An investigation of the source of an MRSA outbreak at a UK hospital found that the cause was an intermittently operated ventilation system. Ventilation grilles were found to be contaminated with EMRSA-15. It was found that daily system shutdown was causing a temporary negative pressure which drew air in from the ward and likely contaminated the outlet grilles. The index for the outbreak was a patient moved into the hospital from another large hospital. States that it is likely that contaminated air was blown back from the grilles at switch-on.
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