Our study shows that a multidisciplinary quality improvement approach can implement a sustainable prevention strategy, resulting in the reduction of invasive MRSA infections in NICU. In our unit, this also led to a significant decrease in other bloodstream nosocomial infections, a goal which was not primarily targeted by the prevention policy.
The importance of a multidisciplinary approach, along with a bundle strategy for the prevention and control of MRSA spread in NICU, is widely recognised and it has been reported elsewhere [4–7]. While taking into account these different papers, it is interesting to note that similar adopted measures are not universally successful and that in some cases, as in the study of Lepelletier et al. , several consecutive actions had to be added, in order to control the MRSA outbreak. One report from Haley and colleagues  has successfully demonstrated how identical measures applied to eradicate endemic MRSA in their NICU had a different impact over time, according to changing local factors (overcrowding and understaffing).
Actually, clinical reviews concerning adult patients  show that, even if guidelines and recommendations for prevention and control of MRSA are similar worldwide, this problem has very different prevalence from country to country, thus suggesting that relevant differences must exist depending on the method used to implement the best practices.
The strength of our study, in relation to previous investigations in this field, was to describe in detail the step-by-step process which allowed us to convert the common knowledge about preventive and control strategies into an effective change of behaviours and organization. This process is often difficult, as it must take into account the extensive understanding of specific difficulties, sometimes pertaining to local factors affecting HCW attitudes.
The innovative tools of our approach were: 1) the anonymous reporting system implementation and 2) the institution of the operational team.
Reporting systems, recommended by the Institute of Medicine  for identifying and addressing medical errors, have been increasingly used in neonatology to prevent and manage iatrogenic events [16, 17], but in the context of this study the anonymous mail box was mainly used to propose positive inputs and organizational suggestions for the project, as in private companies .
The key benefit of the operational team was that this was very representative of the multiple categories of health providers devoted to the continuous care of newborn infants in our units. Its use of feedback communication systems and its accountability for elaborating written procedures facilitated the acceptance of the multiple changes required for the success of the outbreak ma-nagement strategy. This group represented a credible voice, permitting the useful communication between the institutional and scientific leadership and the ground-level staff, and it also allowed an effective exchange between the two distinct teams caring for newborns in NICU 1 and NICU 2.
The implication of the cleaning staff members in the project was also remarkable and we believe that it played an important role in the improvement of the local hygiene conditions of our obsolescent structures.
Our study has several limitations. First, we recognize that the retrospective collection of data does not represent the most rigorous approach to evaluate clinical management or quality improvement interventions. In particular, the lack of a prospective reporting system for some indicators during the first part of the study is a possible bias that limits the interpretation of the results.
The incidence of MRSA infections declined substantially after the intervention, but we acknowledge that the study methodology make it impossible to determine whether the decline resulted from the natural history of the outbreak or a delayed response to the initial outbreak control measures. Moreover, the uncontrolled, before-after design does not allow us to determine which, or even if, any of the bundle interventions contributed to the reduction of MRSA infection rate, and this is the major limitation of this study.
Secondly, our results cannot be automatically generalized, as they represent the consequence of an implementation process which was appositely tailored upon our unit specificities.
Finally, a great effort of inter-institutional discussion and inter-professional collaboration was required by our strategy and regrettably, the economic costs of this effort were not estimated in our study and we trust that this outcome would have been very interesting for the readers.