Infection control practices are not uniformly successful in limiting outbreaks of vancomycin-resistant enterococci (VRE). Despite the implementation of barrier precautions for VRE-infected patients, nearly one-half of the inpatients at our center were found to have gastrointestinal colonization by VRE. In an attempt to control the outbreak, we altered the antibiotic formulary by restricting the use of cefotaxime and vancomycin and adding beta-lactamase inhibitors to replace third-generation cephalosporins. The use of clindamycin was also restricted because of a concomitant outbreak of Clostridium difficile colitis. After 6 months, the average monthly use of cefotaxime, ceftazidime, vancomycin, and clindamycin had decreased by 84%, 55%, 34%, and 80%, respectively (P < .02). The point prevalence of fecal colonization with VRE decreased from 47% to 15% (P < .001), and the number of patients whose clinical specimens were culture positive also gradually decreased. A change in antibiotic use appears to have significantly affected our VRE outbreak when previous measures failed.

Acinetobacter species are problematic nosocomial pathogens. In November 1997, pathogens isolated by microbiology laboratories were collected from 15 hospitals in Brooklyn, New York. Acinetobacter species accounted for 10% of gram-negative isolates. Only half of Acinetobacter species were susceptible to carbapenems; 11 hospitals had at least 1 isolate resistant to carbapenems. Other Acinetobacter susceptibility rates were as follows: polymyxin, 99%; amikacin, 87%; ampicillin/sulbactam, 47%; ceftazidime, 25%; and ciprofloxacin 23%. Overall, 10% were resistant to all commonly used antibiotics. Genetic analysis by use of pulsed-field gel electrophoresis of 12 carbapenem-resistant isolates revealed 4 strains that were recovered from >1 hospital, which suggests interinstitutional spread. Antibiotic usage data from 11 hospitals revealed that the use of third-generation cephalosporins was associated significantly with the percentage of carbapenem-resistant strains (P=.03). Resistant Acinetobacter species have become endemic in Brooklyn, New York. Citywide strategies that involve surveillance, infection-control practices, and the reduction of antibiotic usage may be necessary to control the spread of these pathogens.

The largest group of patients who present with the syndrome of lung hemorrhage and nephritis have ANCAs and not anti-GMB antibodies. Appropriate tests for antibodies to proteinase 3, antibodies to myeloperoxidase, and anti-GBM antibodies provide reliable guides for making a diagnosis in patients with this pulmonary renal syndrome.

In November 1997, all Enterobacteriaceae isolated at 15 hospitals in Brooklyn were collected. Extended-spectrum beta-lactamases (ESBLs) were present in 44% of 409 Klebsiella pneumoniae isolates. Six isolates had reduced susceptibility to carbapenems, including two that were not susceptible to any of the antibiotics tested. Pulsed field gel electrophoresis revealed a commonality of resistant isolates within and between hospitals. The occurrence of ESBLcontaining isolates was associated with cephalosporin usage (P = 0.055). ESBLs were present in 4.7% of Escherichia coli and 9.5% of Proteus mirabilis isolates. It is concluded that ESBL-producing Enterobacteriaceae are endemic in Brooklyn, are spread between hospitals, and may be associated with cephalosporin usage.

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