dgkh000154
10.3205/dgkh000154
urn:nbn:de:0183-dgkh0001543
Research Article
MRSA in a large German University Hospital: Male gender is a significant risk factor for MRSA acquisition
MRSA in einem deutschen Universitätsklinikum: Männliches Geschlecht ist ein signifikanter Risikofaktor für den Erwerb von MRSA
Kupfer
Kupfer
Markus
M
Institute for Medical Microbiology and Hygiene, Faculty of Medicine Carl Gustav Carus, Technical University of Dresden, Fetcherstrasse 74, 01307 Dresden, GermanyInstitute for Medical Microbiology and Hygiene, Faculty of Medicine Carl Gustav Carus, Technical University of Dresden, Germany
markus.kupfer@rehaklinik-online.de
author
Jatzwauk
Jatzwauk
Lutz
L
Institute for Medical Microbiology and Hygiene, Faculty of Medicine Carl Gustav Carus, Technical University of Dresden, Germany
Lutz.Jatzwauk@uniklinikum-dresden.de
author
Monecke
Monecke
Stephan
S
Institute for Medical Microbiology and Hygiene, Faculty of Medicine Carl Gustav Carus, Technical University of Dresden, Germany
Monecke@rocketmail.com
author
Möbius
Möbius
Jana
J
atr Chemnitz – Clinic for Rehabilitation and Sports medicine, Beckerstrasse 16, 09120 Chemnitz, Germanyatr Chemnitz – Clinic for Rehabilitation and Sports medicine, Chemnitz, Germany
Jana.Moebius@rehaklinik-online.de
author
Weusten
Weusten
Axel
A
Department of Trauma and Orthopaedic Surgery, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, United KingdomDepartment of Trauma and Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, United Kingdom
aweusten@yahoo.com
author
German Medical Science
Düsseldorf, Köln
610
20100921
engl
1863-5245
5
2
GMS Krankenhaushygiene Interdisziplinär
GMS Krankenhaushyg Interdiszip
11
Hintergrund: Die steigende Anzahl von Patienten mit Methicillin resistenten Staphylococcus aureus (MRSA)-Kolonisation oder -Infektion ist unter klinischen, epidemiologischen wie auch ökonomischen Gesichtspunkten ein Problem. Um die Situation des Uniklinikums Dresden (UKD) national einzuordnen, intern zu analysieren und das MRSA-Management weiter zu optimieren, wurde diese Untersuchung durchgeführt.Methode: In einer retro- und im letzten Jahr der Auswertung prospektiven 7 Jahresstudie (2001 bis 2007) wurden 798 stationäre MRSA-Fälle in Anlehnung an das nationale MRSA-Surveillancesystem MRSA-KISS (Krankenhaus-Infektions-Surveillance-System) erfasst und hinsichtlich Risikofaktoren analysiert. Die Isolate von Patienten der Intensivstationen aus dem Jahr 2007 wurden genotypisiert (Microarray Technology, CLONDIAG®) und Transmissionswege aufgezeigt.Ergebnisse: Durchschnittlich waren MRSA-Patienten 59,8 Jahre alt und zu 75% älter als 50 Jahre. Eine signifikante (p<0,001) Häufung von MRSA konnte im Bezug auf das männliche Geschlecht herausgestellt werden. Die Verweildauer der MRSA-Patienten war im Vergleich zu Patienten ohne MRSA-Nachweis um den Faktor 4,15 höher. Nicht nosokomiale Fälle (n=385) zeigten im Bezug auf den Aufenthaltsort vor der stationären Aufnahme, dass 62,5% aus ihrer häuslichen Umgebung (nicht Pflegeheime), 26,6% aus medizinischen Einrichtungen und 4,9% aus Pflegeheimen aufgenommen wurden (6% nicht eruierbar). Im nationalen Vergleich mit den MRSA-KISS Referenzdaten ordnet sich das Universitätsklinikum Dresden bezüglich nosokomialer und nicht nosokomialer Inzidenzdichte und MRSA-Last von 2004 bis 2007 jeweils kleiner/gleich des 25%-Quantils ein. Die nosokomialen Fälle pro 1.000 MRSA-Tage sind im nationalen Vergleich über dem 50%-Quantil einzuordnen. Intensivstationen zeigten im klinikinternen Stationsgruppenvergleich die höchsten Inzidenzdichten, die höchste MRSA-Last und die meisten nosokomialen MRSA-Fälle. Die Genotypisierung auf ITS ergab, dass unterschiedliche Epidemiestämme vorkamen (ST 5, ST 22, ST 228). Das Auftreten von genotypisch identischen MRSA konnte in der Minorität der Fälle (5 von 22) nachgewiesen werden. Schlussfolgerung: Zusätzlich zu den vom Robert-Koch-Institut publizierten Risikofaktoren hat sich in der eigenen Patientenklientel das männliche Geschlecht als signifikanter Risikofaktor darstellt. Die MRSA-Belastung ist im Stationsgruppenvergleich auf den Intensivstationen besonders groß. Aufenthaltsort nicht nosokomialer MRSA-Fälle vor Hospitalisation ist mehrheitlich die häusliche Umgebung. Die durchschnittliche Verweildauer von MRSA-Patienten ist höher als die anderer Patienten. Die Genotypisierung stellt eine sinnvolle Maßnahme dar um die Transmissionskette von MRSA zu verstehen und gezielt Hygienemaßnahmen einzuleiten.
Background: The continually rising number of hospital acquired infections and particularly MRSA (Methicillin-resistant Staphylococcus aureus) colonization poses a major challenge from both clinical and epidemiological perspectives. The assessment of risk factors is vital in determining the best prevention, diagnosis and treatment strategies. Materials and methods: We analyzed 798 cases of MRSA in a large German University Hospital over a 7-year period. Data was collected retro- and prospectively including patient age, sex, type of ward and duration of inpatient stay. In addition we analyzed all cases on ICU with regards to cross infection and MRSA genotyping via DNA MicroArray Technology. The years 2004 to 2007 were analyzed with a specific focus on gender.Results: Male gender is significantly correlated with increased risk of MRSA acquisition (p<0.001), the predominant setting for MRSA is on ICU. 75% of the MRSA positive patients are over 50 years of age (average age 59.8 years). The inpatient time was 4.15 times higher in MRSA carriers compared with non-MRSA cases, however this was not significant. MRSA genotyping on ICU showed mainly the subtypes ST 5, ST 22, ST 228, however cross contamination with identical genotypes was only detected in a minority of cases (5 out of 22).Conclusion: Unlike previous studies which show no or inconclusive evidence of gender as a risk factor, our data confirm that male gender is a significant risk factor for MRSA carrier status. Further research will be required to investigate the aetiology of these findings.
IntroductionOver the past two decades the number of nosocomial infections has risen steadily . Methicillin-resistant Staphylococcus aureus (MRSA) has been the main focus of attention due to its obvious direct and indirect consequences for all involved parties , , . Patients with MRSA have a significantly longer in-hospital stay, a worse prognosis and higher mortality. They also instigate higher costs in their diagnosis and therapy, are subject to social stigma and suffer from greater psychological stress , , , , , , , . The prevalence of resistant S. aureus has shown a dramatic increase worldwide since 1990 , . In Germany the ratio of MRSA to Methicillin susceptible S. aureus (MSSA) blood cultures has risen from 1.7% to 21% in 15 years (1990–2005), putting Germany to a mid position amongst all EU countries with the steepest rise in MRSA infections. Furthermore, the development of further resistant pathogens seems imminent due to documented Vancomycin Resistant Staphylococcus Aureus (VRSA) cases in countries neighbouring Germany , , . The aim of this study was to analyse a representative cohort of inpatients with MRSA, to identify risk factors for MRSA acquisition, transmission pathways and particularly affected specialties. Furthermore we aimed to audit the prevalence of MRSA in an East-German University Hospital as compared to the national situation .
Material and methodsAll data originates from a Saxonian University hospital with 1,250 beds and treats 50,000 in-patients per year. The study period was 7 years between 01.01.2001 and 31.12.2007. Data from the first 6 years were collected retrospectively and the last year prospectively. Patients were screened for MRSA in keeping with the modified guidelines outlined by the Robert Koch-Institute in the presence of at least one risk factor (Table 1 ). Processing of specimens was undertaken by the Institute for M<![CDATA[icr</PlainText></TextGroup>obiology and Hygiene of the Technical University Dresden, Germany. Specimens taken from patients on the intensive care units at the University Hospital in the year 2007 were analysed and sent for genotyping.</Pgraph><Pgraph>Individual specimens were plated on Columbia blood agar (Oxoid, Wesel, Germany) and incubated overnight at 37°C. Single colonies were used for further subculturing. Screening for clumping factor and coagulase was performed using Pastorex Staph-Plus (Bio-Rad, Munich, Germany) and rabbit plasma (Becton-Dickinson, Heidelberg, Germany). Routine susceptibility tests were performed using the VITEK I system (bio-Mérieux, Nürtingen, Germany) as recommended by the manufacturer. Methicillin resistance was confirmed by detection of penicillin-binding protein 2’ (PBP2’) using an agglutination assay (MRSA-screen; Innogenetics, Ghent, Belgium). Penicillinase activity was detected using the BBL DrySlide N<TextGroup><PlainText>itr</PlainText></TextGroup>ocefin test (Becton Dickinson). The identified MRSA were plated on Columbia blood agar (Oxoid, Wesel, Germany) and incubated overnight again.</Pgraph><Pgraph>Genotyping was undertaken with DNA microarray technology (CLONDIAG Chip Technologies GmbH) as described previously <TextLink reference="18"></TextLink>, <TextLink reference="19"></TextLink>.</Pgraph><Pgraph>In case of a positive MRSA result the patient was isolated in keeping with the protocol of the Robert Koch-Institute (isolation in one-bed-room, use of protective clothing, basic hygienic actions, screening as explains above, use of one way masks, isolation lifted after three negative samples being taken at 24 h intervals) and the MRSA case was recorded. Data recording included age at first MRSA presentation, gender, and hospital acquired versus community acquired infection, time of inpatient stay, ward and location settings previous to admission. Wards were subdivided into intensive care, general surgical and medical wards and other surgical wards (Table 2 <ImgLink imgNo="2" imgType="table"/>). National comparison was performed in accordance with the criteria and standards outlined by the MRSA-KISS study <TextLink reference="20"></TextLink>. For statistical reasons the differentiation of gender could only be performed in the years 2004 to 2007. An MRSA case was defined as a patient testing positive for MRSA during the hospitalisation. Recurrent admissions were classified as new cases. Using these standards we were able to identify 1,079 MRSA cases, 74% of which were inpatients (n=798), 25.98% outpatients and 0.02% day cases. Only inpatients were included in this study. P<0.001 was taken as the level of significance.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Results">
<MainHeadline>Results</MainHeadline><Pgraph>798 cases were identified during a 7-year time period (Figure 1 <ImgLink imgNo="1" imgType="figure"/>). Patients with MRSA were between 50 to 74 years with a median of 60 years (Figure 2 <ImgLink imgNo="2" imgType="figure"/>). Male to female ratio showed a significant predominance (p<0.001; χ<Superscript>2</Superscript>-Test) of the male gender (Figure 3 <ImgLink imgNo="3" imgType="figure"/>). Most patients were admitted directly from their own home (62.6%) prior to admission followed by other medical facilities (26.5%) and more rarely nursing homes (4.9%). MRSA positive patients had a 4.15 times longer in-hospital stay (not significant; p>0.001). ICU had the highest MRSA prevalence (Figure 4 <ImgLink imgNo="4" imgType="figure"/>). ICU had the highest MRSA prevalence, except for the year 2007 when the surgical wards had the highest MRSA rates (cases per 1,000 patient days). Despite the higher MRSA rates in ICU, we were able to observe a reduction of MRSA cases per 1,000 inpatient days as compared to the surgical wards where this rate continually increased (Figure 4 <ImgLink imgNo="4" imgType="figure"/>). We also det<TextGroup><PlainText>ecte</PlainText></TextGroup>d a correlation of hospital acquired infection rate per 1,000 inpatient days with MRSA inpatient days (k=0.99). Genotyping of MRSA samples from ICU (2007 only) showed the Barnim-(ST 22) and Rheine-Hessen (ST 5) as well as South German (ST 228) strains only. Between three and five subtypes of the main strain were sampled for genotyping, respectively (Table 3 <ImgLink imgNo="3" imgType="table"/>). Of note, the anaesthetic ICU was only affected by two different subtypes of the South German strains.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Discussion">
<MainHeadline>Discussion</MainHeadline><Pgraph>Two thirds of MRSA patients were above 50 years of age in keeping with the current literature <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>, <TextLink reference="23"></TextLink>. However, age as an independent risk factor has not been registered in the literature or with the Centers for Disease Control and Prevention (CDC) or with the Robert Koch-Institute. Older people have more risk factors <TextLink reference="24"></TextLink>. In addition they are the largest patient subgroup in hospitals, which could be seen as a confounder (Table 1 <ImgLink imgNo="1" imgType="table"/>). Further research will be required to investigate this <TextLink reference="25"></TextLink>, <TextLink reference="26"></TextLink>. In contrast to previous studies that showed no or no significant gender predominance we were able to demonstrate that male sex is a significant risk factor (p<0.001) for MRSA <TextLink reference="27"></TextLink>, <TextLink reference="28"></TextLink>, <TextLink reference="29"></TextLink>. We attribute this to the fact that most risk factors, which predispose individuals to acquiring MRSA, were mainly possessed by men rather than women. Van Landeghem et al. <TextLink reference="30"></TextLink> stated that diabetes mellitus related terminal renal failure, requiring dialysis, was more common in men (59%), which added to the risk profile. Invasive devices were a further factor such as bladder catheters. In nursing homes only 5% of women but 30% of men were catheterised. Similarly, due to obvious patho-anatomical considerations we would assume that in the general community more men than women are catheterised <TextLink reference="31"></TextLink>. Hornberg et al. argue that peripheral vascular disease in diabetics is four times more common in men, leading to delayed wound healing with prolonged or repeated hospital inpatient days. Both factors add to the MRSA risk profile <TextLink reference="8"></TextLink>, <TextLink reference="32"></TextLink>. </Pgraph><Pgraph>The increase in hospital days among MRSA patients is in keeping with the literature. This tendency decreased during our observation time <TextLink reference="1"></TextLink>, <TextLink reference="9"></TextLink>, <TextLink reference="17"></TextLink>, <TextLink reference="21"></TextLink>. MRSA infections not acquired in hospital (n=385) showed that the pre-hospital residence was their own home in 62.5% of the cases, medical facilities in 26.6% and only 4.9% were from nursing homes (6% could not be traced). These numbers show a high prevalence of MRSA patients in presumed “non-risk” areas. </Pgraph><Pgraph>The East German University Hospital Dresden can be seen (regarding <Mark2>all</Mark2> MRSA cases per 1,000 inpatient days) under the 25% percentile between 2004–2007 compared to the national average monitored by the MRSA-KISS study. The hospital acquired MRSA rate per 1,000 <Mark2>MRSA days</Mark2> is comparably high on national comparison. Further data will be necessary to evaluate this.</Pgraph><Pgraph>The highest infection rate among the hospital wards was seen on the intensive care units followed by the surgical wards (Table 2 <ImgLink imgNo="2" imgType="table"/>). Medical wards were third and minor surgical wards last, in keeping with the current literature <TextLink reference="33"></TextLink>, <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink>.</Pgraph><Pgraph>In keeping with literature, ICU’s are known to provide the highest risk for nosocomial infection. The elevated risk of MRSA within the ICU is most likely to be due to the preselected cohort of patients with a larger number in risk factors and comorbidities <TextLink reference="6"></TextLink>, <TextLink reference="36"></TextLink>, <TextLink reference="37"></TextLink>, <TextLink reference="38"></TextLink>, <TextLink reference="39"></TextLink>). Other factors involve the increased inpatient time, the use of invasive devices, high prevalence of multiresistant bacteria and increased use of antibiotics <TextLink reference="40"></TextLink>, <TextLink reference="41"></TextLink>, <TextLink reference="42"></TextLink>.</Pgraph><Pgraph>Genotyping of MRSA strains on ICU showed Rheine-Hessen- (ST 5), Barnim- (ST 22) and South German (ST 228) strains (Table 3 <ImgLink imgNo="3" imgType="table"/>), representing three of the four most common types in Germany. Horizontal infection was only seen in a minority of cases. Persistence of MRSA on the ward was observed independently of patient contacts. This highlights the importance of Panton-Valentine-Leukozidin and the relationship of staff and medical equipment <TextLink reference="12"></TextLink>, <TextLink reference="24"></TextLink>. </Pgraph></TextBlock>
<TextBlock linked="yes" name="Conclusion">
<MainHeadline>Conclusion</MainHeadline><Pgraph>MRSA is a challenging problem under clinical and epidemiological perspectives. In this study we were able to demonstrate that male gender is significantly correlated with an increased risk of MRSA acquisition (p<0.001), the most predominant setting for MRSA being the intensive care unit. 75% of MRSA positive patients are over 50 years of age. The inpatient time was 4.15 times higher in MRSA carriers compared to MSSA cases, however this was not significant. MRSA genotyping on ICU showed mainly the subtypes ST 5, ST 22, ST 228. Cross contamination with identical genotypes was only detected in a minority of cases (5 out of 22).</Pgraph><Pgraph>Unlike previous studies which show no or inconclusive evidence of gender as a risk factor, our data confirm that male gender is a significant risk factor for MRSA carrier status. Further research will be required to investigate the aetiology of these findings.</Pgraph></TextBlock>
<References linked="yes">
<Reference refNo="1">
<RefAuthor>Kipp F</RefAuthor>
<RefAuthor>Friedrich AW</RefAuthor>
<RefAuthor>Becker K</RefAuthor>
<RefAuthor>von Eiff C</RefAuthor>
<RefTitle>Bedrohliche Zunahme Methicillin-resistenter Staphylococcus-aureus-Stämme: Strategien zur Kontrolle und Prävention in Deutschland</RefTitle>
<RefYear>2004</RefYear>
<RefJournal>Dtsch Arztebl</RefJournal>
<RefPage>2045-50</RefPage>
<RefTotal>Kipp F, Friedrich AW, Becker K, von Eiff C. Bedrohliche Zunahme Methicillin-resistenter Staphylococcus-aureus-Stämme: Strategien zur Kontrolle und Prävention in Deutschland. Dtsch Arztebl. 2004;101(28-29):2045-50.</RefTotal>
</Reference>
<Reference refNo="2">
<RefAuthor>Marcotte AL</RefAuthor>
<RefAuthor>Trzeciak MA</RefAuthor>
<RefTitle>Community-acquired methicillin-resistant Staphylococcus aureus: an emerging pathogen in orthopaedics</RefTitle>
<RefYear>2008</RefYear>
<RefJournal>J Am Acad Orthop Surg</RefJournal>
<RefPage>98-106</RefPage>
<RefTotal>Marcotte AL, Trzeciak MA. Community-acquired methicillin-resistant Staphylococcus aureus: an emerging pathogen in orthopaedics. J Am Acad Orthop Surg. 2008;16(2):98-106.</RefTotal>
</Reference>
<Reference refNo="3">
<RefAuthor>Noskin GA</RefAuthor>
<RefAuthor>Rubin RJ</RefAuthor>
<RefAuthor>Schentag JJ</RefAuthor>
<RefAuthor>Kluytmans J</RefAuthor>
<RefAuthor>Hedblom EC</RefAuthor>
<RefAuthor>Smulders M</RefAuthor>
<RefAuthor></RefAuthor>
<RefTitle>The burden of Staphylococcus aureus infections on hospitals in the United States: an analysis of the 2000 and 2001 Nationwide Inpatient Sample Database</RefTitle>
<RefYear>2005</RefYear>
<RefJournal>Arch Intern Med</RefJournal>
<RefPage>1756-61</RefPage>
<RefTotal>Noskin GA, Rubin RJ, Schentag JJ, Kluytmans J, Hedblom EC, Smulders M, et al. The burden of Staphylococcus aureus infections on hospitals in the United States: an analysis of the 2000 and 2001 Nationwide Inpatient Sample Database. Arch Intern Med. 2005;165(15):1756-61. DOI: 10.1001/archinte.165.15.1756</RefTotal>
<RefLink>http://dx.doi.org/10.1001/archinte.165.15.1756</RefLink>
</Reference>
<Reference refNo="4">
<RefAuthor>D'Agata EM</RefAuthor>
<RefAuthor>Webb GF</RefAuthor>
<RefAuthor>Horn MA</RefAuthor>
<RefAuthor>Moellering RC Jr</RefAuthor>
<RefAuthor>Ruan S</RefAuthor>
<RefTitle>Modeling the invasion of community-acquired methicillin-resistant Staphylococcus aureus into hospitals</RefTitle>
<RefYear>2009</RefYear>
<RefJournal>Clin Infect Dis</RefJournal>
<RefPage>274-84</RefPage>
<RefTotal>D'Agata EM, Webb GF, Horn MA, Moellering RC Jr, Ruan S. Modeling the invasion of community-acquired methicillin-resistant Staphylococcus aureus into hospitals. Clin Infect Dis. 2009;48(3):274-84. DOI: 10.1086/595844</RefTotal>
<RefLink>http://dx.doi.org/10.1086/595844</RefLink>
</Reference>
<Reference refNo="5">
<RefAuthor>Cosgrove SE</RefAuthor>
<RefAuthor>Sakoulas G</RefAuthor>
<RefAuthor>Perencevich EN</RefAuthor>
<RefAuthor>Schwaber MJ</RefAuthor>
<RefAuthor>Karchmer AW</RefAuthor>
<RefAuthor>Carmeli Y</RefAuthor>
<RefTitle>Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a meta-analysis</RefTitle>
<RefYear>2003</RefYear>
<RefJournal>Clin Infect Dis</RefJournal>
<RefPage>53-9</RefPage>
<RefTotal>Cosgrove SE, Sakoulas G, Perencevich EN, Schwaber MJ, Karchmer AW, Carmeli Y. Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a meta-analysis. Clin Infect Dis. 2003;36(1):53-9. DOI: 10.1086/345476</RefTotal>
<RefLink>http://dx.doi.org/10.1086/345476</RefLink>
</Reference>
<Reference refNo="6">
<RefAuthor>Thompson DS</RefAuthor>
<RefAuthor>Workman R</RefAuthor>
<RefAuthor>Strutt M</RefAuthor>
<RefTitle>Contribution of acquired meticillin-resistant Staphylococcus aureus bacteraemia to overall mortality in a general intensive care unit</RefTitle>
<RefYear>2008</RefYear>
<RefJournal>J Hosp Inf</RefJournal>
<RefPage>223-7</RefPage>
<RefTotal>Thompson DS, Workman R, Strutt M. Contribution of acquired meticillin-resistant Staphylococcus aureus bacteraemia to overall mortality in a general intensive care unit. J Hosp Inf. 2008;70(3):223-7. DOI: 10.1016/j.jhin.2008.07.004</RefTotal>
<RefLink>http://dx.doi.org/10.1016/j.jhin.2008.07.004</RefLink>
</Reference>
<Reference refNo="7">
<RefAuthor>Munoz P</RefAuthor>
<RefAuthor>Hortal J</RefAuthor>
<RefAuthor>Giannella M</RefAuthor>
<RefAuthor>Barrio JM</RefAuthor>
<RefAuthor>Rodriguez-Creixems M</RefAuthor>
<RefAuthor>Perez MJ</RefAuthor>
<RefAuthor></RefAuthor>
<RefTitle>Nasal carriage of S. aureus increases the risk of surgical site infection after major heart surgery</RefTitle>
<RefYear>2008</RefYear>
<RefJournal>J Hosp Inf</RefJournal>
<RefPage>25-31</RefPage>
<RefTotal>Munoz P, Hortal J, Giannella M, Barrio JM, Rodriguez-Creixems M, Perez MJ, et al. Nasal carriage of S. aureus increases the risk of surgical site infection after major heart surgery. J Hosp Inf. 2008;68(1):25-31. DOI: 10.1016/j.jhin.2007.08.010</RefTotal>
<RefLink>http://dx.doi.org/10.1016/j.jhin.2007.08.010</RefLink>
</Reference>
<Reference refNo="8">
<RefAuthor>Fascia DT</RefAuthor>
<RefAuthor>Singanayagam A</RefAuthor>
<RefAuthor>Keating JF</RefAuthor>
<RefTitle>Methicillin-resistant Staphylococcus aureus in orthopaedic trauma: identification of risk factors as a strategy for control of infection</RefTitle>
<RefYear>2009</RefYear>
<RefJournal>J Bone Joint Surg Br</RefJournal>
<RefPage>249-52</RefPage>
<RefTotal>Fascia DT, Singanayagam A, Keating JF. Methicillin-resistant Staphylococcus aureus in orthopaedic trauma: identification of risk factors as a strategy for control of infection. J Bone Joint Surg Br. 2009;91(2):249-52. DOI: 10.1302/0301-620X.91B2.21339</RefTotal>
<RefLink>http://dx.doi.org/10.1302/0301-620X.91B2.21339</RefLink>
</Reference>
<Reference refNo="9">
<RefAuthor>von Eiff C</RefAuthor>
<RefAuthor>Kipp F</RefAuthor>
<RefTitle>Kolonisation und Infektion durch methicillinresistente Staphylococcus-aureus-Stämme</RefTitle>
<RefYear>2007</RefYear>
<RefJournal>Trauma Berufskr</RefJournal>
<RefPage>274-7</RefPage>
<RefTotal>von Eiff C, Kipp F. Kolonisation und Infektion durch methicillinresistente Staphylococcus-aureus-Stämme. Trauma Berufskr. 2007; 9(Suppl 3): 274-7. DOI: 10.1007/s10039-007-1300-x</RefTotal>
<RefLink>http://dx.doi.org/10.1007/s10039-007-1300-x</RefLink>
</Reference>
<Reference refNo="10">
<RefAuthor>Simon A</RefAuthor>
<RefAuthor>Exner M</RefAuthor>
<RefAuthor>Kramer A</RefAuthor>
<RefAuthor>Engelhart S</RefAuthor>
<RefTitle>Umsetzung der MRSA-Empfehlung der KRINKO von 1999 – Aktuelle Hinweise des Vorstands der DGKH</RefTitle>
<RefYear>2009</RefYear>
<RefJournal>Hyg Med</RefJournal>
<RefPage>90-101</RefPage>
<RefTotal>Simon A, Exner M, Kramer A, Engelhart S. Umsetzung der MRSA-Empfehlung der KRINKO von 1999 – Aktuelle Hinweise des Vorstands der DGKH. Hyg Med. 2009;34(3):90-101. Available from: http://www.dgkh.de/pdfdata/empfehlung_mrsa_2009.pdf</RefTotal>
<RefLink>http://www.dgkh.de/pdfdata/empfehlung_mrsa_2009.pdf</RefLink>
</Reference>
<Reference refNo="11">
<RefAuthor>Jukema G</RefAuthor>
<RefAuthor>Kluytmans J</RefAuthor>
<RefTitle>MRSA Infektionen: Reaktionen anderer Länder. Beispiel Niederlande</RefTitle>
<RefYear>2007</RefYear>
<RefJournal>Trauma Berufskr</RefJournal>
<RefPage>278-80</RefPage>
<RefTotal>Jukema G, Kluytmans J. MRSA Infektionen: Reaktionen anderer Länder. Beispiel Niederlande. Trauma Berufskr. 2007;9(3):278-80. DOI: 10.1007/s10039-007-1309-1</RefTotal>
<RefLink>http://dx.doi.org/10.1007/s10039-007-1309-1</RefLink>
</Reference>
<Reference refNo="12">
<RefAuthor>Kaminski A</RefAuthor>
<RefAuthor>Muhr G</RefAuthor>
<RefTitle>MRSA-Kolonisation bei medizinischem Personal</RefTitle>
<RefYear>2007</RefYear>
<RefJournal>Trauma Berufskr</RefJournal>
<RefPage>290-1</RefPage>
<RefTotal>Kaminski A, Muhr G. MRSA-Kolonisation bei medizinischem Personal. Trauma Berufskr. 2007;9(Suppl 3):290-1. DOI: 10.1007/s10039-007-1285-5</RefTotal>
<RefLink>http://dx.doi.org/10.1007/s10039-007-1285-5</RefLink>
</Reference>
<Reference refNo="13">
<RefAuthor>Hübner NO</RefAuthor>
<RefAuthor>Kramer A</RefAuthor>
<RefTitle>Antibiotikaresistenz bei Staphylococcus aureus Implikationen für ambulantes operieren</RefTitle>
<RefYear>2008</RefYear>
<RefJournal>Ambul Chir</RefJournal>
<RefPage>30-2</RefPage>
<RefTotal>Hübner NO, Kramer A. Antibiotikaresistenz bei Staphylococcus aureus Implikationen für ambulantes operieren. Ambul Chir. 2008;12(1):30-2.</RefTotal>
</Reference>
<Reference refNo="14">
<RefAuthor>Witte W</RefAuthor>
<RefAuthor>Kresken M</RefAuthor>
<RefAuthor>Braulke C</RefAuthor>
<RefAuthor>Cuny C</RefAuthor>
<RefTitle>Increasing incidence and widespread dissemination of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals in central Europe, with special reference to German hospitals</RefTitle>
<RefYear>1997</RefYear>
<RefJournal>Clin Microbiol Infect</RefJournal>
<RefPage>414-22</RefPage>
<RefTotal>Witte W, Kresken M, Braulke C, Cuny C. Increasing incidence and widespread dissemination of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals in central Europe, with special reference to German hospitals. Clin Microbiol Infect. 1997;3(4):414-22. DOI: 10.1111/j.1469-0691.1997.tb00277.x</RefTotal>
<RefLink>http://dx.doi.org/10.1111/j.1469-0691.1997.tb00277.x</RefLink>
</Reference>
<Reference refNo="15">
<RefAuthor>Grundmann H</RefAuthor>
<RefTitle>Staphylococcus aureus resistance trends: 1999-2007</RefTitle>
<RefYear>2008</RefYear>
<RefBookTitle>EARSS – Annual Report 2007</RefBookTitle>
<RefPage>49-50</RefPage>
<RefTotal>Staphylococcus aureus resistance trends: 1999-2007. In: Grundmann H, editor. EARSS – Annual Report 2007. Bilthoven: EARSS; 2008. p. 49-50. Available from: http://www.rivm.nl/earss/Images/EARSS%202007_FINAL_tcm61-55933.pdf</RefTotal>
<RefLink>http://www.rivm.nl/earss/Images/EARSS%202007_FINAL_tcm61-55933.pdf</RefLink>
</Reference>
<Reference refNo="16">
<RefAuthor>Grundmann H</RefAuthor>
<RefTitle>Staphylococcus aureus</RefTitle>
<RefYear>2008</RefYear>
<RefBookTitle>EARSS – Annual Report 2007</RefBookTitle>
<RefPage>108-9</RefPage>
<RefTotal>Staphylococcus aureus. In: Grundmann H, editor. EARSS – Annual Report 2007. Bilthoven: EARSS; 2008. p. 108-9. Available from: http://www.rivm.nl/earss/Images/EARSS%202007_FINAL_tcm61-55933.pdf</RefTotal>
<RefLink>http://www.rivm.nl/earss/Images/EARSS%202007_FINAL_tcm61-55933.pdf</RefLink>
</Reference>
<Reference refNo="17">
<RefAuthor>Herbst B</RefAuthor>
<RefAuthor>Kortmann H</RefAuthor>
<RefTitle>MRSA-Infektion – eine moderne Pest?</RefTitle>
<RefYear>2007</RefYear>
<RefJournal>Trauma Berufskr</RefJournal>
<RefPage>281-9</RefPage>
<RefTotal>Herbst B, Kortmann H. MRSA-Infektion – eine moderne Pest? Trauma Berufskr. 2007;9(Suppl 3):281-9. DOI: 10.1007/s10039-007-1232-5</RefTotal>
<RefLink>http://dx.doi.org/10.1007/s10039-007-1232-5</RefLink>
</Reference>
<Reference refNo="18">
<RefAuthor>Monecke S</RefAuthor>
<RefAuthor>Ehricht R</RefAuthor>
<RefTitle>Rapid genotyping of methicillin-resistant Staphylococcus aureus (MRSA) isolates using miniaturised oligonucleotide arrays</RefTitle>
<RefYear>2005</RefYear>
<RefJournal>Clin Microbiol Infect</RefJournal>
<RefPage>825-33</RefPage>
<RefTotal>Monecke S, Ehricht R. Rapid genotyping of methicillin-resistant Staphylococcus aureus (MRSA) isolates using miniaturised oligonucleotide arrays. Clin Microbiol Infect. 2005;11(10):825-33. DOI: 10.1111/j.1469-0691.2005.01243.x</RefTotal>
<RefLink>http://dx.doi.org/10.1111/j.1469-0691.2005.01243.x</RefLink>
</Reference>
<Reference refNo="19">
<RefAuthor>Monecke S</RefAuthor>
<RefAuthor>Jatzwauk L</RefAuthor>
<RefAuthor>Weber S</RefAuthor>
<RefAuthor>Slickers P</RefAuthor>
<RefAuthor>Ehricht R</RefAuthor>
<RefTitle>DNA microarray-based genotyping of methicillin-resistant Staphylococcus aureus strains from Eastern Saxony</RefTitle>
<RefYear>2008</RefYear>
<RefJournal>Clin Microbiol Infect</RefJournal>
<RefPage>1157-64</RefPage>
<RefTotal>Monecke S, Jatzwauk L, Weber S, Slickers P, Ehricht R. DNA microarray-based genotyping of methicillin-resistant Staphylococcus aureus strains from Eastern Saxony. Clin Microbiol Infect. 2008;13(12):1157-64.</RefTotal>
</Reference>
<Reference refNo="20">
<RefAuthor>Nationales Referenzzentrum (NRZ) für Surveillance von nosokomialen Infektionen</RefAuthor>
<RefTitle></RefTitle>
<RefYear>2007</RefYear>
<RefBookTitle>MRSA-KISS: Surveillance-Protokoll Methicillin-Resistenter Staphylococcus aureus in Krankenhäusern</RefBookTitle>
<RefPage></RefPage>
<RefTotal>Nationales Referenzzentrum (NRZ) für Surveillance von nosokomialen Infektionen. MRSA-KISS: Surveillance-Protokoll Methicillin-Resistenter Staphylococcus aureus in Krankenhäusern. Berlin: NRZ; 2007.</RefTotal>
</Reference>
<Reference refNo="21">
<RefAuthor>Diller R</RefAuthor>
<RefAuthor>Sonntag AK</RefAuthor>
<RefAuthor>Mellmann A</RefAuthor>
<RefAuthor>Grevener K</RefAuthor>
<RefAuthor>Senninger N</RefAuthor>
<RefAuthor>Kipp F</RefAuthor>
<RefAuthor></RefAuthor>
<RefTitle>Evidence for cost reduction based on pre-admission MRSA screening in general surgery</RefTitle>
<RefYear>2008</RefYear>
<RefJournal>Int J Hyg Environ Health</RefJournal>
<RefPage>205-12</RefPage>
<RefTotal>Diller R, Sonntag AK, Mellmann A, Grevener K, Senninger N, Kipp F, et al. Evidence for cost reduction based on pre-admission MRSA screening in general surgery. Int J Hyg Environ Health. 2008;211(1-2):205-12. DOI: 10.1016/j.ijheh.2007.06.001</RefTotal>
<RefLink>http://dx.doi.org/10.1016/j.ijheh.2007.06.001</RefLink>
</Reference>
<Reference refNo="22">
<RefAuthor>Hoefnagels-Schuermans A</RefAuthor>
<RefAuthor>Borremans A</RefAuthor>
<RefAuthor>Peetermans W</RefAuthor>
<RefAuthor>Van Lierde S</RefAuthor>
<RefAuthor>Reybrouck G</RefAuthor>
<RefAuthor>Van Eldere J</RefAuthor>
<RefTitle>Origin and transmission of methicillin-resistant Staphylococcus aureus in an endemic situation: differences between geriatric and intensive-care patients</RefTitle>
<RefYear>1997</RefYear>
<RefJournal>J Hosp Inf</RefJournal>
<RefPage>209-22</RefPage>
<RefTotal>Hoefnagels-Schuermans A, Borremans A, Peetermans W, Van Lierde S, Reybrouck G, Van Eldere J. Origin and transmission of methicillin-resistant Staphylococcus aureus in an endemic situation: differences between geriatric and intensive-care patients. J Hosp Inf. 1997;36(3):209-22. DOI: 10.1016/S0195-6701(97)90196-1</RefTotal>
<RefLink>http://dx.doi.org/10.1016/S0195-6701(97)90196-1</RefLink>
</Reference>
<Reference refNo="23">
<RefAuthor>Shukla S</RefAuthor>
<RefAuthor>Nixon M</RefAuthor>
<RefAuthor>Acharya M</RefAuthor>
<RefAuthor>Korim MT</RefAuthor>
<RefAuthor>Pandey R</RefAuthor>
<RefTitle>Incidence of MRSA surgical-site infection in MRSA carriers in an orthopaedic trauma unit</RefTitle>
<RefYear>2009</RefYear>
<RefJournal>J Bone Joint Surg Br</RefJournal>
<RefPage>225-8</RefPage>
<RefTotal>Shukla S, Nixon M, Acharya M, Korim MT, Pandey R. Incidence of MRSA surgical-site infection in MRSA carriers in an orthopaedic trauma unit. J Bone Joint Surg Br. 2009;91(2):225-8. DOI: 10.1302/0301-620X.91B2.21715</RefTotal>
<RefLink>http://dx.doi.org/10.1302/0301-620X.91B2.21715</RefLink>
</Reference>
<Reference refNo="24">
<RefAuthor>Robert Koch-Institut</RefAuthor>
<RefTitle>Infektionen durch Streptococcus pyogenes</RefTitle>
<RefYear>2008</RefYear>
<RefJournal>Epid Bull</RefJournal>
<RefPage>359-62</RefPage>
<RefTotal>Robert Koch-Institut. Infektionen durch Streptococcus pyogenes. Epid Bull. 2008;(42):359-62. Available from: http://www.mrsa-net.org/pdf/RKI42_08.pdf</RefTotal>
<RefLink>http://www.mrsa-net.org/pdf/RKI42_08.pdf</RefLink>
</Reference>
<Reference refNo="25">
<RefAuthor>Knopf H</RefAuthor>
<RefTitle>Nosocomial infections caused by multiresistant bacteria. Clinical management of infections with multiresistant Staphylococcus aureus (MRSA)</RefTitle>
<RefYear>1997</RefYear>
<RefJournal>Urologe A</RefJournal>
<RefPage>248-54</RefPage>
<RefTotal>Knopf H. Nosocomial infections caused by multiresistant bacteria. Clinical management of infections with multiresistant Staphylococcus aureus (MRSA). Urologe A. 1997;36(3):248-54. DOI: 10.1007/s001200050099</RefTotal>
<RefLink>http://dx.doi.org/10.1007/s001200050099</RefLink>
</Reference>
<Reference refNo="26">
<RefAuthor>Deutsches Statistisches Bundesamt</RefAuthor>
<RefTitle></RefTitle>
<RefYear>2008</RefYear>
<RefBookTitle>Diagnosedaten der Patienten und Patientinnen in Krankenhäusern (einschl</RefBookTitle>
<RefPage></RefPage>
<RefTotal>Deutsches Statistisches Bundesamt. Diagnosedaten der Patienten und Patientinnen in Krankenhäusern (einschl. Sterbe- und Stundenfälle). Wiesbaden: Destatis; 2008. (Fachserie 12; Reihe 6.2.1). Available from: http://www.gbe-bund.de/gbe10/owards.prc_show_pdf?p_id=11497&p_sprache=D</RefTotal>
<RefLink>http://www.gbe-bund.de/gbe10/owards.prc_show_pdf?p_id=11497&p_sprache=D</RefLink>
</Reference>
<Reference refNo="27">
<RefAuthor>Cavalcanti SM</RefAuthor>
<RefAuthor>Franca ER</RefAuthor>
<RefAuthor>Cabral C</RefAuthor>
<RefAuthor>Vilela MA</RefAuthor>
<RefAuthor>Montenegro F</RefAuthor>
<RefAuthor>Menezes D</RefAuthor>
<RefAuthor></RefAuthor>
<RefTitle>Prevalence of Staphylococcus aureus introduced into intensive care units of a University Hospital</RefTitle>
<RefYear>2005</RefYear>
<RefJournal>Braz J Infect Dis</RefJournal>
<RefPage>56-63</RefPage>
<RefTotal>Cavalcanti SM, Franca ER, Cabral C, Vilela MA, Montenegro F, Menezes D, et al. Prevalence of Staphylococcus aureus introduced into intensive care units of a University Hospital. Braz J Infect Dis. 2005;9(1):56-63. DOI: 10.1590/S1413-86702005000100010</RefTotal>
<RefLink>http://dx.doi.org/10.1590/S1413-86702005000100010</RefLink>
</Reference>
<Reference refNo="28">
<RefAuthor>Aizen E</RefAuthor>
<RefAuthor>Ljubuncic Z</RefAuthor>
<RefAuthor>Ljubuncic P</RefAuthor>
<RefAuthor>Aizen I</RefAuthor>
<RefAuthor>Potasman I</RefAuthor>
<RefTitle>Risk factors for methicillin-resistant Staphylococcus aureus colonization in a geriatric rehabilitation hospital</RefTitle>
<RefYear>2007</RefYear>
<RefJournal>J Gerontol A Biol Sci Med Sci</RefJournal>
<RefPage>1152-6</RefPage>
<RefTotal>Aizen E, Ljubuncic Z, Ljubuncic P, Aizen I, Potasman I. Risk factors for methicillin-resistant Staphylococcus aureus colonization in a geriatric rehabilitation hospital. J Gerontol A Biol Sci Med Sci. 2007;62(10):1152-6.</RefTotal>
</Reference>
<Reference refNo="29">
<RefAuthor>Lye WC</RefAuthor>
<RefAuthor>Leong SO</RefAuthor>
<RefAuthor>Lee EJ</RefAuthor>
<RefTitle>Methicillin-resistant Staphylococcus aureus nasal carriage and infections in CAPD</RefTitle>
<RefYear>1993</RefYear>
<RefJournal>Kidney Int</RefJournal>
<RefPage>1357-62</RefPage>
<RefTotal>Lye WC, Leong SO, Lee EJ. Methicillin-resistant Staphylococcus aureus nasal carriage and infections in CAPD. Kidney Int. 1993;43(6):1357-62. DOI: 10.1038/ki.1993.191</RefTotal>
<RefLink>http://dx.doi.org/10.1038/ki.1993.191</RefLink>
</Reference>
<Reference refNo="30">
<RefAuthor>Van Landeghem MA</RefAuthor>
<RefTitle>Hat die Inzidenz der dialysepflichtigen Niereninsuffizienz bei Diabetikern zugenommen?</RefTitle>
<RefYear>2005</RefYear>
<RefJournal>Med Klin</RefJournal>
<RefPage>241-5</RefPage>
<RefTotal>Van Landeghem MA. Hat die Inzidenz der dialysepflichtigen Niereninsuffizienz bei Diabetikern zugenommen? Med Klin. 2005;100(5):241-5. DOI: 10.1007/s00063-005-1030-4</RefTotal>
<RefLink>http://dx.doi.org/10.1007/s00063-005-1030-4</RefLink>
</Reference>
<Reference refNo="31">
<RefAuthor>Schulte D</RefAuthor>
<RefTitle></RefTitle>
<RefYear>2006</RefYear>
<RefBookTitle>Inzidenz, Risikofaktoren sowie Präventionsmöglichkeiten durch Hygiene</RefBookTitle>
<RefPage></RefPage>
<RefTotal>Schulte D. Inzidenz, Risikofaktoren sowie Präventionsmöglichkeiten durch Hygiene. Frankfurt/Main: Gesundheitsamt; 2006. Available from: http://www.frankfurt.de/sixcms/media.php/738/APH%20Nosokomiale%20Infektionen%20Vortrag.pdf</RefTotal>
<RefLink>http://www.frankfurt.de/sixcms/media.php/738/APH%20Nosokomiale%20Infektionen%20Vortrag.pdf</RefLink>
</Reference>
<Reference refNo="32">
<RefAuthor>Hornberg C</RefAuthor>
<RefAuthor>Schaefer TR</RefAuthor>
<RefAuthor>Koller A</RefAuthor>
<RefAuthor>Wetz HH</RefAuthor>
<RefTitle>Das Problem der MRSA-Infektionen bei der Behandlung des Diabetischen Fusssyndroms</RefTitle>
<RefYear>2003</RefYear>
<RefJournal>Orthopaede</RefJournal>
<RefPage>218-24</RefPage>
<RefTotal>Hornberg C, Schaefer TR, Koller A, Wetz HH. Das Problem der MRSA-Infektionen bei der Behandlung des Diabetischen Fusssyndroms. Orthopaede. 2003;32(3):218-24. DOI: 10.1007/s00132-003-0456-8</RefTotal>
<RefLink>http://dx.doi.org/10.1007/s00132-003-0456-8</RefLink>
</Reference>
<Reference refNo="33">
<RefAuthor>Supriya M</RefAuthor>
<RefAuthor>Shakeel M</RefAuthor>
<RefAuthor>Santangeli L</RefAuthor>
<RefAuthor>Ah-See KW</RefAuthor>
<RefTitle>Controlling MRSA in head and neck cancer patients: what works?</RefTitle>
<RefYear>2009</RefYear>
<RefJournal>Otolaryngol Head Neck Surg</RefJournal>
<RefPage>224-7</RefPage>
<RefTotal>Supriya M, Shakeel M, Santangeli L, Ah-See KW. Controlling MRSA in head and neck cancer patients: what works? Otolaryngol Head Neck Surg. 2009;140(2):224-7. DOI: 10.1016/j.otohns.2008.11.029</RefTotal>
<RefLink>http://dx.doi.org/10.1016/j.otohns.2008.11.029</RefLink>
</Reference>
<Reference refNo="34">
<RefAuthor>Shams WE</RefAuthor>
<RefAuthor>Rapp RP</RefAuthor>
<RefTitle>Methicillin-resistant staphylococcal infections: an important consideration for orthopedic surgeons</RefTitle>
<RefYear>2004</RefYear>
<RefJournal>Orthopedics</RefJournal>
<RefPage>565-8</RefPage>
<RefTotal>Shams WE, Rapp RP. Methicillin-resistant staphylococcal infections: an important consideration for orthopedic surgeons. Orthopedics. 2004;27(6):565-8.</RefTotal>
</Reference>
<Reference refNo="35">
<RefAuthor>Sancineto CF</RefAuthor>
<RefAuthor>Barla JD</RefAuthor>
<RefTitle>Treatment of long bone osteomyelitis with a mechanically stable intramedullar antibiotic dispenser: nineteen consecutive cases with a minimum of 12 months follow-up</RefTitle>
<RefYear>2008</RefYear>
<RefJournal>J Trauma</RefJournal>
<RefPage>1416-20</RefPage>
<RefTotal>Sancineto CF, Barla JD. Treatment of long bone osteomyelitis with a mechanically stable intramedullar antibiotic dispenser: nineteen consecutive cases with a minimum of 12 months follow-up. J Trauma. 2008;65(6):1416-20. DOI: 10.1097/TA.0b013e31818c6a09</RefTotal>
<RefLink>http://dx.doi.org/10.1097/TA.0b013e31818c6a09</RefLink>
</Reference>
<Reference refNo="36">
<RefAuthor>Lucet JC</RefAuthor>
<RefAuthor>Paoletti X</RefAuthor>
<RefAuthor>Lolom I</RefAuthor>
<RefAuthor>Paugam-Burtz C</RefAuthor>
<RefAuthor>Trouillet JL</RefAuthor>
<RefAuthor>Timsit JF</RefAuthor>
<RefAuthor></RefAuthor>
<RefTitle>Successful long-term program for controlling methicillin-resistant Staphylococcus aureus in intensive care units</RefTitle>
<RefYear>2005</RefYear>
<RefJournal>Int Care Med</RefJournal>
<RefPage>1051-7</RefPage>
<RefTotal>Lucet JC, Paoletti X, Lolom I, Paugam-Burtz C, Trouillet JL, Timsit JF, et al. Successful long-term program for controlling methicillin-resistant Staphylococcus aureus in intensive care units. Int Care Med. 2005;31(8):1051-7. DOI: 10.1007/s00134-005-2679-0</RefTotal>
<RefLink>http://dx.doi.org/10.1007/s00134-005-2679-0</RefLink>
</Reference>
<Reference refNo="37">
<RefAuthor>Bloemendaal AL</RefAuthor>
<RefAuthor>Fluit AC</RefAuthor>
<RefAuthor>Jansen WM</RefAuthor>
<RefAuthor>Vriens MR</RefAuthor>
<RefAuthor>Ferry T</RefAuthor>
<RefAuthor>Argaud L</RefAuthor>
<RefAuthor></RefAuthor>
<RefTitle>Acquisition and cross-transmission of Staphylococcus aureus in European intensive care units</RefTitle>
<RefYear>2009</RefYear>
<RefJournal>Inf Contr Hosp Epidemiol</RefJournal>
<RefPage>117-24</RefPage>
<RefTotal>Bloemendaal AL, Fluit AC, Jansen WM, Vriens MR, Ferry T, Argaud L, et al. Acquisition and cross-transmission of Staphylococcus aureus in European intensive care units. Inf Contr Hosp Epidemiol. 2009;30(2):117-24. DOI: 10.1086/593126</RefTotal>
<RefLink>http://dx.doi.org/10.1086/593126</RefLink>
</Reference>
<Reference refNo="38">
<RefAuthor>Spencer RC</RefAuthor>
<RefTitle>Epidemiology of infection in ICUs</RefTitle>
<RefYear>1994</RefYear>
<RefJournal>Int Care Med</RefJournal>
<RefPage>2-6</RefPage>
<RefTotal>Spencer RC. Epidemiology of infection in ICUs. Int Care Med. 1994;20(4):2-6. DOI: 10.1007/BF01713975</RefTotal>
<RefLink>http://dx.doi.org/10.1007/BF01713975</RefLink>
</Reference>
<Reference refNo="39">
<RefAuthor>Vincent JL</RefAuthor>
<RefAuthor>Bihari DJ</RefAuthor>
<RefAuthor>Suter PM</RefAuthor>
<RefAuthor>Bruining HA</RefAuthor>
<RefAuthor>White J</RefAuthor>
<RefAuthor>Nicolas-Chanoin MH</RefAuthor>
<RefAuthor>Wolff M</RefAuthor>
<RefAuthor>Spencer RC</RefAuthor>
<RefAuthor>Hemmer M</RefAuthor>
<RefTitle>The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee</RefTitle>
<RefYear>1995</RefYear>
<RefJournal>JAMA</RefJournal>
<RefPage>639-44</RefPage>
<RefTotal>Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, Wolff M, Spencer RC, Hemmer M. The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee. JAMA. 1995;274(8):639-44.</RefTotal>
</Reference>
<Reference refNo="40">
<RefAuthor>Sadoyama G</RefAuthor>
<RefAuthor>Santos KR</RefAuthor>
<RefAuthor>Brilhante AP</RefAuthor>
<RefAuthor>Filho PP</RefAuthor>
<RefTitle>Staphylococcus aureus as source of catheter-related bloodstream infection evaluated by PFGE and rep-PCR typing in a Brazilian hospital</RefTitle>
<RefYear>2008</RefYear>
<RefJournal>APMIS</RefJournal>
<RefPage>953-60</RefPage>
<RefTotal>Sadoyama G, Santos KR, Brilhante AP, Filho PP. Staphylococcus aureus as source of catheter-related bloodstream infection evaluated by PFGE and rep-PCR typing in a Brazilian hospital. APMIS. 2008;116(11):953-60. DOI: 10.1111/j.1600-0463.2008.01053.x</RefTotal>
<RefLink>http://dx.doi.org/10.1111/j.1600-0463.2008.01053.x</RefLink>
</Reference>
<Reference refNo="41">
<RefAuthor>Nicastri E</RefAuthor>
<RefAuthor>Leone S</RefAuthor>
<RefAuthor>Petrosillo N</RefAuthor>
<RefAuthor>Ballardini M</RefAuthor>
<RefAuthor>Pisanelli C</RefAuthor>
<RefAuthor>Magrini P</RefAuthor>
<RefAuthor></RefAuthor>
<RefTitle>Decrease of methicillin resistant Staphylococcus aureus prevalence after introduction of a surgical antibiotic prophylaxis protocol in an Italian hospital</RefTitle>
<RefYear>2008</RefYear>
<RefJournal>New Microbiol</RefJournal>
<RefPage>519-25</RefPage>
<RefTotal>Nicastri E, Leone S, Petrosillo N, Ballardini M, Pisanelli C, Magrini P, et al. Decrease of methicillin resistant Staphylococcus aureus prevalence after introduction of a surgical antibiotic prophylaxis protocol in an Italian hospital. New Microbiol. 2008;31(4):519-25.</RefTotal>
</Reference>
<Reference refNo="42">
<RefAuthor>Daeschlein G</RefAuthor>
<RefAuthor>Assadian O</RefAuthor>
<RefAuthor>Rangous I</RefAuthor>
<RefAuthor>Kramer A</RefAuthor>
<RefTitle>Risk factors for Staphylococcus aureus nasal carriage in residents of three nursing homes in Germany</RefTitle>
<RefYear>2006</RefYear>
<RefJournal>J Hosp Inf</RefJournal>
<RefPage>216-20</RefPage>
<RefTotal>Daeschlein G, Assadian O, Rangous I, Kramer A. Risk factors for Staphylococcus aureus nasal carriage in residents of three nursing homes in Germany. J Hosp Inf. 2006;63(2):216-20. DOI: 10.1016/j.jhin.2005.12.014</RefTotal>
<RefLink>http://dx.doi.org/10.1016/j.jhin.2005.12.014</RefLink>
</Reference>
</References>
<Media>
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<Caption><Pgraph><Mark1>Table 1: Risk factors with screening as consequence </Mark1></Pgraph><Pgraph>Microbiological screening comprises swabs of vestibules nasi, throat and wounds (including eczema and chronic wounds).</Pgraph></Caption>
</Table>
<Table format="png">
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<Caption><Pgraph><Mark1>Table 2: Disciplines and their subgroups</Mark1></Pgraph></Caption>
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<Caption><Pgraph><Mark1>Table 3: MRSA strains and their genotype detected by microarray technology</Mark1></Pgraph></Caption>
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<Figure format="png" height="616" width="983">
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<Caption><Pgraph><Mark1>Figure 1: Nosocomial and non-nosocomial MRSA cases in 100 inpatients</Mark1></Pgraph></Caption>
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<Caption><Pgraph><Mark1>Figure 2: Age of 798 MRSA-Positives (Box-Whiskers-plot graphic)</Mark1></Pgraph></Caption>
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<Figure format="png" height="496" width="756">
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<Caption><Pgraph><Mark1>Figure 3: Relative distribution of MRSA positives selected by gender</Mark1></Pgraph></Caption>
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<Figure format="png" height="595" width="776">
<MediaNo>4</MediaNo>
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<Caption><Pgraph><Mark1>Figure 4: Nosocomial MRSA cases in 1,000 inpatient-days, selected by ward-type</Mark1></Pgraph></Caption>
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