Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Dr. Saumya Navit

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Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
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Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help ones reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
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Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journalsNo manuscriptsNo authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2011 | Month : June | Volume : 5 | Issue : 3 | Page : 476 - 479 Full Version

An investigation of MRSA from the Burns Ward: the importance of hand hygiene

Published: June 1, 2011 | DOI:

Jr Specialist Microbiology, Dr Baba Saheb Ambedkar Hospital, Rohini, New Delhi. Corresponding Author. Consultant & Head, Department of Microbiology, R.M.L. PGIMER & Hospital, New Delhi-110001, India.

Correspondence Address :
Nirmaljt Kaur, Senior Specialist, Department of Microbiology,
R.M.L. PGIMER & Hospital, New Delhi-110001, India.


Introduction: MRSA (Methicillin Resistant Staphylococcus aureus) deserves special attention in health care settings. It becomes difficult to treat this infection/eradicate its colonization once it has established. However, its spread can be controlled. An increase in MRSA isolation from the wound swabs of the burns patients over a period of four months prompted us to undertake the present investigation.

Material and Methods: Eleven HCWs (Health Care workers) were screened. Hand smears and nasal swabs were cultured and identified by standard microbiological methods. A re-orientation programme was arranged for all HCWs in the burns ward and the importance of standard work precautions, especially hand hygiene was highlighted. Swabs were taken from the same workers after six weeks.

Results: Out of eleven health care workers, seven were found to be MRSA carriers (63.6%). Swabs which were taken from the same workers after six weeks, revealed a decrease in the MRSA colonization in the hands by 75% and in the nose by 25%. Also, the number of MRSA isolations from the wound swabs of patients in the burns ward decreased from 35.3% to 13.9%.

Conclusion: The current study emphasizes the need for an early diagnosis of MRSA and for being vigilant so that if any outbreak of multidrug resistant organisms occurs in a ward/ ICU, steps to control them can be initiated at the earliest. It also highlights the importance of hand hygiene so that the hands that deliver care may not deliver germs.


MRSA, Burns, Hand Hygiene

Staphylococcus aureus are gram-positive cocci which possess the ability to colonize as well as to cause infections in individuals, which may range from simple cutaneous infections to toxic shock syndrome and life threatening blood stream infections. The control of this organism becomes difficult especially when it is multidrug resistant thus limiting the treatment options. To almost every new drug which is introduced, resistance follows soon.

S. aureus strains have developed resistance to virtually all antibiotic classes which are available clinically. These include cell wall inhibitors such as ß-lactams and glycopeptides, ribosomal inhibitors including macrolide-lincosamide-streptogramin B (MLSB), aminoglycosides, tetracyclines, fusidic acid, DNA gyrase blocking quinolones, the antimetabolite-trimethoprim sulfamethoxazole, the RNA polymerase inhibitor-rifampin, newer oxazolidinones, etc (1)(2).

Penicillin was the first beta lactam antibiotic to be introduced in 1940. Soon resistance to it emerged in 1942. ß-lactamase (Penicillinase) was extracted in 1944. Penicillinase stable ß-lactams such as cephalosporins and semi synthetic penicillins such as methicillin and nafcillin became available in the late 1950s (3). Methicillin was introduced in 1959 but its natural resistance in S. aureus was identified soon after by Jevons in 1960 (4). Such isolates are known as MRSA (Methicillin resistant Staphylococcus aureus). The drug of choice for such cases is vancomycin. Vancomycin intermediate resistant isolates of S. aureus (VISA) were first described in 1997 in Japan (3). Vancomycin resistant S. aureus (VRSA) was first described in June 2002 in the U.S.

in a dialysis patient (3). VISA and VRSA strains, though they are rare, are serious threats to the treatment of infections which are caused by such organisms. Other treatment options for the MRSA infections are linezolid, rifampicin + flouroquinolones, pristinamycin, co-trimoxazole, (trimethoprim-sulphamethoxazole), doxycline or minocycline and clindamycin (5).

Methicillin is a β-lactamase resistant penicillin. Methicillin/ oxacillin resistance implies resistance to all penicillins, cephalosporins, carbapenems and ß-lactamase inhibitor combinations. These isolates are generally also resistant to other classes of drugs including macrolides, tetracyclines, aminoglycosides, chloramphenicol, etc (6).

Burn wounds are open and raw wounds which allow various micro-organisms which are capable of establishing themselves, to grow and multiply resulting in serious infections. MRSA with limited treatment options is particularly difficult to treat. The control of this organism is therefore very important so that it does not spread to other patients. The present study was conducted as an investigation to track the source of the infections when an increase in MRSA cases was seen in the burns ward.

Material and Methods

The present study was conducted during a period of four months during which pus/wound swabs from wounds which were suspected of infection from the burns ward were cultured routinely on blood agar, MacConkey’s agar and in BHI broth. After overnight incubation at 37°C, the isolates were identified by standard microbiological methods (7) and their antibiotic sensitivity was studied. During this process an increase in the MRSA isolateswas seen from the burns ward. Considering the pathogenic potential of MRSA in such patients with limited treatment options, an investigation was conducted in the burns ward to find out the source of the infection. All the staff members of the burns unit, with access to the patients, were screened for MRSA colonization. Fingerprints from their hands and nasal swabs were taken. For reasons of compliance, samples could not be taken from other sites like the axilla, the umbilicus, the perineum, etc. An HCW was classified as a “carrier”, if at least one of the samples grew MRSA. In total, eleven HCWs were screened. Their fingerprints, both from the left and right hands, were taken directly on blood agar plates and these were incubated at 37°C overnight. The nasal swabs were moistened with sterile saline before sampling and were processed in the same way as the pus/ wound swabs were processed. Swabs were also taken from the main dressing table, the small dressing trolley; the patient trolley and the dressing room sink and these were also processed as mentioned above. After overnight incubation, suspected colonies which morphologically resembled staphylococci were selected. Their gram staining and catalase, slide and tube coagulase tests were done. The gram positive cocci which were catalase and coagulase positive were identified as S. aureus and they were subjected to the antibiotic susceptibility test on Mueller Hinton agar (MHA) at pH 7.2-7.4, by uniformly inoculating them by a cotton swab which was lightly saturated with a suspension of visual equivalence to 0.5 Mac Farland’s nephelometric standards. Within 15 minutes of inoculation, an oxacillin (1μg) disc along with other antibiotic discs, were put 30 mm centre to centre from each other. Other antibiotics which were tested were cefuroxime (30 µg), tetracycline (30 µg), erythromycin (15 µg), co-trimoxazole (25 µg), ciprofloxacin (5µg), amoxicillin/clavulanic acid (20 + 10 µg), vancomycin (30 µg), linezolid (30 µg) and clindamycin (2 µg). If the zone of inhibition of oxacillin was ≤ 10 mm i.e. resistant, the strains were re-tested with the same concentration as the oxacillin disc on MHA with 2-4% NaCl and incubated at 30-35°C for complete 24 hours. If they were found to be resistant, these isolates were recorded as MRSA and were followed up. A reorientation in the infection control practices was done for the burns ward staff by the Microbiology Department and the standard work precautions were explained to them. The importance of hand hygiene was specifically highlighted.

Hand washing with antibacterial soaps and an alcoholic hand rub was advised and mupirocin ointment for nasal application and barrier nursing was advocated, to contain the infection. After six weeks, repeat samples from the staff were taken and the results were compared.


In January 2007, there was no isolate of S. aureus in the burns ward. In February, within a period of one week four isolates were identified, all of them being MRSA.

During a period of 4 months i.e. 1st Feb-31st May, 51 pus/ wound swabs were received from the burns ward, out of which 13 samples were sterile. In 12 such samples more than one organism was isolated. The most common organism which was isolated was Pseudomonas aeruginosa and it was isolated in 27 cases. Out of 19 S. aureus strains which were isolated, 18 were methicillin resistant (95% of all S. aureus isolates) (Table/Fig 1). These were 100% susceptible to vancomycin and linezolidMRSA cases were also isolated from intensive care units; the ENT, Obstetrics and Gynaecology, Orthopedics, Surgery, Paediatricsand Skin wards and from Out Patient Departments (OPDs). Overall in the hospital, the rate of MRSA was 34.2% of all the S. aureus isolates. Others which were frequently isolated were Pseudomonas, Acinetobacter, Escherichia coli, Klebsiella and Proteus.

Out of 11 HCWs of the burns ward which were screened for MRSA, 8 were identified as carriers of S. aureus. Seven of these isolates were MRSA i.e. 63.6% of all HCWs. MRSA was seen to colonize the hands and nose equally.

MRSA was also isolated from the patient trolley in the dressing room.

The sensitivity pattern of these isolates matched with those from the patients in being sensitive only to vancomycin, tetracycline and linezolid, but resistant to oxacillin, erythromycin, cefuroxime, ciprofloxacin, clindamycin, co-trimoxazole and the amoxicillinclavulanic acid combination. However, due to resource limited settings, molecular support could not be established.

After strengthening the infection control practices, the number of MRSA isolations from the burns ward fell to only ‘two’ in June. Repeat samples from the HCWs also showed a decreasing trend (Table/Fig 2). Hand washing alone decreased the incidence of MRSA by 75% and nasal carriage by 25% among the health care workers from the burns ward.

The frequency of hand washing was increased before and after handling patients and between handling patients, but the compliance for mupirocin was poor.

Last year, the overall rate of MRSA in our hospital was 22.6%. Only 10 strains of S. aureus were isolated from the burns patients and 3 were MRSA.


Historically, the resistance to Penicillinase stable penicillins has been referred to as “Methicillin resistance”; thus, the acronym ‘MRSA’ is still commonly used even though methicillin is not being used now-a-days, as the more stable and similar penicillins, oxacillin, flucloxacillin and dicloxacillin are available. Oxacillin is used as an indicator drug and as a marker of resistance in the susceptibility testing of all staphylococcal isolates as it is more resistant to degradation during storage and more likely to detect hetero-resistant strains (6). There are two different MRSA clusters- HA-MRSA (hospital acquired MRSA) and CA-MRSA (community acquired MRSA) (8). Clinically and epidemiologically, these are believed to be two separate evolutions. The hospital isolates are multi-resistant and clonal and are associated with risk factors like recent hospitalization or surgery, nursing home residency orhaving an indwelling catheter or device. On the other hand, the CA-MRSA strains are pauci-resistant and polyclonal and produce skin diseases and severe pneumonia in otherwise healthy people. The MRSA in patients at risk are likely to be the multi-resistant hospital type, whereas in patients without risks they are likely to be more susceptible but more invasive too. So, the MRSA which is isolated from the hospital environment or elsewhere in the community due to infection or colonization is particularly important and has to be checked. For HA- MRSA, the associated factors include prior antibiotic exposure, prolonged hospitalization, surgery, admission to an intensive care unit, nursing home residency and close approximation to a patient who was colonized or infected with MRSA. Inpatients having an S. aureus infection have on an average, 3 times the length of hospital stay, 3 times the total charges and 5 times the risk of in- hospital deaths as compared to in-patients without this infection (9).

Burn wounds provide a particularly rich environment for microorganisms to grow, as these are exposed surfaces which are raw, wet and rich in electrolytes, requiring frequent dressing changes, handling by multiple health care workers (HCW), the use of intraluminal devices and the empirical use of antibiotics including newer ones and due to the inherent immunocompromised state of the patients (10). In the present study also, the sources were traced to the hands and nares of the HCWs and the contaminated dressing trolley which was used for all the patients for the purpose of dressing.

These patients are also on multiple antibiotics, which provided a survival chance to the multidrug resistant organisms (MDRO). Also, the limited therapeutic options for these MDROs may influence antibiotic usage in such a way that the normal flora may be suppressed and a favourable environment may be created for the development of colonization, when these sites are exposed to MDROs (11). The most common microbial isolates from burns are Pseudomonas aeruginosa, Staphylococcus aureus, Escherichia coli, Klebsiella and Proteus.

According to a survey from the SENTRY Antimicrobial Surveillance Program, methicillin resistance varies from <2% in Netherlands to >70% in Japan and Hong Kong (12). In Netherlands, it is low, as an important part of the Dutch strategy is to attempt the eradication of the carriage of such organisms immediately after discharge from the hospital so that it does not spread in the community (13). In one study which was conducted in a tertiary care hospital in India, the MRSA carriage ranged from 28.4% in outpatients to 33.5% in the in-patients (14). In All India Institute of Medical Sciences, Delhi, the prevalence of MRSA was 38.56% (15).

The prevention of nosocomial infections involves routine and terminal cleaning. Alcohol has proven to be effective as a topical sanitizer against MRSA. Alcohol based hand rubs should be placed in all the wards so that the staff can clean their hands more regularly. According to a Centre for Disease Control CDC report, hand washing alone would save the lives of around 30, 000 patients per year in the U.S., not from MRSA alone but from all nosocomial infections (16).

The application of mupirocin (2%) into the anterior nares of the HCWs is highly efficacious in eliminating S. aureus carriage (17).

The administration of vancomycin is associated with many problems, not only as its route of administration is inconvenient butalso as it is inferior in terms of efficacy as compared to the antistaphylococcal penicillins (18).

MRSA are just as pathogenic as Methicillin Susceptible S. aureus (MSSA), but their treatment is challenging. Also, they spread easily in hospital settings, thus causing higher mortality rates and increased costs (19). The scarcity of the treatment options and the morbidity and mortality which are associated with the MRSA infections, provide a strong argument for judicious use of antibiotics and the need for a well defined antibiotic policy, so that the emergence of such organisms is prevented. This is applicable not only for the control of MRSA but also for other MDROs as well.


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Sampathkumar P. Methicillin resistant Staphylococcus aureus: the latest health scare. Mayo Clin Proc 2007; 82: 1463-1467.
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