Action research on promoting hand hygiene practices in an intensive care unit.

AIM: Evaluate the intensive care acquired infections incidence and the change over time in infection practices in one intensive care unit. DESIGN: We used an action research approach with cyclical activities. METHODS: Our study included two cycles with hand hygiene observation based on the WHO's five-moments observation tool, observing hand hygiene practices, analysing the observations, and giving feedback on observations, intensive care acquired infection rates, and alcohol-based hand rub consumption. The Revised Standards for Quality Improvement Reporting Excellence is the basis for this research report describing research aimed at improving patient safety and quality of care. RESULTS: During the study, annual alcohol-based hand rub consumption increased by 6.7 litres per 1000 patient days and observed hand hygiene compliance improved. In the first cycle of the study, there was a decrease in critical care acquired infection rates, but the improvement was not sustainable.

Whole genome sequencing reveals new links between spa t172/CC59 methicillin-resistant Staphylococcus aureus cases in low-endemicity region of Southwest Finland, 2007‒2016.

Methicillin-resistant Staphylococcus aureus (MRSA) rates have remained relatively low in Finland. In Southwest Finland, however, annual MRSA incidence increased from 12 to 25/100,000 between 2007 and 2016 with spa t172 strain causing one fourth (237/983) of all cases. This provoked us to study the molecular epidemiology of t172-MRSA, aiming to better understand the transmission of this strain type. We combined epidemiological data and whole genome sequencing (WGS) of a set of 64 (27%, 64/237) t172-MRSA isolates covering 10 years. Isolates represented sporadic and index cases of all identified healthcare-associated outbreaks (HAOs) and family clusters (FCs). Among the included 62 isolates, core-genome MLST analysis revealed eight genomic clusters comprising 24 (38.7%) isolates and 38 (61.3%) non-clustered isolates. Cluster 1 comprised ten and the remaining seven clusters two isolates each, respectively. Two epidemiologically distinct HAOs were linked in cluster 1. FCs were involved in all clusters. All strains were associated with epidemic clonal complex CC59. We were able to confirm the spread of several successful t172-MRSA subclones in regional healthcare and the community. WGS complemented routine surveillance by revealing undetected links between t172-MRSA cases. Targeted, WGS-based typing could enhance MRSA surveillance without the need for routine WGS diagnostics.

Three clusters of carbapenemase-producing Citrobacter freundii in Finland, 2016-20.

OBJECTIVES: Carbapenemase-producing Enterobacterales (CPE) have spread widely into health care facilities (HCF) but clusters caused by carbapenemase-producing (CP) Citrobacter freundii have been uncommon until recent years. Here we describe CP C. freundii clusters detected in Finland during 2016-20. METHODS: As a part of the national CPE surveillance, clinical microbiology laboratories send potential CP C. freundii isolates to the reference laboratory for confirmation and further characterization. Whole genome sequencing (WGS) with Illumina MiSeq sequencer was used to detect clusters. Resistance genes and STs were analysed using SRST2 and typing with core genome (cg) MLST. A case was defined as a patient with a CP C. freundii isolate belonging to one of the detected clusters. RESULTS: We detected three CP C. freundii clusters: cluster 1 included 16 cases in five HCFs during 2016-20, cluster 2 had two cases in two HCFs during 2018-19 and cluster 3 had two cases in one HCF in 2020. The isolates (11 clinical and 5 screening) in cluster 1 had KPC-2 carbapenemase and were sequence type (ST)18. Cluster 2 (2 clinical isolates) had OXA-181/GES-5 carbapenemases and were ST604 and cluster 3 (two screening isolates) had KPC-3 carbapenemase and were ST116. None of the cases had a history of recent travel abroad. CONCLUSIONS: CP C. freundii also causes outbreaks and can be a reservoir of carbapenemase genes. The long intervals between successive cases, mostly found in clinical specimens in two clusters, suggest that besides unknown carriers, environmental contamination may play a role in transmission.

Performance of the Check-Direct ESBL Screen for BD MAXTM for detection of asymptomatic faecal carriage of extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae.

OBJECTIVES: Accurte diagnostic methods are crucial for the detection of extended-spectrum ß-lactamase-producing Enterobacterales (ESBL-E). Besides culture-based gold-standard methods, new molecular gene detection tests are reaching the market. The aim of this study was to investigate the performance of the direct quantitative PCR (qPCR)-based methods Check-Direct ESBL and CPE Screen for BD MAXTM in relation to traditional culture-based methods for detection of ESBL-E faecal carriage. METHODS: Faecal samples were collected from healthy adult volunteers. Samples were cultured on chromogenic ESBL agar plates and were screened for ESBL-producing Escherichia coli and Klebsiella pneumoniae. Confirmed ESBL- and AmpC-producing isolates were further analysed using whole-genome sequencing. In addition, faecal samples were analysed using Check-Direct ESBL and CPE Screen for BD MAXTM and the results were compared with the gold-standard culture-based method. RESULTS: Of 176 faecal samples examined, 11 (6.3%) grew ESBL-producing E. coli or K. pneumoniae isolates. Among 173 analysed samples, Check-Direct ESBL Screen for BD MAXTM detected 22 (12.7%) ESBL-positive samples. No carbapenemase-producing isolates were detected. Two culture-positive samples remained negative with Check-Direct ESBL Screen for BD MAXTM. Culture-negative but qPCR-positive discrepancy was observed in 12 samples (6.9%). Altogether, concordant results were obtained for 158 samples (91.3%; 9 positive and 149 negative). CONCLUSION: Check-Direct ESBL Screen for BD MAXTM is a fast screening method for ESBL carriage. However, several discrepant results were observed, which hinders interpretation. More clinical samples should be tested in combination with culture to evaluate the true benefits of this method.

Changing epidemiology of methicillin-resistant Staphylococcus aureus in a low endemicity area-new challenges for MRSA control.

The incidence of methicillin-resistant Staphylococcus aureus (MRSA) has increased sharply in Hospital District of Southwest Finland (HD). To understand reasons behind this, a retrospective, population-based study covering 10 years was conducted. All new 983 MRSA cases in HD from January 2007 to December 2016 were analysed. Several data sources were used to gather background information on the cases. MRSA cases were classified as healthcare-associated (HA-MRSA), community-associated (CA-MRSA), and livestock contact was determined (livestock-associated MRSA, LA-MRSA). Spa typing was performed to all available strains. The incidence of MRSA doubled from 12.4 to 24.9 cases/100000 persons/year. The proportion of clinical infections increased from 25 to 32% in the 5-year periods, respectively, (p < 0.05). The median age decreased from 61 years in 2007 to 30 years in 2016. HA-MRSA accounted for 68% of all cases, of which 32% associated with 26 healthcare outbreaks. The proportion of CA-MRSA cases increased from 13% in 2007 to 43% in 2016. Of CA-MRSA cases, 43% were among family clusters, 32% in immigrants and 4% were LA-MRSA. The Gini-Simpson diversity index for spa types increased from 0.86 to 0.95 from the first to the second 5-year period. The proportion of a predominant strain t172 decreased from 43% in 2009 to 7% in 2016. The rise in the proportion of CA-MRSA, the switch to younger age groups, the complexity of possible transmission routes and the growing spa-type diversity characterize our current MRSA landscape. This creates challenges for targeted infection control measures, demanding further studies.

Outbreak of invasive pneumococcal disease among shipyard workers, Turku, Finland, May to November 2019.

We report an outbreak of invasive pneumococcal disease and pneumococcal pneumonia among shipyard workers, in Turku, Southwest Finland. In total, 31 confirmed and six probable cases were identified between 3 May and 28 November 2019. Streptococcus pneumoniae serotypes 12F, 4 and 8 were isolated from blood cultures of 25 cases. Occupational hygiene measures and vaccination of ca 4,000 workers are underway to control the outbreak at the shipyard.

Analysis of hospital infection register indicates that the implementation of WHO surgical safety checklist has an impact on early postoperative neurosurgical infections.

WHO surgical safety checklist has been proven to reduce postoperative infections in several studies. The aim of our study was to focus on surgical site infections (SSIs) after neurosurgical operations, and to determine whether the checklist implementation would have an impact on the reported SSIs. We used hospital-acquired infection (HAI) register to evaluate the effects of WHO surgical safety checklist in neurosurgery. The HAI register was searched for superficial and deep SSIs, deep organ SSIs, infections following orthopaedic implantation, and other surgical infections of 4678 neurosurgical patients operated on between 2007 and 2011. The data analysis consisted of 95 and 104 neurosurgical postoperative infections before and after the checklist implementation. Time from operation to infection was shorter before than after checklist implementation (p = 0.039), indicating a positive effect of the checklist use in the onset of early HAIs. The overall incidence of SSIs of all neurosurgical patients did not differ (4.1% and 4.5%, respectively) and no differences were noticed in the incidences of the subgroups of superficial SSIs, deep SSIs, and deep organ SSIs. The reduction in early postoperative infection rate along with checklist implementation, but not in the long run indicates the complexity of preventing HAIs in neurosurgical patients and need for a multistep infection control approach.

Predictive Value of C-Reactive Protein (CRP) in Identifying Fatal Outcome and Deep Infections in Staphylococcus aureus Bacteremia.

INTRODUCTION: Clear cut-off levels could aid clinicians in identifying patients with a risk of fatal outcomes or complications such as deep infection foci in Staphylococcus aureus bacteremia (SAB). Cut-off levels for widely used clinical follow-up parameters including serum C-reactive protein (CRP) levels and white blood cell counts (WBC) have not been previously studied. METHODS: 430 adult SAB patients in Finland took part in prospective multicentre study in which their CRP levels and WBC counts were measured on the day of the positive blood culture, every other day during the first week, twice a week during hospitalization and at 30 days. Receiver operating characteristic (ROC) analysis was used to evaluate the prognostic value of CRP and WBC on the day of the positive blood culture and at days 4, 7, and 14 in predicting mortality and the presence of deep infections at 30 days. Adjusted hazard ratios (HR) for CRP level and WBC count cut-off values for mortality were calculated by the Cox regression analysis and adjusted odds ratios (OR) for cut-off values to predict the presence of deep infection by the binary logistic regression analysis. RESULTS: The succumbing patients could be distinguished from the survivors, starting on day 4 after the positive blood culture, by higher CRP levels. Cut-off values of CRP for day 30 mortality in adjusted analysis, that significantly predicted fatal outcome were at day 4 CRP >103 mg/L with sensitivity of 77%, specificity of 55%, and HR of 3.5 (95% CI, 1.2-10.3; p = 0.024), at day 14 CRP >61 mg/L with a sensitivity of 82%, specificity of 80% and HR of 3.6 (95% CI, 1.1-10.3; p<0.039) and cut-off value of WBC at day 14 >8.6 x109/L was prognostic with sensitivity of 77%, specificity of 78% and HR of 8.2 (95% CI, 2.9-23.1; p<0.0001). Cut-off values for deep infection in adjusted analysis were on the day of the positive blood culture CRP >108 mg/L with sensitivity of 77%, specificity of 60%, and HR of 2.6 (95% CI, 1.3-4.9; p = 0.005) and at day 14 CRP >22 mg/L with sensitivity of 59%, specificity of 68%, and HR of 3.9 (95% CI, 1.6-9.5; p = 0.003). The lack of decline of CRP in 14 days or during the second week were neither prognostic nor markers of deep infection focus. CONCLUSIONS: CRP levels have potential for the early identification of SAB patients with a greater risk for death and deep infections.

Adherence to surgical hand rubbing directives in a hospital district of Southwest Finland.

BACKGROUND: The primary objective was to measure the compliance with alcohol-based surgical hand rubbing (SHR) among operation room personnel. The secondary objective was to evaluate the effect of feedback sessions on compliance. METHODS: This was a prospective observational before-after intervention study. Between October 2010 and June 2012 the hygiene nurses observed SHR among operation room personnel in the hospital district of Southwest Finland. After feedback sessions a second observation round was conducted in the main operation room of Turku University Hospital. The first observation round comprised 477 observations: 259 (54%) were doctors, 190 (40%) nurses and 28 (5%) other personnel. In the second observation round a total of 210 observations were made. RESULTS: During the first round in 42% of observations the 3 min SHR time recommended by WHO was used. Median times for SHR were 1 min 50 s (range 0 min to 5 min 44 s) for doctors and 3 min 25 s (range 1 min 1 s to 8 min 15 s) for nurses, respectively (p < 0.0001). In 40% of observations hands were not properly dried after a wash before applying SHR and in 45% hands were not allowed to dry properly after SHR before donning surgical gloves. After feedback, time for SHR did not significantly improve but technique did. CONCLUSIONS: SHR was performed incorrectly in most observations even after feedback. The results stress the importance of more effective education, helping techniques and positive role models for operation room personnel to promote SHR.

[Update on current care guideline: sepsis (adults]. / Sepsis (aikuiset).

The incidence of severe sepsis and septic shock requiring intensive care in Finnish adult population has increased to 0.60 11000 /y. Despite improved prognosis, hospital mortality related to severe sepsis and septic shock is high 24.1%. Key recommendations include prompt administration of antimicrobial therapy, optimally after blood cultures, quantitative fluid resuscitation and imaging studies to identify possible source of infection. Crystalloids are suitable for fluid resuscitation. Norepinephrine is the first-choice vasopressor in septic shock. Hydrocortisone should be considered only if fluid and vasopressor treatment does not restore hemodynamics.

Pentraxin 3 (PTX3) is associated with severe sepsis and fatal disease in emergency room patients with suspected infection: a prospective cohort study.

BACKGROUND: Early diagnostic and prognostic stratification of patients with suspected infection is a difficult clinical challenge. We studied plasma pentraxin 3 (PTX3) upon admission to the emergency department in patients with suspected infection. METHODS: The study comprised 537 emergency room patients with suspected infection: 59 with no systemic inflammatory response syndrome (SIRS) and without bacterial infection (group 1), 67 with bacterial infection without SIRS (group 2), 54 with SIRS without bacterial infection (group 3), 308 with sepsis (SIRS and bacterial infection) without organ failure (group 4) and 49 with severe sepsis (group 5). Plasma PTX3 was measured on admission using a commercial solid-phase enzyme-linked immunosorbent assay (ELISA). RESULTS: The median PTX3 levels in groups 1-5 were 2.6 ng/ml, 4.4 ng/ml, 5.0 ng/ml, 6.1 ng/ml and 16.7 ng/ml, respectively (p<0.001). The median PTX3 concentration was higher in severe sepsis patients compared to others (16.7 vs. 4.9 ng/ml, p<0.001) and in non-survivors (day 28 case fatality) compared to survivors (14.1 vs. 5.1 ng/ml, p<0.001). A high PTX3 level predicted the need for ICU stay (p<0.001) and hypotension (p<0.001). AUC(ROC) in the prediction of severe sepsis was 0.73 (95% CI 0.66-0.81, p<0.001) and 0.69 in case fatality (95% CI 0.58-0.79, p<0.001). PTX3 at a cut-off level for 14.1 ng/ml (optimal cut-off value for severe sepsis) showed 63% sensitivity and 80% specificity. At a cut-off level 7.7 ng/ml (optimal cut-off value for case fatality) showed 70% sensitivity and 63% specificity in predicting case fatality on day 28.In multivariate models, high PTX3 remained an independent predictor of severe sepsis and case fatality after adjusting for potential confounders. CONCLUSIONS: A high PTX3 level on hospital admission predicts severe sepsis and case fatality in patients with suspected infection.

Role of plasma bactericidal/permeability-increasing protein, group IIA phospholipase A(2), C-reactive protein, and white blood cell count in the early detection of severe sepsis in the emergency department.

OBJECTIVES: To study the diagnostic values of bactericidal/permeability-increasing protein (BPI), group IIA phospholipase A(2) (PLA(2)GIIA), white blood cell count (WBC), and C-reactive protein (CRP) in identifying severe sepsis upon admission in an emergency room. METHODS: This was a single-centre prospective cohort study involving 525 adult patients admitted to the emergency room with suspected infection. Plasma samples were taken concurrently with the blood cultures. Forty-nine patients with severe sepsis and 476 other patients (58 with no systemic inflammatory response syndrome (SIRS) and no bacterial infection, 63 with bacterial infection but no SIRS, 53 with SIRS but no bacterial infection, and 302 with sepsis but no organ dysfunction) were evaluated. BPI and PLA(2)GIIA were measured by time-resolved fluoroimmunoassay, and CRP with an immunoturbidimetric assay. WBC was measured using an automatic cell counter. RESULTS: There was a positive correlation between the plasma levels of PLA(2)GIIA and CRP (Pearson's correlation coefficient 0.60, p < 0.001). On logistic regression analysis the odds ratio (OR) (95% confidence limits (95% Cl)) for BPI was 2.66 (1.54-4.60, p = 0.001), for PLA(2)GIIA 1.48 (1.20-1.81, p < 0.001), for CRP 1.35 (1.02-1.77, p = 0.036), and for WBC 2.81 (1.48-5.34, p = 0.002). The differences in area under the receiver operator characteristic curve (AUC) between these parameters were not significant. On multivariate logistic regression analysis only PLA(2)GIIA could differentiate patients with severe sepsis from others (OR 1.37, 95% Cl 1.05-1.78, p = 0.019). After adjusting for confounders PLA(2)GIIA remained a significant independent predictor of severe sepsis. CONCLUSIONS: PLA(2)GIIA seemed to be superior to CRP, BPI, and WBC in differentiating patients with severe sepsis. BPI gave no additional information in this respect.

Early detection of severe sepsis in the emergency room: diagnostic value of plasma C-reactive protein, procalcitonin, and interleukin-6.

OBJECTIVES: To determine the diagnostic values of plasma C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6) using an electrochemiluminescence immunoassay (ECLIA) method (Roche Diagnostics GmbH, Mannheim, Germany) to identify severe sepsis in an emergency room (ER) setting. METHODS: This was a single-centre prospective follow-up study of 539 consecutive adult patients admitted to the ER with suspected infection. Blood samples were taken concurrently with blood cultures at admission. Patients were divided into 5 groups on the basis of systemic inflammatory response syndrome (SIRS) criteria, documentation of bacterial infection, and organ dysfunction. Fifty-nine patients with no SIRS or bacterial infection, 68 patients with bacterial infection but no SIRS, 54 patients with SIRS but no bacterial infection, 309 patients with sepsis (SIRS and bacterial infection), and 49 patients with severe sepsis (sepsis and organ failure) were evaluated. RESULTS: In a logistic regression model, the odds ratio (OR) for PCT was 1.58 (95% confidence interval (CI) 1.37-1.82, p < 0.0001), for IL-6 was 1.54 (95% CI 1.32-1.80, p < 0.0001), and for CRP was 1.33 (95% CI 1.01-1.75, p = 0.045). The area under the curve (AUC) was 0.77 (95% CI 0.71-0.84) for PCT, 0.72 (95% CI 0.64-0.80) for IL-6, and 0.60 (95% CI 0.51-0.69) for CRP. PCT emerged as the best marker for severe sepsis, but the difference in AUC was not significant between PCT and IL-6. In multivariate logistic regression analysis, after adjusting for confounders, PCT and IL-6 remained significant independent predictors of severe sepsis. CONCLUSIONS: PCT and IL-6 proved superior to CRP in detecting patients with severe sepsis. The findings thus support the use of either PCT or IL-6 as an early tool to diagnose severe sepsis. The automatic ECLIA method allows even night-shift measurements.

[Update on current care guidelines. Treatment of severe sepsis in adults]. / Aikuisten vaikean sepsiksen hoito.

According to the Finnsepsis Study, the incidence in Finland of severe sepsis requiring intensive care was 0.38/1,000 inhabitants/year. ICU and hospital mortality was 15.5% and 28.3%, respectively. The Finnsepsis Study showed that compliance with protocols was rather poor and antimicrobial treatment was often delayed. These guidelines emphasize the importance of prompt antibiotic and fluid therapy. In shock, norepinephrine is the first line vasopressor. Low-dose hydrocortisone may be used to shorten the need for vasopressors. Activated protein C should be considered in selected patients. The blood glucose target recommendation is between 5 and 8 mmol/l.

Incidence, treatment, and outcome of severe sepsis in ICU-treated adults in Finland: the Finnsepsis study.

OBJECTIVE: To determine the incidence and outcome of severe sepsis in the adult Finnish population and to evaluate how treatment guidelines in severe sepsis are applied in clinical practice. STUDY DESIGN: A prospective study in 24 closed multidisciplinary ICUs in 21 hospitals (4 university and 17 tertiary hospitals) in Finland. PATIENTS: All 4,500 consecutive ICU admission episodes were screened for severe sepsis during a 4-month period (1 November 2004 - 28 February 2005). The referral population was 3,743,225. RESULTS: The severe sepsis criteria were fulfilled in 470 patients, who had 472 septic episodes. The incidence of severe sepsis in the ICUs in Finland was 0.38/1000 in the adult population (95% confidence interval 0.34-0.41). The mean ICU length of stay was 8.2+/-8.1 days. ICU, hospital, and 1-year mortality rates were 15.5%, 28.3%, and 40.9%, respectively. Respiratory failure requiring ventilation support was the most common organ failure (86.2%); septic shock was present in 77% and acute renal failure in 20.6% of cases. Activated protein C was given to only 15 of the 55 patients with indication (27%) and low-dose corticosteroids to 150 of 366 (41%) patients with septic shock. CONCLUSIONS: This prospective study found the incidence of ICU-treated severe sepsis in Finland to be 0.38 per 1,000 of the population. The ICU and hospital mortalities were also lower than earlier reported in United States or Australia. Evidence-based sepsis therapies were not used as often as recommended.

Time-resolved fluoroimmunoassays of the complete set of secreted phospholipases A2 in human serum.

Time-resolved fluoroimmunoassays (TR-FIA) were developed for all human secreted phospholipases A(2) (PLA(2)), viz. group (G) IB, GIIA, GIID, GIIE, GIIF, GIII, GV, GX and GXIIA PLA(2) and the GXIIB PLA(2)-like protein. Antibodies were raised in rabbits against recombinant human PLA(2) proteins and used in sandwich-type TR-FIAs as both catching and detecting antibodies, the latter after labeling with Europium. The antibodies were non-cross-reactive. The analytical sensitivities were 1 microg/L for the TR-FIA for GIB PLA(2), 1 microg/L (GIIA), 35 microg/L (GIID), 3 microg/L (GIIE), 4 microg/L (GIIF), 14 microg/L (GIII), 11 microg/L (GV), 2 microg/L (GX), 92 microg/L (GXIIA) and 242 microg/L (GXIIB). All secreted PLA(2)s were assayed by these TR-FIAs in serum samples from 34 patients (23 men and 11 women, mean age 53.2 years) treated in an intensive care unit for septic infections, and in control samples from 28 volunteer blood donors (14 men and 14 women, mean age 57.0 years). Five serum samples (3 in the sepsis group and 2 in the blood donor group) gave high TR-FIA signals that were reduced to background (blank) levels by the addition of non-immune rabbit IgG to the sera. This reactivity was assumed to be due to the presence of heterophilic antibodies in these subjects. In all other subjects, including septic patients and healthy blood donors, the TR-FIA signals for GIID, GIIE, GIIF, GIII, GV, GX and GXIIA PLA(2) and the GXIIB PLA(2)-like protein were at background (blank) levels. Four patients in the sepsis group had pancreatic involvement and elevated concentration of GIB PLA(2) in serum (median 19.0 microg/L, range 13.1-33.7 microg/L, n = 4) as compared to the healthy blood donors (median 1.8 microg/L, range 0.8-3.4 microg/L, n = 28, P < 0.0001). The concentration of GIIA PLA(2) in the sera of septic patients (median 315.7 microg/L, range 15.9-979.6 microg/L, n = 34) was highly elevated as compared to that of the blood donors (median 1.8 microg/L, range 0.8-5.8 microg/L, n = 28, P < 0.0001). Our current results confirmed elevated concentrations of GIB and GIIA PLA(2) in the sera of patients suffering from acute pancreatitis or septic infections, respectively, as compared to healthy subjects. However, in the same serum samples, the concentrations of the other secreted PLA(2)s, viz. GIID, GIIE, GIIF, GIII, GV, GX and GXIIA PLA(2) and the GXIIB PLA(2)-like protein were below the respective analytical sensitivities of the TR-FIAs. It is concluded that generalized bacterial infections do not lead to elevated serum levels of GIIE, GIIF, GIII, GV and GX PLA(2)s above the detection limits of the current TR-FIAs.

Elimination of epidemic methicillin-resistant Staphylococcus aureus from a university hospital and district institutions, Finland.

From August 1991 to October 1992, two successive outbreaks of methicillin-resistant Staphylococcus aureus (MRSA) occurred at a hospital in Finland. During and after these outbreaks, MRSA was diagnosed in 202 persons in our medical district; >100 cases involved epidemic MRSA. When control policies failed to stop the epidemic, more aggressive measures were taken, including continuous staff education, contact isolation for MRSA-positive patients, systematic screening for persons exposed to MRSA, cohort nursing of MRSA-positive and MRSA-exposed patients in epidemic situations, and perception of the 30 medical institutions in that district as one epidemiologic entity brought under surveillance and control of the infection control team of Turku University Hospital. Two major epidemic strains, as well as eight additional strains, were eliminated; we were also able to prevent nosocomial spread of other MRSA strains. Our data show that controlling MRSA is possible if strict measures are taken before the organism becomes endemic. Similar control policies may be successful for dealing with new strains of multiresistant bacteria, such as vancomycin-resistant strains of S. aureus.