The German Nosocomial Infection Surveillance System (KISS) began in 1997 as a nationwide surveillance project for voluntary registration of nosocomial infections in intensive care units (ICUs). This study investigates trends in the rates of central venous catheter (CVC)–associated primary bloodstream infections (BSIs) in ICUs since participation in KISS.

Eighty-four ICUs that had participated in KISS for at least 24 months were considered for more detailed analysis. Monthly rates of primary BSI for the 84 ICUs were pooled for the 24 months. The best model for describing the curve of reduction was sought. Additionally, incidence densities were compared using the z test.

For the 212 ICUs participating, a relative 25.7% decrease (from 2.1 to 1.6 primary BSIs per 1,000 CVC-days) was observed from January 1997 to June 2001. The 84 ICUs that participated in KISS for a minimum of 24 months accumulated 552,359 patient-days and 404,897 CVC-days during their 24 months. A linear regression model was selected to explain the curve of primary BSI reduction in the 84 ICUs. It showed a decrease from 2.1 to 1.5 primary BSIs per 1,000 CVC-days, meaning an overall relative reduction of 28.6% during the 2-year observation period. These results were significant (Student's t test for the monthly reduction coefficient; P = .04). The reduction of primary BSIs was shown for both clinical sepsis and laboratory-confirmed, CVC-associated primary BSIs.

Performing surveillance with KISS was associated with a reduction of the rates of CVC-associated primary BSIs in ICU patients (Infect Control Hosp Epidemiol 2003;24:501-505).

To investigate an outbreak of methicillin-susceptible Staphylococcus aureus (MSSA); infections in a neonatal clinic.

Prospective chart review, environmental sampling, and genotyping by two independent methods: pulsed-field gel electrophoresis (PFGE) and randomly amplified polymorphic DNA polymerase chain reaction (RAPD-PCR). A case-control study was performed with 31 controls from the same clinic.

A German 1,350-bed tertiary-care teaching university hospital.

There was a significant increase in the incidence of pyodermas with MSSA 10 neonates in good physical condition with no infection immediately after birth developed pyodermas. A shared spatula and ultrasound gel were the only identified infection sources. The gel contained MSSA and was used for hip-joint sonographies in all neonates. PFGE and RAPD-PCR patterns from 6 neonates and from the gel were indistinguishable and thus genetically related clones. The case-control study revealed no significant risk factor with the exception of cesarean section (P=.006). The attack rate by days of hip-joint sonography between April 15 and April 27, 1994, was 11.8% to 40%.

Inappropriate hygienic measures in connection with lubricants during routine ultrasound scanning may lead to nosocomial S aureus infections of the skin. To our knowledge this source of S aureus infections has not previously been described.

Although alcohol-based hand rinses and gels have recommended application times of 30 to 60 seconds, healthcare workers usually take much less time for hand hygiene. We compared the efficacies of four alcohol-based hand rubs produced in Europe (hand rinses A, B, and C and one gel formulation) with the efficacy of the European Norm 1500 (EN 1500) reference waterless hand antisepsis agent (60% 2-propanol) at short application times.

Comparative crossover study.

Infection Control Program laboratory of a large tertiary-care teaching hospital.

Twelve healthy volunteers.

Measurement of residual bacterial counts and log reduction factors following inoculation of fingertips with Staphylococcus aureus American Type Culture Collection (ATCC) 6538, Pseudomonas aeruginosa ATCC 15442, and a clinical isolate of Enterococcus faecalis.

All hand rinses satisfied EN 1500 standards following a single application for 15 and 30 seconds, but reduction factors for the gel formulation were significantly lower for all tested organisms (all P < .025).

Under stringent conditions similar to clinical practice, all three hand rinses proved to be more efficacious than the marketed alcohol-based gel in reducing bacterial counts on hands. Further studies are necessary to determine the in vivo efficacy of alcohol-based gels and whether they are as efficacious as alcohol-based rinses in reducing the transmission of nosocomial infections.

To assess changes in the epidemiology of nosocomial candidemia in the post-fluconazole era among hospitalized patients using a case–control study design.

Candidemia case-patients were matched 1:1 on diagnosis, age, and length of stay with control-patients. Conditional logistic regression was used to determine predictors and outcomes of candidemia. Treatment regimens and compliance with national practice guidelines were compared among case-patients.

Barnes-Jewish Hospital, a 1,278-bed, tertiary-care center affiliated with Washington University School of Medicine, St. Louis, Missouri.

Patients admitted from January 1 to December 31, 2000. Case-patients were identified through the hospital microbiological surveillance system and matched with control-patients.

Predictors of candidemia included Hickman catheters (odds ratio [OR], 9.53; 95% confidence interval [CI95], 1.34 to 68.01), gastric acid suppressants (OR, 6.38; CI95, 2.33 to 17.43), nasogastric tubes (OR, 3.69; CI95, 1.27 to 10.78), antibiotics (OR, 1.46; CI95,1.15 to 1.86), and admission to the intensive care unit (OR, 6.40; CI95, 2.12 to 19.31). The crude case-fatality rate was 40%. Seventeen (15%) of the case-patients received the recommended treatment regimen according to recently published practice guidelines.

The epidemiology of candidemia has changed little at our hospital during the past decade and remains a significant cause of mortality. Further studies on the benefits of preventive therapy will be essential to improve the outcome of this infection.

A paucity of data exists regarding the effectiveness of daily Chlorhexidine gluconate (CHG) bathing in non–intensive care unit (ICU) settings.

To evaluate the effectiveness of daily CHG bathing in a non-ICU setting to reduce methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enteroccocus (VRE) hospital-acquired infections (HAIs), compared with daily bathing with soap and water.

Quasi-experimental study design; the primary outcome was the composite incidence of MRSA and VRE HAIs. Clostridium difficile HAI incidence was measured as a nonequivalent dependent variable with which to assess potential confounders.

Four general medicine units, with a total of 94 beds, at a 719-bed academic tertiary-care facility in Providence, Rhode Island.

A total of 7,102 and 7,699 adult patients were admitted to the medical service in the control and intervention groups, respectively. Patients admitted from January 1 through December 31, 2008, were bathed daily with soap and water (control group), and those admitted from February 1, 2009, through March 31, 2010, were bathed daily with CHG-impregnated cloths (intervention group).

Daily bathing with CHG was associated with a 64% reduced risk of developing the primary outcome, namely, the composite incidence of MRSA and VRE HAIs (hazard ratio, 0.36 [95% CI, 0.2-0.8]; P = .01). There was no change in the incidence of C. difficile HAIs (P = .6). Colonization with MRSA was associated with an increased risk of developing a MRSA HAI (hazard ratio, 8 [95% CI, 3-19]; P < .001).

Daily CHG bathing was associated with a reduced HAI risk, using a composite endpoint of MRSA and VRE HAIs, in a general medical inpatient population.

To present a hypothetical model of the change in economic costs and health benefits to society that result from nosocomial infection control programs.

We use a modeling framework to represent how 2 types of costs change with nosocomial infection control programs: costs incurred by the hospital sector and community health services, as well as the private costs to patients. We also demonstrate how to value the health benefits of nosocomial infection control programs, using quality-adjusted life years.

Hypothetical modeling to incorporate the societal perspective.

A cohort of 50,000 simulated patients at risk of surgical site infection following total hip replacement.

A total of 8 hypothetical interventions that change costs and health outcomes among the cohort by preventing cases of surgical site infection following total hip replacement.

We demonstrate that when infection control interventions reduce economic costs and increase health benefits, they should be adopted without further question. If, however, interventions increase economic costs and increase health benefits, then the trade—off between costs and benefits should be examined. Decision-makers should assess the cost per unit of health benefit from infection control programs, consider the impact on health budgets, and compare infection control with alternative uses of scarce healthcare resources.

Reference data from intensive care units (ICUs) are not applicable to non-ICU patients because of the differences in device use rates, length of stay, and severity of underlying diseases among the patient populations. In contrast to the huge amount of data available for ICU patients, appropriate surveillance data for non-ICU patients have been missing in Germany.

To establish a new module (“DEVICE-KISS”) of the German Nosocomial Infection Surveillance System for generating stratified reference data for non-ICU wards.

Non-ICU patients from 42 German hospitals.

Monthly patient-days, device-days and nosocomial infections (NIs) (using Centers for Disease Control and Prevention definitions) were counted. Device use rates were calculated, and NI rates were stratified by different medical specialities.

From July 2002 through June 2004, among the 77 wards, there were a total of 536,955 patient-days and 74,188 device-days (for CVC-associated primary bloodstream infections, there were 181,401 patient-days and 8,317 central vascular catheter [CVC]-days in 29 wards; for urinary catheter–associated urinary tract infections, there were 445,536 patient-days and 65,871 urinary catheter–days in 65 wards) and 483 NIs (36 bloodstream infections and 447 urinary tract infections). The mean device use rates were 4.6 device-days per 100 patient-days for CVCs (29 wards) and 14.8 device-days per 100 patient-days for urinary catheters (65 wards), respectively. Mean device-associated NI rates were 4.3 infections per 1,000 CVC-days for CVC-associated bloodstream infections and 6.8 infections per 1,000 urinary catheter–days for catheter-associated urinary tract infections.

DEVICE-KISS allows non-ICUs to recognize an outlier position with regard to NIs by providing well-founded reference data for non-ICU patients.

To evaluate the impact and burden of the new National Healthcare Safety Network surveillance definition, mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI), in hematology, oncology, and stem cell transplant populations.

Retrospective cohort study.

Two hematology, oncology, and stem cell transplant units at a large academic medical center.

Central line–associated bloodstream infections (CLABSIs) identified during a 14-month period were reviewed and classified as MBI-LCBI or non-MBI-LCBI (MBI-LCBI criteria not met). During this period, interventions to improve central line maintenance were implemented. Characteristics of patients with MBI-LCBI and non-MBI-LCBI were compared. Total CLABSI, MBI-LCBI, and non-MBI-LCBI rates were compared between baseline and postintervention phases of the study period.

Among 66 total CLABSI cases, 47 (71%) met MBI-LCBI criteria. Patients with MBI-LCBI and non-MBI-LCBI were similar in regard to most clinical and demographic characteristics. Between the baseline and postintervention study periods, the overall CLABSI rate decreased from 3.37 to 3.21 infections per 1,000 line-days (incidence rate ratio, 0.95; 4.7% reduction, P=.84), the MBI-LCBI rate increased from 2.08 to 2.61 infections per 1,000 line-days (incidence rate ratio, 1.25; 25.3% increase, P=.44), and the non-MBI-LCBI rate decreased from 1.29 to 0.60 infections per 1,000 line-days (incidence rate ratio, 0.47; 53.3% reduction, P=.12).

Most CLABSIs identified among hematology, oncology, and stem cell transplant patients met MBI-LCBI criteria, and CLABSI prevention efforts did not reduce these infections. Further review of the MBI-LCBI definition and impact is necessary to direct future definition changes and reporting mandates.

Infect Control Hosp Epidemiol 2014;00(0): 1–6

Assessments of infectious disease spread in hospitals seldom account for interfacility patient sharing. This is particularly important for pathogens with prolonged incubation periods or carrier states.

We quantified patient sharing among all 32 hospitals in Orange County (OC), California, using hospital discharge data. Same-day transfers between hospitals were considered “direct” transfers, and events in which patients were shared between hospitals after an intervening stay at home or elsewhere were considered “indirect” patient-sharing events. We assessed the frequency of readmissions to another OC hospital within various time points from discharge and examined interhospital sharing of patients with Clostridium difficile infection.

In 2005, OC hospitals had 319,918 admissions. Twenty-nine percent of patients were admitted at least twice, with a median interval between discharge and readmission of 53 days. Of the patients with 2 or more admissions, 75% were admitted to more than 1 hospital. Ninety-four percent of interhospital patient sharing occurred indirectly. When we used 10 shared patients as a measure of potential interhospital exposure, 6 (19%) of 32 hospitals “exposed” more than 50% of all OC hospitals within 6 months, and 17 (53%) exposed more than 50% within 12 months. Hospitals shared 1 or more patient with a median of 28 other hospitals. When we evaluated patients with C. difficile infection, 25% were readmitted within 12 weeks; 41% were readmitted to different hospitals, and less than 30% of these readmissions were direct transfers.

In a large metropolitan county, interhospital patient sharing was a potential avenue for transmission of infectious agents. Indirect sharing with an intervening stay at home or elsewhere composed the bulk of potential exposures and occurred unbeknownst to hospitals.

Carbapenem-resistant Enterobacteriaceae (CRE) are rapidly emerging in hospitals in the United States and are posing a significant threat. To better understand the transmission dynamics and the acquisition of resistant strains, a thorough analysis of epidemiologic and molecular characteristics was performed.

CRE isolated at Detroit Medical Center were analyzed from September 2008 to September 2009. blaKPC genes were investigated by polymerase chain reaction (PCR), and repetitive extragenic palindromic PCR (rep-PCR) was used to determine genetic similarity among strains. Epidemiologic and outcomes analyses were performed.

Ninety-two unique patient CRE isolates were recovered. Sixty-eight strains (74%) were Klebsiella pneumoniae, 7 were Klebsiella oxytoca, 15 were Enterobacter species, and 2 were Escherichia coli. Fifteen isolates (16%) were resistant to Colistin, 14 (16%) were resistant to tigecycline, and 2 were resistant to all antimicrobials tested. The mean ± standard deviation age of patients was 63 ± 2 years. Sixty patients (68%) were admitted to the hospital from long-term care facilities. Only 70% of patients received effective antimicrobial therapy when infection was suspected, with a mean time to appropriate therapy of 120 ± 23 hours following sample culturing. The mean length of hospitalization after sample culturing was 18.6 ± 2.5 days. Of 57 inpatients, 18 (32%) died in the hospital. Independent predictors for mortality were intensive care unit stay (odds ratio [OR], 15.8; P = .003) and co-colonization with CRE and either Acinetobacter baumannii or Pseudomonas aeruginosa (OR, 17.2; P = .006). Among K. pneumoniae CRE, rep-PCR revealed 2 genetically related strains that comprised 70% and 20% of isolates, respectively.

In this large U.S. cohort of patients with CRE infection, which reflects the modern continuum of medical care, co-colonization with CRE and A. baumannii or P. aeruginosa was associated with increased mortality. Two predominant clones of K. pneumoniae accounted for the majority of cases of CRE infection.

Clostridium difficile is the most common cause of infectious nosocomial diarrhea and can be found in up to 30% of asymptomatic hospitalized patients. Our primary aim was to compare the clinical characteristics of hospitalized patients who received antibiotics and developed C. difficile-associated diarrhea (CDAD) with those of hospitalized patients who received antibiotics and did not develop the disease.

Case-control study comprising inpatients at a single institution.

Case-patients were defined as patients who had diarrhea and tested positive for C. difficile. Control-patients (matched 4:1 to case-patients) were defined as patients who received antibiotics for at least 5 days and did not develop CDAD.

On univariate analysis, nine variables were associated with CDAD. Only three of the variables, need for intensive care, length of stay, and macrolide antibiotic use, were found to be significant (P < .05) on logistic regression analysis. The odds ratios for status as a CDAD case were 3.68 (CI95, 1.44 to 9.40) for stay in the intensive care unit and 1.03 (CI95, 1.02 to 1.05) for each day of hospital stay. Receipt of macrolide antibiotics reduced risk significantly; the odds ratio was 0.23 (CI95, 0.19 to 0.87).

We identified need for intensive care and length of stay as important risk factors for the development of CDAD. We also identified macrolide antibiotic use as protective against its development. Patients receiving intensive care may represent a population to study for targeted prophylaxis.

To determine the incidence of urinary tract infections (UTIs) following transrectal ultrasound guided needle biopsy of the prostate (TRUBP) and the bacteriology of these infections.

Retrospective evaluation of the charts and records of all patients who underwent TRUBP between June 1, 2002, and August 31, 2003.

American University of Beirut Medical Center, a tertiary-care center in Lebanon.

Two hundred seven patients underwent TRUBP. All received prophylactic antibiotics. One hundred twenty (58%) received ciprofloxacin alone, whereas 87 (42%) received both ciprofloxacin and gentamicin. Sixty-one patients (29.5%) had an enema prior to the procedure, whereas 146 (70.5%) did not.

Thirteen patients (6.3%) were admitted with UTI. All had rigors and fever on admission. Symptoms appeared at a mean of 2.7 days and the mean hospital stay was 9.2 days. The mean duration of antibiotic treatment was 23.2 days. Ten (77%) of the patients had positive bacteriology. Urine cultures were positive in 8 (61.5%) of the patients and blood cultures in 6 (46.2%). All positive cultures grew Escherichia coli resistant to ciprofloxacin, with 5 isolates producing extended-spectrum beta-lactamases.

TRUBP continues to be associated with significant infectious complications, especially UTI. Given the increasing incidence of antibiotic resistance mainly among the Enterobacteriaceae, antimicrobial prophylaxis practices should be reevaluated and the universal administration of quinolones alone or in combination with aminoglycosides should be reconsidered.

Determine the epidemiology and risk factors for colonization with vancomycin-resistant Enterococcus faecium.

Survey; case-control study.

Children's hospital.

Pediatric oncology patients.

Contact isolation, restriction of vancomycin prescribing.

There was a high prevalence of colonization with vancomycin-resistant enterococci among pediatric oncology patients. The length of hospitalization and the administration of vancomycin and other intravenous antibiotics was associated with colonization. Prevention of colonization was associated with restriction of vancomycin use and contact isolation.

Vancomycin use may predispose to colonization with vancomycin-resistant E faecium. Vancomycin-resistant E faecium may be nosocomially spread. Contact isolation and restriction of vancomycin use may prevent spread of vancomycin-resistant E faecium.

Antianaerobic antibiotic therapy promotes persistent high-density growth of vancomycin-resistant enterococci (VRE) in the stool of colonized patients. We tested the hypothesis that antibiotic regimens with potent antianaerobic activity promote overgrowth of coexisting antibiotic-resistant, gram-negative bacilli in the stool of VRE-colonized patients.

Eight-month prospective study examining the effect of antibiotic therapy on the stool density of gram-negative bacilli resistant to ceftazidime, ciprofloxacin, or piperacillin/tazobactam.

A Department of Veterans Affairs medical center including an acute care hospital and nursing home.

All VRE-colonized patients with at least 3 stool samples available for analysis.

One-hundred forty stool samples were obtained from 37 study patients. Forty-nine (61%) of 80 stool samples obtained during therapy with an antianaerobic regimen were positive for an antibiotic-resistant, gram-negative bacillus, whereas only 14 (23%) of 60 samples obtained 4 or more weeks after completion of such therapy were positive (P < .001). Twenty-four (65%) of the 37 patients had one or more stool cultures positive for a gram-negative bacillus resistant to ciprofloxacin, ceftazidime, or piperacillin/tazobactam. The density of these organisms was higher during therapy with antianaerobic regimens than in the absence of such therapy for at least 2 weeks (mean ± standard deviation, 5.6 ± 1.4 and 3.9 ± 0.71 log10 organisms/g; P < .001).

Limiting the use of antianaerobic antibiotics in VRE-colonized patients may reduce the density of colonization with coexisting antibiotic-resistant, gram-negative bacilli.

To evaluate the clinical effectiveness of preoperative skin antiseptic preparations and application techniques for the prevention of surgical site infections (SSIs).

Systematic review of the literature using Medline, EMBASE, and other databases, for the period January 2001 to June 2011.

Comparative studies (including randomized and nonrandomized trials) of preoperative skin antisepsis preparations and application techniques were included. Two researchers reviewed each study and extracted data using standardized tables developed before the study. Studies were reviewed for their methodological quality and clinical findings.

Twenty studies (n = 9,520 patients) were included in the review. The results indicated that presurgical antiseptic showering is effective for reducing skin flora and may reduce SSI rates. Given the heterogeneity of the studies and the results, conclusions about which antiseptic is more effective at reducing SSIs cannot be drawn.

The evidence suggests that preoperative antiseptic showers reduce bacterial colonization and may be effective at preventing SSIs. The antiseptic application method is inconsequential, and data are lacking to suggest which antiseptic solution is the most effective. Disinfectant products are often mixed with alcohol or water, which makes it difficult to form overall conclusions regarding an active ingredient. Large, well-conducted randomized controlled trials with consistent protocols comparing agents in the same bases are needed to provide unequivocal evidence on the effectiveness of one antiseptic preparation over another for the prevention of SSIs.

We have developed and analyzed a large surgical prophylaxis database and now report the factors significantly associated with early infection, readmission due to infection, and death within 28 days of surgery. This study is intended to be a stepping-stone for further studies using our clinical database.

A computerized database of 9,016 surgical patients from a 400-bed community hospital was examined. Multivariate logistic regression and tree-based modeling were used to identify factors associated with the outcomes. Factors considered included surgical procedure, prophylactic antibiotic, age, gender, serum creatinine, and albumin.

12.6% had an early infection, 2.5% were read-mitted due to infection, and 2.5% died within 28 days. Most combination prophylactic antibiotics were associated with an increased probability of an early infection. Decreased albumin and increased age were associated with an increased probability of an early infection. Tracheostomy and amputations were associated with an increased probability of an early infection, whereas gallbladder and orthopedic procedures involving the arm were associated with a decreased probability. Factors associated with readmission due to infection included dialysis shunt, vascular repair, and an early infection. Factors associated with increased probability of death within 28 days included age, albumin, serum creatinine, and an early infection. Gallbladder procedures and obstetric-gynecologic procedures were associated with a decreased probability of death within 28 days.

Older patients and those with a decreased albumin were most likely to have an early infection. To the extent that an early infection was a significant risk factor for readmission due to infection, the impact of age and albumin on the probability of readmission due to infection is demonstrated by their effects on early infections. Interestingly, albumin and age were significantly associated with death within 28 days, in addition to early infection, showing the predictive association between these factors and early death.

Vancomycin-resistant enterococci (VRE) have become a public health concern with implications for patient mortality and costs. Hospital antibiotic usage may impact VRE incidence, but the relationship is poorly understood. Animal investigations suggest that ceftriaxone may be associated with VRE proliferation. We measured antimicrobial usage and VRE bloodstream infection (VRE-BSI) incidence to test our hypothesis that increased ceftriaxone usage would be associated with a higher incidence of VRE-BSI.

Retrospective cohort study.

University of Alabama at Birmingham Medical Center, a 900-bed urban tertiary care hospital.

All patients admitted during the study period contributed data.

We conducted a retrospective analysis of antimicrobial usage and VRE-BSI from 2005 to 2008 (43 months). Antimicrobial usage was quantified as days of therapy (DOTs) per 1,000 patient-days. VRE-BSI incidence was calculated as cases per 1,000 patient-days. Negative binomial regression with adjustment for correlation between consecutive observations was used to measure the association between antimicrobial usage and VRE-BSI incidence at the hospital- and care-unit levels.

VRE-BSI incidence increased from 0.06 to 0.17 infections per 1,000 patient-days. Hospital VRE-BSI incidence was associated with prior-month ceftriaxone DOTs (incidence rate ratio, 1.38 per 10 DOTs; P = .005). After controlling for ceftriaxone, prior-month cephalosporin usage (class) was not predictive of VRE-BSI (P = .70). Similarly, prior-month usage of piperacillin-tazobactam, ceftazidime, cefepime, cefazolin, or vancomycin was not predictive of VRE-BSI when considered individually (P ≥ .4 for all comparisons). The final model suggests that type of intensive care unit was related to VRE-BSI incidence.

Ceftriaxone usage in the prior month, but not cephalosporin (class) or vancomycin usage, was related to VRE-BSI incidence. These findings suggest that an antimicrobial stewardship program that limits ceftriaxone may reduce nosocomial VRE-BSI incidence.

To evaluate the efficacy of patient and staff cohorting to control vancomycin-resistant enterococci (VRE) at an Indianapolis community hospital.

To interrupt transmission of VRE, a VRE point-prevalence survey of hospital inpatients was conducted, and VRE-infected or -colonized patients were cohorted on a single ward with dedicated nursing staff and patient-care equipment. To assess the impact of the intervention, staff compliance with contact isolation procedures was observed, and the VRE point-prevalence survey was repeated 2 months after the cohort ward was established.

Following the establishment of the cohort ward, VRE prevalence among all hospitalized inpatients decreased from 8.1% to 4.7% (25 positive cultures among 310 patients compared to 13 positive cultures among 276 patients, P=.14); VRE prevalence among patients whose VRE status was unknown before cultures were obtained decreased from 5.9% to 0.8% (18 positive cultures among 303 patients compared to 2 positive cultures among 262 patients, P=.002); and observed staff-patient interactions compliant with published isolation recommendations increased (5 [22%] of 23 interactions compared to 36 [88%] of 41 interactions, P<.0001).

Our data suggest that, in hospitals with endemic VRE or continued VRE transmission despite implementation of contact isolation measures, establishing a VRE cohort ward may be a practical and effective method to improve compliance with infection control measures and thereby to control epidemic or endemic VRE transmission.