The recent article by Slaughter and colleagues [1] comparing the effect of universal use of gloves and gowns with that of universal glove use alone in a medical intensive care unit showed that the use of gloves and gowns was no better than the use of gloves only in preventing rectal colonization by vancomycin-resistant enterococci. We compared the cost of our glove and gown use before and after an outbreak of vancomycin-resistant enterococci in our institution. The annual cost of glove use was $28 602 before the outbreak and $31 483 after the start of the outbreak, for a difference of $2881 per year. The annual cost of gown use was $1868 before the outbreak and $10 291 after the outbreak, for a difference of $8423 per year (an increase threefold greater than that of glove use). Our annual expenses for gloves and gowns have thus increased by $11 304 since the outbreak began. If we were to switch from strict contact isolation to the use of gloves only for our patients with vancomycin-resistant enterococci, we could potentially save our institution approximately $8000 a year. However, as Slaughter and colleagues reiterate, other investigators have shown that improved compliance is associated with the requirement of a greater level of precautions [2, 3]. We compared compliance with handwashing after contact with patients under strict contact isolation with compliance after contact with patients not under isolation; compliance was 100% in the former situation and 51% in the latter. We also found that only 70% of staff members who donned gloves for patient contact washed their hands after removing their gloves.

We do not know whether the cost of using disposable gowns to improve compliance with handwashing can be justified, but we do know that it is substantial. In hospitals in which vancomycin-resistant enterococci are already endemic in the intensive care units, is it cost-effective to do rectal surveillance culture of noncolonized patients for isolation of vancomycin-resistant enterococci? Should we assume that rectal colonization with vancomycin-resistant enterococci is permanent and that patients so colonized should always be isolated? These are the questions to which we eagerly await some unambiguous answers.