Molecular characterization of vancomycin-resistant Enterococcus faecium strains isolated from carriage and clinical samples in a tertiary hospital, Turkey

Genomic characterization of vancomycin-resistant Enterococcus faecium clonal complex 17 isolated from urine in tertiary hospitals in Northeastern Thailand

Vancomycin-resistant Enterococci (VREs) have increasingly become a major nosocomial pathogen worldwide, earning high-priority category from the World Health Organization (WHO) due to their antibiotic resistance. Among VREs, vancomycin-resistant Enterococcus faecium (VREfm) is particularly concerning, frequently isolated and resistant to many antibiotics used in hospital-acquired infections. This study investigated VREfm isolates from rural tertiary hospitals in Northeastern Thailand based both antibiotic susceptibility testing and whole-genome sequencing. All isolates showed resistance to vancomycin, ampicillin, erythromycin, tetracycline, ciprofloxacin, norfloxacin, and rifampin. Nitrofurantoin and tigecycline resistance were also observed in nearly all isolates. Conversely, all isolates remained susceptible to chloramphenicol, daptomycin, and linezolid. Genomic characterization revealed that all VREfm isolates belonged to clonal complex 17 (CC17), primarily consisting of sequence type (ST) 80, followed by ST17, ST761, and ST117. Additionally, all isolates harbored numerous antimicrobial-resistant genes, including vanA, tet(L), tet(M), aac(6')-li, ant(6)-Ia, aph(3')-III, aac(6')-aph(2″), aph(2″)-la, ant(9)-la, erm(B), msr(C), erm(T), erm(A), fosB, dfrG, and cfr(B). Notably, all isolates contained virulence genes, for collagen adhesin (acm) and cell wall adhesin (efafm), while hylEfm (glycosyl hydrolase) was detected in VREfm ST80. This study provided important information for understanding the genomic features of VREfm isolated from urine.

An Outbreak of Vancomycin-Resistant Enterococci in a City Hospital Intensive Care Unit: Molecular Characterization of Resistance

Background and Objectives: Vancomisin-resistant Enterococci (VRE), is a resistant microorganism that colonizes and causes infections in hospitalized patients. The aim of this study was to show the spread of vancomycin-resistant Enterococcus faecium (VREfm) step-by-step in all intensive care units, which started with the growth of VREfm on 2 December 2021 in the blood culture of a patient hospitalized in the anesthesia intensive care unit of our hospital and was found to have reached epidemic size in the surveys. Materials and Methods: Rectal swab samples were taken from all patients hospitalized in intensive care units, VRE colonization was determined, the VanA and VanB resistance genes associated with the vancomycin resistance of VREfm isolates were determined by PCR method, and clonal association analysis was performed by Arbitrarily Primed-PCR (AP-PCR) and PFGE (pulsed-field gel electrophoresis). Results: In our study, VRE were detected in 61 of 2601 rectal swab samples. In total, fifty-four (85.52%) of the VRE isolates were Enterococcus faecium, three (4.91%) was Enterococcus faecalis, three (4.91%) was Enterococcus gallinorum, and one (1.63%) was Enterococcus casseliflavus. It was determined that all of the 54 VREfm isolates, which were the most detected among all VRE isolates, carried the vanA gene. In the clonal association analysis of the isolates by AP-PCR and PFGE methods, it was found that they had 12 different genotypes, 48 of them were included in any cluster, the clustering rate was 88.8%, and the largest cluster was the genotype 1 cluster, with 36 isolates. Of the 54 patients with VREfm isolated recently, 18.51 percent of the clinical samples were isolated before the survey, and 9.25% were isolated after the survey. It was determined that 100% of VREfm isolates were resistant to ampicillin, levofloxacin, ciprofloxacin, high-level gentamicin, trimethoprimsulfamethoxazole, and teicoplanin, 7.4% to tigecycline, and 1.85% to linezolid. Conclusions: In our study, in the clonal association analysis performed by isolating VREfm in rectal swab samples, it was found that 88.8% of the samples were indistinguishably similar, and that the increase in the number of VREfm infections after the index case in our hospital was associated with the epidemic. VREfm infections cause long-term hospitalization, costs and also deaths, which shows the seriousness of the event, and the importance of the combination of epidemiological and molecular analysis in epidemic research.

Vankomisine Dirençli Enterococcus faecium: Kısa Bir Derleme

Antimikrobiyal direnç (AMD) ile ilişkili morbidite ve mortalite küresel bir halk sağlığı sorunudur. Sağlık hizmeti ilişkili enfeksiyonlarda sık olarak görülen vankomisine dirençli Enterococcus faecium (VRE), Dünya Sağlık Örgütü’nün AMD’i olan öncelikli patojenler listesinde yüksek öncelik verdiği bir Gram pozitif koktur. Son zamanlarda Türkiye’de invaziv enfeksiyonlarda VRE izolasyon oranı %15.8 bildirilmiştir. Vankomisine direncin ana mekanizması, hedef bölgedeki D-Alanil-D-Alanin terminal molekülünün değişmesi ve ilacın affinitesinin azalmasıdır. Vankomisin direncinden sorumlu olan van geni kromozomal olarak kodlanmakta veya plazmid, transpozon gibi mobil genetik elemanlar ile kazanılmaktadır. Yayılımındaki ana mekanizma, mobil genetik elemanların Enterokoklar veya Staphylococcus aereus gibi farklı tür bakteriler arasında transfer edilebilmeleridir. Bu derlemede PubMed ve Web of Science veritabanlarında “Vankomisin-dirençli Enterococcus faecium”, “Vankomisin direnç mekanizmaları”, “Gram pozitif koklarda vankomisin direnci” terimleri ile arama yapılarak elde edilen literatür verileri özetlenmiş ve önerilerle birlikte kısaca tartışılmıştır.

Prevalence of Genes Encoding Resistance to Aminoglycosides and Virulence Factors Among Intestinal Vancomycin-Resistant Enterococci

Background: Vancomycin-resistant enterococci (VRE) are recognized as nosocomial pathogens with increased importance in recent years. These bacteria are frequently isolated from patients admitted to intensive care units (ICUs). Enterococcal pathogenicity is enhanced by different antibiotic resistance and virulence determinants. Objectives: The present study aimed to assess the prevalence of genes encoding resistance to antibiotics and virulence factors in intestinal VRE isolates from ICU patients. Methods: In this study, 23 VREs were investigated. Minimum inhibitory concentrations (MICs) to nine antimicrobial agents were examined using E-test. Genes encoding vancomycin resistance (vanABCDMN), aminoglycoside-modifying enzymes (aac(6')-Ie-aph(2")-Ia, aph(2")-Ib, aph(2")-Ic, aph(2")-Id, aph(3')-IIIa, ant(3')-Ia, ant(4')-Ia, ant(6')-Ia), together with genes for various virulence factor (ace/acm, asa1, cylA, efaA, esp, gelE and hyl), were detected using multiplex PCR. Results: The species distribution of the tested VRE was as follows: Nine Enterococcus casseliflavus, seven E. gallinarum, and seven E. faecium. The vanA gene was found in all E. faecium, in six of which the classical VanA phenotype was observed. The vancomycin (vanC) phenotype was associated with the presence of vanC1 gene in E. gallinarum and the vanC2 gene in E. casseliflavus isolates. The aac(6')-Ie-aph(2")-Ia gene was encoding high-level gentamicin resistance (HLGR) in the studied VRE. All E. faecium were positive for acm and esp, while acm in combination with esp or hyl was detected in 2 vanC enterococci. Conclusions: According to the findings, there was a correlation between the phenotype and the genotype of glycopeptide resistance in the tested VRE. HLGR was more prevalent in E. faecium because of the presence of aac(6')-Ie-aph(2")-Ia. The higher prevalence of virulence determinants was confirmed in vanA isolates compared to the studied vanC-carrying enterococci.

Prevalence of Virulence Genes and Antibiotic Resistance Pattern in Enterococcus Faecalis Isolated from Urinary Tract Infection in Shahrekord, Iran

Background

This study aims to specify the antimicrobial resistance pattern and virulence genes of Enterococcus faecalis isolated from urinary tract infections in Shahrekord, Iran.

Methods

Urine samples of 1000 people suspected of having urinary tract infections referred to Shahrekord medical diagnostic laboratories were examined. Biofilm assays were performed by microtiter plate test through reading the OD490. Polymerase Chain Reaction (PCR) was applied to study the virulence factors.

Results

Enterococcus faecalis was detected in 60 samples. After performing microbiological tests, all samples were positive in the molecular analysis. Strong, moderate and weak biofilm reactions reported 66.67%, 25%, and 8.33% respectively. The most resistance reported to cotrimoxazole, vancomycin and amikacin and the lowest resistance to nitrofurantoin (8.33%) was reported. Statistical analysis with Fisher's exact test showed a statistically significant relationship between biofilm production and resistance to cotrimoxazole, vancomycin and cefotaxime. Prevalence of efe A, ace, gel E, esp, cyl M, agg, cyl A and cyl B in strong biofilm formation isolates was reported 100%, 87.5%, 82%, 62.5%, 55%, 37.5% 25% and 22.5% respectively. There was a significant relationship between the frequency of efa A and strong biofilm reaction.

Conclusion

The presence of E. faecalis strains resistant to co-trimoxazole and vancomycin and present of some virulence factors is alarming the researchers. Since antibiotic resistance genes are probably transmitted among enterococci, and Staphylococci, controlling infections made by enterococci as well as the appropriate administration of antibiotics could treat the nosocomial infections effectively.

Analysis of Vancomycin-Resistant Enterococci in Hemato-Oncological Patients

Enterococci are important bacterial pathogens, and their significance is even greater in the case of vancomycin-resistant enterococci (VRE). The study analyzed the presence of VRE in the gastrointestinal tract (GIT) of hemato-oncological patients. Active screening using selective agars yielded VRE for phenotypic and genotypic analyses. Isolated strains were identified with MALDI-TOF MS, (Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry) their susceptibility to antibiotics was tested, and resistance genes (vanA, vanB, vanC-1, vanC2-C3) and genes encoding virulence factors (asa1, gelE, cylA, esp, hyl) were detected. Pulsed-field gel electrophoresis was used to assess the relationship of the isolated strains. Over a period of three years, 103 VanA-type VRE were identified in 1405 hemato-oncological patients. The most frequently detected virulence factor was extracellular surface protein (84%), followed by hyaluronidase (40%). Unique restriction profiles were observed in 33% of strains; clonality was detected in 67% of isolates. The study found that 7% of hemato-oncological patients carried VRE in their GIT. In all cases, the species identified was Enterococcus faecium. No clone persisted for the entire 3-year study period. However, genetically different clusters were observed for shorter periods of time, no longer than eight months, with identical VRE spreading among patients.

Linezolid-resistant Enterococcus faecium strains isolated from one hospital in Poland -commensals or hospital-adapted pathogens?

One of the most pressing problems of enterococci infections is occurring resistance to linezolid, which is an antibiotic used in the treatment of infections caused by vancomycin-resistant strains (VRE). The main objective of our research was to investigate the relationship of 19 linezolid-resistant E. faecium isolates from 18 patients hospitalized at Clinical Hospital in Gdansk (Poland). One of the LZDREF was isolated in 2003 (K2003), and another 18 were collected from 2013 to 2017. Genotyping with PCR MP method indicated 14 main unrelated genetic profiles and no association with K2003 strain. Two isolates with the same genotype and genetically closely related two sub-types (2 isolates for each sub-type) were hospital-derived colonizations of patients. The other unrelated genotypes were discussed in the context of colonization, nosocomial infections, and commensal origin, taking into account prior exposure to linezolid. We determined the presence of a point mutation G2576T in six loci of 23S rDNA. There was also a significant correlation (p<0.0015) between the presence of MIC>32 value and the presence of G2576T point mutation on the sixth rrn. We also detected 5 virulence genes for all isolates: gelE, cylA, asa1, hyl, esp. Correlation (p≤0.0001) was observed between the presence of gelE gene encoding gelatinase and two other genes: cylA and asa1 encoding cytolysin and collagen binding protein responsible for aggregation of bacterial cells, respectively. Significant correlation was also observed between asa1 and cfr genes encoding 23S rRNA rybonuclease responsible for resistance to PhLOPSA antibiotics (p = 0.0004). The multidimensional analysis has also shown the correlation between cfr gene and GI-tract (p = 0, 0491), which suggests horizontal gene transfer inside the gut microbiota and the risk of colonization with linezolid-resistant strains without previously being treated with the antibiotic. The patient could have been colonized with LZDRVREF strains which in the absence of competitive microbiota quickly settle in ecological niches favourable for them and pose a risk for the patient.

Antibiotic Resistance and Molecular Epidemiology of Vancomycin-Resistant Enterococci in a Tertiary Care Hospital in Turkey

PURPOSE

Vancomycin-resistant enterococci (VRE) have become a global health threat in the last two decades. In this study, we aimed to determine antibiotic resistance using phenotypic and genotypic methods in VRE strains obtained from inpatients and to investigate clonal relatedness among strains.

METHODS

Identification and antibiotic susceptibility of 47 VRE strains obtained from inpatients at Karabuk University Hospital from 2014 to 2015 were determined using the BD Phoenix™ automated microbiology system. Vancomycin resistance genes (Van A and B) were detected by polymerase chain reaction. Clonal relatedness among the strains was evaluated by pulsed-field gel electrophoresis (PFGE).

RESULTS

All 47 VRE strains obtained from rectal (n=35), blood (n=7), and urine (n=5) samples were confirmed as Enterococcus faecium; they were resistant to ampicillin, gentamicin, vancomycin, and teicoplanin. One E. faecium isolate was intermediately resistant to linezolid. No strain was resistant to quinupristin-dalfopristin or daptomycin. Only vanA was detected among strains. According to the PFGE results, 31 of 47 strains were clonally related with a clustering rate of 66%. No common clone was detected.

CONCLUSION

VRE infections are associated with high mortality, morbidity, and healthcare expenditures. Increasing resistance to last-line drugs, such as linezolid and daptomycin, among VRE strains is a great concern. Therefore, comprehensive measures should be performed to reduce VRE colonization. Although there was no common clone VRE outbreak, polyclonal spread was observed in our hospital. The high clustering rate indicated cross-contamination. Thus, a more effective infection control program should be implemented.

Neonatal sepsis due to glycopeptide resistant Enterococcus faecium from colonized maternal gut- rare case evidence

Background

Vancomycin-resistant enterococcal infections in the neonatal ICU are growing global problems. We report a case of neonatal septicemia by multidrug-resistant vancomycin-resistant Enterococcus faecium (VRE), the source of infection being the mother's gut.

Case presentation

A newborn male child admitted to the neonatal intensive care unit (NICU) was diagnosed to have mild meconium aspiration syndrome, early onset neonatal septicemia, and bacteremia by multidrug and vancomycin-resistant Enterococcus faecium. Screening of gut flora of the baby and the mother were carried out to trace the source of infection. Stool cultures of the mother and the baby yielded Vancomycin-Resistant Enterococcus faecium. All three isolates of Enterococcus faecium had similar antibiogram, harbored the vanA gene and similar pulsed-field gel electrophoresis pattern. Baby responded to the 1 week therapy with oral linezolid suspension 20 mg/kg/day, 1 ml/t.d.s. No VRE was isolated from baby on a repeat stool culture 1 week after the linezolid therapy. He was discharged with the advice for the continuance of linezolid for seven more days.

Conclusion

Isolation of MDR-VRE from the blood culture of the baby and stool specimens of the mother and the baby with the same antibiogram profile and clonal similarities reveals that maternal gut colonization was responsible for neonatal sepsis. Optimal infection control measures and the development of guidelines for monitoring VRE colonization in pregnant women might be useful in reducing the occurrence of neonatal sepsis.

From days to hours: Can MALDI-TOF MS system replace both conventional and molecular typing methods with new cut off level for Vancomycin Resistant Enterococcus faecium

Vancomycin-Resistant E. faecium (VRE) strains from clinical specimens were identified by conventional methods before. Following the phenotype-based identification, all strains were also identified using both BD Phoenix and VITEK MS bioMérieux System. Strains were typed with the Bruker MALDI-TOF MS system, pulsed field gel electrophoresis (PFGE) and 16S rRNA gene sequencing analysis and then the sensitivity compared for each. A cut off value of 850 assigned with Bruker MALDI-TOF MS system was found to give equal sensitivity to that of PFGE. Results obtained were compared with those of molecular typing. The main advantage of MALDI-TOF MS technology over the others was the much shorter analysis time which lasted only a few hours rather than days or a whole week. Also, the Bruker MALDI-TOF MS system was used for typing and compared with the gold standard method and this study is first to report the determined cut off level for typing of VRE strains.

Carbapenem-resistant Gram-negative bacteria associated with catheter-related bloodstream infections in three intensive care units in Egypt

We aimed to identify the carbapenem-resistant Gram-negative bacteria (GNB) causing catheter-related bloodstream infections (CRBSI) in intensive care units (ICU) in a tertiary care Egyptian hospital, to study their resistance mechanisms by phenotypic and genetic tests, and to use ERIC-PCR for assessing their relatedness. The study was conducted over 2 years in three ICUs in a tertiary care hospital in Egypt during 2015-2016. We identified 194 bloodstream infections (BSIs); 130 (67.01%) were caused by GNB, of which 57 were isolated from CRBSI patients (73.84%). Identification of isolates was performed using conventional methods and MALDI-TOF MS. Antimicrobial susceptibility testing (AST) was done by disc diffusion following CLSI guidelines. Phenotypic detection of carbapenemases enzymes activity was by modified Hodge test and the Carba-NP method. Isolates were investigated for the most common carbapenemases encoding genes bla_KPC, bla_NDM, and bla_OXA-48 using multiplex PCR. Molecular typing of carbapenem-resistant isolates was done by ERIC-PCR followed by sequencing of common resistance genes. The overall rate of CRBSI in our study was 3.6 per 1000 central venous catheter (CVC) days. Among 57 Gram-negative CRBSI isolates, Klebsiella pneumoniae (K. pneumoniae) was the most frequently isolated (27/57; 47.4%), of which more than 70% were resistant to Meropenem. Phenotypic tests for carbapenemases showed that 37.9% of isolates were positive by modified Hodge test and 63.8% by Carba-NP detection. Multiplex PCR assay detected the bla_NDM in 28.6% of the isolates and bla_KPC in 26.8%, bla_NDM and bla_KPC were detected together in the same isolate in 5.6%, while bla_OXA-48-like were not detected. ERIC-PCR detected limited genetic relatedness between K. pneumoniae isolates. Elevated resistance rates were observed to all antibiotics including carbapenems among K. pneumoniae isolates causing CRBSI. ERIC-PCR showed that the resistant isolates were mainly polyclonal. Our results call for reinforcement of antimicrobial stewardship and measures to prevent CRBSI.

Molecular Epidemiology of Vancomycin-Resistant Enterococcus faecalis and Enterococcus faecium Isolated from Clinical Specimens in the Northwest of Iran

This study was conducted to investigate the phenotypic and genotypic characteristics of vancomycin-resistant Enterococcus faecalis and Enterococcus faecium. Antibiotic resistance and virulence genes in the aforementioned resistant isolates were studied using the epsilometer (E)-test and polymerase chain reaction (PCR). These isolates were subjected to typing by pulsed-field gel electrophoresis (PFGE). Thirty vancomycin-resistant enterococci (VRE; 18.75%) were isolated from a total of 160 various clinical specimens cultured for any bacterial growth. Of these, 11 (36.7%) isolates were identified as E. faecalis and 19 (63.3%) as E. faecium. Minimum inhibitory concentrations (MICs) of vancomycin, teicoplanin, and three alternative therapeutic options (linezolid, daptomycin, and quinupristin/dalfopristin) were determined using the E-test. Multiplex PCR was done for confirming species, identification of the resistant genotypes, and the detection of the virulence genes. Finally, the clonal relationship of all VRE strains was studied by PFGE. All VRE strains showed vancomycin MIC ≥256 μg/mL, and 27 (90%) isolates carried the vanA gene, whereas none of the isolates carried vanB. The most common resistance antibiotic pattern observed was toward rifampicin (n = 30 [100%]). Among all virulence genes studied, gelE (n = 28 [93.33%]) was found as the most prevalent virulent gene. VRE isolates exhibited 90%, 46.67%, 100%, and 66.67% resistance to teicoplanin, linezolid, quinupristin/dalfopristin, and daptomycin, respectively. Molecular typing demonstrated 16 PFGE types of VRE isolates (A-P). Although vanA was carried by most of the isolates, PFGE displayed small clonal dissemination among VR E. faecium and VR E. faecalis species.

Spread of Vancomycin-Resistant Enterococcus faecium Isolates Despite Validated Infection Control Measures in an Italian Hospital: Antibiotic Resistance and Genotypic Characterization of the Endemic Strain

An alarming increase of vancomycin-resistant Enterococcus faecium (VREfm) isolates was detected in an Italian referral hospital subjected to policies of infection control validated by the Joint Commission International. Analysis of the population structure of 122 consecutive, nonreplicate VREfm isolates collected over an 18-month period identified a single major clone that spread around the whole hospital, rapidly establishing an endemic state. It belonged to sequence type (ST) 17 and showed a highly multidrug-resistant phenotype, being resistant to all antimicrobial classes for the carriage of several resistance determinants. Furthermore, some strains with decreased susceptibility to daptomycin were detected. Eighteen out of the 122 isolates did not group in the major clone. They showed a low spreading potential inside the hospital wards, even if most of them displayed a multidrug-resistant phenotype and belonged to a hospital-adapted lineage. Causes that led to the VREfm endemic state have not been fully elucidated. However, it is conceivable that the increase in systemic antibiotic consumption and the use of selective digestive tract decontamination, including vancomycin in critically ill patients during the period before 2014, may have played a role in the ST17 clone dissemination, but additional traits conferring high fitness in hospital environment cannot be excluded.

Biofilm synthesis and presence of virulence factors among enterococci isolated from patients and water samples

The goal of this study was to compare biofilm synthesis among enterococci recovered from clinical samples (infection or colonization) of patients as well as environmental samples in order to determine possible virulence factors and clonal relationship. During a two-year period, clinical samples (blood, catheter tips, bronchial secretions, wounds, peritoneal fluid, urine) and rectal swabs collected from hospitalized patients as well as environmental water samples were tested for the presence of Enterococcus faecalis and Enterococcus faecium. Antibiotic susceptibility testing was performed by the disc diffusion method and Etest. Strains were tested for the presence of vanA, vanB, esp, ace and asp genes by PCR. Clones were identified by PFGE (SmaI). From infected patients, 48 strains were identified: 24 Enterococcus faecium (10 vanA-positive, 14 vancomycin-susceptible) and 24 Enterococcus faecalis (one vanA-positive, 23 vancomycin-susceptible). Among 143 colonizing isolates, 134 were Enterococcus faecium (58 vanA-positive, 11 vanB-positive, 65 vancomycin-susceptible) and nine Enterococcus faecalis (three vanA-positive, two vanB-positive, four vancomycin-susceptible). Among 167 environmental water samples, 51 Enterococcus faecalis and 19 Enterococcus faecium isolates, all glycopeptide-susceptible, were recovered. In total, 64 strains produced biofilm, whereas 34 were esp-positive, 64 asp-positive and 54 ace-positive. Biofilm production was associated with the presence of esp (P < 0.001) and ace genes (P = 0.021), being higher in infecting (P < 0.001) and water (P 0.005) isolates as compared with colonizing ones. Clones of environmental water-strains were different than the patients' clones. The differences found in the incidence of antibiotic resistance, virulence factors and clones suggest that hospital and water enterococci are of different origin.