Peripherally inserted central venous catheters. Low-risk alternatives for ongoing venous access.

We prospectively evaluated the use of peripherally inserted central venous catheters to provide ongoing venous access in general medical and surgical patients in a Department of Veterans Affairs medical center. Between 1985 and 1988 trained nurses successfully inserted 393 catheters in 460 suitable patients (an 85.4% success rate). Correct catheter tip placement in the superior vena cava was documented in 359 of the 393 (91.3%) catheter insertions, but an additional 30 catheters were in a position deemed adequate for the intended use. The mean duration of catheter use was 27.6 +/- 5.2 (1 standard deviation) days (median 20 days, range 1 to 370 days). A total of 65 patients left the hospital with catheters in place, with the mean length of catheter use at home being 36.2 +/- 6.0 days (range 2 to 266). In all, 79% of the catheters were in use until the successful completion of therapy or patient death; catheter-related complications led to premature catheter removal in the remaining 21%. Catheter-related complications included bland phlebitis (8.2%), occlusion (8.2%), local infection (3.6%), bacteremia or fungemia (2.1%), mechanical failure or rupture (2.6%), venous thrombosis (0.7%), and other (3.3%). One patient required vein excision for the management of suppurative phlebitis, but no deaths were attributed to catheter use. This study illustrates the use and safety of peripherally inserted central venous catheters to provide reliable vascular access over prolonged periods in an elderly veteran population. At our facility, percutaneous central venous catheters and surgically implanted (Hickman or Broviac) catheters are now reserved for use in patients in whom peripherally inserted catheters cannot be placed.     

Evaluation of bacteremia in a pediatric intensive care unit: epidemiology, microbiology, sources sites and risk factors

Bacteremia is a common cause of morbidity and mortality in children treated in pediatric intensive care unit (PICU). We have investigated the causative agents of bacteremia in our PICU over a one-year period, to determine mortality associated with such infection and identify the dependent predictors for morbidity and mortality. From 1 January till 31 December 2006, 479 patients were admitted in the PICU and 379 blood culture samples were taken. Samples were incubated in the BACTEC 9050 System, and isolates identified by routine microbiological methods. A pair of samples taken for aerobic and anaerobic culture were statistically regarded as one sample. Data collected from the medical records of each patient were recorded onto standardized collections sheets and included demographic information, predisposing conditions, source(s) of infection, important clinical and laboratory parameters at the time of infection, and microbiological data. Based on these data, positive blood cultures were classified as either contaminants or true bacteremias. During a year period, 117 episodes of bacteremia were documented in 72 patients. The most frequent isolates were the coagulase-negative staphylococci 32.2% (39), followed by Candida spp. 30.5% (36). The mean white blood cell count (WBC) on the day of bacteremia was 15.2 x 10(9)/L (range 0.1-48.0 x 10(9)/L), and 3.3% of episodes occurred in neutropenic (WBC count < 1 x 10(9)/L) children. The mean temperature on the day of infection was 38.2 +/- 1.1 degrees C (range, 34-41 degrees C). Some newborns 23% (n = 5) had a significantly lower mean temperature (p < 0.02) and lower mean WBC count (p < 0.05) than older children. Hemodynamic instability was noted in 11% of bacteremic episodes. Among all bacteremias, intravascular catheters were implicated in 22.6%, pneumonia in 20.4%, genitourinary tract in 14.2%, surgical wounds in 11.7% and, gastrointestinal tract in 9.8%. Seven patients died because of sepsis. Early diagnosis, prompt blood culture reports, followed by appropriate antibiotic treatment is essential in reducing mortality in such patients. Short hospital stay and restricted use of invasive devices should be the aims to reduce the risk of bacteremia during the stay in the PICU.     

Virulence factors in Proteus bacteria from biofilm communities of catheter-associated urinary tract infections

More than 40% of nosocomial infections are those of the urinary tract, most of these occurring in catheterized patients. Bacterial colonization of the urinary tract and catheters results not only in infection, but also various complications, such as blockage of catheters with crystalline deposits of bacterial origin, generation of gravels and pyelonephritis. The diversity of the biofilm microbial community increases with duration of catheter emplacement. One of the most important pathogens in this regard is Proteus mirabilis. The aims of this study were to identify and assess particular virulence factors present in catheter-associated urinary tract infection (CAUTI) isolates, their correlation and linkages: three types of motility (swarming, swimming and twitching), the ability to swarm over urinary catheters, biofilm production in two types of media, urease production and adherence of bacterial cells to various types of urinary tract catheters. We examined 102 CAUTI isolates and 50 isolates taken from stool samples of healthy people. Among the microorganisms isolated from urinary catheters, significant differences were found in biofilm-forming ability and the swarming motility. In comparison with the control group, the microorganisms isolated from urinary catheters showed a wider spectrum of virulence factors. The virulence factors (twitching motility, swimming motility, swarming over various types of catheters and biofilm formation) were also more intensively expressed.     

Rhodotorula infection. A systematic review of 128 cases from literature

Rhodotorula is an emerging opportunistic pathogen, particularly in immunocompromised patients. Many cases of fungemia associated with catheters, endocarditis, peritonitis, meningitis, and endophthalmitis are infections incited by this yeast. The main purpose of this study was to review all cases of Rhodotorula infection reported in the literature and to describe risk factors, underlying conditions and outcome. From 128 cases, 79% were fungemia (103 cases), 7% eye infections (nine cases) and 5% (six cases) peritonitis associated with continuous ambulatory peritoneal dialysis. Eighty seven percent of Rhodotorula infections are associated with underlying immunosuppression or cancer. The most common isolated risk factor associated with Rhodotorula infection was the use of a central venous catheter, which was found in 83.4% of Rhodotorula fungemia (86 cases). Rhodotorula mucilaginosa was the most common species of fungemia (74% of cases), followed by Rhodotorula glutinis with 7.7%. The species was not identified in 17% of the cases of fungemias. Amphotericin was the drug of choice in the treatment of fungemia and most of the eye infections were treated with topical amphotericin, although all patients lost their vision. All peritonitis cases associated with continous ambulatory peritoneal dialysis needed to have the Tenckoff catheter changed. The overall mortality of Rhodotorula infection was 12.6%.     

High vancomycin resistance among biofilms produced by Staphylococcus species isolated from central venous catheters

Biofilm production is an important mechanism that allows microbes to escape host defences and antimicrobial therapy. Vancomycin has been used largely for the treatment of methicillin-resistant staphylococcal infections. Here, we determined the minimal inhibitory concentration (MIC) and minimal biofilm eradication concentration (MBEC) for 82 Staphylococcus species isolated from central venous catheters (CVC). Our results showed that the 41 strong and moderate-biofilm-producing isolates presented a higher MBEC/MIC ratio for vancomycin than the 24 weak-biofilm-producing isolates, illustrating the importance of biofilm production ability and the difficulty in treating biofilm-related infections. The MBEC was significantly higher in moderate-biofilm-producing isolates than in weak-biofilm-producing isolates (p < 0.001) and in strong-biofilm-producing isolates than in weak-biofilm-producing isolates (p = 0.001). The correlation between the MIC and the MBEC was poor. Based on our results, we recommend that bacterial biofilms be suspected in all cases of CVC infection.     

Catheter lock technique: in vitro efficacy of ethanol for eradication of methicillin-resistant staphylococcal biofilm compared with other agents

Biofilm formation in central venous catheters (CVC) is a prerequisite for catheter-related bloodstream infection (CRBSI). The catheter lock technique has been used to treat biofilm infection, but the ideal agent, concentration and the minimum exposure time necessary to eradicate the biofilms are not clearly known. In this study, biofilm-producing strains of staphylococci were used to find out the minimum biofilm eradication concentration of ethanol compared with three other conventional antibacterial agents. Eight representative methicillin-resistant staphylococci, from colonized CVCs, were studied. The biofilms were exposed to 1, 5 and 10?mg?mL(-1) of gentamicin, ciprofloxacin and vancomycin. The ethanol concentrations used were 20%, 40% and 80%. Biofilms were examined for the presence of live organisms after exposure to these agents from 30?min to 24?h. The three antibiotics were unable to eradicate the biofilms even after 24?h, while ethanol at 40% concentration could do so for all the isolates in 1?h. Our study highlights the efficacy and rationale of using 40% ethanol for a short period as catheter lock solution to eradicate biofilms and thus to prevent CRBSI, instead of using high concentrations of antibiotics for extended periods.     

恶性肿瘤患者院内细菌感染临床高危因素调查分析

目的探讨恶性肿瘤患者院内细菌感染的危险因素。方法收集2009年1月至2011年12月大连医科大学附属二院肿瘤内科恶性肿瘤院内细菌感染的98例患者的临床资料,对感染相关高危因素采用单因素及Logistic多因素回归分析。结果单因素分析显示性别、感染部位、留置导尿、WBC下降程度及PS评分与G＋/G-菌感染种类有关（P〈0.05）,但进一步进行多因素分析后显示只有性别和留置导尿对细菌感染种类有影响（OR值分别为0.257、7.726）;细菌种类、性别、深静脉置管及化疗疗程数是血液感染发生的危险因素（OR值分别为8.634、8.000、2.012、0.025）。结论女性较男性更易发生G＋菌感染,而留置导尿则以发生G-菌感染为主;G-菌感染、女性、深静脉置管及多疗程化疗者易发生血液感染。应针对各种危险因素采取有效的预防措施,减少恶性肿瘤患者院内细菌感染的发生。     

Eap1p, an adhesin that mediates Candida albicans biofilm formation in vitro and in vivo

Candida albicans is the leading cause of systemic fungal infections in immunocompromised humans. The ability to form biofilms on surfaces in the host or on implanted medical devices enhances C. albicans virulence, leading to antimicrobial resistance and providing a reservoir for infection. Biofilm formation is a complex multicellular process consisting of cell adhesion, cell growth, morphogenic switching between yeast form and filamentous states, and quorum sensing. Here we describe the role of the C. albicans EAP1 gene, which encodes a glycosylphosphatidylinositol-anchored, glucan-cross-linked cell wall protein, in adhesion and biofilm formation in vitro and in vivo. Deleting EAP1 reduced cell adhesion to polystyrene and epithelial cells in a gene dosage-dependent manner. Furthermore, EAP1 expression was required for C. albicans biofilm formation in an in vitro parallel plate flow chamber model and in an in vivo rat central venous catheter model. EAP1 expression was upregulated in biofilm-associated cells in vitro and in vivo. Our results illustrate an association between Eap1p-mediated adhesion and biofilm formation in vitro and in vivo.     

一起中心静脉置管后菌血症暴发的调查

目的对一起中心静脉置管后菌血症暴发感染进行调查分析,探讨防治措施,为预防和控制医院感染提供参考依据。方法对肿瘤内科4例患者在2008年8月4日-8日期间因中心静脉置管后菌血症暴发流行进行调查分析。结果4例患者血培养、中心静脉导管尖端和治疗室台面等均分离出产酸克雷伯菌,且药物菌谱完全一致。结论此次产酸克雷伯菌引起的菌血症为局部暴发流行。部分人员无菌观念淡薄、无菌操作执行不严可能是引起此次感染的主要原因。提示中心静脉置管者,一旦出现不明原因的感染症状,应考虑中心静脉置管因素。     

Model of Staphylococcus aureus central venous catheter-associated infection in rats.

BACKGROUND AND PURPOSE: Staphylococcus aureus is an important cause of intravascular catheter-associated bacteremia. We developed a rat central venous catheter (CVC)-associated infection model to study pathogenesis and treatment. METHODS: A silastic lumen-within-lumen catheter and rodent-restraint jacket were designed. Subcutaneously tunneled catheters were inserted in the jugular vein of 20 male Sprague Dawley rats. Twelve rats (group 1) were inoculated with S. aureus via the CVC; three rats (group 2) were inoculated with S. aureus via the tail vein, five rats (group 3) served as uninfected controls; and three rats (group 4) were inoculated with S. aureus via the tail vein but did not undergo CVC insertion. Five to eight days after inoculation, animals were euthanized, CVCs were aseptically removed, and quantitative culture was done. Quantitative culture also was performed on blood, heart, liver, lungs, and kidneys. RESULTS: Infection, characterized by bacteremia and metastatic disease, was observed in all rats inoculated via the CVC with as few as 100 colony-forming units (CFU) of S. aureus. Rats of group 2 were not as likely to develop CVC-associated infection, and none of the animals of groups 3 or 4 developed infection. CONCLUSIONS: This model of CVC-associated infection should prove suitable for studying pathogenesis and treatment of the condition.     

Mini-review: Antimicrobial central venous catheters – recent advances and strategies

Central venous catheters (CVCs) nowadays constitute critical devices used in medical care, namely in intensive care units. However, CVCs also represent one of the indwelling medical devices with enhanced risk of nosocomial device-related infection. Catheter-related infections (CRIs) are a major cause of patient morbidity and mortality, often justifying premature catheter removal and an increase in costs and use of resources. Adhesion and subsequent biofilm formation on the surfaces of indwelling catheters is elemental to the onset of pathogenesis. Seeking the prevention of CVC colonisation and CRI, a variety of approaches have been studied, tested and, in some cases, already applied in clinical practice. This review looks at the current preventive strategies often used to decrease the risk of CRIs due to colonization and biofilm formation on catheter surfaces, as well as at the more recent approaches under investigation.     

Mini-review: Antimicrobial central venous catheters--recent advances and strategies

Central venous catheters (CVCs) nowadays constitute critical devices used in medical care, namely in intensive care units. However, CVCs also represent one of the indwelling medical devices with enhanced risk of nosocomial device-related infection. Catheter-related infections (CRIs) are a major cause of patient morbidity and mortality, often justifying premature catheter removal and an increase in costs and use of resources. Adhesion and subsequent biofilm formation on the surfaces of indwelling catheters is elemental to the onset of pathogenesis. Seeking the prevention of CVC colonisation and CRI, a variety of approaches have been studied, tested and, in some cases, already applied in clinical practice. This review looks at the current preventive strategies often used to decrease the risk of CRIs due to colonization and biofilm formation on catheter surfaces, as well as at the more recent approaches under investigation.     

Review of techniques for diagnosis of catheter-related Candida biofilm infections

Recent evidence shows that many hospital-acquired infections, including most device-associated infections, involve the persistence of sessile organisms in the form of biofilms that are attached to a device surface and encased in an extracellular matrix. The cells in this environment exhibit an altered phenotype with respect to antimicrobial resistance and thus are extraordinarily difficult to eradicate without device removal. Although a number of implantable and topical devices are at risk for Candida biofilm formation, this review focuses on the diagnosis of the most common of these infections, biofilm growth on the surface of central venous catheters and urinary catheters.     

Hospital-Wide Multidisciplinary,Multimodal Intervention Programme to Reduce Central Venous Catheter-Associated Bloodstream Infection

Central line-associated bloodstream infection (CLABSI) is the major complication of central venous catheters (CVC). The aim of the study was to test the effectiveness of a hospital-wide strategy on CLABSI reduction. Between 2008 and 2011, all CVCs were observed individually and hospital-wide at a large university-affiliated, tertiary care hospital. CVC insertion training started from the 3^rd quarter and a total of 146 physicians employed or newly entering the hospital were trained in simulator workshops. CVC care started from quarter 7 and a total of 1274 nurses were trained by their supervisors using a web-based, modular, e-learning programme. The study included 3952 patients with 6353 CVCs accumulating 61,366 catheter-days. Hospital-wide, 106 patients had 114 CLABSIs with a cumulative incidence of 1.79 infections per 100 catheters. We observed a significant quarterly reduction of the incidence density (incidence rate ratios [95% confidence interval]: 0.92 [0.88–0.96]; P<0.001) after adjusting for multiple confounders. The incidence densities (n/1000 catheter-days) in the first and last study year were 2.3/1000 and 0.7/1000 hospital-wide, 1.7/1000 and 0.4/1000 in the intensive care units, and 2.7/1000 and 0.9/1000 in non-intensive care settings, respectively. Median time-to-infection was 15 days (Interquartile range, 8-22). Our findings suggest that clinically relevant reduction of hospital-wide CLABSI was reached with a comprehensive, multidisciplinary and multimodal quality improvement programme including aspects of behavioural change and key principles of good implementation practice. This is one of the first multimodal, multidisciplinary, hospital-wide training strategies successfully reducing CLABSI.     

Biofilms in device-related infections

The use of various medical devices including indwelling vascular catheters, cardiac pacemakers, prosthetic heart valves, chronic ambulatory peritoneal dialysis catheters and prosthetic joints has greatly facilitated the management of serious medical and surgical illness. However, the successful development of synthetic materials and introduction of these artificial devices into various body systems has been accompanied by the ability of microorganisms to adhere to these devices in the environment of biofilms that protect them from the activity of antimicrobial agents and from host defense mechanisms. A number of host, biomaterial and microbial factors are unique to the initiation, persistence and treatment failures of device-related infections. Intravascular catheters are the most common devices used in clinical practice and interactions associated with these devices are the leading cause of nosocomial bacteremias. The infections associated with these devices include insertion site infection, septic thrombophlebitis, septicemia, endocarditis and metastatic abscesses. Other important device-related infections include infections of vascular prostheses, intracardiac prostheses, total artificial hearts, indwelling urinary catheters, orthopedic prostheses, endotracheal tubes and extended wear lenses. The diagnosis and management of biofilm-associated infections remain difficult but critical issues. Appropriate antimicrobial therapy is often not effective in eradicating these infections and the removal of the device becomes necessary. Several improved diagnostic and therapeutic modalities have been reported in recent experimental studies. The clinical usefulness of these strategies remains to be determined.     

Disruption of the GPI Protein-Encoding Gene <Emphasis Type="Italic">IFF4</Emphasis> of <Emphasis Type="Italic">Candida</Emphasis> <Emphasis Type="Italic">albicans</Emphasis> Results in Decreased Adherence and Virulence

Candida albicans is the most important cause of systemic fungal infection in immunocompromised humans. Candidiasis is often initiated by the adherence and the colonization of inert surfaces such as peripheral venous catheters, central catheters, prosthetic cardiac valves, and other prostheses. We have studied the early stage of adherence and have shown that the disruption of C. albicans IFF4 gene encoding a GPI-anchor protein, led to a decrease of adherence of the germ tubes to plastic. Here, we demonstrated the role of the IFF4 gene in adherence to silicone catheter, as well as in virulence using a murine model of disseminated candidiasis. The iff4 Δ null mutant showed both a decrease of adherence to silicone catheter and a reduction of virulence. This work presents evidence for the importance of the IFF4 gene in host-fungal interaction.     

Rhodotorula Fungemia of an Intensive Care Unit Patient and Review of Published Cases

Rhodotorula species are commensal yeasts that have emerged as a cause of life-threatening fungemia in severely immunocompromised patients. A case of Rhodotorula mucilaginosa fungemia in a 48-year-old woman that had undergone consecutive abdominal surgeries due to ovarian cancer and bowel necrosis while she was receiving fluconazole prophylaxis is presented. Several risk factors were identified such as presence of central venous catheters, solid organ neoplasm, abdominal surgery and administration of antibiotics. Identification was performed using commercial systems. The yeast was resistant to fluconazole, posaconazole and voriconazole and to echinocandins, whereas MIC to amphotericin B was 1.5?mg/L. Furthermore, published cases of Rhodotorula spp fungemia during the last decade are reviewed. In conclusion, Rhodotorula spp must be considered a potential pathogen in patients with immunosupression and central venous catheters. Correct identification is mandatory for appropriate management, as Rhodotorula spp are resistant to antifungal agents, such as fluconazole and echinocandins.     

Citropin 1.1-treated central venous catheters improve the efficacy of hydrophobic antibiotics in the treatment of experimental staphylococcal catheter-related infection

An in vitro antibiotic susceptibility assay for Staphylococcus aureus biofilms developed on 96-well polystyrene tissue culture plates was performed to elucidate the activity of citropin 1.1, rifampin and minocycline. Efficacy studies were performed in a rat model of staphylococcal CVC infection. Silastic catheters were implanted into the superior cava. Twenty-four hours after implantation the catheters were filled with citropin 1.1 (10 microg/mL). Thirty minutes later the rats were challenged via the CVC with 1.0 x 10(6) CFU of S. aureus strain Smith diffuse. Administration of antibiotics into the CVC (the antibiotic lock technique) began 24 h later. The study included: one control group (no CVC infection), one contaminated group that did not receive any antibiotic prophylaxis, one contaminated group that received citropin 1.1-treated CVC, two contaminated groups that received citropin 1.1-treated CVC plus rifampin and minocycline at concentrations equal to MBCs for adherent cells and 1024 microg/mL in a volume of 0.1 mL that filled the CVC and two contaminated groups that received rifampin or minocycline at the same concentrations. All catheters were explanted 7 days after implantation. Main outcome measures were: minimal inhibitory concentration (MIC), minimal bactericidal concentration (MBC), synergy studies, quantitative culture of the biofilm formed on the catheters and surrounding venous tissues, and quantitative peripheral blood cultures. MICs of conventional antibiotics against the bacteria in a biofilm were at least four-fold higher than against the freely growing planktonic cells. In contrast, when antibiotics were used on citropin 1.1 pre-treated cells they showed comparable activity against both biofilm and planktonic organisms. The in vivo studies show that when CVCs were pre-treated with citropin 1.1 or with a high dose of antibiotics, biofilm bacterial load was reduced from 10(7) to 10(3) CFU/mL and bacteremia reduced from 10(3) to 10(1) CFU/mL. When CVCs were treated both with citropin 1.1 and antibiotics, biofilm bacterial load was further reduced to 10(1) CFU/mL and bacteremia was not detected, suggesting 100% elimination of bacteremia and a log 6 reduction in biofilm load. Citropin 1.1 significantly reduces bacterial load and enhances the effect of hydrophobic antibiotics in the treatment of CVC-associated S. aureus infections.     

Bacillus cereus biofilm formation on central venous catheters of hospitalised cardiac patients

Formation of bacterial biofilms is a risk with many in situ medical devices. Biofilm-forming Bacillus species are associated with potentially life-threatening catheter-related blood stream infections in immunocompromised patients. Here, bacteria were isolated from biofilm-like structures within the lumen of central venous catheters (CVCs) from two patients admitted to cardiac hospital wards. Isolates belonged to the Bacillus cereus group, exhibited strong biofilm formation propensity, and mapped phylogenetically close to the B. cereus emetic cluster. Together, whole genome sequencing and quantitative PCR confirmed that the isolates constituted the same strain and possessed a range of genes important for and up-regulated during biofilm formation. Antimicrobial susceptibility testing demonstrated resistance to trimethoprim-sulphamethoxazole, clindamycin, penicillin and ampicillin. Inspection of the genome revealed several chromosomal β-lactamase genes and a sulphonamide resistant variant of folP. This study clearly shows that B. cereus persisting in hospital ward environments may constitute a risk factor from repeated contamination of CVCs.     

Strict infection control measures do not prevent clonal spread of coagulase negative staphylococci colonizing central venous catheters in neutropenic hemato-oncologic patients

Coagulase negative staphylococci (CoNS) are a main cause of catheter related infections (CRI). Earlier studies (1994-1996) revealed a high incidence of CRI (6 per 1000 catheter days) among neutropenic hemato-oncologic patients in the Erasmus MC Hematology Department (Rotterdam, The Netherlands). This was mainly explained by expansion of two methicillin resistant Staphylococcus epidermidis (MRSE) clones (Nouwen et al., J. Clin. Microbiol. 36 (1998) 2696-2702). In a new, 16-bed unit in the same institution, we investigated the effect of strict clinical isolation measures on the incidence of CRI. During two 6-month screening periods (period I: April 1998-December 1998 and period II: April 1999-October 1999) all patients receiving a central venous catheter were prospectively monitored for the development of CRI. During period I every visitor of the cubicles had to wear hair caps, masks, gowns and gloves. During period II these procedures were abolished, but hands were cleansed using alcohol and masks were worn during both periods in case of coughing and sneezing. All CoNS strains isolated from blood cultures were genetically classifies by pulsed field gel electrophoresis (PFGE). The incidence of CRI during period I was 13.0 per 1000 catheter days, in comparison to 9.6 in period II (P=0.84). During this latter period, 19 CRI were diagnosed, 14 catheter related bacteremia episodes (CRB) and five local infections. Seventy-two percent (n=9) of CRB were due to a CoNS. The mean catheter survival until appearance of a CRI increased from 43 days during period I to 78 days in period II (P=0.39). The mean catheter survival until infection related removal was increased from 43 days to 133 days (P=0.12). During period I less experienced intervention radiologists introduced the catheters, which may have limited the efficacy of the strict hygiene measures. Thus, abolishing strict isolation precautions had no negative effect on the incidence of CRI. After genotyping of 38 MRSE strains isolated from blood and central venous catheter cultures of 12 patients in period II, eight PFGE types were found. Three types were found in more than one patient, but based on epidemiological data patient-to-patient spread could not be proven. No genotypic identity between patient and personnel CoNS isolates was shown and the two major clonal types that were present between 1994 and 1996 were not encountered. However, from December 1998 onwards new MRSE clones could be identified (types E and J). In conclusion, despite a constant rate of CRI and implementation of optimal patient care, clonal spread of MRSE strains was not prevented by strict hygiene measures.