Infection Control Experience in a Cooperative Care Center for Transplant Patients • Author(s): Ahmad Nusair , MD; Dawn Jourdan , RN; Sharon Medcalf , RN; Nedra Marion , RN;Peter C. Iwen , PhD; Paul D. Fey , PhD; Elizabeth Reed , MD; Alan Langnas , DO; Mark E. Rupp, MDSource: Infection Control and Hospital Epidemiology, Vol. 29, No. 5 (May 2008), pp. 424-429Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/10.1086/587188 .

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infection control and hospital epidemiology may 2008, vol. 29, no. 5

o r i g i n a l a r t i c l e

Infection Control Experience in a Cooperative Care Centerfor Transplant Patients

Ahmad Nusair, MD; Dawn Jourdan, RN; Sharon Medcalf, RN; Nedra Marion, RN; Peter C. Iwen, PhD;Paul D. Fey, PhD; Elizabeth Reed, MD; Alan Langnas, DO; Mark E. Rupp, MD

objective. To characterize infection control experience during a 6.5-year period in a cooperative care center for transplant patients.

design. Descriptive analysis.

setting. A cooperative care center for transplanted patients, in which patients and care partners are housed in a homelike environment,and care partners assume responsibility for patient care duties.

patients. Nine hundred ninety one transplant patients.

methods. Infection control definitions from the Centers for Disease Control and Prevention were used to ascertain infection rates.Environmental cultures were used to detect methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE),Clostridium difficile, and fungi during the first 18 months. Surveillance cultures were performed for a subset of patients and care partners.

results. From June 1999 through December 2005, there were 19,365 patient-days observed. The most common healthcare-associatedinfection encountered was intravascular catheter–related bloodstream infection, with infection rates of 5.74 and 4.94 cases per 1,000 patient-days for hematopoietic stem cell transplant (HSCT) and solid organ transplant (SOT) patients, respectively. C. difficile–associated diarrheawas observed more frequently in HSCT patients than in SOT patients (3.97 vs 0.57 cases per 1000 patient-days; ). There was noP ! .0001evidence of environmental contamination with MRSA, VRE, or C. difficile. Acquisition of MRSA was not observed. Acquisition of VREwas documented.

conclusion. This study documented that cooperative care was associated with some risk of healthcare-associated infection, most notablyintravascular catheter–associated bloodstream infection and C. difficile–associated diarrhea, it appears the incidences of these infectionswere roughly commensurate with those in other care settings.

Infect Control Hosp Epidemiol 2008; 29:424-429

From the Departments of Internal Medicine (A.N., E.R., M.E.R.), Pathology and Microbiology (P.C.I., P.D.F.), and Surgery (A.L.), University of NebraskaMedical Center, and the Department of Healthcare Epidemiology, the Nebraska Medical Center (D.J., S.M., N.M., M.E.R.), Omaha, Nebraska.

Received November 27, 2007; accepted January 30, 2008; electronically published March 28, 2008.� 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2008/2905-0007$15.00. DOI: 10.1086/587188

In recent years, largely to contain healthcare costs, a varietyof models of healthcare delivery have been utilized, includingoutpatient infusion centers, long-term acute care hospitals,home healthcare, and cooperative care. Each of these settingspresents unique infection control challenges. In cooperativecare, a lay person, usually a family member or spouse, servesas the primary care giver for a patient who would otherwisebe housed in an acute care inpatient facility.1 This uniquemodel was first utilized at the New York University MedicalCenter during the 1980s.2 In June 1999, a cooperative carecenter for solid organ transplant (SOT) and hematopoieticstem cell transplant (HSCT) patients was opened at the Uni-versity of Nebraska Medical Center.3-5 Herein, we report ourexperience with infection control issues in this cooperativecare center during the first 6.5 years of operation. More spe-cifically, we report the rate of healthcare-associated infectionin SOT and HSCT patients, as well as the rates of infection

due to multidrug-resistant organisms, Clostridium difficile,and filamentous fungi. Additionally, we report on the resultsof environmental cultures performed during the initialmonths of operation to assess contamination by organismsof epidemiologic interest and active surveillance cultures per-formed to assess acquisition of methicillin-resistant Staphy-lococcus aureus (MRSA) and vancomycin-resistant entero-cocci (VRE).

methods

Setting

The Cooperative Care Program at the University of NebraskaMedical Center is housed in the Lied Transplant Center.Forty-four cooperative care suites are located on 2 floors ofthe 12-floor transplant center. The homelike suites have sep-arate living and sleeping areas, a kitchenette, and a bathroom.

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infection control in a transplant cooperative care center 425

An additional sink and storage area for medical supplies inthe patient’s sleeping area accommodates the provision ofhealth care. There is no mixing of air between rooms, whichare served by individual water-source heat pumps that achieveat least 6 air exchanges per hour with 15% fresh outside airfiltered at 70% efficiency. A 20-bed treatment center, located1 floor below the cooperative care suites, is open 24 hours aday to provide infusions and to allow for patient assessmentand care. The air handling system for the treatment centeris provided by a central unit that supplies 45% fresh air with8-10 air exchanges per hour with 85% filtration efficiency.Other amenities include a pharmacy, dining room, exercisefacility, laundry rooms, lounge, and outdoor garden. A moredetailed description of the transplant center and the coop-erative care facility has been published elsewhere.3 Care part-ners are involved with the collection of patient data, the ad-ministration of medication, the care of catheters, thetransportation of patients to appointments and procedures,and the assistance of activities of daily living. Care partnersundergo an educational program that, among other things,instructs them in the appropriate care of intravascular andurinary catheters, the observation of signs and symptoms ofinfection, hand hygiene, and the minimization of environ-mental risks for infection.3,4

Infection Control and Isolation Precautions

Patients colonized or infected with multidrug-resistant or-ganisms (eg, MRSA and VRE) were not placed in contactisolation and were free to come and go as they pleased. Thesepatients and their care partners received routine informationand instruction regarding hand hygiene and standard infec-tion control precautions. The electronic medical record wasflagged with a computerized alert, and, when these patientswere seen in the treatment center, they were cared for withcontact isolation precautions that included use of gowns,gloves, and other dedicated equipment. The cooperative carerooms were not designed to care for persons with diseasesspread by small droplet nuclei, and, therefore, patients knownor suspected to have these conditions were not housed in thecooperative care facility.

Environmental Cleaning

Cooperative care suites were cleaned daily by hospital envi-ronmental service workers; the cleaning regime included stan-dard removal of trash, changing of linen, and vacuuminghigh-traffic areas. Horizontal and high-touch surfaces weredisinfected daily with a quaternary ammonium disinfectant.At the time of patient discharge, the bedspread and blanketswere laundered, and the refrigerator and microwave ovenwere cleaned.

Surveillance for Healthcare-Associated Infection

Definitions and methods from the Centers for Disease Con-trol and Prevention’s National Nosocomial Infections Sur-

veillance system manual were utilized for surveillance ofhealthcare-associated infection.6 Since complete data on de-vice utilization were lacking, infection rates were expressedas the number of infections per 1,000 patient-days. For sur-veillance purposes, in anticipation that there would be dif-ferent risk factors for, and different rates of, healthcare-as-sociated infections, the patients were divided into 2populations: HSCT patients and SOT patients. Healthcare-associated infections were categorized into 6 main groups:bloodstream infection, gastrointestinal tract infection, sur-gical site infection, urinary tract infection, pneumonia, andother. The last category (other) consisted of ear, nose, andthroat infections, conjunctivitis, bronchitis, and the other raremiscellaneous infections. Rates of infection from year to yearwere compared using 1-way analysis of variance (GraphpadPrism software, version 4.02; Graphpad Prism).

Environmental Cultures

To ascertain the prevalence of environmental contaminationwith VRE, MRSA, C. difficile, and fungi, environmental cul-tures were performed before the cooperative care center wasopened (in January 1999) and periodically during the first18 months of operation (in September 1999, April 2000, andOctober 2000). A convenience sample of 25 of 44 cooperativecare suites and 4 of 20 treatment center rooms were surveyed.The locations within each cooperative care suite that weresampled included the patient’s sleeping area, the living roomarea, and bathroom. The surfaces swabbed for detection ofMRSA and VRE were sink handles, countertops, and bedsidetables; for C. difficile, culture samples were obtained fromtoilet seats and nearby floor and wall surfaces. The sampleswere obtained by rubbing saline-moistened cotton swabs overa 40 cm2 area. Separate swabs and sample areas were utilizedfor recovery of MRSA, VRE, and C. difficile.

For VRE isolation, the swab samples were placed in tryp-ticase soy broth (Difco) containing colistin sulfate at a con-centration of 7.5 mg/mL, nystatin at 12.5 mg/mL, vancomycinat 3 mg/mL, and trimethoprim at 5 mg/mL (antimicrobial vialCNVT) (Difco) and incubated for 72 hours at 37�C. Positivecultures were subcultured onto trypticase soy agar (Difco)plates containing the same mixture of antimicrobial drugs(CNVT; Difco). Enterococci were identified by standard tech-niques, and vancomycin susceptibility confirmed by brothmicrodilution (Dade MicroScan).

For isolation of MRSA, the swab samples were placed inbrain-heart infusion broth (Difco) containing 6.5% NaCl,colistin at a concentration of 10 mg/mL, nalidixic acid at 10mg/mL, and oxacillin at 6 mg/mL and incubated for 72 hoursat 30�C. The MRSA isolates were identified using theMicroScan system and confirmed by the oxacillin disk dif-fusion method.

For C. difficile isolation, cycloserine-cefoxitin agar plates(M-CCA) were inoculated and incubated anaerobically at37�C for 72 hours.7 Characteristic colonies were identified as

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426 infection control and hospital epidemiology may 2008, vol. 29, no. 5

table 1. Healthcare-Associated Infections in Transplant Patients in a Cooperative Care Cen-ter, June 1999 to December 2005

Type of infection

HSCT patients(14,106 patient-days)

SOT patients(5,259 patient-days)

P a

No. ofcases

Incidence rate per1,000 patient-days

No. ofcases

Incidence rate per1,000 patient-days

Bloodstream 81 5.74 26 4.94 .58Gastrointestinal tract 56 3.97 3 0.57 !.0001Surgical site … … 9 1.25b …Urinary tract 2 0.14 4 0.76 .05Pneumonia 9 0.64 1 0.19 .36Other 21 1.49 8 1.52 .99

note. HSCT, hematopoietic stem cell transplant; SOT, solid organ transplant.a Fisher exact test.b Rate of surgical site infection is expressed as percentage of patients.

C. difficile using the RapID-ANA System (Innovative Diag-nostics Systems). Fungal organisms from the environmentwere detected using the settling method with Sabouroud dex-trose agar (Difco) plates. These plates were placed in each ofthe rooms surveyed and were exposed for 30 minutes. Inaddition, quantitative fungal cultures were performed usingSabouroud dextrose agar in a N6 Andersen Air Sampler(Andersen).

Patient and Care Partner Acquisition ofMultidrug-Resistant Organisms

To define the rate of acquisition and the pattern of trans-mission of MRSA and VRE in cooperative care patients andcare partners, cultures of rectal and nares samples were per-formed at the time of admission to and at the time of dis-charge from the cooperative care center. Selective broth en-richment media, as described above, were used to recoverMRSA and VRE. This protocol was reviewed by the Universityof Nebraska Medical Center Institutional Review Board, andinformed consent was obtained from participating patientsand care partners. All patients and care partners admitted tothe cooperative care program between May 1999 and January2000 were asked whether they wanted to enroll in the study.To determine clonality of strains and establish patterns oftransmission, all isolates of MRSA and VRE detected duringthe study were characterized by analysis of SmaI restrictionfragment-length polymorphism patterns of chromosomalDNA by pulsed-field gel electrophoresis, as described else-where.8 There was no attempt to link the environmental cul-tures described above to the rooms occupied by patients orcare partners who were found to harbor MRSA or VRE.

results

Healthcare-Associated Infections

From June 1999 through December 2005, there were 991patients admitted to the cooperative care center, and theyaccounted for 19,365 patient-days. HSCT patients accounted

for 14,106 patient days, and SOT patients accounted for 5,259patient days. Table 1 summarizes the rates of healthcare-as-sociated infection observed in transplant patients at the co-operative care center. Bloodstream infection (BSI) was themost common healthcare-associated infection experienced bytransplant patients, with a rate of 5.74 BSIs per 1,000 patient-days for HSCT patients and 4.94 BSIs per 1,000 patient-daysfor SOT patients ( ). The rates of BSI in SOT patientsP p .58did not vary significantly from year to year. However, inHSCT patients, the rate of BSI was significantly higher in2005 than in it was in previous years ( ). From 1999P p .004through 2004, the rates ranged from 2.16 BSIs per 1,000patient-days to 5.9 BSIs per 1,000 patient-days. In 2005, therate increased to 13.34 BSIs per 1,000 patient-days. C. diffi-cile–associated diarrhea was the second most common health-care-associated infection observed in HSCT patients, whereassurgical site infections were the second most common health-care-associated infection observed in SOT patients. Pneu-monia occurred more frequently in HSCT patients than inSOT patients. Urinary tract infections were rare in transplantpatients at the cooperative care center.

The microbiology of BSIs observed in the cooperative carecenter is documented in Table 2. The proportion of BSIscaused by various organisms was similar in the 2 populationsof transplant patients. Approximately 63% of BSIs werecaused by gram-positive cocci, with coagulase-negative staph-ylococci (37%) being the most frequently observed pathogen.Five (4.7%) of the 107 BSIs were caused by S. aureus, ofwhich 3 (60%) were methicillin-resistant strains. Seven(6.5%) of the 107 BSIs were caused by Enterococcus species,of which 4 (57%) were vancomycin-resistant strains. Gram-negative bacilli caused approximately 38% of BSIs, with Pseu-domonas aeruginosa being the most common causative agent.Only 4% of BSIs were caused by yeast, with 80% of thecausative pathogens being C. albicans. Twelve percent of theinfections were polymicrobic. The overall rate of infectiondue to MRSA was 0.15 per 1,000 patient-days, and the overallrate of infection due to VRE was 0.26 per 1,000 patient-days.

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infection control in a transplant cooperative care center 427

table 2. Pathogens Responsible for Bloodstream Infections inTransplant Patients in a Cooperative Care Center, June 1999 toDecember 2005

Pathogen

No. (%) of patients withpathogen isolated

HSCT(n p 81)

SOT(n p 26)

Gram-positive cocci 47 (58) 20 (77)Coagulase-negative

staphylococci 30 (37) 10 (38)Staphylococcus aureus 2 (4) 3 (12)Enterococcal species 3 (4) 4 (15)Other 12 (15) 3 (12)

Gram-negative bacilli 34 (42) 7 (27)Pseudomonas aeruginosa 8 (10) 2 (8)Klebsiella species 5 (6) 1 (4)Escherichia coli 3 (4) 3 (12)Other 18 (22) 1 (4)

Candida species 3 (4) 1 (4)Polymicrobial infection 7 (9) 6 (23)

note. Percentages do not add up to 100% because of polymicrobialinfections. HSCT, hematopoietic stem cell transplant; SOT, solid organtransplant.

All defined MRSA infections were BSIs, as were 80% of in-fections due to VRE.

Environmental Contamination

In January 1999, before the opening of the cooperative carecenter, samples of environmental surfaces in 29 rooms andother patient care areas were cultured for multidrug-resistantorganisms and C. difficile. No MRSA, VRE, or C. difficileorganisms were isolated. Air sampling revealed very fewspores of expected environmental fungi, except in 1 isolatedarea of the building. Whereas other areas of the building hadvery low levels or no aspergillus detected, on the east side ofseveral of the cooperative care floors, settling plates and quan-titative samples revealed excessive amounts of Aspergillus fu-migatus. In air from the contaminated areas, the spore countsranged from 7 cfu/m3 to too numerous to count. A thoroughinspection of the building in this area revealed a water leakassociated with one of the elevator shafts and obvious moldgrowth. Following repair of the leak and removal of contam-inated building material, a subsequent air-quality survey wasperformed, and the follow-up quantitative samples revealedonly low levels (!0.1 cfu/m3) of Aspergillus species. The co-operative care center was not designed to be a strict protectiveenvironment, and the small numbers of environmental fungiin the air samples were expected.

In September 1999, April 2000, and October 2000 (ie, 3,10, and 16 months after opening the cooperative care center,respectively), the environmental surveys were repeated. Thecultures were performed after routine cleaning of patientrooms and common areas. No isolates of MRSA or VRE wererecovered. Isolates of C. difficile was recovered from the bath-

room of 1 of the cooperative care suites in the October 2000survey. Air sampling continued to reveal small numbers ofexpected environmental fungi. The fungal species isolated, indescending order of frequency, were Cladosporium, Penicil-lium, and Alternaria. During the 3-month survey (September1999), only low concentrations of Aspergillus species isolateswere recovered (!0.1 cfu/m3); none were recovered duringthe 10- and 16-month surveys. No patient in the cooperativecare center had an invasive mold infection diagnosed duringthe 6.5 years of the study.

Patient and Care Partner Surveillance Cultures

Of the 185 patients admitted to the cooperative care programduring its first 8 months of operation, 45 (24%) were ableto give informed consent for nasal and rectal surveillancecultures. Unfortunately, only 21 (47%) of the 45 had culturesperformed at the time of discharge. Of the 185 care partnersadmitted during the same time of operation, 39 (21%) wereable to give informed consent for nasal and rectal surveillancecultures, and only 15 (38%) of the 39 had cultures performedat the time of discharge. None of the patients or care partnerswere found to harbor MRSA in the anterior nares at the timeof admission or discharge from cooperative care. Three(6.7%) of 45 patients had VRE isolates recovered from rectalcultures at the time of admission, and 6 (28.6%) of 21 patientswere colonized with VRE at the time of discharge. None ofthe 39 care partners harbored VRE at the time of admission,and 1 (6.7%) of the 15 exhibited VRE carriage at discharge.Two of the 6 care partners of the 6 VRE-colonized patientshad cultures performed at discharge. One of these care part-ners also had a VRE isolate recovered from the rectal swabsample. Molecular typing of all of the VRE isolates by pulsed-field gel electrophoresis revealed 5 distinct banding patterns.Interestingly, the isolates from the 1 colonized patient andcare partner pair were disparate. Also, 3 of the patients whohad VRE isolates recovered from rectal cultures at the timeof discharge had identical banding patterns (data not shown).

discussion

Cooperative care is an innovative means to provide healthcare to transplant patients and presents unique infection con-trol concerns. All of the patients are immunosuppressed byvirtue of their underlying disease, transplant procedure, and/or immunosuppressant medication regimen. However, thecooperative care facility was not designed as a strict protectiveenvironment, and patient rooms were not maintained underpositive air pressure or filtered with high-efficiency particulateair filters. In addition, almost all of the patients have a centralvenous catheter, thus placing them at risk for intravascularcatheter–associated infections. All patients are relatively mo-bile, and most are ambulatory.

The major difference between the acute care hospital andthe cooperative care facility is the presence of the care partneras the main provider of health care. The care partners are

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428 infection control and hospital epidemiology may 2008, vol. 29, no. 5

instructed in basic infection control precautions as part ofthe orientation process. Issues that are covered include handhygiene, respiratory etiquette, aseptic techniques, and care ofintravascular catheters and other devices. Access to profes-sional healthcare workers is provided at the treatment center,where patients can be examined and can receive infusions orundergo minor procedures. Because the care partners arehoused with the patients and because the patients are mobile,it was decided that traditional contact isolation precautionswere not practical on the cooperative care floors. However,a patient’s medical record is electronically flagged, and, whenthe patient is in the treatment center or the acute care hos-pital, appropriate isolation precautions are employed. In ad-dition, a sink for hand washing and a cabinet, stocked withgowns, gloves, and masks, located immediately inside thepatient living area, allow healthcare workers seeing a patientin the cooperative care room to utilize appropriate infectioncontrol measures. This system of education and applicationof infection control precautions for healthcare workers, pa-tients, and care partners appears to be acceptable.

Not unexpectedly, given the burden of intravascular de-vices, BSI was the most frequently observed healthcare-as-sociated infection in the cooperative care center. Althoughreliable data on intravascular catheter usage were not availableduring the time of the study, the central venous catheterutilization ratio (ie, the ratio of the number of central venouscatheter–days to the number of patient-days) in 2005 and2006 for patients in cooperative care was 0.94 (unpublisheddata). Because data on strict device utilization were not ini-tially available in the cooperative care center, direct compar-ison of infection rates between the inpatient units and co-operative care units was not possible. However, if recentutilization ratios are used to establish central venous catheter–days, the rate of BSI in the cooperative care area is comparableto the rate for inpatient transplant patients. In 2005, a sig-nificant increase in the rate of BSI was observed. This increasewas attributed to the introduction of a positive-displacementintravascular access valve, as reported elsewhere.9

Because MRSA and VRE have been problematic pathogensin transplant patients,10-13 we were very interested in assessingthe rate of colonization and infection by these pathogens.Although the sample size was small, we were surprised thatMRSA was not observed in any of the surveillance cultures.However, several issues should be kept in mind in interpretingthis observation. The study was largely performed at a timebefore community-acquired MRSA was widespread in ourlocality (unpublished data), and most of the patients werereceiving trimethoprim-sulfamethoxazole as part of their rou-tine posttransplantation prophylaxis. Although VRE was rel-atively frequently detected in the subset of patients who hadsurveillance cultures performed, it only rarely caused invasivedisease (0.26 infections per 1,000 patient-days). Interestingly,the 1 patient and care partner pair who were colonized withVRE harbored disparate strains. However, selection bias ispossible, because only 1 colony was subcultured from plates

for molecular-typing studies, and it is known that personscan be colonized with multiple strains of VRE.14,15 VRE wasnot recovered from environmental cultures, indicating thatroutine environmental cleaning with a low-level disinfectantwas adequate in the cooperative care setting. However, itshould be noted that environmental cultures were not spe-cifically targeted for rooms that had housed patients colonizedwith VRE. Lastly, the difficulty in getting patients and carepartners to consent to surveillance cultures was problematicand limited the usefulness of this portion of the study. Thisreluctance to consent to surveillance cultures may also haveimplications regarding the acceptance of recommendationsto perform widespread active surveillance cultures to combatthe spread of MRSA and VRE.16

Clostridium difficile–associated diarrhea was commonly ob-served in HSCT patients in cooperative care (3.97 cases per1,000 patient-days). Antibiotic therapy and chemotherapy arequite common in these patients and may at least partiallyexplain the incidence of C. difficile–associated diarrhea. C.difficile was recovered only rarely from environmental cul-tures, and bleach disinfection of the environment was notperformed in the cooperative care center.

The potential value of air sampling before the cooperativecare center opened was demonstrated, because preoccupancycultures clearly demonstrated the excessive presence of As-pergillus spores in a specific area of the cooperative care center.Since environmental exposure to Aspergillus spores is a knownrisk factor for the development of invasive aspergillosis, thiswas of obvious concern considering the immunosuppressednature of the patients to be housed in the cooperative carecenter.17 Because of the excessive fungal spore counts in theair at that location, a thorough inspection was performed,which identified a structural flaw resulting in a water leakand overgrowth of fungi. Had the air-quality assessment notbeen performed, the cooperative care patients may have beenexposed to a potentially lethal pathogen. However, the flawwas identified and fixed, and subsequent air samples revealedonly very low levels of Aspergillus spores (!0.1 cfu/m3). Nocooperative care patients with invasive aspergillosis were iden-tified during the 6.5-year study period.

In conclusion, we believe that cooperative care is an in-novative development in the provision of care to transplantpatients. Although this study documented that cooperativecare was associated with some risk of healthcare-associatedinfection, most notably intravascular catheter–associatedbloodstream infection and C. difficile–associated diarrhea, itappears the incidences of these infections were roughly com-mensurate with those in other care settings. It is notable thatthe relatively low rates of infection were achieved while al-lowing patients a remarkable level of freedom and provisionof daily care by nonprofessional care partners. In the future,we hope to introduce practices and protocols that will furtherdiminish the occurrence of catheter-associated bloodstreaminfections and C. difficile–associated diarrhea in patientshoused in the cooperative care center.

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infection control in a transplant cooperative care center 429

acknowledgments

We thank the staff of the Lied Cooperative Care Center for their assistance.We thank James R. Anderson, PhD, for assistance with biostatistical analysisof data.

Financial support. This work was partially supported by an institutionalgrant from the Clinical Research Center at the University of Nebraska MedicalCenter.

Potential conflicts of interest. All authors report no conflicts of interestrelevant to this study.

Address reprint requests to Mark E. Rupp, MD, 984031 Nebraska MedicalCenter, Omaha, NE 68198-4031 (merupp@unmc.edu).

Presented in part: 11th Annual Meeting of the Society for HealthcareEpidemiology of America; Toronto, Canada; April 1-3, 2001 (Abstract 202);17th Annual Meeting of the Society for Healthcare Epidemiology of America;Baltimore, Maryland; April 14-17, 2007 (Abstract 152).

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