Nursing and physician attire as possible

source of nosocomial infections

Yonit Wiener-Well, MD,a Margalit Galuty, RN, MSc,a,b Bernard Rudensky, PhD,c Yechiel Schlesinger, MD,a
Denise Attias, BSc,c and Amos M. Yinnon, MDa
Jerusalem, Israel

Background: Uniforms worn by medical and nursing staff are not usually considered important in the transmission of microor-
ganisms. We investigated the rate of potentially pathogenic bacteria present on uniforms worn by hospital staff, as well as the bac-
terial load of these microorganisms.
Methods: Cultures were obtained from uniforms of nurses and physicians by pressing standard blood agar plates at the abdominal
zone, sleeve ends, and pockets. Each participant completed a questionnaire.
Results: A total of 238 samples were collected from 135 personnel, including 75 nurses (55%) and 60 physicians (45%). Of these,
79 (58%) claimed to change their uniform every day, and 104 (77%) defined the level of hygiene of their attire as fair to excellent.
Potentially pathogenic bacteria were isolated from at least one site of the uniforms of 85 participants (63%) and were isolated from
119 samples (50%); 21 (14%) of the samples from nurses’ gowns and 6 (6%) of the samples from physicians’ gowns (P 5 NS)
included of antibiotic-resistant bacteria.
Conclusion: Up to 60% of hospital staff’s uniforms are colonized with potentially pathogenic bacteria, including drug-resistant or-
ganisms. It remains to be determined whether these bacteria can be transferred to patients and cause clinically relevant infection.
Key Words: Uniform; attire; pathogenic bacteria; nosocomial infection.
Copyright ª 2011 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights
reserved. (Am J Infect Control 2011;39:555-9.)

Several studies have demonstrated bacterial con-
tamination of the uniforms and clothing of health
care workers (HCWs) during patient care activities.1-4
Physicians’ white coats2,5 and ties,6,7 medical students’
coats,4 and nurses’ uniforms1,3 have all been shown to
be colonized with pathogenic organisms and thus may
be a potential source of cross-infection. The maximal
contamination occurs in areas of greatest hand contact
(ie, pockets and cuffs), allowing recontamination of
already washed hands.1,2,4
With the increasing prevalence of multidrug-
resistant bacteria in hospital settings, investigating
the role of environmental factors, including staff attire,
in the spread of infection is important.8 The medical
departments of our hospital, like those of many others,
From the Infectious Disease Unit,a Shaare Zedek Nursing School,b and
Clinical Microbiology Laboratory,c Shaare Zedek Medical Center,
Hebrew University‒Hadassah Medical School, Jerusalem, Israel.
Address correspondence to Yonit Wiener-Well, MD, Infectious Disease
Unit, Shaare Zedek Medical Center, PO Box 3235, Jerusalem 91301,
Israel. E-mail: yonitw@zahav.net.il.
Presented as an abstract at the 48th Interscience Conference on Anti-
microbial Agents and Chemotherapy, Washington, DC, October 25-28,
2008.
Conflict of interest: None to report.
0196-6553/$36.00
Copyright ª 2011 by the Association for Professionals in Infection
Control and Epidemiology, Inc. Published by Elsevier Inc. All rights
reserved.
doi:10.1016/j.ajic.2010.12.016
admit many elderly patients, including many from
nursing homes.9,10 This patient population has a signif-
icant rate of colonization with resistant bacteria on ad-
mission to the hospital, which increases during
hospitalization.11,12 Despite continuing efforts to im-
prove infection control measures, HCWs may uninten-
tionally carry bacteria on their attire, including nurses’
uniforms and physicians’ white coats. Nevertheless,
few organizations have made recommendations for
provision and exchange of HCWs’ clothing.13
We assessed the rate of contamination of uniforms
with potentially pathogenic bacteria, comparing attire
worn by nurses and physicians, and semiquantitatively
determined the bacterial load on uniforms.
METHODS
Setting
The study was conducted in a 550-bed, university-
affiliated hospital, Jerusalem’s second largest. The Divi-
sion of Internal Medicine consists of 5 departments,
and the surgical wing includes a general surgery de-
partment and departments for orthopedics, obstetrics,
urology, otorrhinolaryngology, ophthalmology, plastic
surgery, and cardiac surgery.
Enrolled staff
A total of 135 physicians and nurses from the med-
ical and surgical wings were included in this study. We
used a convenience sample, including all subjects on

555
556 Wiener-Well et al.
duty at the time of sampling. Less than 5% of the staff
refused to take part in this study. Each participant com-
pleted a questionnaire with items evaluating how long
the participant had been wearing his or her current at-
tire, how frequently he or she changes attire, and how
he or she would rate the attire’s level of hygiene.
Definition of uniforms
Physicians wear long-sleeved white coats on top of
their own clothes; each individual determines the fre-
quency of coat changes. Nurses wear 2-piece uniforms,
which they change daily. Operating room 2-piece scrub
suits are used by physicians and nurses, and are changed
daily. All uniforms are provided by the hospital.
Sampling
Individual impressions were taken from different
sites of white coat or uniforms, using 9 cm2 plates con-
taining 5% tryptic soy blood agar pressed for 10 sec-
onds, as described previously.2,4 All participants were
sampled on the mid-abdominal zone, at umbilical
height. The second sampling site was either the termi-
nal portion of sleeves or, for a short-sleeved uniform,
the side pockets. The dominant side of the participant
was chosen for sampling of sleeve ends and pockets.
Each participant was sampled at 2 areas, except for
staff wearing operating room scrub suits, which were
sampled only at the abdominal site, because these suits
do not have long sleeves or pockets.
As a control, we cultured 4 randomly chosen uni-
forms immediately on receipt from the hospital laun-
dry and before use.
Microbiological evaluation
Plates were incubated for 48 hours at 358C and
then examined for total colony count. Organisms
were Gram-stained and identified by standard microbi-
ological methods. Antibiotic sensitivity was tested on
Iso-sensitest agar by the Kirby-Bauer disc-diffusion
method. Staphylococci were identified as Staphylococ-
cus aureus using Pastorex Staph-Plus (Bio-Rad, Marnes-
la-Coquette, France), and methicillin resistance was
determined by growth on Mueller-Hinton agar contain-
ing 4% sodium chloride and 6 mg/mL of oxacillin.
Vancomycin-resistant enterococci were identified by
growth on enterococcal agar (BD Microbiology Sys-
tems, Sparks, Maryland), containing 6 mg/mL of vanco-
mycin and by analysis with Etest (AB Biodisk, Solna,
Sweden). Extended-spectrum b-lactamase producing
Enterobacteriaceae were isolated using MacConkey
agar containing 2 mg/mL of ceftazidime and brain
heart infusion broth containing 2 mg/mL of ceftazidime,
American Journal of Infection Control
September 2011
and confirmed by the double-disc method.14,15 Gram-
negative bacteria were identified using the API Kit
(bioMerieux, Marcy l’Etiole, France).
Definition of bacteria
The recovered bacteria were classified into 2 groups:
(1) nonpathogenic skin flora, including coagulase-
negative staphylococci, Bacillus spp, Micrococcus spp,
diphtheroids, lactose-nonfermenting gram-negative
bacilli (except for Pseudomonas and Acinetobacter)
and Streptococcus viridians, and (2) pathogenic bacte-
ria, including S aureus, Enterobacteriaceae, Pseudomo-
nas, and Acinetobacter spp.
Resistant pathogenic bacteria were defined as
methicillin-resistant S aureus (MRSA); vancomycin-
resistant Enterococcus; extended spectrum b-lactamase–
producing Enterobacteriaceae; Pseudomonas resistant to
gentamicin, ciprofloxacin, and ceftazidime; and Acineto-
bacter resistant to meropenem.
Statistical analysis
All statistical analyses were done using the x2 test for
dichotomous variables and the Mann-Whitney U test
for continuous variables. A P value ,.05 was consid-
ered to indicate statistical significance.
RESULTS
A total of 238 samples were obtained from 135 per-
sonnel, including 60 (45%) physicians and 75 (55%)
nurses. Of the participants, 85 (63%) were female, 88
(65%) were age .30 years, and 73 (54%) had .5 years
of working experience. Sixty percent worked in surgical
departments and 40% worked in medical departments.
Seventy-nine participants (58%) reported changing his
or her uniform every day, and 104 (77%) rated his or
her uniform as moderately clean to very clean (Table 1).
Nonpathogenic skin bacteria were isolated and iden-
tified from all gown cultures (100%), but these data are
not reported here. These contaminants included
coagulase-negative staphylococci (in 50% of samples),
Bacillus spp (20%), Micrococcus (18%), diphtheroids,
lactose-nonfermenting gram-negative bacilli (exclud-
ing Pseudomonas and Acinetobacter), Streptococcus
viridans, and others.
Of the 238 samples obtained, 119 (50%) were posi-
tive for any pathogen, most with one pathogen (94 cul-
tures; 79% of the positive cultures) and fewer with 2 or
3 different pathogens (21 [18%] and 4 [3%] of the pos-
itive cultures, respectively). There were no significant
differences between physicians and nurses. Potentially
pathogenic bacteria were isolated from at least one site
of the gowns in 85 of the 135 participants (63%), 49
www.ajicjournal.org Wiener-Well et al. 557
Vol. 39 No. 7

Table 1. Risk factors and distribution of different pathogens isolated from attire cultures (n 5 238)
Cultures with
Cultures with Acinetobacter, S aureus, Enterobacteriaceae, Pseudomonas, resistant
Variable (n) pathogens, n (%)* n (%) n (%) n (%) n (%) pathogens, n (%)y

Profession
Physicians (60) 44 (48) 29 (31) 17 (18) 7 (8) 3 (3) 6 (6)
Nurses (75) 75 (51) 60 (41) 15 (10) 11(8) 5 (3) 21 (14)
Sex
Female (85) 83 (51) 60 (37) 19 (12) 16 (10) 6 (4) 17 (10)
Male (50) 36 (48) 29 (39) 13 (17) 2 (3) 2 (3) 10 (13)
Wing
Surgery (81) 62 (46) 51 (38) 12 (9) 7 (5) 7 (5) 11 (8)
Internal medicine (54) 57 (55) 38 (37) 20 (19) 11 (11) 1 (1) 16 (15)
Age, years
#30 (47) 33 (39) 25 (29) 9 (11) 4 (5) 0 (0) 8 (9)
31-40 (48) 46 (53) 32 (37) 15 (17) 8 (9) 3 (3) 12 (14)
41-50 (30) 32 (64) 25 (50) 6 (12) 5 (10) 5 (10) 7 (14)
$51 (10) 8 (47) 7 (41) 2 (12) 1 (6) 0 (0) 0 (0)
Seniority, years
#5 (62) 51 (47) 38 (35) 14 (13) 8 (7) 3 (3) 12 (11)
6-10 (23) 19 (45) 14 (33) 9 (21) 2 (5) 0 (0) 5 (12)
11-20 (32) 31 (52) 23 (38) 4 (2) 6 (10) 4 (7) 7 (12)
$21 (18) 18 (67) 14 (52) 5 (19) 2 (7) 1 (4) 3 (11)
Type of attire
White coat (26) 28 (54) 17 (32) 10 (19) 4 (8) 1 (2) 3 (6)
Uniforms (77) 75 (49) 58 (38) 18 (12) 13 (8) 5 (3) 21 (14)
Operating room uniforms (32) 16 (50) 14 (43) 4 (13) 1 (3) 2 (6) 3 (9)
Frequency of attire changes, days
1 (79) 58 (46) 44 (35) 15 (12) 8 (6) 6 (5) 10 (8)x
2 (20) 27 (66) 23 (56) 5 (12) 5 (12) 1 (2) 12 (29)x
3 (12) 9 (44) 7 (32) 2 (9) 1 (5) 1 (5) 2 (9)
4-7 (19) 18 (47) 9 (24) 8 (21) 4 (11) 0 (0) 2 (5)
$8 (5) 7 (70) 6 (60) 2 (20) 0 (0) 0 (0) 1 (10)
Cleanliness of attirez
Clean (51) 40 (45) 32 (36) 13 (15) 5 (6) 2 (2) 13 (14)
Moderate (53) 51 (55) 34 (37) 12 (13) 11 (12) 5 (5) 6 (7)
Not clean (31) 28 (48) 23 (40) 7 (12) 2 (3) 1 (2) 4 (14)
Sample site
Abdomen (135) 68 (50) 55 (41) 15 (11) 10 (7) 5 (4) 11 (8)
Sleeve (21) 10 (48) 6 (29) 4 (19) 2 (10) 0 (0) 2 (10)
Pocket (82) 41 (50) 28 (34) 13 (16) 6 (7) 3 (4) 14 (17)
*Number of cultures with pathogens is lower than the sum of 4 pathogens due to more than one pathogen in some of the cultures.
y
Definition of resistant pathogen: see Materials and Methods.
z
As defined by the owner of the attire.
x
P , .05 for the difference between changing attire daily and every other day.

from nurses (65% of participating nurses) and 36 from
physicians (60% of participating physicians).
We assessed various demographic and clinical risk
factors for isolation of any pathogen or resistant path-
ogen from gown cultures and found no significant risk
factors for isolation of any pathogen from gown cul-
tures (Table 1). The rate of contamination with resistant
pathogens was higher in attire changed every 2 days
compared with that changed every day (29% vs 8%;
P , .05), in cultures from nurses’ uniforms compared
with physicians’ uniforms (14% vs 6%), in male per-
sonnel compared with female personnel (13% vs
10%), in medical departments compared with surgical
departments (15% vs 8%), in uniforms worn in the
departments compared with operating room scrub
suits (14% vs 9%), and on pockets compared with ab-
dominal zones and sleeve ends (17% vs 8% and 10%,
respectively). The frequency of attire changes attire
was the only risk factor that reached statistical signifi-
cance. No correlation was found between the rate of
cultures positive for resistant pathogens and the per-
sonnels’ age, seniority, or rating of their attire’s
cleanliness.
Isolated pathogenic bacteria were divided into
4 groups; their distribution is given in Table 2. Acineto-
bacter spp were the most common isolated pathogenic
bacteria (89/238 cultures; 37%), followed by S aureus
(32/238 cultures; 13%), Enterobacteriaceae (18/238
558 Wiener-Well et al. American Journal of Infection Control
September 2011

cultures; 8%), and Pseudomonas (8/238 cultures; 3%). Table 2. Bacterial load of different pathogens isolated
The highest mean bacterial load (number of colony- from gown cultures (n 5 147)
forming units [CFU] per culture plate) was found for
Colonies/plate,
S aureus (14 6 18 CFU), with a higher load for MRSA Bacteria (number of isolates) mean 6 SD (range)
than for methicillin-sensitive S aureus (21 6 28 CFU
vs 11 6 13 CFU) (Table 2). Acinetobacter (89) 4 6 6 (1-36)
Only common skin bacteria were isolated from the A baumannii (31) 4 6 8 (1-36)
A lwoffi (58) 4 6 4 (1-18)
control sample of 4 uniforms cultured immediately af- Staphylococcus aureus (32) 14 6 18 (1-80)
ter receipt from the hospital laundry but before use. Methicillin-sensitive S aureus (24) 11 6 13 (1-62)
Bacterial loads were significantly lower than on the MRSA (8) 21 6 28 (2-80)
uniforms being worn. Enterobacteriaceae (18) 5 6 8 (1-33)
Enterobacter cloacae (7) 4 6 5 (1-14)
Klebsiella pneumoniae (6) 9 6 12 (1-33)
DISCUSSION Klebsiella oxytoca (2) 1 (1-1)
Citrobacter freundii (1) 2
The role of HCWs’ attire in the transmission of bacteria Escherichia coli (1) 2
and development of nosocomial infections is not clear. Pantoea agglomerans (1) 1
Several studies found frequent contamination of nurses’ Pseudomonas (8) 3 6 2 (1-6)
P stutzeri (4) 2 6 2 (1-4)
uniforms16 and transmission of bacteria through the P putida (2) 5 6 1 (4-6)
textile of uniforms,17 with varying efficiencies of fabrics P aeruginosa (1) 3
used as barriers for bacterial transfer.18,19 One study con- P fluorescens (1) 2
ducted in a burn unit demonstrated the possibility of
transferring S aureus from nurses’ gowns to patients
and bed sheets,20 and covering up with plastic aprons
was found to more effectively prevent cloth-borne to be determined. S aureus, especially MRSA, was asso-
cross-contamination between burn patients compared ciated with higher bacterial load compared with other
with a plastic isolation tent.21 pathogenic bacteria evaluated in the present study as
Other studies have reported conflicting findings re- well as compared with results of a previous study.2
garding the role of HCWs’ attire in transmission of bac- Quite likely, the more significant the pathogenic bacte-
teria. Tammelin et al22 investigated the possibility of rial load, the more efficient the transmission from
reducing wound contamination during cardiothoracic HCWs’ uniforms to patients. We did not culture for na-
surgery through the use of special scrub suits. The sal or throat carriage of S aureus, but previous stud-
use of tightly woven scrub suits did not reduce the air ies2,16 found that only 20%-35% of S aureus isolates
count or wound contamination with methicillin- from coats had the same phage type as those cultured
resistant Staphylococcus epidermidis. Patients’ chest from the subjects’ noses. These data suggest that per-
skin was the main source of wound contamination. sonnel attire may be one route by which pathogenic
We found that HCWs’ coats and uniforms were fre- bacteria are transmitted to patients. In contrast to a pre-
quently contaminated with potentially pathogenic bac- vious study,4 the staff’s perception of their attire’s
teria; 85 of 135 uniforms (63%) and 50% of all samples cleanliness did not correlate with isolation of patho-
(238) were positive for pathogenic organisms, 11% of genic bacteria.
which were multidrug-resistant. Our data show a This study has several limitations. First, the fre-
higher incidence of contaminated uniforms than re- quency with which HCWs changed their uniforms
ported previously;1,2,4 however, some of the previous was only estimated, and we could not determine the
studies cultured only for S aureus on coats or included exact number of days that each item had been used be-
medical students and not nurses or physicians. An- fore sampling. Second, our control sample comprised
other study reported a similar high incidence (54%) only 4 clean uniforms obtained directly from the hos-
of pathogenic and even resistant bacteria, including pital laundry. We did not examine all uniforms after
vancomycin-resistant enterococci, MRSA, and Clostrid- laundering and before work, and thus the efficiency
ium difficile.3 of the laundry was only partially assessed. Third, our
The high prevalence of contaminated uniforms hospital supplies laundry service to approximately
might be related to inadequate compliance with hand 60% of its staff, whereas the remainder choose to use
hygiene, given that the sampled sites (ie, abdominal domestic laundry. Our participants were not asked
zone, sleeve ends, and pockets on the dominant side) whether they used the hospital service or washed their
are characterized by frequent hand touches. Whether uniforms at home. Concern has been expressed that
high compliance with hand hygiene practices is associ- domestic washing machines do not provide sufficient
ated with reduced bacterial load on uniforms remains decontamination of staff clothing; however, a recently
www.ajicjournal.org
Vol. 39 No. 7
published review suggests that they may be ade-
quate.23 Finally, there could have been a selection
bias, due to the fact that personnel were chosen by con-
venience, although ,5% refused to participate. A
larger study, including all physicians and nurses from
all departments, could have been more representative.
In summary, we isolated potentially pathogenic bac-
teria from 63% of sampled uniforms, with no signifi-
cant differences between nurses and physicians or
between staff from medical departments and surgical
departments. Antibiotic-resistant bacteria were isolated
from samples from 14% of nurses’ uniforms and 6% of
physicians’ uniforms. Whether HCWs’ clothes play a
major role in the transmission of pathogens to patients
and development of nosocomial infections is not clear.
Nonetheless, we believe that data suffice to formulate
recommendations regarding HCWs’ uniforms. Wearing
a clean uniform daily, providing adequate laundering,
improving hand hygiene practices, and using plastic
aprons when performing tasks that may involve
splashing or contact with body fluids likely will de-
crease the bacterial load on uniforms. Wearing short-
sleeved coats or even having physicians discard their
white coats could further reduce the cloth-borne trans-
mission of pathogens.
References
1. Babb JR, Davies JG, Ayliffe GAJ. Contamination of protective clothing
and nurses’ uniforms in an isolation ward. J Hosp Infect 1983;4:149-57.
2. Wong D, Nye K, Hollis P. Microbial flora on doctors’ white coats. BMJ
1991;303:1602-4.
3. Perry C, Marshall R, Jones E. Bacterial contamination of uniforms. J
Hosp Infect 2001;48:238-41.
4. Loh W, Ng VV, Holton J. Bacterial flora on the white coats of medical
students. J Hosp Infect 2000;45:65-8.
5. Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich
EN. Bacterial contamination of health care workers’ white coats. Am J
Infect Control 2009;37:101-5.
6. Biljan MM, Hart CA, Sunderland D, Manasse PR, Kingsland CR. Multi-
centre randomized double-blind crossover trial on contamination of
conventional ties and bow ties in routine obstetric and gynaecological
practice. BMJ 1993;307:1582-4.
7. Lopez PJ, Ron O, Parthasarathy P, Soothill J, Spitz L. Bacterial counts
from hospital doctors’ ties are higher than those from shirts. Am J In-
fect Control 2009;37:79-80.
Wiener-Well et al. 559
8. Zachary KC, Bayne PS, Morrison VJ, Ford DS, Silver LC, Hooper DC.
Contamination of gowns, gloves, and stethoscopes with vancomycin-
resistant enterococci. Infect Control Hosp Epidemiol 2001;22:560-4.
9. Raveh D, Gratch L, Yinnon AM, Sonnenblick M. Demographic and clin-
ical characteristics of patients admitted to medical departments. J Eval
Clin Pract 2005;11:33-44.
10. Sonnenblick M, Raveh D, Gratch L, Yinnon AM. Clinical and demo-
graphic characteristics of elderly patients hospitalized in an internal
medicine department in Israel. Int J Clin Pract 2007;61:247-54.
11. Benenson S, Yinnon AM, Schlesinger Y, Rudensky B, Raveh D. Optimi-
zation of empirical antibiotic selection for suspected Gram-negative
bacteremia in the emergency department. Int J Antimicrob Agent
2005;25:398-403.
12. Friedmann R, Raveh D, Zartzer E, Rudensky B, Broide E, Attias D,
et al. Prospective evaluation of colonization with extended-spectrum
b-lactamase (ESBL)-producing Enterobacteriaceae among patients at
hospital admission and of subsequent colonization with ESBL-
producing Enterobacteriaceae among patients during hospitalization.
Infect Control Hosp Epidemiol 2009;30:534-42.
13. British Medical Association. Uniform and dress code for doctors: guid-
ance from the central consultants and specialists committee. London:
British Medical Association; 2008.
14. Clinical and Laboratory Standards Institute. Performance standards
for antimicrobial susceptibility testing: 16th informational supplement.
Wayne (PA): Clinical and Laboratory Standards Institute; 2006. p. 37.
15. Carter MW, Oakton KJ, Warner M, Livermore DM. Detection of
extended-spectrum b-lactamases in Klebsiellae with the Oxoid combi-
nation disc method. J Clin Microbiol 2000;38:4228-32.
16. Speers R Jr, Shooter RA, Gaya H, Patel N, Hewitt JH. Contamination
of nurses’ uniforms with Staphylococcus aureus. Lancet 1969;2:233-5.
17. Hambraeus A, Ransjo U. An instrument for measuring bacterial pene-
tration through fabrics used for barrier clothing. J Hyg 1979;82:361-86.
18. Hambraeus A, Ransjo U. Attempts to control clothes-borne infections
in burn units, I: experimental investigations of some clothes for barrier
nursing. J Hyg 1977;79:193-202.
19. Lankester BJA, Bartlett GE, Garneti N, Blom AW, Bowker KE,
Bannister GC. Direct measurement of bacterial penetration through
surgical gowns: a new method. J Hosp Infect 2002;50:281-5.
20. Hambraeus A. Transfer of Staphylococcus aureus via nurses’ uniforms.
J Hyg 1973;71:799-814.
21. Ransjo U. Attempts to control clothes-borne infections in burn units,
III: an open-roofed plastic isolator or plastic aprons to prevent contact
transfer of bacteria. J Hyg 1979;82:385-95.
22. Tammelin A, Hambraus A, Stahle E. Source and route of methicillin-
resistant Staphylococcus epidermidis transmitted to the surgical wound
during cardio-thoracic surgery: possibility of preventing wound con-
tamination by use of special scrub suits. J Hosp Infect 2001;47:266-76.
23. Wilsom JA, Loveday HP, Hoffman PN, Pratt RJ. Uniform: an evidence
review of the microbiological significance of uniforms and uniform pol-
icy in the prevention and control of healthcare-associated infections.
Report to the Department of Health (England). J Hosp Infect 2007;
66:301-7.