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A methicillin-resistant Staphylococcus aureus (MRSA) control policy, aimed at eradication, was established at a 1000-bed hospital in 1985, applied consistently for 10.5 years, and then relaxed. Its components included screening of high-risk patients, transfer of carriers to exhaust-ventilated isolation rooms, closure of wards to new admissions when local transmission was detected, MRSA screening during outbreaks, and prospective collection of clinical and epidemiological information. During the eradication policy period, every 6 months, a mean of 5.1 patients (range 1-12) already carrying MRSA were admitted, and a mean of 3.6 (range 0-16) acquired carriage in the hospital. The largest outbreak comprised 11 patients despite epidemic MRSA strain EMRSA-16 being introduced six times, and MRSA did not become endemic. MRSA-positive admissions increased progressively from 1993; nursing staff workload increased, areas available for alternative patient accommodation were reduced, the resulting ward closures interfered with clinical services, and hence the control policy was relaxed in mid-1995. Isolation facilities were overwhelmed with 622 new patient-isolates in the next 18 months, and there were 67 clinical infections in 1996. The proportion of blood cultures positive for MRSA rose nearly sevenfold by 1996 and 27-fold by 1997. Thus, repeated eradication of MRSA, even epidemic strains, by use of a stringent policy, is possible given sufficient resources, whereas flexible national guidelines designed to control, but not eradicate, epidemic staphylococci, are currently unlikely to be successful. The costs of eradication policies need to be weighed against those of endemicity.

The prevalence of Salmonella enterica serotype Paratyphi A infection is increasing, and multidrug resistance is a well-recognized problem. Resistance to fluoroquinolones is common and leads to more frequent use of newer agents like azithromycin. We report the first case of azithromycin resistance and treatment failure in a patient with S. Paratyphi A infection. CASE REPORTA 48-year-old male doctor presented to the accident and emergency department with a 2-week history of rigors, fever, and lethargy following a 10-day vacation in Islamabad, Pakistan. He had not been vaccinated against typhoid or taken antimalarial chemoprophylaxis. He developed diarrhea 2 days prior to the end of his stay in Pakistan and took oral metronidazole at 400 mg three times daily for 5 days. The diarrhea resolved, but his temperature continued to spike to 39°C over the following 2 weeks. He had a prior medical history of hypercholesterolemia and gout and had had an appendectomy as a young student. His regular medications consisted of allopurinol at 200 mg once daily and simvastatin at 20 mg once daily. Clinical examination on presentation was unremarkable other than a temperature of 38.5°C.Initial laboratory investigations revealed a raised alanine transaminase (ALT) level of 93 IU/liter (normal value, 10 to 50 IU/liter), a bilirubin level of 20 mol/liter (normal value, 3 to 17 mol/liter), and a C-reactive protein (CRP) level of 70 mg/liter (normal value, Ͻ5 mg/liter). Full blood count, serum electrolytes, and creatinine were within normal limits. Chest and abdominal radiographs showed no abnormalities. A malaria blood film and antigen test were negative.In view of the possibility of enteric fever, he was started on oral ciprofloxacin at 500 mg twice daily according to the hospital antibiotic policy. He was reluctant to be admitted to the hospital and was discharged with a follow-up appointment in the infectious diseases outpatient clinic. Blood cultures taken on admission yielded Salmonella enterica serotype Paratyphi A, which was reported as sensitive to ciprofloxacin on disc testing.The patient presented again following 7 days of treatment with persistent fever and rigors. He remained reluctant to be admitted, and so antimicrobial therapy was changed to oral azithromycin.His symptoms worsened over the next 3 days, and he was admitted to the hospital. He complained of increasing frequency of rigors and fevers, occurring every 4 h and lasting for 2 h, and a dry cough. He had been fully adherent to the antimicrobial therapy prescribed. On examination he had a temperature of 38°C and the spleen was palpable 1 cm below the costal margin. In view of the poor response to treatment, antimicrobial therapy was changed to intravenous ceftriaxone at 2 g once daily.Laboratory investigations revealed a raised CRP level of 65 mg/liter (normal value, Ͻ5 mg/liter), an ALT level of 358 IU/liter (normal value, 10 to 50 IU/liter), an alkaline phosphatase level of 256 IU/liter (normal value, 30 to 200 IU/liter), and a negative malaria film. A repeat ches...

Multiple introductions of methicillin-resistant Staphylococcus aureus (MRSA) strains occurred to a new hospital in Hong Kong. Two years of clinical microbiological surveillance of the resulting outbreaks was combined with laboratory investigation by phage and antibiogram typing, and plasmid profiling. The outbreaks on the special care baby (SCBU) and burns (BU) units were studied in detail, and colonization of staff and contamination of the environment were investigated. MRSA were spread by the hands of staff on the SCBU, where long-term colonization of dermatitis was important, but were probably transmitted on the BU by a combination of the airborne, transient hand-borne and environmental routes. Simple control measures to restrict hand-borne spread on the SCBU were highly effective, but control was not successful on the BU.