Journal of Hospital Infection

Editorial Board

2012-02-01

Guidelines on the facilities required for minor surgical procedures and minimal access interventions

2011-12-22

Summary: There have been many changes in healthcare provision in recent years, including the delivery of some surgical services in primary care or in day surgery centres, which were previously provided by acute hospitals. Developments in the fields of interventional radiology and cardiology have further expanded the range and complexity of procedures undertaken in these settings. In the face of these changes there is a need to define from an infection prevention and control perspective the basic physical requirements for facilities in which such surgical procedures may be carried out. Under the auspices of the Healthcare Infection Society, we have developed the following recommendations for those designing new facilities or upgrading existing facilities. These draw upon best practice, available evidence, other guidelines where appropriate, and expert consensus to provide sensible and feasible advice. An attempt is also made to define minimal access interventions and minor surgical procedures. For minimal access interventions, including interventional radiology, new facilities should be mechanically ventilated to achieve 15 air changes per hour but natural ventilation is satisfactory for minor procedures. All procedures should involve a checklist and operators should be appropriately trained. There is also a need for prospective surveillance to accurately determine the post-procedure infection rate. Finally, there is a requirement for appropriate applied research to develop the evidence base required to support subsequent iterations of this guidance.

Virucidal efficacy of hydrogen peroxide vapour disinfection

E. Tuladhar, P. Terpstra, M. Koopmans, E. Duizer — 2011-12-09

Summary: Background: Viral contamination of surfaces is thought to be important in transmission. Chemical disinfection can be an effective means of intervention, but little is known about the virucidal efficacy of hydrogen peroxide vapour (HPV) against enteric and respiratory viruses.Aim: To measure the virucidal efficacy of HPV against respiratory and enteric viruses on materials representing those found in institutions and homes.Methods: Poliovirus, human norovirus genogroup II.4 (GII.4), murine norovirus 1, rotavirus, adenovirus and influenza A (H1N1) virus dried on to stainless steel, framing panel and gauze carriers were exposed to HPV 127ppm for 1h at room temperature in an isolator. Poliovirus was also exposed to HPV at different locations in a room. The virucidal effect was measured by comparing recoverable viral titres against unexposed controls. Polymerase chain reaction was used to evaluate the effect of HPV on viral genome reduction.Findings: HPV disinfection resulted in complete inactivation of all viruses tested, characterized by >4 log10 reduction in infectious particles for poliovirus, rotavirus, adenovirus and murine norovirus on stainless steel and framing panel carriers, and >2 log10 reduction for influenza A virus on stainless steel and framing panel carriers, and for all viruses on gauze carriers. Complete inactivation of poliovirus was demonstrated at several locations in the room. Reductions in viral genomes were minimal on framing panel and gauze carriers but significant on stainless steel carriers; human norovirus GII.4 genome was most resistant to HPV treatment.Conclusion: HPV could be an effective virucidal against enteric and respiratory viruses contaminating in-house environments.

Hydrogen peroxide vapour decontamination of surfaces artificially contaminated with norovirus surrogate feline calicivirus

K. Bentley, B.K. Dove, S.R. Parks, J.T. Walker, A.M. Bennett — 2011-12-14

Summary: Background: Noroviruses are a leading cause of gastrointestinal disease and are of particular concern in healthcare settings such as hospitals. As the virus is reported to be environmentally stable, effective decontamination following an outbreak is required to prevent recurrent outbreaks.Aim: To investigate the use of hydrogen peroxide vapour to decontaminate a number of surfaces that had been artificially contaminated with feline calicivirus (FCV), a surrogate for norovirus. The surfaces tested were representative of those found in hospital wards.Methods: FCV was used to contaminate materials representative of a hospital setting (stainless steel, glass, vinyl flooring, ceramic tile and PVC plastic cornering). The carriers were exposed to 30% (w/w) hydrogen peroxide vapour at 5-min intervals over 20min, after which postexposure viral titres were measured.Findings: Hydrogen peroxide vapour reduced the viral titre by 4 log10 on all surfaces tested within 20min of exposure. The reduction in viral titre took longest to achieve on stainless steel (20min), and the quickest effect was seen on vinyl flooring (10min). For glass, plastic and ceramic tile surfaces, the desired reduction in viral titre was seen within 15min of exposure. Hydrogen peroxide vapour allows for large-scale decontamination of areas following outbreaks of infectious organisms.Conclusion: Hydrogen peroxide vapour is effective against FCV and is active on a range of surfaces. Therefore, it may represent a suitable decontamination system for use following a hospital outbreak of norovirus.

Comparison of cleaning efficacy between in-use disinfectant and electrolysed water in an English residential care home

N.S. Meakin, C. Bowman, M.R. Lewis, S.J. Dancer — 2011-12-23

Summary: Background: Infection control in hospitals and care homes remains a key issue. They are regularly inspected regarding standards of hygiene, but visual assessment does not necessarily correlate with microbial cleanliness. Pathogens can persist in the inanimate environment for extended periods of time.Aim: This prospective study compared the effectiveness of a novel sanitizer containing electrolysed water, in which the active ingredient is stabilized hypochlorous acid (Aqualution™), with the effectiveness of the quaternary ammonium disinfectant in current use for microbial removal from hand-touch surfaces in a care home. The study had a two-period crossover design.Methods: Five surfaces were cleaned daily over a four-week period, with screening swabs taken before and after cleaning. Swabs were cultured in order to compare levels of surface microbial contamination [colony-forming units (cfu)/cm2] before and after cleaning with each product.Findings: Cleaning with electrolysed water reduced the mean surface bacterial load from 2.6 [interquartile range (IQR) 0.30–30.40] cfu/cm2 to 0.10 (IQR 0.10–1.40) cfu/cm2 [mean log10 reduction factor 1.042, 95% confidence interval (CI) 0.79–1.30]. Cleaning with the in-use quaternary ammonium disinfectant increased the bacterial load from 0.90 (IQR 0.10–8.50) cfu/cm2 to 93.30 (IQR 9.85–363.65) cfu/cm2 (mean log10 reduction −1.499, 95% CI −1.87 to −1.12) (P < 0.0001). Using two proposed benchmark standards for surface microbial levels in hospitals, electrolysed water resulted in a higher ‘pass rate’ than the in-use quaternary ammonium disinfectant (80–86% vs 15–21%, P < 0.0001).Conclusion: Electrolysed water exerts a more effective bacterial kill than the in-use quaternary ammonium disinfectant, which suggests that it may be useful as a surface sanitizer in environments such as care homes.

Air sampling methods to evaluate microbial contamination in operating theatres: results of a comparative study in an orthopaedics department

2011-12-05

Summary: Aim: To evaluate the level of microbial contamination of air in operating theatres using active [i.e. surface air system (SAS)] and passive [i.e. index of microbial air contamination (IMA) and nitrocellulose membranes positioned near the wound] sampling systems.Methods: Sampling was performed between January 2010 and January 2011 in the operating theatre of the orthopaedics department in a university hospital in Southern Italy.Findings: During surgery, the mean bacterial loads recorded were 2232.9colony-forming units (cfu)/m2/h with the IMA method, 123.2cfu/m3 with the SAS method and 2768.2cfu/m2/h with the nitrocellulose membranes. Correlation was found between the results of the three methods. Staphylococcus aureus was detected in 12 of 60 operations (20%) with the membranes, five (8.3%) operations with the SAS method, and three operations (5%) with the IMA method.Conclusion: Use of nitrocellulose membranes placed near a wound is a valid method for measuring the microbial contamination of air. This method was more sensitive than the IMA method and was not subject to any calibration bias, unlike active air monitoring systems.

Understaffing, overcrowding, inappropriate nurse:ventilated patient ratio and nosocomial infections: which parameter is the best reflection of deficits?

F. Schwab, E. Meyer, C. Geffers, P. Gastmeier — 2011-12-21

Summary: Background: In stressed and high-throughput systems, periodic overcrowding (high bed occupancy) and understaffing (low nurse:patient ratio) are widely described risk factors for nosocomial infections.Aim: The impact of bed occupancy (patient:bed ratio), nurse:patient ratio and nurse:ventilated patient ratio on nosocomial bloodstream infections (BSI) and pneumonia were investigated in 182 intensive care units (ICU).Methods: The ICUs reported monthly data on device use and nosocomial device-associated infections to the German hospital surveillance system for nosocomial infections in 2007. Information on the number of healthcare workers on the ward per 24h in 2007 and structure parameters was obtained by questionnaires. The association between occupancy or staff parameters and the number of nosocomial infections per month was analysed using generalized estimating equation models.Findings: In total, 1313 cases of pneumonia and 513 cases of BSI were reported from 182 ICUs with 1921 surveillance months and 563,177 patient-days. Fewer nosocomial infections were associated with a higher nurse:ventilated patient ratio [adjusted incidence rate ratio 0.42 (95% confidence interval 0.32–0.55) for months with nurse:ventilated patient ratios >75th percentile compared with ≤25th percentile]. Interestingly, the nurse:patient ratio was not a significant parameter with respect to the occurrence of BSI and pneumonia. High bed occupancy (>75th percentile) was associated with fewer nosocomial infections.Conclusion: A staffing parameter that reflects the intensity of care, such as the nurse:ventilated patient ratio, may enable better evaluation of workload and resources, especially at a time when nursing resources are being reduced but nosocomial infections are increasing.

Cross-sectional survey of meticillin-resistant Staphylococcus aureus home-based decolonization practices in Scotland

K. Currie, L. Cuthbertson, L. Price, J. Reilly — 2011-12-19

Summary: Background: Despite limited evidence of meticillin-resistant Staphylococcus aureus (MRSA) decolonization efficacy, the practice of decolonization for both pre-admission and on-admission patients is growing. Recent research within National Health Service (NHS) Scotland revealed low rates of treatment and consequent low efficacy in home-based decolonization. As no national guidelines on home-based decolonization currently exist, practices within NHS Scotland may be variable.Aim: To establish current pre-admission MRSA home-based decolonization protocols and patient advice within NHS Scotland. Similarities and differences were identified to determine possible sources of variability.Methods: Cross-sectional survey distributed electronically to MRSA Screening Project Managers within each NHS geographical region in Scotland (N = 15).Findings: Thirteen out of 15 NHS regions responded; one region reported no standard protocol. From the remaining 12 regions, 100% recommended use of mupirocin and antiseptic bodywash daily for five days; this was the only consistent aspect of practice across responding regions. Variation was noted in advice regarding method of mupirocin application, bodywash product and volume of bodywash recommended. Six regions (50%) specified bodywash skin contact time, yet these times varied across regions. Mouth care was advocated by three regions (25%). Daily change of facecloths and clothes was endorsed by five regions (41.7%); four regions (33.3%) promoted daily towel changes. Only one region (8.3%) suggested daily bedroom cleaning; three regions (25%) advised changing bed linen daily.Conclusions: Variation in protocols and patient advice may influence efficacy of home-based decolonization and further research may inform the development of evidence-based clinical guidelines.

Outbreak of adenovirus serotype 8 conjunctivitis in preterm infants in a neonatal intensive care unit

Y. Ersoy, B. Otlu, P. Türkçüoğlu, F. Yetkin, S. Aker, C. Kuzucu — 2011-12-12

Summary: Background: Adenovirus keratoconjunctivitis outbreaks have rarely been reported in preterm infants. An outbreak of adenovirus conjunctivitis occurred between 15 January and 25 February at a neonatal intensive care unit of a university hospital in Turkey.Aim: To describe the evolution, investigation and management of the outbreak.Methods: Adenovirus type 8 was identified in 14 samples by polymerase chain reaction analysis. A case–control study was performed to determine the risk factors.Findings: Fifteen preterm neonates, five healthcare workers (HCWs) and four parents suffered from conjunctivitis signs such as lacrimation, swelling and redness of the eye. A retinopathy of prematurity (ROP) examination was found to be the most important risk factor for adenovirus conjunctivitis (odds ratio: 17.5; 95% confidence interval: 1.9–163.0; P=0.012). The eyelid speculum (blepharostat) used during the ROP examination was not sterilized between each patient and was found to be the cause of contamination.Conclusion: The outbreak was controlled by measures such as barrier precautions, hand hygiene, sterilization of the blepharostat, suspending patient transfer to other units, and excluding infected HCWs for at least 15 days.

Ventilator-associated pneumonia due to meticillin-resistant Staphylococcus aureus: risk factors and outcome in a large general hospital

2012-01-06

Summary: Background: Data about risk factors and impact on outcome of methicillin-resistant S. aureus (MRSA) in unselected patients with ventilator-associated pneumonia (VAP) are limited.Aim: To assess predisposing factors and outcome of VAP due to MRSA in a large teaching institution.Methods: Prospective study carried out over four years in the three adult ICUs of our hospital. Patients with MRSA-VAP were compared with those with bacterial VAP due to other microorganisms.Findings: Overall, 474 episodes of bacterial VAP were collected. Significant differences between MRSA-VAP (111) and VAP due to other microorganisms (363) were found for median age (68 vs. 62 years), median APACHE II score (12 vs. 11), neurosurgery (5.4% vs. 13.8%), abdominal surgery (35% vs. 19%), prior treatment with any antibiotic (82.9% vs. 64.5%) and with imipenem (24% vs. 11%) at present admission before VAP, and pleural effusion (12% vs. 5%). Multivariate analysis adjusted for confounding factors showed that higher APACHE II score, prior treatment with any antibiotic and pleural effusion were independent risk factors for MRSA. As for treatment and outcome, the differences between MRSA-VAP and other VAP were inadequate empiric treatment (70% vs. 53%), median cost of antibiotics per episode (€974 vs. €726), and in-hospital mortality (60% vs. 47%). At multivariate analysis, however, MRSA was not found to be an independent risk factor for mortality.Conclusion: MRSA is a common cause of VAP. Underlying conditions predispose to its high mortality.

Do admissions and discharges to long-term care facilities influence hospital burden of Clostridium difficile infection?

R. Ricciardi, J. Nelson, J.L. Griffith, T.W. Concannon — 2011-12-02

Summary: Background: Substantial geographical clustering of Clostridium difficile infection (CDI) outbreaks in hospitals in the USA have previously been demonstrated.Aim: To test the hypothesis that hospital burden of CDI is associated with admission from and discharge to long-term care facilities (LTCFs).Methods: Hospital discharge data from 19 states in the USA were used to identify all patients discharged with a diagnosis of CDI from 1 January 2002 to 31 December 2004. For every hospital, the proportion of discharges with a diagnosis of CDI was calculated, and those above the 90th percentile were classified as ‘high CDI’ hospitals. We tested the association between this measure of hospital burden of CDI and the rates of admission from and discharges to LTCFs. We adjusted for other hospital level characteristics, case-complexity and local population characteristics.Findings: We identified 38,372,951 discharges during the three-year study period. Of all discharges, 274,311 (0.71%) had a primary or secondary diagnosis of CDI. Hospitals had a mean CDI burden of 7.8 cases per 1000 discharges. High CDI hospitals (N = 610; 10.0%) had a mean CDI burden of 34.8 cases per 1000 discharges. Compared to other hospitals, high CDI hospitals were more likely to have a high proportion of admissions from or discharges to LTCFs. This association persisted after adjustments for other hospital characteristics, case-complexity, and area population characteristics.Conclusion: A high rate of admission from or discharge to LTCFs is associated with an increased hospital burden of CDI.

Varicella zoster virus infection among healthcare workers in Taiwan: seroprevalence and predictive value of history of varicella infection

M.-F. Wu, Y.-W. Yang, W.-Y. Lin, C.-Y. Chang, M.-S. Soon, C.-E. Liu — 2011-12-21

Summary: Background: Varicella zoster infection can be spread by infected healthcare workers (HCWs) to coworkers and patients. A self-reported history of chickenpox infection is sometimes taken as proof of immunity.Aim: To establish the relationship between positive recall history and serological immunity against varicella zoster virus (VZV) amongst healthcare workers in a tertiary hospital in Taiwan.Methods: Between May 2008 and April 2009, all HCWs in a Taiwanese tertiary care hospital were tested for VZV immunoglobulin G (IgG), and completed a self-administered questionnaire to determine their history of varicella infection or vaccination. Those who were seronegative were vaccinated.Findings: All HCWs (N=3733) at the hospital participated in this study. Their mean age was 34.6 years, and the seroprevalence of VZV was 91.1%. Sensitivity, specificity, and positive and negative predictive values of a self-reported history of varicella infection were 82.3%, 48.6%, 96.3% and 14.4%, respectively. Corresponding figures for a history of varicella vaccination were 23.4%, 69.4%, 90.9% and 6.5%, respectively. The recall history of younger HCWs and medical professionals (doctors, nurses and paramedical staff) to varicella had higher sensitivity. However, only the recall history of medical professionals had a significantly higher positive predictive value.Conclusion: A positive recall history of varicella infection and vaccination did not ensure the presence of protective VZV IgG, and a negative history was not predictive of a lack of immunity. For effective prevention of nosocomial infection, VZV IgG status should be documented for all HCWs, and susceptible HCWs should be vaccinated.

Nutritional risk as predictor for healthcare-associated infection among hospitalized elderly patients in the acute care setting

2011-12-08

Summary: Background: Poor nutritional status is associated with high rates of healthcare-associated infections (HCAIs) among hospitalized elderly patients. Early recognition of patients at risk for HCAIs is important. The Geriatric Nutritional Risk Index (GNRI) is a screening tool able to predict nutrition-related complications.Aim: To examine the use of GNRI as a predictor of HCAIs in the acute care setting.Methods: A total of 248 consecutive patients aged >65 years, admitted as emergencies to the medical ward of an acute care hospital, were enrolled. On admission, clinical and laboratory assessment, anthropometric measurements, performance status, and GNRI score estimation were performed. HCAIs were recorded during admission.Findings: On admission, 53.8% of the patients were not at risk, 37.2% at low or medium risk and 8.9% at high risk for nutrition-related complications, as stratified by using the GNRI. During hospitalization 23.7% of the patients developed HCAIs. Patients with HCAIs had higher mortality (P < 0.001) and longer hospital stay (P < 0.001). In multivariate analysis, a performance status >1 [hazard ratio (HR): 2.08; 95% confidence interval (CI): 1.07–4.02; P = 0.03] and diabetes (HR: 2.57; 95% CI: 1.37–4.84; P = 0.003) were associated with increased risk for HCAIs, whereas GNRI score (per unit increase) had a protective effect (HR: 0.97; 95% CI: 0.95–0.99; P = 0.01). Well-nourished patients (GNRI >98) were significantly more likely to remain free from HCAIs during hospitalization (P = 0.003).Conclusion: GNRI can accurately stratify hospitalized elderly patients according to risk for developing HCAIs.

Five-year prospective study of tuberculin skin testing among new healthcare personnel at a university hospital in Thailand

2011-12-23

Summary: We determined the prevalence of a positive tuberculin skin test (TST) and the incidence of TST conversion among new healthcare personnel (HCP) in a hospital in Thailand. During 2005–2008, TST was performed on 1438 HCP and the prevalence of positive TST was 66.3%. Age, male gender, and the presence of Bacille Calmette–Guérin (BCG) scar were associated with odds of positive TST (all P < 0.05). The incidence of TST conversion was 4.8 per 100 HCP-years. Nine (0.6%) HCP were diagnosed with active tuberculosis. The annual surveillance programme is important for the early diagnosis and prevention of tuberculosis among HCP in Thailand.

Nosocomial postneurosurgical Acinetobacter baumannii meningitis: a retrospective study of six cases admitted to Hamad General Hospital, Qatar

F.Y. Khan, M. Abukhattab, K. Baager — 2011-12-08

Summary: This article reports six cases of nosocomial Acinetobacter baumannii meningitis in patients who had undergone neurosurgical procedures with placing of external ventricular drains. The mean time between surgery and onset of infection was 27 days [standard deviation (SD) 14] Multi-drug resistance was observed in three cases (50%) and carbapenem resistance was noted in two cases (33%). All patients had received empirical antibiotics and these were appropriate in five cases (83%). The mean duration of antimicrobial treatment was 12.5 (SD 2.4) days. Two of the six patients (33%) died in hospital.

Regarding Secker TJ, Hervé R, Keevil CW. Adsorption of prion and tissue proteins to surgical stainless steel surfaces and the efficacy of decontamination following dry and wet storage conditions. J Hosp Infect 2011;78:251–255

M. Feckie — 2011-12-12

I write regarding the article entitled ‘Adsorption of prion and tissue proteins to surgical stainless steel surfaces and the efficacy of decontamination following dry and wet storage conditions’ by Secker et al., published in the August issue of the Journal of Hospital Infection.

Response to the letter from M. Feckie

T.J. Secker, R. Hervé, C.W. Keevil — 2011-12-08

We wish to respond to the letter by M. Feckie regarding our paper. Despite his reservations about the potential for person-to-person transmission of PrPSc via surgical instruments, it has been clearly demonstrated that PrPSc infection can be transmitted by blood and blood products. This therefore suggests a risk of PrPSc transmission from any surgical procedure where instruments have been in contact with human tissues containing PrPSc. Furthermore, the interim data from the current national survey of abnormal prion prevalence in archived appendix specimens suggests that 288 per million people are potentially infected with the abnormal prion protein associated with variant Creutzfeld–Jakob disease (vCJD), supporting similar data from 2004. These individuals, equating to ∼18,000 of the current UK population, are then associated as potential sources of PrPSc transmission.

Response to: Buehlmann et al. ‘Effectiveness of a new decolonisation regimen for eradication of extended-spectrum β-lactamase-producing Enterobacteriaceae’

J.A. Severin, W.H. Goessens, M.C. Vos — 2011-12-12

We read with great interest the paper of Buehlmann et al., who studied the effectiveness of a new decolonisation regimen for eradication of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae. ESBL-producing Enterobacteriaceae have emerged worldwide as pathogens of both hospital- and community-acquired infections, even in countries with low antibiotic consumption among humans such as The Netherlands.

Reply to: Buehlmann et al. ‘Effectiveness of a new decolonisation regimen for eradication of extended-spectrum β-lactamase-producing Enterobacteriaceae’

A.F. Widmer, R. Frei — 2011-12-28

We appreciate the comments by Severin and colleagues and wish to respond to the questions they raise. First, most studies used solid media for screening of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL) such as the selective chromogenic media that we used for our study. The cited study by Murk et al. who demonstrated improved detection of ESBL with enrichment broth was performed in intensive care unit patients undergoing selective digestive decontamination with an antibiotic cocktail, a situation where an enrichment broth might decrease carry-over and increase sensitivity. Our patients were exclusively screened after discontinuation of active antimicrobial therapy. Therefore, we do not believe that enrichment cultures would have increased sensitivity in this setting.

Clostridium difficile and routine cleaning – alternative options to the use of stronger chlorine-releasing disinfectants

F. Mustafa Awadel-Kariem, E. Price, B. Cookson, H. O’Connor — 2011-12-26

Speight et al.’s informative paper indicates a problem with testing disinfectants against Clostridium difficile, in that the microbial reductions required in the test may not be sufficient in-use, given the actual hospital challenge. Indeed, the inoculum causing C. difficile infection (CDI) in a susceptible patient may be so low that removing it may not be feasible with disinfectants. An ‘irreducible minimum’ of CDI with this approach may thus be a real issue and other recommended interventions, such as improved antimicrobial stewardship to reduce patient susceptibility, will continue to be needed.

Spread and persistence of Clostridium difficile spores during and after cleaning with sporicidal disinfectants

B. Meyer, M. Exner, J. Gebel — 2011-12-15

We read with interest the Letter to the Editor by Ali et al. The authors tested two different hard-surface disinfectants, which are sporicidal according to EN 13704. They did not detect a sporicidal effect exceeding the effect of mere mechanical cleaning in a test close to practice, similar to the test published by Exner et al. We would like to point out one important factor, which the authors did not address. The authors specify that ‘prior to use cloths were treated with tap water (control) or one of the two commercially available sporicidal disinfectants’. The authors do not comment on the amount of water or disinfectant used for this, nor on the amount of water or disinfectant spread and left on the test surfaces. The relevance of the amount of disinfectant (besides concentration of the active ingredient) has been assessed in a very early work, which was unfortunately published in the German language only. It is concluded in this work that below a certain amount of liquid per surface area an appropriate effect cannot be achieved in surface disinfection, despite the use of appropriate in-use concentrations. Thus, surface disinfection cannot be achieved by ‘damp dusting’ using a surface disinfectant, but only by fully wetting a surface with an appropriate disinfectant at an appropriate use concentration. We would like to encourage further research taking into account these issues to be able to assess the effect of disinfectants correctly and instruct users appropriately. A European standard for testing the efficacy of disinfectants under conditions close to practice, including wiping the surface, is in preparation within the Technical Committee 216 of the CEN (European Committee for Standardization).

Spread and persistence of Clostridium difficile spores during and after cleaning with sporicidal disinfectants

S. Ali, G. Moore, A.P.R. Wilson — 2011-12-16

We would like to express our thanks to Meyer et al. for their interest in our recently published letter. Some interesting points were raised, and, in response, we report some preliminary findings from our current work.

Corrigendum to “Pontiac fever among retirement home nurses associated with airborne legionella” Journal of Hospital Infection 2011; 78: 269–273

2011-12-26

Please note that the order of authors should have appeared as follows: T. Remena,b, L. Mathieuc, A. Hautemanierea,b,*, M. Deloge-Abarkana, P. Hartemanna,b, D. Zmirou-Naviera,b