Mechanisms of resistance of enterococci to beta-lactam antibiotics

Conjugation of Polycationic Peptides Extends the Efficacy Spectrum of β-Lactam Antibiotics

Antibiotic-resistant enterococci represent a significant global health challenge. Unfortunately, most β-lactam antibiotics are not applicable for enterococcal infections due to intrinsic resistance. To extend their antimicrobial spectrum, polycationic peptides are conjugated to examples from each of the four classes of β-lactam antibiotics. Remarkably, the β-lactam-peptide conjugates gained an up to 1000-fold increase in antimicrobial activity against vancomycin-susceptible and vancomycin-resistant enterococci. Even against β-lactam-resistant Gram-negative strains, the conjugates are found to be effective despite their size exceeding the exclusion volume of porins. The extraordinary gain of activity can be explained by an altered mode of killing. Of note, the conjugates showed a concentration-dependent activity in contrast to the parent β-lactam antibiotics that exhibited a time-dependent mode of action. In comparison to the parent β-lactams, the conjugates showed altered affinities to the penicillin-binding proteins. Furthermore, it is found that peptide conjugation also resulted in a different elimination route of the compounds when administered to rodents. In mice systemically infected with vancomycin-resistant enterococci, treatment with a β-lactam-peptide conjugate reduced bacterial burden in the liver compared to its originator. Therefore, peptide modification of β-lactam antibiotics represents a promising platform strategy to broaden their efficacy spectrum, particularly against enterococci.

Global status of antimicrobial resistance in clinical Enterococcus faecalis isolates: systematic review and meta-analysis

BACKGROUND

Due to the increasing emergence of antibiotic resistance in Enterococcus faecalis (E. faecalis), it indicated as potentially opportunistic pathogen causing various healthcare-associated and life-threatening diseases around the world.

OBJECTIVE

The aim of this meta-analysis was to evaluate the weighted pooled resistance rates in clinical E. faecalis isolates based on over time, areas, antimicrobial susceptibility testing (AST), and infection source.

METHODS

We searched the studies in PubMed, Scopus, and Web of Science (November 30, 2022). All statistical analyses were carried out using the statistical package R.

RESULTS

The analysis encompassed a total of 74 studies conducted in 28 countries. According to the meta-regression, the chloramphenicol, fosfomycin, imipenem, linezolid, minocycline, norfloxacin, quinupristin-dalfopristin, and tetracycline resistance rate increased over time. Analysis revealed statistically significant differences in antibiotic resistance rates for ampicillin, chloramphenicol, erythromycin, gentamicin, penicillin, rifampicin, teicoplanin, tetracycline, and vancomycin across various countries.

CONCLUSIONS

Globally, the prevalence of drug resistant E. faecalis strains are on the increase over time. Daptomycin and tigecycline can be an effective agent for the treatment of clinical E. faecalis infections. Considering the low prevalence of antibiotic resistance in continents of Europe and Australia, it is suggested to take advantage of their preventive strategies in order to obtain efficient results in other places with high prevalence of resistance.

The Genetic Landscape of Antimicrobial Resistance Genes in Enterococcus cecorum Broiler Isolates

Enterococcus cecorum is associated with bacterial chondronecrosis with osteomyelitis (BCO) in broilers. Prophylactic treatment with antimicrobials is common in the poultry industry, and, in the case of outbreaks, antimicrobial treatment is needed. In this study, the minimum inhibitory concentrations (MICs) and epidemiological cutoff (ECOFF) values (COWT) for ten antimicrobials were determined in a collection of E. cecorum strains. Whole-genome sequencing data were analyzed for a selection of these E. cecorum strains to identify resistance determinants involved in the observed phenotypes. Wild-type and non-wild-type isolates were observed for the investigated antimicrobial agents. Several antimicrobial resistance genes (ARGs) were detected in the isolates, linking phenotypes with genotypes for the resistance to vancomycin, tetracycline, lincomycin, spectinomycin, and tylosin. These detected resistance genes were located on mobile genetic elements (MGEs). Point mutations were found in isolates with a non-wild-type phenotype for enrofloxacin and ampicillin/ceftiofur. Isolates showing non-wild-type phenotypes for enrofloxacin had point mutations within the GyrA, GyrB, and ParC proteins, while five amino acid changes in penicillin-binding proteins (PBP2x superfamily) were observed in non-wild-type phenotypes for the tested β-lactam antimicrobials. This study is one of the first that describes the genetic landscape of ARGs within MGEs in E. cecorum, in association with phenotypical resistance determination.

Detailed Soluble Proteome Analyses of a Dairy-Isolated Enterococcus faecalis: A Possible Approach to Assess Food Safety and Potential Probiotic Value

Enterococci are common inhabitants of the gastrointestinal tracts of humans and animals and thanks to their capability to tolerate different environmental conditions and their high rates of gene transfer, they are able to colonize various ecological niches, as food matrices. Enterococcus faecalis bacteria are defined as controversial microorganisms. From one side they are used as food starters, bio-control agents and probiotics to improve human or animal health. From the other side, in the last two decades enterococci have emerged as important nosocomial pathogens, because bearing high-level of resistance to antibiotics and several putative virulence factors. In this study, the soluble proteome quantitation data (LC-MS/MS) of the food-isolated strain E. faecalis D27 (dairy-isolate) was compared with the soluble proteome quantitation data of the pathogenic E. faecalis UW3114 (urinary tract infection isolate) and with the one of the health promoting strain E. faecalis Symbioflor1, respectively. The comparison of cytosolic protein expression profiles highlighted statistically significant changes in the abundance of proteins mainly involved in specific metabolic pathways, nutrient transport, stress response, and cell wall modulation. Moreover, especially in the dairy isolate and the clinical isolate, several proteins with potential pathogenic implications were found, such as serine proteases, von Willebrand factor, serine hydrolase with beta lactamase activity, efflux transporter, and proteins involved in horizontal gene transfer. The analysis of the extracellular proteome provided interesting results concerning proteins involved in bacterial communication, such as pheromones and conjugative elements and also proteins able to interact with human components. The phenotypic characterization evaluating (i) biofilm formation (ii) hemolytic activity on blood agar plates (iii) protease activity (iv) gelatinase (v) antibiotic resistance pattern, enabled us to elucidate the risks associated with the poor characterized foodborne E. faecalis D27.

[Infective endocarditis in the XXI century: epidemiological, therapeutic, and prognosis changes]

Infective endocarditis (IE) is an uncommon and severe disease. Nowadays, in developed countries, IE patients are older, usually have a degenerative heart valve disease, and up to 30% acquire this infection within the health care system. In consequence, staphylococci species are the most frequently isolated microorganisms. Antimicrobial treatment for IE has significantly changed over the last decades. In IE episodes due to Staphylococcus aureus, cloxacillin-resistance makes antimicrobial election more difficult. Other microorganisms, such as enterococci and some species of streptococci, show high rates of resistance to antimicrobial agents established in guidelines. Despite improvements in the diagnosis, and medical and surgical treatment of IE, this disease continues to be associated with high rates of in-hospital mortality. At present, due to epidemiological changes, antimicrobial prophylaxis can avoid few cases of IE. Prevention of nosocomial bacteremia, an early diagnosis of IE, prompt identification of IE patients at a higher risk of mortality, and a multidisciplinary approach of this disease could be valid strategies in order to improve the outcome of these patients.

Treatment strategies for infective endocarditis

IMPORTANCE OF THE FIELD

Despite significant advances in medical, surgical, and critical care interventions, infective endocarditis (IE) remains a disease associated with considerable morbidity and mortality. Estimates from the American Heart Association place the incidence of IE in the US at 10,000 - 15,000 new cases each year. This may be due to the changing epidemiology of IE, including increasing antimicrobial resistance, increasing heart surgeries, prosthetic valve implantation, and widespread use of intravenous drugs. Furthermore, a new form of the disease, healthcare-associated IE, which is associated with new therapeutic modalities such as intravenous catheters, hyperalimentation lines, pacemakers, and dialysis shunts, has emerged.

AREAS COVERED IN THIS REVIEW

We present the latest therapeutic and preventive strategies for IE caused by a variety of bacterial and fungal pathogens. The general methods employed included an extensive literature search, confined to the last 10 years, using key words such as 'infective endocarditis', 'culture-negative endocarditis', 'treatment guidelines for IE', and 'prophylaxis for IE'.

WHAT THE READER WILL GAIN

Comprehensive information regarding the changing epidemiology of IE is provided. The latest guidelines with respect to therapy and prophylaxis of IE are reviewed.

TAKE HOME MESSAGE

Successful management of IE depends on maintaining a high index of suspicion for the disease and, when IE is diagnosed, close cooperation of medical and surgical disciplines is required. Further research is needed to better understand and provide optimal therapy for complex situations such as multidrug-resistant and polymicrobial IE.

Antibacterial susceptibility testing in the clinical laboratory

This article familiarizes the clinician with the principles of bacterial susceptibility testing and reporting to facilitate communication with the clinical microbiology laboratory. As resistance continues to emerge among a wide range of clinically relevant bacteria, the complexity of this communication increases. This updated version provides an overview of the important susceptibility concerns for most commonly isolated bacterial pathogens.

Pilot study of ampicillin-ceftriaxone combination for treatment of orthopedic infections due to Enterococcus faecalis

Serious Enterococcus faecalis infections usually require combination therapy to achieve a bactericidal effect. In orthopedic infections, the prognosis of enterococcal etiology is considered poor, and the use of aminoglycosides is questioned. The ampicillin-ceftriaxone combination has recently been accepted as alternative therapy for enterococcal endocarditis. After one of our patients with endocarditis and vertebral osteomyelitis was cured with ampicillin-ceftriaxone, we started a pilot study of orthopedic infections. Patients with infections due to E. faecalis (with two or more surgical samples or blood cultures) diagnosed during 2005 to 2008 were recruited. Polymicrobial infections with ampicillin- and ceftriaxone-resistant microorganisms were excluded. Patients received ampicillin (8 to 16 g/day)-ceftriaxone (2 to 4 g/day) and were followed up prospectively. Of 31 patients with E. faecalis infections, 10 received ampicillin-ceftriaxone. Including the first patient, 11 patients were treated with ampicillin-ceftriaxone: 3 with prosthetic joint infections, 3 with instrumented spine arthrodesis device infections, 2 with osteosynthesis device infections, 1 with foot osteomyelitis, and 2 with vertebral osteomyelitis and endocarditis. Six infections (55%) were polymicrobial. All cases except the vertebral osteomyelitis ones required surgery, with retention of foreign material in six cases. Ampicillin-ceftriaxone was given for 25 days (interquartile range, 15 to 34 days), followed by amoxicillin (amoxicilline) being given to seven patients (64%). One patient with endocarditis died within 2 weeks (hemorrhagic stroke) and was not evaluable. For one patient with prosthesis retention, the infection persisted; 9/10 patients (90%) were cured, but 1 patient was superinfected. Follow-up was for 21 months (interquartile range, 14 to 36 months). Ampicillin-ceftriaxone may be a reasonable synergistic combination to treat orthopedic infections due to E. faecalis. Our experience, though limited, shows good outcomes and tolerability and may provide a basis for further well-designed comparative studies.

Prevalence, species distribution and antimicrobial resistance of enterococci isolated from dogs and cats in the United States

AIMS

The contribution of dogs and cats as reservoirs of antimicrobial resistant enterococci remains largely undefined. This is increasingly important considering the possibility of transfer of bacteria from companion animals to the human host. In this study, dogs and cats from veterinary clinics were screened for the presence of enterococci.

METHODS AND RESULTS

A total of 420 enterococci were isolated from nasal, teeth, rectal, belly and hindquarters sites of 155 dogs and 121 cats from three clinics in Athens, GA. Eighty per cent (124 out of 155) of the dogs and 60% (72 out of 121) of the cats were positive for enterococci. From the total number of dog samples (n = 275), 32% (n = 87) were from hindquarter, 31% (n = 86) were rectal, and 29% (n = 79) were from the belly area. The majority of isolates originated from rectal samples (53 out of 145; 37%) from cats. The predominant species identified was Enterococcus faecalis (105 out of 155; 68%) from dogs and E. hirae (63 out of 121; 52%) from cats. Significantly more E. faecalis were isolated from rectal samples than any other enterococcal species (P < 0.05) for both dogs and cats suggesting site specific colonization of enterococcal species. The highest levels of resistance were to ciprofloxacin in E. faecium (9 out of 10; 90%), chloramphenicol resistance in E. faecalis (17 out of 20; 85%) and gentamicin resistance in E. faecalis (19 out of 24; 79%) from dog samples and nitrofurantoin resistance in E. faecium (15 out of 19; 79%) from cats. Multi-drug resistance (MDR) (resistance > or =2 antimicrobials) was observed to as few as two and as many as eight antimicrobials regardless of class.

CONCLUSION

This study demonstrated that dogs and cats are commonly colonized with antimicrobial resistant enterococci.

SIGNIFICANCE AND IMPACT OF THE STUDY

Dogs and cats may act as reservoirs of antimicrobial resistance genes that can be transferred from pets to people.

In vitro Antimicrobial Activity of Ampicillin-Ceftriaxone and Ampicillin-Ertapenem Combinations Against Clinical Isolates of Enterococcus faecalis with High Levels of Aminoglycoside Resistance

This paper reports on the in vitro antimicrobial activity of ampicillin-ceftriaxone and ampicillin-ertapenem combinations against five strains of E. faecalis with high-level aminoglycoside resistance recovered from blood of septicemic patients. Double disk diffusion test and time killing curves were used. A bacteriostatic synergistic effect between ampicillin and ceftriaxone was detected using the disk diffusion assay for three of the five enterococcal strains studied. With the same three isolates enhanced bactericidal activity was also observed using time killing experiments. Overall, for these three strains, after 24 hr of contact, a decrease >/= 2 log(10) from the initial bacterial inoculum was registered with most ampicillin-ceftriaxone combinations, reaching with some of them a colony reduction >/= 3 log(10). This bactericidal interaction was negatively influenced increasing the bacterial inoculum. In all five isolates neither a bacteriostatic nor a bactericidal cooperation was observed for ampicillin combined with 2 mg/l of ertapenem.This investigation broadened the evidence of antimicrobial synergism in vitro between ampicillin and ceftriaxone in selected strains of Enterococcus faecalis with high-level aminoglycoside resistance.

Antibacterial susceptibility testing in the clinical laboratory

This article familiarizes the clinician with the principles of bacterial susceptibility testing and reporting to facilitate communication with the clinical microbiology laboratory. The emergence of resistance in nearly all commonly isolated bacterial organisms has highlighted the need for ongoing dialogue between the laboratory and those who use its services.

Enterococcus cecorum empyema thoracis successfully treated with cefotaxime

We report the first case of Enterococcus cecorum empyema thoracis and spontaneous bacterial peritonitis in a 44-year-old man with underlying cirrhosis. The patient responded to cefotaxime (MIC, 0.25 microg/ml) treatment and drainage of the empyema. Susceptibility of E. cecorum to expanded-spectrum cephalosporins could be due to its production of types of penicillin-binding proteins similar to those produced by Streptococcus species rather than to those produced by Enterococcus species (as predicted by phylogenetic analysis of the 16S rRNA gene sequences).

Aggregation substance-mediated adherence of Enterococcus faecalis to immobilized extracellular matrix proteins

Aggregation substance (AS) of Enterococcus faecalis (E. faecalis), a sex pheromone plasmid encoded cell surface protein, mediates the formation of bacterial aggregates, thereby promoting plasmid transfer. The influence of pAD1-encoded AS, Asa1, on binding to immobilized extracellular matrix proteins was studied. The presence of AS increased enterococcal adherence to fibronectin more than eight-fold, to thrombospondin more than four-fold, to vitronectin more than three-fold, and to collagen type I more than two-fold (P<0.001). In contrast, binding to laminin and collagen type IV occurred independently of AS. Adherence of the constitutively AS expressing E. faecalis OG1X(pAM721) to immobilized fibronectin was found to be approximately five times higher than that of Staphylococcus aureus Cowan and approximately 30 times higher than that of Streptococcus bovis. Investigation of strains with various deletions within the structural gene of asa1 suggests that attachment to immobilized fibronectin is mainly mediated by amino acids within the variable region or by neighbouring residues. Thus, AS may promote adherence to injured epithelium and endothelium, where extracellular matrix proteins are exposed, thereby facilitating colonization and infection.

Emerging multiply resistant enterococci among clinical isolates. I. Prevalence data from 97 medical center surveillance study in the United States. Enterococcus Study Group

To assess the evolving problem of therapeutic drug resistances among enterococci, we organized a comprehensive national (United States) surveillance trial using 99 recruited microbiology laboratories in 48 of the 49 contiguous states or districts. All but two sites completed the protocol that generated information from nearly 2000 enterococci, usually isolated from blood cultures. All strains were speciated by the same method (API 20S) and were susceptibility tested by three methods (broth microdilution, disk diffusion, and Etest) against ampicillin, penicillin, vancomycin, teicoplanin, gentamicin, and streptomycin. Strains resistant to a glycopeptide or penicillin, or possessing high-level aminoglycoside resistance were referred to the monitor's laboratory for validation and additional susceptibility testing against other alternative antimicrobial agents. The most common species were Enterococcus faecalis and Enterococcus faecium. However, antimicrobial resistance occurred most often among the E. faecium isolates. Twenty-three percent of participant centers (22 sites) reported 87 vancomycin-resistant isolates, which accounts for 4.4% of the isolates evaluated. A recent audit (March 1994) of the laboratories not reporting vancomycin resistance during the study interval (October-December 1992) revealed that 61% of sites have now recognized these strains, a threefold increase in 12-15 months. Teicoplanin remained active against 28% (Van B phenotype) of vancomycin-resistant enterococci (10 E. faecalis, 13 E. faecium, and one Enterococcus spp.). Ampicillin-resistant beta-lactamase-positive strains were found only at one medical center (two strains, 0.2% of referred or validated strains); however, ampicillin-resistant strains represented 12% of all enterococcal, but nearly 60% of E. faecium strains.(ABSTRACT TRUNCATED AT 250 WORDS)

Cloning and sequencing of the low-affinity penicillin-binding protein 3r-encoding gene of Enterococcus hirae S185: modular design and structural organization of the protein

The clinical isolate Enterococcus hirae S185 has a peculiar mode of resistance to penicillin in that it possesses two low-affinity penicillin-binding proteins (PBPs): the 71-kDa PBP5, also found in other enterococci, and the 77-kDa PBP3r. The two PBPs have the same low affinity for the drug and are immunochemically related to each other. The PBP3r-encoding gene has been cloned and sequenced, and the derived amino acid sequence has been compared by computer-assisted hydrophobic cluster analysis with that of the low-affinity PBP5 of E. hirae R40, the low-affinity PBP2' of Staphylococcus aureus, and the PBP2 of Escherichia coli used as the standard of reference of the high-M(r) PBPs of class B. On the basis of the shapes, sizes, and distributions of the hydrophobic and nonhydrophobic clusters along the sequences and the linear amino acid alignments derived from this analysis, the dyad PBP3r-PBP5 has an identity index of 78.5%, the triad PBP3r-PBP5-PBP2' has an identity index of 29%, and the tetrad PBP3r-PBP5-PBP2'-PBP2 (of E. coli) has an identity index of 13%. In spite of this divergence, the low-affinity PBPs are of identical modular design and possess the nine amino acid groupings (boxes) typical of the N-terminal and C-terminal domains of the high-M(r) PBPs of class B. At variance with the latter PBPs, however, the low-affinity PBPs have an additional approximately 110-amino-acid polypeptide stretch that is inserted between the amino end of the N-terminal domain and the carboxy end of the membrane anchor. While the enterococcal PBP5 gene is chromosome borne, the PBP3r gene appears to be physically linked to the erm gene, which confers resistance to erythromycin and is known to be plasmid borne in almost all the Streptococcus spp. examined.

Molecular investigation of clinical Enterococcus faecium isolates highly resistant to gentamicin

Over a 10-month period, 22 beta-lactamase negative E. faecium strains resistant to ampicillin were isolated from severely compromised hospitalized patients. Most isolates were clinically significant. Twenty of these strains were also resistant to extraordinarily high levels of gentamicin, a finding described rarely in E. faecium. By whole-cell DNA restriction endonuclease digestion, the 20 strains with both ampicillin and high-level gentamicin resistance segregated into only 3 different groups, suggesting introduction of limited clones into this population of patients. Plasmid DNA profiles and plasmid DNA restriction enzyme analysis supported this grouping for 18 of these 20 strains, the two remaining isolates had slightly different profiles. Both strains lacking high-level gentamicin resistance had clearly different molecular profiles. The results of hybridization experiments strongly suggested the presence of a similar genetic determinant of high-level gentamicin resistance in E. faecalis and E. faecium. High-level gentamicin resistance in E. faecium was shown to be transferable on conjugative plasmids, so that further dissemination of this resistance trait may be anticipated. Our data indicate that the use of a nucleic acid probe is a promising diagnostic tool for screening both E. faecium and E. faecalis for high-level gentamicin resistance.