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Graves N, Mitchell BG, Otter JA, Kiernan M. The cost-effectiveness of temporary single-patient rooms to reduce risks of healthcare-associated infection. J Hosp Infect 2021; 116:21-28. [PMID: 34246721 DOI: 10.1016/j.jhin.2021.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/30/2021] [Accepted: 07/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The use of single rooms for patient isolation often forms part of a wider bundle to prevent certain healthcare-associated infections (HAIs) in hospitals. Demand for single rooms often exceeds what is available and the use of temporary isolation rooms may help resolve this. Changes to infection prevention practice should be supported by evidence showing that cost-effectiveness is plausible and likely. AIM To perform a cost-effectiveness evaluation of adopting temporary single rooms into UK National Health Service (NHS) hospitals. METHODS The cost-effectiveness of a decision to adopt a temporary, single-patient, isolation room to the current infection prevention efforts of an NHS hospital was modelled. Primary outcomes are the expected change to total costs and life-years from an NHS perspective. FINDINGS The mean expected incremental cost per life-year gained (LYG) is £5,829. The probability that adoption is cost-effective against a £20,000 threshold per additional LYG is 93%, and for a £13,000 threshold the probability is 87%. The conclusions are robust to scenarios for key model parameters. If a temporary single-patient isolation room reduces risks of HAI by 16.5% then an adoption decision is more likely to be cost-effective than not. Our estimate of the effectiveness reflects guidelines and reasonable assumptions and the theoretical rationale is strong. CONCLUSION Despite uncertainties about the effectiveness of temporary isolation rooms for reducing risks of HAI, there is some evidence that an adoption decision is likely to be cost-effective for the NHS setting. Prospective studies will be useful to reduce this source of uncertainty.
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Affiliation(s)
- N Graves
- Health Services & Systems Research, Duke-NUS Medical School, Singapore.
| | - B G Mitchell
- School of Nursing and Midwifery, University of Newcastle, Ourimbah, NSW, Australia
| | - J A Otter
- National Institute for Healthcare Research Health Protection Research Unit (NIHR HPRU) in HCAI and AMR, Imperial College London & Public Health England, Hammersmith Hospital, London, UK
| | - M Kiernan
- Gama Healthcare Ltd, Hemel Hempstead, UK
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Kluytmans-van den Bergh MFQ, Bruijning-Verhagen PCJ, Vandenbroucke-Grauls CMJE, de Brauwer EIGB, Buiting AGM, Diederen BM, van Elzakker EPM, Friedrich AW, Hopman J, Al Naiemi N, Rossen JWA, Ruijs GJHM, Savelkoul PHM, Verhulst C, Vos MC, Voss A, Bonten MJM, Kluytmans JAJW. Contact precautions in single-bed or multiple-bed rooms for patients with extended-spectrum β-lactamase-producing Enterobacteriaceae in Dutch hospitals: a cluster-randomised, crossover, non-inferiority study. THE LANCET. INFECTIOUS DISEASES 2019; 19:1069-1079. [PMID: 31451419 DOI: 10.1016/s1473-3099(19)30262-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/24/2019] [Accepted: 05/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Use of single-bed rooms for control of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae is under debate; the added value when applying contact precautions has not been shown. We aimed to assess whether an isolation strategy of contact precautions in a multiple-bed room was non-inferior to a strategy of contact precautions in a single-bed room for preventing transmission of ESBL-producing Enterobacteriaceae. METHODS We did a cluster-randomised, crossover, non-inferiority study on medical and surgical wards of 16 Dutch hospitals. During two consecutive study periods, either contact precautions in a single-bed room or contact precautions in a multiple-bed room were applied as the preferred isolation strategy for patients with ESBL-producing Enterobacteriaceae cultured from a routine clinical sample (index patients). Eligible index patients were aged 18 years or older, had no strict indication for barrier precautions in a single-bed room, had a culture result reported within 7 days of culture and before discharge, and had no wardmate known to be colonised or infected with an ESBL-producing Enterobacteriaceae isolate of the same bacterial species with a similar antibiogram. Hospitals were randomly assigned in a 1:1 ratio by computer to one of two sequences of isolation strategies, stratified by university or non-university hospital. Allocation was masked for laboratory technicians who assessed the outcomes but not for patients, treating doctors, and infection-control practitioners enrolling index patients. The primary outcome was transmission of ESBL-producing Enterobacteriaceae to wardmates, which was defined as rectal carriage of an ESBL-producing Enterobacteriaceae isolate that was clonally related to the index patient's isolate in at least one wardmate. The primary analysis was done in the per-protocol population, which included patients who were adherent to the assigned room type. A 10% non-inferiority margin for the risk difference was used to assess non-inferiority. This study is registered with Nederlands Trialregister, NTR2799. FINDINGS 16 hospitals were randomised, eight to each sequence of isolation strategies. All hospitals randomised to the sequence single-bed room then multiple-bed room and five of eight hospitals randomised to the sequence multiple-bed room then single-bed room completed both study periods and were analysed. From April 24, 2011, to Feb 27, 2014, 1652 index patients and 12 875 wardmates were assessed for eligibility. Of those, 693 index patients and 9527 wardmates were enrolled and 463 index patients and 7093 wardmates were included in the per-protocol population. Transmission of ESBL-producing Enterobacteriaceae to at least one wardmate was identified for 11 (4%) of 275 index patients during the single-bed room strategy period and for 14 (7%) of 188 index patients during the multiple-bed room strategy period (crude risk difference 3·4%, 90% CI -0·3 to 7·1). INTERPRETATION For patients with ESBL-producing Enterobacteriaceae cultured from a routine clinical sample, an isolation strategy of contact precautions in a multiple-bed room was non-inferior to a strategy of contact precautions in a single-bed room for preventing transmission of ESBL-producing Enterobacteriaceae. Non-inferiority of the multiple-bed room strategy might change the current single-bed room preference for isolation of patients with ESBL-producing Enterobacteriaceae and, thus, broaden infection-control options for ESBL-producing Enterobacteriaceae in daily clinical practice. FUNDING Netherlands Organisation for Health Research and Development.
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Affiliation(s)
- Marjolein F Q Kluytmans-van den Bergh
- Department of Infection Control, Amphia Hospital, Breda, Netherlands; Amphia Academy Infectious Disease Foundation, Amphia Hospital, Breda, Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands.
| | - Patricia C J Bruijning-Verhagen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
| | - Christina M J E Vandenbroucke-Grauls
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Anton G M Buiting
- Laboratory for Medical Microbiology and Immunology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Bram M Diederen
- Regional Laboratory of Public Health, Haarlem, Netherlands; Microvida Laboratory for Microbiology, Bravis Hospital, Roosendaal, Netherlands
| | | | - Alex W Friedrich
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Joost Hopman
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nashwan Al Naiemi
- Department of Medical Microbiology and Infection Control, Ziekenhuisgroep Twente, Almelo/Hengelo, Netherlands
| | - John W A Rossen
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Gijs J H M Ruijs
- Laboratory for Microbiology and Infectious Diseases, Isala Clinics, Zwolle, Netherlands
| | - Paul H M Savelkoul
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands; Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Carlo Verhulst
- Microvida Laboratory for Microbiology, Amphia Hospital, Breda, Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, Netherlands
| | - Andreas Voss
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, Netherlands; Department of Medical Microbiology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
| | - Jan A J W Kluytmans
- Department of Infection Control, Amphia Hospital, Breda, Netherlands; Microvida Laboratory for Microbiology, Amphia Hospital, Breda, Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
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Morfin-Otero R, Perez-Gomez HR, Gonzalez-Diaz E, Esparza-Ahumada S, Rodriguez-Noriega E. Enterococci as Increasing Bacteria in Hospitals: Why Are Infection Control Measures Challenging for This Bacteria? CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0166-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Reconsidering Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus. Infect Control Hosp Epidemiol 2015; 36:1163-72. [DOI: 10.1017/ice.2015.156] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUNDWhether contact precautions (CP) are required to control the endemic transmission of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) in acute care hospitals is controversial in light of improvements in hand hygiene, MRSA decolonization, environmental cleaning and disinfection, fomite elimination, and chlorhexidine bathing.OBJECTIVETo provide a framework for decision making around use of CP for endemic MRSA and VRE based on a summary of evidence related to use of CP, including impact on patients and patient care processes, and current practices in use of CP for MRSA and VRE in US hospitals.DESIGNA literature review, a survey of Society for Healthcare Epidemiology of America Research Network members on use of CP, and a detailed examination of the experience of a convenience sample of hospitals not using CP for MRSA or VRE.PARTICIPANTSHospital epidemiologists and infection prevention experts.RESULTSNo high quality data support or reject use of CP for endemic MRSA or VRE. Our survey found more than 90% of responding hospitals currently use CP for MRSA and VRE, but approximately 60% are interested in using CP in a different manner. More than 30 US hospitals do not use CP for control of endemic MRSA or VRE.CONCLUSIONSHigher quality research on the benefits and harms of CP in the control of endemic MRSA and VRE is needed. Until more definitive data are available, the use of CP for endemic MRSA or VRE in acute care hospitals should be guided by local needs and resources.Infect Control Hosp Epidemiol 2015;36(10):1163–1172
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Lepelletier D, Berthelot P, Lucet JC, Fournier S, Jarlier V, Grandbastien B. French recommendations for the prevention of 'emerging extensively drug-resistant bacteria' (eXDR) cross-transmission. J Hosp Infect 2015; 90:186-95. [PMID: 25986165 DOI: 10.1016/j.jhin.2015.04.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/07/2015] [Indexed: 11/15/2022]
Abstract
Controlling the spread of multi- or extensively drug-resistant bacteria (MDR or XDR) includes a dual strategy for reducing antibiotic prescriptions and preventing their spread from patient carriers. Standard precautions are applicable to all health professionals caring for any patients; additional barrier precautions (isolation) are recommended for patients carrying transmissible infectious diseases or MDR bacteria in sporadic or epidemic situations. Moreover, additional precautions may be required for populations at particular risk of infection or colonization by emerging XDR (eXDR), defined in our country as carbapenemase-producing Enterobacteriaceae and vancomycin-resistant enterococci. Our ability to detect and identify eXDR carriers early and ensure their follow-up, through effective communication between all those involved, is a significant challenge for controlling their spread. Thus, the French High Committee for Public Health has updated and standardized all French existing recommendations concerning the prevention of the cross-transmission of these bacteria, and these recommendations are summarized in this review. The recommendations are based on scientific and operational knowledge up to 2013. Different preventive strategies are recommended for patients found to be carrying eXDR and those who are considered to be at risk of having eXDR because of a history of contact. The local context, the experience of the infection control team, the different times at which detection of eXDR takes place (during admission, hospitalization, etc.) and the epidemiological situation (sporadic cases, clusters, outbreaks, widespread epidemic) must be included in risk assessments that in turn inform the control measures that should be applied in each clinical circumstance.
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Affiliation(s)
- D Lepelletier
- Unité de Gestion du risque Infectieux, Service de Bactériologie-Hygiène Hospitalière, CHU Nantes, Nantes, France; Université de Nantes, EA 3826, UFR Médecine, Nantes, France.
| | - P Berthelot
- Unité d'Hygiène Inter-Hospitalière, Service des Maladies Infectieuses et Laboratoire des Agents Infectieux et Hygiène, CHU St-Etienne, St Etienne, France
| | - J-C Lucet
- Unité Hospitalière de Lutte contre l'Infection Nosocomiale, GH Bichat - Claude Bernard, AP-HP, Paris, France
| | | | - V Jarlier
- Laboratoire de Bactériologie, Hôpital La Pitié-Salpêtrière, AP-HP, Paris, France; CLIN central de l'AP-HP, Paris, France
| | - B Grandbastien
- Unité de Lutte contre les Infections Nosocomiales, Service du Risque Infectieux, des Vigilances et d'Infectiologie, CHRU Lille, Lille, France
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Cervera C, van Delden C, Gavaldà J, Welte T, Akova M, Carratalà J. Multidrug-resistant bacteria in solid organ transplant recipients. Clin Microbiol Infect 2014; 20 Suppl 7:49-73. [DOI: 10.1111/1469-0691.12687] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 05/16/2014] [Accepted: 05/18/2014] [Indexed: 12/23/2022]
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Behta M, Landzberg R, Jia H, Marine M, Ross B, Chaudhry R, Cohen B, Larson E. Time lag for posting transmission-based isolation precaution signs. Am J Infect Control 2013; 41:433-7. [PMID: 22980515 DOI: 10.1016/j.ajic.2012.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 05/24/2012] [Accepted: 05/24/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Rapid identification and isolation of patients colonized or infected with virulent pathogens is essential to minimize risk of exposure to other patients, visitors, and health care workers. OBJECTIVE Our objective was to determine the time lag between when a patient is identified as requiring isolation precautions and when an isolation sign is posted outside of their room. METHODS Patients requiring assessment of isolation precautions because of a new positive culture, readmission, or transfers within the institution were identified through an electronic surveillance system. Observers recorded the presence of isolation signs at the patient's door at time (T) 0hr, T2hr, T4hr, T24hr, and T48hr or until an isolation sign was posted. RESULTS The majority of patients was adults in nonintensive care units. Isolation signs were present for 79.0% of the patients at T0hr and increased to 83.8% by T48hr. No difference was seen between the unit type or indications for isolation. The most common organisms for which isolation was indicated were influenza and resistant enterococci, Staphylococcus aureus; isolation sign postings at T0hr were 87.9%, 85.7%, and 80.7%, respectively. There was a significant difference seen in compliance among the adult (82.8%) and pediatrics (66.7%) sites (P = .0268). CONCLUSION Isolation precautions are indicated to prevent transmission of virulent pathogens; however, their implementation in a timely manner can be challenging. In this study, approximately 20% of patients for whom isolation was needed had no sign posted within the first 24 hours, and there were only minimal increases thereafter. Simple processes are needed for early identification of patients, communication of the protective equipment needed, and continuous monitoring of adherence to guidelines.
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Affiliation(s)
- Maryam Behta
- Department of Information Services, New York-Presbyterian Hospital, New York, NY, USA
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Mutters NT, Frank U. Sources of systematic errors in the epidemiology of vancomycin-resistant enterococci. Infection 2013; 41:305-10. [PMID: 23386219 DOI: 10.1007/s15010-013-0410-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 01/15/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE The rates of vancomycin resistance among enterococci (VRE) have been increasing worldwide. However, reports on vancomycin-resistant enterococci (VRE) are easily biased and meta-data reporting is insufficient. Additionally, no standardised protocol for VRE testing currently exists. The aim of our study was to investigate, for the first time, the impact of introduced bias in VRE reports. We also analysed the sensitivity of our in-house screening test for VRE, namely, a broth-enriched PCR assay. METHODS Retrospective review of microbial and clinical data on all patients tested for VRE who had been admitted to a large university hospital over a 5-year period and an analysis of the possible impact of introduced bias. Our screening test was also evaluated using clinical isolates. RESULTS A total of 27,636 screening tests were carried out over the 5-year study period, of which 2,459 were VRE-positive. The number of screening tests increased dramatically over the study period, with 1,053 tests carried out on 435 patients in 2006 and 9,444 tests carried out on 5,104 patients in 2010. VRE prevalence was 8.1 % over the 5-year period. The introduction of measurement bias caused a clear overestimation of absolute VRE numbers. The sensitivity of our screening test was 95.5 % with a positive predictive value of 39 %. CONCLUSION Biased reports lead to the implementation of high-cost containment measures that may be both unnecessary and detrimental to the patient. Our data show that systematic errors in VRE reports caused a clear overestimation of absolute VRE numbers, thereby indicating an outbreak situation even though the actual prevalence of VRE was decreasing. We suggest that reports of VRE must take measurement and analysis biases into account, otherwise any conclusion drawn is unreliable and inconclusive.
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Affiliation(s)
- N T Mutters
- Division Medical Microbiology and Hygiene, Department of Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
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Backman C, Taylor G, Sales A, Marck PB. An integrative review of infection prevention and control programs for multidrug-resistant organisms in acute care hospitals: a socio-ecological perspective. Am J Infect Control 2011; 39:368-378. [PMID: 21429622 DOI: 10.1016/j.ajic.2010.07.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Revised: 07/28/2010] [Accepted: 07/29/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND The infection rates of multidrug-resistant organisms (MDRO) are increasing in Canada and the United States. The prevention and control of MDRO infections remain an important issue in acute care hospitals. Although comprehensive infection prevention and control programs have been recommended, there is little evidence to date of their effectiveness or of what aspects are most important. OBJECTIVES Our objectives were to review and critique the literature on the relationship between an MDRO infection and control program and MDRO rates in acute care hospitals. METHODS Studies including original research published between January 1, 1998, and May 14, 2009, were identified through MEDLINE, CINAHL, EMBASE, PUBMED, The Cochrane Library, and expert consultation. A comprehensive search strategy was developed with a librarian to find studies that covered the main subject areas of this integrative review. RESULTS Of the 1,382 papers retrieved, 47 were reviewed, and 32 studies met the inclusion criteria. The interventions in the included studies were assessed using the tier 1/tier 2 framework. A total of 18 (56.25%) studies had an administrative measure as an intervention; 20 (62.5%) studies had education and training of health care personnel; 8 (25.0%) studies had judicious use of antimicrobial agents; 17 (53.1%) studies used surveillance; 24 (75.0%) studies had infection control precautions to prevent transmission; 7 studies (21.9%) introduced environmental measures; and 9 (28.1%) studies used patient decolonization. Although all the 32 studies were quasiexperimental studies, only 2 (5.9%) studies provided sample size calculations, and only 5 studies reported confounding factors. Whereas 27 used an interrupted time series design and 2 were controlled pre- and post-intervention designs, 3 were pre- and post-intervention without control groups. CONCLUSION This integrative review demonstrated that the evidence of the relationship between MDRO infection prevention and control programs and the rates of MDRO is weak. Although major methodologic weaknesses exist in the published literature making it not possible to exclude other plausible explanations for the reduction of the acquisition of MDRO, the overall evidence does support the use of multiple interventions to reduce the rates of MDRO in acute care hospitals. Whereas it is unclear which bundles of interventions are effective, there is a clear suggestion that multiple simultaneous interventions can be effective in reducing MDRO infections. In addition, despite the limitations of interrupted time series, multiple studies employing active surveillance cultures were associated with reduced MDRO infections. Future individual reports of outbreaks and intervention studies should be written in a standardized manner using the recommended Outbreak Reports and Intervention Studies of Nosocomial Infection (ORION) guidelines. Further research is needed on the proposed tier 1/tier 2 framework clearly indicating all the interventions implemented.
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Affiliation(s)
- Chantal Backman
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.
| | - Geoffrey Taylor
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Anne Sales
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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Johnston BL, Bryce E. Hospital infection control strategies for vancomycin-resistant Enterococcus, methicillin-resistant Staphylococcus aureus and Clostridium difficile. CMAJ 2009; 180:627-31. [PMID: 19289807 DOI: 10.1503/cmaj.080195] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- B Lynn Johnston
- Department of Medicine, Capital District Health Authority, Halifax, NS.
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