Occurrence and spread of antibiotic resistances in Enterococcus faecium.

Enterococci are the second to third most important bacterial genus in hospital infections. Especially Enterococcus (E.) faecium possesses a broad spectrum of natural and acquired antibiotic resistances which are presented in detail in this paper. From medical point of view, the transferable resistances to glycopeptides (e.g., vancomycin, VAN, or teicoplanin, TPL) and streptogramins (e.g., quinupristin/dalfopristin, Q/D) in enterococci are of special interest. The VanA type of enterococcal glycopeptide resistance is the most important one (VAN-r, TPL-r); its main reservoir is E. faecium. Glycopeptide-resistant E. faecium (GREF) can be found in hospitals and outside of them, namely in European commercial animal husbandry in which the glycopeptide avoparcin (AVO) was used as growth promoter in the past. There are identical types of the vanA gene clusters in enterococci from different ecological origins (faecal samples of animals, animal feed, patients in hospitals, persons in the community, waste water samples). Obviously, across the food chain (by GREF-contaminated meat products), these multiple-resistant bacteria or their vanA gene clusters can reach humans. In hospital infections, widespread epidemic-virulent E. faecium isolates of the same clone with or without glycopeptide resistance can occur; these strains often harbour different plasmids and the esp gene. This indicates that hospital-adapted epidemic-virulent E. faecium strains have picked up the vanA gene cluster after they were already widely spread. The streptogramin virginiamycin was also used as feed additive in commercial animal husbandry in Europe for more than 20 years, and it created reservoirs for streptogramin-resistant E. faecium (SREF). In 1998/1999, SREF could be isolated in Germany from waste water of sewage treatment plants, from faecal samples and meat products of animals that were fed virginiamycin (cross resistance to Q/D), from stools of humans in the community, and from clinical samples. These isolations of SREF occurred in a time before the streptogramin combination Q/D was introduced for therapeutic purposes in German hospitals in May 2000, while other streptogramins were not used in German clinics. This seems to indicate that the origin of these SREF or their streptogramin resistance gene(s) originated from other sources outside the hospitals, probably from commercial animal husbandry. In order to prevent the dissemination of multiple antibiotic-resistant enterococci or their transferable resistance genes, a prudent use of antibiotics is necessary in human and veterinary medicine, and in animal husbandry.

Antimicrobial susceptibilities of Lactobacillus, Pediococcus and Lactococcus human isolates and cultures intended for probiotic or nutritional use.

OBJECTIVES: To determine MICs of 16 antimicrobials representing all major classes for 473 taxonomically well-characterized isolates of lactic acid bacteria (LAB) encompassing the genera Lactobacillus, Pediococcus and Lactococcus. To propose tentative epidemiological cut-off (ECOFF) values for recognizing intrinsic and acquired antimicrobial resistances in numerically dominant species. METHODS: On the basis of depositors' information, LAB were grouped in categories of probiotic, nutritional, probiotic or nutritional research, human and animal isolates and tested for their antibiotic susceptibilities by broth microdilution using LAB susceptibility test medium (LSM). Tentative ECOFFs were defined according to the recommendations of the European Committee on Antimicrobial Susceptibility Testing. Isolates showing acquired antimicrobial resistance(s) were selected for PCR-based detection of resistance gene(s) and in vitro conjugative transfer experiments. RESULTS: Tentative ECOFF values of 13 antibiotics were determined for up to 12 LAB species. Generally, LAB were susceptible to penicillin, ampicillin, ampicillin/sulbactam, quinupristin/dalfopristin, chloramphenicol and linezolid. LAB exhibited broad or partly species-dependent MIC profiles of trimethoprim, trimethoprim/sulfamethoxazole, vancomycin, teicoplanin and fusidic acid. Three probiotic Lactobacillus strains were highly resistant to streptomycin. Although erythromycin, clindamycin and oxytetracycline possessed high antimicrobial activities, 17 Lactobacillus isolates were resistant to one or more of these antibiotics. Eight of them, including six probiotic and nutritional cultures, possessed erm(B) and/or tet(W), tet(M) or unidentified members of the tet(M) group. In vitro intra- and interspecies filter-mating experiments failed to show transfer of resistance determinants. CONCLUSIONS: Finding of acquired resistance genes in isolates intended for probiotic or nutritional use highlights the importance of antimicrobial susceptibility testing in documenting the safety of commercial LAB.

Rapid emergence of resistance to linezolid during linezolid therapy of an Enterococcus faecium infection.

We report the emergence of linezolid resistance (MICs of 16 to 32 mg/liter) in clonally related vancomycin-susceptible and -resistant Enterococcus faecium isolates from an intensive care unit patient after 12 days of linezolid therapy. Only linezolid-susceptible isolates of the same clone were detected at 28 days after termination of linezolid therapy.

Molecular epidemiology of hospital-acquired vancomycin-resistant enterococci.

Vancomycin-resistant Enterococcus faecium strains are a significant cause of nosocomial infections in predisposed patients. Multiple-locus variable-number tandem repeat analysis (MLVA) has been validated recently by use of a global strain collection. In this report, we applied MLVA together with multilocus sequence typing (MLST) and pulsed-field gel electrophoresis (PFGE) to type 14 isolates from three clusters of patients colonized or infected with vancomycin-resistant Enterococcus faecium and another 10 epidemiologically unrelated isolates from the same hospital. The clusters could be distinguished by all three typing methods, which proved to be concordant. PFGE patterns provided the highest resolution. We observed seven sequence types (ST), six MLVA types (MT), and nine distinct ST/MT combinations. The combination of MLST and MLVA may be an alternative to PFGE in hospital epidemiology, providing the benefits of high accuracy, reproducibility, and portability.

Evaluation of new broth media for microdilution antibiotic susceptibility testing of Lactobacilli, Pediococci, Lactococci, and Bifidobacteria.

Nine pure or mixed broth media were evaluated for their suitabilities to determine MICs in a microdilution test of 19 antibacterial agents for lactic acid bacteria (LAB) of the genera Lactobacillus, Pediococcus, Lactococcus, and Bifidobacterium. A mixed formulation of Iso-Sensitest broth (90%) and deMan-Rogosa-Sharpe broth (10%) with or without supplementation with L-cysteine, referred to as the LAB susceptibility test medium, provided the most optimal medium basis in terms of growth support of nonenterococcal LAB and correct indication of MICs of international control strains.

Identification of enterococci and determination of their glycopeptide resistance in German and Austrian clinical microbiology laboratories.

OBJECTIVE: To determine exactly how German and Austrian routine laboratories perform tests for the identification of enterococci and determination of their glycopoptide resistance. METHODS: Six enterococcal test strains with different types of glycopeptide resistance (Enterococcus faecium, VanA; E. faecalis, VanA; E. faecium, VanB; E. faecalis, VanB; E. gallinarum, VanC1; E. casseliflavus, VanC2) were sent as anonymous isolates to 73 clinical microbiology laboratories (65 in Germany; eight in Austria). The participating laboratories had to identify the strains up to the species level and to determine their antibiotic susceptibilities to the glycopeptides vancomycin and teicoplanin by the test method(s) that are used daily in the corresponding laboratories. RESULTS: The analysis of the results received from 62 laboratories (56 from Germany, six from Austria) demonstrated that the most used routine method in susceptibility testing was the agar diffusion test, followed by the Etest, and the microbroth dilution procedure. The majority of participants had no difficulties in susceptibility testing with the VanA-type strains. However, the agar diffusion test was often not able to recognize clearly the VanB and VanC strains; some problems also arose with VanB isolates in the Etest. With the microbroth dilution method, the corresponding type of glycopeptide resistance was correctly determined in the majority of enterococcal test strains. Difficulties also arose in identification, especially with the VanC strains (E. gallinarum and E. casseliflavus), which were often falsely identified as E. faecium. The reasons for these errors are obviously based on the lack of important tests (such as motility and presence of a yellow pigment) in some commercially available identification test kits.

A potential virulence gene, hylEfm, predominates in Enterococcus faecium of clinical origin.

An open reading frame (hyl(Efm)) with homologies to previously described hyaluronidase genes has been identified in nonstool isolates of Enterococcus faecium. E. faecium isolates (n=577) from diverse sources were screened for the presence of hyl(Efm) and esp(Efm), a putative virulence gene associated with epidemic E. faecium strains. The presence of esp(Efm) was roughly twice that of hyl(Efm), but both were found primarily in vancomycin-resistant E. faecium isolates in nonstool cultures obtained from patients hospitalized in the United States. These data suggest that specific E. faecium strains may be enriched in determinants that make them more likely to cause clinical infections. Differences in the prevalence of these strains may help explain variations in the clinical importance of multiresistant E. faecium across different continents.