Location of antibiotic resistance markers in clinical isolates of Enterococcus faecalis with similar antibiotypes

Non-faecium non-faecalis enterococci: a review of clinical manifestations, virulence factors, and antimicrobial resistance

SUMMARYEnterococci are a diverse group of Gram-positive bacteria that are typically found as commensals in humans, animals, and the environment. Occasionally, they may cause clinically relevant diseases such as endocarditis, septicemia, urinary tract infections, and wound infections. The majority of clinical infections in humans are caused by two species: Enterococcus faecium and Enterococcus faecalis. However, there is an increasing number of clinical infections caused by non-faecium non-faecalis (NFF) enterococci. Although NFF enterococcal species are often overlooked, studies have shown that they may harbor antimicrobial resistance (AMR) genes and virulence factors that are found in E. faecium and E. faecalis. In this review, we present an overview of the NFF enterococci with a particular focus on human clinical manifestations, epidemiology, virulence genes, and AMR genes.

Mechanisms of antibiotic resistance in enterococci

Multidrug-resistant (MDR) enterococci are important nosocomial pathogens and a growing clinical challenge. These organisms have developed resistance to virtually all antimicrobials currently used in clinical practice using a diverse number of genetic strategies. Due to this ability to recruit antibiotic resistance determinants, MDR enterococci display a wide repertoire of antibiotic resistance mechanisms including modification of drug targets, inactivation of therapeutic agents, overexpression of efflux pumps and a sophisticated cell envelope adaptive response that promotes survival in the human host and the nosocomial environment. MDR enterococci are well adapted to survive in the gastrointestinal tract and can become the dominant flora under antibiotic pressure, predisposing the severely ill and immunocompromised patient to invasive infections. A thorough understanding of the mechanisms underlying antibiotic resistance in enterococci is the first step for devising strategies to control the spread of these organisms and potentially establish novel therapeutic approaches.

Unraveling antimicrobial resistance genes and phenotype patterns among Enterococcus faecalis isolated from retail chicken products in Japan

Multidrug-resistant enterococci are considered crucial drivers for the dissemination of antimicrobial resistance determinants within and beyond a genus. These organisms may pass numerous resistance determinants to other harmful pathogens, whose multiple resistances would cause adverse consequences. Therefore, an understanding of the coexistence epidemiology of resistance genes is critical, but such information remains limited. In this study, our first objective was to determine the prevalence of principal resistance phenotypes and genes among Enterococcus faecalis isolated from retail chicken domestic products collected throughout Japan. Subsequent analysis of these data by using an additive Bayesian network (ABN) model revealed the co-appearance patterns of resistance genes and identified the associations between resistance genes and phenotypes. The common phenotypes observed among E. faecalis isolated from the domestic products were the resistances to oxytetracycline (58.4%), dihydrostreptomycin (50.4%), and erythromycin (37.2%), and the gene tet(L) was detected in 46.0% of the isolates. The ABN model identified statistically significant associations between tet(L) and erm(B), tet(L) and ant(6)-Ia, ant(6)-Ia and aph(3’)-IIIa, and aph(3’)-IIIa and erm(B), which indicated that a multiple-resistance profile of tetracycline, erythromycin, streptomycin, and kanamycin is systematic rather than random. Conversely, the presence of tet(O) was only negatively associated with that of erm(B) and tet(M), which suggested that in the presence of tet(O), the aforementioned multiple resistance is unlikely to be observed. Such heterogeneity in linkages among genes that confer the same phenotypic resistance highlights the importance of incorporating genetic information when investigating the risk factors for the spread of resistance. The epidemiological factors that underlie the persistence of systematic multiple-resistance patterns warrant further investigations with appropriate adjustments for ecological and bacteriological factors.

Analysis of the prevalence of tetracycline resistance genes in clinical isolates of Enterococcus faecalis and Enterococcus faecium in a Japanese hospital

Prevalence of seven tetracycline resistance (TC(R)) genes--tet(L), tet(M), tet(K), tet(O), tet(S), tet(T), and tet(U)--which are known to be distributed to gram-positive cocci was analyzed for 224 Enterococcus faecalis and 46 Enterococcus faecium clinical isolates obtained in a Japanese hospital. Any of the TC(R) genes was detected in 75.9% of all the enterococcal strains. The tet(M) was detected at highest rates in both E. faecalis (75.0%) and E. faecium (69.6%), followed by tet(L), which was harbored in 6.7% of E. faecalis isolates and 30.4% of E. faecium isolates. The tet(O), tet(S), and tet(T) were detected in E. faecalis at low frequencies mostly associated with tet(M), while tet(K) and tet(U) were not detected. Nucleotide sequences of tet(S) from E. faecalis strains were identical to that reported in Listeria monocytogenes. Sequences of tet(O) from two E. faecalis strains were almost identical to each other and also to those from Streptococcus pneumoniae, Streptococcus pyogenes, Streptococcus mutans, Campylobacter jejuni, and Campylobacter coli, although minor sequence divergence was observed. The tet(T), which had been reported only in Streptococcus pyogenes, was found in five E. faecalis strains. Sequence of the enterococcal tet(T) differed from that of S. pyogenes by only four nucleotides (four amino acids) and showed high sequence identity (99.8%, amino acid level). Enterococcal strains with any one TC(R) gene or those with two TC(R) genes showed generally similar MICs of tetracyclines, and no evident difference in resistance level was observed.

Multiple-antibiotic resistance of Enterococcus spp. isolated from commercial poultry production environments

The potential impact of food animals in the production environment on the bacterial population as a result of antimicrobial drug use for growth enhancement continues to be a cause for concern. Enterococci from 82 farms within a poultry production region on the eastern seaboard were isolated to establish a baseline of susceptibility profiles for a number of antimicrobials used in production as well as clinical environments. Of the 541 isolates recovered, Enterococcus faecalis (53%) and E. faecium (31%) were the predominant species, while multiresistant antimicrobial phenotypes were observed among all species. The prevalence of resistance among isolates of E. faecalis was comparatively higher among lincosamide, macrolide, and tetracycline antimicrobials, while isolates of E. faecium were observed to be more frequently resistant to fluoroquinolones and penicillins. Notably, 63% of the E. faecium isolates were resistant to the streptogramin quinupristin-dalfopristin, while high-level gentamicin resistance was observed only among the E. faecalis population, of which 7% of the isolates were resistant. The primary observations are that enterococci can be frequently isolated from the poultry production environment and can be multiresistant to antimicrobials used in human medicine. The high frequency with which resistant enterococci are isolated from this environment suggests that these organisms might be useful as sentinels to monitor the development of resistance resulting from the usage of antimicrobial agents in animal production.

Distribution of theerm(B) Gene,tetracycline Resistance Genes, and Tn1545-like Transposons in Macrolide- and Lincosamide-Resistant Enterococci from Pigs and Humans

The distribution of the erm (B) and the tetracycline resistance genes tet(K), tet(L), tet(M), tet(O), and tet(S) was investigated among macrolide- and lincosamide-resistant enterococci originating from humans, pigs, and pork carcasses. The presence of transposons of the Tn916/Tn1545 family was also traced in these isolates. Furthermore, the porcine strains were tested for the presence of glycopeptide resistance genes vanA and vanB. The erm(B) gene was found in 85% of the porcine and in all human isolates. Ninety-eight percent of the porcine and 89% of the human erm(B)-positive enterococci carried the tet(M) gene. Seventy-seven percent and 70%, respectively, of these strains harbored a Tn1545-like element. Tet(L) was observed in 68% of the porcine and in 65% of the human enterococci. The other tetracycline resistance genes were very rare and the glycopeptide resistance genes vanA and vanB were not detected among the porcine isolates. The similar frequencies of resistance genes and the highly mobile Tn1545-like transposon among porcine and human enterococci might indicate exchange of resistant strains or their resistance genes between humans and pigs or the existence of a common reservoir.

Occurrence and spread of antibiotic resistances in Enterococcus faecium

Enterococci are the second to third most important bacterial genus in hospital infections. Especially Enterococcus (E.) faecium possesses a broad spectrum of natural and acquired antibiotic resistances which are presented in detail in this paper. From medical point of view, the transferable resistances to glycopeptides (e.g., vancomycin, VAN, or teicoplanin, TPL) and streptogramins (e.g., quinupristin/dalfopristin, Q/D) in enterococci are of special interest. The VanA type of enterococcal glycopeptide resistance is the most important one (VAN-r, TPL-r); its main reservoir is E. faecium. Glycopeptide-resistant E. faecium (GREF) can be found in hospitals and outside of them, namely in European commercial animal husbandry in which the glycopeptide avoparcin (AVO) was used as growth promoter in the past. There are identical types of the vanA gene clusters in enterococci from different ecological origins (faecal samples of animals, animal feed, patients in hospitals, persons in the community, waste water samples). Obviously, across the food chain (by GREF-contaminated meat products), these multiple-resistant bacteria or their vanA gene clusters can reach humans. In hospital infections, widespread epidemic-virulent E. faecium isolates of the same clone with or without glycopeptide resistance can occur; these strains often harbour different plasmids and the esp gene. This indicates that hospital-adapted epidemic-virulent E. faecium strains have picked up the vanA gene cluster after they were already widely spread. The streptogramin virginiamycin was also used as feed additive in commercial animal husbandry in Europe for more than 20 years, and it created reservoirs for streptogramin-resistant E. faecium (SREF). In 1998/1999, SREF could be isolated in Germany from waste water of sewage treatment plants, from faecal samples and meat products of animals that were fed virginiamycin (cross resistance to Q/D), from stools of humans in the community, and from clinical samples. These isolations of SREF occurred in a time before the streptogramin combination Q/D was introduced for therapeutic purposes in German hospitals in May 2000, while other streptogramins were not used in German clinics. This seems to indicate that the origin of these SREF or their streptogramin resistance gene(s) originated from other sources outside the hospitals, probably from commercial animal husbandry. In order to prevent the dissemination of multiple antibiotic-resistant enterococci or their transferable resistance genes, a prudent use of antibiotics is necessary in human and veterinary medicine, and in animal husbandry.

Comparison of antimicrobial resistance phenotypes and resistance genes in Enterococcus faecalis and Enterococcus faecium from humans in the community, broilers, and pigs in Denmark

Enterococcus faecalis and E. faecium isolated from humans in the community (98 and 65 isolates), broilers (126 and 122), and pigs (102 and 88) during 1998 were tested for susceptibility to 12 different antimicrobial agents and for the presence of selected genes encoding resistance using PCR. Furthermore, the presence of vancomycin resistant enterococci was examined in 38 human stool samples using selective enrichment. Widespread resistance to chloramphenicol, macrolides, kanamycin, streptomycin, and tetracycline was found among isolates from all three sources. All E. faecium isolates from humans and pigs were susceptible to avilamycin, whereas 35% of isolates from broilers were resistant. All E. faecium isolates from humans were susceptible to vancomycin, whereas 10% and 17% of isolates from broilers and pigs, respectively, were resistant. A vancomycin resistant E. faecium isolate was found in one of the 38 human fecal samples examined using selective enrichment. All vancomycin resistant isolates contained the vanA gene, all chloramphenicol resistant isolates the cat(pIP501) gene, and all five gentamicin resistant isolates the aac6-aph2 gene. Sixty-one (85%) of 72 erythromycin resistant E. faecalis examined and 57 (90%) of 63 erythromycin resistant E. faecium isolates examined contained ermB. Forty (91%) of the kanamycin resistant E. faecalis and 18 (72%) of the kanamycin resistant E. faecium isolates contained aphA3. The tet(M) gene was found in 95% of the tetracycline resistant E. faecalis and E. faecium isolates of human and animal origin, examined. tet(K) was not observed, whereas tet(L) was detected in 17% of tetracycline resistant E. faecalis isolates and in 16% of the E. faecium isolates. tet(O) was not detected in any of the isolates from pigs, but was observed in 38% of E. faecalis isolates from broilers, in two E. faecalis isolates from humans and in three E. faecium isolates from broilers. tet(S) was not detected among isolates from animals, but was observed in 31% of E. faecalis and one E. faecium isolate from humans. This study showed a frequent occurrence of antimicrobial resistance and the presence of selected resistance genes in E. faecalis and E. faecium isolated from humans, broilers and pigs. Differences in the occurrence of resistance and tetracycline resistance genes were observed among isolates from the different sources. However, similar resistance patterns and resistance genes were detected frequently indicating that transmission of resistant enterococci or resistance genes takes place between humans, broilers, and pigs.

Plasmid-borne high-level resistance to gentamicin in Enterococcus hirae, Enterococcus avium, and Enterococcus raffinosus

Enterococcus hirae, E. avium, and E. raffinosus isolated in Romania, Tunisia, and Portugal harbored plasmids pICC8, pIP1700, and pIP1701, respectively, encoding resistance to high levels of gentamicin (Gmr). The Gmr marker was carried on pIP1700 by a Tn4001-like element and on pICC8 and pIP1701 by Tn4001-truncated structures. pICC8 carried, in addition to Gmr, chloramphenicol, erythromycin, and tetracycline-minocycline (TetM) resistance determinants. The gene tetM of pICC8 was carried on a Tn916-like element.

Heterogeneric conjugal transfer of the pheromone-responsive plasmid pIP964 (IncHlyI) of Enterococcus faecalis in the apparent absence of pheromone induction

Erythromycin-resistant derivatives of the pheromone-responsive plasmid pIP964 from Enterococcus faecalis were constructed to study its host range. This was done by inserting the integrative vector pAT112 and the related replicon pTCR1 harboring oriR of the broad host range plasmid pAM beta 1 into the hemolysin-bacteriocin operon of pIP964, to give pTCR2 and pTCR3, respectively. Plasmid pTCR2 was transferred by filter matings from E. faecalis to Enterococcus faecium and Listeria monocytogenes at frequencies of 2 x 10(-7) and 5 x 10(-7) per donor, respectively, in the apparent absence of pheromone induction and cellular aggregation. In these hosts, pTCR2 remained intact as a self-replicating element and maintained its transfer capabilities. Plasmid pTCR3, but not pTCR2, was transferred at similar frequencies from E. faecalis to Lactococcus lactis and Streptococcus agalactiae. Thus, the transfer system of pIP964 possesses a broader host-range than its replication system.

The sex pheromone system of Enterococcus faecalis. More than just a plasmid-collection mechanism?

The sex pheromone system of Enterococcus faecalis was discovered by observing a clumping reaction of E. faecalis strains during conjugative transfer of plasmids. It was found that only a special type of E. faecalis plasmids, the so-called sex pheromone plasmids, are transferred via this mechanism. Various experiments, especially by the group of D. B. Clewell, led to the formulation of a model describing how the sex pheromone system works. Small linear peptides, the so-called sex pheromones, are excreted by strains not possessing the corresponding sex pheromone plasmid. Donor strains harboring the plasmid do not produce the corresponding sex pheromone; they react to the presence of the peptide by production of a plasmid-encoded adhesin, the so-called aggregation substance. This adhesin allows contact between the non-motile mating partners; after conjugative transfer of the plasmid, the former recipient possesses and replicates the new plasmid. Thereby the population of E. faecalis strains is shifted to a high percentage of donor strains. This is especially true because a donor strain will still excrete sex pheromones corresponding to plasmids it does not harbor; therefore, such a strain can also function as recipient for other sex pheromone plasmids it does not possess. Various aspects of this unique plasmid collection mechanism have been studied during the last few years. The data indicate that, with the exception of pAM373, all sex pheromone plasmids possess one DNA region which is highly similar to and codes for the adhesin. It is also becoming more and more clear that regulatory functions/proteins are not conserved between different sex pheromone plasmids. Induction of adhesin synthesis needs the action of a regulatory cascade composed of unique features; at the moment we are just beginning to understand this cascade. By sequencing the first structural gene for one of those adhesins, we realized that the aggregation substance might act also as an adhesin for eucaryotic cells, probably by interaction with integrins. At least in the case of the in vitro cultured pig kidney tubulus cell line LLC-PK1 this idea could be verified. An interesting aspect of the sex pheromone system of E. faecalis is its evolution. I will discuss the idea that two different components, both of which well might contribute to virulence of the opportunistic pathogenic bacterium, were combined in the species E. faecalis to result in this unique plasmid collection system.

Study of heterogeneity of chloramphenicol acetyltransferase (CAT) genes in streptococci and enterococci by polymerase chain reaction: characterization of a new CAT determinant

An assay based on the utilization of degenerate primers that enable enzymatic amplification of an internal fragment of cat genes known to be present in gram-positive cocci was developed to identify the genes encoding chloramphenicol resistance in streptococci and enterococci. The functionality of this system was illustrated by the detection of cat genes belonging to four different hydridization classes represented by the staphylococcal genes catpC221, catpC194, catpSCS7, and the clostridial gene catP, and by the characterization of a new streptococcal cat gene designated catS. A sequence related to the clostridial catQ gene, which was present in one streptococcal strain, was not detected by this assay. These results reveal that these six cat genes account for chromosomal-borne chloramphenicol resistance in 12 group A, B, and G streptococci tested. By contrast, only three of these six cat genes (catpC221, catpC194, and catpSCS7) were detected on the 10 enterococcal plasmids studied here that encode resistance to chloramphenicol.

Identification of new sex pheromone plasmids in Enterococcus faecalis

We describe the identification of the following new sex pheromone plasmids in Enterococcus faecalis: a haemolysin-bacteriocin plasmid, pIP964; three R plasmids, pIP1017, pIP1438 and pIP1440; and two cryptic conjugative plasmids, pIP1141 and pMV120. The identification was based on the formation of cell aggregates on filter membranes during conjugation, on efficient transfer in broth matings, and on a positive clumping reaction of cells carrying these plasmids. In addition these plasmids hybridized with DNA probes specific for sex pheromone-induced structural genes encoding surface proteins required for conjugative transfer of the plasmids.

A truncated Tn916-like element in a clinical isolate of Enterococcus faecium

A 58.7-kb nonconjugative plasmid (pKQ1) previously reported in a clinical isolate of Enterococcus faecium was found to contain both a tetM and an erythromycin resistance (erm) determinant. The plasmid contained a region homologous to the A, F, H, and G HincII fragments of Tn916. However, the 4.8-kb B fragment of Tn916 which contained the tetM determinant was replaced by a 7.3-kb fragment, and the 3.6-kb HincII C fragment of Tn916 was missing. An element homologous to Tn917 was juxtaposed to the truncated Tn916-like element. The Tn917-like element was similar in size to the erm transposon Tn917 as determined by a ClaI restriction digest which spanned approximately 99% of the transposon. When Bacillus subtilis or Streptococcus sanguis were transformed with pKQ1, no zygotically induced transposition of the tetM element was detected. Similarly no transposition of the Tn917-like element was detected.

Natural occurrence of structures in oral streptococci and enterococci with DNA homology to Tn916

Seventeen oral streptococci and 18 enterococci were tested for the presence of DNA sequences homologous to the conjugative transposon Tn916 encoding tetracycline resistance. All the strains were resistant to tetracyclines, including minocycline, and most of them were resistant to other antibiotics. Tn916-like structures, identified by hybridization of HincII-digested DNA, were found on the chromosomes of 11 oral streptococci and four enterococci and on two plasmids, pIP1549 and pIP1440, one harbored by an Enterococcus hirae strain and the other harbored by an Enterococcus faecalis strain. Sequences homologous to Tn916, only some of which corresponded to its internal HincII structure (Tn916-modified elements), were chromosomally located in three oral streptococci and two enterococci and were plasmid borne in pIP614 harbored by an E. faecalis strain. Nine enterococci and three oral streptococci carried either the Tet M or the Tet O determinant chromosomally, but they carried no other sequences homologous to Tn916.

Tetracycline resistance heterogeneity in Enterococcus faecium

The tetracycline (Tet) determinants, which encode resistance either to tetracyclines without minocycline (Tcr) or to tetracyclines including minocycline (Tcr-Mnr), of 30 wild-type clinical isolates of Enterococcus faecium were identified and localized. The Tet determinants were transferred by conjugation into a plasmid-free Enterococcus faecalis recipient at frequencies of 10(-6) to 10(-9) transconjugants per donor, as follows: Tcr, 6 strains; Tcr-Mnr, 14 strains; both Tcr and Tcr-Mnr, 6 strains; no detectable transfer, 4 strains. Classes L (Tcr phenotype) and M and O (Tcr-Mnr phenotype) of the Tet determinants were identified by DNA-DNA hybridization experiments. The Tet L determinant was plasmid-borne in 18 strains and was chromosomal in 2 strains. Tet M was chromosomal in 27 strains and plasmid-borne (pIP1534) in 1 strain; pIP1534 also carried Tet L. Tet M was located on Tn916-like elements in 22 strains and on a Tn916-modified element in 1 strain. Tet O was detected in only one strain in which it was plasmid-borne. Both Tet L and Tet M determinants were carried by 19 strains. One strain carried, in addition to chromosomal nonconjugative Tet L and Tet M determinants, a conjugative Tcr-Mnr marker which did not correspond to any Tet determinant tested in this study. These results attest to the genetic complexity of tetracycline resistance in E. faecium strains.

Identification of chromosomal antibiotic resistance genes in Streptococcus anginosus ("S. milleri")

Determinants encoding resistance to antibiotics, except penicillin, of 5 of 21 Streptococcus anginosus clinical isolates that we examined transferred by conjugation into Enterococcus faecalis and into 1 to 5 streptococcal recipients at frequencies of 10(-6) to 10(-8) transconjugants per donor. No R plasmids were detected in any wild-type strain. DNA homology was detected between chromosomal fragments and the following genes: aadE in 7 strains that were highly resistant to streptomycin, aph-3 in 8 strains that were highly resistant to kanamycin, ermB in 11 of 15 strains that were resistant to erythromycin, and tetM in 14 and tetO in 3 of the 18 strains that were resistant to tetracycline-minocycline. A Tn916-like structure was found in 10 of the 14 strains that carried the tetM gene.

Does a tetracycline resistance determinant of class N exist?

pMV120 was reported to carry the tetracycline resistance (Tcr) determinant of class N. We obtained tetracycline-susceptible transconjugants harboring plasmids with restriction enzyme profiles indistinguishable from those of pMV120 isolated from tetracycline-resistant clones. We conclude that pMV120 is a cryptic plasmid and that class N of Tcr determinants does not exist.

High-level chromosomal gentamicin resistance in Streptococcus agalactiae (group B)

This is the first report of high-level gentamicin resistance in a group B streptococcus. Strain B128 of serotype II was isolated from an infected leg wound in 1987. B128 was resistant to high levels of gentamicin as well as of all other available aminoglycosides and was also resistant to tetracyclines. No bactericidal synergism was found between ampicillin or vancomycin and any of these aminoglycosides. Gentamicin, kanamycin, streptomycin, and tetracycline resistance determinants transferred by conjugation into a plasmid-free group B streptococcus recipient at a frequency of 10(-8) to 10(-9) transconjugants per donor cell. No transconjugants were detected when streptococci of groups A, C, and G, Streptococcus sanguis, or Enterococcus faecalis was used as a recipient. No plasmids were detected in B128 or in any of the four transconjugants tested. By DNA-DNA hybridization, homology was detected between gene aac6/aph2, of E. faecalis origin, and a 2.4-kilobase HindIII chromosomal fragment of B128; homology to the genes aph3 and aadE, of E. faecalis origin, was found with HindIII chromosomal fragments of the same size (3.0 kilobases). Strains like B128, which potentially can be responsible for severe neonatal infections, are of great clinical concern, since there are to date no antibiotic combinations exhibiting bactericidal synergism against them.

Presence of chromosomal elements resembling the composite structure Tn3701 in streptococci

Tn3701, carried by Streptococcus pyogenes A454, is the first chromosomal composite element to be described; it contains in its central region Tn3703, a transposon similar to Tn916. A comparison by DNA-DNA hybridization of Tn3701 with omega(cat-tet) and Tn3951, carried by Streptococcus pneumoniae BM6001 and by Streptococcus agalactiae B109, respectively, revealed that the two latter structures are also Tn3701-like composite elements. The DNAs of 27 other antibiotic-resistant group A, B, C, and G streptococci and of S. pneumoniae BM4200 showed sequence homologies to Tn3701 (14 strains, including BM4200), to the regions of Tn3701 outside of Tn3703 (5 strains), and to Tn916 alone (8 strains). The DNAs of five strains did not detectably hybridize with any probe. The tetM gene was identified in most chromosomal genetic elements coding for tetracycline-minocycline resistance. Since Tn3701-like elements are widely disseminated among antibiotic-resistant streptococci (47% of the 34 strains studied), we propose that Tn3701 be considered the prototype of chromosomal composite elements.

Susceptibility of enterococci and epidemiology of enterococcal infection in the 1980s

Enterococcisensu strictoform part of the normal gut flora (1) and may be found in the mouth, vagina and anterior urethra (2). They are opportunist pathogens which can cause serious infection including endocarditis. Nosocomial enterococcal infection appears to be increasing both in the UK (Public Health Laboratory Service [PHLS] Communicable Disease Surveillance Centre [CDSC], unpublished) and the USA (3) and to correspond to usage of broad spectrum β-lactam antimicrobial agents (4−7) and invasive surgical devices (8, 9). At the same time, the incidence of enterococci resistant or tolerant to previously commonly employed antimicrobial agents or their synergistic combinations is increasing and is compromising therapy of serious enterococcal infection. Strains of enterococci with high-level resistance to streptomycin and kanamycin (minimal inhibitory concentrations [MICs] > 2000 mg/L) were first reported in 1970 (10, 11) and rapidly became widespread (8, 12−14).

Genetic basis of antibiotic resistance in Aerococcus viridans

Resistance to at least one of the following antibiotics was found in eight wild-type strains of Aerococcus viridans: erythromycin (six strains), tetracycline and minocycline (five strains), chloramphenicol (one strain), and high levels of streptomycin (one strain). None of the strains transferred any of their antibiotic resistance markers into streptococcal, enterococcal, or A. viridans recipients by conjugation. By DNA-DNA hybridization experiments, the ermB gene of transposon Tn917, of Enterococcus faecalis origin, was detected in five of the six strains resistant to erythromycin and was localized for one strain on the chromosome and for four strains on nonconjugative small (4.7- to 4.9-kilobase) plasmids. The tetM gene of the conjugative transposon Tn916, of E. faecalis origin, was localized on the chromosome of four of the five strains resistant to tetracycline and minocycline; in three of these strains a structure similar to that of Tn916 was found. Homology to the tetO gene of pUA466, of Campylobacter jejuni origin, was detected on the chromosome of the fifth strain. No sequence homology was detected in any strain with probes corresponding to the tetL gene of group B Streptococcus origin, to the ermA gene of the transposon Tn554 of Staphylococcus aureus origin, or to the cat genes of either pC194 or pC221 of S. aureus origin.

High-level resistance to gentamicin in clinical isolates of Streptococcus (Enterococcus) faecium

During a 14-month period beginning in July 1986, three distinct clinical isolates of Streptococcus (Enterococcus) faecium demonstrating high-level resistance (MIC, greater than 2,000 micrograms/ml) to gentamicin, kanamycin, tobramycin, and streptomycin were recovered from individual patients at one institution. Combinations of ampicillin with any of these agents failed to show bactericidal synergism. By filter-mating techniques, high-level gentamicin resistance could be transferred into a susceptible recipient of the same species at frequencies as high as 1 x 10(-4); transfer into Streptococcus faecalis JH2-7 occurred at lower frequencies (less than 2 x 10(-7). Aminoglycoside substrate profile analysis of clinical isolates as well as of laboratory-derived cured strains and transconjugants revealed 2"-aminoglycoside phosphotransferase and 3'-aminoglycoside phosphotransferase (III) phosphorylating enzymes, AAC-6' acetylating activity above that attributable to the intrinsic activity characteristic of S. faecium, and a streptomycin adenylylating enzyme. All three isolates carried a 51-megadalton plasmid. Curing of this plasmid or conjugative transfer into susceptible recipients was associated with the loss or acquisition of high-level gentamicin resistance, respectively. Loss of high-level gentamicin resistance was also observed when curing techniques resulted in a decrease in the size of this plasmid equivalent to a 10-megadalton deletion. Transferable, high-level resistance to gentamicin and other aminoglycosides, which was previously recognized in S. faecalis, has now emerged in clinical isolates of S. faecium, with the attendant concerns for possible spread.