li>
<li class="chapter" data-level="" data-path="gearfetting-yn-frysk.html"><a href="gearfetting-yn-frysk.html"><i class="fa fa-check"></i>Gearfetting yn Frysk</a></li>
<li class="chapter" data-level="" data-path="samenvatting-in-het-nederlands.html"><a href="samenvatting-in-het-nederlands.html"><i class="fa fa-check"></i>Samenvatting in het Nederlands</a></li>
<li class="chapter" data-level="" data-path="zusammenfassung-auf-deutsch.html"><a href="zusammenfassung-auf-deutsch.html"><i class="fa fa-check"></i>Zusammenfassung auf Deutsch</a></li>
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<i class="fa fa-circle-o-notch fa-spin"></i><a href="./">A New Instrument for Microbial Epidemiology</a>
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<h1 class="title">A New Instrument for Microbial Epidemiology</h1>
<h2 class="subtitle"><em>Empowering Antimicrobial Resistance Data Analysis</em></h2>
<p class="author"><em>Matthijs S. Berends</em></p>
<p class="date" style="margin-top: 1.5em;"><em>25 August 2021</em></p>
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<div id="preamble" class="section level1 unnumbered">
<h1>Preamble</h1>
<p>This is the integral PhD thesis ‘A New Instrument for Microbial Epidemiology’ (DOI <a href="https://doi.org/10.33612/diss.177417131">10.33612/diss.177417131</a>) by <a href="https://www.rug.nl/staff/m.s.berends">Matthijs S. Berends</a>, which was defended publicly at the University of Groningen, the Netherlands, on 25 August 2021.</p>
<p>All texts were copied from the printed version ‘as is’; no modifications were made, although non-essential parts were left out (such as the personal acknowledgements and the curriculum vitae).</p>
<p>The shortened URL of the online version of this PhD thesis (an R Markdown project) is <a href="https://git.io/PhDthesisAMR">git.io/PhDthesisAMR</a> (case-sensitive).</p>
<div id="short-summary-250-words" class="section level3 unnumbered">
<h3>Short summary (250 words)</h3>
<p>Treating infectious diseases requires insights into the microorganisms causing infectious diseases. Antimicrobial resistance (AMR) in microorganisms limits treatment possibilities and poses an enormous healthcare problem worldwide. The spread and AMR patterns of microorganisms, risk factors for infection, and preventive and control measures of infectious disease are studied within the field of Microbial Epidemiology, a cross-over field between Epidemiology and Clinical Microbiology. For analysing the spread and AMR patterns of microorganisms, however, no standardised method previously existed. This thesis showcases the development and applied use of a new instrument to analyse AMR data: the AMR package for R. From multiple viewpoints, the AMR package and its advantages are put into perspective: from a technical viewpoint, from an infection management viewpoint and from a clinical viewpoint. These combined provide a common ground for comprehending what the AMR package could yield in the field and how it can set a new empowered starting point for future applications of microbial epidemiology, in clinical and research settings alike. This thesis subsequently elaborates on these multiple viewpoints by illustrating the use of this new instrument in epidemiological research projects in the Dutch-German cross-border region to better understand the occurrence and AMR patterns of microorganisms on a (eu)regional level. In conclusion, this thesis shows the added value of a consistent data-analytical instrument to prepare and analyse AMR data in a full-region approach, that can also be used in clinical settings to obtain novel insights on AMR patterns.</p>
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