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Rani V, Aye NK, Saksena R, Dabi KC, Mannan MAU, Gaind R. Risk factors and outcome associated with the acquisition of MDR linezolid-resistant Enterococcus faecium: a report from tertiary care centre. Eur J Clin Microbiol Infect Dis 2024; 43:767-775. [PMID: 38372832 DOI: 10.1007/s10096-024-04784-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 02/09/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE The aim of the study was to determine the resistance profile of linezolid-resistant Enterococcus faecium (LREfm) and to investigate risk factors and outcomes associated with LREfm infections. MATERIAL AND METHODS A prospective case-control study was undertaken (2019 to 2022) and included 202 patients with LREfm infections (cases) and 200 controls with LSEfm infections. Clinical data was prospectively collected and analysed for risk factors and outcomes. Antimicrobial susceptibility was performed, and resistance profile was studied using WHOnet. RESULTS Risk factors associated with LREfm infection were site of infection UTI (OR 5.87, 95% CI 2.59-13.29, p ≤ 0.001), prior use of carbapenem (OR 2.85 95% CI 1.62-5.02, p ≤ 0.001) and linezolid (OR 10.13, 95% CI 4.13-24.82, p ≤ 0.001), use of central line (OR 5.54, 95% CI 2.35-13.09, p ≤ 0.001), urinary catheter (OR 0.29, 95% CI 0.12-0.70, p ≤ 0.001) and ventilation (OR 14.87, 95% CI 7.86-28.11, p ≤ 0.007). The hospital stay 8-14 days (< 0.001) prior to infection and the mortality rate (p = 0.003) were also significantly high among patients with LREfm infections. Linezolid and vancomycin resistance coexisted; further, MDR, XDR and PDR phenotypes were significantly higher among LREfm. CONCLUSION This study provided insight into epidemiology of MDR LREfm in a setting where linezolid use is high. The main drivers of infections with LREfm are multiple, including use of carbapenems and linezolid. Invasive procedures and increased hospital stay facilitate spread through breach in infection control practises. As therapeutic options are limited, ongoing surveillance of LREfm and VRE is critical to guide appropriate use of linezolid and infection control policies.
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Affiliation(s)
- Vandana Rani
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
- Department of Molecular Biology and Genetic Engineering, School of Bioengineering and Biosciences, Lovely Professional University, Phagwara, Punjab, 144422, India
| | - N Kitoi Aye
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
| | - Rushika Saksena
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
| | - Kailash Chandra Dabi
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
| | - Mohammad Amin-Ul Mannan
- Department of Molecular Biology and Genetic Engineering, School of Bioengineering and Biosciences, Lovely Professional University, Phagwara, Punjab, 144422, India.
- Division of Infectious Disease, The Lundquist Institute, UCLA Harbor Medical Center, Los Angeles, CA, 90502, USA.
| | - Rajni Gaind
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India.
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Liu P, Zeng B, Wu X, Zheng F, Zhang Y, Liao X. Risk exploration and prediction model construction for linezolid-resistant Enterococcus faecalis based on big data in a province in southern China. Eur J Clin Microbiol Infect Dis 2024; 43:259-268. [PMID: 38032514 PMCID: PMC10821975 DOI: 10.1007/s10096-023-04717-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Enterococcus faecalis is a common cause of healthcare-associated infections. Its resistance to linezolid, the antibiotic of last resort for vancomycin-resistant enterococci, has become a growing threat in healthcare settings. METHODS We analyzed the data of E. faecalis isolates from 26 medical institutions between 2018 and 2020 and performed univariate and multivariate logistic regression analyses to determine the independent predictors for linezolid-resistant E. faecalis (LREFs). Then, we used the artificial neural network (ANN) and logistic regression (LR) to build a prediction model for linezolid resistance and performed a performance evaluation and comparison. RESULTS Of 12,089 E. faecalis strains, 755 (6.25%) were resistant to linezolid. Among vancomycin-resistant E. faecalis, the linezolid-resistant rate was 24.44%, higher than that of vancomycin-susceptible E. faecalis (p < 0.0001). Univariate and multivariate regression analyses showed that gender, age, specimen type, length of stay before culture, season, region, GDP (gross domestic product), number of beds, and hospital level were predictors of linezolid resistance. Both the ANN and LR models constructed in the study performed well in predicting linezolid resistance in E. faecalis, with AUCs of 0.754 and 0.741 in the validation set, respectively. However, synthetic minority oversampling technique (SMOTE) did not improve the prediction ability of the models. CONCLUSION E. faecalis linezolid-resistant rates varied by specimen site, geographic region, GDP level, facility level, and the number of beds. At the same time, community-acquired E. faecalis with linezolid resistance should be monitored closely. We can use the prediction model to guide clinical medication and take timely prevention and control measures.
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Affiliation(s)
- Peijun Liu
- Administration Department of Nosocomial Infection, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian Province, China
| | - Bangwei Zeng
- Administration Department of Nosocomial Infection, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian Province, China.
| | - Xiaoyan Wu
- Administration Department of Nosocomial Infection, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian Province, China
| | - Feng Zheng
- Information Department, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian Province, China
| | - Yangmei Zhang
- Administration Department of Nosocomial Infection, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian Province, China
| | - Xiaohua Liao
- Administration Department of Nosocomial Infection, Fujian Medical University Union Hospital, Fuzhou, 350001, Fujian Province, China
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3
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Bunnell K, Duong A, Ringsred T, Mian A, Bhathena S. Aminopenicillins for treatment of ampicillin-resistant enterococcal urinary tract infections. Am J Health Syst Pharm 2022; 79:1056-1065. [PMID: 35299243 DOI: 10.1093/ajhp/zxac068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE The purpose of this review is to describe the theory behind and data supporting use of aminopenicillins in the treatment of ampicillin-resistant enterococcal urinary tract infections. SUMMARY Aminopenicillin concentrations in the urine may be high enough to achieve bacterial eradication and clinical cure for infections affecting the lower genitourinary tract, even in the context of in vitro resistance based on established susceptibility breakpoints. A literature search was conducted to identify original research articles describing the use of aminopenicillins in the treatment of urinary tract infections caused by ampicillin-resistant Enterococcus species. Three published retrospective cohort studies were identified, all of which reported that aminopenicillins had similar rates of clinical cure as other antibiotic classes prescribed for the treatment of enterococcal urinary tract infections. CONCLUSION Both pharmacokinetic/pharmacodynamic principles and limited retrospective clinical data support the use of aminopenicillins in the treatment of lower urinary tract infections caused by Enterococcus species, even when the isolates have a minimum inhibitory concentration that exceeds the susceptibility breakpoint.
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Affiliation(s)
- Kristen Bunnell
- Medical College of Wisconsin School of Pharmacy, Milwaukee, WI, USA
| | - Amy Duong
- University of Rochester Medical Center, Rochester, NY, USA
| | | | - Asia Mian
- Aurora West Allis Medical Center, West Allis, WI, USA
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Cag Y, Haciseyitoglu D, Ozdemir AA, Cag Y. Antibiotic Resistance and Bacteria in Urinary Tract Infections in Pediatric Patients. Medeni Med J 2021; 36:217-224. [PMID: 34915679 PMCID: PMC8565589 DOI: 10.5222/mmj.2021.78535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/21/2021] [Indexed: 11/05/2022] Open
Abstract
Objective Antibiotic resistance against bacterial pathogens associated with urinary tract infections (UTI) is rapidly increasing worldwide. In this study, we aimed at determining the causative microorganisms in children under 17 years of age diagnosed with UTI in our hospital and the antibiotic resistance rates of these causes. Methods We isolated and retrospectively analyzed 4801 urine samples of children under 17 years old who presented with bacterial growth in their urine cultures. The isolated bacteria and their antibiotic resistance profiles were statistically analyzed. Results Most (2001/77.2%) of 2592 patients included in the study were female and the mean age and median interquartile range (IQR) was 55 (12-98) months. Except for the neonatal period, the female gender was predominant in all age groups (p<0.0001). The most frequently isolated bacteria included Escherichia coli (67.7%), Klebsiella spp. (10.7%), and Enterococcus spp. (8.8%). The most and least resistant antibiotics were ampicillin (66.6%) and meropenem (0.3%) for E. coli, respectively. Although resistance of E. faecalis to ampicillin and ciprofloxacin is at a low level, E. faecium is much more resistant to these antibiotics (p<0.0001). Conclusion It is important that each center determines its own resistant antibiotics so as to guide empirical treatment. Re-evaluating each antibiotic that is started to be used empirically according to the results of culture and sensitivity in addition to switching to a suitable antibiotic would be very effective in reducing resistance rates.
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Affiliation(s)
- Yakup Cag
- University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, Department of Pediatrics, Istanbul, Turkey
| | - Demet Haciseyitoglu
- Zonguldak Karaelmas University Faculty of Medicine, Department of Medical Microbiology, Zonguldak, Turkey
| | | | - Yasemin Cag
- Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
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Wang L, Zhang Y, Liu S, Huang N, Zeng W, Xu W, Zhou T, Shen M. Comparison of Anti-Microbic and Anti-Biofilm Activity Among Tedizolid and Radezolid Against Linezolid-Resistant Enterococcus faecalis Isolates. Infect Drug Resist 2021; 14:4619-4627. [PMID: 34764658 PMCID: PMC8577528 DOI: 10.2147/idr.s331345] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/13/2021] [Indexed: 12/24/2022] Open
Abstract
Background The emergence and spread of linezolid-resistant Enterococcus faecalis (E. faecalis) have emerged as a serious threat to human health globally. Therefore, this study aims to compare the anti-microbic as well as the anti-biofilm activity of linezolid, tedizolid, and radezolid against linezolid-resistant E. faecalis. Methods A total of 2128 E. faecalis isolates were assessed from the First Affiliated Hospital of Wenzhou Medical University from 2011 to 2019. Antibiotic sensitivity was evaluated using the micro broth dilution method. Oxazolidinone-resistant chromosomal and plasmid-borne genes such as cfr, cfr(A), cfr(B), cfr(C), cfr(D), optrA, and poxtA were detected by PCR and then sequenced to detect the presence of mutations in the domain V of the 23S rRNA and the ribosomal proteins L3, L4, and L22. Conjugation experiments were conducted using the broth method. The inhibition and eradication of biofilm were evaluated through crystal violet staining, whereas the efflux pump activities were detected by agar dilution. Results Out of 2128 isolated E. faecalis, 71 (3.34%) were linezolid-resistant isolates in which the MICs of tedizolid and radezolid ranged from 1 to 4 μg/mL and 0.5–1 μg/mL, respectively. The MIC50/MIC90 of tedizolid and radezolid were 4 and 8-fold lower than the linezolid, respectively. Out of 71 resistant isolates, 57 (80.28%) carried optrA, 1 (1.41%) carried cfr, 4 (5.63%) carried optrA and cfr, and 6 (8.45%) carried optrA and cfr(D), with no mutations of 23S rRNA gene and ribosomal proteins L3, L4, and L22. Besides, the transfer rate of the optrA, cfr, and cfr(D) was 17.91%, 0% and 0%, respectively. Radezolid showed more effectiveness in eradicating biofilm (8 × MIC). However, tedizolid was more effective than radezolid and linezolid in inhibiting the biofilm formation (1/4 MIC, 1/8MIC, and 1/16MIC). Additionally, in combination with CCCP, the MICs of radezolid in all linezolid-resistant isolates decreased ≥4-fold. Conclusion Radezolid showed greater antimicrobial activity than tedizolid and linezolid against linezolid-resistant E. faecalis. However, both tedizolid and radezolid showed differential activity on biofilm inhibition, eradication, and efflux pump compared to linezolid. Thus, our study might bring important clinical value in the application of these drugs for resistant pathogenic strains.
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Affiliation(s)
- Lingbo Wang
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
| | - Ying Zhang
- School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
| | - Shixing Liu
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
| | - Na Huang
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
| | - Weiliang Zeng
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
| | - Wenya Xu
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
| | - Tieli Zhou
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
| | - Mo Shen
- Department of Clinical Laboratory, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
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Gostev V, Leyn S, Kruglov A, Likholetova D, Kalinogorskaya O, Baykina M, Dmitrieva N, Grigorievskaya Z, Priputnevich T, Lyubasovskaya L, Gordeev A, Sidorenko S. Global Expansion of Linezolid-Resistant Coagulase-Negative Staphylococci. Front Microbiol 2021; 12:661798. [PMID: 34589061 PMCID: PMC8473885 DOI: 10.3389/fmicb.2021.661798] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Coagulase-negative staphylococci (CoNS) for a long time were considered avirulent constituents of the human and warm-blooded animal microbiota. However, at present, S. epidermidis, S. haemolyticus, and S. hominis are recognized as opportunistic pathogens. Although linezolid is not registered for the treatment of CoNS infections, it is widely used off-label, promoting emergence of resistance. Bioinformatic analysis based on maximum-likelihood phylogeny and Bayesian clustering of the CoNS genomes obtained in the current study and downloaded from public databases revealed the existence of international linezolid-resistant lineages, each of which probably had a common predecessor. Linezolid-resistant S. epidermidis sequence-type (ST) 2 from Russia, France, and Germany formed a compact group of closely related genomes with a median pairwise single nucleotide polymorphism (SNP) difference of fewer than 53 SNPs, and a common ancestor of this lineage appeared in 1998 (1986-2006) before introduction of linezolid in practice. Another compact group of linezolid-resistant S. epidermidis was represented by ST22 isolates from France and Russia with a median pairwise SNP difference of 40; a common ancestor of this lineage appeared in 2011 (2008-2013). Linezolid-resistant S. hominis ST2 from Russia, Germany, and Brazil also formed a group with a high-level genome identity with median 25.5 core-SNP differences; the appearance of the common progenitor dates to 2003 (1996-2012). Linezolid-resistant S. hominis isolates from Russia demonstrated associated resistance to teicoplanin. Analysis of a midpoint-rooted phylogenetic tree of the group confirmed the genetic proximity of Russian and German isolates; Brazilian isolates were phylogenetically distant. repUS5-like plasmids harboring cfr were detected in S. hominis and S. haemolyticus.
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Affiliation(s)
- Vladimir Gostev
- Department of Medical Microbiology and Molecular Epidemiology, Pediatric Research and Clinical Center for Infectious Diseases, Saint Petersburg, Russia.,Department of Medical Microbiology, North-Western State Medical University Named After I. I. Mechnikov, Saint Petersburg, Russia
| | - Semen Leyn
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, United States
| | - Alexander Kruglov
- Laboratory of Clinical Microbiology, National Agency for Clinical Pharmacology and Pharmacy, Moscow, Russia
| | - Daria Likholetova
- Department of Medical Microbiology and Molecular Epidemiology, Pediatric Research and Clinical Center for Infectious Diseases, Saint Petersburg, Russia.,Saint Petersburg State University, Saint Petersburg, Russia
| | - Olga Kalinogorskaya
- Department of Medical Microbiology and Molecular Epidemiology, Pediatric Research and Clinical Center for Infectious Diseases, Saint Petersburg, Russia
| | - Marina Baykina
- Laboratory of Clinical Microbiology, National Agency for Clinical Pharmacology and Pharmacy, Moscow, Russia
| | - Natalia Dmitrieva
- Department of Microbiology, N. N. Blokhin Russian Cancer Research Center, Moscow, Russia
| | - Zlata Grigorievskaya
- Department of Microbiology, N. N. Blokhin Russian Cancer Research Center, Moscow, Russia
| | - Tatiana Priputnevich
- Department of Microbiology, Clinical Pharmacology and Epidemiology, National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - Lyudmila Lyubasovskaya
- Department of Microbiology, Clinical Pharmacology and Epidemiology, National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - Alexey Gordeev
- Department of Microbiology, Clinical Pharmacology and Epidemiology, National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - Sergey Sidorenko
- Department of Medical Microbiology and Molecular Epidemiology, Pediatric Research and Clinical Center for Infectious Diseases, Saint Petersburg, Russia.,Department of Medical Microbiology, North-Western State Medical University Named After I. I. Mechnikov, Saint Petersburg, Russia
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Egan SA, Shore AC, O'Connell B, Brennan GI, Coleman DC. Linezolid resistance in Enterococcus faecium and Enterococcus faecalis from hospitalized patients in Ireland: high prevalence of the MDR genes optrA and poxtA in isolates with diverse genetic backgrounds. J Antimicrob Chemother 2021; 75:1704-1711. [PMID: 32129849 PMCID: PMC7303821 DOI: 10.1093/jac/dkaa075] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/21/2020] [Accepted: 02/06/2020] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES To investigate the prevalence of the optrA, poxtA and cfr linezolid resistance genes in linezolid-resistant enterococci from Irish hospitals and to characterize associated plasmids. METHODS One hundred and fifty-four linezolid-resistant isolates recovered in 14 hospitals between June 2016 and August 2019 were screened for resistance genes by PCR. All isolates harbouring resistance genes, and 20 without, underwent Illumina MiSeq WGS. Isolate relatedness was assessed using enterococcal whole-genome MLST. MinION sequencing (Oxford Nanopore) and hybrid assembly were used to resolve genetic environments/plasmids surrounding resistance genes. RESULTS optrA and/or poxtA were identified in 35/154 (22.7%) isolates, the highest prevalence reported to date. Fifteen isolates with diverse STs harboured optrA only; one Enterococcus faecium isolate harboured optrA (chromosome) and poxtA (plasmid). Seven Enterococcus faecalis and one E. faecium harboured optrA on a 36 331 bp plasmid with 100% identity to the previously described optrA-encoding conjugative plasmid pE349. Variations around optrA were also observed, with optrA located on plasmids in five isolates and within the chromosome in three isolates. Nine E. faecium and 10 E. faecalis harboured poxtA, flanked by IS1216E, within an identical 4001 bp region on plasmids exhibiting 72.9%-100% sequence coverage to a 21 849 bp conjugative plasmid. E. faecalis isolates belonged to ST480, whereas E. faecium isolates belonged to diverse STs. Of the remaining 119 linezolid-resistant isolates without linezolid resistance genes, 20 investigated representatives all harboured the G2576T 23S RNA gene mutation associated with linezolid resistance. CONCLUSIONS This high prevalence of optrA and poxtA in diverse enterococcal lineages in Irish hospitals indicates significant selective pressure(s) for maintenance.
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Affiliation(s)
- Sarah A Egan
- Microbiology Research Unit, Division of Oral Biosciences, Dublin Dental University Hospital, University of Dublin, Trinity College, Lincoln Place, Dublin 2, Ireland
| | - Anna C Shore
- Microbiology Research Unit, Division of Oral Biosciences, Dublin Dental University Hospital, University of Dublin, Trinity College, Lincoln Place, Dublin 2, Ireland
| | - Brian O'Connell
- Department of Clinical Microbiology, School of Medicine, University of Dublin, Trinity College Dublin, St. James's Hospital, Dublin 8, Ireland.,National MRSA Reference Laboratory, St. James's Hospital, James's Street, Dublin 8, Ireland
| | - Grainne I Brennan
- National MRSA Reference Laboratory, St. James's Hospital, James's Street, Dublin 8, Ireland
| | - David C Coleman
- Microbiology Research Unit, Division of Oral Biosciences, Dublin Dental University Hospital, University of Dublin, Trinity College, Lincoln Place, Dublin 2, Ireland
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Jiang L, Xie N, Chen M, Liu Y, Wang S, Mao J, Li J, Huang X. Synergistic Combination of Linezolid and Fosfomycin Closing Each Other's Mutant Selection Window to Prevent Enterococcal Resistance. Front Microbiol 2021; 11:605962. [PMID: 33633692 PMCID: PMC7899970 DOI: 10.3389/fmicb.2020.605962] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/30/2020] [Indexed: 12/21/2022] Open
Abstract
Enterococci, the main pathogens associated with nosocomial infections, are resistant to many common antibacterial drugs including β-lactams, aminoglycosides, etc. Combination therapy is considered an effective way to prevent bacterial resistance. Preliminary studies in our group have shown that linezolid combined with fosfomycin has synergistic or additive antibacterial activity against enterococci, while the ability of the combination to prevent resistance remains unknown. In this study, we determined mutant prevention concentration (MPC) and mutant selection window (MSW) of linezolid, fosfomycin alone and in combination including different proportions for five clinical isolates of Enterococcus and characterized the resistance mechanism for resistant mutants. The results indicated that different proportions of linezolid combined with fosfomycin had presented different MPCs and MSWs. Compared with linezolid or fosfomycin alone, the combination can restrict the enrichment of resistant mutants at a lower concentration. A rough positive correlation between the selection index (SI) of the two agents in combination and the fractional inhibitory concentration index (FICI) of the combination displayed that the smaller FICI of linezolid and fosfomycin, the more probable their MSWs were to close each other. Mutations in ribosomal proteins (L3 and L4) were the mechanisms for linezolid resistant mutants. Among the fosfomycin-resistant mutants, only two strains have detected the MurA gene mutation related to fosfomycin resistance. In conclusion, the synergistic combination of linezolid and fosfomycin closing each other’s MSW could effectively suppress the selection of enterococcus resistant mutants, suggesting that the combination may be an alternative for preventing enterococcal resistance. In this study, the resistance mechanism of fosfomycin remains to be further studied.
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Affiliation(s)
- Lifang Jiang
- Department of Basic and Clinical Pharmacology, School of Pharmacy, Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Major Autoimmune Diseases, School of Pharmacy, Anhui Institute of Innovative Drugs, Anhui Medical University, Hefei, China
| | - Na Xie
- Department of Basic and Clinical Pharmacology, School of Pharmacy, Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Major Autoimmune Diseases, School of Pharmacy, Anhui Institute of Innovative Drugs, Anhui Medical University, Hefei, China
| | - Mingtao Chen
- Department of Basic and Clinical Pharmacology, School of Pharmacy, Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Major Autoimmune Diseases, School of Pharmacy, Anhui Institute of Innovative Drugs, Anhui Medical University, Hefei, China
| | - Yanyan Liu
- Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Shuaishuai Wang
- Department of Basic and Clinical Pharmacology, School of Pharmacy, Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Major Autoimmune Diseases, School of Pharmacy, Anhui Institute of Innovative Drugs, Anhui Medical University, Hefei, China
| | - Jun Mao
- Department of Basic and Clinical Pharmacology, School of Pharmacy, Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Major Autoimmune Diseases, School of Pharmacy, Anhui Institute of Innovative Drugs, Anhui Medical University, Hefei, China
| | - Jiabin Li
- Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaohui Huang
- Department of Basic and Clinical Pharmacology, School of Pharmacy, Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Major Autoimmune Diseases, School of Pharmacy, Anhui Institute of Innovative Drugs, Anhui Medical University, Hefei, China
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9
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Layer F, Weber RE, Fleige C, Strommenger B, Cuny C, Werner G. Excellent performance of CHROMagar TM LIN-R to selectively screen for linezolid-resistant enterococci and staphylococci. Diagn Microbiol Infect Dis 2020; 99:115301. [PMID: 33444893 DOI: 10.1016/j.diagmicrobio.2020.115301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/17/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
The increasing number of nosocomial pathogens with resistances against last resort antibiotics like linezolid leads to a pressing need for the reliable detection of these drug-resistant bacteria. National guidelines on infection prevention, e.g., in Germany, have already recommend screening for linezolid-resistant bacteria, although a corresponding screening agar medium has not been provided. In this study we analyzed the performance and reliability of a commercial, chromogenic linezolid screening agar. The medium was capable to predict more than a hundred linezolid-resistant isolates of E. faecium, E. faecalis, S. aureus, S. epidermidis, and S. hominis with excellent sensitivity and specificity. All isolates were collected at the National Reference Centre between 2010 and 2020.
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Affiliation(s)
- Franziska Layer
- Robert Koch Institute, Wernigerode Branch, Department of Infectious Diseases, Division Nosocomial Pathogens and Antibiotic Resistances, National Reference Centre for Staphylococci and Enterococci, Wernigerode, Germany
| | - Robert E Weber
- Robert Koch Institute, Wernigerode Branch, Department of Infectious Diseases, Division Nosocomial Pathogens and Antibiotic Resistances, National Reference Centre for Staphylococci and Enterococci, Wernigerode, Germany
| | - Carola Fleige
- Robert Koch Institute, Wernigerode Branch, Department of Infectious Diseases, Division Nosocomial Pathogens and Antibiotic Resistances, National Reference Centre for Staphylococci and Enterococci, Wernigerode, Germany
| | - Birgit Strommenger
- Robert Koch Institute, Wernigerode Branch, Department of Infectious Diseases, Division Nosocomial Pathogens and Antibiotic Resistances, National Reference Centre for Staphylococci and Enterococci, Wernigerode, Germany
| | - Christiane Cuny
- Robert Koch Institute, Wernigerode Branch, Department of Infectious Diseases, Division Nosocomial Pathogens and Antibiotic Resistances, National Reference Centre for Staphylococci and Enterococci, Wernigerode, Germany
| | - Guido Werner
- Robert Koch Institute, Wernigerode Branch, Department of Infectious Diseases, Division Nosocomial Pathogens and Antibiotic Resistances, National Reference Centre for Staphylococci and Enterococci, Wernigerode, Germany.
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Mahmoudi L, Sepasian A, Firouzabadi D, Akbari A. The Impact of an Antibiotic Stewardship Program on the Consumption of Specific Antimicrobials and Their Cost Burden: A Hospital-wide Intervention. Risk Manag Healthc Policy 2020; 13:1701-1709. [PMID: 33061704 PMCID: PMC7520156 DOI: 10.2147/rmhp.s265407] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 08/10/2020] [Indexed: 12/22/2022] Open
Abstract
Background Inappropriate use of antimicrobials (AM) is a major concern worldwide that leads to the propagation of antimicrobial resistance (AMR). In addition to its clinical implications, AMR imposes an economic burden on communities, especially developing countries with more infectious diseases and less available resources. Antimicrobial stewardship programs (ASPs) have been found to be effective in reducing AMR. This study was designed to evaluate the effect of implementing an ASP in reducing AM consumption, its economic burden, and AMR as a consecutive result. Materials and Methods Consumption of caspofungin, amphotericin B, voriconazole, colistin, linezolid, vancomycin, and carbapenems was compared in a prospective cross-sectional study between two time periods introduced as pre- and post-ASP. Drug use density presented as anatomical therapeutic chemical (ATC)/defined daily doses (DDD) and normalized per 1000 bed days, cost savings, and AMR patterns were evaluated. Results A total of 9400 AM prescriptions were analyzed during a 2-year period. Consumption measured in DDD/1000 bed days dropped by 24.8, 25.0, 35.3, 47.0, 39.2, 10.5, and 23.2 percent for amphotericin B, caspofungin, colistin, voriconazole, meropenem, imipenem, and vancomycin, respectively. Linezolid consumption increased by 26.8% after implementing ASP. The expenditure of target AMs in the average value of USD decreased by 41.3% after the intervention compared to the time before using ASP (P-value=0.001). Implementing ASP also increased AM susceptibility of Pseudomonas aeruginosa, while the susceptibility of methicillin-resistant Staphylococcus aureus did not change significantly. Conclusion The results of this study suggest that establishment of ASP can lead to a reduction in improper administration of AMs and their expenditure resulting in economic benefit and lowering AMR at hospitals with minimum resources. Clinical pharmacists' role was critical to the success of this ASP and was uniquely empowered at our center.
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Affiliation(s)
- Laleh Mahmoudi
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Sepasian
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Dena Firouzabadi
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Akbari
- Department of Anesthesiology, Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
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Rodríguez-Noriega E, Hernández-Morfin N, Garza-Gonzalez E, Bocanegra-Ibarias P, Flores-Treviño S, Esparza-Ahumada S, González-Díaz E, Pérez-Gómez HR, Mendoza-Mujica C, León-Garnica G, Morfín-Otero R. Risk factors and outcome associated with the acquisition of linezolid-resistant Enterococcus faecalis. J Glob Antimicrob Resist 2020; 21:405-409. [DOI: 10.1016/j.jgar.2020.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/25/2019] [Accepted: 01/13/2020] [Indexed: 01/13/2023] Open
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12
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Egan SA, Corcoran S, McDermott H, Fitzpatrick M, Hoyne A, McCormack O, Cullen A, Brennan GI, O'Connell B, Coleman DC. Hospital outbreak of linezolid-resistant and vancomycin-resistant ST80 Enterococcus faecium harbouring an optrA-encoding conjugative plasmid investigated by whole-genome sequencing. J Hosp Infect 2020; 105:726-735. [PMID: 32439548 DOI: 10.1016/j.jhin.2020.05.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/11/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Linezolid is an antibiotic used to treat infections caused by multi-drug-resistant Gram-positive bacteria. Linezolid resistance in enterococci has been reported with increasing frequency, with a recent rise in resistance encoded by optrA, poxtA or cfr. AIM To investigate a hospital outbreak of linezolid- and vancomycin-resistant Enterococcus faecium (LVREfm) using whole-genome sequencing (WGS). METHODS Thirty-nine VREfm from patient screening (19 isolates, 17 patients) and environmental sites (20 isolates) recovered in October 2019 were investigated. Isolates were screened using polymerase chain reaction for optrA, poxtA and cfr, and underwent Illumina MiSeq WGS. Isolate relatedness was assessed using E. faecium core genome multi-locus sequence typing (cgMLST). One LVREfm underwent MinION long-read WGS (Oxford Nanopore Technologies) and hybrid assembly with MiSeq short-read sequences to resolve an optrA-encoding plasmid. FINDINGS Twenty isolates (51.3%) were LVREfm and optrA-positive, including the LVREfm from the index patient. A closely related cluster of 28 sequence type (ST) 80 isolates was identified by cgMLST, including all 20 LVREfm and eight linezolid-susceptible VREfm, with an average allelic difference of two (range 0-10), indicating an outbreak. Nineteen (95%) LVREfm harboured a 56,684-bp conjugative plasmid (pEfmO_03). The remaining LVREfm exhibited 44.1% sequence coverage to pEfmO_03. The presence of pEfmO_03 in LVREfm and the close relatedness of the outbreak cluster isolates indicated the spread of a single strain. The outbreak was terminated by enhanced infection prevention and control (IPC) and environmental cleaning measures, ceasing ward admissions and ward-dedicated staff. CONCLUSION WGS was central in investigating an outbreak of ST80 LVREfm. The rapid implementation of enhanced IPC measures terminated the outbreak.
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Affiliation(s)
- S A Egan
- Microbiology Research Unit, Division of Oral Biosciences, Dublin Dental University Hospital, University of Dublin, Trinity College, Dublin, Ireland
| | - S Corcoran
- Department of Clinical Microbiology, Bon Secours Hospital Dublin, Glasnevin, Dublin, Ireland
| | - H McDermott
- Department of Clinical Microbiology, Bon Secours Hospital Dublin, Glasnevin, Dublin, Ireland
| | - M Fitzpatrick
- Infection Prevention and Control Department, Bon Secours Hospital Dublin, Glasnevin, Dublin, Ireland
| | - A Hoyne
- Department of Clinical Microbiology, Bon Secours Hospital Dublin, Glasnevin, Dublin, Ireland
| | - O McCormack
- Department of Clinical Microbiology, Bon Secours Hospital Dublin, Glasnevin, Dublin, Ireland
| | - A Cullen
- Pharmacy Department, Bon Secours Hospital Dublin, Glasnevin, Dublin, Ireland
| | - G I Brennan
- National MRSA Reference Laboratory, St. James's Hospital, Dublin, Ireland
| | - B O'Connell
- National MRSA Reference Laboratory, St. James's Hospital, Dublin, Ireland; Department of Clinical Microbiology, School of Medicine, University of Dublin, Trinity College, St. James's Hospital, Dublin, Ireland
| | - D C Coleman
- Microbiology Research Unit, Division of Oral Biosciences, Dublin Dental University Hospital, University of Dublin, Trinity College, Dublin, Ireland.
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13
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In vitro synergistic effect of retapamulin with erythromycin and quinupristin against Enterococcus faecalis. J Antibiot (Tokyo) 2020; 73:630-635. [PMID: 32346089 DOI: 10.1038/s41429-020-0312-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/28/2020] [Accepted: 04/07/2020] [Indexed: 12/15/2022]
Abstract
To find a therapeutic alternative for the treatment of skin and soft tissue infections, we evaluated the effects of combinations of retapamulin with macrolide, lincosamide, and streptogramin (MLS) antibiotics against Staphylococcus aureus, Streptococcus pyogenes, Enterococcus faecium, and Enterococcus faecalis. Using both the disk diffusion test and checkerboard assay, we initially examined the effects of combinations of retapamulin with MLS antibiotics against standard strains of these species. Combinations of retapamulin with erythromycin, quinupristin/dalfopristin and quinupristin showed synergistic activity against E. faecalis only. Synergy of retapamulin with clindamycin and dalfopristin was not observed. Then, a checkerboard assay was performed to evaluate the effects of the combinations against 15 clinical strains of E. faecalis. Retapamulin and quinupristin, the most synergistic combination, showed activity against all erythromycin-susceptible, -intermediate, and -resistant strains tested. Among the eight strains with high-level erythromycin resistance, five strains were synergistically inhibited in the presence of only 1 μg of retapamulin per ml. Time-kill assay revealed that combinations of retapamulin with erythromycin and quinupristin were bacteriostatic. These results suggest that combinations of retapamulin with erythromycin and quinupristin have in vitro synergistic activity against E. faecalis, including strains with high-level erythromycin resistance.
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14
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Moure Z, Lara N, Marín M, Sola-Campoy PJ, Bautista V, Gómez-Bertomeu F, Gómez-Dominguez C, Pérez-Vázquez M, Aracil B, Campos J, Cercenado E, Oteo-Iglesias J. Interregional spread in Spain of linezolid-resistant Enterococcus spp. isolates carrying the optrA and poxtA genes. Int J Antimicrob Agents 2020; 55:105977. [PMID: 32330583 DOI: 10.1016/j.ijantimicag.2020.105977] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 03/11/2020] [Accepted: 04/06/2020] [Indexed: 12/12/2022]
Abstract
The emergence of linezolid-resistant Enterococcus spp. (LRE) due to transferable resistance determinants is a matter of concern. To understand the contribution of the plasmid-encoded optrA and poxtA genes to the emergence of LRE, clinical isolates from different Spanish hospitals submitted to the Spanish Reference Laboratory from 2015-2018 were analysed. Linezolid resistance mechanisms were screened in all isolates by PCR and sequencing. Genetic relatedness of Enterococcus spp. carrying optrA and poxtA was studied by PFGE and MLST. Antimicrobial susceptibility was tested by broth microdilution using EUCAST standards. A total of 97 LRE isolates were studied, in 94 (96.9%) of which at least one resistance determinant was detected; 84/97 isolates (86.6%) presented a single resistance mechanism as follows: 45/84 (53.6%) carried the optrA gene, 38/84 (45.2%) carried the G2576T mutation and 1/84 (1.2%) carried the poxtA gene. In addition, 5/97 isolates (5.2%) carried both optrA and the G2576T mutation and 5/97 (5.2%) carried both optrA and poxtA. The optrA gene was more frequent in Enterococcus faecalis (83.6%) than Enterococcus faecium (11.1%) and was mainly associated with community-acquired urinary tract infections. Carriage of the poxtA gene was more frequent in E. faecium (13.9%) than E. faecalis (1.6%). Among the optrA-positive E. faecalis isolates, two main clusters were detected by PFGE. These two clusters belonged to ST585 and ST480 and were distributed throughout 11 and 6 Spanish provinces, respectively. This is the first description of LRE carrying the poxtA gene in Spain, including the co-existence of optrA and poxtA in five isolates.
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Affiliation(s)
- Zaira Moure
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - Noelia Lara
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Mercedes Marín
- Microbiology Department, Hospital Gregorio Marañón, Madrid, Spain
| | - Pedro J Sola-Campoy
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Verónica Bautista
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | | | - Cristina Gómez-Dominguez
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - María Pérez-Vázquez
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - Belén Aracil
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - José Campos
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - Emilia Cercenado
- Microbiology Department, Hospital Gregorio Marañón, Madrid, Spain
| | - Jesús Oteo-Iglesias
- Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain.
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Werner G, Fleige C, Klare I, Weber RE, Bender JK. Validating a screening agar for linezolid-resistant enterococci. BMC Infect Dis 2019; 19:1078. [PMID: 31870418 PMCID: PMC6929501 DOI: 10.1186/s12879-019-4711-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/17/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Linezolid is an alternative treatment option for infections with multidrug-resistant Gram-positive bacteria including vancomycin-resistant enterococci. Some countries report an increasing number of isolates with resistance to linezolid. The recent publication of the Commission for Hospital Hygiene in Germany on enterococci/VRE recommends screening for linezolid-resistant enterococci (LRE). However, a suitable selective medium or a genetic test is not available. Our aim was to establish a selective screening agar for LRE detection and validate its application with a comprehensive collection of clinical LRE and linezolid-susceptible enterococci. METHODS We decided to combine the selective power of an enterococcal screening agar with a supplementation of linezolid. Several rounds of analyses with reference, control and test strains and under varying linezolid concentrations of a wider and a smaller range were investigated and assessed. The collection of linezolid-resistant enterococcal control strains included isolates with different resistance mechanisms (23S rDNA mutations, cfr(B), optrA, poxtA). Finally, we validated our LRE screening agar with 400 samples sent to our National Reference Centre in 2019. RESULTS Several rounds of pre-tests and confirmatory analyses favored Enterococcosel® Agar supplemented with a concentration of 2 mg/L linezolid. A 48 h incubation period was essential for accurate identification of LRE strains. Performance of the LRE screening agar revealed a sensitivity of 96.6% and a specificity of 94.4%. CONCLUSIONS Here we describe preparation of a suitable screening agar and a procedure to identify LRE isolates with high accuracy.
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Affiliation(s)
- Guido Werner
- Division Nosocomial Pathogens and Antibiotic Resistances, Department of Infectious Diseases, National Reference Centre for Staphylococci and Enterococci (NRC), Robert Koch Institute, Wernigerode Branch, Wernigerode, Germany.
| | - Carola Fleige
- Division Nosocomial Pathogens and Antibiotic Resistances, Department of Infectious Diseases, National Reference Centre for Staphylococci and Enterococci (NRC), Robert Koch Institute, Wernigerode Branch, Wernigerode, Germany
| | - Ingo Klare
- Division Nosocomial Pathogens and Antibiotic Resistances, Department of Infectious Diseases, National Reference Centre for Staphylococci and Enterococci (NRC), Robert Koch Institute, Wernigerode Branch, Wernigerode, Germany
| | - Robert E Weber
- Division Nosocomial Pathogens and Antibiotic Resistances, Department of Infectious Diseases, National Reference Centre for Staphylococci and Enterococci (NRC), Robert Koch Institute, Wernigerode Branch, Wernigerode, Germany
| | - Jennifer K Bender
- Division Nosocomial Pathogens and Antibiotic Resistances, Department of Infectious Diseases, National Reference Centre for Staphylococci and Enterococci (NRC), Robert Koch Institute, Wernigerode Branch, Wernigerode, Germany
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