Geographic variations and trends in antimicrobial resistance among Enterococcus faecalis and Enterococcus faecium in the SENTRY Antimicrobial Surveillance Program (1997-2000)

Bayesian estimation of the prevalence of antimicrobial resistance: a mathematical modelling study

BACKGROUND

Estimates of the prevalence of antimicrobial resistance (AMR) underpin effective antimicrobial stewardship, infection prevention and control, and optimal deployment of antimicrobial agents. Typically, the prevalence of AMR is determined from real-world antimicrobial susceptibility data that are time delimited, sparse, and often biased, potentially resulting in harmful and wasteful decision-making. Frequentist methods are resource intensive because they rely on large datasets.

OBJECTIVES

To determine whether a Bayesian approach could present a more reliable and more resource-efficient way to estimate population prevalence of AMR than traditional frequentist methods.

METHODS

Retrospectively collected, open-source, real-world pseudonymized healthcare data were used to develop a Bayesian approach for estimating the prevalence of AMR by combination with prior AMR information from a contextualized review of literature. Iterative random sampling and cross-validation were used to assess the predictive accuracy and potential resource efficiency of the Bayesian approach compared with a standard frequentist approach.

RESULTS

Bayesian estimation of AMR prevalence made fewer extreme estimation errors than a frequentist estimation approach [n = 74 (6.4%) versus n = 136 (11.8%)] and required fewer observed antimicrobial susceptibility results per pathogen on average [mean = 28.8 (SD = 22.1) versus mean = 34.4 (SD = 30.1)] to avoid any extreme estimation errors in 50 iterations of the cross-validation. The Bayesian approach was maximally effective and efficient for drug-pathogen combinations where the actual prevalence of resistance was not close to 0% or 100%.

CONCLUSIONS

Bayesian estimation of the prevalence of AMR could provide a simple, resource-efficient approach to better inform population infection management where uncertainty about AMR prevalence is high.

Population Pharmacokinetics of Flucloxacillin In Bone and Soft Tissue- Standard Dosing is Not Sufficient to Achieve Therapeutic Concentrations

PURPOSE

Flucloxacillin is a β-lactam penicillin commonly used in the treatment of bone and soft tissue infections. In a recent porcine study, we found surprisingly low time for which the free concentration was maintained above the minimal inhibitory concentration (fT>MIC) in bone and soft tissue, following flucloxacillin oral (PO) and intravenous (IV) administration at 1g every 6h (q6h). In addition to plasma, sampling was obtained from subcutaneous tissue, knee joint, cancellous bone and cortical bone, using microdialysis. To identify flucloxacillin dosing regimens that result in theoretically therapeutic concentrations, we developed a population pharmacokinetic (PK) model for the porcine data, and combined it with a human flucloxacillin population PK model for simulations.

METHODS

A four-compartment model was developed, and various dosing regimens and modes of administration were simulated. Predicted concentrations were compared to %fT>MIC (0.5 mg/L and 2 mg/L).

RESULTS

Continuous infusion (CI) resulted in higher %fT>MIC compared to intermittent administration. For intermittent IV dosing (4, 8 and 12g/24h), fT>MIC (0.5 mg/L) was ≥70% in plasma, and ranged between 42-96% in the sampled tissue in a typical individual. By applying CI, 4g/day was sufficient to achieve ≥98% fT>MIC (0.5 mg/L) in all sampled tissues. For MIC 2 mg/L, ≥50% fT>MIC was only achieved in plasma at CI 8 and 12g/24h and IV 3g q6h.

CONCLUSIONS

To reach efficacious flucloxacillin bone and tissue concentrations, dose increment or continuous infusion needs to be considered.

Risk factors for enterococcal bacteriuria in dogs: A retrospective study

BACKGROUND

In humans, Enterococcus spp. urinary tract infections (UTI) are commonly associated with urinary catheter-induced urothelial inflammation but this is not the case in dogs.

HYPOTHESIS/OBJECTIVES

To identify risk factors predisposing dogs to enterococcal bacteriuria.

ANIMALS

Seventy dogs with Enterococcus spp. bacteriuria (case) and 70 dogs with Enterococcus coli bacteriuria (control).

METHODS

A single center retrospective case-control study with subjects and controls identified by a medical records search for Enterococcus spp. (subject) or E coli (control) bacteriuria from January 1, 2014 to December 31, 2017. Cases and controls were balanced with respect to average age and weight. Binary logistic regression was used to estimate and test whether the odds of having Enterococcus spp. bacteriuria (instead of E coli) were associated with the presence of any given characteristic.

RESULTS

A history of recurrent bacteriuria was significantly more common in Enterococcus spp. cases than in E coli controls (odds ratio [OR]: 2.07; 95% confidence interval [CI]: 1.04-4.16, P = .04). Comorbidities associated with the presence of Enterococcus spp. bacteriuria included lower urinary tract (LUT) anatomic abnormalities (OR: 2.94; 95% CI: 1.17-8.10, P = .02), urolithiasis (P = .01), and the presence of LUT neoplasia (P = .04). Small frequencies (n = 12 and n = 6, respectively) compromise our ability to precisely estimate the genuine OR for the latter 2 characteristics.

CONCLUSIONS AND CLINICAL IMPORTANCE

If the identified risk factors promote Enterococcus spp. colonization in dogs via induced LUT inflammation similar to people then Enterococcus spp. bacteriuria could be a sentinel for underlying LUT inflammation.

In search of novel protein drug targets for treatment of Enterococcus faecalis infections

Enterococcus faecalis (Ef) is one of the major pathogens involved in hospital-acquired infections. It can cause nosocomial bacteremia, surgical wound infection, and urinary tract infection. It is important to mention here that Ef is developing resistance against many commonly occurring antibiotics. The occurrence of multidrug resistance (MDR) and extensive-drug resistance (XDR) is now posing a major challenge to the medical community. In this regard, to combat the infections caused by Ef, we have to look for an alternative. Rational structure-based drug design exploits the three-dimensional structure of the target protein, which can be unraveled by various techniques such as X-ray crystallography or nuclear magnetic resonance (NMR) spectroscopy. In this review, we have discussed the complete picture of Ef infections, the possible treatment available at present, and the alternative treatment options to be explored. This study will help in better understanding of novel biological targets against Ef and the compounds, which are likely to bind with these targets. Using these detailed structural informations, rational structure-based drug design is achievable and tight inhibitors against Ef can be prepared.

Temporal and Geographic Variation in Antimicrobial Susceptibility and Resistance Patterns of Enterococci: Results From the SENTRY Antimicrobial Surveillance Program, 1997-2016

Background

The SENTRY Antimicrobial Surveillance Program was established in 1997 and presently encompasses more than 750 000 bacterial isolates from over 400 medical centers worldwide. Among these pathogens, enterococci represents a prominent cause of bloodstream (BSIs), intra-abdominal (IAIs), skin and skin structure, and urinary tract infections (UTIs). In the present study, we reviewed geographic and temporal trends in Enterococcus species and resistant phenotypes identified throughout the SENTRY Program.

Methods

From 1997 to 2016, a total of 49 491 clinically significant enterococci isolates (15 species) were submitted from 298 medical centers representing the Asia-Pacific (APAC), European, Latin American (LATAM), and North American (NA) regions. Bacteria were identified by standard algorithms and matrix-assisted laser desorption ionization–time of flight mass spectrometry. Susceptibility (S) testing was performed by reference broth microdilution methods and interpreted using Clinical and Laboratory Standards Institute/US Food and Drug Administration and European Committee on Antimicrobial Susceptibility Testing criteria.

Results

The most common Enterococcus species in all 4 regions were Enterococcus faecalis (64.7%) and E. faecium (EFM; 29.0%). Enterococci accounted for 10.7% of BSIs in NA and was most prominent as a cause of IAIs (24.0%) in APAC and of UTIs (19.8%) in LATAM. A steady decrease in the susceptibility to ampicillin and vancomycin was observed in all regions over the 20-year interval. Vancomycin-resistant enterococci (VRE) accounted for more than 8% of enterococcal isolates in all regions and was most common in NA (21.6%). Among the 7615 VRE isolates detected, 89.1% were the VanA phenotype (91.0% EFM) and 10.9% were VanB. Several newer antimicrobial agents demonstrated promising activity against VRE, including daptomycin (99.6–100.0% S), linezolid (98.0%–99.6% S), oritavancin (92.2%–98.3% S), tedizolid (99.5%–100.0% S), and tigecycline (99.4%–100.0% S).

Conclusions

Enterococci remained a prominent gram-positive pathogen in the SENTRY Program from 1997 through 2016. The overall frequency of VRE was 15.4% and increased over time in all monitored regions. Newly released agents with novel mechanisms of action show promising activity against VRE.

Variation in antibiotic susceptibility of uropathogens by age among ambulatory pediatric patients

We compared uropathogen antibiotic susceptibility across age groups of ambulatory pediatric patients. For Escherichia coli (n=5,099) and other Gram-negative rods (n=626), significant differences (p<0.05) existed across age groups for ampicillin, cefazolin, and trimethoprim/sulfamethoxazole susceptibility. In E. coli, differences in trimethoprim/sulfamethoxazole susceptibility varied from 79% in children under 2 to 88% in ages 16-18 (p<0.001), while ampicillin susceptibility varied from 30% in children under 2 to 53% in ages 2-5 (p=0.015). Uropathogen susceptibility to common urinary anti-infectives may be lower in the youngest children. Further investigation into these differences is needed to facilitate appropriate and prudent treatment of urinary tract infections.

Could chloramphenicol be used against ESKAPE pathogens? A review of in vitro data in the literature from the 21st century

The widespread use of antibiotics has been associated with the emergence of antimicrobial resistance among bacteria. 'ESKAPE' (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acintobacter baumannii, Pseudomonas aeruginosa and Enterobacter spp.) pathogens play a major role in the rapidly changing scenario of antimicrobial resistance in the 21st century. Chloramphenicol is a broad spectrum antibiotic that was abandoned in developed countries due to its association with fatal aplastic anemia. However, it is still widely used in the developing world. In light of the emerging problem of multi-drug resistant pathogens, its role should be reassessed. Our paper reviews in vitro data on the activity of chloramphenicol against ESKAPE pathogens. Susceptibility patterns for Gram-positives were good, although less favorable for Gram-negatives. However, in combination with colistin, chloramphenicol was found to have synergistic activity. The risk-benefit related to chloramphenicol toxicity has not been analyzed. Therefore, extra precautions should be taken when prescribing this agent.

Structure, function, and biology of the Enterococcus faecalis cytolysin

Enterococcus faecalis is a Gram-positive commensal member of the gut microbiota of a wide range of organisms. With the advent of antibiotic therapy, it has emerged as a multidrug resistant, hospital-acquired pathogen. Highly virulent strains of E. faecalis express a pore-forming exotoxin, called cytolysin, which lyses both bacterial and eukaryotic cells in response to quorum signals. Originally described in the 1930s, the cytolysin is a member of a large class of lanthionine-containing bacteriocins produced by Gram-positive bacteria. While the cytolysin shares some core features with other lantibiotics, it possesses unique characteristics as well. The current understanding of cytolysin biosynthesis, structure/function relationships, and contribution to the biology of E. faecalis are reviewed, and opportunities for using emerging technologies to advance this understanding are discussed.

Genotypic diversity, antibiotic resistance and bacteriocin production of enterococci isolated from rhizospheres

This study aimed to identify and to characterize rhizospheric-derived enterococci. The results showed the prevalence of Enterococcus faecium species (97%) vs. Enterococcus durans (3%). Susceptibility testing for antibiotics showed a low percentage of resistance to erythromycin (3.2%) and tetracycline (11.2%), and intermediate resistance to vancomycin (6.5%). Nevertheless, a high proportion of bacteriocin production was recorded. Furthermore, PCR detection of antibiotic resistance and bacteriocin production-encoding genes was investigated. Pulsed-field gel electrophoresis typing (PFGE) showed a great variability of enterococci in the rhizosphere. Moreover, mutilocus-sequence-typing analysis (MLST) revealed the identification of three new sequence types (STs), which were registered as ST613, ST614 and ST615.

Risk factors for vancomycin-resistant enterococci colonisation in critically ill patients

Vancomycin-resistant enterococci (VRE) are important hospital pathogens and have become increasingly common in patients admitted to the intensive care unit (ICU). To determine the incidence and the risk factors associated with VRE colonisation among ICU patients, active surveillance cultures for VRE faecal carriages were carried out in patients admitted to the ICU of the University Hospital of Uberlândia, Minas Gerais, Brazil. Risk factors were assessed using a case-control study. Seventy-seven patients (23.1%) were found to be colonised with vanC VRE and only one patient (0.3%) was colonised with vanA VRE. Independent risk factors for VRE colonisation included nephropathy [odds ratio (OR) = 13.6, p < 0.001], prior antibiotic use (OR = 5.5, p < 0.03) and carbapenem use (OR = 17.3, p < 0.001). Our results showed a higher frequency (23.1%) of Enterococcus gallinarum and Enterococcus casseliflavus, species that are intrinsically resistant to low levels of vancomycin (vanC), without an associated infection, associated with prior antibiotic use, carbapenem use and nephropathy as comorbidity. This study is the first to demonstrate the risk factors associated with vanC VRE colonisation in ICU hospitalised patients. Although vanA and vanB enterococci are of great importance, the epidemiology of vanC VRE needs to be better understood. Even though the clinical relevance of vanC VRE is uncertain, these species are opportunistic pathogens and vanC VRE-colonised patients are a potential epidemiologic reservoir of resistance genes.

Use of recombinase-based in vivo expression technology to characterize Enterococcus faecalis gene expression during infection identifies in vivo-expressed antisense RNAs and implicates the protease Eep in pathogenesis

Enterococcus faecalis is a member of the mammalian gastrointestinal microflora that has become a leading cause of nosocomial infections over the past several decades. E. faecalis must be able to adapt its physiology based on its surroundings in order to thrive in a mammalian host as both a commensal and a pathogen. We employed recombinase-based in vivo expression technology (RIVET) to identify promoters on the E. faecalis OG1RF chromosome that were specifically activated during the course of infection in a rabbit subdermal abscess model. The RIVET screen identified 249 putative in vivo-activated loci, over one-third of which are predicted to generate antisense transcripts. Three predicted antisense transcripts were detected in in vitro- and in vivo-grown cells, providing the first evidence of in vivo-expressed antisense RNAs in E. faecalis. Deletions in the in vivo-activated genes that encode glutamate 5-kinase (proB [EF0038]), the transcriptional regulator EbrA (ebrA [EF1809]), and the membrane metalloprotease Eep (eep [EF2380]) did not hinder biofilm formation in in vitro assays. In a rabbit model of endocarditis, the ΔebrA strain was fully virulent, the ΔproB strain was slightly attenuated, and the Δeep strain was severely attenuated. The Δeep virulence defect could be complemented by the expression of the wild-type gene in trans. Microscopic analysis of early Δeep biofilms revealed an abundance of small cellular aggregates that were not observed in wild-type biofilms. This work illustrates the use of a RIVET screen to provide information about the temporal activation of genes during infection, resulting in the identification and confirmation of a new virulence determinant in an important pathogen.

Pathogens resistant to antibacterial agents

Resistance to antimicrobial drugs is increasing at an alarming rate among both gram-positive and gram-negative bacteria. Traditionally, bacteria resistant to multiple antimicrobial agents have been restricted to the nosocomial environment. A disturbing trend has been the recent emergence and spread of resistant pathogens in nursing homes, in the community, and in the hospital. This article reviews the epidemiology, molecular mechanisms of resistance, and treatment options for pathogens resistant to antimicrobial drugs.

Trends in antimicrobial resistance of clinical isolates of Enterococcus faecalis and Enterococcus faecium in Greece between 2002 and 2007

We analysed trends in antimicrobial resistance of Enterococcus faecalis (N=1498) and E. faecium (N=625) recovered from clinical infections during 2002-2007 in a Greek tertiary care hospital. Molecular assays were used to confirm speciation and genotype of vancomycin-resistant enterococci (VRE). The incidence of infections per 1000 admissions caused by E. faecalis and E. faecium increased during the study period (chi(2) for trend=25.5 and 13.3, respectively; P<0.0001). Resistance to ampicillin, high level gentamicin and streptomycin, vancomycin, teicoplanin and linezolid was found in E. faecalis/E. faecium at rates of 1.3/82.4%, 45.6/51.2%, 48.9/69.1%, 0.5/9.6%, 0.1/8.2% and 0.3/1.6%, respectively. The vanA gene was identified in 79.1% of the VRE isolates, with vanB found in the remaining 20.1%. Analysis of antimicrobial resistance trends showed consistently high rates of ampicillin resistance among E. faecium isolates. For both enterococcal species, high level resistance to gentamicin and streptomycin were noted to have increased significantly (P<0.0001). Regardless of these alarming trends, strains exhibiting resistance to oxazolidinones seem to be only sporadic in our region and a trend toward increasing resistance rates to glycopeptides was not detected.

Therapeutic options for infections due to vancomycin-resistant enterococci

BACKGROUND

Vancomycin-resistant enterococci (VRE) are an important cause of nosocomial infection occurring in critical care or immunocompromised patients.

OBJECTIVES

To provide updated information about therapeutic options for VRE infection.

METHODS

MEDLINE, EMBASE, and the Cochrane Library were searched to identify in vitro susceptibility data of VRE isolates, randomized and non-randomized controlled trials, case series, and cohort studies of VRE therapy published before 31 July 2008.

RESULTS/CONCLUSION

The updated in vitro susceptibility data for VRE show high resistance to ampicillin and aminoglycosides. Quinupristin-dalfopristin is limited by its lack of activity against vancomycin-resistant Enterococcus faealis and its musculoskeletal side effects. Emerging linezolid resistance has been reported to cause hospital spread and may be related to prolonged linezolid use. Quinupristin-dalfopristin resistance is usually linked to agricultural use of streptogramin. Nitrofurantoin and fosfomycin are alternatives in uncomplicated VRE urinary tract infection. Daptomycin and tigecycline have shown excellent potential for treating VRE infection.

Incidence and risk factors of infection caused by vancomycin-resistant enterococcus colonization in neurosurgical intensive care unit patients

OBJECTIVE

This study was aimed to identify the incidence and risk factors of vancomycin-resistant enterococcus (VRE) colonization in neurosurgical practice of field, with particular attention to intensive care unit (ICU).

METHODS

This retrospective study was carried out on the Neurosurgical ICU (NICU), during the period from January. 2005 to December. 2007, in 414 consecutive patients who had been admitted to the NICU. Demographics and known risk factors were retrieved and assessed by statistical methods.

RESULTS

A total of 52 patients had VRE colonization among 414 patients enrolled, with an overall prevalence rate of 6.1%. E. faecium was the most frequently isolated pathogen, and 92.3% of all VRE were isolated from urine specimen. Active infection was noticed only in 2 patients with bacteremia and meningitis. Relative antibiotic agents were third-generation cephalosporin in 40%, and vancomycin in 23%, and multiple antibiotic usages were also identified in 13% of all cases. Multivariate analyses showed Glasgow coma scale (GCS) score less than 8, placement of Foley catheter longer than 2 weeks, ICU stay over 2 weeks and presence of nearby VRE-positive patients had a significantly independent association with VRE infection.

CONCLUSION

When managing the high-risk patients being prone to be infected VRE in the NICU, extreme caution should be paid upon. Because prevention and outbreak control is of ultimate importance, clinicians should be alert the possibility of impending colonization and infection by all means available. The most crucial interventions are careful hand washing, strict glove handling, meticulous and active screening, and complete segregation.

The ecology, epidemiology and virulence of Enterococcus

Enterococci are Gram-positive, catalase-negative, non-spore-forming, facultative anaerobic bacteria, which usually inhabit the alimentary tract of humans in addition to being isolated from environmental and animal sources. They are able to survive a range of stresses and hostile environments, including those of extreme temperature (5-65 degrees C), pH (4.5-10.0) and high NaCl concentration, enabling them to colonize a wide range of niches. Virulence factors of enterococci include the extracellular protein Esp and aggregation substances (Agg), both of which aid in colonization of the host. The nosocomial pathogenicity of enterococci has emerged in recent years, as well as increasing resistance to glycopeptide antibiotics. Understanding the ecology, epidemiology and virulence of Enterococcus species is important for limiting urinary tract infections, hepatobiliary sepsis, endocarditis, surgical wound infection, bacteraemia and neonatal sepsis, and also stemming the further development of antibiotic resistance.

Improved detection of vanB2-containing enterococcus faecium with vancomycin susceptibility by Etest using oxgall supplementation

We have isolated a number of vanB-containing Enterococcus faecium isolates on bile esculin screening agar containing 6 mg/liter vancomycin, which on subsequent susceptibility testing using Etest have repeatedly demonstrated vancomycin MICs of <or=4 mg/liter. To investigate this genotype-phenotype incongruence of "low-MIC vancomycin-resistant enterococci" (LM-VRE), we examined the molecular characteristics of these isolates, including the presence of the vanB operon, using PCR amplification and DNA sequencing. All LM-VRE isolates contained vanB associated with the transposon Tn1549 and were polyclonal. Sequencing of the vanB ligase gene showed no differences from the prototype vanB2. In addition, we examined supplemented media to improve phenotypic detection of these isolates. Etest detection of LM-VRE improved when Mueller-Hinton agar (MHA) and brain heart infusion agar (BHIA) were supplemented with 10 g/liter oxgall (MHA-Oxg and BHIA-Oxg, respectively). We assessed the sensitivity and specificity of these media to detect vancomycin resistance using vancomycin-resistant vanB-containing E. faecium (n = 11), vancomycin-susceptible (van negative) E. faecium (n = 11), vancomycin-susceptible (van negative) E. faecalis (n = 11), and our LM-VRE (n = 23) isolates. After 48 h of incubation, both MHA-Oxg and BHIA-Oxg were 100% (34/34) sensitive and 100% (22/22) specific in the identification of vancomycin resistance. These findings suggest that supplementation of MHA or BHIA with 10 g/liter oxgall should be considered in laboratories where VRE detection protocols rely primarily on strain phenotype rather than early vanB gene detection by PCR.

Assessment of safety of enterococci isolated throughout traditional Terrincho cheesemaking: virulence factors and antibiotic susceptibility

Enterococci account for an important fraction of the adventitious microflora of traditional cheeses manufactured in Mediterranean countries from small ruminants' raw milk and play an important role in the development of suitable organoleptic characteristics of the final product. It has been suggested that animals used for food or animals that supply edible products are a reservoir of antibiotic-resistant enterococci. The main purpose of this research effort was thus to identify, to the species level, a total of 73 enterococci with high tolerance to acidic pH and bile salts (as prevailing environmental conditions in the first portion of the gastrointestinal tract), which were previously isolated from the milk feedstock to the final product of Terrincho cheesemaking, and to determine their profiles of antibiotic susceptibility, coupled with the occurrence of specific virulence factors (especially in those that might eventually be claimed to exhibit suitable probiotic and technological performances). Isolates, identified by both API 20 STREP and PCR methods, were found to belong to the following Enterococcus species: E. casseliflavus, E. durans, E. faecalis, E. faecium, and E. gallinarum. Susceptibility of those isolates was observed to most antibiotics tested, whereas none harbored aminoglycoside resistance genes. PCR screenings for cytolysin genes (cylL(L), cylL(s), cylM, cylB, and cylA), surface adhesin genes (efaA(fs), efaA(fm), and esp), the aggregation protein gene (agg), and the extracellular metalloendopeptidase gene (gelE) were performed. All isolates proved negative for cylL(L), cylM, cylB, and agg genes. Both E. faecalis strains were positive for the cell wall-associated protein Esp and the cell wall adhesin efaA(fs), whereas the cell wall adhesin efaA(fm) was detected in 11 of the 12 E. faecium strains. Only one strain possessed the cylL(s) determinant, and another possessed the cylA gene. Incidence of virulence determinants was thus very low; hence, the enterococcal adventitious microflora tested is essentially safe.

Antimicrobial resistance and molecular epidemiology of vancomycin-resistant enterococci from North America and Europe: a report from the SENTRY antimicrobial surveillance program

Increases in prevalence of vancomycin-resistant enterococci (VRE) have been documented globally since its emergence in the 1980s. A SENTRY Antimicrobial Surveillance Program (2003) objective monitored VRE isolates with respect to antimicrobial susceptibility trends, geographic resistance variability, and clonal dissemination. In 2003, VRE isolates from North America (United States and Canada, n = 839, 26 sites) and Europe (n = 56, 10 sites) were susceptibility tested using Clinical and Laboratory Standards Institute (CLSI) reference methodologies. Based on resistance profiles, 155 isolates displayed similar multidrug-resistant (MDR) profiles and were temporally related; these were subsequently submitted for typing by pulsed-field gel electrophoresis (PFGE). Most of the submitted isolates were Enterococcus faecium (91.0%) and Enterococcus faecalis (7.8%). Among VRE, the VanA phenotype was more prevalent in North America (76%) than Europe (40%), and all isolates had elevated resistance rates to other antimicrobial classes including the following: 1) chloramphenicol resistance among E. faecalis being greater in North America than in Europe (28.6% versus 7.1%, respectively) but reversed among E. faecium (0.5% and 15.0%, the latter due to clonal occurrences); 2) ciprofloxacin resistance in North America >99% for both species and in Europe varying from 85.7% to 87.5%; 3) rare occurrences of linezolid resistance in North America (0.8% to 1.8%) due to G2576U ribosomal mutation; 4) higher quinupristin/dalfopristin resistance observed among European E. faecium strains (10.0% versus 0.6%); and 5) higher rifampin resistance rates among European E. faecalis (21.4% versus 5.4%). Thirty-five MDR epidemic clusters were identified by PFGE in 21 North American and 2 European medical centers including the following: 1) VanA (20 sites, 27 clonal occurrences) and VanB (1 site, 2 clonal occurrences); 2) elevated quinupristin/dalfopristin MIC results (not vatD/E, 3 sites); and 3) chloramphenicol resistance (chloramphenicol acetyltransferase-positive strains, 3 sites). The esp gene, part of the putative E. faecium pathogenicity island and a marker for the clonal complex-17 lineage, was detected in 76% of vancomycin-resistant E. faecium. Clonal spread appears to be a dominant factor of MDR VRE dissemination on both continents, and further monitoring is critical to assist in the control of these resistant pathogens.

Vigilancia de resistencias a los antimicrobianos: estudio VIRA 2006

INTRODUCTION

The objective of this study was to determine the current antimicrobial susceptibility patterns of the most frequent multi-resistant bacteria and to analyze any possible changes with respect to the two VIRA studies carried out in 2001 and 2004.

METHODS

In February 2006, the 40 participating hospitals sent the following microorganisms: non-penicillin-susceptible Streptococcus pneumoniae (92), methicillin-resistant Staphylococcus aureus (MRSA) (290), clinically significant coagulase-negative staphylococci (136), ampicillin-resistant Enterococcus faecium (89), ampicillin-resistant Haemophilus influenzae (67), ciprofloxacin-resistant Escherichia coli (365), Pseudomonas aeruginosa (181), and Acinetobacter baumannii (92). The hospitals provided epidemiological data on these microorganisms. Susceptibility was determined with a broth microdilution method.

RESULTS

Among the non-penicillin-susceptible S. pneumoniae isolates, the proportion of those ones resistant to this antibiotic showed a significant (p < 0.001) decrease (59.8% in 2001, 30.2% in 2004 and 14.3% in 2006). Among MRSA, we detected one isolate nonsusceptible to linezolid, four resistant to quinupristin-dalfopristin and one strain with a vancomycin MIC of 4 microg/mL. The prevalence of extended-spectrum beta-lactamase-producing E. coli was 12.1%. Resistance of A. baumannii to imipenem varied from 27% in the 2001-2004 period to 47.8% in 2006 (p < 0.005).

CONCLUSION

These results again emphasize that resistance surveillance systems are an important tool for preventing the emergence and spread of multi-resistant pathogens.

Antibiotic resistance of enterococci and related bacteria in an urban wastewater treatment plant

The main objective of this work was to study the ecology of enterococci and related bacteria in raw and treated wastewater from a treatment plant receiving domestic and pretreated industrial effluents in order to assess the influence of treatment on the prevalence of antibiotic resistance phenotypes among this group of bacteria. The predominant species found in the raw wastewater were Entercoccus hirae, Entercoccus faecium and Entercoccus faecalis. Wastewater treatment led to a reduction in E. hirae (alpha<0.1) and an increase in E. faecium (alpha<0.1); the relative proportions of E. faecalis remained the same in the raw and in the treated wastewater. Among the isolates tested, no vancomycin resistance was observed among the enterococci. Entercoccus faecium and E. faecalis showed resistance prevalence values reaching 33%, 40% and 57% for the antibiotics ciprofloxacin, erythromycin and tetracycline, respectively. Antibiotic-resistant strains of enterococci were not eliminated by wastewater treatment. A positive selection of ciprofloxacin-resistant enterococci was indicated by a significant increase in resistance prevalence (alpha<0.02) in treated wastewater compared with the raw wastewater.

Antibiotic resistance and mechanisms implicated in clinical enterococci in a Tunisian hospital

Susceptibility testing for 15 antibiotics was performed in a series of 191 clinical enterococci recovered in a Tunisian Hospital during 2000-2003. Species detected were the following ones (number of isolates): E. faecalis (139), E. faecium (41), E. casseliflavus (5), E. gallinarum (3), E. avium (2) and E. hirae (1). The percentages of antibiotic resistance detected were as follows (E. faecalis/ E. faecium/ other species) : penicillin (0/ 73/ 9%), tetracycline (78/ 44/ 54%), chloramphenicol (52/ 29/ 27%), erythromycin (66/ 100/ 82%), spiramycin (84/ 83/ 64%), pristinamycin (100/ 0/ 73%), trimethoprim-sulfamethoxazole (88/ 78/ 91%), rifampicin (72/ 41/ 0%), vancomycin (0/ 0/ 36%), teicoplanin (0/ 0/ 0%), high-level-resistance for gentamicin (24/ 29/ 45%), streptomycin (34/ 56/ 55%) and kanamycin (41/ 68/ 55%). Increased vancomycin minimum inhibitory concentrations (MICs) were only detected in E. casseliflavus and E. gallinarum isolates (MIC range 8-24 microg/ml). The erm(B), catA, tet(M), aac(6')-aph(2''), aph(3')-IIIa, and ant(6)-Ia genes were detected in 91%, 32%, 86%, 98%, 100%, and 72% of the E. faecium and E. faecalis isolates resistant to erythromycin, chloramphenicol, tetracycline and high-level-resistant to gentamicin, kanamycin and streptomycin, respectively. A total of 20 unrelated pulsed-field-gel-electrophoresis patterns were found in the series of 46 high-level gentamicin-resistant E. faecalis and E. faecium isolates of this study.

High rate of resistance to quinupristin-dalfopristin in Enterococcus faecium clinical isolates from Korea

We tested the in vitro susceptibilities of 603 enterococcal isolates from eight tertiary-care hospitals in Korea. The quinupristin-dalfopristin resistance rate in Enterococcus faecium was very high (25 isolates, 10.0%). It was suggested that both clonal spread and the sporadic emergence of quinupristin-dalfopristin-resistant isolates may explain the high prevalence of quinupristin-dalfopristin resistance in Korea.

Characterization of Antibiotic Resistance Genes and Virulence Factors in Faecal Enterococci of Wild Animals in Portugal

Antibiotic susceptibility was tested in 140 non-selected enterococci (73 Enterococcus faecalis, 45 E. faecium and 22 of other species) recovered from faecal samples of 77 wild animals in Portugal. Susceptibility testing for 11 antibiotics (vancomycin, teicoplanin, ampicillin, streptomycin, gentamicin, kanamycin, chloramphenicol, tetracycline, erythromycin, quinupristin-dalfopristin and ciprofloxacin) was determined by disk diffusion and agar dilution methods. Forty-four isolates (31.4%) showed susceptibility to all the antibiotics tested (5.5% of E. faecalis; 62.2% of E. faecium; and 78.6% of E. hirae). Neither ampicillin-resistance nor acquired-vancomycin-resistance was detected and 1.4% of the isolates showed high-level-resistance for gentamicin or streptomycin. Tetracycline and erythromycin resistances were shown in 28.6% and 20.1% of the isolates, respectively. Antibiotic resistance genes were studied by polymerase chain reaction (PCR) and sequencing and tet(M) + tet(L), erm(B) or aac(6')-aph(2'') genes were detected in most of tetracycline-, erythromycin- or gentamicin-resistant enterococci respectively. Genes encoding virulence factors were studied by PCR and a wide variety of virulence genes were detected in most of E. faecalis isolates but were rarely found in E. faecium and not detected in the other species. The prevalence of genes encoding virulence factors in E. faecalis was as follows: cpd (98.6%), gelE (75.3%), agg (30.1%), fsr (17.8%), ace (9.6%) and esp (4.1%). Low percentages of antibiotic resistance was found in the faecal enterococci of wild animals but a wide variety of virulence genes were detected among E. faecalis isolates although were rare in the other species.

A survey of antimicrobial resistance in a tertiary referral hospital in the United Arab Emirates

Published data on antimicrobial resistance are lacking for the United Arab Emirates (UAE). Knowledge of local patterns of resistance is essential to optimize guidelines for empirical antimicrobial treatment. Awareness of susceptibility patterns in other parts of the world may be important for determining empirical antimicrobial therapy for travelers or patients transferred from abroad. Antibiograms from unique isolates of common hospital and community bacteria are described in a tertiary referral hospital in the UAE, which had no antimicrobial restrictions and limited resources. Antimicrobial resistance rates were unpredictable and were high for Gram-negative organisms, such as Escherichia coli, Shigella sonnei, Campylobacter spp, and also Streptococcus pneumoniae. In contrast, methicillin-resistant Staphylococcus aureus (MRSA) comprised less than 5% of S. aureus isolates and glycopeptide-resistant enterococci (GRE) were not detected during the surveillance period. Our results provide data on antimicrobial resistance for the UAE and highlight the need for resources for surveillance of antimicrobial resistance.

Gram-positive resistance: pathogens, implications, and treatment options: insights from the Society of Infectious Diseases Pharmacists

Despite the advent of new antibiotics, resistance in gram-positive pathogens, including staphylococci and enterococci, continues to increase. This is evident with the recent emergence of vancomycin-resistant Staphylococcus aureus . Newer treatment agents are available, including quinupristin-dalfopristin, linezolid, and daptomycin. In addition, investigational agents are being explored. Clinical trials have been conducted for various infections, such as skin and skin structure infections, pneumonia, and bloodstream infections. Antibacterial activity, site of infection, and potential for adverse effects must be taken into account when making decisions regarding therapy.

Daptomycin: a cyclic lipopeptide antimicrobial agent

Objectives:

The aims of this article were: to summarize the pharmacology, pharmacokinetics, and efficacy ofdaptomycin; to explore its safety profile; and to discuss its current and potential roles as an antimicrobial therapy.

Methods:

A literature search was conducted using the MEDLINE (1966–August 2004) and InternationalPharmaceutical Abstracts (1970–August 2004) databases with the search terms daptomycin, LY146032, and lipopeptide antibiotics. Abstracts of the Interscience Conference on Antimicrobial Agents and Chemotherapy and documents submitted to the US Food and Drug Administration were also reviewed.

Results:

Phase III study results suggest no difference in efficacy or tolerability between daptomycin 4 mg/kgIV QD and vancomycin or semisynthetic penicillins for complicated skin and skin-structure infections. Animal studies suggest daptomycin may be useful for the treatment of endocarditis. Daptomycin is not indicated for pneumonia, with poorer outcomes than conventional treatment It is available as an IV medication and exhibits 92% plasma protein binding in vitro. In healthy adult humans, daptomycin has a volume of distribution of 0.1 Ukg and a plasma elimination half-life of ∼9 hours, and is eliminated primarily by renal excretion (∼54%). In patients with reduced renal function, including those receiving hemodialysis and peritoneal dialysis, the dose interval should be 48 hours. No dosage adjustment appears to be necessary for mild to moderate hepatic impairment. The use of daptomycin in patients with severe hepatic impairment has not been assessed. The most commonly reported adverse events include constipation, nausea, injection-site reactions, headache, and diarrhea. Patients should also be monitored regularly for skeletal muscle toxicity.

Conclusions:

Daptomycin may be useful for complicated skin and skin-structure infections and gram-positive pathogens resistant to conventional antimicrobials. However, limited data are currently available for duration of treatment beyond 14 days and at doses >4 mg/kg QD.

Antimicrobial activity of dalbavancin tested against Gram-positive clinical isolates from Latin American medical centres

The activity of dalbavancin, a new semi-synthetic lipoglycopeptide antibiotic, was evaluated in comparison with other antibacterial agents against 1229 Gram-positive organisms collected from medical centres in Latin America. Dalbavancin was the most potent compound tested against isolates of Staphylococcus aureus (MIC(50), 0.06 mg/L) and coagulase-negative staphylococci (MIC(50), 0.03 mg/L), independently of methicillin susceptibility. Dalbavancin inhibited all Streptococcus pneumoniae isolates at </= 0.06 mg/L. Dalbavancin also demonstrated excellent activity against beta-haemolytic (MIC(50), </= 0.008 mg/L) and viridans group (MIC(50), 0.016 mg/L) streptococci. All vancomycin-susceptible Enterococcus spp. isolates were inhibited by dalbavancin at </= 0.25 mg/L, but some vancomycin-resistant Enterococcus spp. isolates were only inhibited by dalbavancin levels of >/= 8 mg/L. Dalbavancin exhibited excellent activity against isolates of Corynebacterium spp. and Listeria spp. Dalbavancin may provide an important therapeutic option for Gram-positive infections, excluding those caused by enterococci with VanA-type resistance.

Daptomycin: a lipopeptide antibiotic for the treatment of serious Gram-positive infections

Infections caused by drug-resistant pathogens are on the rise. Daptomycin, a cyclic lipopeptide with activity against most Gram-positive pathogens, including vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus, is a newly US-FDA approved antimicrobial for complicated skin and skin structure infections (cSSSI). Daptomycin has a unique mechanism of action that results in destruction of the membrane potential. The rapid bactericidal activity of daptomycin makes it an attractive antibiotic for serious Gram-positive infections.

Utility of the Chronic Disease Score and Charlson Comorbidity Index as comorbidity measures for use in epidemiologic studies of antibiotic-resistant organisms

Comorbidity is a known risk factor for antibiotic-resistant bacterial infections. Although aggregate comorbidity measures are useful in epidemiologic research, none of the existing measures was developed for use with this outcome. This study compared the utility of two comorbidity measures, the Charlson Comorbidity Index and the Chronic Disease Score, in assessing the comorbidity-attributable risk of nosocomial infections with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE). Two case-control studies were conducted at the University of Maryland Medical System in Baltimore, Maryland. Cases were inpatients with a first positive clinical culture of MRSA or VRE at least 48 hours postadmission (July 1, 1998-July 1, 2001). Three inpatient controls were randomly selected per case. The MRSA study included 2,164 patients, and the VRE study included 1,948. The scores' discrimination and calibration were measured by using the c statistic and Hosmer-Lemeshow chi-square test. The Charlson Comorbidity Index (c = 0.653) and Chronic Disease Score (c = 0.608) were similar discriminators of MRSA and VRE (c = 0.670 and c = 0.647, respectively). Calibration of the scores was poor for both outcomes (p < 0.05). A revised comorbidity measure specific to resistant infections would likely provide a better assessment of the comorbidity-attributable risk of antibiotic-resistant infections.

Pathogens resistant to antimicrobial agents: epidemiology, molecular mechanisms, and clinical management

Resistance to antimicrobial drugs is increasing at an alarming rate among both gram-positive and gram-negative bacteria. Traditionally, bacteria resistant to multiple antimicrobial agents have been restricted to the nosocomial environment. A disturbing trend has been the recent emergence and spread of resistant pathogens and resistance traits in nursing homes, the community, as well as in hospitals. This article reviews the epidemiology, molecular mechanisms of resistance, and treatment options for pathogens resistant to antimicrobial drugs.

Antimicrobial resistance of Enterococcus sp. isolated from the intestinal tract of patients from a university hospital in Brazil

This study reports the results about antimicrobial resistance of Enterococcus spp. isolated from intestinal tract of patients from a university hospital in Brazil. The identification of strains at species level was performed by conventional biochemical tests, API 20 Strep (bioMérieux), and polymerase chain reaction assay. The species distribution was E. faecium (34%), followed by E. faecalis (33%), E. gallinarum (23.7%), E. casseliflavus (5.2%), E. avium (1%), and E. hirae (1%). Intrinsic resistance to vancomycin characterized by presence of vanC genes was found in E. gallinarum and E. casseliflavus. The high prevalence of VanC phenotype enterococci is very important because these species have been reported as causing a wide variety of infections. Vancomycin-resistant E. faecium or E. faecalis were not found and no one isolate of these species was a beta-lactamase producer. Thirteen clinical isolates of enterococci (13.4%) showed multiresistance patterns, which were defined by resistance to three classes of antibiotics plus resistance to at least one aminoglycoside (gentamicin and/or streptomycin). The resistance to several antimicrobials shown by enterococcal strains obtained in this study is of concern because of the decrease in the therapeutic options for treatment of infections caused by enterococci.

In vivo efficacy and pharmacokinetics of AC98-6446, a novel cyclic glycopeptide, in experimental infection models

AC98-6446 is a novel semisynthetic derivative of a natural product related to the mannopeptimycins produced by Streptomyces hygroscopicus. Naturally occurring esterified mannopeptimycins exhibited excellent in vitro activity but only moderate in vivo efficacy against staphylococcal infection. The in vivo efficacy and pharmacokinetics of AC98-6446 were investigated in murine acute lethal, bacterial thigh and rat endocarditis infections. Pharmacokinetics were performed in mice, rats, monkeys, and dogs. Acute lethal infections were performed with several gram-positive isolates: Staphylococcus aureus (methicillin-susceptible and methicillin-resistant staphylococci), vancomycin-resistant Enterococcus faecalis, and penicillin-susceptible and -resistant Streptococcus pneumoniae. The 50% effective dose for all isolates tested ranged from 0.05 to 0.39 mg/kg of body weight after intravenous (i.v.) administration. Vancomycin was more than fivefold less efficacious against all of these same infections. Results of the thigh infection with S. aureus showed a static dose for AC98-6446 of 0.4 mg/kg by i.v. administration. Reduction of counts in the thigh of >2 log(10) CFU were achieved with doses of 1 mg/kg. i.v. administration of 3 mg/kg twice a day for 3 days resulted in a >3 log(10) reduction in bacterial counts of vancomycin-susceptible and -resistant E. faecalis in a rat endocarditis model. Pharmacokinetics of AC98-6446 showed an increase in exposure (area under the concentration-time curve) from mouse to dog species. The i.v. half-life (t(1/2)) increased threefold between rodents and the higher species dosed. Efficacy of AC98-6446 has been demonstrated in several models of infection with resistant gram-positive pathogens. This glycopeptide exhibited bactericidal activity in these models, resulting in efficacy at low doses with reduction in bacterial load.

Public health consequences of macrolide use in food animals: a deterministic risk assessment

The potential impact on human health from antibiotic-resistant bacteria selected by use of antibiotics in food animals has resulted in many reports and recommended actions. The U.S. Food and Drug Administration Center for Veterinary Medicine has issued Guidance Document 152, which advises veterinary drug sponsors of one potential process for conducting a qualitative risk assessment of drug use in food animals. Using this guideline, we developed a deterministic model to assess the risk from two macrolide antibiotics, tylosin and tilmicosin. The scope of modeling included all label claim uses of both macrolides in poultry, swine, and beef cattle. The Guidance Document was followed to define the hazard, which is illness (i) caused by foodborne bacteria with a resistance determinant, (ii) attributed to a specified animal-derived meat commodity, and (iii) treated with a human use drug of the same class. Risk was defined as the probability of this hazard combined with the consequence of treatment failure due to resistant Campylobacter spp. or Enterococcus faecium. A binomial event model was applied to estimate the annual risk for the U.S. general population. Parameters were derived from industry drug use surveys, scientific literature, medical guidelines, and government documents. This unique farm-to-patient risk assessment demonstrated that use of tylosin and tilmicosin in food animals presents a very low risk of human treatment failure, with an approximate annual probability of less than 1 in 10 million Campylobacter-derived and approximately 1 in 3 billion E. faecium-derived risk.

Phenotypic characteristics and population genetics ofEnterococcus faecaliscultured from patients in Tehran during 2000–2001

Conventional bacteriology techniques were used to identify enterococci isolates cultured from patients at different hospitals in Tehran during 2000–2001. The identification was confirmed using species-specific PCR targeting the D-alanyl-D-alanine ligase gene. A total of 59 isolates of Enterococcus faecalis were identified. The rates of resistance to different antibiotics were in the following order: penicillin 84%, ciprofloxacin 42%, high-level gentamicin 30%, nitrofurantoin 14%, imipenem 4%, and chloramphenicol 2%. Resistance to ampicillin was found to be rare among the Iranian isolates of E. faecalis. Multi-locus enzyme electrophoresis was then used to analyze the strains. Forty-five electrophoretic types were obtained when 10 enzyme loci were screened. Although the collection of bacterial isolates was limited in time and location, considerable heterogeneity was found. Analysis of strains for linkage disequilibrium demonstrated that the studied population is not clonal, since the index of association was not significantly different from zero (Ia= 0.0296). Enterococcus faecalis isolates recovered from patients in Tehran were genetically diverse and seemed to possess a high potential for genetic recombinations, though none were resistant to vancomycin.Key words: Enterococcus faecalis, population genetics, MEE analysis, nosocomial infections.