***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Intensive care units ( ICUs ) are high-risk setting s for the transmission of methicillin-resistant Staphylococcus aureus ( MRSA ) and vancomycin-resistant enterococcus ( VRE ) . METHODS In a cluster-r and omized trial , we evaluated the effect of surveillance for MRSA and VRE colonization and of the exp and ed use of barrier pre caution s ( intervention ) as compared with existing practice ( control ) on the incidence of MRSA or VRE colonization or infection in adult ICUs . Surveillance cultures were obtained from patients in all participating ICUs ; the results were reported only to ICUs assigned to the intervention . In intervention ICUs , patients who were colonized or infected with MRSA or VRE were assigned to care with contact pre caution s ; all the other patients were assigned to care with universal gloving until their discharge or until surveillance cultures obtained at admission were reported to be negative . RESULTS During a 6-month intervention period , there were 5434 admissions to 10 intervention ICUs , and 3705 admissions to 8 control ICUs . Patients who were colonized or infected with MRSA or VRE were assigned to barrier pre caution s more frequently in intervention ICUs than in control ICUs ( a median of 92 % of ICU days with either contact pre caution s or universal gloving [ 51 % with contact pre caution s and 43 % with universal gloving ] in intervention ICUs vs. a median of 38 % of ICU days with contact pre caution s in control ICUs , P<0.001 ) . In intervention ICUs , health care providers used clean gloves , gowns , and h and hygiene less frequently than required for contacts with patients assigned to barrier pre caution s ; when contact pre caution s were specified , gloves were used for a median of 82 % of contacts , gowns for 77 % of contacts , and h and hygiene after 69 % of contacts , and when universal gloving was specified , gloves were used for a median of 72 % of contacts and h and hygiene after 62 % of contacts . The mean ( ±SE ) ICU-level incidence of events of colonization or infection with MRSA or VRE per 1000 patient-days at risk , adjusted for baseline incidence , did not differ significantly between the intervention and control ICUs ( 40.4±3.3 and 35.6±3.7 in the two groups , respectively ; P=0.35 ) . CONCLUSIONS The intervention was not effective in reducing the transmission of MRSA or VRE , although the use of barrier pre caution s by providers was less than what was required . ( Funded by the National Institute of Allergy and Infectious Diseases and others ; STAR*ICU Clinical Trials.gov number , NCT00100386 . ) OBJECTIVE To assess the efficacy of a multimodal , central ly coordinated , multisite h and hygiene culture-change program ( HHCCP ) for reducing rates of  methicillin-resistant Staphylococcus aureus ( MRSA ) bacteraemia and disease in Victorian hospitals . DESIGN , PARTICIPANTS AND SETTING A pilot HHCCP was conducted over a 24-month period ( October 2004 to September 2006 ) in six Victorian health care institutions ( 4 urban , 2 rural ; total beds , 2379 ) . Subsequently , we assessed the efficacy of an identical program implemented throughout Victorian public hospitals over a 12-month period ( beginning between March 2006 and July 2006 ) . MAIN OUTCOME MEASURES Rates of h and hygiene ( HH ) compliance ; rates of MRSA disease ( patients with bacteraemia and number of clinical isolates per 100 patient discharges [ PD ] ) . RESULTS Mean HH compliance improved significantly at all pilot program sites , from 21 % ( 95 % CI , 20%-22 % ) at baseline to 48 % ( 95 % CI , 47%-49 % ) at 12 months and 47 % ( 95 % CI , 46%-48 % ; range , 31%-75 % ) at 24 months . Mean baseline rates for the number of patients with MRSA bacteraemia and the number of clinical MRSA isolates were 0.05/100 PD per month ( range , 0.00 - 0.13 ) and 1.39/100 PD per month ( range , 0.16 - 2.39 ) , respectively . These were significantly reduced after 24 months to 0.02/100 PD per month for bacteraemia ( P = 0.035 for trend ; 65 fewer patients with bacteraemia ) and 0.73/100 PD per month for MRSA isolates ( P = 0.003 ; 716 fewer isolates ) . Similar findings were noted 12 months after the statewide roll-out , with an increase in mean HH compliance ( from 20 % to 53 % ; P < 0.001 ) and reductions in the rates of MRSA isolates ( P = 0.043 ) and bacteraemias ( P = 0.09 ) . CONCLUSIONS Pilot and subsequent statewide implementation of a multimodal HHCCP was effective in significantly improving HH compliance and reducing rates of MRSA infection Enterococci have emerged as a prominent cause of nosocomial infection over the past two decades [ 1 , 2 ] . During the past 6 years , a rapid emergence has been seen in hospitals of strains that are resistant to the three mainstay antibiotics used to treat enterococcal infectionsampicillin , vancomycin , and gentamicin and that are frequently resistant to all commercially available agents [ 3 ] . Vancomycin-resistant enterococci are cause for alarm not only because effective antibiotics are lacking , but also because vancomycin resistance may spread to other bacteria , particularly Staphylococcus aureus . Enterococcal infections traditionally have been attributed to strains from patients ' endogenous flora [ 4 ] , but several recent reports have shown that enterococci can be spread by carriage on the h and s of personnel [ 5 , 6 ] or by equipment [ 7 ] . Several studies [ 6 , 8 - 12 ] that have evaluated clusters of infection or colonization caused by vancomycin-resistant enterococci have documented identical strain types in many patients ; this further supports the hypothesis of spread among patients . The Hospital Infection Control Practice s Advisory Committee ( HICPAC ) and the Centers for Disease Control and Prevention ( CDC ) have jointly recommended measures to prevent the nosocomial transmission of vancomycin-resistant enterococci . Use of single rooms or cohorting for patients infected or colonized with vancomycin-resistant enterococci is advocated . Use of gloves and gowns by hospital employees entering the rooms of such patients is also recommended if substantial contact with the patient or with environmental surfaces in the patient 's room is anticipated ; if the patient is incontinent ; or if the patient has diarrhea , has had an ileostomy , has had a colostomy , or has wound drainage not contained by a dressing [ 13 ] . Although use of gloves alone has successfully limited the spread of resistant gram-negative bacilli [ 14 ] , the efficacy of the use of gowns above and beyond that of the use of gloves alone [ 15 , 16 ] has not been shown in a controlled trial . We did an epidemiologic study and a controlled clinical trial comparing the efficacy of the universal use of gloves with that of the universal use of gowns and gloves in the prevention of colonization by vancomycin-resistant enterococci in a medical intensive care unit of a hospital in which vancomycin-resistant enterococci are endemic . Methods Setting and Study Design This clinical trial was conducted under the direction of the Infection Control Committee of Cook County Hospital in Chicago , Illinois , a 900-bed public teaching hospital . The newly constructed medical intensive care unit , which is supervised by a staff of intensivists , was opened for patient care in September 1994 . It contains 12 beds in single rooms and 4 beds in double rooms . During the 4.5-month study period ( 26 October 1994 to 7 March 1995 ) , the unit was geographically divided so that eight beds were in a glove- and -gown section and eight were in a glove-only section . Both double rooms were in the glove-only section . Patients were assigned to beds by the charge nurse on the basis of bed availability . Hospital employees were required to wear clean , nonsterile latex gloves when entering a room and to remove them and wash their h and s with antibacterial soap before leaving the room . In double rooms , h and s were washed and fresh gloves were donned if the health care worker moved from one patient to the other . In addition , employees wore isolation gowns ( disposable , nonwoven polypropylene gowns that withst and 11.5 cm hydrostatic pressure and do not absorb water [ American Threshold , Enka , North Carolina ] ) when entering a glove- and -gown room , and they removed them before leaving . Because many patients have vancomycin-resistant enterococci when they are admitted to the intensive care unit and because identification of colonized patients by culture is often delayed , glove- and -gown or glove-only pre caution s were instituted immediately after admission for all patients . A sign listing the appropriate pre caution s was posted at the door of each room .  Blood pressure cuffs and thermometers were dedicated for use on individual patients on the basis of current HICPAC recommendations . Rooms were cleaned daily with a phenolic disinfectant . Use of oral vancomycin was restricted to patients who had antibiotic-associated colitis that did not respond to metronidazole . The records of all patients who stayed in the intensive care unit for 48 hours or more were review ed , and clinical , laboratory , and demographic data were extracted from those records . Compliance At the beginning of the study and every 1 to 2 weeks thereafter , we held educational meetings with medical intensive care unit nurses , house staff , and attending physicians to present the new infection control measures and to provide encouragement and feedback about compliance . Compliance was monitored by unobtrusive observers on all shifts approximately 7 hours per week . Beds were monitored in r and om order for 10-minute periods . All hospital employees were monitored and were expected to comply ; visitors were asked to comply with isolation pre caution s but were not monitored . Compliance with donning gloves on entry , removing gloves before leaving , and h and washing was monitored for all beds ; compliance with donning gowns on entry and removing them before leaving was monitored for glove- and -gown beds . We evaluated compliance on the basis of room entry , regardless of whether the person being evaluated had contact with the patient or objects in the room . Surveillance Culturing Rectal swabs ( Culturette System , Becton Dickinson Microbiology Systems , Cockeysville , Maryl and ) were obtained daily from patients in the intensive care unit . Swabs were also obtained 1 week and 2 weeks after discharge from the intensive care unit for patients who remained hospitalized and had had negative surveillance cultures when they left the intensive care unit . Patients were defined as having acquired vancomycin-resistant enterococci in the intensive care unit if a rectal culture positive for vancomycin-resistant enterococci was first obtained more than 3 days after admission . After construction was completed but before the units were occupied by patients , environmental sample s were taken on swabs moistened with modified Stuart transport medium ( supplied with the Culturette System ) from all patient rooms and from common areas . After the rooms were occupied , sample s were taken monthly . Surfaces sample d included those of bed rails , bed linen , countertops , overbed tables , drawer and cabinet h and les , light switches , soap dispensers , monitor key pads , infusion equipment , bedside charts , blood pressure cuffs , stethoscopes , bed scales , refrigerator door h and les , telephones , computers , and doorknobs . Microbiological Methods Rectal swabs were inoculated onto Enterococcosel agar ( Becton Dickinson Microbiology Systems ) and Columbia colistin-nalidixic acid agar ( Difco Laboratories , Detroit , Michigan ) supplemented with vancomycin , 6 g/mL , and amphotericin B , 8 g/mL. Plates were examined after 24 and 48 hours of incubation at 37 C , and growth on either plate was subcultured to both types of media to confirm the presence of vancomycin-resistant enterococci . Environmental sample s were plated on trypticase soy agar ( Becton Dickinson Microbiology Systems ) supplemented with vancomycin , 6 g/mL and gentamicin , 4 g/mL [ 8 ] . The first rectal isolate of vancomycin-resistant enterococcus from each patient and all clinical and environmental isolates of vancomycin-resistant enterococci were identified to the species level by the API 20 Strep system ( bioMerieux Vitek , Inc. , Hazelwood , Missouri ) , the production of yellow pigment , and the 30 C motility test [ 17 ] . Testing of susceptibility to vancomycin , ampicillin , and teicoplanin  was done by disk diffusion [ 18 ] . We determined minimum inhibitory concentrations ( MICs ) for vancomycin ( Sigma Chemical Co. , St. Louis , Missouri ) and teicoplanin ( Marion Merrell Dow , Cincinnati , Ohio ) by using the agar-dilution method [ 19 ] . Screening for high-level aminoglycoside resistance was done on brain-heart infusion agar containing either gentamicin , 500 g/mL ( Sigma Chemical Co. ) or streptomycin , 20 
    Output:
    
This systematic review suggests a significant role for the implementation of h and hygiene .