Urinary tract infection with an Enterococcus faecalis isolate that requires vancomycin for growth

Fierce poison to others: the phenomenon of bacterial dependence on antibiotics

Beyond the development of resistance, the effects of antibiotics on bacteria and microbial communities are complex and far from exhaustively studied. In the context of the current global antimicrobial resistance crisis, understanding the adaptive and physiological responses of bacteria to antimicrobials is of paramount importance along with the development of new therapies. Bacterial dependence on antibiotics is a phenomenon in which antimicrobials instead of eliminating the pathogens actually provide a boost for their growth. This trait comprises an extreme example of the complexities of responses elicited by microorganisms to these drugs. This compelling evolutionary trait was readily described along with the first wave of antibiotics use and dependence to various antimicrobials has been reported. Nevertheless, current molecular characterizations have been focused on dependence on vancomycin, linezolid and colistin, three critically important antibiotics frequently used as last resource therapy for multi resistant pathogens. Outstanding advances have been made in understanding the molecular basis for the dependence to vancomycin, including specific mutations involved. Regarding linezolid and colistin, the general physiological components affected by the dependence, namely ribosomes and membrane function respectively, have been established. Nonetheless the implications of antibiotic dependence in clinically relevant features, such as virulence, epidemics, relationship with development of resistance, diagnostics and therapy effectiveness require clarification. This review presents a brief introduction of the phenomenon of bacterial dependence to antibiotics and a summary on early and current research concerning the basis for this trait. Furthermore, the available information on the effect of dependence in key clinical aspects is discussed. The studies performed so far underline the need to fully disclose the biological and clinical significance of this trait in pathogens to successfully assess its role in resistance and to design adjusted therapies.

Vancomycin Resistance in Enterococcus and Staphylococcus aureus

Enterococcus faecalis, Enterococcus faecium and Staphylococcus aureus are both common commensals and major opportunistic human pathogens. In recent decades, these bacteria have acquired broad resistance to several major classes of antibiotics, including commonly employed glycopeptides. Exemplified by resistance to vancomycin, glycopeptide resistance is mediated through intrinsic gene mutations, and/or transferrable van resistance gene cassette-carrying mobile genetic elements. Here, this review will discuss the epidemiology of vancomycin-resistant Enterococcus and S. aureus in healthcare, community, and agricultural settings, explore vancomycin resistance in the context of van and non-van mediated resistance development and provide insights into alternative therapeutic approaches aimed at treating drug-resistant Enterococcus and S. aureus infections.

Colistin Dependency among Colistin-Heteroresistant Acinetobacter baumannii Isolates

Colistin dependent (CD) isolates are dependent on colistin for optimal growth. Here we aimed to systematically determine the emergence of CD among colistin-heteroresistant carbapenem-resistant Acinetobacter baumannii (CRAB) isolates. We also examined the phenotypic characteristics of CD and the evolution of CD strains to overt resistance. Additionally, we examined whether detection of growth in blood cultures was impaired by CD. Heteroresistant isolates, as determined by population analysis profiling, were exposed to colistin; when the colony count with colistin was significantly higher than without, isolates were suspected to be CD. CD was confirmed by Etest and growth curves. CD strains with colistin minimum inhibitory concentrations > 2 mg/L after growth in colistin-free media were considered colistin-resistant. Of the 65 heteroresistant strains tested, eight became CD after colistin exposure. These strains attained higher colony counts and growth rates with colistin vs. without, and grew adjacent to the colistin Etest strip. CD strains exhibited increased susceptibilities to multiple antibiotics compared to their parent heteroresistant strains. All CD strains tested became colistin-resistant following growth without colistin. CD strains were detected in blood culture bottles, but time to detection was significantly prolonged compared with parent strains, suggesting that CD may lead to delay in detection of CRAB bacteremia.

vB_EfaS-DELF1, a novel Siphoviridae bacteriophage with highly effective lytic activity against vancomycin-resistant Enterococcus faecalis

Enterococcus faecalis is an environmental agent of bovine mastitis in cows and has many cytopathic effects on the urinary tract in both humans and animals. In this study, a novel lytic bacteriophage, vB_EfaS-DELF1, was isolated against 21 E. faecalis isolated from bovine mastitis, including vancomycin-resistant E. faecalis (VRE). vB_EfaS-DELF1 bacteriophage was specific for E. faecalis and showed no lytic effects against other tested Enterococcus spp., Gram-negative, or Gram-positive bacteria. Moreover, no activity was observed against yogurt starters. The phage suspension was stable in a wide range of pH, salinity, and temperature. It retained its activity in 3.5 % fat milk. vB_EfaS-DELF1 has the common phenotypic features of Siphoviridae with a double-strand DNA of 40,248 bp in length and a G + C content of 34.9 %. The genome encodes 62 putative ORFs and no tRNA. No undesirable genes such as lysogenic mediators, antibiotic resistance, or virulence factor genes were detected in the genome. The comparative genomic analysis demonstrated similarity to the other available phage genomes. The highest similarity was observed with two other phages (50 % coverage and 82.38 % identities with IME-EFm1; 35 % coverage and 86.22 % identities with IME-EFm5) that were placed in the same clade. The differences with the other aligned phages were high and were placed in distant clusters. Regarding the specificity of this new bacteriophage against all of the tested E. faecalis isolates and, in particular, against the vancomycin-resistant ones, and also the absence of antibiotic resistance or virulence genes in its genome, vB_EfaS-DELF1 is suggested as a potential candidate for biocontrol of E. faecalis infections.

The female urinary microbiota in relation to the reproductive tract microbiota

Human urine is traditionally considered to be sterile, and whether the urine harbours distinct microbial communities has been a matter of debate. Potential links between female urine and reproductive tract microbial communities is currently not clear. Here, we collected urine samples from 147 Chinese women of reproductive age and explored the nature of colonization by 16S rRNA gene amplicon sequencing, quantitative real-time PCR, and live bacteria culture. To demonstrate the utility of this approach, the intra-individual Spearman's correlation was used to explore the relationship between urine and multiple sites of the female reproductive tract. PERMANOVA was also performed to explore potential correlations between the lifestyle and various clinical factors and urinary bacterial communities. Our data demonstrated distinct bacterial communities in urine, indicative of a non-sterile environment. Streptococcus-dominated, Lactobacillus-dominated, and diverse type were the three most common urinary bacterial community types in the cohort. Detailed comparison of the urinary microbiota with multiple sites of the female reproductive tract microbiota demonstrated that the urinary microbiota were more similar to the microbiota in the cervix and uterine cavity than to those of the vagina in the same women. Our data demonstrate the potential connectivity among microbiota in the female urogenital system and provide insight and resources for exploring diseases of the urethra and genital tract.

Isolation and first draft genome sequence of a linezolid-dependent Staphylococcus aureus clinical strain

Background: Antibiotic-dependent pathogenic bacteria are sporadically isolated from patients that received prolonged antibiotic treatments. Evolution of antibiotics dependence and its clinical implications are scarcely studied. Materials & methods: A linezolid-dependent Staphylococcus aureus strain was isolated from a cystic fibrosis patient. A draft genome sequence was obtained and searched for known antibiotics resistance determinants and virulence factors. Results: The genome was assembled into 79 contigs for a total of 2.83 Mbp. This strain is a sequence type 5 methicillin-resistant Staphylococcus aureus with a type I SCCmec cassette also conserving the Panton-Valentine leukocidin. The G2576T substitution, conferring linezolid resistance, was harbored by all five copies of the 23S rRNA. Conclusion: The linezolid-dependent strain is related to a strain circulating in Latin America that acquired a mutation conferring linezolid resistance.

Antimicrobial Resistance and Biofilm Formation in Enterococcus spp. Isolated from Humans and Turkeys in Poland

Enterococci are a natural component of the intestinal flora of many organisms, including humans and birds. As opportunistic pathogens, they can cause fatal infections of the urinary tract and endocarditis in humans, whereas in poultry symptoms are joint disease, sepsis, and falls in the first week of life. The study covered 107 Enterococcus strains—56 isolated from humans and 51 from turkeys. Among the isolates investigated Enterococcus faecalis was detected in 80.36% of human and 80.39% of turkey samples. Enterococcus faecium was identified in 8.93% of human and 17.65% of turkey strains. The highest percentage of the strains was resistant to tetracycline as follows: 48 (85.71%) and 48 (94.12%) of human and turkey strains, respectively. Resistance to erythromycin occurred in 37.50% of the human and in 76.47% of turkey strains, otherwise 27.10% of all strains showed resistance to ciprofloxacin. Our study revealed that 25% of human and 15.69% of turkey strains were resistant to vancomycin. Multidrug resistance showed in 32.14% and 43.14% of human and turkey strains, respectively. The tetracycline resistance gene, tetM, was detected in 82.24% of all strains analyzed, whereas the tetO gene was found in 53.57% of human but only in 7.84% of turkey strains. The vancomycin resistance gene (vanA) was detected in seven Enterococcus strains (six isolated from turkeys and one from humans). The ermB gene (resistance to macrolide) was detected in 55.14% of all isolates (42.86% of human and 68.63% of turkey strains), whereas the ermA gene was detected in 17.65% of turkey but only in 3.57% of human isolates. All the strains had the ability to form biofilms. A stronger biofilm was formed after 24-hour incubation by strains isolated from turkeys, whereas after 48 hours of incubation all examined strains produced strong biofilm.

Broad-host-range Inc18 plasmids: Occurrence, spread and transfer mechanisms

Conjugative plasmid transfer is one of the major mechanisms responsible for the spread of antibiotic resistance and virulence genes. The incompatibility (Inc) 18 group of plasmids is a family of plasmids replicating by the theta-mechanism, whose members have been detected frequently in enterococci and streptococci. Inc18 plasmids encode a variety of antibiotic resistances, including resistance to vancomycin, chloramphenicol and the macrolide-lincosamide-streptogramine (MLS) group of antibiotics. These plasmids comprising insertions of Tn1546 were demonstrated to be responsible for the transfer of vancomycin resistance encoded by the vanA gene from vancomycin resistant enterococci (VRE) to methicillin resistant Staphylococcus aureus (MRSA). Thereby vancomycin resistant S. aureus (VRSA) were generated, which are serious multi-resistant pathogens challenging the health care system. Inc18 plasmids are widespread in the clinic and frequently have been detected in the environment, especially in domestic animals and wastewater. pIP501 is one of the best-characterized conjugative Inc18 plasmids. It was originally isolated from a clinical Streptococcus agalactiae strain and is, due to its small size and simplicity, a model to study conjugative plasmid transfer in Gram-positive bacteria. Here, we report on the occurrence and spread of Inc18-type plasmids in the clinic and in different environments as well as on the exchange of the plasmids among them. In addition, we discuss molecular details on the transfer mechanism of Inc18 plasmids and its regulation, as exemplified by the model plasmid pIP501. We finish with an outlook on promising approaches on how to reduce the emerging spread of antibiotic resistances.

Draft Genome Sequence of a Vancomycin-Resistant and Vancomycin-Dependent Enterococcus faecium Isolate

Vancomycin-resistant enterococci have emerged as major nosocomial pathogens worldwide. While antimicrobial pressure promotes nosocomial colonization with these enterococci, prolonged exposure to vancomycin may foster the transition from vancomycin resistance to vancomycin dependence. Here, we report the draft genome sequence of a vancomycin-dependent Enterococcus faecium isolate showing partial teicoplanin dependence.

Dissemination of Enterococcus faecalis and Enterococcus faecium in a ricotta processing plant and evaluation of pathogenic and antibiotic resistance profiles

In this work, the sources of contamination by Enterococcus spp. in a ricotta processing line were evaluated. The isolated strains were tested for virulence genes (gelE, cylA,B, M, esp, agg, ace, efaA, vanB), expression of virulence factors (hemolysin and gelatinase), and the resistance to 10 different antibiotics. Enterococcus faecium and Enterococcus faecalis were subjected to discriminatory identification by intergenic spacer region (ITS)-polymerase chain reaction and sequencing of the ITS region. The results showed that Enterococcus spp. was detected in the raw materials, environment samples and the final product. None of the 107 Enterococcus isolates were completely free from all virulence genes considered. A fraction of 21.5% of the isolates containing all of the genes of the cylA, B, M operon also expressed β-hemolysis. Most of the isolates showed the gelE gene, but only 9.3% were able to hydrolyze gelatin. In addition, 23.5% of the observed Enterococcus isolates had the vanB gene but were susceptible to vancomycin in vitro. The dissemination of antibiotic-resistant enterococci was revealed in this study: 19.3% of the E. faecium samples and 78.0% of the E. faecalis samples were resistant to at least one of the antibiotics tested. Sequencing of region discriminated 5 and 7 distinct groups among E. faecalis and E. faecium, respectively. Although some similarity was observed among some of the isolates, all E. faecalis and E. faecium isolates had genetic differences both in the ITS region and in the virulence profile, which makes them different from each other.

Heteroresistance to cephalosporins and penicillins in Acinetobacter baumannii

Heteroresistance to antimicrobial agents may affect susceptibility test results and therapeutic success. In this study, we investigated heteroresistance to cephalosporins and penicillins in Acinetobacter baumannii, a major pathogen causing nosocomial infections. Two A. baumannii isolates exhibited heteroresistance to ampicillin-sulbactam, ticarcillin-clavulanic acid, cefepime, and cefpirome, showing a distinct colony morphology of circular rings within the inhibition halos. Pulsed-field gel electrophoresis (PFGE) and outer membrane protein (OMP) analysis demonstrated that subpopulations around the disks/Etest strips and the original strains all belonged to the same PFGE type and OMP profile. Population analysis profile (PAP) showed the presence of heteroresistant subpopulations with high cefepime resistance levels in two isolates (008 and 328). Interestingly, A. baumannii 008 contained two peaks: one was grown in the presence of up to 1 μg of cefepime/ml, the other apparently occurred when the concentration of cefepime was raised to 256 μg/ml. After serial passages without exposure to cefepime, the PAP curve maintained the same trend observed for the original strain of A. baumannii 008. However, the PAP curve showed a shift to relatively lower cefepime resistance (from 256 to 64 μg/ml) in A. baumannii 328 after 10 passages in antibiotic-free Mueller-Hinton agar plates. Convergence to a monotypic resistance phenotype did not occur. Growth rate analysis revealed that slower growth in resistant subpopulations may provide a strategy against antibiotic challenge. To our knowledge, this is the first report of heteroresistance to cephalosporins and penicillins in A. baumannii.

Acquisition of VanB-type vancomycin resistance by Bacillus subtilis: the impact on gene expression, cell wall composition and morphology

The vancomycin resistance operons from Enterococci, Staphylococci and Actinomycetes encode a VanRS two-component signal transduction system (TCS) and a suite of enzymes to modify the peptidoglycan biosynthetic precursor lipid II and to eliminate the D-Ala-D-Ala from the cell. Commingling of these regulatory and enzymatic activities with host functions has the potential to significantly impact host gene expression and cell wall metabolism. Here we report the effects of individually expressing the VanR(B) S(B) TCS and the VanY(B) WH(B) BX(B) resistance proteins in Bacillus subtilis. VanY(B) WH(B) BX(B) expression confers resistance to 2 µg ml(-1) of vancomycin with concomitant reduced Van-FL staining and leads to a cell division defect. In contrast to E. faecalis and S. aureus, VanS(B) is active in B. subtilis without vancomycin addition. Individual expression of the VanR(B) S(B) TCS and the VanY(B) WH(B) BX(B) resistance proteins repress and increase, respectively, expression of PhoPR regulon genes in the phosphate-limited state. When vancomycin-resistant cells are exposed to elevated vancomycin levels, mutant strains with increased resistance to vancomycin and a growth dependency on vanY(B) WH(B) BX(B) expression frequently arise. Mutation of the endogenous Ddl ligase is the necessary and sufficient cause of both phenotypes. We discuss how these effects may influence establishment of van operons in new host bacteria.

[Microbiological and epidemiological characteristics of vancomycin-dependent enterococci]

BACKGROUND

Vancomycin-dependent enterococci (VDE) are clinically equivalent to vancomycin-resistant enterococci (VRE), but more difficult to detect. This study was purposed to characterize VDE microbiologically and epidemiologically.

METHODS

The patients from whom VDE were detected from April 2007 to March 2008 were investigated. For available isolates, minimal inhibitory concentrations (MICs) of and the levels of dependence on vancomycin and teicoplanin were measured by E test (AB Biodisk, Sweden), and a test for reversion of VDE to non-dependent VRE (NDVRE) and pulsed field gel electrophoresis (PFGE) were performed. Patients' demographic and clinical findings were reviewed via electronic medical records.

RESULTS

VDE were recovered from 6 (2.2%) of 272 patients carrying VRE during this study period. All patients were already colonized or infected by VRE and treated with vancomycin for 13 to 107 days. VDE were isolated from pleural fluid (one), urine (four), and stool (one). All isolates carried vanA with vancomycin MICs of >256 microg/mL, but two of them had intermediate susceptibilities to teicoplanin. Because 4 VDE isolates were reverted to NDVRE with single passage, vancomycin dependence was measurable for only two isolates as equal and above 0.064 and 0.5 microg/mL respectively, and was reverted after 5 and 7 passages, respectively. Six VDE isolates showed no related clones in PFGE analysis, and 3 of 4 available pairs of initial VRE isolates and subsequent VDE isolates were identical clones.

CONCLUSIONS

VDE were not rare and seemed to emerge independently from VRE with a prolonged use of vancomycin. Vancomycin-dependence was reverted within several passages.

VanB-type Enterococcus faecium clinical isolate successively inducibly resistant to, dependent on, and constitutively resistant to vancomycin

Three Enterococcus faecium strains isolated successively from the same patient, vancomycin-resistant strain BM4659, vancomycin-dependent strain BM4660, and vancomycin-revertant strain BM4661, were indistinguishable by pulsed-field gel electrophoresis and harbored plasmid pIP846, which confers VanB-type resistance. The vancomycin dependence of strain BM4660 was due to mutation P(175)L, which suppressed the activity of the host Ddl D-Ala:D-Ala ligase. Reversion to resistance in strain BM4661 was due to a G-to-C transversion in the transcription terminator of the vanRS(B) operon that lowered the free energy of pairing from -13.08 to -6.65 kcal/mol, leading to low-level constitutive expression of the resistance genes from the P(RB) promoter, as indicated by analysis of peptidoglycan precursors and of VanX(B) D,D-dipeptidase activity. Transcription of the resistance genes, studied by Northern hybridization and reverse transcription, initiated from the P(YB) resistance promoter, was inducible in strains BM4659 and BM4660, whereas it started from the P(RB) regulatory promoter in strain BM4661, where it was superinducible. Strain BM4661 provides the first example of reversion to vancomycin resistance of a VanB-type dependent strain not due to a compensatory mutation in the ddl or vanS(B) gene. Instead, a mutation in the transcription terminator of the regulatory genes resulted in transcriptional readthrough of the resistance genes from the P(RB) promoter in the absence of vancomycin.

[Emergence of vancomycin-dependent enterococci following glycopeptide therapy: case report and review]

INTRODUCTION

Outbreaks of vancomycin-resistant enterococci have been increasingly reported in France over the last three years. We report here, the emergence of a vancomycin-dependent enterococci isolate following glycopeptide therapy.

PATIENTS AND METHODS

An Enterococcus faecium isolate that required vancomycin for growth was cultured from the stools of a liver transplant recipient who was colonised with vancomycin-resistant enterococci and who received vancomycin treatment for methicillin-resistant Staphylococcus aureus infection. The resistant isolate and the dependent isolate were typed by pulsed-field gel electrophoresis. The sequence of the ddl gene coding for the D-Ala: D-Ala ligase was analysed.

RESULTS

The dependent isolate was primary cultured onto a vancomycin-containing screening medium and could not be subcultured in the absence of vancomycin. Both the resistant and dependent isolates harboured the vanA gene and they had the same DNA restriction pattern after pulsed-field gel electrophoresis. Dependence on vancomycin was associated with a 1-bp deletion in the D-Ala: D-Ala ligase gene leading to an early stop odon.

CONCLUSION

Cultures onto vancomycin-containing media are warranted for clinical specimens from patients, who are known to carry vancomycin-resistant enterococci and receive vancomycin therapy.

Enterococcal endocarditis on native and prosthetic valves: a review of clinical and prognostic factors with emphasis on hospital-acquired infections as a major determinant of outcome

Enterococci are the third leading cause of infectious endocarditis, and despite advances in diagnosis and treatment, the mortality of enterococcal endocarditis has not changed in recent decades. Although variables such as advanced age, cardiac failure, and brain emboli have been recognized as risk factors for mortality, cooperative multi-institutional studies have not assessed the role of other variables, such as nosocomial acquisition of infection, the presence of comorbidities, or the changing antimicrobial susceptibility of enterococci, as factors determining prognosis.We conducted the current study to determine the risk factors for mortality in patients with enterococcal endocarditis in a single institution. We reviewed 47 consecutive episodes of enterococcal endocarditis in 44 patients diagnosed according to the modified Duke criteria from a retrospective cohort study of cases of infectious endocarditis. The main outcome measure was inhospital mortality. We applied stepwise logistic regression analysis to identify risk factors for mortality.Predisposing heart conditions were observed in 86.3% of patients, and 17 had prosthetic valve endocarditis. A portal of entry was suspected or determined in 38.2%; the genitourinary tract was the most common source of the infection (29.7%). Comorbidities were present in 52.2% of cases. Twelve episodes (25.5%) were acquired during hospitalization. Only 3 isolates of Enterococcus faecalis were highly resistant to gentamicin. Eighteen patients (40.9%) needed valve replacement due to cardiac failure or relapse. Comparing cases of native valve and prosthetic valve endocarditis, we found no differences regarding complications, the need for surgical treatment, or mortality. Eight of 44 (18%) episodes were fatal. Age over 70 years (p = 0.05), heart failure (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.15-2.25; p = 0.001), presence of 1 or more comorbidities (OR, 3.2; 95% CI, 1.11-9.39; p = 0.02), and nosocomial acquisition (OR, 8.05; 95% CI, 1.50-43.2; p = 0.01) were associated with mortality. In the multivariate analysis, only nosocomial acquisition increased the risk of mortality. In patients with enterococcal endocarditis, nosocomial acquisition of infection is an important factor determining outcome. As the incidence of bacteremia and the population of elderly people at risk continue to grow, the hazard of acquiring nosocomial enterococcal endocarditis may increase; hence, major emphasis must be put on prevention.

Occurrence of the van genes in Enterococcus faecalis and Enterococcus faecium from clinical isolates in Korea

Enterococcus faecalis and Enterococcus faecium isolated from Korea patients in 1998 and 2005 were tested for susceptibility to nine different antimicrobial agents, including vancomycin and teicoplanin. Polymerase chain reaction (PCR) was used for the detection of several vancomycin resistance genes such as vanA ('high level'), vanB ('moderate high level'), vanC1 and vanC2 ('low level'). Both E. faecalis and E. faecium exhibited a resistance of 80% and more than 60% to synercid and mupirocin, respectively. Moreover, an average of 76% of all isolates was resistant to ciprofloxacin, gentamicin, lincomycin, cefotaxime, and meropenem, confirming the multiple drug resistance of most of the isolates. No resistance to vancomycin or teicoplanin was observed in the 1998 E. faecalis and E. faecium isolates. However, the 2005 E. faecalis and E. faecium isolates exhibited resistance of 16% and 12% to vancomycin and teicoplanin, respectively. In addition, vanA gene was detected in 4 strains of 2005 E. faecium isolates, thus showing a high resistance to vancomycin. No other vancomycin resistance genes, including vanB, vanC1, and vanC2, were found in our isolates. In this study, we compared the occurrence of antimicrobial resistance and the presence of specific resistance genes in E. faecalis and E. faecium. The results showed that the 2005 isolates were usually more resistant than the 1998 isolates.

Enterococcal Infection in Children

From relative obscurity, enterococci have become a leading cause of nosocomial infection. This has been attributed, in part, to the growth in susceptible host populations, increased use of intravascular devices, prolonged hospital stay, and widespread antibiotics use. Furthermore, the facility with which enterococci acquire resistance characteristics coupled with their capacity to survive in the environment renders them uniquely suited as nosocomial opportunists and have resulted in global dissemination of resistant strains. Debate continues as to whether most serious infections arise from a person's indigenous flora or dissemination of virulent clones. Enterococci are normal inhabitants of the human gastrointestinal tract. Classically associated with endocarditis and wound and urinary tract infections, increasingly they are a cause of nosocomial bacteremia. The rise in incidence of serious enterococcal infection has been particularly evident in neonatal, paediatric intensive care, and haematology/oncology units. Spread of resistant phenotypes has posed a difficult therapeutic challenge. We have been rescued, albeit perhaps only temporarily, by the addition of newer agents, such as linezolid, to the therapeutic armamentarium. However, there is no room for complacency. Linezolid resistance already has been reported. Efforts must continue to focus on prevention of the emergence and dissemination of resistance through policies of rational antibiotic use, infection control and education.

Vancomycin resistance in gram-positive cocci

The first vancomycin-resistant clinical isolates of Enterococcus species were reported in Europe in 1988. Similar strains were later detected in hospitals on the East Coast of the United States. Since then, vancomycin-resistant enterococci have spread with unexpected rapidity and are now encountered in hospitals in most countries. This article reviews the mode of action and the mechanism of bacterial resistance to glycopeptides, as exemplified by the VanA type, which is mediated by transposon Tn1546 and is widely spread in enterococci. The diversity, regulation, evolution, and recent dissemination of methicillin-resistant Staphylococcus aureus are then discussed.

A vancomycin-dependent VanA-type Enterococcus faecalis strain isolated in Japan from chicken imported from China

AIMS

The characterization of KC122.1, which is a vancomycin-dependent VRE (Vancomycin-resistant enterococci) (Enterococcus faecalis) and the first case in Japan of a VRE isolate obtained from chicken meat imported from China.

METHODS AND RESULTS

PCR amplification of vanA, vanS and ddl gene and direct sequencing of the PCR products were performed. KC122.1 was a VanA-type VRE showing high-level vancomycin resistance and low-level teicoplanin resistance, and its vanS gene had three point mutations. The ddl gene of KC122.1 was sequenced and two changes were found at the ninth codon (GCC-GAC) and the stop codon (TAA-CAA). The latter change was also found in the laboratory strain E. faecalis FA2-2.

CONCLUSIONS

Three point mutations in vanS resulted in high-level vancomycin resistance and low-level teicoplanin resistance. The change at the ninth codon resulted in the inactivation of the ddl gene and vancomycin-dependent growth. An eight amino acid extension at the C-terminal did not impair the function of the D-Ala : D-Ala ligase.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first example of the isolation of VRE from chicken meat imported from China and the first vancomycin-dependent VRE from a nonhuman source.

Outbreak of Vancomycin-Resistant Enterococci (VRE) in a Hematological Oncology Ward and Hygienic Preventive Measures. A Long-Term Study

BACKGROUND

We report on two endemic outbreaks of VRE (vancomycin-resistant enterococci, vanA type Enterococcus faecium) on a hematological oncology ward in a university hospital and a new strategic concept to fight against spread of VRE.

PATIENTS AND METHODS

During management of the outbreak, a total of 1,124 patients and 1,700 specimens were investigated from June 1999 to December 2001. Protective measures were instituted. Intensive prophylactic infection control was practiced until December 2003.

RESULTS

Of the 1,124 patients, 44 were VRE-positive. From 1,700 environment specimens, 110 VRE isolates were obtained from the inanimate environment, 5 from the living environment. Molecular biological typing identified 5 different clones which had spread on the ward in different locations.

CONCLUSION

The study shows the need for prophylactic microbiological screening investigations in the risk group of hematological oncology patients and consistent implementation of protective hygiene measures to prevent the spread of multiresistant infectious pathogens on risk wards. It is also shown that intervention can to control such an endemic outbreak.

Molecular cloning, overexpression, purification, and characterization of an aerobic FMN-dependent azoreductase from Enterococcus faecalis

Azo dyes represent a major class of synthetic colorants that are ubiquitous in foods and consumer products. Enterococcus faecalis is a predominant member of the human gastrointestinal microflora. Strain ATCC 19433 grew in the presence of azo dyes and metabolized them to colorless products. A gene encoding a putative FMN-dependent aerobic azoreductase that shares 34% identity with azoreductase (AcpD) of Escherichia coli has been identified in this strain. The gene in E. faecalis, designated as azoA, encoded a protein of 208 amino acids with a calculated isoelectric point of 4.8. AzoA was heterologously overexpressed in E. coli with a strong band of 23 kDa on SDS-PAGE. The purified recombinant enzyme was a homodimer with a molecular weight of 43 kDa, probably containing one molecule of FMN per dimer. AzoA required FMN and NADH, but not NADPH, as a preferred electron donor for its activity. The apparent Km values for both NADH and 2-[4-(dimethylamino)phenylazo]benzoic acid (Methyl red) substrates were 0.14 and 0.024 mM, respectively. The apparent Vmax was 86.2 microM/min/mg protein. The enzyme was not only able to decolorize Methyl red, but was also able to convert sulfonated azo dyes Orange II, Amaranth, Ponceau BS, and Ponceau S. AzoA is the first aerobic azoreductase to be identified and characterized from human intestinal gram-positive bacteria.

Nosocomial infection with vancomycin-dependent enterococci

In three patients with nosocomial vancomycin-resistant enterococcal infections, infections attributable to vancomycin-dependent enterococci developed.

We report three patients infected with unique strains of vancomycin-dependent enterococci. Two were first infected by genetically identical strains of vancomycin-resistant enterococci (VRE). All three patients had much greater exposure to vancomycin and third-generation cephalosporins than did two control groups (patients infected with VRE and hospitalized patients without enterococcal infections). While antimicrobial pressure promotes nosocomial colonization by VRE, prolonged exposure to vancomycin may foster the transition from vancomycin resistance to dependence.

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.

Effect of raw-milk cheese consumption on the enterococcal flora of human feces

Enterococci are one of the major facultative anaerobic bacterial groups that reside in the human gastrointestinal tract. In the present study, the composition of the enterococcal fecal flora in three healthy humans was analyzed before, during, and after the daily consumption of approximately 125 g of a raw-milk Cheddar-type cheese containing 3.2 x 10(4) enterococci/g of cheese. Enterococcal counts ranged between 1.4 x 10(2) and 2.5 x 10(8) CFU/g of feces and differed from subject to subject and from week to week. The cheese contained mainly Enterococcus casseliflavus and a small population of Enterococcus faecalis. Clonal relationships were determined by pulsed-field gel electrophoresis. Before and after consumption of the cheese, samples from humans contained mainly Enterococcus faecium, with some of the clones being resident. During consumption of the cheese, one particular transient clone of E. faecalis, clone Fs2, which was present in small numbers in the cheese, largely dominated the feces. Two clones of E. casseliflavus from the cheese were also found in the feces of one of the subjects during cheese consumption. These results suggest that a clone need not be present in a food in high numbers to establish itself in the intestine.

Comparison of agar-based media for primary isolation of glycopeptide-resistant enterococci

OBJECTIVE: To compare four vancomycin-containing agar media for the isolation of glycopeptide-resistant enterococci (GRE) from clinical fecal specimens: kanamycin---aesculin---azide (KAA) agar; bile---aesculin---polymixin (BAP) agar; aztreonam---amphotericin blood (CBAA) agar; and neomycin blood (CBN) agar. METHODS: Fecal specimens from 125 patients were inoculated onto each medium. Media were examined for enterococci after incubation for up to 48 h. Enterococci were identified to species level, and glycopeptide phenotypes were determined by measuring minimum inhibitory concentrations of vancomycin and teicoplanin. RESULTS: GRE were isolated from 44/125 samples. Enterococcus faecalis and Enterococcus faecium isolates, expressing glycopeptide resistance of the VanA or VanB phenotypes, were recovered from 27/33 (82%) specimens on BAP medium, 26/33 (79%) on KAA medium, and 21/33 (64%) on CBN and CBAA media. Enterococcus gallinarum and Enterococcus casseliflavus isolates expressing low-level glycopeptide resistance (VanC phenotype) were recovered from 14/15 (93%) specimens on CBAA medium, 7/15 (47%) on KAA and CBN media, and 6/15 (40%) on BAP medium. CONCLUSIONS: The media tested in this study, with the exception of CBN medium, detected at least 75% of patients colonized by GRE. Further development of BAP, CBAA and KAA media is warranted to improve growth and selectivity.

Comparison of two commercially available selective media to screen for vancomycin-resistant enterococci

Campylobacter medium (CAMPY, Becton Dickinson [BD] Microbiology Systems, Cockeysville, MD) and Vancomycin Screen Agar (VSA, BD) were compared for their ability to screen for vancomycin-resistant Enterococcus (VRE) from primary plates. A microdilution minimal inhibitory concentration (MIC) assay (Pasco, BD) served as the reference vancomycin MIC. In the random sample of 200 enterococcal clinical isolates tested, the distribution of isolates was as follows: Enterococcus faecium, 113 (97 VRE); Enterococcus faecalis, 71(12 VRE); Enterococcus gallinarum, 10; and Enterococcus casseliflavus, 6. Of the 75 vancomycin-susceptible strains, none grew on CAMPY and 4 grew on VSA, whereas all 109 VRE isolates grew on both screen plates. Of the 16 strains with a Van C phenotype, ie, E. gallinarum and E. casseliflavus, 2 grew on CAMPY and 14 on VSA. Of the 899 clinical specimens plated onto both agars, 45 of 67 VRE were detected with both media, 20 were detected only with CAMPY and 2 were not detected by either screen plate. CAMPY compared with VSA as a primary plating medium was more sensitive and, when used to screen for VRE isolates from primary plates, was more specific for strains displaying Van A and B phenotypes.

D-Ala:D-Ala ligase gene flanking the vanC cluster: evidence for presence of three ligase genes in vancomycin-resistant Enterococcus gallinarum BM4174

An open reading frame located 230 nucleotides downstream from the stop codon of vanS(c) and in the opposite direction relative to the other genes of the vanC cluster was identified in Enterococcus gallinarum BM4174. This gene (designated ddl2) encoded a protein of 343 amino acids that had significant predicted structural similarity to D-Ala:D-Ala ligases and displayed 33 and 35% amino acid identity to VanC-1 and the previously reported partial sequence of Ddl from E. gallinarum, respectively. Biochemical characterization by thin-layer chromatography confirmed that Ddl2 is a D-Ala:D-Ala ligase with no detectable D-Ala:D-Ser ligase activity. The vancomycin dependence of Enterococcus faecalis BM4320 (ddl mutant) was lost on electroporation of a plasmid construct expressing ddl2 constitutively. The latter strain was able to grow in the absence of vancomycin, and peptidoglycan precursor analysis under the same conditions indicated the synthesis of pentapeptide[D-Ala] as the main precursor, confirming the activity of Ddl2 in vivo. Expression of ddl and ddl2 in BM4174 was tested by reverse transcription-PCR: results suggested that both D-Ala:D-Ala ligases were expressed concomitantly. Our findings indicate that vancomycin-resistant E. gallinarum BM4174 is likely to express one D-Ala:D-Ser and two D-Ala:D-Ala ligase genes.

Enterococcal diversity in the environment of an Irish Cheddar-type cheesemaking factory

Enterococci are natural residents of human and animal intestinal tracts and grow to high levels in a variety of artisanal cheeses. The aim of this study was to determine the diversity of enterococci in a farmhouse raw-milk cheese production unit. Putative enterococci were isolated from the faeces of all the cows and all the people associated with the cheesemaking, from the milk and cheese during manufacture and ripening and from the environment in three separate trials. Almost 1400 isolates were screened using a genus-specific primer. The results indicated that all the human, milk, curd and cheese isolates but only 33.7%, 6.7% and 4.4% of the bovine isolates from the three trials, respectively, were members of the genus Enterococcus. RAPD-PCR was used to type the enterococcal isolates. In general, only E. faecium was found in the bovine faeces while E. casseliflavus dominated the human faeces, milk and cheese followed by lower numbers of E. faecalis. Environmental sampling of the water in the milking parlour and rinses of the cows' teats, the bulk-milk storage tank and the milking machine corroborated these results as E. casseliflavus and E. faecalis were the only Enterococcus species found in these samples. The putative vancomycin-resistant enterococci (VRE), isolated in Trial 1, were shown to be Pediococcus spp. by genotypic and phenotypic analysis.

Vancomycin-resistant enterococci: mechanisms and clinical observations

Enterococci are not generally regarded as highly virulent bacterial pathogens. However, resistance to many antimicrobial drugs complicates treatment of enterococcal infections. Acquired resistance to high concentrations of glycopeptide antibiotics, specifically vancomycin, has exacerbated this problem. This article seeks to concisely review the mechanisms of that resistance and its effects on clinical management of enterococcal infections, as well as clinical microbiology and infection control.

Sequencing of the ddl gene and modeling of the mutated D-alanine:D-alanine ligase in glycopeptide-dependent strains of Enterococcus faecium

Glycopeptide dependence for growth in enterococci results from mutations in the ddl gene that inactivate the host D-Ala:D-Ala ligase. The strains require glycopeptides as inducers for synthesis of resistance proteins, which allows for the production of peptidoglycan precursors ending in D-Ala-D-Lac instead of D-Ala-D-Ala. The sequences of the ddl gene from nine glycopeptide-dependent Enterococcus faecium clinical isolates were determined. Each one had a mutation consisting either in a 5-bp insertion at position 41 leading to an early stop codon, an in-frame 6-bp deletion causing the loss of two residues (KDVA243-246 to KA), or single base-pair changes resulting in an amino acid substitution (E13 --> G, G99 --> R, V241 --> D, D295 --> G, P313 --> L). The potential consequences of the deletion and point mutations on the 3-D structure of the enzyme were evaluated by comparative molecular modeling of the E. faecium enzyme, using the X-ray structure of the homologous Escherichia coli D-Ala:D-Ala ligase DdlB as a template. All mutated residues were found either to interact directly with one of the substrates of the enzymatic reaction (E13 and D295) or to stabilize the position of critical residues in the active site. Maintenance of the 3-D structure in the vicinity of these mutations in the active site appears critical for D-Ala:D-Ala ligase activity.

Occurrence of the vanA and vanC2/C3 genes in Enterococcus species isolated from poultry sources in Malaysia

Enterococcus species isolated from poultry sources were characterized for their resistance to antibiotics, plasmid content, presence of van genes and their diversity by randomly amplified polymorphic DNA-polymerase chain reaction (RAPD-PCR). The results showed that all isolates were multi-resistance to the antibiotics tested. Ampicillin (15/70) followed by chloramphenicol (37/70) were the most active antibiotics tested against the Enterococcus spp. isolates, while the overall resistant rates against the other antibiotics were between 64.3% to 100%. All vancomycin-resistant E. faecalis, E. durans, E. hirae and E. faecium isolates tested by the disk diffusion assay were positive in PCR detection for presence of vanA gene. All E. casseliflavus isolates were positive for vanC2/C3 gene. However, none of the Enterococcus spp. isolates were positive for vanB and vanC1 genes. Plasmids ranging in sizes between 1.1 to ca. 35.8 MDa were detected in 38/70 of the Enterococcus isolates. When the genetic relationship among all isolates of the individual species were tested by RAPD-PCR, genetic differences detected suggested a high genetic polymorphisms of isolates in each individual species. Our results indicates that further epidemiological studies are necessary to elucidate the role of food animals as reservoir of VRE and the public health significance of infections caused by Enterococcus spp.

Acquired and intrinsic glycopeptide resistance in enterococci

Enterococci are Gram-positive cocci responsible for severe human infections, such as endocarditis, meningitis, and septicemia and constitute an increasingly frequent cause of nosocomial infections. Enterococci are resistant to nearly all classes of drugs including, since 1986, glycopeptides. Vancomycin and teicoplanin act by blocking cell wall formation and resistance is due to synthesis of modified late peptidoglycan precursors. Glycopeptide resistance can be intrinsic or acquired and strains may be resistant to vancomycin and teicoplanin, or to vancomycin only. Five types of glycopeptide resistance and their biochemical mechanisms have been described in enterococci. Clinical isolates that are dependent on vancomycin for growth have been isolated. Data suggest a dual origin for resistance: glycopeptide-producing organisms or enterococcal species intrinsically resistant to these drugs.

Occurrence of the vancomycin-resistant genes vanA, vanB, vanCl, vanC2 and vanC3 in Enterococcus strains isolated from poultry and pork

It is suspected that the use of avoparcin as a feeding antibiotic for the fat stock contributes to development of cross-resistance against vancomycin and teicoplanin. After isolating enterococci strains from poultry and pork meat by cultivation on citrate azide Tween carbonate agar (CATC) and screening the vancomycin resistance on Columbia colistin nalidixic acid agar (CNA, supplemented with 5% sheepblood and 5 mg vancomycin/l) the polymerase chain reaction (PCR) was used for the detection of the vancomycin resistance genes vanA ('high level'), vanB ('moderate high level'), vanC1, vanC2 and vanC3 ('low level'). Out of 1643 E.-isolates from 115 poultry and 50 pork samples, 420 isolates could be identified as vancomycin resistant, 202 isolates of which carry the vanA, one isolate both the vanA and the vanC1, 38 isolates the vanC1, 14 isolates the vanC2, nine isolates both the vanC1 and the vanC3 gene and 156 isolates carry no gene. The vanB gene was not found in these isolates. Comparing vanA-positive food isolates with those from different human sources by means of the pulsed field gel electrophoresis (PFGE) it could clearly be demonstrated that they do not show homological fingerprints according to the source of origin. It is therefore unlikely that there is a close genetic relationship between isolates from animal foodstuff and humans.

Vancomycin-dependent enterococcal strains: case report and review

We report, to our knowledge, the first isolation of VDE from a burn unit. Our experience was similar to earlier reports, in that continuous administration of vancomycin and previous VRE isolation preceded the recovery of VDE. Given the increasing prevalence of VRE as a nosocomial pathogen, intensive care units must now be attuned to the emergence of VDE as serious pathogen.

Vancomycin-resistant enterococci: recent advances in genetics, epidemiology and therapeutic options

Vancomycin-resistant enterococci (VRE) have gained much attention in the last decade. Currently, there are five known types of vancomycin resistance based on genes encoding ligase enzymes that the organisms use to produce their cell wall precursors, namely, VanA, VanB, VanC, VanD and VanE. An additional unclassified type was discovered in Australia. The basis of resistance among these phenotypes appears to be similar in that the resistant organisms produce peptidoglycan precursors that end in moieties other than D-alanyl-D-alanine, the usual target of vancomycin. The other dipeptide-like termini identified to date include D-alanyl-D-lactate and D-alanyl-D-serine, which have low affinity for glycopeptides. Recent evidence suggests that glycopeptide-producing organisms might be the remote origin of the vancomycin resistance genes. In European countries, avoparcin, a glycopeptide used in farm animals as a growth promoter, has been linked to the occurrence of VRE and occasional common strains have been identified in food products, farm animals, healthy subjects and hospitalized patients. There have been no such reports in the USA where heavy use of vancomycin and use of broad spectrum antibiotics such as cephalosporins have been identified as important risk factors for acquisition of VRE. Transmission within the same or between hospitals has been reported in many countries. Infection control measures and efforts to use antibiotics, particularly vancomycin, more appropriately have been implemented in a number of healthcare facilities with varying degrees of success. Many antibiotics, as a single agent or a combination of drugs, as well as various new antibiotics have been tested in vitro, in animal models, or used in anecdotal cases but clinical data from large comparative trials are not available to date. Because of the limited susceptibility of many VRE to other agents, efforts to control these organisms are particularly important. Copyright 1999 Harcourt Publishers LtdCopyright 1999 Harcourt Publishers Ltd.

Moderate-level resistance to glycopeptide LY333328 mediated by genes of the vanA and vanB clusters in enterococci

Three of five natural plasmids carrying a wild-type vanA gene cluster did not confer LY333328 glycopeptide resistance on Enterococcus faecalis JH2-2 (MIC = 2 microg/ml). The two remaining plasmids conferred resistance to the drug (MIC, 8 microg/ml). The vanB gene cluster did not confer resistance to LY333328, since this antibiotic was not an inducer. Mutations in the vanS(B) sensor gene that allowed induction by teicoplanin or constitutive expression of the vanB cluster led to LY333328 resistance (MIC, 8 to 16 microg/ml). Overproduction of the VanH, VanA, and VanX proteins for D-alanyl-D-lactate (D-Ala-D-Lac) synthesis and D-Ala-D-Ala hydrolysis was sufficient for resistance to LY333328 (MIC, 16 microg/ml). Mutations in the host D-Ala:D-Ala ligase contributed to LY333328 resistance in certain VanA- and VanB-type strains, but the MICs of the antibiotic did not exceed 16 microg/ml. Addition of D-2-hydroxybutyrate in the culture medium of mutants that did not produce the VanH D-lactate dehydrogenase led to incorporation of this D-2-hydroxy acid at the C-terminal ends of the peptidoglycan precursors and to LY333328 resistance (MIC, 64 microg/ml). The vanZ gene of the vanA cluster conferred resistance to LY333328 (MIC, 8 microg/ml) by an unknown mechanism. These data indicate that VanA- and VanB-type enterococci may acquire moderate-level resistance to LY333328 (MIC </= 16 microg/ml) in a single step by various mechanisms.

The threat of vancomycin resistance

Vancomycin, produced in 1958, an essential antibiotic in the modern age, often is reserved for use in patients who are gravely ill or for infections caused by organisms resistant to penicillin, cephalosporin, or other antibiotics. Bacterial resistance to vancomycin has caused great concern among many healthcare professionals. First reported in 1986 in Europe and in 1988 in the United States, vancomycin-resistant enterococci (VRE) have become a major cause of nosocomial infections. During this time, scattered reports of clinical infections caused by vancomycin-resistant coagulase-negative staphylococci also were reported. Recently, enterococci that require vancomycin in media for growth, vancomycin-dependent enterococci (VDE), have been reported to cause clinically significant infections. Vancomycin or other glycopeptide intermediately resistant Staphylococcus aureus (VISA/GISA) also has emerged. The mechanisms of resistance to vancomycin for VRE, and probably for VISA/GISA, relate to the acquired ability of these organisms to circumvent the vancomycin-mediated disruption of bacterial cell wall synthesis. Risk factors that lead to VRE colonization or infection include prior antibiotic therapy, prolonged hospitalization, hospitalization in an intensive care unit, concomitant serious medical and surgical illnesses, exposure to equipment contaminated with VRE, and exposure to patients with VRE. Patients colonized or infected with VRE, healthcare workers with contaminated hands, and environmental surfaces in healthcare facilities are major reservoirs of VRE. Risk factors for VDE and VISA/GISA are less well understood, although both organisms emerge in patients receiving vancomycin or other glycopeptide antibiotics. Infection and antibiotic control procedures for both organisms, including restriction of vancomycin use, optimization of the antibiotic formulary, education of hospital personnel, early detection and reporting of vancomycin resistance, isolation of colonized patients, and appropriate cleansing of the environment are used to prevent the spread of these organisms in healthcare settings.

Two-step acquisition of resistance to the teicoplanin-gentamicin combination by VanB-type Enterococcus faecalis in vitro and in experimental endocarditis

The activity of vancomycin and teicoplanin combined with gentamicin was investigated in vitro against strains of Enterococcus faecalis resistant to vancomycin and susceptible to teicoplanin (VanB type) and against mutants that had acquired resistance to teicoplanin by three different mechanisms. In vitro, gentamicin selected mutants with two- to sixfold increases in the level of resistance to this antibiotic at frequencies of 10(-6) to 10(-7). Teicoplanin selected teicoplanin-resistant mutants at similar frequencies. Both mutations were required to abolish the activity of the gentamicin-teicoplanin combination. As expected, simultaneous acquisition of the two types of mutations was not observed. In therapy with gentamicin or teicoplanin alone, each selected mutants in three of seven rabbits with aortic endocarditis due to VanB-type E. faecalis BM4275. The vancomycin-gentamicin combination selected mutants that were resistant to gentamicin and to the combination. In contrast, the teicoplanin-gentamicin regimen prevented the emergence of mutants resistant to one or both components of the combination. These results suggest that two mutations are also required to suppress the in vivo activity of the teicoplanin-gentamicin combination.