Financial impact of healthcare-associated infections on intensive care units estimated for fifty Brazilian university hospitals affiliated to the unified health system.

BACKGROUND: Studies show that healthcare-associated infections (HAIs) represent a crucial issue in healthcare and can lead to substantial economic impacts in intensive care units (ICUs). AIM: To estimate direct costs associated with the most significant HAIs in 50 teaching hospitals in Brazil, affiliated to the unified health system (Sistema Único de Saúde: SUS). METHODS: A Monte Carlo simulation model was designed to estimate the direct costs of HAIs; first, epidemiologic and economic parameters were established for each HAI based on a cohort of 949 critical patients (800 without HAI and 149 with); second, simulation based on three Brazilian prevalence scenarios of HAIs in ICU patients (29.1%, 51.2%, and 61.6%) was used; and third, the annual direct costs of HAIs in 50 university hospitals were simulated. FINDINGS: Patients with HAIs had 16 additional days in the ICU, along with an extra direct cost of US$13.892, compared to those without HAIs. In one hypothetical scenario without HAI, the direct annual cost of hospital care for 26,649 inpatients in adult ICUs of 50 hospitals was US$112,924,421. There was an increase of approximately US$56 million in a scenario with 29.1%, and an increase of US$147 million in a scenario with 61.6%. The impact on the direct cost became significant starting at a 10% prevalence of HAIs, where US$2,824,817 is added for each 1% increase in prevalence. CONCLUSION: This analysis provides robust and updated estimates showing that HAI places a significant financial burden on the Brazilian healthcare system and contributes to a longer stay for inpatients.

Costs of healthcare-associated infections to the Brazilian public Unified Health System in a tertiary-care teaching hospital: a matched case-control study.

BACKGROUND: Little is known about the economic burden of healthcare-associated infections (HAIs) in Brazil. AIM: To analyse the costs of hospitalization by reimbursement from the Brazilian government, via the Brazilian Unified Health System (SUS) affiliation, and direct costs in the adult Intensive Care Unit (ICU). METHODS: The matched-pairs case-control study (83 patients with HAIs and 83 without HAIs) was performed at a referral tertiary-care teaching hospital in Brazil in January 2018. In order to calculate the HAI costs from the perspective of the payer, the total cost for each hospitalization was obtained through the Hospital's Billing Sector. Direct costs were calculated annually for 949 critical patients during 2018. FINDINGS: The reimbursement cost per hospitalization of patients with HAIs was 75% (US$2721) higher than patients without HAIs (US$1553). When a patient has an HAI, in addition to a longer length of stay (15 days), there was an extra increase (US$996) in the reimbursement cost per hospitalization. An HAI in the ICU was associated with a total direct cost eight times higher compared with patients who did not develop infections in this unit, US$11,776 × US$1329, respectively. The direct cost of hospitalization in the ICU without HAI was 56.5% less than the reimbursement (US$1329 × US$3052, respectively), whereas for the patient with an HAI, the direct cost was 111.5% above the reimbursement (US$11,776 × US$5569, respectively). CONCLUSION: HAIs contribute to a longer stay and an eight-fold increase in direct costs. It is necessary to reinforce programmes that prevent HAIs in Brazilian hospitals.

Multi-hospital point prevalence study of healthcare-associated infections in 28 adult intensive care units in Brazil.

BACKGROUND: Healthcare-associated infection (HAI) represents a major problem for patient safety worldwide. AIM: To provide an up-to-date picture of the extent, aetiology, risk factors and patterns of infections in intensive care units (ICUs) in 28 Brazilian hospitals of different sizes. METHODS: A one-day point prevalence survey in 2016 enrolled the ICUs of hospitals from the 12 meso-regions in Minas Gerais state, south-east Brazil. Hospitals were classified as university or non-university hospitals. All patients with >48 h of admission to the study ICUs at the time of the survey were included. FINDINGS: In total, 303 patients were studied; of these, 155 (51.2%) were infected and 123 (79.4%) had at least one ICU-acquired infection. The most common ICU-acquired infections were pneumonia (53.0%) and bloodstream infection (27.6%). One hundred and nineteen bacterial isolates were cultured; the most common were Acinetobacter baumannii (27.1%), Pseudomonas aeruginosa (27.1%) and Staphylococcus aureus (39.0%). According to type of infection, the most common pathogens were P. aeruginosa (30.4%) in pneumonia, coagulase-negative staphylococci (23.4%) and Enterobacteriaceae (23.4%) in bloodstream infections, and Enterobacteriaceae (47.6%) in urinary tract infections. CONCLUSION: This study found that the overall prevalence of ICU-acquired infections in surveyed Brazilian hospitals was higher than that reported in most European countries and the USA. A greater proportion of infections were caused by non-fermenting Gram-negative bacteria. These observations, along with a high rate of antimicrobial use, illustrate the urgent need for HAIs to be a priority in the public health agenda of Brazil.

Outbreaks of colistin-resistant and colistin-susceptible KPC-producing Klebsiella pneumoniae in a Brazilian intensive care unit.

BACKGROUND: Carbapenem-resistant Enterobacteriaceae (CRE), especially those that produce Klebsiella pneumoniae carbapenemase (KPC) and are associated with colistin resistance, pose a severe health threat due to the limited treatment options. AIM: To describe two outbreaks of KPC-producing K. pneumoniae in an adult intensive care unit (AICU) in Brazil. In May 2015, 14 patients had colistin-susceptible KPC-producing strains (ColS-KPC), and in July 2015, nine patients had colistin-resistant KPC-producing strains (ColR-KPC). METHODS: Between September 2014 and August 2015, we performed surveillance at a university hospital and all CRE were tested for blaKPC genes. Clonality was investigated by pulsed-field gel electrophoresis. Resistance to colistin was confirmed by broth microdilution method. Consumption of carbapenems and colistin was expressed as defined daily doses. FINDINGS: In all, 111 patients with CRE were identified during the surveillance period; K. pneumoniae was the major isolate (77.13%). The two outbreaks were identified when infection rates (KPC per 1000 patient-days) exceeded the background level. Rates of carbapenem and colistin consumption were high. Control measures (bedside alcohol gel, contact precautions, regular rectal swabs) did not curtail the outbreaks. Mortality rates were 42.9% and 44.4% for ColS-KPC- and ColR-KPC-infected patients, respectively. After the death of four infected patients with ColR-KPC, the unit was closed to new admissions. CONCLUSION: Our experience demonstrates the serious risks presented by KPC, and especially ColR-KPC, in Brazilian AICUs. Selective pressure from excessive antibiotic use and transmission on healthcare workers' hands were likely the major factors in transmission.

Bacterial colonization of pressure ulcers: assessment of risk for bloodstream infection and impact on patient outcomes.

BACKGROUND: Pressure ulcers (PUs) represent a major problem for hospitalized patients, health professionals and society. AIM: To evaluate the impact of in-hospital PUs as a reservoir of multidrug-resistant organisms (MDROs), risk factor for bacteraemia and predictor of poor prognosis. METHODS: A prospective cohort study of patients with stage II or greater PUs hospitalized in a tertiary acute care university teaching hospital for more than 48 h was performed to evaluate colonization/infection by potential and/or multi-resistant hospital pathogens from April to December 2005 and from August 2009 to April 2010. FINDINGS: A total of 145 patients with stage II or greater PUs were included. Of these, 76.5% (111/145) had PUs colonized and/or infected with either S. aureus (20.7%), Gram-negative bacilli (32.5%), or both (46.8%) and most were MDROs (64.8%). Bacteraemia was detected in 50.5% (56/111) of the patients. The ulcers were considered to be the probable source of bacteraemia in 53.6% (30/56) of the episodes. Prior administration of antibiotics (P = 0.04) and infected wound (P < 0.001) were the variables independently associated with bloodstream infection as well as associated with a higher 30-day mortality rate; risk factors for the latter included hospitalization in ICU (P = 0.03) and mechanical ventilation use (P = 0.05). CONCLUSIONS: Our results suggest that besides being a major reservoir of MDROs, patients with PUs constitute a high-risk population for bacteraemia with a poor outcome. Broad-spectrum antibiotics and infected wound were independent factors predisposing patients to both bacteraemia and death.

Staphylococcus aureus e estafilococos coagulase negativosresistentes à vancomicina em um Hospital Universitário Brasileiro / Vancomycin-resistant Staphylococcus aureus and coagulase-negative staphylococci in a Brazilian University Hospital

Infecções hospitalares por Methicillin-Resistant S. aureus (MRSA) e Methicillin-Resistant Coagulase-Negative Staphylococci (MRCoNS) estão entre as mais frequentes mundialmente, justificando um aumento significativo no uso de vancomicina. Com o objetivo de avaliar a presença de estafilococos resistentes aos glicopeptídeos em pacientes em uso terapêutico desse antimicrobiano, internados no Hospital de Clínicas da Universidade Federal de Uberlândia, Uberlândia MG, foi realizado um estudo longitudinal prospectivo incluindo 41 pacientes, 21 adultos e 20 crianças, entre dezembro de 2000 e março de 2002. O monitoramento microbiológico foi realizado por meio de swabs coletados a partir da cavidade bucal e reto e cultivo primário em Ágar Manitol Salgado acrescido de 6 mg/mL de oxacilina. Amostras selecionadas foram testadas quanto à sensibilidade aos glicopeptídeos pelas técnicas de gel difusão e diluição em ágar e a análise de heterorresistência, pela semeadura utilizando inóculo correspondente à escala 0,5 de McFarland (108 UFC/mL) e análise do perfil populacional. Um único paciente, nefropata em programa de hemodiálise apresentou-se colonizado com uma amostra do fenótipo Vancomycin-Intermediate S. aureus (VISA) (CIM = 8 miug/mL) e em doze, foram isoladas amostras de estafilococos heterorresistentes, correspondendo oito hVISA e quatro hVICoNS. O estudo do perfil populacional, confirmou a presença de subpopulações de células resistentes, sendo seis hVISA e duas hVICoNS. A presença de amostras heterorresistentes à vancomicina pode representar um risco potencial no futuro.

Methicillin-resistant Staphylococcus aureus (MRSA) and Methicillin-resistant Coagulase-negative Staphylococci (MRCoNS) are among the most frequent hospital infections around the world, and are associated with a significant rise in the use of vancomycin. In order to assess the presence of staphylococci resistant to glycopeptides in patients taking this antibiotic in Uberlândia Federal University Hospital, Uberlândia (MG, Brazil), a prospective longitudinal study of 41 patients (21 adults and 20 children) was performed between December 2000 and March 2002. Microbiological monitoring was carried out by means of swabs collected from the oral cavity and rectum, screened by culturing in Salt Mannitol Agar plus 6 ?g/mL oxacillin. Selected samples were tested for susceptibility to glycopeptides, by the techniques of gel diffusion and dilution in agar, and for heteroresistance, by seeding with an inoculum at a density of 0.5 on the McFarland scale (108 CFU/mL) and performing a population analysis profile (PAP). A single nephropathy patient was colonized with a strain of vancomycin intermediate S. aureus (VISA) phenotype (MIC = 8 miug/mL). In twelve patients, heteroresistant staphylococci were isolated, corresponding to eight hVISA and four hVICoNS. The PAP study confirmed the presence of six hVISA and two hVICoNS. The presence of heteroresistant vancomycin samples may pose a potential risk in the future.

Effect of neonatal intensive care unit environment on the incidence of hospital-acquired infection in neonates.

The influence of the inanimate hospital environment and hospital design on nosocomial infection is a topic for discussion. This study evaluated the impact of the neonatal intensive care unit (NICU) environment on the risk of hospital-acquired infection (HAI). HAI surveillance was performed during a four-year period when the NICU was moved initially from an old facility to temporary accommodation and then eventually to a new and better-designed facility. The rate of HAI rose significantly from 12.8 to 18.6% (P<0.01) after moving to the temporary unit, which had a lower sink:cot ratio and a higher monthly admission rate. In contrast, the rates of catheter-associated staphylococcal bacteraemia decreased significantly after moving to the new NICU (P<0.0001). Since peripherally inserted central catheters (PICCs) were introduced concomitantly with the move to the new unit, however, the catheter type may have contributed towards this reduction in CVC-related staphylococcal bacteraemias. Moving to a temporary NICU with poor handwashing facilities and higher admission activity resulted in higher rates of HAI.

Hospital surface contamination in wards occupied by patients infected with MRSA or MSSA in a Brazilian university hospital

The hospital environment, especially surfaces, represents a secondary reservoir for pathogens such as Staphylococcus aureus. The present study was carried out at the Hospital de Clínicas da Universidade Federal de Uberlândia (HC-UFU) in Brazil, from January to August 2004, with the aim of qualitatively and quantitatively assessing the presence of S. aureus on surfaces touched by hands (bed rail, bedside table and door handle), on the floor and in the air, in wards where the patients were infected or not infected with this organism. Twenty-six wards with at least one infected patient and 26 wards with uninfected patients were investigated. Surfaces and air were sampled during bedmaking, by means of sterile 10cm2 adhesive tapes and 90mm-diameter exposed culture plates, respectively. Cultures were carried out on Egg Yolk Salt Agar, containing 7.5% NaCl and 1% egg yolk, and colonies identified by lecithinase and coagulase tests and Gramstain. About 50% of the wards were S. aureus contaminated, without significant differences between the groups (46.1% in the infected patient wards versus 53.8% in controls); the correlation between counts of the pathogen on the surfaces and in the air was 66.7%. Inspite of the fact that these bacteria were frequently present in the assessed wards, the microbial density waslow (less than 1 CFU/cm2). The association between environmental contamination and the epidemiology of S. aureus nosocomial infections is complex and thus further investigations are needed to reach a better understanding of this relationship.

Problemas da vigilância epidemiológica de infecções hospitalares sem o uso de critérios microbiológicos no Brasil / Problems in nosocomial infection surveillance in Brazilian hospitals arising from nonuse of microbiological criteria to identify pathogens

É enfatizada a importância das infecções hospitalares como um problema médico-hospitalar e de saúde pública nos dias atuais em função das taxas significativas de morbidade e mortalidade relacionadas com as mesmas, e dos custos financeiros. Adicionalmente, revê as principais infecções hospitalares, a saber, pneumonias, infecções de sítio cirúrgico, infecções urinárias e de corrente sanguínea no tocante a morbidade, mortalidade, custos, classificação e fatores de risco. A principal preocupaçãoda revisão é mostrar a importância de dados microbiológicos no diagnóstico e na vigilância destas infecções, pela sua sensibilidade e especificidade, e deforma mais particular, naquelas mais comuns. Outras questões que são de importância na vigilância epidemiológica, como infecções assintomáticas, diferenciação entre colonização e infecção, alta precoce e vigilância pós-alta são também comentadas. O autor faz referência as dificuldades de hospitais no país, que são mais agudas do que o descrito na maioria daqueles do hemisfério norte, tais como a escassez de recursos financeiros e de profissionais de saúde, dificuldade na mudança de comportamento por parte dos mesmos, e sua marcante heterogeneidade quanto à clientela atendida, e distribuição quanto ao número de leitos, particularmente em unidades críticas, níveis de complexidade dos serviços disponíveis e sobretudo a carência de laboratórios de microbiologia.

An outbreak of conjunctivitis caused by multiresistant Pseudomonas aeruginosa in a Brazilian newborn intensive care unit.

We report an outbreak of conjunctivitis due to Pseudomonas aeruginosa involving seven infants admitted in the Neonatal Intensive Care Unit (NICU) of the Uberlândial Federal University Hospital between March and September 2001. Three infants developed systemic complications (01 sepsis and 02 pneumonias). Ten isolates were obtained from conjunctival cultures and all were resistant to ceftazidime and aminoglycosides. Fast identification of the organism and treatment with imipenem were important in containing the outbreak of P. aeruginosa.

An outbreak of conjunctivitis caused by multiresistant Pseudomonas aeruginosa in a Brazilian Newborn Intensive Care Unit

We report an outbreak of conjunctivitis due to Pseudomonas aeruginosa involving seven infants admitted in the Neonatal Intensive Care Unit (NICU) of the Uberlândial Federal University Hospital between March and September 2001. Three infants developed systemic complications (01 sepsis and 02 pneumonias). Ten isolates were obtained from conjunctival cultures and all were resistant to ceftazidime and aminoglycosides. Fast identification of the organism and treatment with imipenem were important in containing the outbreak of P. aeruginosa

Typing of Staphylococcus aureus from surgical site infections: comparison of pulsed-field gel electrophoresis (PFGE) and PCR technique using repetitive extragenic palindromic (rep) and Tn916-Shine-Dalgarno (TnSD) target sequences.

Staphylococcus aureus continues to be the main cause of surgical site infections. DNA typing is useful for studying this type of infection and establishing control programs within hospitals. In this study 19 S. aureus strains were isolated from surgical site infections of 19 patients, between August and December 1994 at the Rio de Janeiro University Hospital. The strains were typed by pulsed-field gel electrophoresis (PFGE) and by two polymerase chain reaction techniques targeting the repetitive extragenic palindromic and Tn916-Shine Dalgarno sequences. Analysis of the PFGE patterns divided the collection into 15 types, while PCR techniques identified 11 distinct strain patterns. There were two clusters, 1 of four strains and 1 of two strains with related PFGE and PCR patterns. Of the remaining strains, 10 were clustered in 5 PCR patterns but their PFGE patterns showed 4 to 6 different bands, and they were considered to be possibly related. The comparison of the S. aureus typing systems in the present study indicated that the PCR methods are useful for initial screening of genetically related isolates, but strains with identical PCR fingerprint need to be typed with PFGE for detailed strain differentiation.

Uso de antimicrobianos como promotores de crescimento e resistência em isolados de Escherichia coli e de Enterobacteriaceae lactose-negativa da microflora fecal de frangos de corte / Antimicrobial use as growth promoters and resistance for isolates of Escherichia coli and of Enterobacteriaceae lactose negative of the fecal microflora of broiler chickens

Foram coletadas amostras de fezes de aves durante um ciclo de criaçäo (45 dias) e analisadas quantitativamente quanto à presença de Escherichia coli e de Enterobacteriaceae lactose-negativa (ELN). As contagens de colônias lactose-positivas e negativas foram realizadas em placas de ágar MacConkey e os isolados foram submetidos ao teste de susceptibilidade aos antimicrobianos in vitro, pela técnica de difusäo em gel. Os números desses microrganismos estabilizaram-se na faixa de 10 elevado a sexta potência UFC/g de fezes para E. coli, e de 10 elevado a quinta potência UFC/g de fezes para ELN. A resistência e a multirresistência aos antimicrobianos de isolados de E. coli foram observadas em 98,6 por cento e 65,7 por cento, e nos de ELN em 98,1 por cento e 84,6 por cento, respectivamente. Os espectros de resistência de E. coli e ELN foram: 52 e 57 por cento ao cloranfenicol, 51 e 67 por cento à cefalotina, 48 e 84 por cento à tetraciclina, 45 e 74 por cento ao ácido nalidíxico, 42 e 57 por cento à ampicilina, 28 e 55 por cento a sulfametoxazol + trimetoprim e 26 e 22 por cento à gentamicina, respectivamente. 0 estudo demonstrou que os frangos de corte podem funcionar como reservatórios de genes de resistência a antibióticos importantes em medicina veterinária e humana

Risk factors for methicillin resistant and sensitive Staphylococcus aureus infection in a Brazilian university hospital.

Two hundred three isolates of S. aureus were collected from 140 patients during a 1 year period in our hospital in Minas Gerais, Brazil. Of these patients, 102 acquired the infection in the hospital (nosocomial) and are the subject of this report. Fifty-seven patients had Methicillin-sensitive S. aureus (MSSA) strains identified, and 45 had Methicillin-resistant S. aureus (MRSA) strains. The most common sites of clinical infections by S. aureus were bloodstream (bacteremia), surgical/skin wounds and lung (pneumonia). The patients with MRSA infections were most likely to be in the surgical and clinical wards, but those with MSSA infections were most likely to be in the neonatal and emergency units. By univariate analysis, we found several factors associated with an increased risk of MRSA infections: age, mean preinfections and total duration of hospital stay, use of 3 or more antimicrobials, presence of 3 or more indwelling devices (mainly vascular and urinary catheters). Colonization (67.6% x 27.8%; p<0.05) and multicolonization (89% x 11.0%; p<0.05) were more associated with MRSA infection. Of the total of 203 isolates, 110 MRSA were found to be multiresistant, with 106 showing resistance to 5 or more antibiotics, compared to 15/93 (16%) of the MSSA isolates. The most serious cases and higher colonization rates of MRSA occurred in elderly patients. The presence of nosocomial MRSA is a serious medical problem which requires continued attention to care in the overuse of antibiotics and indwelling devices in hospitals.

Survey of the knowledge and practice of infection control among dental practitioners.

A survey on various aspects of infection control (overall knowledge/problem recognition, formal polices/reducing risk, and willingness to obtain additional education) was conducted among dental professionals and dental students. The survey was administered by a questionnaire at the offices of dental practitioners in Uberlândia and among dentistry students at the Federal University of Uberlândia. The two groups (professional dentists and students) differed significantly (P<0.0001) regarding recognition and reduction of the problem, but they were similarly willing to improve their knowledge of infection control. Dentists scored significantly higher than dental students on questions of recognition and reduction. A high proportion of students reported a lack of concern regarding routine handwashing before and after patient care (28.9% gave wrong answers). Of the dentists, only 8.8% reported a lack of knowledge about this matter. A higher proportion (P<0.0001) of dentists reported glove use and other basic barrier precautions (97.1% versus 51.9% among the students). However, the proportion of dentists who reported that they were aware of HBV vaccination was lower than among the students (81.5% versus 92.0%, p=0.0037). Additional education is required to promote a more realistic perception of the risks for HIV, HBV, and HCV transmission in dental offices and among dental students, and the use of all recommended infection control practices.

Vancomycin use in a Brazilian University Hospital: comparison with Hospital infection control practices advisory committee guidelines

Emergence of vancomycin-resistant bacteria is of concer. In an effort to reduce this danger, guidelines to ensure proper prescribing of vancomycin have been proposed to the Hospital Infections Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control. To evaluate use of vancomycin at Uberlândia University Hospital in Brazil, each patient who received the drug during a 10 month period had nasal and recal cultures done within 48 hours of initiation of therapy, then at weekly intervals until discharge. Their hospital records were reviewed to obtain demographic and clinical data, and each was scored as to whether or not HICPAC guidelines were followed. Thirty-one patients were enrolled in the study; 15 of whom had been approved for vancomycin by the hospital infectious diseases (ID) specialist, and 16 who had the drug given without approval. During the study, 4 strains of VRE (Vancomycin Resitant Enterococci) and 8 strains of MRSA (Methicillin Resistant S.aureus) emerged. The use of vancomycin did not follow HICPAC guidelines in 21/31 patients (68 percent), in that the drug was prescribed empirically without prior documenation of need. This occurred 13 of 16 (81 percent) times when no approval by an ID specialist was provided, and 8 of 15 times (53 percent) after approval by a ID specialist. In 6 of 8 patients (75 percent), empirical use of vancomycin was approved by an ID specialist in patients with severe illnesses, each of whom subsequently died. his could be considered appropriate use, although outside the guidelines. Only 3 of 13 patients (23 percent) were severely ill when vancomycin was used without ID approval. Most of the vancomycin use which did not follow HICPAC guidelines occurred on the medicine service in patients moderately ill with pneumonia or bacteremia, and associated with invasive procedures. We conclude that there is a special need to improve education regarding the appropriate use of vancomycin and to increase review of its use by an ID specialist, particularly on medicine services of our hospital.

DNA typing of methicillin-resistant Staphylococcus aureus: isolates and factors associated with nosocomial acquisition in two Brazilian university hospitals.

Control and prevention of methicillin-resistant Staphylococcus aureus (MRSA) infections should include early identification of patients at higher risk of MRSA acquisition and analysis of isolates by discriminatory bacterial DNA typing methods. One hundred and three MRSA isolates cultured between Sept. 1994 and Sept. 1995 from 62 patients in two teaching hospitals (hospital 1, in Rio de Janeiro; hospital 2, in Minas Gerais) were tested for antimicrobial resistance and genomic DNA was analysed by pulsed-field gel electrophoresis (PFGE). Ten profiles were identified: A, B, C, I and J in hospital 1 and A, B, D, E, F, G and H in hospital 2. PFGE patterns A and B were isolated at both hospitals. The majority (80%) of isolates had similar PFGE patterns (type A). Subtype A1 was isolated at both hospitals, but was more frequent in hospital 2 (54%), while subtype A2 predominated in hospital 1 (63%). MRSA isolates were resistant to the majority of antimicrobial agents tested. However, susceptibility to vancomycin alone was found in 32% of the isolates at hospital 1, whereas 48% of isolates from hospital 2 were susceptible to both vancomycin and mupirocin, and 34% demonstrated susceptibility to vancomycin, mupirocin and chloramphenicol. Thirty-nine percent of all isolates were mupirocin-resistant, with 90% of these belonging to PFGE pattern A. Four main risk factors were associated with MRSA infection or colonisation which may be useful in the early identification of patients at risk: >7 days hospitalisation (95%), very dependent patients (84%), invasive procedures (79%) and recent antimicrobial therapy (79%). The data demonstrate that PFGE pattern A is disseminated in both hospitals. However, at both hospitals subtypes of pattern A and the other PFGE types were associated with different antibiotic resistance patterns.