title: Effectiveness of preemptive barrier precautions in controlling nosocomial colonization and infection by methicillin-resistant Staphylococcus aureus in a burn unit.
abstract: BACKGROUND
  We report the effectiveness of preemptive enhanced barrier precautions in containing a methicillin-resistant Staphylococcus aureus (MRSA) outbreak in a university hospital burn unit and further controlling endemic nosocomial MRSA infection in the unit during the succeeding 27 months.
  
  
  METHODS
  During a 6-month period, 12 patients in a 7-bed burn unit were found to be colonized (7) or infected (5) by MRSA. An epidemiologic study was undertaken.
  
  
  RESULTS
  Seven of the 10 strains of MRSA from patients that were available for DNA typing were clonally identical. Early in the outbreak, a health care worker was found to be a concordant nasal carrier and was successfully decolonized with nasal mupirocin. However, despite stringent compliance with isolation of MRSA-positive patients (targeted precautions), new cases of MRSA colonization or infection continued to occur. The outbreak was rapidly terminated after implementing preemptive barrier precautions with all patients in the unit: a new, clean gown and gloves for any physical contact with the patient or their environment. Although 25% of all nosocomial S aureus isolates in our hospital are resistant to methicillin, the incidence of endemic MRSA colonization and infection in the burn unit has remained very low since implementing barrier precautions unit wide (baseline rate, 2.2 [95% CI: 1.0-4.2] cases per 1000 patient-days; outbreak rate, 7.2 [95% CI: 4.4-11.0] cases per 1000 patient-days; post-outbreak termination endemic rate, 1.1 (95% CI: 0.4-2.3) cases per 1000 patient-days). The rate ratio comparing the outbreak and the baseline period was 3.20 (95% CI: 1.40-7.95, P = .002); the rate ratio comparing the post-outbreak period with the baseline period was 0.48 (95% CI: 0.14-1.53, P = .10), and it has not been necessary to screen personnel for MRSA carriage to prevent nosocomial MRSA infections in this highly vulnerable population.
  
  
  CONCLUSIONS
  Preemptive barrier precautions were highly effective in controlling the outbreak and, most notably, have also been highly effective in maintaining a very low incidence of nosocomial MRSA infection endemically in the succeeding 27 months of follow-up. Use of clean gloves, with or without a gown, bears consideration for all high-risk hospitalized patients to prevent cross transmission of all multiresistant nosocomial pathogens.
authors.affiliation: Infectious Diseases, Department of Medicine, University of Wisconsin Medical School and University of Wisconsin Hospital and Clinics, Madison, Wisconsin 53792, USA.
authors.forename: Nasia
authors.initials: N
authors.lastname: Safdar
authors.forename: John
authors.initials: J
authors.lastname: Marx
authors.forename: Nicholas A
authors.initials: NA
authors.lastname: Meyer
authors.forename: Dennis G
authors.initials: DG
authors.lastname: Maki
mesh_terms: D002053:Burn Units; D002353:Carrier State / Q000382:microbiology; D003428:Cross Infection / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control*; D016172:DNA Fingerprinting; D004269:DNA, Bacterial / Q000235:genetics / Q000302:isolation & purification; D015252:Deoxyribonucleases, Type II Site-Specific / Q000378:metabolism; D004196:Disease Outbreaks; D016521:Electrophoresis, Gel, Pulsed-Field; D005838:Genotype; D006801:Humans; D015994:Incidence; D017053:Infection Control / Q000379:methods*; D017757:Infectious Disease Transmission, Professional-to-Patient; D016106:Methicillin Resistance; D017720:Molecular Epidemiology; D016712:Mupirocin / Q000627:therapeutic use; D009666:Nose / Q000382:microbiology; D013203:Staphylococcal Infections / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control*; D013211:Staphylococcus aureus / Q000145:classification / Q000187:drug effects* / Q000302:isolation & purification; D014922:Wisconsin
chemical_list: D004269:DNA, Bacterial; D016712:Mupirocin; C025651:CCCGGG-specific type II deoxyribonucleases; D015252:Deoxyribonucleases, Type II Site-Specific