Molecular epidemiology of vancomycin-resistant Enterococcus faecium in a large urban hospital over a 5-year period

Quantifying Human Health Risks from Virginiamycin Use in Food Animals in China

Virginiamycin (VM), a streptogramin antibiotic, has been used to promote healthy growth and treat illnesses in farm animals in the United States and other countries. The combination streptogramin Quinupristin-Dalfopristin (QD) was approved in the United States in 1999 for treating patients with vancomycin-resistant Enterococcus faecium (VREF) infections. Many chickens and swine test positive for QD-resistant E. faecium, raising concerns that using VM in food animals might select for streptogramin-resistant strains of E. faecium that could compromise QD effectiveness in treating human VREF infections. Such concerns have prompted bans and phase-outs of VM as growth promoters in the United States and Europe. This study quantitatively estimates potential human health risks from QD-resistant VREF infections due to VM use in food animals in China. Plausible conservative (risk-maximizing) quantitative risk estimates are derived for future uses, assuming 100% resistance to linezolid and daptomycin and 100% prescription rate of QD to high-level (VanA) VREF-infected patients. Up to one shortened life every few decades to every few thousand years might occur in China from VM use in animals, although the most likely risk is zero (e.g., if resistance is not transferred from bacteria in food animals to bacteria infecting human patients). Sensitivity and probabilistic uncertainty analyses suggest that this conclusion is robust to several data gaps and uncertainties. Potential future human health risks from VM use in animals in China appear to be small or zero, even if QD is eventually approved for use in human patients.

Emergence of Vancomycin-Resistant Enterococci in San Francisco Bay Area Hospitals During 1994 to 1998

Objective:

To determine the magnitude of van-comycin-resistant enterococci (VRE) in three counties in the San Francisco Bay area.

Design:

Active laboratory-based surveillance for VRE from January 1995 through December 1996 and a laboratory-based and hospital-based questionnaire survey for 1993 to 1994 and 1997 to 1998.

Setting:

All 33 general acute care hospitals in three counties in the San Francisco Bay area.

Participants:

Laboratories and infection control professionals serving these hospitals, and staff of the California Emerging Infections Program.

Results:

The number of hospitals reporting 1 or more patient clinical VRE isolates was 1 (3%) in 1993, 7 (21%) in 1994, 31 (94%) in 1995, and 33 (100%) in 1996 to 1998. The number of patient isolates increased from 1 in 1993 to 24 in 1994, 176 in 1995,429 in 1996, 730 in 1997, and 864 in 1998. Most VRE isolates in 1995 and 1996 were from urine and were not associated with serious clinical disease. However, the number of isolates from blood increased from 9 (6% of total) in 1995 to 44 (12% of the total) in 1996, 90 (14%) in 1997, and 100 (13%) in 1998.

Conclusions:

Our data document the rapid emergence and increase of VRE in all hospitals in three counties in the San Francisco Bay area during 1994 to 1998. Infection control measures for VRE together with antibiotic utilization programs should be implemented to limit further spread.

Molecular epidemiology and risk factors for colonization by vancomycin-resistant Enterococcus in patients with hematologic malignancies

OBJECTIVE

To study the molecular epidemiology of vancomycin-resistant Enterococcus (VRE) colonization and to identify modifiable risk factors among patients with hematologic malignancies.

SETTING

A hematology-oncology unit with high prevalence of VRE colonization.

PARTICIPANTS

Patients with hematologic malignancies and hematopoietic stem cell transplantation recipients admitted to the hospital.

METHODS

Patients underwent weekly surveillance by means of perianal swabs for VRE colonization and, if colonized, were placed in contact isolation. We studied the molecular epidemiology in fecal and blood isolates by pulsed-field gel electrophoresis over a 1-year period. We performed a retrospective case-control study over a 3-year period. Cases were defined as patients colonized by VRE, and controls were defined as patients negative for VRE colonization. Case patients and control patients were matched by admitting service and length of observation time.

RESULTS

Molecular genotyping demonstrated the primarily polyclonal nature of VRE isolates. Colonization occurred at a median of 14 days. Colonized patients were characterized by longer hospital admissions. Previous use of ceftazidime was associated with VRE colonization (P < .001), while use of intravenous vancomycin and antibiotics with anaerobic activity did not emerge as a risk factor. There was no association with neutropenia or presence of colonic mucosal disruption, and severity of illness was similar in both groups.

CONCLUSION

Molecular studies showed that in the majority of VRE-colonized patients the strains were unique, arguing that VRE acquisition was sporadic rather than resulting from a common source of transmission. Patient-specific factors, including prior antibiotic exposure, rather than breaches in infection control likely predict for risk of fecal VRE colonization.

Human health risk assessment of penicillin/aminopenicillin resistance in enterococci due to penicillin use in food animals

Penicillin and ampicillin drugs are approved for use in food animals in the United States to treat, control, and prevent diseases, and penicillin is approved for use to improve growth rates in pigs and poultry. This article considers the possibility that such uses might increase the incidence of ampicillin-resistant Enterococcus faecium (AREF) of animal origin in human infections, leading to increased hospitalization and mortality due to reduced response to ampicillin or penicillin. We assess the risks from continued use of penicillin-based drugs in food animals in the United States, using several assumptions to overcome current scientific uncertainties and data gaps. Multiplying the total at-risk population of intensive care unit (ICU) patients by a series of estimated factors suggests that not more than 0.04 excess mortalities per year (under conservative assumptions) to 0.14 excess mortalities per year (under very conservative assumptions) might be prevented in the whole U.S. population if current use of penicillin drugs in food animals were discontinued and if this successfully reduced the prevalence of AREF infections among ICU patients. These calculations suggest that current penicillin usage in food animals in the United States presents very low (possibly zero) human health risks.

Enterococcal colonization of infants in a neonatal intensive care unit: associated predictors, risk factors and seasonal patterns

Background

During and shortly after birth, newborn infants are colonized with enterococci. This study analyzes predictors for early enterococcal colonization of infants in a neonatal intensive care unit and describes risk factors associated with multidrugresistant enterococci colonization and its seasonal patterns.

Methods

Over a 12-month period, we performed a prospective epidemiological study in 274 infants admitted to a neonatal intensive care unit. On the first day of life, we compared infants with enterococcal isolates detected in meconium or body cultures to those without. We then tested the association of enterococcal colonization with peripartal predictors/risk factors by using bivariate and multivariate statistical methods.

Results

Twenty-three percent of the infants were colonized with enterococci. The three most common enterococcal species were E. faecium (48% of isolates), E. casseliflavus (25%) and E. faecalis (13%). Fifty-seven percent of the enterococci found were resistant to three of five antibiotic classes, but no vancomycin-resistant isolates were observed. During winter/spring months, the number of enterococci and multidrug-resistant enterococci were higher than in summer/fall months (p = 0.002 and p < 0.0001, respectively). With respect to enterococcal colonization on the first day of life, predictors were prematurity (p = 0.043) and low birth weight (p = 0.011). With respect to colonization with multidrug-resistant enterococci, risk factors were prematurity (p = 0.0006), low birth weight (p < 0.0001) and prepartal antibiotic treatment (p = 0.019). Using logistic regression, we determined that gestational age was the only parameter significantly correlated with multidrug-resistant enterococci colonization. No infection with enterococci or multidrugresistant enterococci in the infants was detected. The outcome of infants with and without enterococcal colonization was the same with respect to death, necrotizing enterocolitis, intracerebral hemorrhage and bronchopulmonary dysplasia.

Conclusion

In neonatal intensive care units, an infant's susceptibility to early colonization with enterococci in general, and his or her risk for colonization with multidrug-resistant enterococci in particular, is increased in preterm newborns, especially during the winter/spring months. The prepartal use of antibiotics with no known activity against enterococci appears to increase the risk for colonization with multidrug-resistant enterococci.

Heterogeneity of vat(E)-carrying plasmids in Enterococcus faecium recovered from human and animal sources

In this study, quinupristin/dalfopristin (Q/D)-resistant Enterococcus faecium isolates (33 from poultry farms and 1 from a human outpatient) with Q/D minimal inhibitory concentrations ranging from 4 microg/mL to 32 microg/mL were analysed. Polymerase chain reaction detected the presence of vat(E) in all isolates. Using pulsed-field gel electrophoresis (PFGE), 14 distinct PFGE patterns were identified. The human E. faecium isolate was distinguishable from the 33 farm isolates by PFGE. Southern hybridisation localised the vat(E) gene to an 11 kb plasmid and resulted in five plasmid hybridisation types. The vat(E)-carrying plasmid from the human isolate showed a nearly identical hybridisation pattern to a plasmid from a farm isolate. This study showed that the vat(E) gene, conferring resistance to Q/D, was carried on different plasmids in a heterogeneous group of E. faecium, some of which may be acquired by E. faecium capable of infecting humans.

Use of strain typing data to estimate bacterial transmission rates in healthcare settings

OBJECTIVE

To create an affordable and accurate method for continuously monitoring bacterial transmission rates in healthcare settings.

DESIGN

We present a discrete simulation model that relies on the relationship between in-hospital transmission rates and strain diversity. We also present a proof of concept application of this model to a prospective molecular epidemiology data set to estimate transmission rates for Pseudomonas aeruginosa and Staphylococcus aureus.

SETTING

Inpatient units of an academic referral center.

PATIENTS

All inpatients with nosocomial infections.

INTERVENTION

Mathematical model to estimate transmission rates.

RESULTS

Maximum likelihood estimates for transmission rates of these two species on different hospital units ranged from 0 to 0.36 transmission event per colonized patient per day.

CONCLUSIONS

This approach is feasible, although estimates of transmission rates based solely on strain typed clinical cultures may be too imprecise for routine use in infection control. A modest level of surveillance sampling substantially improves the estimation accuracy.

Potential human health benefits of antibiotics used in food animals: a case study of virginiamycin

Risk management of food-animal antibiotics has reached a crucial juncture for public health officials worldwide. While withdrawals of animal antibiotics previously used to control animal bacterial illnesses are being encouraged in many countries, the human health impacts of such withdrawals are only starting to be understood. Increases in animal and human bacterial illness rates and antibiotic resistance levels in humans in Europe despite bans on animal antibiotics there have raised questions about how animal antibiotic use affects human health. This paper presents a quantitative human health risk and benefits assessment for virginiamycin (VM), a streptogramin antibiotic recommended for withdrawal from use in food animals in several countries. It applies a new quantitative Rapid Risk Rating Technique (RRRT) that estimates and multiplies data-driven exposure, dose-response, and consequence factors, as suggested by WHO (2003) to estimate human health impacts from withdrawing virginiamycin. Increased human health risks from more pathogens reaching consumers if VM use is terminated (6660 estimated excess campylobacteriosis cases per year in the base case) are predicted to far outweigh benefits from reduced streptogramin-resistant vancomycin-resistant Enterococcus faecium (VREF) infections in human patients (0.27 estimated excess cases per year in the base case). While lack of information about impacts of VM withdrawal on average human illnesses-per-serving of food animal meat precludes a deterministic conclusion, it appears very probable that such a withdrawal would cause many times more human illnesses than it would prevent. This qualitative conclusion appears to be robust to several scientific and modeling uncertainties.

The emergence of glycopeptide-resistant Enterococcus faecium in a university hospital in southwestern Greece

BACKGROUND

Enterococci and especially glycopeptide-resistant strains (GRE) are widely distributed in the hospital environment, by acquiring resistance determinants and virulence factors.

METHODS

The study included 48 GRE isolated during a 1-year period from different inpatients in a tertiary hospital in southwestern Greece. Antibiotic susceptibility was determined by the Etest, and the presence of resistance and virulence genes was shown by PCR. Clonal types were identified by pulsed-field gel electrophoresis of SmaI DNA digests.

RESULTS

All GRE were multi-resistant of the VanA phenotype, verified by the detection of the gene by PCR. Two major clones were distributed in all hospital wards. The majority of the strains (46 of 48) harbored the esp gene, while 27 GRE expressed also the gelE and/or as genes.

CONCLUSIONS

The spread of two clones expressing the vanA gene and virulence factors were responsible for the emergence of GRE in the University Hospital of Patras.

Quantifying human health risks from virginiamycin used in chickens

The streptogramin antimicrobial combination Quinupristin-Dalfopristin (QD) has been used in the United States since late 1999 to treat patients with vancomycin-resistant Enterococcus faecium (VREF) infections. Another streptogramin, virginiamycin (VM), is used as a growth promoter and therapeutic agent in farm animals in the United States and other countries. Many chickens test positive for QD-resistant E. faecium, raising concern that VM use in chickens might compromise QD effectiveness against VREF infections by promoting development of QD-resistant strains that can be transferred to human patients. Despite the potential importance of this threat to human health, quantifying the risk via traditional farm-to-fork modeling has proved extremely difficult. Enough key data (mainly on microbial loads at each stage) are lacking so that such modeling amounts to little more than choosing a set of assumptions to determine the answer. Yet, regulators cannot keep waiting for more data. Patients prescribed QD are typically severely ill, immunocompromised people for whom other treatment options have not readily been available. Thus, there is a pressing need for sound risk assessment methods to inform risk management decisions for VM/QD using currently available data. This article takes a new approach to the QD-VM risk modeling challenge. Recognizing that the usual farm-to-fork ("forward chaining") approach commonly used in antimicrobial risk assessment for food animals is unlikely to produce reliable results soon enough to be useful, we instead draw on ideas from traditional fault tree analysis ("backward chaining") to reverse the farm-to-fork process and start with readily available human data on VREF case loads and QD resistance rates. Combining these data with recent genogroup frequency data for humans, chickens, and other sources (Willems et al., 2000, 2001) allows us to quantify potential human health risks from VM in chickens in both the United States and Australia, two countries where regulatory action for VM is being considered. We present a risk simulation model, thoroughly grounded in data, that incorporates recent nosocomial transmission and genetic typing data. The model is used to estimate human QD treatment failures over the next five years with and without continued VM use in chickens. The quantitative estimates and probability distributions were implemented in a Monte Carlo simulation model for a five-year horizon beginning in the first quarter of 2002. In Australia, a Q1-2002 ban of virginiamycin would likely reduce average attributable treatment failures by 0.35 x 10(-3) cases, expected mortalities by 5.8 x 10(-5) deaths, and life years lost by 1.3 x 10(-3) for the entire population over five years. In the United States, where the number of cases of VRE is much higher, a 1Q-2002 ban on VM is predicted to reduce average attributable treatment failures by 1.8 cases in the entire population over five years; expected mortalities by 0.29 cases; and life years lost by 6.3 over a five-year period. The model shows that the theoretical statistical human health benefits of a VM ban range from zero to less than one statistical life saved in both Australia and the United States over the next five years and are rapidly decreasing. Sensitivity analyses indicate that this conclusion is robust to key data gaps and uncertainties, e.g., about the extent of resistance transfer from chickens to people.

Clinical and molecular characterization of vancomycin-resistant Enterococcus faecium strains during establishment of endemicity

To characterize the molecular epidemiology of vancomycin-resistant Enterococcus faecium (VREF) in Tennessee, VREF isolates that were recovered from patients during a 3-year period at a tertiary care center and throughout the state were typed by means of pulsed-field gel electrophoresis. Clinical characteristics and outcomes of patients colonized or infected with different strain types were also examined. A total of 34 different strain types were identified. A single VREF strain (type O) predominated (63 [61%] of 103 single-patient isolates (i.e., 1 isolate per patient) obtained from 7 different health care institutions). There were no significant differences between patients harboring type O strains and those harboring non-type O strains (P> or =.05). The rate of recovery of type O subtypes and strains other than type O increased over the 3-year study period. Establishment of VREF endemicity was initially characterized by clonal spread of type O strains. Subsequently, polyclonal dissemination may have been due to microevolutionary changes among type O strains.

PCR fragment length polymorphism analysis of vancomycin-resistant Enterococcus faecium

In this study, the glycopeptide resistance element, Tn1546, in 124 VanA Enterococcus faecium clinical isolates from 13 Michigan hospitals was evaluated using PCR fragment length polymorphism. There were 26 pulsed-field gel electrophoresis (PFGE) types, which consisted of epidemiologically related and unrelated isolates from separate patients (1992 to 1996). Previously published oligonucleotides specific for regions in the vanA gene cluster of Tn1546 were used to amplify vanRS, vanSH, vanHAX, vanXY, and vanYZ. The glycopeptide resistance element, Tn1546, of E. faecium 228 was used as the basis of comparison for all the isolates in this study. Five PCR fragment length patterns were found, as follows. (i) PCR amplicons were the same size as those of EF228 for all genes in the vanA cluster in 19.4% of isolates. (ii) The PCR amplicon for vanSH was larger than that of EF228 (3.7 versus 2.3 kb) due to an insertion between the vanS and vanH genes (79.2% of isolates). (iii) One isolate in a unique PFGE group had a vanSH amplicon larger than that of EF228 (5.7 versus 2.3 kb) due to an insertion in the vanS gene and an insertion between the vanS and vanH genes. (iv) One isolate did not produce a vanSH amplicon, but when vanS and vanH were amplified separately, both amplicons were the same size as those as EF228. (v) One isolate had a vanYZ PCR product larger than that of EF228 (2.8 versus 1.6 kb). This study shows that in a majority of the VanA E. faecium isolates, Tn1546 is altered compared to that of EF228. A total of 79.2% of the study isolates had the same-size insertion between the vanS and vanH genes. The results of this study show dissemination of an altered Tn1546 in heterologous VanA E. faecium in Michigan hospitals.