4. Performance of an individual assessment of residents with MRSA that includes mobility, comprehension, hygiene, ability to contain colonized secretions, and any bacteriologic data implicating the resident in transmission. This will allow formulation of an individual care plan to isolate colonized secretions and maximize activities of daily living. The MRSA carrier state creates a conflict between 2 powerful principles of nursing home practice, ie, maintaining a safe environment and maximizing independence in activities of daily living. This conflict is greatest in a colonized resident with poor hygiene who is independently mobile. Control measures used in hospitals should not automatically be extrapolated into nursing homes. Contact secretion precautions should be applied, especially if secretions were poorly contained and close contact was required. A SHEA position paper on antimicrobial resistance in long-term care recommended that residents colonized with resistant pathogens not be restricted from group activities unless they are shedding large numbers of organisms and the resident was epidemiologically linked to infection in other residents.19 Unfortunately, there may be a delay between transmission and the discovery of transmission by culturing infected secretions. In addition, some mobile carriers not implicated in transmission are observed to be contaminating the common environment during independent activity. Nursing home staff have great difficulty reconciling this observation with their own efforts to contain secretions. We, therefore, believe that physical separation that is well tolerated should be implemented without evidence of transmission. If the resident leaves his or her room, colonized sites should be secured and covered and assisted hand washing and possibly clean clothes provided. Personal items and equipment could be left behind, with regular decontamination of surfaces frequently touched by the resident. The care plan must be individualized and will be limited by the facility resources. Unfortunately, basic hygiene in common areas cannot be maintained in some residents without some restriction of activities of daily living. This step requires significant attention to the resident's psychosocial adaption. If antibiotic treatment of MRSA is administered because of infection or transmission, the sites of colonization should be fully characterized to optimize therapy. Consider the presence of such things as foreign bodies, devitalized tissue, ischemia, sinusitis, bronchiectasis, elevated postvoid residua, and osteomyelitis. If an underlying substrate is not addressed mechanically, decolonization is especially unlikely. Management recommendations for known carriers will continue to evolve. Perhaps residents, surrogates, and the public should be informed that nursing homes, like child day care facilities, care for individuals who have received multiple courses of antibiotics and might carry antibiotic-resistant bacteria. Residents socialize and interact with one another and can exchange bacteria during social interactions.