A carbapenem-resistant isolate of Escherichia coli was identified that possessed a 23-kb plasmid encoding Klebsiella pneumoniae carbapenemase type 2 (KPC-2). A subsequent surveillance study involving hospitals in Brooklyn, New York, revealed that, among 1417 E. coli isolates, 7 isolates (from 3 hospitals) possessed bla(KPC-2). E. coli possessing KPC-2 is emerging in our region, and improved methods for detection are urgently needed.

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This case illustrates the need to better define the geographic extent and modes of transmission of this debilitating disease so that primary control measures can be identified. In addition, health workers must be provided with the training and tools to diagnose and treat M. ulcerans. Research into a point-of-care diagnostic test is needed so that timely treatment can minimize disability and costs to the family. Acknowledgments Thanks to Emily Duecke, Sidy Ba, Carlos Bleck, and Teunella Wolters for their sharp clinical skills and therapeutic efforts on behalf of this patient. About the Author Ms. Turner is a family nurse practitioner living and working in Dakar, Senegal. Her background includes trauma and pediatric primary care in high-income and low-income countries. References 1. Sakyi SA, Aboagye SY, Otchere ID, Yeboah-Manu D. Clinical and laboratory diagnosis of Buruli ulcer disease: a systematic review.

Enterococci resistant to ampicillin, vancomycin, and/or aminoglycosides are a growing clinical problem. We studied the in vitro activity of the new fluoroquinolone clinafloxacin (PD 127,391) against 15 clinical isolates of multidrug-resistant Enterococcus faecium. In kill-kinetic studies, clinafloxacin (1 ,ug/ml) was bactericidal against 7 of 12 susceptible isolates, although substantial regrowth occurred in 4 isolates at 48 h. The addition of ampicillin (20 ,ug/ml) resulted in bactericidal activity in all 12 isolates, and no regrowth was seen. For three isolates resistant to clinafloxacin, effective killing was not observed at these concentrations of antibiotics. Clinafloxacin with ampicillin shows promising activity against many of these multiply resistant enterococci.Nosocomial outbreaks of increasingly resistant enterococci have been recently documented (4,5,7). Prolonged treatment with a cell wall agent is recommended for infections with enterococci possessing high-level aminoglycoside resistance (8). However, effective therapeutic regimens have not been established for enterococci with concomitant resistance to vancomycin, ampicillin, and aminoglycosides. The combination of ampicillin and ciprofloxacin has been previously shown to be bactericidal against many of these isolates in vitro; however, this activity was dependent on concentrations which were near the peak levels achieved clinically (6). Newer quinolones have been reported to have greater activity against gram-positive bacteria (9, 13) and deserve further investigation. We evaluated the activities of two of these agents against strains of multidrug-resistant Enterococcus faecium.Fifteen isolates of E. faecium were collected from two hospitals in Brooklyn, N.Y., and from the Centers for Disease Control, Atlanta, Ga., as previously described (6) 630-3761. and 1 ,g/ml, and the combination of both antibiotics. These concentrations of clinafloxacin are well within the levels achievable in humans (1). For three isolates with higher-level quinolone resistance (ciprofloxacin, MIC > 16 jxg/ml; clinafloxacin, MIC > 2 ,ug/ml), a higher concentration of clinafloxacin (3 ,ug/ml) was also tested. Cultures was incubated in glass tubes at 37°C. The cultures were vortexed at 20 h of incubation and prior to colony count determinations. Aliquots were obtained at 0, 4, 24, and 48 h of incubation, diluted in normal saline, and streaked onto tryptic soy agar with 5% sheep blood. In separate studies, antibiotic carryover was tested for using similar antibiotic concentrations, and no carryover effect was detected. The lowest number of detectable organisms was 33 CFU/ml. Killing rates for the ampicillin-plus-clinafloxacin combination were confirmed with repeated studies. Bactericidal activity was defined as a decrease of log1o CFU per milliliter of .3 at 24 h. Results are expressed as the change in loglo CFU per milliliter (mean ± standard deviation).A microbiological assay using well diffusion with Escherichia coli ATCC 25922 was used to measure the levels of bioact...

Antibiotic resistant strains of enterococci are being isolated with increasing frequency. Effective treatment of infections caused by Enterococcus faecium resistant to ampicillin, vancomycin and aminoglycosides has not been established. We studied the activity of ramoplanin, a new lipoglycopeptide antibiotic, against two strains of multidrug resistant E. faecium. In time kill studies, ramoplanin was bactericidal against both strains, but not in the presence of 50% serum. The combination of ramoplanin and penicillin was bactericidal even in the presence of serum. In rabbits with experimental endocarditis neither penicillin nor ramoplanin significantly reduced vegetation colony counts when given alone, although ramoplanin significantly reduced spleen and kidney bacterial counts of both strains. The combination of ramoplanin plus penicillin resulted in a significant reduction of vegetation bacterial counts (-3.2 and -3.7 log10 cfu/g for strains VA3 and MMC3, respectively, P < 0.01). All spleen cultures and 9 out of 10 kidney cultures from each strain were sterile following combination therapy. While ramoplanin will not be available for parenteral therapy, further research into the development of other lipoglycopeptide antibiotics is warranted.