Enterococcal endocarditis: can we win the war?

Risk factors for neurological complications in left-sided infective endocarditis

BACKGROUND AND PURPOSE

Neurological complications following infective endocarditis (IE) directly contribute to long-term morbidity. We examined the risk factors for different neurological complications of left-sided IE.

METHODS

Using a database of consecutive adults admitted to a health system with left-sided IE from 2015 to 2019, the frequency of cerebral infarcts, intraparenchymal hemorrhage, cerebral microbleeds (CMB), mycotic aneurysm, and encephalopathy was determined. Variables with significant differences comparing each neurological complication (p < 0.1) were entered into regression models along with age to determine predictors.

RESULTS

211 patients with mean age 54 (±18) years, and 69 (33%) females were included. Infarcts were found in 118 (56%) patients, intraparenchymal hemorrhage was found in 17 (8%) patients, CMB were found in 58 (27%) patients, mycotic aneurysms were found in 22 (10%) patients, and encephalopathy occurred in 16 (8%) patients. In multivariable models, vegetation size ≥15 mm was associated with a higher risk of infarcts (aOR 2.26, 95% CI (1.12-4.57)), and the presence of a mycotic aneurysm was a risk factor for intraparenchymal hemorrhage (aOR 18.79, 95% CI (3.97-88.97)). Prosthetic valves (aOR 2.89, 95% CI (1.11-7.54)) and Staphylococcus aureus infection (aOR 3.50, 95% CI (1.08-11.36)) were associated with CMB. No risk factors emerged as predictors of encephalopathy.

CONCLUSIONS

Large vegetation size is associated with stroke in patients with IE. Mycotic aneurysms are found at a higher frequency in young patients and are the primary cause of intraparenchymal hemorrhage. CMB may be related to prosthetic valves and Staphylococcus aureus infection.

Comparative genomics and pangenomics of vancomycin-resistant and susceptible Enterococcus faecium from Irish hospitals

Introduction. Enterococcus faecium has emerged as an important nosocomial pathogen, which is increasingly difficult to treat due to the genetic acquisition of vancomycin resistance. Ireland has a recalcitrant vancomycin-resistant bloodstream infection rate compared to other developed countries.

Hypothesis/Gap statement. Vancomycin resistance rates persist amongst E. faecium isolates from Irish hospitals. The evolutionary genomics governing these trends have not been fully elucidated.

Methodology. A set of 28 vancomycin-resistant isolates was sequenced to construct a dataset alongside 61 other publicly available Irish genomes. This dataset was extensively analysed using in silico methodologies (comparative genomics, pangenomics, phylogenetics, genotypics and comparative functional analyses) to uncover distinct evolutionary, coevolutionary and clinically relevant population trends.

Results. These results suggest that a stable (in terms of genome size, GC% and number of genes), yet genetically diverse population (in terms of gene content) of E. faecium persists in Ireland with acquired resistance arising via plasmid acquisition (vanA) or, to a lesser extent, chromosomal recombination (vanB). Population analysis revealed five clusters with one cluster partitioned into four clades which transcend isolation dates. Pangenomic and recombination analyses revealed an open (whole genome and chromosomal specific) pangenome illustrating a rampant evolutionary pattern. Comparative resistomics and virulomics uncovered distinct chromosomal and mobilomal propensity for multidrug resistance, widespread chromosomal point-mutation-mediated resistance and chromosomally harboured arsenals of virulence factors. Interestingly, a potential difference in biofilm formation strategies was highlighted by coevolutionary analysis, suggesting differential biofilm genotypes between vanA and vanB isolates.

Conclusions. These results highlight the evolutionary history of Irish E. faecium isolates and may provide insight into underlying infection dynamics in a clinical setting. Due to the apparent ease of vancomycin resistance acquisition over time, susceptible E. faecium should be concurrently reduced in Irish hospitals to mitigate potential resistant infections.

Native valve, prosthetic valve, and cardiac device-related infective endocarditis: A review and update on current innovative diagnostic and therapeutic strategies

Infective endocarditis (IE) is a life-threatening microbial infection of native and prosthetic heart valves, endocardial surface, and/or indwelling cardiac device. Prevalence of IE is increasing and mortality has not significantly improved despite technological advances. This review provides an updated overview using recent literature on the clinical presentation, diagnosis, imaging, causative pathogens, treatment, and outcomes in native valve, prosthetic valve, and cardiac device-related IE. In addition, the experimental approaches used in IE research to improve the understanding of disease mechanisms and the current diagnostic pipelines are discussed, as well as potential innovative diagnostic and therapeutic strategies. This will ultimately help towards deriving better diagnostic tools and treatments to improve IE patient outcomes.

Effects of dicopper oxide and copper sulfate on growth performance and gut microbiota in broilers

An experiment was conducted to determine the effects of two sources of copper (Cu) from copper sulfate (CuSO4) and dicopper oxide (Cu2O, CoRouge) at three levels of inclusion (15, 75, and 150 mg/kg) on growth performance and gut microbiota of broilers. A total of 840 one-d-old male chickens (Ross 308) were weighed and randomly allocated to seven dietary treatments: negative control (NC, a basal diet without Cu addition), and the NC supplemented with 15, 75, or 150 mg Cu/kg from CuSO4 or Cu2O (12 replicate pens/treatment, 10 chicks per pen). Broilers were challenged by reusing an old litter with high concentrations in Clostridium perfringens to promote necrotic enteritis. Broiler performance was registered at d 21, 35, and 42. Excreta samples were collected at d 14, 28, and 42 for antimicrobial resistance (AMR) analyses. At d 43, one broiler per pen was euthanized to obtain ileal content for microbial characterization. Body weight d 35 and daily gain d 42 improved (P < 0.05) in Cu2O as Cu dose inclusion increased from 15 mg/kg to 150 mg/kg. Supplementation of 150 mg/kg of Cu from Cu2O decreased the abundance (P < 0.01) of some families such as Streptococcaceae and Corynebacteriaceae and increased the abundance (P < 0.05) of some commensal bacteria like Clostridiaceae and Peptostreptococcaceae. Phenotypic AMR was not different among treatments on d 14 and 28. Isolated Enterococcus spp. from broilers fed the NC diet on d 42 showed higher (P < 0.05) resistance to enrofloxacin, gentamicin, and chloramphenicol compared with Cu treatments. By contrast, the isolated Escherichia coli from broilers fed 150 mg/kg of Cu, either from CuSO4 or Cu2O, showed higher (P < 0.05) resistance to streptomycin and chloramphenicol compared to the NC. This study suggests that supplementing 150 mg/kg of Cu from Cu2O establishes changes in the gut microbiota by regulating the bacterial population in the ileum, which may explain the positive impact on broilers' growth performance.

Advances and Prospects in Vaccine Development against Enterococci

Enterococci are the second most common Gram-positive pathogen responsible for nosocomial infections. Due to the limited number of new antibiotics that reach the medical practice and the resistance of enterococci to the current antibiotic options, passive and active immunotherapies have emerged as a potential prevention and/or treatment strategy against this opportunistic pathogen. In this review, we explore the pathogenicity of these bacteria and their interaction with the host immune response. We provide an overview of the capsular polysaccharides and surface-associated proteins that have been described as potential antigens in anti-enterococcal vaccine formulations. In addition, we describe the current status in vaccine development against enterococci and address the importance and the current advances toward the development of well-defined vaccines with broad coverage against enterococci.

Comparative Microbiome Analysis of Three Species of Laboratory-Reared Periplaneta Cockroaches

Cockroaches inhabit various habitats, which will influence their microbiome. Although the microbiome can be influenced by the diet and environmental factors, it can also differ between species. Therefore, we conducted 16S rDNA-targeted high-throughput sequencing to evaluate the overall bacterial composition of the microbiomes of 3 cockroach species, Periplaneta americana, P. japonica, and P. fuliginosa, raised in laboratory for several generations under the same conditions. The experiments were conducted using male adult cockroaches. The number of operational taxonomic units (OTUs) was not significantly different among the 3 species. With regard to the Shannon and Pielou indexes, higher microbiome values were noted in P. americana than in P. japonica and P. fuliginosa. Microbiome composition was also evaluated, with endosymbionts accounting for over half of all OTUs in P. japonica and P. fuliginosa. Beta diversity analysis further showed that P. japonica and P. fuliginosa had similar microbiome composition, which differed from that of P. americana. However, we also identified that P. japonica and P. fuliginosa host distinct OTUs. Thus, although microbiome compositions may vary based on multiple conditions, it is possible to identify distinct microbiome compositions among different Periplaneta cockroach species, even when the individuals are reared under the same conditions.

Effectiveness of Efflux Pump Inhibitors as Biofilm Disruptors and Resistance Breakers in Gram-Negative (ESKAPEE) Bacteria

Antibiotic resistance represents a significant threat to the modern healthcare provision. The ESKAPEE pathogens (Enterococcus faecium., Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter spp. and Escherichia coli), in particular, have proven to be especially challenging to treat, due to their intrinsic and acquired ability to rapidly develop resistance mechanisms in response to environmental threats. The development of biofilm has been characterised as an essential contributing factor towards antimicrobial-resistance and tolerance. Several studies have implicated the involvement of efflux pumps in antibiotic resistance, both directly, via drug extrusion and indirectly, through the formation of biofilm. As a result, the underlying mechanism of these pumps has attracted considerable interest due to the potential of targeting these protein structures and developing novel adjunct therapies. Subsequent investigations have revealed the ability of efflux pump-inhibitors (EPIs) to block drug-extrusion and disrupt biofilm formation, thereby, potentiating antibiotics and reversing resistance of pathogen towards them. This review will discuss the potential of EPIs as a possible solution to antimicrobial resistance, examining different challenges to the design of these compounds, with an emphasis on Gram-negative ESKAPEE pathogens.

Antibiotic Susceptibility and Virulence Genes in Enterococcus Isolates from Wild Mammals Living in Tuscany, Italy

Drug resistance is of great importance to human and animal health, but wild environments are still poorly understood in terms of their function as reservoirs of dangerous microbes and resistance determinants. The aim of the study was to determine the antibiotic susceptibility and virulence factors of Enterococcus bacteria from wildlife in Tuscany, Italy. Of the 36 mammalian fecal samples, 52 isolates were derived and classified as Enterococcus faecium (46% of isolates), Enterococcus hirae (19%), Enterococcus faecalis (13%), Enterococcus gallinarum (8%), Enterococcus casseliflavus (6%), Enterococcus durans (4%), Enterococcus mundtii (2%), and Enterococcus canintestini (2%) using both matrix-assisted laser desorption/ionization-time of flight mass spectrometry and methods based on analysis of genetic material. The isolates tested showed the most frequent resistance to tetracycline (36.5% isolates), ciprofloxacin (36.5%), and erythromycin (25%). Three isolates showed high level of resistance (minimal inhibitory concentration ≥1,024 μg/mL) to vancomycin and teicoplanin, and 15% of the isolates demonstrated multidrug resistance. No isolate resistant to ampicillin, linezolid, or streptomycin was found. Among resistance genes, aac(6)-Ii (50% isolates), msrA/B (48%), msrC (42%), and tetM (31%) were identified most frequently. All E. faecium and E. faecalis isolates were positive for the efaAfm and efaAfs genes, respectively. Other virulence-associated genes, that is, gelE, cylA, asa1, esp, ace, orf1481, ptsD, and sgrA, were found in the majority of E. faecalis and several E. faecium isolates. Multilocus sequence typing analysis performed for selected isolates revealed three new sequence types. The results obtained indicate that wild mammals might act as reservoirs of resistance and virulence determinants that could be transferred between different ecosystems.

Infective endocarditis: a retrospective cohort study

BACKGROUND

Infective endocarditis (IE) is a potentially life-threatening infection of the heart's endocardial surface. Despite advances in the diagnosis and management of IE, morbidity and mortality remain high.

AIM

To characterize the demographics, bacteriology and outcomes of IE cases presenting to an Irish tertiary referral centre.

DESIGN

Retrospective cohort study.

METHODS

Patients were identified using Hospital Inpatient Enquiry and Clinical Microbiology inpatient consult data, from January 2005 to January 2014. Patients were diagnosed with IE using Modified Duke Criteria. Standard Bayesian statistics were employed for analysis and cases were compared to contemporary international registries.

RESULTS

Two hundred and two patients were diagnosed with IE during this period. Mean age 54 years. Of these, 136 (67%) were native valve endocarditis (NVE), 50 (25%) were prosthetic valve endocarditis (PVE) and 22 (11%) were cardiovascular implantable electronic device-associated endocarditis. Culprit organism was identified in 176 (87.1%) cases and Staphylococcal species were the most common (57.5%). Fifty-nine per cent of NVE required surgery compared to 66% of PVE. Mean mortality rate was 17.3%, with NVE being the lowest (12.5%) and PVE the highest (32%). Increasing age was also associated with increased mortality. Fifty-three (26.2%) patients had embolic complications.

CONCLUSIONS

This Irish cohort exhibited first-world demographic patterns comparable to those published in contemporary international literature. PVE required surgery more often and was associated with higher rates of mortality than NVE. Embolic complications were relatively common and represent important sequelae, especially in the intravenous drug user population. It is also pertinent to aggressively treat older cohorts as they were associated with increased mortality.

Pathogenicity of Enterococci

Enterococci are unusually well adapted for survival and persistence in a variety of adverse environments, including on inanimate surfaces in the hospital environment and at sites of infection. This intrinsic ruggedness undoubtedly played a role in providing opportunities for enterococci to interact with other overtly drug-resistant microbes and acquire additional resistances on mobile elements. The rapid rise of antimicrobial resistance among hospital-adapted enterococci has rendered hospital-acquired infections a leading therapeutic challenge. With about a quarter of a genome of additional DNA conveyed by mobile elements, there are undoubtedly many more properties that have been acquired that help enterococci persist and spread in the hospital setting and cause diseases that have yet to be defined. Much remains to be learned about these ancient and rugged microbes, particularly in the area of pathogenic mechanisms involved with human diseases.

Epidemiological and clinical profile of infective endocarditis at a Brazilian tertiary care center: an eight-year prospective study

INTRODUCTION

Infective endocarditis (IE) is a systemic infectious disease requiring a multidisciplinary team for treatment. This study presents the epidemiological and clinical data of 73 cases of IE in Rio de Janeiro, Brazil.

METHODS

This observational prospective cohort study of endocarditis patients during an eight-year study period described 73 episodes of IE in 70 patients (three had IE twice). Community-associated (CAIE) and healthcare-acquired infective endocarditis (HAIE) were diagnosed according to the modified Duke criteria. The collected data included demographic, epidemiologic, and clinical characteristics, including results of blood cultures, echocardiographic findings, surgical interventions, and outcome.

RESULTS

Analysis of data from the eight-year study period and 73 cases (70 patients) of IE showed a mean age of 46 years (SD=2.5 years; 1-84 years) and that 65.7% were male patients. The prevalence of CAIE and HAIE was 32.9% and 67.1%, respectively. Staphylococcus aureus (30.1%), Enterococcus spp. (19.1%), and Streptococcus spp. (15.0%) were the prevalent microorganisms. The relevant signals and symptoms were fever (97.2%; mean 38.6 + 0.05°C) and heart murmur (87.6%). Vegetations were observed in the mitral (41.1%) and aortic (27.4%) valves. The mortality rate of the cases was 47.9%.

CONCLUSIONS

In multivariate analysis, chronic renal failure (relative risk [RR]= 1.60; 95% confidence interval [CI] 1.01-2.55), septic shock (RR= 2.19; 95% CI 1.499-3.22), and age over 60 years (RR= 2.28; 95% CI 1.44-3.59) were indirectly associated with in-hospital mortality. The best prognosis was related to the performance of cardiovascular surgery (hazard ratio [HR]= 0.51; 95% CI 0.26-0.99).

A Comparison of Three Different Bioinformatics Analyses of the 16S-23S rRNA Encoding Region for Bacterial Identification

Rapid and reliable identification of bacterial pathogens directly from patient samples is required for optimizing antimicrobial therapy. Although Sanger sequencing of the 16S ribosomal RNA (rRNA) gene is used as a molecular method, species identification and discrimination is not always achievable for bacteria as their 16S rRNA genes have sometimes high sequence homology. Recently, next generation sequencing (NGS) of the 16S–23S rRNA encoding region has been proposed for reliable identification of pathogens directly from patient samples. However, data analysis is laborious and time-consuming and a database for the complete 16S–23S rRNA encoding region is not available. Therefore, a better, faster, and stronger approach is needed for NGS data analysis of the 16S–23S rRNA encoding region. We compared speed and diagnostic accuracy of different data analysis approaches: de novo assembly followed by Basic Local Alignment Search Tool (BLAST), operational taxonomic unit (OTU) clustering, or mapping using an in-house developed 16S–23S rRNA encoding region database for the identification of bacterial species. De novo assembly followed by BLAST using the in-house database was superior to the other methods, resulting in the shortest turnaround time (2 h and 5 min), approximately 2 h less than OTU clustering and 4.5 h less than mapping, and a sensitivity of 80%. Mapping was the slowest and most laborious data analysis approach with a sensitivity of 60%, whereas OTU clustering was the least laborious approach with 70% sensitivity. Although the in-house database requires more sequence entries to improve the sensitivity, the combination of de novo assembly and BLAST currently appears to be the optimal approach for data analysis.

Preventing subclinical necrotic enteritis through Lactobacillus johnsonii BS15 by ameliorating lipid metabolism and intestinal microflora in broiler chickens

Increasing studies have focused on the beneficial effects of Lactobacillus johnsonii in certain diseases. Here, we studied the prevention ability of a probiotic strain, L. johnsonii BS15 on subclinical necrotic enteritis (SNE), and its underlying mechanism. 180 male Cobb 500 chicks were randomly allotted into three groups and administrated with BS15 (1 × 10⁶ cfu/g) or Man Rogosa Sharpe liquid medium throughout a 28-day experimental period. With the exception of the normal group, SNE infection was treated for the remaining experimental period after the chicks were fed with normal diet 14 days. Results showed that BS15 notably suppressed the SNE-induced loss of average daily gain and liver functional abnormality. Additionally, BS15 facilitated lipid metabolism of SNE boilers when the contents of peroxisome proliferator activated receptor γ and adipose triglyceride lipase in adipose tissue and serum high-density lipoprotein cholesterol decreased. BS15 also attenuated the hepatic lipid accumulation of stricken chicks by suppressing the genes expression of acetyl-CoA carboxylase, fatty acid synthase and sterol regulatory element binding protein-1c as well as stimulating the genes expression of peroxisome proliferator activated receptor α and carnitine palmitoyltransferase-1. Moreover, BS15 enhanced the development of SNE gut by improving the intestinal development and digestion as well as adjusting the gut microflora. Therefore, BS15 may provide a promising natural preventative strategy against SNE, which may be contributed to the amelioration of lipid metabolism and intestinal microflora.

Comparative Pharmacodynamics of Single-Dose Oritavancin and Daily High-Dose Daptomycin Regimens against Vancomycin-Resistant Enterococcus faecium Isolates in an In Vitro Pharmacokinetic/Pharmacodynamic Model of Infection

There are limited therapeutic options to treat infections caused by vancomycin-resistant Enterococcus faecium (VREfm). The lipoglycopeptide oritavancin exhibits in vitro activity against this pathogen, although its utility against infections caused by VREfm has not been clinically established. In this study, the pharmacodynamic activity of free-drug levels associated with 12 mg/kg/day of daptomycin and a single 1,200-mg dose of oritavancin were determined against three VanA VREfm isolates in an in vitro pharmacokinetic/pharmacodynamic model.

Vancomycin-Resistant Enterococci: Therapeutic Challenges in the 21st Century

Vancomycin-resistant enterococci are serious health threats due in part to their ability to persist in rugged environments and their propensity to acquire antibiotic resistance determinants. Enterococci have now established a home in our hospitals and possess mechanisms to defeat most currently available antimicrobials. This article reviews the history of the struggle with this pathogen, what is known about the traits associated with its rise in the modern medical environment, and the current understanding of therapeutic approaches in severe infections caused by these microorganisms. As the 21st century progresses, vancomycin-resistant enterococci continue to pose a daunting clinical challenge.

Live Probiotic Lactobacillus johnsonii BS15 Promotes Growth Performance and Lowers Fat Deposition by Improving Lipid Metabolism, Intestinal Development, and Gut Microflora in Broilers

Numerous studies have focused on the beneficial effects of probiotics in animals. Even so, additional information should be obtained about the mechanisms by which a useful probiotic strain successfully exerts such beneficial effects. In this study, we evaluated the effect of the dietary supplementation of both live and disrupted Lactobacillus johnsonii (LJ) strain BS15 in broilers at different ages. Specifically, growth performance, lipid metabolism, gut microbiota, intestinal development, and digestive ability of the broilers were assessed. A total of 180 1-day-old Cobb 500 chicks were randomly distributed into three groups. These chicks were fed diets supplemented with 1 × 10⁶ colony-forming units (cfu) LJ per gram of feed (LJ group); 1 × 10⁶ cfu disrupted LJ per gram of feed (D-LJ group); and de Man, Rogosa, and Sharpe liquid medium (control group), respectively, throughout a 42-day experimental period. The results demonstrated that LJ supplementation of feed had a positive effect on the average daily gain and starter feed conversion ratio. In addition, LJ supplementation of feed decreased serum triglyceride and low-density lipid cholesterol levels, as well as abdominal fat deposition. LJ also reduced the mRNA levels of lipoprotein lipase in adipose tissue and stearoyl-CoA desaturase-1 in the liver. LJ diminished the mRNA quantities of the sterol regulatory element binding protein-1c and fatty acid synthase, as well as increased the level of serum high-density lipid cholesterol. LJ increased the mRNA quantities of peroxisome proliferator-activated receptor α, acyl-CoA oxidase in the liver, and carnitine palmitoyltransferase-1. LJ also improved the intestinal development and digestive ability mainly by increasing the villus height/crypt depth ratio in the ileum. The probiotic increased the levels of epidermal growth factor and insulin-like growth factor-1, as well as the activities of trypsin and lipase in the jejunum and ileum. LJ exerted beneficial effects on the intestinal flora. Specifically, LJ markedly enhanced the population of Bacteroidetes and Lactobacillus spp. Moreover, the probiotic reduced the population of Enterobacteriaceae and the Firmicutes/Bacteroidetes ratio. Slight changes caused by disrupted LJ were detected. These findings indicated that live LJ supplementation may promote growth performance and lower fat deposition in broilers.

Enterococcal Infective Endocarditis following Periodontal Disease in Dogs

In humans, one of the major factors associated with infective endocarditis (IE) is the concurrent presence of periodontal disease (PD). However, in veterinary medicine, the relevance of PD in the evolution of dogs’ endocarditis remains poorly understood. In order to try to establish a correlation between mouth-associated Enterococcus spp. and infective endocarditis in dogs, the present study evaluated the presence and diversity of enterococci in the gum and heart of dogs with PD. Samples were collected during necropsy of 32 dogs with PD and visually diagnosed with IE, which died of natural causes or euthanasia. Enterococci were isolated, identified and further characterized by Pulsed-Field Gel Electrophoresis (PFGE); susceptibility to antimicrobial agents and pathogenicity potential was also evaluated. In seven sampled animals, PFGE-patterns, resistance and virulence profiles were found to be identical between mouth and heart enterococci obtained from the same dog, allowing the establishment of an association between enterococcal periodontal disease and endocarditis in dogs. These findings represent a crucial step towards understanding the pathogenesis of PD-driven IE, and constitute a major progress in veterinary medicine.

Identification and functional characterization of the putative polysaccharide biosynthesis protein (CapD) of Enterococcus faecium U0317

Most bacterial species produce capsular polysaccharides that contribute to disease pathogenesis through evasion of the host innate immune system and are also involved in inhibiting leukocyte killing. In the present study, we identified a gene in Enterococcus faecium U0317 with homologies to the polysaccharide biosynthesis protein CapD that is made up of 336 amino acids and putatively catalyzes N-linked glycosylation. A capD deletion mutant was constructed and complemented by homologous recombination that was confirmed by PCR and sequencing. The mutant revealed different growth behavior and morphological changes compared to wild-type by scanning electron microscopy, also the capD mutant showed a strong hydrophobicity and that was reversed in the reconstituted mutant. For further characterization and functional analyses, in-vitro cell culture and in-vivo a mouse infection models were used. Antibodies directed against alpha lipotechoic acid (αLTA) and the peptidyl-prolyl cis-trans isomerase (αPpiC), effectively mediated the opsonophagocytic killing in the capD knock-out mutant, while this activity was not observed in the wild-type and reconstituted mutant. By comparison more than 2-fold decrease was seen in mutant colonization and adherence to both T24 and Caco2 cells. However, a significant higher bacterial colonization was observed in capD mutant during bacteremia in the animal model, while virulence in a mouse UTI (urinary tract infection) model, there were no obvious differences. Further studies are needed to elucidate the function of capsular polysaccharide synthesis gene clusters and its involvement in the disease pathogenesis with the aim to develop targeted therapies to treat multidrug-resistant E. faecium infections.

Enterococcal endocarditis revisited

The Enterococcus species is the third main cause of infective endocarditis (IE) worldwide, and it is gaining relevance, especially among healthcare-associated cases. Patients with enterococcal IE are older and have more comorbidities than other types of IE. Classical treatment options are limited due to the emergence of high-level aminoglycosides resistance (HLAR), vancomycin resistance and multidrug resistance in some cases. Besides, few new antimicrobial alternatives have shown real efficacy, despite some of them being recommended by major guidelines (including linezolid and daptomycin). Ampicillin plus ceftriaxone 2 g iv./12 h is a good option for Enterococcus faecalis IE caused by HLAR strains, but randomized clinical trials are essential to demonstrate its efficacy for non-HLAR EFIE and to compare it with ampicillin plus short-course gentamicin. The main mechanisms of resistance and treatment options are also reviewed for other enterococcal species.

Daptomycin for the treatment of bacteraemia due to vancomycin-resistant enterococci

Treatment of severe infections caused by vancomycin-resistant enterococci (VRE) is challenging due to the scarcity of reliable therapeutic alternatives. In this context, daptomycin (DAP), a lipopeptide antibiotic, has emerged as an interesting alternative as it is one of the few compounds that retain in vitro bactericidal activity against VRE isolates, although it has not been approved for this purpose by regulatory agencies. In this review, we will summarise the clinical, animal and in vitro evidence evaluating the efficacy of DAP for the management of deep-seated VRE infections. In addition, we will address important clinical concerns such as the emergence of DAP resistance during therapy and reports of therapeutic failure with DAP monotherapy. Finally, we will discuss possible future strategies (such as the use of higher doses and/or combination therapies) to optimise the use of this antibiotic against VRE.

What's New in the Treatment of Enterococcal Endocarditis?

Enterococcus spp. are among the common pathogens causing infective endocarditis (IE). Despite major medical advances and new potent antimicrobial agents, the mortality has not significantly improved for several decades. The usual lack of bactericidal activity of penicillin or ampicillin, the toxicity from the combination of penicillin plus aminoglycosides, and the increased reports of high-level resistance to aminoglycosides have led to the exploration of other regimens for treatment of Enterococcus faecalis IE. As an example, ampicillin plus ceftriaxone is now a well-recognized regimen for this organism. However, the emerging of new drug resistances in Enterococcus faecium dramatically reduces the therapeutic alternatives for this organism in IE which continues to be an immense challenge for clinicians even with the availability of newer antimicrobial agents. This article summarizes the current treatment options for enterococcal endocarditis and reviews of recent publications on the topic.

Infective endocarditis epidemiology over five decades: a systematic review

AIMS

To Assess changes in infective endocarditis (IE) epidemiology over the last 5 decades.

METHODS AND RESULTS

We searched the published literature using PubMed, MEDLINE, and EMBASE from inception until December 2011.

DATA FROM

Einstein Medical Center, Philadelphia, PA were also included. Criteria for inclusion in this systematic review included studies with reported IE microbiology, IE definition, description of population studied, and time frame. Two authors independently extracted data and assessed manuscript quality. One hundred sixty studies (27,083 patients) met inclusion criteria. Among hospital-based studies (n=142; 23,606 patients) staphylococcal IE percentage increased over time, with coagulase-negative staphylococcus (CNS) increasing over each of the last 5 decades (p<0.001) and Staphylococcus aureus (SA) in the last decade (21% to 30%; p<0.05). Streptococcus viridans (SV) and culture negative (CN) IE frequency decreased over time (p<0.001), while enterococcal IE increased in the last decade (p<0.01). Patient age and male predominance increased over time as well. In subgroup analysis, SA frequency increased in North America, but not the rest of the world. This was due, in part, to an increase in intravenous drug abuse IE in North America (p<0.001). Among population-based studies (n=18; 3,477 patients) no significant changes were found.

CONCLUSION

Important changes occurred in IE epidemiology over the last half-century, especially in the last decade. Staphylococcal and enterococcal IE percentage increased while SV and CN IE decreased. Moreover, mean age at diagnosis increased together with male:female ratio. These changes should be considered at the time of decision-making in treatment of and prophylaxis for IE.

Efficacy of tigecycline alone and in combination with gentamicin in the treatment of experimental endocarditis due to linezolid-resistant Enterococcus faecium

We evaluated the efficacy of tigecycline in a rabbit model of experimental endocarditis caused by a linezolid-resistant clinical strain of Enterococcus faecium. Tigecycline-treated animals had a 2.8-log10-CFU/g reduction in microbial counts in excised vegetations compared with controls. Addition of gentamicin caused a further arithmetical reduction in colony counts. The therapeutic effect was sustained 5 days after completion of treatment, as shown by relapse studies performed in treatment groups.