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Enterococci have become a significant cause of nosocomial infections in the past two decades. Moreover, acquisition of new resistance traits such as aminoglycoside resistance, β-lactamase production, high-level resistance to penicillins due to penicillin-binding protein changes and glycopeptide resistance has dramatically limited therapeutic options for disease caused by these organisms. Although hospital-associated enterococcal infections were previously thought to be derived from endogenous flora, recent epidemiologic studies, assisted in some instances by the application of new molecular techniques, have identified both intra- and inter-hospital spread of strains of enterococci. These studies have indicated that person-to-person transmission via the hands of health care personnel may occur and have implicated inanimate objects as a possible source of enterococcal infection. It has also been shown that a major risk factor for nosocomial acquisition of enterococci is the use of antibiotics, presumably because enterococci are resistant to many of the commonly used antimicrobial regimens. With the information currently available, there can be little doubt that nosocomial infections due to enterococci will continue to be important in the future. Rapid identification of patients infected or colonized by multi-resistant enterococci, strict adherence to infection control practices, and prudent use of antibiotics all seem necessary to control and prevent nosocomial infections due to enterococci.

The effect of daily administration of trimethoprim (TMP), trimethoprim–sulfamethoxazole (TMP-SMX), or placebo on aerobically grown fecal gram-negative bacteria was monitored in 136 students from the United States during a two-week diarrhea-prevention study in Mexico. Unlike patients in other studies with these agents, who had urinary-tract infection or granulocytopenia, most persons in this study had no change in total fecal Enterobacteriaceae and had high-level TMP and SMX resistance in virtually all these strains. Escherichia coli was the predominant TMP-resistant organism isolated; 96 per cent of 165 TMP-resistant Esch. coli isolates were resistant to at least four antimicrobial agents, and 25 per cent were resistant to seven. TMP resistance was transferable in 40 of 100 strains tested. Despite the lack of TMP resistance in other studies of prophylaxis, our results clearly demonstrate the remarkable capacity for emergence and dissemination of resistance to this agent. (N Engl J Med. 1982; 306:...

In an attempt to assess cardiac risk in non-cardiac surgery, 1001 patients over 40 years of age who underwent major operative procedures were examined preoperatively, observed through surgery, studied with at least one postoperative electrocardiogram, and followed until hospital discharge or death. Documented postoperative myocardial infarction occurred in only 18 patients; though most of these patients had some pre-existing heart disease, there were few preoperative factors which were statistically correlated with postoperative infarction. Postoperative pulmonary edema was strongly correlated with preoperative heart failure, but 21 of the 36 patients who developed pulmonary edema did not have any prior history of heart failure. Nearly all of these 21 patients were elderly, had abnormal preoperative electrocardiograms, and had intraabdominal or intrathoracic surgery. In the absence of an acute infarction, bifascicular conduction defects, with or without PR interval prolongation, never progressed to complete heart block. Spinal anesthesia protected against postoperative heart failure but not against other cardiac complication. By multivariate regression analysis, postoperative cardiac death was significantly correlated with (a) myocardial infarction in the previous 6 months; (b) third heart sound or jugular venous distention immediately preoperatively; (c) more than five premature ventricular contractions per minute documented at any time preoperatively; (d) rhythm other than sinus, or premature atrial contractions on preoperative electrocardiogram; (e) age over 70 years; (f) significant valvular aortic stenosis; (g) emergency operation; (h) a 33% or greater fall in systolic blood pressure for more than 10 minutes intraoperatively. Notably unimportant factors included smoking, glucose intolerance, hyperlipidemia, hypertension, peripheral atherosclerotic vascular disease, angina, and distant myocardial infarction.