Patient isolation measures for infants with candida colonization or infection for preventing or reducing transmission of candida in neonatal units

Mohan P, Eddama O, Weisman LE

Background - Methods - Results - References


Dates

Date edited: 23/05/2007
Date of last substantive update: 01/03/2007
Date of last minor update: / /
Date next stage expected 22/05/2009
Protocol first published: Issue 3, 2006
Review first published: Issue 3, 2007

Contact reviewer

Dr. Pammi Mohan, MD, DCh, MRCPCH
Assistant Professor
Pediatrics, Section of Neonataology
Baylor College of Medicine
6621, Fannin, MC.WT 6-104
Houston
Texas USA
77030
Telephone 1: 001 832 826 1380
Telephone 2: 001-713-795-9230
Facsimile: 001 832 825 2799
E-mail: mohanv@bcm.tmc.edu
Secondary address (home):
2250, Holly Hall street
Apt # 126
Houston
Texas USA
77054
Telephone: 001-713-795-9230

Contribution of reviewers

Dr. Mohan reviewed the literature, wrote the protocol, searched for studies, reviewed studies and completed the review.

Dr. Weisman assisted in the preparation of the protocol, reviewed studies and assisted in the writing of the review.

Mr. Eddama commented on and assisted with the health economics content of the review.

Internal sources of support

None

External sources of support

None

What's new

Dates

Date review re-formatted: / /
Date new studies sought but none found: / /
Date new studies found but not yet included/excluded: / /
Date new studies found and included/excluded: / /
Date reviewers' conclusions section amended: / /
Date comment/criticism added: / /
Date response to comment/criticisms added: / /

Text of review

Synopsis


Fungal infection with Candida has become increasingly common in the neonatal intensive care unit. Candida infection causes many deaths and significantly increases health care costs. Candida spreads among babies by contact, generally by health care staff and sometimes by family members. In addition to routine steps to control infection, keeping babies who have candida in separate rooms (single room isolation) or cared for together (cohorting) may help to stop the spread of candida. In this review, the authors sought studies that evaluated these measures, but could not find any. Therefore, the authors recommend that appropriate studies be performed in the future to answer this important question that may save lives and costs.

Abstract



Background


Candida is one of the most common nosocomial infections in the intensive care setting worldwide and is associated with increased healthcare costs. In neonates, candida infection is associated with high mortality and morbidity. Candida is transmitted by direct and indirect contact. Routine infection control measures that include standard precautions are routinely employed to prevent spread of nosocomial infections. Patient isolation measures, i.e. single room isolation or cohorting, are usually recommended for infections spread by contact.

Objectives


To determine the effect of patient isolation measures (single room isolation and/or cohorting) for infants with candida colonization or infection as an adjunct to routine infection control measures on the transmission of candida to other infants in the neonatal unit.

Search strategy


Relevant trials in any language were searched in the following databases in Jan 2007: The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2006), MEDLINE (1966 - Jan 2007) and PREMEDLINE, EMBASE (1980 - Jan 2007), CINAHL (1982 - Jan 2007). Proceedings of the Pediatric Academic Societies (American Pediatric Society, Society for Pediatric Research) and the European Society for Pediatric Research (1987 - Jan 2007) were also searched in Jan 2007. Authors or other experts were contacted for more information on relevant published or unpublished trials. Additional searches were also made in the reference lists of relevant journal articles and in the reviewer's personal files.

Selection criteria


Types of studies: Cluster randomized trials (where clusters may be defined by hospital, ward, or other subunits of the hospital).
Types of participants: Neonatal units caring for infants colonized or infected with candida.
Types of interventions: A policy of patient isolation measures (single room isolation or cohorting of infants with candida colonization or infection) compared to routine isolation measures.

Data collection & analysis


The standard methods of the Cochrane Neonatal Review Group (CNRG) were to be used to identify studies and to assess the methodological quality of eligible trials. The statistical package (RevMan 4.2) provided by the Cochrane Collaboration was to be used. In cluster-randomized trials, if the unit of analysis of the trial was the cluster (not individuals) and analysis took into account the correlation between clusters, the inverse variance method was to be used for meta-analysis. If this was not the case, a narrative synthesis was to be made without meta-analysis. Infection rates and colonization rates were to be expressed as rate ratios for each trial and if appropriate for meta-analysis, the generic inverse variance method in RevMan was to be used.

Main results


No eligible trials were identified.

Reviewers' conclusions


The review found no evidence to either support or refute the use of patient isolation measures (single room isolation or cohorting) in neonates with candida colonization or infection.

Despite the evidence for transmission of candida by direct or indirect contact and evidence of cross-infection by health care workers, no standard policy of patient isolation measures beyond routine infection control measures exists in the neonatal unit. There is an urgent need to research the role of patient isolation measures for preventing transmission of candida in the neonatal unit. Cluster randomized trials involving multiple units or hospitals with randomized allocation of one type of patient isolation measure or the other (i.e. single room isolation or cohorting) with careful consideration for determining an appropriate sample size and analysis would be the most appropriate method to research this intervention.

Background


Candida has emerged as a common cause of infection in neonates (Beck-Sague 1993). In very low birth weight (VLBW, birth weight < 1500 g) infants, Candida albicans is the third most common cause (5.8%) of first episodes of late onset sepsis (LOS) (defined as sepsis after the first 72 hours of life) (Stoll 2002). The incidence of infections due to Candida varies inversely with the gestational age and birth weight (Stoll 2002; Saiman 2000). Candida infection is seen in 2.6% to 12.9% of VLBW infants (Baley 1984; Faix 1989; Saiman 2000) and 5.5% to 20% of ELBW infants (extremely low birth weight infants, birth weight < 1000 g) (Kaufman 2001; Saiman 2000). Although Candida albicans is the major Candida species isolated from neonates, infection with other species such as C. parapsilosis, C. tropicalis and fluconazole resistant C. glabrata is also increasing (Faix 1992; Kossoff 1998; Fairchild 2002). In a multicenter cohort study of 2847 infants, overall mortality in infants with candidemia was 22.9% (Saiman 2001). Systemic candidiasis is associated with an increase in hospital stay and duration of mechanical ventilation (Makhoul 2001). Candida infection and colonization is associated with significant health care costs, which are due to increased length of hospital stay, costs of antifungal therapy and associated co-morbidities (Miller 2001; Olaechea 2004).

Infection with candida can manifest as mucocutaneous or systemic candidiasis. Mucocutaneous candidiasis (MCC) may be defined as candidal infection of the skin and mucous membranes. MCC includes oral thrush, diaper dermatitis, congenital candidiasis and invasive fungal dermatitis that has the potential to spread into the blood or other tissues (Rowen 2003). Colonization can be defined as the presence of a microorganism in or on a host with growth and multiplication, but without any overt clinical expression or detected immune response in the host at the time the microorganism is isolated (Jarvis 1996). Use of third generation cephalosporins, central venous catheters, intravenous lipids and H2 receptor antagonists (ranitidine) are risk factors for C. albicans colonization, whereas delivery by cesarean section is protective (Saiman 2001). In a prospective study of 146 VLBW infants, fungal colonization was noted to be 26.7%; of those colonized; 28% developed mucocutaneous candidiasis and 7.7% developed systemic candidiasis (Baley 1986). Colonization has been noted to precede invasive fungal infection in neonates (Huang 1998; Baley 1986).

Transmission:
Transmission of C. albicans vertically from mother to the infant (Waggoner-Fountain 96) and nosocomial transmission of both albicans and non-albicans species of Candida has been documented (Pfaller 1998a; Pfaller 1998b). In addition to the endemic prevalence of Candida colonization and infection, epidemics or outbreaks with a single strain or multiple strains may be associated with clusters of infection in the neonatal unit (Khatib 1998). Health care staff may harbor Candida and be a source of infection. In one study of 2989 cultures from health care workers' hands, 5% were positive for C. albicans and 19% for C. parapsilosis (Saiman 2001). C. albicans and C. parapsilosis have been shown to survive on glass (three days), stainless steel (14 days), fabrics (14 days) and finger pads of volunteers (20% of C. albicans remained detectable one hour post-inoculation) for sufficient duration to cause cross infection (Traore 2002). Cross infection by health care workers causing outbreaks of C. albicans (Burnie 1985; Dorko 2001), C. parapsilosis (Huang 1999), C. tropicalis (Finkelstein 1993) and C. lusitaniae (Fowler 1998) have been reported.

Infection control measures:
Infection control measures routinely employed in the neonatal unit include handwashing, using 'standard precautions' with all patient contact, caring for catheters in a manner that minimizes the risk of catheter contamination, optimizing nurse-patient ratios, avoiding overcrowding, and performing continuous monitoring and surveillance for nosocomial infection (Adams-Chapman 2002). The Center for Disease Control (CDC) recommends the use of 'standard precautions' consistently in all patients (Garner 1996b), which should be undertaken for blood, all body fluids, secretions and excretions, non-intact skin and mucous membranes. These precautions include handwashing, and the use of gloves, masks, gowns, eye and face shields. Unlike bacterial nosocomial infections, the efficacy of handwashing in the prevention of Candida transmission in the neonatal unit is not proven. In a study evaluating the efficacy of antiseptic soaps for handwashing in vitro against Candida species, germicidal chlorine with 5.25% sodium hypochlorite (Clorox), 4% chlorhexidene gluconate in alcohol (Hibiclens) and 10% povidone-iodine (Clinidine) were found to be effective but 3% para-meta-chloro-xylenol (Ultradex) was not (Silverman 1999). Use of alcohol based hand sanitizer was found to be as effective as conventional handwashing and induced better compliance in healthcare workers (Larson 2005; Ng 2004; Boyce 2002). In a systematic review evaluating the evidence for gowning in neonatal units, gowning was shown to have no effect on the incidence of systemic nosocomial infections, incidence of colonization or length of stay in the hospital (Webster 2003). The efficacy of each of the routine infection control measures alone is difficult to estimate, but an integrated approach that combines routine infection control measures with education and training of health care staff has been very effective in reducing neonatal nosocomial infections (Schelonka 2006; Horbar 2004).

Isolation and or cohorting may be effective in controlling nosocomial infections (Gastmeier 2004). It is clear that candida can be spread from patient to patient. Protective isolation by wearing gloves and gowns reduces nosocomial bacterial and fungal colonization, as well as the rate of infection in the Pediatric Intensive Care Unit (PICU) (Klein 1989). CDC guidelines recommend single room isolation for infections transmitted by contact (either directly or indirectly via equipment or other surfaces)(Garner 1996a; Garner 1996b). However, Neonatal Intensive Care Units (NICU) are often faced with lack of isolation rooms and/or health care personnel devoted to the care of babies in these isolation rooms. Isolation requirements may depend on factors including severity of illness in the infant, available resources and the transmissibility of the infection. Guidelines of the American Academy of Pediatrics (AAP) state that it may be unnecessary to isolate a neonate (except in the case of neonatal varicella-zoster or epidemic of bacterial infection) under the following conditions:
i) there is sufficient medical and nursing staff on duty
ii) sufficient space between stations
iii) two or more sinks for handwashing available in each nursery area
iv) continuing instruction is provided regarding the way infections spread (AAP 2002)

Cohorting is the physical segregation of infants in separate areas where newborns with similar exposures, colonization, or infections are cared for. Care is usually provided by designated staff assigned exclusively to these infants. Cohorting infants colonized or infected with pathogens that are transmissible by contact may be useful in controlling or reducing horizontal transmission of infection or colonization. Cohorting may be more feasible than single room isolation during outbreaks in the NICU setting. Cohorting does not require isolation rooms and may reduce resource utilization compared to single room isolation. However, the success of this system depends on the strict adherence of the health care staff to the cohort system (AAP 2002).

Isolation measures are extensively followed for infections and colonizations with methicillin resistant Staphylococcus aureus (MRSA) and vancomycin resistant enterococcus. Though generally thought to be effective, evidence from randomized controlled trials evaluating single room isolation and cohorting for MRSA colonization and infection is lacking. In a systematic review of isolation policies for MRSA colonization and infection, no randomized trials were identified (Cooper 2004). The prospective trials that were identified were of poor design with major confounding variables. Definite conclusions regarding the efficacy of isolation measures could not be drawn from this review. In a prospective, interrupted time-series study involving two centers, isolation of MRSA colonized patients in single rooms or cohorted bays in adult intensive care units did not reduce cross-infection (Cepeda 2005). However, a cluster-randomized trial would be the best means to evaluate the efficacy of patient isolation measures to prevent or reduce cross-infection.

The implications of the spread of candida infections in the neonatal unit, especially to VLBW and ELBW infants, are enormous. However, infection control measures can be expensive and consume valuable resources. It is not known whether the additional costs of these measures are worth the benefits in terms of reduction in the transmission of candida in the neonatal unit. There is a need for economic evaluation of infection control measures in the present cost conscious health care environment (Saint 2001; Drummond 1991). The effect of single room isolation or cohorting of candida colonized or infected infants as an adjunct to routine infection control measures on the transmission of candida in the neonatal unit and its economic implications has not been systematically reviewed.

Objectives


1. To determine the effect of patient isolation measures (single room isolation and cohorting) for infants with candida colonization or infection as an adjunct to routine infection control measures (which include standard precautions like handwashing, wearing protective clothing such as gloves and gowns and use of incubators) on the transmission of candida to other infants in the neonatal unit.

The following comparisons will be made:
Comparison 1: Patient isolation measures as an adjunct to routine infection control measures vs. routine infection control measures

Subgroups within this comparison will be analyzed if data were available:
1. Single room isolation vs. routine isolation measures
2. Cohorting vs. routine isolation measures

Comparison 2: Single room isolation vs. cohorting for infants used as adjuncts to routine infection control measures


Definitions

Colonization:
Isolation of candida from the skin or mucous membranes without clinical manifestations.

Infection:
1) Mucocutaneous candidiasis: clinical manifestation of skin and mucous membranes with isolation of Candida
2) Systemic or invasive candidiasis: Isolation of candida in the blood, CSF (meningitis), urine obtained by suprapubic aspirate or by sterile catheterisation (UTI) or from any other sterile site (e.g. pleural fluid, peritoneal fluid, intravascular devices, etc).

Criteria for considering studies for this review



Types of studies


Cluster randomized trials (where clusters may be defined by hospital, ward, other subunits of the hospital)

Types of participants


Neonatal units (including Level III or intensive care unit and Level II or intermediate care unit) who have a policy for patient isolation measures for candida colonization and infection.

Types of interventions


A policy of patient isolation measures namely single room isolation or cohorting of infants with candida colonization or infection compared to routine isolation measures.

Operational definitions
Single room isolation: Isolation of an individual infant with candida colonization or infection in a separate room in the NICU with nursing personnel devoted to looking after the infant, until discharge or at least two negative surveillance cultures.

Cohorting: Physical segregation of infants with candida colonization or infection in a separate area in the NICU with infants with similar candida colonization or infection, with nursing personnel designated to looking after these cohorts until discharge or at least two negative surveillance cultures.

Routine measures: Measures other than 'single room isolation' or 'cohorting' already in place for control of transmission of infections in the NICU, including handwashing, use of 'standard precautions' with all patient contact, appropriate catheter care to minimize the risk of catheter contamination, optimizing nurse-patient ratio, avoiding overcrowding, and continuous monitoring and surveillance of nosocomial infection use of incubators among others.

Types of outcome measures


Primary outcome
Transmission of candida in the 'neonatal unit' as estimated by colonization and infection rates of candida in the neonatal unit (including Level III or intensive care unit and Level II or intermediate care unit).

Definitions of outcome measures (Harris 2001)
Infection rate will be presented as number of candida infections per 100 patients or 1000 patient days.
Colonization rate will be presented as number of candida colonization per 100 patients or 1000 patient days.

For both infection and colonization rates, the denominator will be all infants in the neonatal unit irrespective of candida colonization or infection status and colonization and infection rates will be tabulated separately.

Search strategy for identification of studies


Please refer to Cochrane Neonatal Review Group's search strategy. Relevant trials in any language were searched in the following databases in Jan 2007:
1. The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2006)
2. Electronic journal reference databases -
MEDLINE (1966 - Jan 2007) and PREMEDLINE
EMBASE (1980 - Jan 2007)
CINAHL (1982 - Jan 2007)
3. Abstracts of conferences - Proceedings of the Pediatric Academic Societies (American Pediatric Society, Society for Pediatric Research) and the European Society for Pediatric Research (1987-Jan 2007) were searched.
4. Communication with authors for more information on relevant published articles or abstracts and with other prominent authors in the field for possible unpublished articles did not reveal any cluster randomized trial fitting the selection criteria.

6. Additional searches were made in the reference lists of relevant journal articles and in the reviewer's personal files.
Search strategy for MEDLINE AND PREMEDLINE. This was adapted to suit EMBASE, CINAHL and the Cochrane Controlled Trials Register
#1 Explode 'candida' [MESH heading] /all subheadings
#2 Explode ''candidiasis" [MESH heading]/all subheadings
#3 Search 'mucocutaneous' near candid*
#4 Search 'cutaneous' near candid*
#5 Search candid* near colonization
#6 Search 'thrush'
#7 #1 OR #2 OR #3 OR #4 OR #5 OR #6

#8 Explode 'Infant-Newborn' [MESH heading]/ all subheadings
#9 neonat*
#10 #8 OR #9

#11 Search infect* near control*
#12 Search patient near isolation*
#13 Search 'communicable disease control'
#14 Search '(communicable adj disease adj control)'
#15 'outbreak'
#16 'epidemic'
#17 'endemic'
#18 'incidence'
#19 'prevalence'
#20 'screening'
#21 'surveillance'
#22 'coloniz*'
#23 'colonis*'
#24 'Isolation'
#25 'Segregation'
#26 'cohorting'
#27 'economic*'
#28 Explode 'economics' [MESH heading]/all subheadings
#29'cost*'
#30 #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR
#21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29

#31 #7 AND #10 AND #30
#32 #31 and (TG=HUMAN)
No language restriction will be applied

Methods of the review


The standard methods of conducting Cochrane systematic reviews were used. The titles and the abstracts of studies identified by the search strategy were independently assessed for eligibility to be included into the review by the review authors PM and LW. If this could not be done reliably, then the full text version was obtained for assessment. Differences were resolved by discussion. Forms were designed for trial inclusion/exclusion, data extraction and for requesting additional unpublished information from authors of the original reports. If eligible trials were identified, data extraction was to be done independently by the reviewer authors using specifically designed forms and compared for any differences.

Assessment of the quality of studies
If eligible trials were identified, the standardized review methods of the Cochrane Neonatal Review Group (CNRG) were to be used to assess the methodological quality of the studies. Then the two review authors independently would have assessed the quality of the included studies using the standard criteria developed by the CNRG.
A- Adequate allocation concealment
B - Uncertainty about whether the allocation was adequately concealed
C - Inadequate allocation concealment
D - No allocation concealment

In addition, the following issues were to be reported:
- Blinding of interventions
- Blinding of outcome assessment
- Completeness of follow-up of all randomized infants, irrespective of whether they received the allocated intervention or not (intention to treat basis)

If cluster randomized trials were identified, the methodological assessment would include whether the sample size was estimated based on the intracluster correlation co-efficient and whether the trial had been analyzed at the cluster level (the unit of randomization) and not at the individual level.

Analysis
The statistical analyses were to be performed according to the recommendations of the CNRG. Planned analyses were to be undertaken for the subgroups defined under the 'Criteria for considering studies for the review'. The effects of the intervention in the individual trials were to be analyzed. Heterogeneity of treatment effects between trials was to be assessed using the I2 statistic. The statistical package (RevMan 4.2) provided by the Cochrane Collaboration was to be used. In cluster-randomized trials, if the unit of analysis of the trial was the cluster (not individuals) and analysis took into account the correlation between clusters, the inverse variance method were to be used for meta-analysis. If this was not the case, a narrative synthesis was to be made without meta-analysis. Infection rates and colonization rates were to be expressed as rate ratios for each trial and if appropriate for meta-analysis, the generic inverse variance method in RevMan was to be used (Deeks 2004).

Description of studies


No studies identified by our search strategy met our inclusion criteria and no ongoing trials were identified.

A study comparing nosocomial infection rate with a historical control nosocomial infection rate in a PICU was identified.

Excluded studies:
Ben-Abraham 2002
In a PICU redesigned from an open single space design to individual single rooms, nosocomial infection rate including candida infections significantly declined compared to historical nosocomial infection rates. However, this study compared prospectively gathered data to retrospective historical data, which could have introduced significant bias.

Methodological quality of included studies


Not applicable as there were no studies included.

Results


No eligible trials were identified.

Discussion


No cluster randomized trial that addressed the question of patient isolation measures beyond routine infection control measures for infants colonized or infected with Candida to prevent or reduce the transmission of candida in the neonatal unit were identified. In addition, no published study reporting a neonatal unit's policy of patient isolation measures for infants colonized or infected with candida apart from routine infection control precautions were found.

The goal of any isolation measure is to prevent transmission of microorganisms from infected or colonized patients to other patients, hospital visitors, and healthcare workers and at the same time interfere minimally with patient care (Edmond 1997). The CDC recommends 'standard precautions' that apply to blood, all body fluids and secretions (except sweat), nonintact skin and mucous membranes for all patients and 'transmission based precautions' based on an individual agent's mode of transmission i.e. airborne, droplet or contact. For infections spread by direct or indirect contact, single room isolation or cohorting with patients infected or colonized with a similar organism is recommended (Garner 1996a; Garner 1996b). These isolation measures are commonly practiced for methicillin resistant S. aureus and vancomycin resistant enterococci infection or colonization. Though generally thought to be effective, the role of patient isolation measures in patients with MRSA colonization in reducing the transmission of infection in adult intensive care patients has recently been questioned (Cepeda 2005). Recommendations for patient isolation measures do not exist for candida infection and colonization in adult, pediatric or neonatal intensive care units.

Despite the fact that candida spreads by contact and candida colonization precedes invasive infection, patient isolation measures beyond routine infection control measures are not generally practiced. Handwashing remains the single most important measure in preventing nosocomial infections, but the efficacy of handwashing in preventing candida transmission by itself remains to be proven. There is scarce data to support or refute the use of patient isolation measures beyond routine infection control measures not only for candida, but also any other colonization or infection in any age group. In a PICU redesigned from an open single space design to individual single rooms, the rate of nosocomial infection including candida infection significantly declined compared to historical nosocomial infection rates. However, this study compared prospectively gathered data to retrospective historical data, which could have introduced significant bias (Ben-Abraham 2002).

Nevertheless, given the high mortality and morbidity after Candida infections in critically ill neonates (Saiman 2001; Makhoul 2001), a strong case exists for neonatal units to develop a policy for patient isolation measures for Candida infection and colonization. Any policy developed will have to be subjected to rigorous testing not only for efficacy but also for cost-effectiveness. In general, candida infections are one of the most common nosocomial bloodstream infections in the United States (NNIS 2001), with an attributable mortality of 20 - 50% in adults (Gudlaugsson 2003; Morgan 2005). The incidence of nosocomial candidemia in all ages is estimated close to 8/100,000 population (NNIS 2001) and hospital costs approaching $ 1billion/yr (Miller 2001). This makes a strong case for interventions to reduce nosocomial candida infections. Patient isolation measures (i.e. single room isolation and cohorting) beyond standard precautions or routine infection control measures should be tested for efficacy in preventing or reducing nosocomial candida infections and for cost-effectiveness.

The most appropriate method to rigorously test the above hypotheses would be to design cluster randomized trials involving multiple units or hospitals with randomized allocation to one type of patient isolation measure or the other (i.e. single room isolation or cohorting). Cluster randomized trials are more complex than randomized control trials and care should be taken during design and execution so that potential biases are avoided (Puffer 2003). Due consideration should be given to the unique analyses required in cluster randomized controlled trials (Murray 2004; Campbell 1998; Goodacre 2005). The importance of standardized reporting of results of cluster-randomized trials cannot be overemphasized (Puffer 2003).

Reviewers' conclusions



Implications for practice


The review found no evidence to either support or refute the use of patient isolation measures (single room isolation or cohorting) in neonates with candida colonization or infection. Despite the evidence for direct or indirect contact transmission of candida and evidence of cross-infection by health care workers, no standard policy of patient isolation measures beyond routine infection control measures exists in neonatal units.

Implications for research


Given the rapid emergence of candida infections and the high mortality and morbidity associated with these infections in the neonatal unit, there is an urgent need to establish or refute a role for patient isolation measures (single room isolation or cohorting) beyond standard precautions for preventing transmission of candida. Cluster randomized trials involving multiple units or hospitals with randomized allocation of one type of patient isolation measure or the other (i.e. single room isolation or cohorting) with careful consideration for determining an appropriate sample size and analysis would be the most appropriate method to research this question.

Acknowledgements


We acknowledge the help of Stavrous Petrou, Health Economist at the National Perinatal Epidemiology Unit, Oxford, U.K. for comments on the protocol.

Potential conflict of interest


None

Characteristics of excluded studies

StudyReason for exclusion
Ben-Abraham 2002Not a neonatal study or a randomized trial

References to studies

References to excluded studies

Ben-Abraham 2002 {published data only}

* Ben-Abraham R, Keller N, Szold O, Vardi A, Weinberg M, Barzilay Z et al. Do isolation rooms reduce the rate of nosocomial infections in the pediatric intensive care unit? Journal of Critical Care 2002;17:176-80.

* indicates the primary reference for the study

Other references

Additional references

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Contact details for co-reviewers Dr Oya Eddama, PhD
Health economist
National Perinatal Epidemiology Unit
NPEU, Institute of Health Sciences
Old Road, Headington
Oxford
UK
OX3 7LF
Telephone 1: 044-01865-289710
Facsimile: 044-01865-289701
E-mail: oya.eddama@npeu.ox.ac.uk

Prof Leonard E Weisman, MD
Director, Perinatal Center, Texas Childrens Hospital
Dept of Pediatrics, Section of Neonatology
Baylor College of Medicine
Houston
Texas USA
77030
E-mail: lweisman@bcm.tmc.edu
Secondary address:
Telephone: 001 832 826 1375

 
This review is published as a Cochrane review in The Cochrane Library, Issue 3, 2007 (see http://www.thecochranelibrary.com for information). Cochrane reviews are regularly updated as new evidence emerges and in response to feedback. The Cochrane Library should be consulted for the most recent version of the review.