case study number 22

Iconic Photos

Famous, Infamous, and Iconic Images

Case Study House No. 22, 1960

Between 1945 and 1966, Californian magazine Arts & Architecture asked major architects of the day to design model homes. The magazine was responding to the postwar building boom with prototype modern homes that could be both easily replicated and readily affordable to the average American. Among many criteria given to the architects was to use “as far as is practicable, many war-born techniques and materials best suited to the expression of man’s life in the modern world.”

Thirty-six model homes were commissioned from major architects of the day, including Richard Neutra, Raphael Soriano, Craig Ellwood, Charles and Ray Eames, Pierre Koenig, Eero Saarinen, A. Quincy Jones, and Ralph Rapson. Not all of them were built but some thirty of them were, mostly around the Greater Los Angeles area.

The magazine also engaged an architectural photographer named Julius Shulman to dutifully record this experiment in residential architecture. Fittingly for Shulman, one of the first architectural photographers to include the inhabitants of homes in the pictures, his most famous image was the 1960 view of Pierre Koenig’s Case Study House No. 22 (also the Stahl House), which showed two well-dressed women conversing casually inside.

In the photo, the cantilevered living room appears to float diaphanously above Los Angeles. “The vertiginous point of view contrasts sharply with the relaxed atmosphere of the house’s interior, testifying to the ability of the Modernist architect to transcend the limits of the natural world,” praised the New York Times . Yet this view was created as meticulously as the house itself. Wide-angle photography belied the actual smallness of the house; furniture and furnishings were staged, and as were the women. Although they were not models (but rather girlfriends of architectural students), they were asked to sit still in the dark as Shulman exposed the film seven minutes to capture lights from LA streets. Then, lights inside were quickly switched on to capture two posing women.

Case Study House No.22 as it appeared in Arts and Architecture . Shulman’s photo with inhabitants did not appear here.

See other Case Study Houses here:

https://en.wikipedia.org/wiki/Case_Study_Houses

Result was the photo Sir Norman Foster termed his favorite “architectural moment”. Indeed, the photo captured excitement and promises the house held, and propelled Case Study No. 22 into the forefront of national consciousness. Some called it the most iconic building in LA. It appeared as backdrop in many movies, TV series and advertisements. Tim Allen was abducted by aliens here in Galaxy Quest ; Greg Kinnear would make it his bachelor pad in Nurse Betty , and Columbo opened its pilot episode here. Italian models in slicked-back hair would frolic poolside in Valentino ads. It was even replicated in the 2004 video game Grand Theft Auto: San Andreas. According to Koenig, Case Study No. 22. was featured in more than 1,200 books — more often than Frank Lloyd Wright’s Fallingwater.

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Stahl House (Case Study House #22)

Immortalized by photographer Julius Shulman, the Stahl House epitomized the ideal of modern living in postwar Los Angeles.

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• Pierre Koenig

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Based on a recent approval by the City of Los Angeles for a new residence at the base of the hillside and below the historic Stahl House, this action now places this Modernist icon at risk. The hillside is especially fragile as it is prone to slides and susceptible to destabilization. This condition will be exacerbated as this proposed new residence is planned to cut into the hillside and erect large retaining walls.

The proposed project received approval despite opposition and documentation submitted that substantiates the problem and potential harm to the Stahl House. An appeal has been filed and the City is reviewing this now. No date has been set yet for when this might come back to the City Planning Commission.

To demonstrate your support for the Stahl House and to ensure the appeal is granted (sending the proposed project back for review), please sign on to the  Save the Stahl House campaign .

Who hasn’t seen the iconic image of architect Pierre Koenig’s Stahl House (Case Study House #22), dramatically soaring over the Los Angeles basin? Built in 1960 as part of the Case Study House program, it is one of the best-known houses of mid-century Los Angeles.

The program was created in 1945 by John Entenza, editor of the groundbreaking magazine  Arts & Architecture . Its mission was to shape and form postwar living through replicable building techniques that used modern industrial materials. With its glass-and-steel construction, the Stahl House remains one of the most famous examples of the program’s principles and aesthetics.

Original owners Buck and Carlotta Stahl found a perfect partner in Koenig, who was the only architect to see the precarious site as an advantage rather than an impediment. The soaring effect was achieved using dramatic roof overhangs and the largest pieces of commercially available glass at the time.

The enduring fame of the Stahl House can be partly attributed to renowned architectural photographer Julius Shulman, who captured nearly a century of growth and development in Southern California but was best-known for conveying the Modern architecture and optimistic lifestyle of postwar Los Angeles. Shulman’s most iconic photo perfectly conveys the drama of the Stahl House at twilight: two women casually recline in the glowing living room as it hovers over the sparkling metropolis below.

View the National Register of Historic Places Nomination

The Conservancy does not own or operate the Stahl House. For any requests, please contact the Stahl House directly at (208) 429-1058.

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Stahl House (Case Study House #22)

Pierre Koenig | Website | 1960 | Visitor Information

1635 Woods Drive , West Hollywood 90069, United States of America

The Stahl House by Pierre Koenig (also known as Case Study House #22) was part of the Case Study House Program, which produced some of the most iconic architectural projects of the 20th Century. The modern residence overlooks Los Angeles from the Hollywood Hills. It was completed in 1959 for Buck Stahl and his family. Stahl envisioned a modernist glass and steel constructed house that offered panoramic views of Los Angeles when he originally purchased the land for the house in 1954 for $13,500. When excavation began, he originally took on the duties of both architect and contractor. It was not until 1957 that Stahl hired Pierre Koenig to take over the design of the family’s residence. The two-bedroom, 2,200 square foot residence is a true testament to modernist architecture and the Case Study House Program. The program was set in place by John Entenza and sponsored by the Arts & Architecture magazine. The aim of the program was to introduce modernist principles into residential architecture, not only to advance the aesthetic but to introduce new ways of life, both stylistically and as a representation of modern lifestyle. Koenig was able to hone in on the vision of Buck Stahl and transform that vision into a modernist icon. The glass and steel construction is the most identifiable trait of the house’s architectural modernism, however, way in which Koenig organized the spatial layout of the house, taking both public and private aspects into great consideration, is also notable. As much as architectural modernism is associated with the materials and methods of construction, the juxtaposition of program and organization are important design principles that evoke utilitarian characteristics. The house is “L”-shaped, completely separating the public and private sections except for a single hallway connecting them. The adjacent swimming pool, which must be crossed to enter the house, is not only a spatial division of public and private but it serves as the interstitial space in which visitors can best experience the panoramic views. The living space of the house is behind the pool and is the only part of the house that has a solid wall, which backs up to the carport and the street. The entire house is one large viewing box, capturing amazing perspectives of the house, the landscape, and Los Angeles. Oddly enough, the Stahl house was fairly unknown and unrecognized for its advancement of modern American residential architecture until 1960 when photographer Julius Shulman captured the pure architectural essence of the house in a shot of two women sitting in the living room overlooking the bright lights of the city of Los Angeles. That photo put the Stahl House on the architectural radar as an architectural gem hidden in the Hollywood Hills. The Stahl House is still one of the most visited and admired buildings today. It has undergone many interior transformations. Today, you will not find the same iconic 1960s furniture inside, but the architecture, the view, and the experience still remain.

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Singulart Magazine > Spotlight on... > Artists > Exploring Case Study House #22 by Julius Shulman

Exploring Case Study House #22 by Julius Shulman

This article pays tribute to Julius Shulman , the godfather of architectural photography, who passed away at 98. Shulman didn’t just document buildings; he captured modernism’s essence with precision. Case Study House #22 stands out among his designs, an architectural vision in the Hollywood Hills. Perched on cliffs, this house became Shulman’s iconic subject. Join us as we uncover the story behind this famous picture and explore Shulman’s captivating journey.

Who was Julius Shulman?

Julius Shulman, the man behind the camera was not only a photographer but an architect’s narrator. Shulman, born in 1910, did not merely photograph buildings, he documented the spirit of modernism.

FUN FACT: Julius Shulman often used unconventional methods to capture his iconic shots. In one instance, he reportedly climbed onto a neighbor’s roof to photograph a house, showcasing his determination and creativity in getting the perfect angle.

Shulman’s story started in the architectural capital of the world, Los Angeles. His lens swayed in the creations of architectural legends such as Richard Neutra, Pierre Koenig, and Charles Eames. The recognizable pictures turned into the vision of the mid-century American spirit and became the symbol of post-war optimism.

What is Happening in Case Study House #22?

Welcome to Case Study House No. 22, which could be considered Shulman’s masterpiece. This architectural masterpiece is indeed a perfect example of the fusion of aesthetics and utility as it stands gracefully on the cliff of Hollywood Hills. Designed and built in 1960, this house was one of the examples of the Case Study Houses program by John Entenza’s Arts & Architecture magazine which was an attempt at popularizing affordable and efficient living spaces.

What’s So Special About Case Study House #22?

The Case Study House number 22 is a significant example of post-war modernist architecture: the house is characterized by a narrow elongated silhouette and a focus on minimalism. Nested on the Hollywood Hills’ cliff, it has become an emblem of California dreaming and style, with its silhouette etched against the endless Los Angeles cityscape. This work of art has been captured in the timeless photograph by Julius Shulman that has put it among the most famous buildings in architectural history.

Looking at the architecture of Case Study House #22 one can say that it is an example of how art and architecture are intertwined with cultural values. Thanks to its unique design and location, it has become an example of a contemporary lifestyle, and its depiction in films and television series has turned it into a cultural reference. This architectural marvel stands as a timeless reminder of the mid-century modern movement and an explanation of why visionary design remains a powerful force to this very day.

Interesting Facts About Case Study House #22

The Perfect Frame: Shulman’s photograph of Case Study House #22 is not merely a snapshot but a carefully composed masterpiece. The interplay of light and shadow, the juxtaposition of sleek lines against the sprawling cityscape, all within the confines of a single frame, is a testament to Shulman’s mastery.

A Star-Studded Icon: Case Study House #22 didn’t just capture the essence of modern architecture; it became an icon itself. Its appearance in countless films, television shows, and advertisements cemented its status as a cultural touchstone.

Behind the Scenes: The photograph’s perfection belies the chaos behind the scenes. Shulman’s assistant, who was responsible for switching on the lights inside the house, got stuck in traffic. With moments to spare, Shulman improvised, capturing the image with the house’s natural glow, elevating it to legendary status.

Timeless Appeal: Despite being over six decades old, Shulman’s photograph continues to captivate audiences worldwide. Its timeless appeal lies in its ability to transcend the boundaries of time and space, offering viewers a glimpse into a world where architecture and art merge seamlessly.

Artwork Spotlight: Architectural Study – Interior

Shulman’s Architectural Study – Interior is available on Singulart. This artwork is a stunning piece that brings the viewer into the world of the modernist style, captured through the details and play of light and shadow and the spirit of the mid-century styles in one image.

Are you looking for a piece of artwork from Julius Shulman ?

Singulart has limited edition prints of Julius Shulman. If you are looking for a piece of Shulman‘s artwork for sale, simply click on the artwork or the button below to discover more!

Frequently Asked Questions

What is julius shulman known for.

Most people agree that Julius Shulman is the most significant architectural photographer in history. In the course of a 70-year career, Shulman not only captured the architectural designs of many of the greatest 20th-century architects, but he also turned commercial architectural photography into a beautiful art.

What techniques did Julius Shulman use?

He rendered features that would otherwise be difficult or impossible to see by using infrared film to highlight the sky against the building’s edge. To express a more dynamic space, he would place tree branches to the outside of the frame in his shots. He also used a distinct sense of art direction. 

In the world of architectural photography, Julius Shulman is a giant, his camera capturing not only structures but the essence of an epoch. And in Case Study House #22, his legacy is at its finest, a perfect example of how art transcends the barriers of time and space.

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PODCAST: Inside LA’s Most Iconic Modernist Home, Case Study House #22

The story of an awe-inspiring building and the family that grew up there.

November 24, 2021 | 39:00

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“Buck wanted to stand in every room from his house, turn his head, and see every view. Even the bathroom. And so that was kind of what inspired the design of the house.”

Among the most famous photographs of modern architecture is Julius Shulman’s picture of Case Study House #22, also known as the Stahl House after the family that commissioned it. Two girls in white dresses sit inside a glass cube that seems to float atop a cliff over the illuminated grid of Los Angeles at night. Built by a family with a “beer budget and champagne tastes,” the two-bedroom home designed by architect Pierre Koenig changed residential design in LA. While Shulman’s image and others of the building have appeared in countless publications, advertisements, films, and TV shows, the story of how the house came to be and what it was like to live there is less well known.

The Greatest American Architectural Photographer of the 20th Century

Julius Shulman is often considered the greatest American architectural photographer of the 20th century. His photography shaped the image of South Californian lifestyle of midcentury America. For 70 years, he created on of the most comprehensive visual archives of modern architecture, especially focusing on the development of the Los Angeles region. The designs of some of the world’s most noted architectures including Richard Neutra, Ray Eames and Frank Lloyd Wright came to life though his photographs. To this day, it is through Shulman’s photography that we witness the beauty of modern architecture and the allure of Californian living.

Neutra and Beyond

Born in 1910 in Brooklyn, Julius Shulman grew up in a small farm in Connecticut before his family moved to Los Angeles at the age of ten. While in Los Angeles, Shulman was introduced to Boy Scouts and often went hiking in Mount Wilson. This allowed him to organically study light and shadow, and be immersed in the outdoors. While in college between UCLA and Berkeley, he was offered to photograph the newly designed Kun House by Richard Neutra. Upon photographing, Shulman sent the six images to the draftsman who then showed them to Neutra. Impressed, Richard Neutra asked Shulman to photograph his other houses and went on to introduce him to other architectures.

The Case Study Houses

Julius Shulman’s photographs revealed the true essence of the architect’s vision. He did not merely document the structures, but interpreted them in his unique way which presented the casual residential elegance of the West Coast. The buildings became studies of light and shadow set against breathtaking vistas. One of the most significant series in Shulman’s portfolio is without a doubt his documentation of the Case Study Houses. The Case Study House Program was established under the patronage of the Arts & Architectue magazine in 1945 in an effort to produce model houses for efficient and affordable living during the housing boom generated after the Second World War. Southern California was used as the location for the prototypes and the program commissioned top architects of the day to design the houses. Julius Shulman was chosen to document the designs and throughout the course of the program he photographed the majority of the 36 houses. Shulman’s photography gave new meaning to the structures, elevating them to a status of international recognition in the realm of architecture and design. His way of composition rendered the structures as inviting places for modern living, reflecting a sense of optimism of modern living.

Case Study House #22

Case Study House #22, also known as the Stahl House was one of the designs Julius Shulman photographed which later become one of the most iconic of his images. Designed by architect Pierre Koenig in 1959, the Stahl House was the residential home of American football player C.H Buck Stahl located in the Hollywood Hills. The property was initially regarded as undevelopable due to its hillside location, but became an icon of modern Californian architecture. Regarded as one of the most interesting masterpieces of contemporary architecture, Pierre Koenig preferred merging unconventional materials for its time such as steel with a simple, ethereal, indoor-outdoor feel. Julius’s dramatic image, taking in a warm evening in the May of 1960, shows two young ladies dressed in white party dresses lounging and chatting. The lights of the city shimmer in the distant horizon matching the grid of the city, while the ladies sit above the distant bustle and chaos. Pierre Koenig further explains in the documentary titled Case Study Houses 1945-1966 saying;

“When you look out along the beam it carries your eye right along the city streets, and the (horizontal) decking disappears into the vanishing point and takes your eye out and the house becomes one with the city below.”

The Los Angeles Good Life

The image presents a fantasy and is a true embodiment of the Los Angeles good life. By situating two models in the scene, Shulman creates warmth, helping the viewer to imagine scale as well as how life would be like living in this very house. In an interview with Taina Rikala De Noriega for the Archives of American Art Shulman recalls the making of the photograph;

“ So we worked, and it got dark and the lights came on and I think somebody had brought sandwiches. We ate in the kitchen, coffee, and we had a nice pleasant time. My assistant and I were setting up lights and taking pictures all along. I was outside looking at the view. And suddenly I perceived a composition. Here are the elements. I set up the furniture and I called the girls. I said, ‘Girls. Come over sit down on those chairs, the sofa in the background there.’ And I planted them there, and I said, ‘You sit down and talk. I’m going outside and look at the view.’ And I called my assistant and I said, ‘Hey, let’s set some lights.’ Because we used flash in those days. We didn’t use floodlights. We set up lights, and I set up my camera and created this composition in which I assembled a statement. It was not an architectural quote-unquote “photograph.” It was a picture of a mood.”

Purity in Line and Design to Perfection

Shulman’s preference to shoot in black and white reduces the subject to its geometrical essence allowing the viewer to observe the reflections, shadows and forms. A Shulman signature, horizontal and vertical lines appear throughout the image to create depth and dimensional perspective. A mastery in composition, the photograph catches purity in line and design to perfection.

A Lifetime of Achievements

Julius Shulman retired from active architectural work in 1989, leaving behind an incredibly rich archive chronicling the development of modern living in Southern California. A large part of his archive resides at the Getty Museum in California. For the next twenty years he participated in major museum and gallery exhibitions around the world, and created numerous books by publishers such as Taschen and Nazraeli Press. Among his honors, Shulman is the only photographer to have been granted honorary lifetime membership in the American Institute of Architects. In 1998 he was given a lifetime achievement award by ICP. Julius passed away in 2009 in his home in Los Angeles.

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Case Study House No. 22

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Primary classification, terms of protection, designations, how to visit, case study house no. 21, lorem ipsum dolor, designer(s).

Pierre Koenig

Nationality, other designers, related news, related chapter, southern california.

C.H. Stahl and Charlotta Stahl/ Completed in 1960

Original Brief

Significant alteration(s) with date(s), current use, current condition, general description, construction period, original physical context, cultural & aesthetic, general assessment.

Case Study House No. 22, by the numbers

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$15,000,000

The most offered to the Stahl family to sell their iconic Case Study House No. 22. (The family declined.)

Cost of a vintage photograph of Julius Shulman’s “Case Study House #22” (1960) at Craig Krull Gallery. (Prints made in the 1990s under Shulman’s instructions: $17,000 to $20,000.)

Price to build the Hollywood Hills home in 1959, excluding pool ($3,651).

Cost of the narrow lot in 1954.

Day rate for a film company to rent Stahl house for a day in 2009. (Lower rates for parties.)

Number of square feet in the two-bedroom, three-bathroom house.

Degrees of unobstructed mountain-to-ocean view one sees from the living room.

Number of times Case Study House No. 22 has been built: first by architect Pierre Koenig, then again in 1989 when Craig Hodgetts and Ming Fung designed a full-scale model for the Los Angeles Museum of Contemporary Art’s exhibition “Blueprints for Modern Living: History and Legacy of the Case Study Houses.”

Number of days it took for the glass house’s steel frame to be erected.

-- Barbara Thornburg Sources: Stahl Trust; “Iconic: Stories of L.A.’s Most Memorable Buildings” by Gloria Koenig; “Koenig” by Neil Jackson; “Pierre Koenig” by David Jenkins and James Steele; “Case Study Houses” by Elizabeth A.T. Smith; and Craig Krull Gallery

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A Virtual Look Into Pierre Koenig's Case Study House #22, The Stahl House

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The case study houses forever changed american architecture.

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Scenes from the new showroom of Herman Miller which shows classic designs by Charles and Ray Eames, ... [+] in Culver City, Ca., Oct. 1, 2009. (Photo by Jay L. Clendenin/Los Angeles Times via Getty Images)

The Case Study House Program’s vision belonged to Los Angeles-based Arts & Architecture magazine Editor John Entenza.

Entenza sponsored and publicized some design competitions in the magazine and emphasized modern, affordable, easily built houses.

He announced the Case Study House Program's launch in the January 1945 issue of Arts & Architecture magazine . He envisioned the program to solve the problem of housing shortages and anticipated the coming building boom that would follow War World II and the Depression.

The front side of the Eames House Case Study #8 designed by architects Charles and Ray Eames in ... [+] Pacific Palisades. June 30, 2005. (Photo by Mark Boster/Los Angeles Times via Getty Images)

A 1937 Harwell Harris house has a Streamline Moderne exterior with a white curved porte cochere in ... [+] front (wide enough for the original owner, powerful architecture magazine editor John Entenza s 1925 Ford) and a round bedroom wall in back overlooking Santa Monica Canyon. Peter Rabitz, a co–worker visiting from Germany, enjoys the view into the canyon on a recent visit. (Photo by Gina Ferazzi/Los Angeles Times via Getty Images)

A 1937 Harwell Harris house has the porte cochere at left and entrance to house at right. (Photo by ... [+] Gina Ferazzi/Los Angeles Times via Getty Images)

The goal of the program was for each architect to create a home "capable of duplication and in no sense being an individual performance," Entenza said in his announcement.

"It is important that the best materials available be used in the best possible way in order to arrive at a good solution of each problem, which in the overall program will be general enough to be of practical assistance to the average American in search of a home in which he can afford to live in," he noted.

Architect Pierre Koenig designed two of the iconic Modernist houses in Los Angeles in the 1950s ... [+] known as Case Study House 21 and 22. Drawing of one of Koenig's designs. (Photo by Anacleto Rapping/Los Angeles Times via Getty Images)

The Case Study House Program served as a model for post-war living, providing the public and the building industry an opportunity to access affordable, mid-century modernism and simple designs.

Floor-to-ceiling glass, steel frames, horizontal lines, modular components, open-floor plans and multi-purpose rooms were all elements of the Case Study’s take on modernism. The furnished projects provided places for owners to enjoy a family-friendly home with public and private spaces to relax, watch TV, listen to music and entertain, merging indoor and outdoor worlds with walls of steel and glass to allow ample light.

Initially, Entenza invited Richard Neutra, Charles Eames, Eero Saarinen and five other architects to submit prototypes and planned that all eight houses would be open to the public until they were occupied. The project was ambitious. The Eames and Entenza houses were designed in 1945 but not completed until 1949. Still, the Case Study program was so successful that it ran until 1966 and saw 350,000 visitors tour the open homes before clients took up residence.

Architect Pierre Koenig designed two of the iconic Modernist houses in Los Angeles in the 1950s ... [+] known as Case Study House 21 and 22. Photos of Pierre and Gloria Koenig main living room inside their West Los Angeles home which Pierre designed. (Photo by Anacleto Rapping/Los Angeles Times via Getty Images)

Twenty homes remain today, but 36 experimental prototypes, many unbuilt, documenting new ideas and residential designs, appeared in the magazine.

The majority of the homes were built in Southern California; some are located in San Diego and Northern California; a group of Case Study apartments was built in Phoenix.

Many architects such as Ray and Charles Eames, Saarinen, Craig Ellwood and Pierre Koenig became icons of modernism and earned international followings. The Case Study Houses launched the reputations of local architects such as Thornton Bell, Whitney R. Smith and Rodney Walker.

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American architectural photographer behind "Case Study House No. #22" and whose works gave the genre a new recognition: 2 wds Daily Themed Crossword

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• Published: 27 August 2024

Rate of nosocomial MRSA transmission evaluated via contact screening

• Maria Konstantinovski 1 , 4 ,
• Crista van Geest 2 ,
• Marguerite Bruijning 1 ,
• Lindsay Kroon-de Keizer 3 ,
• Jacco Wallinga 5 , 6 ,
• Nathalie van Burgel 2 &
• Karin-Ellen Veldkamp 1  

Antimicrobial Resistance & Infection Control volume  13 , Article number:  92 ( 2024 ) Cite this article

Metrics details

The prevention of methicillin-resistant S. aureus (MRSA) transmission in the healthcare setting is a priority in Infection Control practices. A cornerstone of this policy is contact tracing of nosocomial contacts after an unexpected MRSA finding. The objective of this retrospective study was to quantify the rates of MRSA transmission in different clinical settings.

This multi-centre study included MRSA contact screening results from two regional hospitals and one academic hospital. MRSA contact tracing investigations from 2000 until 2019 were reviewed and post-contact screening results were included of index patients with an MRSA-positive culture and their unprotected contacts. Available typing results were used to rule out incidental findings.

Of 27,377 contacts screened after MRSA exposure, 21,488 were Health Care Workers (HCW) and 4816 patients. Post-contact screening was initiated for a total of 774 index cases, the average number of screened contacts per index case was 35.7 (range 1 to 640). MRSA transmission was observed in 0.15% (41) of the contacts, 19 (0.09%) HCW and 22 (0.46%) patients. The number needed to screen to detect one MRSA transmission was 667. The highest risk of MRSA transmission occurred during patient-to-patient contacts, with transmission rates varying from 0.32 to 1.32% among the participating hospitals. No transmissions were detected in HCW (n=2834) in the outpatient setting, and the rate of transmissions among HCW contacts on the wards was 0.13% (19 of 15,874). Among 344 contacts of patients with contact precautions, no transmissions were detected.

Conclusions

Reconsidering current MRSA contact tracing practices may lead to a more targeted approach with a lower number needed to screen.

Worldwide, health care institutions struggle with the consequences of Methicillin-Resistant Staphylococcus Aureus (MRSA) infections and their implications for Infection Control strategies. S.aureus is a common cause of infections both in the community and in health-care facilities, but patients with MRSA infections are 64% more likely to die than patients with drug-sensitive infections [ 2 , 17 , 19 ].

Currently, in the Netherlands, the overall MRSA prevalence rate is estimated to be 2% (percentage of MRSA-positive isolates with respect to all Staphylococcus aureus isolates) (ISIS-AR, 2015-2019). This low percentage can partly be explained by the rigorous nationwide MRSA Search and Destroy (S&D) policy. The Dutch MRSA S&D policy in hospitals involves several interventions to detect and eliminate MRSA. The first step is the distribution of a questionnaire before admission to assess whether pre-defined risk factors are present in patients. Subsequently, all identified high-risk patients are preventatively subjected to contact precautions while awaiting culture results. The second step is strict isolation of each proven MRSA-positive patient in a single room until decolonization has been successfully established. A key component is the post-contact screening of any unprotected person who came into contact with an unexpectedly discovered MRSA carrier in order to prevent secondary nosocomial cases and outbreaks. To achieve this aim, all close contacts are identified by means of “contact tracing” and are microbiologically screened for MRSA (contact screening). However, some aspects of this S&D policy, including the post-contact tracing and screening, are labor- and time-intensive. Reducing the number of screened contacts may lower the total efforts and costs associated with this intervention.

The risk of nosocomial transmission after unprotected contact with an MRSA index patient is not well established and depends on multiple characteristics of the interaction. An optimal screening strategy to identify secondary cases of MRSA infection and carriage will ideally take these factors into account, in addition to local factors such as the prevalence of MRSA and the vulnerability of the patient population [ 6 , 12 ].

This retrospective multi-centre study aimed to evaluate the transmission rates of MRSA following unprotected exposure, as identified through a post-contact screening program, spanning a 20-year period across two regional hospitals and one academic hospital in the Netherlands. The secondary aim was to identify potential settings associated with a higher rate of MRSA transmission, enabling the identification of high-risk settings.

Material and methods

Design and setting.

This multi-centre retrospective study included MRSA contact tracing investigations from 2000 until 2019. All patients with an MRSA-positive culture and all unprotected contacts were included. The three participating hospitals were the Reinier de Graaf Gasthuis (RdGG), Haga Teaching Hospital (Haga) and Leiden University Medical Centre (LUMC). Two of these hospitals are secondary care level hospitals with respectively 30 000 (RdGG) and 40 000 (Haga) yearly admissions, and the third is a tertiary care level hospital (LUMC) with 21 000 yearly admissions.

Infection control precautions

All participating hospitals have an MRSA infection control policy that conforms with the then prevailing national guidelines of the Netherlands (WIP '98-2012). Known MRSA carriers receive care under “strict isolation” precautions. These precautions involve placement in a single room with an anteroom and controlled air circulation, with personnel wearing gowns, gloves, and masks at all times. These precautions differ from the “contact isolation” precautions, which are less stringent. “Contact isolation” entails the use of gowns and gloves when there is direct patient contact, but an anteroom and universal masking are not required. “Contact isolation” precautions are applied to patients awaiting the results of the MRSA screening cultures or for other indications, such as ESBL carriage.

Upon admittance, each patient completes an MRSA screening questionnaire to evaluate the presence of nationally pre-defined MRSA risk factors. Patients identified with MRSA risk factors, as outlined in Table 1 , are then microbiologically screened. In the period from 2000 until 2013, these patients were admitted in strict isolation pending the MRSA screening results. In case of an MRSA finding, no contacts were screened. That policy was updated in 2013, and since then, patients were admitted with contact precautions (CP) only whilst awaiting the results of microbiological screening and consequently these contacts were screened in case of MRSA. Patients without risk factors are not routinely screened for the presence of MRSA.

In the case of an unexpected MRSA finding in a clinical sample, the unprotected contacts of the index are microbiologically screened for transmission of MRSA. Unprotected contacts are defined as contacts without all the necessary isolation precautions, such as gloves, mask and gowns, including health care workers (HCW) that care for patients using contact isolation precautions instead of strict isolation precautions These contacts are screened once and as soon as it is known that they are at risk. However, no HCW are screened on the same day as the interaction with the index.

The selection of the contacts that need to be screened varies between different centres, as there are no strict national definitions. However, the guideline advises first to screen the contacts with close and more intense interactions and only to screen the remaining contacts in second instance. In LUMC and RdGG, the selection of contacts includes HCW with direct physical patient contact and patients who shared a room with an MRSA-positive patient. In Haga, all HCW with any kind of interaction are screened, including supporting staff such as meal service and cleaning staff. Also, in Haga, in case of doubt about the exact interactions of a specific MSRA-positive patient during admission, all the patients admitted to the same ward are considered contacts and are therefore screened.

MRSA carriers

During the whole study period, known MRSA carriers were placed in strict isolation upon admission to one of the participating hospitals, and consequently no contacts were screened.

All persons with at least one MRSA-positive finding are considered MRSA carriers. They are offered a decolonisation treatment. In addition, HCW are temporally relieved from patient duties awaiting clearance of their MRSA status after decolonisation.

Contact tracing investigations

Infection prevention files and contact tracing reports from 2000 to 2019 were reviewed to assess the results of MRSA contact tracing and screening initiated after the identification of MRSA-positive patients. In instances suggestive of matching secondary cases among HCW, any additionally screened contacts were included in the study. All other contact screenings with an HCW index were excluded from the study.

Three contact categories were defined: ward HCW, outpatient clinic HCW and patient-to-patient contacts. Details were collected regarding the index and the number, type and location of MRSA contacts. If known, the most invasive site of an index’s first MRSA positive sample was recorded. In case of a secondary finding, microbiological typing data of the index isolate were compared to the contact isolate to confirm or exclude nosocomial transmission. The National Institute for Public Health and the Environment (RIVM) performed molecular typing as part of the voluntary national MRSA surveillance [ 4 ]. Typing methods varied during the study period, multiple locus variable number of tandem repeats analysis (MLVA), pulsed-field gel electrophoresis (PFGE), and spa typing were used. In cases in which no typing was performed, the antibiotic susceptibility results were compared. Non-matching isolates were considered incidental findings.

Laboratory methods

For MRSA screening, nares, throat and rectal or perineal swabs were obtained from patients in addition to any present catheters or skin defects, while HCW submitted nares and throat swabs only, and skin defects if present.

Microbiological procedures varied over time and reflected the standards of the period. In the first years of the study, only cultures were applied for MRSA screening. Inventarisation swabs were incubated overnight in BHI enrichment broth with 2.5% NaCl and colistine and subcultered the next day on a blood and selective MRSA agar. Colonies suspect for S.aureus underwent further testing to confirm identification and antibiotic susceptibility. An isolate was considered MRSA in case of a positive cefoxitin screen combined with a positive PBP2A latex agglutination test. These isolates were referred to the national reference centre, RIVM, for confirmation, typing and surveillance purposes [ 18 ].

With the introduction of PCR MRSA screening methods at some point around 2008, all laboratories adopted a two-step approach. Screening specimens were incubated overnight in an enrichment broth. MRSA-negative samples would be distinguished by means of a PCR based on the detection of an S. aureus -specific gene target and the mec gene PCR on the broth sample, based on previously published protocols (for RdGG: [ 3 ]; for LUMC: [ 9 ]) and for Haga: [ 11 ]). Indeterminate or positive samples were subcultured for additional assessment. In case of growth of S.aureus -suspicious colonies, additional follow-up testing was applied to confirm identification and susceptibility. The previously mentioned PCR was performed on the isolate to confirm MRSA, and the sample was also referred to the national reference centre for confirmation and typing.

For each category of exposure, the accuracy of the proportions of transmissions and negative contacts was estimated using Jeffrey’s method. The proportion was calculated using Epitools. (Sergeant, ESG, 2018. Epitools Epidemiological Calculators. Ausvet. Available at: http://epitools.ausvet.com.au .) Jeffrey’s method was chosen due to the small number of positive findings very close to zero, in which case the use of Fisher’s exact test is less applicable for comparing proportions [ 5 ]. Fisher’s exact test was used to calculate whether the proportion of MRSA transmissions differed significantly between patients with a positive clinical culture and carriage-only index patients.

In the period from 2000 until the end of 2019, a total of 27,649 contacts were identified. For 272 contacts, the results of the cultures could not be obtained and therefore they were excluded from the study. All the remaining 27,377 contacts were included in the study. For the 27,377 included contacts, results were available of MRSA screening following an unprotected contact with an MRSA-positive patient. This total of 2777 included 3853 records with incomplete data. Among these, 2780 were healthcare workers of unknown type, with no information on whether the contact occurred in an outpatient setting or on a ward. Additionally, for 1073 contacts, no information was recorded regarding the setting or whether these contacts involved patients or healthcare workers. In a small minority of 7 instances, post-contact screening was expanded due to secondary findings to include additional contacts of an MRSA-positive HCW. This expansion was only implemented if the HCW and the index had a matching MRSA isolate.

MRSA-positive cultures were identified in 113 of the 27,377 cultured contacts, accounting for 0.41%. Molecular typing results suggested likely nosocomial transmission in 40 of these contacts, while transmission was ruled out in 72 cases. In one case, no additional typing results were available; consequently, this case was classified as a transmission in subsequent calculations, bringing the number of (assumed) transmissions to 41. Hence, among the 113 MRSA-positive contacts, 64% were deemed incidental findings without secondary transmission.

The overall number of contacts needed to screen (NNS) to detect one MRSA transmission was calculated to be 668 (27,377/41 =668).

The highest percentage of the secondary MRSA findings was due to patient-to-patient contacts, with transmission rates varying from 0.32 to 1.32% among the participating hospitals. No transmissions were detected in HCW in the outpatient setting, and the transmission rate among HCW contacts on the wards was 0.13% (19 of 15,874). A detailed overview is presented in Table 2 . Among the 344 contacts of patients with contact precautions, no transmissions were detected (95% CI 0.00-0.007)

In the study period, post-contact screening was initiated for a total of 774 index cases, 225 in the LUMC, 421 in Haga and 128 in RdGG. The average number of screened contacts per index case was 35.7 (range 1–640). Of all the post-contact screenings, 45% had 10 or fewer contacts, whilst 1% had more than 220 contacts. Figure 1 illustrates the frequency of post-contact screenings categorized by the number of included contacts, providing an overview of the size and distribution of post-contact screenings.

Frequency of post-contact screenings shown by number of included contacts. The bar graph illustrates the frequency of initiated post-contact screenings. The bars indicate the frequency categorized by the size of each screening. The y-axis represents the size of the screenings in increments of 10 contacts, while the x-axis shows the frequency in which screenings of each size were initiated. *post-contact screenings of up to 10 contacts have been initiated 343 times. For clarity, the x-axis is visually limited to 100

Figure 2 presents an overview of the number of indices per hospital and screened contacts per year.

Overview of screened contacts per year and divided per centre. The bar graph shows the total number of screened contacts per year. The table displays the number of index cases per year and per hospital, with the upper row showing the likely transmissions. H-Haga ziekenhuis, R- Reinier de Graaf Gasthuis, L-Leiden University Medical Centre, 9999=Unknown year of occurrence

To determine if clinical infections were more prone to nosocomial transmission than positive carriage sites alone (such as the nose/throat or rectum), we compared the transmission rates between the two groups. Clinical data regarding the initial site of MRSA infection or carriage for the index patients were available for most cases in two of the three hospitals, with the most invasive site recorded. For example, a patient with both a wound infection and throat carriage was categorized as a skin and soft tissue index case.

Analysis of the number of contacts involved showed that the 195 infection index cases led to the screening of 5558 ward HCW and 522 copatients, among whom 14 transmissions were detected, 8 in the HCW group and 6 in the copatient group. By contrast, the 111 carrier-only index cases resulted in the screening of 2451 ward HCW and 282 copatients, among whom 2 transmissions were detected, 1 in the HCW group and 1 in the copatient group. However, the p-value of Fisher’s exact test was not statistically significant. The Supplementary file 1 : table s2 provides an overview of the types of infections.

Index cases with proven transmission among their contacts varied considerably in their clinical characteristics. An overview of the index characteristics and the setting of the MRSA transmissions can be found in the supplement.

MRSA screening results were available for a total of 27,377 contacts after MRSA exposure, 21,488 of whom were HCW and 4816 were patients. A total of 41 (0.15%) secondary MRSA cases were detected. The number of contacts needed to screen to detect one MRSA transmission was 667. The highest rate of MRSA transmission was among patient-to-patient contacts. No transmission was detected among HCW contacts of outpatients with MRSA or of index patients who were treated in accordance with contact precautions.

The proportion of MRSA-positive contacts in this study is broadly consistent with the findings of most previous studies, which reported proportions of secondary cases ranging from 0.19 to 0.5% [ 2 , 7 , 10 ]. However, it differs greatly from the proportions reported by some other studies, which ranged from 4.7 to 12.6% [ 8 , 13 ] This discrepancy can be explained by the fact that the studies that reported very dissimilar percentages used different methods to identify contacts than the present study.

We also observed a variation in transmission percentages between the hospitals which participated in the present study. This variation may be partially explained by differences between screening protocols. For instance, if the interactions of the patient during admission are uncertain, the policy in the Haga Hospital is to screen not only roommates but also all the other patients on the same ward. Including a larger number of contacts with very limited interactions will probably lower the overall transmission rate. By contrast, limiting the selection of screened patients will increase the probability of missing a transmission, but the net effect on the detected transmission rate remains unknown. It is not possible to attribute all the differences in the numbers of secondary cases between the centres to differences between the contact tracing protocols.

An important limitation of this study is its retrospective design. Incomplete administrative data resulted in incomplete records, which may have led to an underestimation of the transmission rates in certain settings or to other unknown effects. To mitigate this limitation, we utilized multiple sources and archives, such as laboratory logs and outbreak reports, to capture all nosocomial transmission events. In addition, the retrospective nature of the study means that various typing methods have been used over the years, which potentially introduced variability into the results. For a more accurate evaluation of local contact screening practices, prospective registration is recommended. Another limitation is the limited generalizability of the results to other countries. The Netherlands is a high-resource setting that endeavours high compliance with basic hygiene practices and hospital hygiene guidelines. Therefore, the findings may not be directly applicable to settings with different resources and hygiene practices.

According to our findings, several factors seemed to increase the probability of MRSA transmission. We observed that MRSA transmission was only likely after contact on a clinical ward, either between patients or between an inpatient and a nurse who cared for that patient. No MRSA-positive contacts were detected among outpatient contacts. We hypothesize that such interactions are usually brief and do not involve close physical contact, which makes transmission less likely. This finding is in accordance with observations of other authors, who showed that MRSA transmission was facilitated by a longer duration and a greater intensity of contact [ 15 , 16 ].

Another factor, albeit not statistically significant, was the trend that contact with a carrier led to fewer secondary cases than contact with an MRSA index an infection. An important limitation for this observation was the lack of data for carriers only, as it was not always known why carriers were screened. In case of a known risk factor and pending screening results, compliance with basic hygiene precautions may be higher, which may lower the chance of transmission.

The highest risk of MRSA acquisition was found in contacts between patients sharing a room. This higher transmission risk was also described by Moore et al and Ng et al in studies that focused on inpatients’ roommates [ 13 , 14 ]. A probable explanation is that sharing a room with an MRSA carrier leads to continuous exposure to an MRSA-colonized environment, which results in a higher transmission risk. These factors could be of special interest in settings with lower overall basic hygiene precautions as the magnifying role of environmental colonization and clinical infections may be mitigated by strict adherence to basic precautions.

The quantity of incidental findings may be influenced by differences in background MRSA carriage , as opposed to nosocomial transmission rates. In several instances, incidental MRSA findings among screened contacts were more prevalent than transmissions. This finding indicates that despite current risk-based screening practices, some MRSA cases remain undetected. However, the incidental carriage rate remained consistently low. Currently, there is no insight into the carriage percentages of MRSA in different demographic groups in the Netherlands. We assume that these percentages vary widely, as incidental MRSA findings may be considered a proxy parameter for MRSA carriage. In the Haga Hospital in The Hague, the incidentally found MRSA outnumbered the detected transmissions. The three hospitals included in this study serve different patient populations, and the cause of the high percentage of incidental findings of MRSA among HCW in the Haga Hospital is unknown. Further research should explore the effects of alternative screening strategies if the background carriage rate significantly outnumbers the transmission risk. Local carriage rates may thus have important implications for developing and evaluating current screening practices.

This study revealed that over the past 20 years, MRSA transmission to HCW occurred at a rate of only 1 to 2 per 1000 contacts in the three participating hospitals, exclusively on clinical wards. Interestingly, the study found a tendency towards reduced transmission rates in situations where contact precautions are implemented, in outpatient settings, and among carriers, although this trend lacks statistical significance. Further investigation into optimal hospital hygiene practices for these specific groups is necessary.

The efficacy of MRSA contact screening should be carefully evaluated. Based on our findings, it may be more efficient to focus post-contact screening efforts exclusively on contacts of inpatients. Revisiting current MRSA preventative practices, informed by local data, may help to develop a more targeted and effective approach.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

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Maria Konstantinovski, Marguerite Bruijning & Karin-Ellen Veldkamp

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Jacco Wallinga

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Study conception and design by MMK and KEV. Data investigation, data collection and curation were performed by MMK CG and MB. LK and NB contributed data analysis and interpretation. JW aided with statistical methodology. KEV provided supervision, revising the manuscript critically together with NB for important intellectual content. The first draft of the manuscript was written by MMK and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Konstantinovski, M., van Geest, C., Bruijning, M. et al. Rate of nosocomial MRSA transmission evaluated via contact screening. Antimicrob Resist Infect Control 13 , 92 (2024). https://doi.org/10.1186/s13756-024-01448-8

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Received : 27 September 2023

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DOI : https://doi.org/10.1186/s13756-024-01448-8

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