Microbiology laboratories in Oregon were surveyed in 1981 to determine how often methicillin-resistant Staphylococcus aureus (MRSA) was being reported to physicians in the state. Results of this survey were surprising in three respects. First, the mean percent of S. aureus isolates reported by laboratories as methicillin-resistant was 8.3%. Second, a significant inverse correlation was found between the percent of reported MRSA and laboratory size (p=0.0001). Finally, laboratories which retested initially resistant isolates reported significantly less MRSA (mean 3.3%, median 1%) than those laboratories which accepted initial results (mean 20%, median 12%) (p=0.0001). Independent testing by the Centers for Disease Control of isolates reported to be MRSA confirmed that some misideiitification was occurring. Participating laboratories were notified of our initial findings and their potentially serious clinical ramifications. Laboratories were resurveyed in 1982, and a significant decrease in the reported MRSA to a mean percentage of 3.4% was observed (p=<0.002). It is unlikely that this situation is unique to Oregon, and similar misreporting of MRSA to physicians in other areas of the country may be compromising the safe and effective treatment of S. aureus infections.

Urinary tract infections associated with the temporary use of indwelling bladder catheters remain a vexing problem in acute care hospitals. The appreciable morbidity and mortality from these infections are still under active investigation. Because of the large numbers of patients at risk, increased attention is also being given to the costs for prevention, detection, treatment, and follow-up of catheter-associated infections.

Before the advent of commercially available systems for maintaining closed sterile urinary drainage, infection was believed to be inevitable. In the past 25 years, the successful prevention of infection in 70% to 80% of catheterized patients by aseptic methods has undoubtedly prevented thousands of deaths from gram-negative bacteremia and stimulated efforts to further reduce the infection rate.

A large outbreak of infections caused by methicillin and aminoglycoside resistant Staphylococcus aureus provided the opportunity to evaluate mechanisms of resistance and compare the usefulness of typing systems. Between January 1979 and December 1980, 63 patients developed infections with S aureus resistant to multiple antibiotics, including methicillin and tobramycin. All isolates had an identical antibiogram and were phage type 47/54/75/77/83A. Beginning in January 1981, a superimposed outbreak caused by S aureus of the same phage type but with a resistance pattern now including gentamicin occurred. The two strains contained different aminoglycoside inactivating enzymes. The initial strain contained a single plasmid of 21.5 mDa molecular weight, whereas the subsequent strain which had acquired gentamicin resistance contained this plasmid plus a heavier one of 33 mDa. Plasmid analysis complements the analysis of antibiograms and phage types and aids in defining epidemiologic patterns of transmission.

During an 11-week period, all antibiotic usage on a 113-bed medical teaching service was reviewed concurrently in weekly sessions between house staff and a review team. Recommendations for change, based on accepted criteria, were communicated by the house officer to the attending physician. In one-half of the patients no change was suggested; in one-third, a recommended change was made; and in only one-sixth was a recommendation not followed. Cost savings were conservatively estimated to approach $10,000 in this pilot study; this extrapolates to almost $300,000 per year for the 714-bed medical center, or more than 18% of the antibiotic expenditures.

This program achieves its objective in a nonthreatening, noncontrolling manner, provides continuing education, and contributes to improved patient care.

We identified 29 episodes of suppurative thrombophlebitis in 27 patients admitted to a large general hospital between May 1980 and May 1984. In 25 patients, the intravenous cannulae had been in place for more than 3 days. Streptococcus faecalis, Pseudomonas aeruginosa or one of the Enterobacteriaceae were implicated in 14 patients. All these patients had recently undergone abdominal surgery or had a major intraabdominal inflammatory process at the time they developed thrombophlebitis. The remaining 13 patients were infected with Staphylococcus aureus, other grampositive cocci or Candida species. Only two of these had an active abdominal process at the time of their infection (x2 = 16.08, P<0.001). There is an apparent association between phlebitis caused by enteric organisms and active intra-abdominal pathology. There were two deaths related to delayed or deferred surgery. Suppurative thrombophlebitis is a lethal, preventable nosocomial infection that requires urgent surgical intervention.