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Impact of the "Zero Resistance" program on acquisition of multidrug-resistant bacteria in patients admitted to Intensive Care Units in Spain. A prospective, intervention, multimodal, multicenter study. Med Intensiva 2023; 47:193-202. [PMID: 36670011 DOI: 10.1016/j.medine.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess the impact of a multimodal interventional project ("Zero Resistance") on the acquisition of multidrug-resistant bacteria (MDR-B) during the patient's ICU stay. DESIGN Prospective, open-label, interventional, multicenter study. SETTING 103 ICUs. PATIENTS Critically ill patients admitted to the ICUs over a 27-month period. INTERVENTIONS Implementation of a bundle of 10 recommendations to prevent emergence and spread of MDR-B in the ICU. MAIN VARIABLE OF INTEREST Rate of patients acquiring MDR-B during their ICU stay, with differentiation between colonization and infection. RESULTS A total of 139,505 patients were included. In 5409 (3.9%) patients, 6020 MDR-B on ICU admission were identified, and in 3648 (2.6%) patients, 4269 new MDR-B during ICU stay were isolated. The rate of patients with MDR-B detected on admission increased significantly (IRR 1.43, 95% CI 1.31-1.56) (p<0.001) during the study period, with an increase of 32.2% between the initial and final monthly rates. On the contrary, the rate of patients with MDR-B during ICU stay decreased non-significantly (IRR 0.93, 95% CI 0.83-1.03) (p=0.174), with a 24.9% decrease between initial and final monthly rates. According to the classification into colonization or infection, there was a highly significant increase of MDR-B colonizations detected on admission (IRR 1.69, 95% CI 1.52-1.83; p<0.0001) and a very significant decrease of MDR-B-infections during ICU stay (IRR 0.67, 95% CI 0.57-0.80, p<0.0001). CONCLUSIONS The implementation of ZR project-recommendations was associated with a significantly reduction an infection produced by MDR-B acquired during the patient's ICU stay.
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Abella Álvarez A, Janeiro Lumbreras D, Lobo Valbuena B, Naharro Abellán A, Torrejón Pérez I, Enciso Calderón V, Varillas Delgado D, Conejo Márquez I, García Manzanedo S, López de la Oliva Calvo L, García Arias M, Gordo Vidal F. [Analysis of the predictive value of preventive isolation criteria in the intensive care unit]. Med Intensiva 2019; 45:205-210. [PMID: 31780256 DOI: 10.1016/j.medin.2019.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/23/2019] [Accepted: 09/16/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the diagnostic accuracy of the criteria used to detect patients carrying multiresistant microorganisms (MRMs). DESIGN A prospective observational study was carried out from May 2014 to May 2015. SETTING Polyvalent Intensive Care Unit. PATIENTS A cohort of consecutively admitted patients meeting the following criteria for preventive isolation according to the "Zero Resistance" project: hospital length of stay>4 days in the last three months ("hospital"); antibiotherapy during one week in the last month ("antibiotic"); institutionalized patients or recurrent contact with healthcare ("institution or care"); MRM carrier in the last 6 months ("previous MRM"). VARIABLES Demographic data, culture results and isolation time. A multivariate analysis was performed using multiple logistic regression between each of the risk factors and patient MRM carrier status. RESULTS During the study period, 575 patients were admitted, of which 28% met the isolation criteria (162). Fifty-one (31%) were MRM carriers. Of the patients who did not meet the criteria, 29 (7%) were carriers. In the multivariate analysis, the only variable independently associated to carrier status was "previous MRM", with OR=12.14 (95%CI 4.24-34.77). CONCLUSIONS The only criterion independently associated with the ability to detect patients with MRMs upon admission to the ICU was the existence of "previous MRM".
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Affiliation(s)
- A Abella Álvarez
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Madrid, España; Grupo de Investigación en Patología Crítica de la Universidad Francisco de Vitoria, Madrid, España
| | - D Janeiro Lumbreras
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Madrid, España
| | - B Lobo Valbuena
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Madrid, España; Grupo de Investigación en Patología Crítica de la Universidad Francisco de Vitoria, Madrid, España
| | - A Naharro Abellán
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Madrid, España
| | - I Torrejón Pérez
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Madrid, España; Grupo de Investigación en Patología Crítica de la Universidad Francisco de Vitoria, Madrid, España
| | - V Enciso Calderón
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Madrid, España
| | - D Varillas Delgado
- Grupo de Investigación en Patología Crítica de la Universidad Francisco de Vitoria, Madrid, España
| | - I Conejo Márquez
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Madrid, España
| | - S García Manzanedo
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Madrid, España
| | | | - M García Arias
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Madrid, España; Grupo de Investigación en Patología Crítica de la Universidad Francisco de Vitoria, Madrid, España
| | - F Gordo Vidal
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Madrid, España; Grupo de Investigación en Patología Crítica de la Universidad Francisco de Vitoria, Madrid, España.
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Shimizu K, Ogura H, Kabata D, Shintani A, Tasaki O, Ojima M, Ikeda M, Shimazu T. Association of prophylactic synbiotics with reduction in diarrhea and pneumonia in mechanically ventilated critically ill patients: A propensity score analysis. J Infect Chemother 2018; 24:795-801. [PMID: 30037757 DOI: 10.1016/j.jiac.2018.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 06/08/2018] [Accepted: 06/13/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The preventive association of synbiotics therapy has not been thoroughly clarified in mechanically ventilated patients. The purpose of this study was to evaluate whether synbiotics therapy has preventive association against septic complications in ventilated critically ill patients. METHODS Critically ill patients who were mechanically ventilated were included in this retrospective observational study. Patients who received synbiotics (Bifidobacterium breve, Lactobacillus casei, and galactooligosaccharides) within 3 days after admission (denoted as synbiotics group) were compared with patients who did not receive synbiotics. The incidences of enteritis, pneumonia, and bacteremia were evaluated as clinical outcome. Enteritis was defined as an acute onset of diarrhea consisting of continuous liquid watery stools for more than 12 h. The confounding factors include APACHE II on admission, gender, the cause of admission and antibiotics. RESULTS We included 179 patients in this study: 57 patients received synbiotics and 122 patients did not receive synbiotics. The incidences of enteritis were significantly lower in the synbiotics group compared with the control group (3.5% vs. 15.6%; p < 0.05). The odds ratios for diarrhea-free days during the first 28 days for the synbiotics group as compared with the controls were 4.354 (95% confidence interval (CI), 2.407 to 7.877; p < 0.001) in an ordinal logistic regression model with propensity scores. The odds ratios for pneumonia-free days during the first 28 days for the synbiotics group were 2.529 (95% CI, 1.715 to 3.731; p < 0.001). The incidences of bacteremia did not have significant differences. CONCLUSION Prophylactic synbiotics appeared to have preventive association on enteritis and pneumonia in mechanically ventilated critically ill patients.
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Affiliation(s)
- Kentaro Shimizu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan.
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan
| | - Daijiro Kabata
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-ku, Osaka, 545-0051, Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, 1-4-3, Asahimachi, Abeno-ku, Osaka, 545-0051, Japan
| | - Osamu Tasaki
- Nagasaki University Hospital Emergency Medical Center, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Masahiro Ojima
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan
| | - Mitsunori Ikeda
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan
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López‐Alcalde J, Mateos‐Mazón M, Guevara M, Conterno LO, Solà I, Cabir Nunes S, Bonfill Cosp X. Gloves, gowns and masks for reducing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in the hospital setting. Cochrane Database Syst Rev 2015; 2015:CD007087. [PMID: 26184396 PMCID: PMC7026606 DOI: 10.1002/14651858.cd007087.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Meticillin-resistant Staphylococcus aureus (MRSA; also known as methicillin-resistant S aureus) is a common hospital-acquired pathogen that increases morbidity, mortality, and healthcare costs. Its control continues to be an unresolved issue in many hospitals worldwide. The evidence base for the effects of the use of gloves, gowns or masks as control measures for MRSA is unclear. OBJECTIVES To assess the effectiveness of wearing gloves, a gown or a mask when contact is anticipated with a hospitalised patient colonised or infected with MRSA, or with the patient's immediate environment. SEARCH METHODS We searched the Specialised Registers of three Cochrane Groups (Wounds Group on 5 June 2015; Effective Practice and Organisation of Care (EPOC) Group on 9 July 2013; and Infectious Diseases Group on 5 January 2009); CENTRAL (The Cochrane Library 2015, Issue 6); DARE, HTA, NHS EED, and the Methodology Register (The Cochrane Library 2015, Issue 6); MEDLINE and MEDLINE In-Process & Other Non-Indexed Citations (1946 to June week 1 2015); EMBASE (1974 to 4 June 2015); Web of Science (WOS) Core Collection (from inception to 7 June 2015); CINAHL (1982 to 5 June 2015); British Nursing Index (1985 to 6 July 2010); and ProQuest Dissertations & Theses Database (1639 to 11 June 2015). We also searched three trials registers (on 6 June 2015), references list of articles, and conference proceedings. We finally contacted relevant individuals for additional studies. SELECTION CRITERIA Studies assessing the effects on MRSA transmission of the use of gloves, gowns or masks by any person in the hospital setting when contact is anticipated with a hospitalised patient colonised or infected with MRSA, or with the patient's immediate environment. We did not assess adverse effects or economic issues associated with these interventions.We considered any comparator to be eligible. With regard to study design, only randomised controlled trials (clustered or not) and the following non-randomised experimental studies were eligible: quasi-randomised controlled trials (clustered or not), non-randomised controlled trials (clustered or not), controlled before-and-after studies, controlled cohort before-after studies, interrupted time series studies (controlled or not), and repeated measures studies. We did not exclude any study on the basis of language or date of publication. DATA COLLECTION AND ANALYSIS Two review authors independently decided on eligibility of the studies. Had any study having been included, two review authors would have extracted data (at least for outcome data) and assessed the risk of bias independently. We would have followed the standard methodological procedures suggested by Cochrane and the Cochrane EPOC Group for assessing risk of bias and analysing the data. MAIN RESULTS We identified no eligible studies for this review, either completed or ongoing. AUTHORS' CONCLUSIONS We found no studies assessing the effects of wearing gloves, gowns or masks for contact with MRSA hospitalised patients, or with their immediate environment, on the transmission of MRSA to patients, hospital staff, patients' caregivers or visitors. This absence of evidence should not be interpreted as evidence of no effect for these interventions. The effects of gloves, gowns and masks in these circumstances have yet to be determined by rigorous experimental studies, such as cluster-randomised trials involving multiple wards or hospitals, or interrupted time series studies.
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Affiliation(s)
- Jesús López‐Alcalde
- CIBER Epidemiología y Salud Pública (CIBERESP) ‐ Universitat Autònoma de BarcelonaIberoamerican Cochrane Centre ‐ Biomedical Research Institute Sant Pau (IIB Sant Pau)BarcelonaCatalunyaSpain08041
| | - Marta Mateos‐Mazón
- University Hospital Central de AsturiasDepartment of Preventive MedicineAvenida de Roma s/nOviedoOviedoSpain33006
| | - Marcela Guevara
- Public Health Institute of Navarre, CIBER Epidemiología y Salud Pública (CIBERESP), IdiSNAC/ Leyre 15PamplonaNavarreSpainE‐31003
| | - Lucieni O Conterno
- Marilia Medical SchoolDepartment of General Internal Medicine and Clinical Epidemiology UnitAvenida Monte Carmelo 800FragataMariliaSão PauloBrazil17519‐030
| | - Ivan Solà
- CIBER Epidemiología y Salud Pública (CIBERESP) ‐ Universitat Autònoma de BarcelonaIberoamerican Cochrane Centre ‐ Biomedical Research Institute Sant Pau (IIB Sant Pau)BarcelonaCatalunyaSpain08041
| | | | - Xavier Bonfill Cosp
- CIBER Epidemiología y Salud Pública (CIBERESP) ‐ Universitat Autònoma de BarcelonaIberoamerican Cochrane Centre ‐ Biomedical Research Institute Sant Pau (IIB Sant Pau)BarcelonaCatalunyaSpain08041
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Optimization of pre-emptive isolations in a polyvalent ICU through implementation of an intervention strategy. Med Intensiva 2015; 39:543-51. [PMID: 25798954 DOI: 10.1016/j.medin.2014.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 11/08/2014] [Accepted: 11/30/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pre-emptive isolation refers to the application of contact precaution measures in patients with strongly suspected colonization by multiresistant bacteria. OBJECTIVE To assess the impact of an intervention program involving the implementation of a consensus-based protocol of pre-emptive isolation (CPPI) on admission to a polyvalent ICU of a general hospital. METHODS A comparative analysis of 2 patient cohorts was made: a historical cohort including patients in which pre-emptive isolation was established according to physician criterion prior to starting CPPI (from January 2010 to February 2011), and a prospective cohort including patients in which CPPI was implemented (from March to November 2011). CPPI included the identification and diffusion of pre-emptive isolation criteria, the definition of sampling methodology, the evaluation of results, and the development of criteria for discontinuation of pre-emptive isolation. Pre-emptive isolation was indicated by the medical staff, and follow-up was conducted by the nursing staff. Pre-emptive isolation was defined as "adequate" when at least one multiresistant bacteria was identified in any of the samples. Comparison of data between the 2 periods was made with the chi-square test for categorical variables and the Student t-test for quantitative variables. Statistical significance was set at P<.05. RESULTS Among the 1,740 patients admitted to the ICU (1,055 during the first period and 685 during the second period), pre-emptive isolation was indicated in 199 (11.4%); 111 (10.5%) of these subjects corresponded to the historical cohort (control group) and 88 (12.8%) to the posterior phase after the implementation of CPPI (intervention group). No differences were found in age, APACHE II score or patient characteristics between the 2 periods. The implementation of CPPI was related to decreases in non-indicated pre-emptive isolations (29.7 vs. 6.8%, P<.001), time of requesting surveillance cultures (1.56 vs. 0.37 days, P<.001), and days of duration of treatment (4.77 vs. 3.58 days, P<.001). In 44 patients (22.1%) in which pre-emptive isolation was indicated, more than one multiresistant bacteria was identified, with an "adequate pre-emptive isolation rate" of 19.8% in the first period and 25.0% in the second period (P<.382). CONCLUSIONS The implementation of CPPI resulted in a significant decrease in pre-emptive isolations which were not indicated correctly, a decrease in the time elapsed between isolation and collection of samples, and a decrease in the duration of isolation measures in cases in which isolation was unnecessary, without increasing the rate of "adequate pre-emptive isolation".
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Camus C, Sebille V, Legras A, Garo B, Renault A, Le Corre P, Donnio PY, Gacouin A, Perrotin D, Le Tulzo Y, Bellissant E. Mupirocin/chlorexidine to prevent methicillin-resistant Staphylococcus aureus infections: post hoc analysis of a placebo-controlled, randomized trial using mupirocin/chlorhexidine and polymyxin/tobramycin for the prevention of acquired infections in intubated patients. Infection 2014; 42:493-502. [PMID: 24464791 DOI: 10.1007/s15010-013-0581-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 12/24/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE The reduction in acquired infections (AI) due to methicillin-resistant Staphylococcus aureus (MRSA) with the mupirocin/chlorhexidine (M/C) decontamination regimen has not been well studied in intubated patients. We performed post hoc analysis of a prior trial to assess the impact of M/C on MRSA AI and colonization. METHODS We conducted a multicenter, placebo-controlled, randomized, double-blind study with the primary aim to reduce all-cause AI. The two regimens used [topical polymyxin and tobramycin (P/T), nasal mupirocin with chlorhexidine body wash (M/C), or corresponding placebos for each regimen] were administered according to a 2 × 2 factorial design. Participants were intubated patients in the intensive care units of three French university hospitals. The patients enrolled in the study (n = 515) received either active P/T (n = 130), active M/C (n = 130), both active regimens (n = 129), or placebos only (n = 126) for the period of intubation and an additional 24 h. The incidence and incidence rates (per 1,000 study days) of MRSA AI were assessed. Due to the absence of a statistically significant interaction between the two regimens, analysis was performed at the margins by comparing all patient receiving M/C (n = 259) to all patients not receiving M/C (n = 256), and all patients receiving P/T (n = 259) to all patients not receiving P/T (n = 256). RESULTS Incidence [odds ratio (OR) 0.39, 95 % confidence interval (CI) (0.16-0.96), P = 0.04] and incidence rates [incidence rate ratio (IRR) 0.41, 95 % CI 0.17-0.97, P = 0.05] of MRSA AI were significantly lower with the use of M/C. We also observed an increase in the incidence (OR 2.50, 95 % CI 1.01-6.15, P = 0.05) and the incidence rate (IRR 2.90, 95 % CI 1.20-8.03, P = 0.03) of MRSA AI with the use of P/T. CONCLUSION Among our study cohort of intubated patients, the use of M/C significantly reduced MRSA AI.
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Affiliation(s)
- C Camus
- Service de Maladies Infectieuses et Réanimation Médicale, Hôpital de Pontchaillou, Centre Hospitalier Universitaire (CHU) de Rennes, Université de Rennes 1, 2 rue Henri Le Guilloux, 35033, Rennes cedex, France,
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Impact of pre-emptive contact precautions for outborn neonates on the incidence of healthcare-associated meticillin-resistant Staphylococcus aureus transmission in a Japanese neonatal intensive care unit. J Hosp Infect 2013; 84:66-70. [DOI: 10.1016/j.jhin.2012.12.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Accepted: 12/31/2012] [Indexed: 11/17/2022]
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Transfer of multidrug-resistant bacteria to healthcare workers' gloves and gowns after patient contact increases with environmental contamination. Crit Care Med 2012; 40:1045-51. [PMID: 22202707 DOI: 10.1097/ccm.0b013e31823bc7c8] [Citation(s) in RCA: 164] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the role of environmental contamination in the transmission of multidrug-resistant bacteria to healthcare workers' clothing. DESIGN Prospective cohort. SETTING Six intensive care units at a tertiary care hospital. SUBJECTS Healthcare workers including registered nurses, patient care technicians, respiratory therapists, occupational/physical therapists, and physicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred twenty of 585 (20.5%) healthcare worker/patient interactions resulted in contamination of healthcare workers' gloves or gowns. Multidrug-resistant Acinetobacter baumannii contamination occurred most frequently, 55 of 167 observations (32.9%; 95% confidence interval [CI] 25.8% to 40.0%), followed by multidrug-resistant Pseudomonas aeruginosa, 15 of 86 (17.4%; 95% CI 9.4% to 25.4%), vancomycin-resistant Enterococcus, 25 of 180 (13.9%, 95% CI 8.9, 18.9%) and methicillin-resistant Staphylococcus aureus, 21 of 152 (13.8%; 95% CI 8.3% to 19.2%). Independent risk factors associated with healthcare worker contamination with multidrug-resistant bacteria were positive environmental cultures (odds ratio [OR] 4.2; 95% CI 2.7-6.5), duration in room for >5 mins (OR 2.0; 95% CI 1.2-3.4), performing physical examinations (OR 1.7; 95% CI 1.1-2.8), and contact with the ventilator (OR 1.8; 95% CI, 1.1-2.8). Pulsed field gel electrophoresis determined that 91% of healthcare worker isolates were related to an environmental or patient isolate. CONCLUSIONS The contamination of healthcare workers' protective clothing during routine care of patients with multidrug-resistant organisms is most frequent with A. baumannii. Environmental contamination was the major determinant of transmission to healthcare workers' gloves or gowns. Compliance with contact precautions and more aggressive environmental cleaning may decrease transmission.
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