Attempts to control clothes-borne infection in a burn unit, 3. An open-roofed plastic isolator or plastic aprons to prevent contact transfer of bacteria

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed.

OBJECTIVES

To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020.

SELECTION CRITERIA

We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate.

MAIN RESULTS

Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants) coveralls were more difficult to doff than isolation gowns (very low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). According to three studies that tested more recently introduced full-body PPE ensembles, there may be no difference in contamination. Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only.

AUTHORS' CONCLUSIONS

We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed.

OBJECTIVES

To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020.

SELECTION CRITERIA

We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate.

MAIN RESULTS

Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants), people with a long gown had less contamination than those with a coverall, and coveralls were more difficult to doff (low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only.

AUTHORS' CONCLUSIONS

We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort, and may therefore even lead to more contamination. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.

Anatomy of a viral entry platform differentially functionalized by integrins α3 and α6

During cell invasion, human papillomaviruses use large CD151 patches on the cell surface. Here, we studied whether these patches are defined architectures with features for virus binding and/or internalization. Super-resolution microscopy reveals that the patches are assemblies of closely associated nanoclusters of CD151, integrin α3 and integrin α6. Integrin α6 is required for virus attachment and integrin α3 for endocytosis. We propose that CD151 organizes viral entry platforms with different types of integrin clusters for different functionalities. Since numerous viruses use tetraspanin patches, we speculate that this building principle is a blueprint for cell-surface architectures utilized by viral particles.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or Severe Acute Respiratory Syndrome (SARS), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Contact precautions by means of personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCW use PPE as instructed.

OBJECTIVES

To evaluate which type of full body PPE and which method of donning or doffing PPE have the least risk of self-contamination or infection for HCW, and which training methods increase compliance with PPE protocols.

SEARCH METHODS

We searched MEDLINE (PubMed up to 15 July 2018), Cochrane Central Register of Trials (CENTRAL up to 18 June 2019), Scopus (Scopus 18 June 2019), CINAHL (EBSCOhost 31 July 2018), and OSH-Update (up to 31 December 2018). We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE.

SELECTION CRITERIA

We included all controlled studies that compared the effects of PPE used by HCW exposed to highly infectious diseases with serious consequences, such as Ebola or SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that used simulated contamination with fluorescent markers or a non-pathogenic virus.We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training in PPE use on the same outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We planned to perform meta-analyses but did not find sufficiently similar studies to combine their results.

MAIN RESULTS

We included 17 studies with 1950 participants evaluating 21 interventions. Ten studies are Randomised Controlled Trials (RCTs), one is a quasi RCT and six have a non-randomised controlled design. Two studies are awaiting assessment.Ten studies compared types of PPE but only six of these reported sufficient data. Six studies compared different types of donning and doffing and three studies evaluated different types of training. Fifteen studies used simulated exposure with fluorescent markers or harmless viruses. In simulation studies, contamination rates varied from 10% to 100% of participants for all types of PPE. In one study HCW were exposed to Ebola and in another to SARS.Evidence for all outcomes is based on single studies and is very low quality.Different types of PPEPPE made of more breathable material may not lead to more contamination spots on the trunk (Mean Difference (MD) 1.60 (95% Confidence Interval (CI) -0.15 to 3.35) than more water repellent material but may have greater user satisfaction (MD -0.46; 95% CI -0.84 to -0.08, scale of 1 to 5).Gowns may protect better against contamination than aprons (MD large patches -1.36 95% CI -1.78 to -0.94).The use of a powered air-purifying respirator may protect better than a simple ensemble of PPE without such respirator (Relative Risk (RR) 0.27; 95% CI 0.17 to 0.43).Five different PPE ensembles (such as gown vs. coverall, boots with or without covers, hood vs. cap, length and number of gloves) were evaluated in one study, but there were no event data available for compared groups.Alterations to PPE design may lead to less contamination such as added tabs to grab masks (RR 0.33; 95% CI 0.14 to 0.80) or gloves (RR 0.22 95% CI 0.15 to 0.31), a sealed gown and glove combination (RR 0.27; 95% CI 0.09 to 0.78), or a better fitting gown around the neck, wrists and hands (RR 0.08; 95% CI 0.01 to 0.55) compared to standard PPE.Different methods of donning and doffing proceduresDouble gloving may lead to less contamination compared to single gloving (RR 0.36; 95% CI 0.16 to 0.78).Following CDC recommendations for doffing may lead to less contamination compared to no guidance (MD small patches -5.44; 95% CI -7.43 to -3.45).Alcohol-based hand rub used during the doffing process may not lead to less contamination than the use of a hypochlorite based solution (MD 4.00; 95% CI 0.47 to 34.24).Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4).Different types of trainingThe use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7).A video lecture on donning PPE may lead to better skills scores (MD 30.70; 95% CI 20.14,41.26) than a traditional lecture.Face to face instruction may reduce noncompliance with doffing guidance more (OR 0.45; 95% CI 0.21 to 0.98) than providing folders or videos only.There were no studies on effects of training in the long term or on resource use.The quality of the evidence is very low for all comparisons because of high risk of bias in all studies, indirectness of evidence, and small numbers of participants.

AUTHORS' CONCLUSIONS

We found very low quality evidence that more breathable types of PPE may not lead to more contamination, but may have greater user satisfaction. Alterations to PPE, such as tabs to grab may decrease contamination. Double gloving, following CDC doffing guidance, and spoken instructions during doffing may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than video or folder based training. Because data come from single small studies with high risk of bias, we are uncertain about the estimates of effects.We still need randomised controlled trials to find out which training works best in the long term. We need better simulation studies conducted with several dozen participants to find out which PPE protects best, and what is the safest way to remove PPE. Consensus on the best way to conduct simulation of exposure and assessment of outcome is urgently needed. HCW exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection in the field.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or SARS, healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Contact precautions by means of personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCWs use PPE as instructed.

OBJECTIVES

To evaluate which type or component of full-body PPE and which method of donning or removing (doffing) PPE have the least risk of self-contamination or infection for HCWs, and which training methods most increase compliance with PPE protocols.

SEARCH METHODS

We searched MEDLINE (PubMed up to 8 January 2016), Cochrane Central Register of Trials (CENTRAL up to 20 January 2016), EMBASE (embase.com up to 8 January 2016), CINAHL (EBSCOhost up to 20 January 2016), and OSH-Update up to 8 January 2016. We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE.

SELECTION CRITERIA

We included all eligible controlled studies that compared the effect of types or components of PPE in HCWs exposed to highly infectious diseases with serious consequences, such as EVD and SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that simulated contamination with fluorescent markers or a non-pathogenic virus.We also included studies that compared the effect of various ways of donning or removing PPE, and the effects of various types of training in PPE use on the same outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We intended to perform meta-analyses but we did not find sufficiently similar studies to combine their results.

MAIN RESULTS

We included nine studies with 1200 participants evaluating ten interventions. Of these, eight trials simulated the exposure with a fluorescent marker or virus or bacteria containing fluids. Five studies evaluated different types of PPE against each other but two did not report sufficient data. Another two studies compared different types of donning and doffing and three studies evaluated the effect of different types of training.None of the included studies reported a standardised classification of the protective properties against viral penetration of the PPE, and only one reported the brand of PPE used. None of the studies were conducted with HCWs exposed to EVD but in one study participants were exposed to SARS. Different types of PPE versus each otherIn simulation studies, contamination rates varied from 25% to 100% of participants for all types of PPE. In one study, PPE made of more breathable material did not lead to a statistically significantly different number of spots with contamination but did have greater user satisfaction (Mean Difference (MD) -0.46 (95% Confidence Interval (CI) -0.84 to -0.08, range 1 to 5, very low quality evidence). In another study, gowns protected better than aprons. In yet another study, the use of a powered air-purifying respirator protected better than a now outdated form of PPE. There were no studies on goggles versus face shields, on long- versus short-sleeved gloves, or on the use of taping PPE parts together. Different methods of donning and doffing procedures versus each otherTwo cross-over simulation studies (one RCT, one CCT) compared different methods for donning and doffing against each other. Double gloving led to less contamination compared to single gloving (Relative Risk (RR) 0.36; 95% CI 0.16 to 0.78, very low quality evidence) in one simulation study, but not to more noncompliance with guidance (RR 1.08; 95% CI 0.70 to 1.67, very low quality evidence). Following CDC recommendations for doffing led to less contamination in another study (very low quality evidence). There were no studies on the use of disinfectants while doffing. Different types of training versus each otherIn one study, the use of additional computer simulation led to less errors in doffing (MD -1.2, 95% CI -1.6 to -0.7) and in another study additional spoken instruction led to less errors (MD -0.9, 95% CI -1.4 to -0.4). One retrospective cohort study assessed the effect of active training - defined as face-to-face instruction - versus passive training - defined as folders or videos - on noncompliance with PPE use and on noncompliance with doffing guidance. Active training did not considerably reduce noncompliance in PPE use (Odds Ratio (OR) 0.63; 95% CI 0.31 to 1.30) but reduced noncompliance with doffing procedures (OR 0.45; 95% CI 0.21 to 0.98, very low quality evidence). There were no studies on how to retain the results of training in the long term or on resource use.The quality of the evidence was very low for all comparisons because of high risk of bias in studies, indirectness of evidence, and small numbers of participants. This means that it is likely that the true effect can be substantially different from the one reported here.

AUTHORS' CONCLUSIONS

We found very low quality evidence that more breathable types of PPE may not lead to more contamination, but may have greater user satisfaction. We also found very low quality evidence that double gloving and CDC doffing guidance appear to decrease the risk of contamination and that more active training in PPE use may reduce PPE and doffing errors more than passive training. However, the data all come from single studies with high risk of bias and we are uncertain about the estimates of effects.We need simulation studies conducted with several dozens of participants, preferably using a non-pathogenic virus, to find out which type and combination of PPE protects best, and what is the best way to remove PPE. We also need randomised controlled studies of the effects of one type of training versus another to find out which training works best in the long term. HCWs exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection.

Nursing and physician attire as possible source of nosocomial infections

BACKGROUND

Uniforms worn by medical and nursing staff are not usually considered important in the transmission of microorganisms. We investigated the rate of potentially pathogenic bacteria present on uniforms worn by hospital staff, as well as the bacterial load of these microorganisms.

METHODS

Cultures were obtained from uniforms of nurses and physicians by pressing standard blood agar plates at the abdominal zone, sleeve ends, and pockets. Each participant completed a questionnaire.

RESULTS

A total of 238 samples were collected from 135 personnel, including 75 nurses (55%) and 60 physicians (45%). Of these, 79 (58%) claimed to change their uniform every day, and 104 (77%) defined the level of hygiene of their attire as fair to excellent. Potentially pathogenic bacteria were isolated from at least one site of the uniforms of 85 participants (63%) and were isolated from 119 samples (50%); 21 (14%) of the samples from nurses' gowns and 6 (6%) of the samples from physicians' gowns (P = NS) included of antibiotic-resistant bacteria.

CONCLUSION

Up to 60% of hospital staff's uniforms are colonized with potentially pathogenic bacteria, including drug-resistant organisms. It remains to be determined whether these bacteria can be transferred to patients and cause clinically relevant infection.

Bacterial flora on the white coats of medical students

This study has demonstrated that the white coats of medical students are more likely to be bacteriologically contaminated at points of frequent contact, such as the sleeve and pocket. The organisms identified were principally skin commensals including Staphylococcus aureus. The cleanliness of the coat as perceived by the student was correlated with bacteriological contamination, yet despite this, a significant proportion of students only laundered their coats occassionally. This study supports the view that the students' white coat is a potential source of cross infection on the ward and its design should be modified in order to facilitate hand washing. Hospitals training medical students should consider taking on the burden of providing freshly laundered white coats for the students.

Reduction of nosocomial infection during pediatric intensive care by protective isolation

To determine whether simple protective isolation reduces the incidence of nosocomial bacterial and fungal infection during pediatric intensive care, we randomly assigned 70 children who were not immuno-suppressed and who required mechanical ventilatory support and three or more days of intensive care to receive standard care (n = 38) or protective isolation (n = 32) with use of disposable, non-waven, polypropylene gowns and nonsterile latex gloves. Risk factors predisposing patients to infection were comparable in the two groups. Nosocomial colonization occurred later among isolated patients (median, vs. 7 days; P less than 0.01) and was associated with subsequent infection in 12 patients, as compared with 12 patients given standard care (P = 0.01). Among patients who were isolated, the interval before the first infection was significantly longer than (median, 20 vs. 8 days; P = 0.04), the daily infection rate was 2.2 times lower than (95 percent confidence interval, 1.2 to 4.0; P = 0.007), and there were fewer days with fewer (13 percent vs. 21 percent; P = 0.001). The benefit of isolation was most notable after seven days of intensive care. Isolation was well tolerated by patients and their families. Regular monitoring showed that the children in each group were touched and handled comparably often by hospital personnel and family members. We conclude that the use of disposable, high-barrier gowns and gloves for the care of selected, high-risk children who require prolonged intensive care significantly reduces the incidence of nosocomial infection, is well tolerated, and does not compromise the delivery of care.

Methicillin-resistant Staphylococcus aureus in two burn units: clinical significance and epidemiological control

Routine isolation adequately controlled MRSA strains in two burns units with a restrictive antibiotic policy. Ventilation control and more rigorous change of clothing offered no further advantage. No carriers among staff were found, but some suffered minor skin lesions that were the source of further MRSA spread. Spread of MRSA from the unit to other parts of the hospital was prevented by early identification of colonized patients and by restricting patient and staff movement.

Nosocomial infection--the irreducible minimum

Prevalence surveys in different countries have shown that about 1 in 10 hospitalized patients at any one time have acquired an infection and the incidence of infection is usually about 3% to 5%. Can this infection rate be significantly reduced and is there an irreducible minimum below which further reduction cannot be obtained? Cross-infection could probably be almost eliminated by the use of plastic isolators or life islands, and endogenous infections reduced by the wider and more rational prophylactic use of topical and systemic antimicrobial agents, and possibly a range of vaccines. However, the use of these techniques on all patients would clearly be impractical and too expensive for use in the foreseeable future. Excessive isolation techniques would have a detrimental psychological effect on many patients. In addition, failure to eradicate the organisms of the normal flora might be associated with more infections caused by antibiotic-resistant bacteria, fungi and viruses which would be more difficult to treat. Even if organisms could be eradicated, morbidity and mortality might not be correspondingly reduced. Priorities must therefore be set on the most effective use of staff and finances. These not only involve a consideration of infection, but all areas of clinical practice, eg, costs of cardiac transplants and provision of geriatric facilities. It therefore seems likely that little additional finance will be available for control of infection, other than possibly for transmissible infections with high mortality such as AIDS.