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BACKGROUND: The prevention of methicillin-resistant S. aureus (MRSA) transmission in the healthcare setting is a priority in Infection Control practices. A cornerstone of this policy is contact tracing of nosocomial contacts after an unexpected MRSA finding. The objective of this retrospective study was to quantify the rates of MRSA transmission in different clinical settings. METHODS: This multi-centre study included MRSA contact screening results from two regional hospitals and one academic hospital. MRSA contact tracing investigations from 2000 until 2019 were reviewed and post-contact screening results were included of index patients with an MRSA-positive culture and their unprotected contacts. Available typing results were used to rule out incidental findings. RESULTS: Of 27,377 contacts screened after MRSA exposure, 21,488 were Health Care Workers (HCW) and 4816 patients. Post-contact screening was initiated for a total of 774 index cases, the average number of screened contacts per index case was 35.7 (range 1 to 640). MRSA transmission was observed in 0.15% (41) of the contacts, 19 (0.09%) HCW and 22 (0.46%) patients. The number needed to screen to detect one MRSA transmission was 667. The highest risk of MRSA transmission occurred during patient-to-patient contacts, with transmission rates varying from 0.32 to 1.32% among the participating hospitals. No transmissions were detected in HCW (n=2834) in the outpatient setting, and the rate of transmissions among HCW contacts on the wards was 0.13% (19 of 15,874). Among 344 contacts of patients with contact precautions, no transmissions were detected. CONCLUSIONS: Reconsidering current MRSA contact tracing practices may lead to a more targeted approach with a lower number needed to screen.

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The implementation of isolation precautions for patients with suspected Coronavirus Disease 2019 (COVID-19) and pending test results is resource intensive. Due to the limited availability of single-bed rooms at our institution, we isolated patients with suspected COVID-19 together with patients without suspected COVID-19 on-site in multiple-bed rooms until SARS-CoV-2-test results were available. We evaluated the likelihood of SARS-CoV-2 transmission to individuals sharing the room with patients isolated on-site. This observational study was performed at the University Hospital Basel, Switzerland, from 03/20 - 11/20. Secondary attack rates were compared between patients hospitalized in multiple-bed rooms and exposed to individuals subjected to on-site isolation precautions (on-site isolation group), and patients exposed to individuals initially not identified as having COVID-19, and not placed under isolation precautions until the diagnosis was suspected (control group). Transmission events were confirmed by whole-genome sequencing. Among 1,218 patients with suspected COVID-19, 67 (5.5%) tested positive for SARS-CoV-2. Of these, 21 were isolated on-site potentially exposing 27 patients sharing the same room. Median contact time was 12 h (interquartile range 7-18 h). SARS-CoV-2 transmission was identified in none of the patients in the on-site isolation group vs. 10/63 (15.9%) in the control group (p = 0.03). Isolation on-site of suspected COVID-19-patients in multiple-bed rooms avoided single-room occupancy and subsequent in-hospital relocation for many patients without confirmed SARS-CoV-2-infection. The absence of secondary transmission among the exposed patients in the on-site isolation group allows for assessment of the risk/benefit ratio of this strategy given the limitation of a small sample size.

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In ICU settings, screening patients upon admission for potential multiresistant bacteria (BMR) carriers is crucial. Traditionally, clinical decisions relied on delayed culture results, but a rapid PCR molecular test called RealCycler-Rezero-U/G (Progenie-molecular©), emerged as an alternative. This study aimed to validate its effectiveness in detecting gram-negative BMR in rectal swabs at ICU admission. Over 24 months, an observational study was conducted on 1,234 admitted patients, with 217 meeting isolation criteria and undergoing both PCR and culture tests. Results showed a 17.5 % positive rate for screening. The PCR test exhibited impressive accuracy at 98.6 % and a strong negative predictive value of 99.4 %. The area under the ROC curve (AUC) was 0.98, indicating high reliability. Notably, PCR results were available 44.5 h earlier than culture. In conclusion, PCR-based molecular testing for gram-negative BMR offers excellent diagnostic performance and a valuable negative predictive value, making it a suitable screening tool for ICU admissions.

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Our national cross-sectional survey of United States hospitals found greater implementation of contact precautions for multidrug-resistant organisms and a higher percentage reporting the use of supplemental no-touch disinfection devices among Veterans Affairs (VA) versus non-VA hospitals. Nationally coordinated infection prevention initiatives within the VA could account for these practice differences.

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The recently updated SHEA/IDSA/APIC practice recommendations for MRSA prevention in acute care facilities list contact precautions (CP) for patients known to be infected or colonized with MRSA as an "essential practice", meaning that it should be adopted in all acute care facilities. We argue that existing evidence on benefits and harms associated with CP do not justify this recommendation. There are no controlled trials that support broad use of CP for MRSA prevention. Data from hospitals that have discontinued CP for MRSA have found no impact on MRSA acquisition or infection. The burden and harms of CP remain concerning, including the environmental impact of increased gown and glove use. We suggest that CP be included among other "additional approaches" to MRSA prevention that can be implemented under specific circumstances (e.g. outbreaks, evidence of ongoing transmission despite application of essential practices).

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Objective: This study aimed to assess the practices and attitudes of the general population towards coronavirus disease-2019 (COVID)-19 after the removal of precautionary and preventive measures in Saudi Arabia. Methods: A cross-sectional study was conducted among the general population in all regions of the Kingdom of Saudi Arabia, from September 2022 to October, 2022 via a virtual survey to evaluate the practices, and attitudes of the general population towards COVID-19. A stratified random sampling technique was applied to collect the sample with inclusion criteria for all individuals who are Arabic language speakers using social media platforms. The individuals selected for this study were 18 years and older. Results: A total of 2406 responses were received for the study questionnaire. Most of participants (66.3%) were females aged 18 to 29 years (61.8%). Half of the participants reported a positive history of COVID-19 infection. Nearly 90% of participants still wear masks, 80% attended a crowded event, and 60% often wash their hands even though the Saudi government has erased the precautions. Females, young (30-39 years) and elderly (60 years and over) individuals, singles, those with a postgraduate degree, those who are employed, and healthcare workers were more likely to adhere to COVID-19 precautionary measures (p<0.05). Conclusion: The study's findings indicate that most of the population discontinued practicing precautionary measures after lifting the measures in Saudi Arabia. More public health initiatives should raise the scores of sanitary best practices to prevent the spread of viral illnesses.

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BACKGROUND: Statistically significant decreases in methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections (HAIs) occurred in Veterans Affairs (VA) hospitals from 2007 to 2019 using a national policy of active surveillance (AS) for facility admissions and contact precautions for MRSA colonized (CPC) or infected (CPI) patients, but the impact of suspending these measures to free up laboratory resources for testing and conserve personal protective equipment for coronavirus disease 2019 (COVID-19) on MRSA HAI rates is not known. METHODS: From July 2020 to June 2022 all 123 acute care VA hospitals nationwide were given the rolling option to suspend (or re-initiate) any combination of AS, CPC, or CPI each month, and MRSA HAIs in intensive care units (ICUs) and non-ICUs were tracked. RESULTS: There were 917 591 admissions, 5 225 174 patient-days, and 568 MRSA HAIs. The MRSA HAI rate/1000 patient-days in ICUs was 0.20 (95% confidence interval [CI], .15-.26) for facilities practicing "AS + CPC + CPI" compared to 0.65 (95% CI, .41-.98; P < .001) for those not practicing any of these strategies, and in non-ICUs was 0.07 (95% CI, .05-.08) and 0.12 (95% CI, .08-.19; P = .01) for the respective policies. Accounting for monthly COVID-19 facility admissions using a negative binomial regression model did not change the relationships between facility policy and MRSA HAI rates. There was no significant difference in monthly facility urinary catheter-associated infection rates, a non-equivalent dependent variable, in the policy categories in either ICUs or non-ICUs. CONCLUSIONS: Facility removal of MRSA prevention practices was associated with higher rates of MRSA HAIs in ICUs and non-ICUs.

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BACKGROUND: 'Contact precautions,' are recommended for hospitalised patients with known methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) colonisation. Despite increasing observational evidence suggesting that gowns and gloves are of no added benefit over hand hygiene and environmental cleaning, guidelines continue to recommend them. METHODS: A cross-sectional online survey of infection prevention professionals, infectious diseases physicians and microbiologists in Australian and New Zealand hospitals was conducted. The purpose was to explore variations in current approaches to known MRSA and VRE colonisation, and determine clinical equipoise for a proposed randomised control trial (RCT) to withdraw the use of gowns and gloves in this setting. RESULTS: 226 responses from 122 hospitals across all Australian jurisdiction and multiple regions of New Zealand were received. While most hospitals implement contact precautions for MRSA (86%) and VRE (92%), variations based on MRSA and VRE subtypes are common. There was strong interest in removing glove and gown use for MRSA (72% and 73%, respectively) and VRE (70% and 68%, respectively). 62% of surveyed hospitals expressed interest in participating in a proposed cluster RCT comparing discontinuation of gown and glove use as part of contact precautions for MRSA and VRE, with their ongoing use. CONCLUSION: The mandated use of PPE in the context of MRSA and VRE colonisation warrants further examination. An RCT is needed to definitively address this issue and to promote a widespread change in practice, if warranted.

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BACKGROUND: In intensive care unit (ICU) settings, the transmission risk of carbapenem-resistant, gram-negative bacteria (CRGNB) is high. There is a paucity of data regarding the effectiveness of interventions, including active screening, preemptive isolation, and contact precautions, to reduce transmission of CRGNB. METHODS: We conducted a pragmatic, cluster-randomized, non-blinded cross-over study in 6 adult ICUs in a tertiary care center in Seoul, South Korea. ICUs were randomly assigned to perform active surveillance testing with preemptive isolation and contact precautions (intervention) or standard precautions (control) during the initial 6-month study period, followed by a 1-month washout period. During a subsequent 6-month period, departments that used standard precautions switched to using interventional precautions and vice versa. The incidence rates of CRGNB were compared between the two periods using Poisson regression analysis. RESULTS: During the study period, there were 2268 and 2224 ICU admissions during the intervention and control periods, respectively. Because a carbapenemase-producing Enterobacterales outbreak occurred in a surgical ICU (SICU), we excluded admissions to the SICU during both the intervention and control periods and performed a modified intention-to-treat (mITT) analysis. In mITT analysis, a total of 1314 patients were included. The acquisition rate of CRGNB was 1.75 cases per 1000 person-days during the intervention period versus 3.33 cases per 1000 person-days during the control period (IRR, 0.53 [95% confidence interval (CI) 0.23-1.11]; P = 0.07). CONCLUSIONS: Although this study was underpowered and showed borderline significance, active surveillance testing and preemptive isolation could be considered in settings with high baseline prevalence of CRGNB. Trial registration Clinicaltrials.gov Identifier: NCT03980197.

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BACKGROUND: Clostridioides difficile is the most common cause of healthcare-associated infections in the United States. It is unknown whether universal gown and glove use in intensive care units (ICUs) decreases acquisition of C. difficile. METHODS: This was a secondary analysis of a cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from 4 January 2012 to 4 October 2012. After a baseline period, ICUs were randomized to standard practice for glove and gown use versus the intervention of all healthcare workers being required to wear gloves and gowns for all patient contact and when entering any patient room (contact precautions). The primary outcome was acquisition of toxigenic C. difficile determined by surveillance cultures collected on admission and discharge from the ICU. RESULTS: A total of 21 845 patients had both admission and discharge perianal swabs cultured for toxigenic C. difficile. On admission, 9.43% (2060/21 845) of patients were colonized with toxigenic C. difficile. No significant difference was observed in the rate of toxigenic C. difficile acquisition with universal gown and glove use. Differences in acquisition rates in the study period compared with the baseline period in control ICUs were 1.49 per 100 patient-days versus 1.68 per 100 patient-days in universal gown and glove ICUs (rate difference, -0.28; generalized linear mixed model, P = .091). CONCLUSIONS: Glove and gown use for all patient contact in medical and surgical ICUs did not result in a reduction in the acquisition of C. difficile compared with usual care. CLINICAL TRIALS REGISTRATION: NCT01318213.

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In the 1980s Contact Precautions were introduced as a precautionary measure to control the emerging threat of antimicrobial resistance in hospitals, particularly methicillin resistant Staphylococcus aureus (MRSA). Today, antimicrobial resistance remains a concerning global public health threat, and a focus for hospital patient safety priorities. In late 2019 a novel respiratory virus described as SARS-CoV-2, was reported. Just as MRSA had prompted control measures developed in the context of limited information and understanding of the pathogen, public health control measures against SARS-CoV-2 were promptly and strictly implemented. Whilst SARS-CoV-2 control measures were successful at containing the virus, numerous detrimental socio-economic and health impacts have led to a rebalancing of harms versus benefits and loosening of restrictions. Conversely, evidence collated over the past 50 years, suggests that Contact Precautions are not superior to well-applied standard infection prevention and control precautions in controlling MRSA acquisition in hospitals. Several harms associated with Contact Precautions, affecting patient safety, financial costs, and organisational culture, are described. However, rebalancing of hospital MRSA control policies has been slow to materialise. This commentary invites infection prevention and control policy makers to reflect and revise policies for the control of MRSA in hospitals so that harms do not outweigh benefits.

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Private sector facilities in the United States have experienced a resurgence of Methicillin-resistant Staphylococcus aureus (MRSA) hospital-onset infections during the COVID-19 pandemic, which eliminated all gains that were achieved over the last decade. The third quarter of 2021, the Standardized Infection Ratio for hospital onset MRSA bloodstream infections was 1.17, well above the baseline value of 1.0. In contrast, the Veterans Health Administration (VHA) has been able to maintain its mitigation efforts and low rates of MRSA hospital-onset infections through the second quarter of fiscal year 2022 (Mar. 31, 2022), the most recent available data. The difference may be explained not only by the VHA's use of uniform mitigating policies which rely on active surveillance and contact precautions, but also on the VAH's ability to maintain adequate staffing during the pandemic. Future research into MRSA mitigation is warranted and this data supports the need for healthcare system transformation.

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INTRODUCTION: Rapid molecular tests could accelerate the control of extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-PE) and carbapenemase-producing organisms (CPO) in intensive care units (ICUs). OBJECTIVE AND METHODS: This interventional 12-month cohort study compared a loop-mediated isothermal amplification (LAMP) assay performed directly on rectal swabs with culturing methods (control period, 6 months), during routine ICU screening. Contact precautions (CP) were implemented for CPO or non-E. coli ESBL-producing Enterobacterales (nEcESBL-PE) carriers. Using survival analysis, we compared the time intervals from admission to discontinuation of unnecessary preemptive CP among patients at-risk and the time intervals from screening to implementation of CP among newly identified carriers. We also compared diagnostic performances, and nEcESBL-PE/CPO acquisition rates. This study is registered, ISRCTN 23588440. RESULTS: We included 1043 patients. During the intervention and control phases, 92/147 (62.6%) and 47/86 (54.7%) of patients at-risk screened at admission were candidates for early discontinuation of preemptive CP. The LAMP assay had a positive predictive value (PPV) of 44.0% and a negative predictive value (NPV) of 99.9% for CPO, and 55.6% PPV and 98.2% NPV for nEcESBL-PE. Due to result notification and interpretation challenges, the median time from admission to discontinuation of preemptive CP increased during the interventional period from 80.5 (95% CI 71.5-132.1) to 88.3 (95% CI 57.7-103.7) hours (p = 0.47). Due to the poor PPV, we had to stop using the LAMP assay to implement CP. No difference was observed regarding the incidence of nEcESBL-PE and CPO acquisition. CONCLUSION: A rapid screening strategy with LAMP assays performed directly on rectal swabs had no benefit for infection control in a low-endemicity setting.

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Outbreaks of SARS-CoV-2 infection frequently occur in hospitals. Preventing nosocomial infection requires insight into hospital transmission. However, estimates of the basic reproduction number (R0) in care facilities are lacking. Analyzing a closely monitored SARS-CoV-2 outbreak in a hospital in early 2020, we estimated the patient-to-patient transmission rate and R0. We developed a model for SARS-CoV-2 nosocomial transmission that accounts for stochastic effects and undetected infections and fit it to patient test results. The model formalizes changes in testing capacity over time, and accounts for evolving PCR sensitivity at different stages of infection. R0 estimates varied considerably across wards, ranging from 3 to 15 in different wards. During the outbreak, the hospital introduced a contact precautions policy. Our results strongly support a reduction in the hospital-level R0 after this policy was implemented, from 8.7 to 1.3, corresponding to a policy efficacy of 85% and demonstrating the effectiveness of nonpharmaceutical interventions.

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Since March 2020, the COVID-19 pandemic forced hospitals worldwide to intensify their infection control measures to prevent health care-associated transmission of SARS-CoV-2. The correct use of personal protective equipment, especially the application of masks, was quickly identified as priority to reduce transmission with this pathogen. Here, we report a nosocomial cluster of methicillin-resistant Staphylococcus aureus (MRSA) that occurred during the COVID-19 pandemic in a gynecology/obstetrics department, despite these intensified contact precautions. Five MRSA originating from clinical samples after surgical intervention led to an outbreak investigation. Firstly, this included environmental sampling of the operation theatre (OT) and, secondly, a point prevalence screening of patients and health care workers (HCW). All detected MRSA were subjected to whole genome sequencing (WGS) and isolate relatedness was determined using core genome multilocus sequence typing (cgMLST). WGS revealed one MRSA cluster with genetically closely related five patient and two HCW isolates differing in a single cgMLST allele at maximum. The outbreak was terminated after implementation of infection control bundle strategies. Although contact precaution measures, which are also part of MRSA prevention bundle strategies, were intensified during the COVID-19 pandemic, this MRSA outbreak could take place. This illustrates the importance of adherence to classical infection prevention strategies.

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Background: Patients with Clostridioides difficile infections (CDIs) contaminate the healthcare environment; however, the relative contribution of contamination by colonized individuals is unknown. Current guidelines do not recommend the use of contact precautions for asymptomatic C difficile carriers. We evaluated C difficile environmental contamination in rooms housing adult inpatients with diarrhea based on C difficile status. Methods: We performed a prospective cohort study of inpatient adults with diarrhea who underwent testing for CDI via polymerase chain reaction (PCR) and enzyme immunoassay (EIA). Patients were stratified into cohorts based on test result: infected (PCR+/EIA+), colonized (PCR+/EIA-), or negative/control (PCR-). Environmental microbiological samples were taken within 24 hours of C difficile testing and again for 2 successive days. Samples were obtained from the patient, bathroom, and care areas. Results: We enrolled 94 patients between November 2019 and June 2021. Clostridioides difficile was recovered in 93 (38%) patient rooms: 44 (62%) infected patient rooms, 35 (43%) colonized patient rooms (P = .08 vs infected 38 patient rooms), and 14 (15%) negative patient rooms (P < .01 vs infected; P < .01 vs colonized). Clostridioides difficile was recovered in 40 (56%), 6 (9%), and 20 (28%) of bathrooms, care areas and patient areas in 40 infected patient rooms; 34 (41%), 1 (1%), and 4 (5%) samples in colonized patient rooms; and 12 (13%), 1 (1%), and 3 (3%) of samples in negative patient rooms, respectively. Conclusions: Patients colonized with C difficile frequently contaminated the hospital environment. Our data support the use of contact precautions when entering rooms of patients colonized with C difficile, especially when entering the bathroom.

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BACKGROUND: Numerous patients carrying carbapenemase-producing Enterobacterales (CPE) and/or vancomycin-resistant Enterococcus faecium (VRE) in France have previously travelled abroad. The risk of spreading CPE/VRE by patients who have stayed abroad without hospitalization is underexplored. This prompted us to screen and isolate all patients who travelled abroad in the previous 12 months upon admission to our hospital. Our aim was to evaluate the efficiency of this CPE/VRE-related risk policy. METHODS: From 2014 to 2018, patients who had travelled abroad in the previous year before their admission underwent microbiological screening and were pre-emptively isolated. Contact precautions were verified and CPE/VRE cross-transmission events investigated. RESULTS: Among 1,780 screened patients, 59 (3.3%) were colonized with CPE and/or VRE, of whom 17 (29.3%) were not hospitalized abroad. Nine generated 18 readmissions. No episodes of CPE/VRE cross-transmission were related to patients with a stay abroad without hospitalization, whereas 2 patients hospitalized abroad generated one episode each, despite implementation of contact precautions reaching values from 73.6% to 87.5%. DISCUSSION: Throughout 17 admissions and 18 readmissions, patients who stayed abroad without hospitalization represented a true risk of spreading CPE/VRE, without generating cross-transmission. CONCLUSIONS: Our strategy of CPE/VRE-related risk policy is successful.

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BACKGROUND: Despite clear evidence of benefits in acute-care hospitals, controversy over the effectiveness of IPC measures for MDROs is perceptible and evidence-based practice has not been established. OBJECTIVE: To investigate the effects of IPC interventions on MDRO colonization and infections in LTCFs. DATA SOURCES: Ovid MEDLINE, EMBASE, and CINAHL from inception to September 2020. ELIGIBILITY CRITERIA: Original and peer-reviewed articles examining the post-intervention effects on MDRO colonization and infections in LTCFs. INTERVENTIONS: (i) Horizontal interventions: administrative engagement, barrier precautions, education, environmental cleaning, hand hygiene, performance improvement, and source control; and (ii) vertical intervention: active surveillance plus decolonization. STUDY APPRAISAL AND SYNTHESIS: We employed a random-effects meta-analysis to estimate the pooled risk ratios (pRRs) for methicillin-resistant Staphylococcus aureus (MRSA) colonization by intervention duration; and conducted subgroup analyses on different intervention components. Study quality was assessed using Cochrane risk of bias tools. RESULTS: Of 3877 studies identified, 19 were eligible for inclusion (eight randomized controlled trials (RCTs)). Studies reported outcomes associated with MRSA (15 studies), vancomycin-resistant Enterococci (VRE) (four studies), Clostridium difficile (two studies), and Gram-negative bacteria (GNB) (two studies). Eleven studies were included in the meta-analysis. The pRRs were close to unity regardless of intervention duration (long: RR 0.81 [95% CI 0.60-1.10]; medium: RR 0.81 [95% CI 0.25-2.68]; short: RR 0.95 [95% CI 0.53-1.69]). Vertical interventions in studies with a small sample size showed significant reductions in MRSA colonization while horizontal interventions did not. All studies involving active administrative engagement reported reductions. The risk of bias was high in all but two studies. CONCLUSIONS: Our meta-analysis did not show any beneficial effects from IPC interventions on MRSA reductions in LTCFs. Our findings highlight that the effectiveness of interventions in these facilities is likely conditional on resource availability-particularly decolonization and barrier precautions, due to their potential adverse events and uncertain effectiveness. Hence, administrative engagement is crucial for all effective IPC programmes. LTCFs should consider a pragmatic approach to reinforce standard precautions as routine practice and implement barrier precautions and decolonization to outbreak responses only.

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BACKGROUND: Vancomycin resistant enterococci (VRE) are on the rise in many European hospitals. In 2018, Switzerland experienced its largest nosocomial VRE outbreak. The national center for infection prevention (Swissnoso) elaborated recommendations for controlling this outbreak and published guidelines to prevent epidemic and endemic VRE spread. The primary goal of this study was to evaluate adherence to this new guideline and its potential impact on the VRE epidemiology in Swiss acute care hospitals. METHODS: In March 2020, Swissnoso distributed a survey among all Swiss acute care hospitals. The level of adherence as well as changes of infection prevention and control (IPC) strategies in the years 2018 and 2019 after publication of the national guidelines were asked along with an inventory on VRE surveillance and outbreaks. RESULTS: Data of 97/146 (66%) participants were available, representing 81.6% of all acute care beds operated in Switzerland in 2019. The vast majority-72/81 (88%) responding hospitals-have entirely or largely adopted our new national guideline. 38/51 (74.5%) hospitals which experienced VRE cases were significantly more likely to have changed their IPC strategies than those 19/38 (50%) hospitals without VRE cases p = 0.017). The new IPC guidelines included (1) introduction of targeted admission screening in 89.5%, (2) screening of close contacts of VRE cases in 56%, and (3) contact precaution for suspected VRE cases 58% of these hospitals. 52 (54%) hospitals reported 569 new VRE cases in 2018 including 14 bacteremia, and 472 new cases in 2019 with 10 bacteremia. The ten largest outbreaks encountered between 2018 and 2019 included 671 VRE cases, of which most (93.4%) consisted of colonization events, 29 (4.3%) infections and 15 (2.2%) bacteremia. CONCLUSION: Wide adoption of this VRE control guideline seemed to have a positive effect on VRE containment in Swiss acute care hospitals over two years, even if its long-term impact on the VRE epidemiology remains to be evaluated. Broad dissemination and strict implementation of a uniform national guideline may therefore serve as model for other countries to fight VRE epidemics on a national level.

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