This study represents the second large-scale assessment of IPC structures and processes in Austrian hospitals using the IPCAF. With 81 participating hospitals, the survey included a convenience sample of all Austrian acute care hospitals (152 as of 2022, [16]), and therefore provides a robust dataset enabling insights into the current state of IPC practices in Austria. To the best of our knowledge, it is the second national IPC re-assessment utilizing the IPCAF, following the recently reported German survey with 660 participating hospitals [15].

The 58.3% response rate observed in 2023 highlights the overall positive uptake of the IPCAF in Austria. The number of hospitals participating in the IPCAF survey in 2023 was higher than in 2018 (81 vs. 65), indicating a growing interest in the tool. The median overall IPCAF score of 645 corresponds to an advanced level of IPC, and largely coincides with data reported from other high-income countries [4, 7, 10, 12,13,14]. The median score in 2023 was slightly higher than in 2018 (4% increase). Notably, the proportion of hospitals allocated to an advanced IPC level has increased since 2018, indicating marked progress in IPC structures and practices in Austrian hospitals.

Despite overall improvements, certain CC demonstrated relatively low median scores. For instance, CC3 (IPC education and training) continued to show suboptimal implementation. A potential explanation is the absence of legally mandated IPC training in Austria. This highlights the need for a greater emphasis on IPC education, as numerous studies have underscored its critical role in reducing rates of healthcare-associated infections, particularly when hands-on training for healthcare workers is employed [17,18,19,20].

Similar to findings from 2018, scores for CC5 (multimodal strategies for the implementation of IPC interventions) were rather low, which is also consistent with findings from other countries [7, 10, 14]. This may be due to the complexity of the concept and a potential lack of knowledge or experience with the individual modules, indicating the need for more comprehensive education and more clarity around the application of multimodal strategies in IPC.

For CC5 and CC7 (workload, staffing, and bed occupancy), significant inter-hospital variability was observed, illustrating a degree of heterogeneity among Austrian hospitals with regard to these topics. Interestingly, results from the 2023 German IPCAF survey, as well as from the global IPCAF survey in 2019, showed a comparable level of heterogeneity regarding these CC [12, 15]. However, as with any divergent result observed in such survey, heterogeneity in responses may also be attributable to difficulties in interpreting specific questions or ambiguous response options. For example, a positive response to the fifth question of CC5 (“Do these strategies include bundles or checklists”) can mean the use of bundles or the use of checklists or the use of both.

When examining potential areas of improvement that were noted in the 2018 Austrian IPCAF survey, some improvements were observed, though they were limited. For instance, while the respective question in CC5 indicated an increased use of strategies like bundles and checklists (79% vs. 64.6%), the median score of CC5 rose only by three points. Considerable improvements were observed in CC1, including a more than twofold increase in hospitals employing a full-time IPC professional per 250 beds and an increase in the number of hospitals with IPC committees. These advancements might indicate a growing awareness of the importance of IPC and a corresponding willingness to invest in dedicated IPC personnel and structures. This increased commitment reflects a broader recognition of the critical role that robust IPC infrastructure plays in enhancing IPC practices. Conversely, when looking at overall staffing indicators that are addressed in the IPCAF (CC7), no clear trend was observed. This is important to mention, because 20% of hospitals did not maintain the agreed ratio of health care workers to patients in at least 50% of units. Because understaffing is a known risk factor for poorer adherence to IPC measures [21], which cannot be compensated solely by an increase of IPC personnel, and considering the still suboptimal implementation of IPC training, future efforts should focus on better monitoring the workload of health care workers and offering training programs for less qualified personnel. No improvement was observed concerning IPC training-related questions in CC3. For example, the percentage of hospitals providing mandatory annual IPC training for staff has not increased between 2018 and 2023, and the proportion of hospitals employing interactive training methods has declined since 2018. This perceived lack of progress is surprising, given the potential of the COVID-19 pandemic to increase recognition of the importance of comprehensive IPC training. However, it could be related to a more focused training, rather than comprehensively addressing all the required IPC knowledge [22]. Scores of questions on surveillance activities (CC4), such as surveillance of multidrug-resistant organisms and antimicrobial resistance, showed only modest progress, likely due to the substantial time and resources required. This is particularly relevant given that the hospitals participating in the survey were already more integrated into surveillance networks, due to their participation in KISS. Their limited progress in these areas underscores the challenges of enhancing surveillance, even where surveillance programs are already present.

Our study has several limitations. First, data reported in this survey does not stem from a representative sample of Austrian hospitals and consequently, may not fully align with the overall IPC situation in Austrian hospitals. Here, it is particularly relevant that the hospitals invited to this survey, were all participants in the German national surveillance network, potentially reflecting a higher-than-average interest in IPC, which could be even more the case for responding hospitals. However, given the large number of participating hospitals, which are a substantial portion of all Austrian acute care hospitals, cautious national extrapolation of the study findings appears justifiable, although a future survey should consider measures to further increase the representativeness. Second, despite explanatory footnotes, not all participants might have been familiar with some complex concepts that were addressed in the IPCAF, such as multimodal strategies, possibly causing erroneous responses. Third, some questions might have been perceived as sensitive, potentially leading to biased responses despite survey confidentiality. Fourth, datasets from hospitals participating in both surveys were not directly linked, precluding longitudinal analysis. Thus, observed differences in IPCAF scores might reflect cohort variations rather than actual changes. Nonetheless, the high number of participating hospitals in both surveys reduces the risk of such distortions. Lastly, given that the IPCAF is designed for global use, certain questions, such as those related to the built environment (CC8), may be only partially applicable for an IPC assessment in high-income settings, where positive responses are almost universal.