Since their inception, hospital infection prevention (IP) and Antimicrobial Stewardship Programs (ASP) have worked to deploy interventions to mitigate risk of infection and antimicrobial resistance arising from our usual systems of care.1 They generated advances in quality improvement and patient safety, even before these were recognised fields. In an early evidence report commissioned by the US Agency for Healthcare Research and Quality in 2002, 4 of 11 safety practices with strongest supporting evidence were directly related to IP.2 An updated report in 2013 included six IP/ASP interventions in the top 10 safety strategies ready for widespread adoption.3

Despite the high-quality evidence supporting these IP/ASP interventions, our approach to adding these to our current practice sometimes feels like adding scaffolding to a rickety building. It supports the underlying structure but remove the scaffolding without fixing the building, and it may just come tumbling down. Consider efforts to improve hand hygiene, which have traditionally involved leadership/accountability, measurement/feedback and communication/marketing, while ensuring that hand sanitizer is available represents one of the only system changes in the WHO hand hygiene bundle.4 Nobody can deny that these interventions can lead to improved hand hygiene and some have even elegantly demonstrated significant reductions in healthcare-associated infections.5 But the question remains whether the scaffolding approach fosters sustainability of hand hygiene compliance without considering system changes that address recognised behavioural factors.6 Similarly we know that audit-and-feedback of targeted antimicrobial therapy leads to reductions in days of antimicrobial therapy, with some studies even demonstrating associated decreases in Clostridium difficile infection, an intended benefit of reducing antibiotic use.7 8 Yet when audit-and-feedback is discontinued, antimicrobial use rises again, suggesting that behaviour change does not easily result from this type of intervention, which requires continuous deployment to sustain these outcomes. …