Activity of glycopeptides against vancomycin-resistant gram-positive bacteria

Pediococcus pentosaceus Endocarditis in a Patient With Recent Transcatheter Aortic Valve Implantation and Liver Cirrhosis: A Case Report and Review of the Literature

Transcatheter aortic valve implantation (TAVI) is increasingly being used in the management of severe aortic stenosis, mainly in older and/or medically compromised patients, due to its minimally invasive nature. As in any valve replacement procedure, endocarditis is a recognized complication, more so in TAVI patients, in whom comorbidities are highly prevalent. We report the case of a 70-year-old male with a history of liver cirrhosis and a recent TAVI, who presented with recurrent fever and sustainedPediococcus pentosaceus bacteremia. The diagnosis of endocarditis was delayed, as the microorganism was initially discarded as a contaminant, given that Pediococci are rarely described as human pathogens. However, in cirrhotic patients, microbiota may cause intermittent bacteremia and thereby affect prosthetic valves. Transthoracic echocardiography was not helpful in validating the diagnosis, as is often the case in TAVI patients. Transesophageal echocardiography was deemed perilous, due to esophageal varices complicating the underlying cirrhosis. Therefore, endocarditis diagnosis was based on sustained bacteremia and Duke's criteria, including the presence of high fever, a predisposing cardiac lesion, splenic infarction, and the exclusion of an alternative diagnosis. Moreover, cirrhosis enhanced the side effects of treatment and led to the need for regimen changes and prolonged hospitalization. Given the precariousness of the situation, confirmation of treatment success by 2-deoxy-2-[fluorine-18]fluoro-D-glucose positron emission tomography-computed tomography (18F-FDG PET-CT) scan was sought. This is the first reported case of Pediococcus TAVI endocarditis in a cirrhotic patient, highlighting the unique challenges in the diagnosis and management of TAVI endocarditis in patients with co-existing conditions.

Genome analysis of probiotic bacteria for antibiotic resistance genes

To date, probiotic bacteria are used in the diet and have various clinical applications. There are reports of antibiotic resistance genes in these bacteria that can transfer to other commensal and pathogenic bacteria. The aim of this study was to use whole-genome sequence analysis to identify antibiotic resistance genes in a group of bacterial with probiotic properties. Also, this study followed existing issues about the importance and presence of antibiotic resistance genes in these bacteria and the dangers that may affect human health in the future. In the current study, a collection of 126 complete probiotic bacterial genomes was analyzed for antibiotic resistance genes. The results of the current study showed that there are various resistance genes in these bacteria that some of them are transferable to other bacteria. The tet(W) tetracycline resistance gene was more than other antibiotic resistance genes in these bacteria and this gene was found in Bifidobacterium and Lactobacillus. In our study, the most numbers of antibiotic resistance genes were transferred with mobile genetic elements. We propose that probiotic companies before the use of a micro-organism as a probiotic, perform an antibiotic susceptibility testing for a large number of antibiotics. Also, they perform analysis of complete genome sequence for prediction of antibiotic resistance genes.

Antibiotic susceptibility of Lactobacillus plantarum strains, isolated from katak

Several Lactobacillus species are accepted as microorganisms with Qualified Presumption of Safety (QPS) in the EFSA’s list. One of them, Lactobacillus plantarum is a widely distributed species with a proven probiotic potential and technological relevance. In addition, every strain must complete several requirements, before implementation. Antibiotic susceptibility is one of EFSA’s important criteria regarding the safety of probiotics. The reason is to avoid any possibility of antibiotic resistance genes transfer to opportunistic pathogens in the gut. In the present study 14 Lactobacillus plantarum strains were assessed for susceptibility to 21 antibiotics from different groups. A high number of resistant strains was determined toward 12 antibiotics (penicillins – penicillin, piperacillin; IIIth generation cephalosporins – cefotaxime, ceftriaxone, ceftazidime; glycopeptides – vancomycin; tetracyclines – tetracycline; aminoglycosides – gentamicin; macrolides – clarithromycin; quinolones – nalidixic acid, ciprofloxacin, levofloxacin). Concerning the other tested antibiotics, strain-specific antibiotic-sensitivity patterns were observed. Antibiotic resistance was also discussed as an advantage in the selection of probiotic strains, however only when it is not transferable. Estimated susceptibility patterns of some of tested candidate probiotic strains are also important, considering the use of the latter as agents accompanying antibiotic therapy

Mechanisms of gram-positive vancomycin resistance (Review)

Vancomycin-resistant bacteria (VRB) are important consideration in medicine and public health as they can cause life-threatening infections that appear to be resistant to therapy and persist in the body after medication. A wide spectrum of antimicrobial resistance characteristics, as well as various environmental and animal settings underlie the evolution of the most prevalent the most prevalent van genes in the VRB genome, indicating significant gene flow. As illnesses caused by VRB have become increasingly complex, several previously effective therapeutic techniques have become ineffective, complicating clinical care further. The focus of this review is the mechanism of vancomycin resistance in Enterococci, Staphylococci and Lactobacilli.

Genotypic and phenotypic characterization of food-associated Lactobacillus plantarum isolates for potential probiotic activities

Lactic acid bacterium, Lactobacillus plantarum, has been applied, for centuries, for food and drink fermentations. Given the benefits associated with fermented products, Lb. plantarum strains have captured considerable industrial and scientific interest, so that they are included as fundamental components of functional foods. Indeed, some strains are marketed as probiotics. In the present study, food- and gut-associated Lb. plantarum isolates were genetically characterized by multilocus sequence typing (MLST) and phenotypically characterized for properties that could influence their probiotic potential. MLST and phylogenetic analysis stratified 22 Lb. plantarum isolates into six lineages. The isolates were further phenotypically characterized by an in vitro assay to assess their potential gut community influence via a limited number of assays including acidification activity, strain displacement activity and their intrinsic range of antibiotic resistance. Given growing recognition of the benefits of fermented foods, and the prevalence of Lb. plantarum in these applications, this study highlights analysis of a subset of preliminary important strain-specific features. These features are of interest to all stakeholders, to inform isolate comparison and selection for current functional food associations, and that can serve as a basis for future strain and food-microbe fermentation product development.

Bioprospecting of probiotics with antimicrobial activities against Salmonella Heidelberg and that produce B-complex vitamins as potential supplements in poultry nutrition

The demand for animal protein for human consumption has been risen exponentially. Modern animal production practices are associated with the regular use of antibiotics, potentially increasing the emerging multi-resistant bacteria, which may have a negative impact on public health. In poultry production, substances capable of maximizing the animals’ performance and displaying an antimicrobial activity against pathogens are very well desirable features. Probiotic can be an efficient solution for such a task. In the present work, lactic acid bacteria (LAB) were isolated from chicken cecum and screened for their antagonistic effect towards many pathogens. Their capacity of producing the B-complex vitamins folate and riboflavin were also evaluated. From 314 isolates, three (C43, C175 and C195) produced Bacteriocin-Like Inhibitory Substances (BLIS) against Staphylococcus aureus (inhibition zones of 18.9, 21.5, 19.5 mm, respectively) and also inhibited the growth of Salmonella Heidelberg. The isolate C43 was identified as Enterococcus faecium, while C173 and C195 were both identified as Lactococcus lactis subsp. lactis. Moreover, the isolates L. lactis subsp. lactis strains C173 and C195 demonstrated high potential to be used as probiotic in poultry feed, in addition to their advantage of producing folate (58.0 and 595.5 ng/mL, respectively) and riboflavin (223.3 and 175.0 ng/mL, respectively).

Bacteria in the apical root canals of teeth with apical periodontitis

BACKGROUND/PURPOSE

Bacteria in the tooth root canal may cause apical periodontitis. This study examined the bacterial species present in the apical root canal of teeth with apical periodontitis. Antibiotic sensitivity tests were performed to evaluate whether these identified bacterial species were susceptible to specific kinds of antibiotics.

METHODS

Selective media plating and biochemical tests were used first to detect the bacterial species in samples taken from the apical portion of root canals of 62 teeth with apical periodontitis. The isolated bacterial species were further confirmed by matrix-assisted laser desorption ionization-time of flight mass spectrometry.

RESULTS

We found concomitant presence of two (32 teeth) or three species (18 teeth) of bacteria in 50 (80.6%) out of 62 tested teeth. However, only 34 bacterial species were identified. Of a total of 118 bacterial isolates (83 anaerobes and 35 aerobes), Prophyromonas endodontalis was detected in 10; Bacteroides, Dialister invisus or Fusobacterium nucleatum in 9; Treponema denticola or Enterococcus faecalis in 8; Peptostreptococcus or Olsenella uli in 6; and Veillonella in 5 teeth. The other 25 bacterial species were detected in fewer than five teeth. Approximately 80-95% of bacterial isolates of anaerobes were sensitive to ampicillin/sulbactam (Unasyn), amoxicillin/clavulanate (Augmentin), cefoxitin, and clindamycin. For E. faecalis, 85-90% of bacterial isolates were sensitive to gentamicin and linezolid.

CONCLUSION

Root canal infections are usually caused by a mixture of two or three species of bacteria. Specific kinds of antibiotic can be selected to control these bacterial infections after antibiotic sensitivity testing.

Should We Vigorously Try to Contain and Control Methicillin-Resistant Staphylococcus aureus?

Objective:

To review practices currently used to control transmission of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals, determine the frequency of their use, and discuss the indications for implementing such measures.

Design:

A questionnaire survey to determine how commonly selected control practices are used, and a literature review of the efficacy of control practices.

Participants:

Two hundred fifty-six of 360 hospital-based members fo the Society for Hospital Epidemiology of America, Inc. (SHEA) completed the survey questionnaire.

Result:

Many different combinations of surveillance and control measures are used by hospitals with MRSA. Nine percent of hospitals stated that no special measures were used to control MRSA. The efficacy of commonly used control measures has not been established by controlled trials.

Conclusions:

Implementing control measures is warranted when MRSA causes a high incidence of serious nosocomial infections, and is desirable when MRSA has been newly introduced into a hospital or into an intensive care unit, or when MRSA accounts for more than 10% of nosocomial staphylococcal isolates. While the value of some practices is well established, measures such as routinely attempting to eradicate carriage of MRSA by colonized patients and personnel require further evaluation.

Renaissance of antibiotics against difficult infections: Focus on oritavancin and new ketolides and quinolones

Lipoglycopeptide, ketolide, and quinolone antibiotics are currently in clinical development, with specific advantages over available molecules within their respective classes. The lipoglycopeptide oritavancin is bactericidal against MRSA, vancomycin-resistant enterococci, and multiresistant Streptococcus pneumoniae, and proved effective and safe for the treatment of acute bacterial skin and skin structure infection (ABSSSI) upon administration of a single 1200 mg dose (two completed phase III trials). The ketolide solithromycin (two phase III studies recruiting for community-acquired pneumonia) shows a profile of activity similar to that of telithromycin, but in vitro data suggest a lower risk of hepatotoxicity, visual disturbance, and aggravation of myasthenia gravis due to reduced affinity for nicotinic receptors. Among quinolones, finafloxacin and delafloxacin share the unique property of an improved activity in acidic environments (found in many infection sites). Finafloxacin (phase II completed; activity profile similar to that of ciprofloxacin) is evaluated for complicated urinary tract and Helicobacter pylori infections. The other quinolones (directed towards Gram-positive pathogens) show improved activity on MRSA and multiresistant S. pneumoniae compared to current molecules. They are in clinical evaluation for ABSSSI (avarofloxacin (phase II completed), nemonoxacin and delafloxacin (ongoing phase III)), respiratory tract infections (zabofloxacin and nemonoxacin (ongoing phase III)), or gonorrhea (delafloxacin).

Vancomycin resistance VanS/VanR two-component systems

Vancomycin is a member of the glycopeptide class of antibiotics. Vancomycin resistance (van) gene clusters are found in human pathogens such as Enterococcus faecalis, Enterococcus faecium and Staphylococcus aureus, glycopeptide-producing actinomycetes such as Amycolotopsis orientalis, Actinoplanes teichomyceticus and Streptomyces toyocaensis and the nonglycopeptide producing actinomycete Streptomyces coelicolor. Expression of the van genes is activated by the VanS/VanR two-component system in response to extracellular glycopeptide antibiotic. Two major types of inducible vancomycin resistance are found in pathogenic bacteria; VanA strains are resistant to vancomycin itself and also to the lipidated glycopeptide teicoplanin, while VanB strains are resistant to vancomycin but sensitive to teicoplanin. Here we discuss the enzymes the van genes encode, the range of different VanS/VanR two-component systems, the biochemistry of VanS/VanR, the nature of the effector ligand(s) recognised by VanS and the evolution of the van cluster.

Antibiotic susceptibility profiles of new probiotic Lactobacillus and Bifidobacterium strains

The antimicrobial susceptibilities and presence of plasmids in four new probiotic lactic acid bacteria (LAB) strains, Lactobacillus rhamnosus HN001 (DR20) HN067, Lactobacillus acidophilus HN017 and Bifidobacterium lactis HN019 (DR10), were determined. Resistance to 18 commonly used antibiotics was assessed by disk diffusion. The three Lactobacillus strains had similar antibiotic susceptibility profiles to those of Lactobacillus plantarum strain HN045 and two commercial probiotic Lactobacillus strains, GG and LA-1. The B. lactis strain HN019 had a similar profile to three commercial probiotic B. lactis strains (Bb12, HN049 and HN098). All 10 strains were sensitive to the Gram-positive spectrum antibiotics erythromycin and novobiocin, the broad-spectrum antibiotics rifampicin, spectinomycin, tetracycline and chloramphenicol and the beta-lactam antibiotics penicillin, ampicillin and cephalothin. By contrast, most strains were resistant to the Gram-negative spectrum antibiotics fusidic acid, nalidixic acid and polymyxin B and the aminoglycosides neomycin, gentamicin, kanamycin and streptomycin. All three L. rhamnosus strains (HN001, HN067 and GG) were resistant to vancomycin and several strains were also resistant to cloxacillin. Of the four new probiotic strains, only L. rhamnosus HN001 contained plasmids; however, a plasmid-free derivative of HN001 had the same antibiotic susceptibility profile as the parent strain.

Solid- and solution-phase synthesis of vancomycin and vancomycin analogues with activity against vancomycin-resistant bacteria

Vancomycin, the prototypical member of the glycopeptide family of antibiotics, is a clinically used antibiotic employed against a variety of drug-resistant bacterial strains including methicillin-resistant Staphylococcus aureus (MRSA). The recent emergence of vancomycin resistance, viewed as a growing threat to public health, prompted us to initiate a program aimed at restoring the potency of this important antibiotic through chemical manipulation of the vancomycin structure. Herein, we describe the development of synthetic technology based on the design of a novel selenium safety catch linker, application of this technology to a solid-phase semisynthesis of vancomycin, and the solid- and solution-phase synthesis of vancomycin libraries. Biological evaluation of these compound libraries led to the identification of a number of in vitro highly potent antibacterial agents effective against vancomycin-resistant bacteria. In addition to aiding these investigations, the solid-phase chemistry described herein is expected to enhance the power of combinatorial chemistry and facilitate chemical biology and medicinal chemistry studies.

Disinfectant and antibiotic resistance of lactic acid bacteria isolated from the food industry

Quaternary ammonium compounds (QACs) are widely used as disinfectant in medical and food environments. There is a growing concern about the increasing incidence of disinfectant-resistant microorganisms from food. Disinfectant-resistant lactic acid bacteria (LAB) may survive disinfection and cause spoilage problems. Moreover, resistant LAB may potentially act as a reservoir for resistance genes. A total number of 320 LAB from food industry and meat were screened for resistance to the QAC benzalkonium chloride (BC). Out of 320 strains, five strains (1.5%) were considered to be resistant and 56 (17.5%) were tolerant to BC. The resistant strains were isolated from food processing equipment after disinfection. The resistant, tolerant, and some sensitive control bacteria were examined for susceptibility to 18 different antibiotics, disinfectants, and dyes using disc agar diffusion test and microdilution method. Little systematic cross-resistance between BC and any of the antimicrobial agents tested were detected except for gentamycin and chlorhexidine. A BC-tolerant strain was much easier to adapt to higher levels of BC as compared to a BC-sensitive strain. No known gram-positive QAC resistance genes (qacA/B, qacC, qacG, and qacH) were detected in the BC-resistant strains. Identification to species level of the BC-resistant isolates was carried out by comparative analysis of 16S-rDNA sequencing. In conclusion, resistance to BC is not frequent in LAB isolated from food and food environments. Resistance may occur after exposure to BC. The BC resistant isolates showed no cross-resistance with other antimicrobial compounds, except for gentamycin and chlorhexidine. Nevertheless, BC-resistant LAB may be isolated after disinfection and may contribute to the dissemination of resistance.

Probiotic bacteria: safety, functional and technological properties

During the past two decades probiotic (health promoting) micro-organisms have been increasingly included in various types of food products, especially in fermented milks. Several aspects, including safety, functional and technological characteristics, have to be taken into consideration in the selection process of probiotic micro-organisms. Safety aspects include specifications such as origin (healthy human GI-tract), non-pathogenicity and antibiotic resistance characteristics. Functional aspects include viability and persistence in the GI-tract, immunomodulation, antagonistic and antimutagenic properties. Before probiotic strains, chosen on the basis of their good safety and functional characteristics, can benefit the consumer, they must first be able to be manufactured under industrial conditions. Furthermore, they have to survive and retain their functionality during storage, and also in the foods into which they are incorporated without producing off-flavours. Factors related to the technological and sensory aspects of probiotic food production are of utmost importance since only by satisfying the demands of the consumer can the food industry succeed in promoting the consumption of functional probiotic products in the future.

Vancomycin-resistant enterococci

After they were first identified in the mid-1980s, vancomycin-resistant enterococci (VRE) spread rapidly and became a major problem in many institutions both in Europe and the United States. Since VRE have intrinsic resistance to most of the commonly used antibiotics and the ability to acquire resistance to most of the current available antibiotics, either by mutation or by receipt of foreign genetic material, they have a selective advantage over other microorganisms in the intestinal flora and pose a major therapeutic challenge. The possibility of transfer of vancomycin resistance genes to other gram-positive organisms raises significant concerns about the emergence of vancomycin-resistant Staphylococcus aureus. We review VRE, including their history, mechanisms of resistance, epidemiology, control measures, and treatment.

Vancomycin-resistant enterococci

After they were first identified in the mid-1980s, vancomycin-resistant enterococci (VRE) spread rapidly and became a major problem in many institutions both in Europe and the United States. Since VRE have intrinsic resistance to most of the commonly used antibiotics and the ability to acquire resistance to most of the current available antibiotics, either by mutation or by receipt of foreign genetic material, they have a selective advantage over other microorganisms in the intestinal flora and pose a major therapeutic challenge. The possibility of transfer of vancomycin resistance genes to other gram-positive organisms raises significant concerns about the emergence of vancomycin-resistant Staphylococcus aureus. We review VRE, including their history, mechanisms of resistance, epidemiology, control measures, and treatment.

In vitro antibacterial activity of LY333328, a new semisynthetic glycopeptide

LY333328 is a semisynthetic N-alkyl derivative of LY264826, a naturally occurring structural analog of vancomycin. LY333328 was evaluated for its in vitro inhibitory and bactericidal activities in comparison with those of the two currently available glycopeptides (vancomycin and teicoplanin). Glycopeptide-susceptible test strains included a total of 311 isolates (most of clinical origin) from the genera Staphylococcus, Enterococcus, Streptococcus, Aerococcus, Gemella, Lactococcus, Listeria, Corynebacterium, and Clostridium. Test strains resistant or intermediate to vancomycin and/or teicoplanin included 56 clinical isolates of Enterococcus (of the VanA, VanB, and VanC phenotypes) and 32 clinical isolates of Staphylococcus (S. haemolyticus, S. epidermidis, and S. aureus), 31 strains of gram-positive genera outside the spectrum of activity of vancomycin (Leuconostoc, Pediococcus, Lactobacillus, and Erysipelothrix), and laboratory-derived organisms obtained after exposure of susceptible Staphylococcus isolates to teicoplanin (6 strains) or laboratory-derived organisms with resistance determinants received from VanA enterococci (2 Enterococcus and 25 Listeria transconjugants). LY333328 was highly active against staphylococci, enterococci, and listeriae (whether they were clinical or laboratory-derived strains) resistant to the currently available glycopeptides. In particular, the MICs of LY333328 did not vary substantially between teicoplanin-susceptible and teicoplanin-resistant staphylococci and between vancomycin-susceptible and vancomycin-resistant enterococci. LY333328 demonstrated fairly good inhibitory activity even against most strains of Leuconostoc, Pediococcus, and Erysipelothrix (MIC range, 1 to 8 microg/ml), whereas it proved less active (although much more active than vancomycin or teicoplanin) against Lactobacillus strains. In minimal bactericidal concentration (MBC) and time-kill studies, LY333328 demonstrated excellent bactericidal activity; enterococci, in particular, which were largely tolerant of vancomycin and teicoplanin, were uniformly killed by LY333328, with MBC-to-MIC ratios of 4 to 8 for most vancomycin-susceptible and vancomycin-resistant strains. In attempts to select for resistant clones, no survivors stably growing in the presence of 10 microg of LY333328 per ml were obtained from the Staphylococcus and Enterococcus test strains exposed to the drug.

D-Alanyl-D-lactate and D-alanyl-D-alanine synthesis by D-alanyl-D-alanine ligase from vancomycin-resistant Leuconostoc mesenteroides. Effects of a phenylalanine 261 to tyrosine mutation

The Gram-positive bacterium Leuconostoc mesenteroides, ATCC 8293, is intrinsically resistant to the antibiotic vancomycin. This phenotype correlates with substitution of D-Ala-D-lactate (D-Ala-D-Lac) termini for D-Ala-D-Ala termini in peptidoglycan intermediates in which the depsipeptide has much lower affinity than the dipeptide for vancomycin binding. Overproduction of the L. mesenteroides D-Ala-D-Ala ligase (LmDdl) 2 in E. coli and its purification to approximately 90% homogeneity allow demonstration that the LmDdl2 does have both depsipeptide and dipeptide ligase activity. Recently, we reported that mutation of an active site tyrosine (Tyr), Tyr216, to phenylalanine (Phe) in the E. coli DdlB leads to gain of D-Ala-D-Lac depsipeptide ligase activity in that enzyme. The vancomycin-resistant LmDdl2 has a Phe at the equivalent site, Phe261. To test the prediction that a Tyr residue predicts dipeptide ligase while an Phe residue predicts both depsipeptide and dipeptide ligase activity, the F261Y mutant protein of LmDdl2 was constructed and purified to approximately 90% purity. F216Y LmDdl2 showed complete loss of the ability to couple D-Lac but retained D-Ala-D-Ala dipeptide ligase activity. The Tyr-->Phe substitution on the active site omega-loop in D-Ala-D-Ala ligases is thus a molecular indicator of both the ability to make D-Ala-D-Lac and intrinsic resistance to the vancomycin class of glycopeptide antibiotics.

In vitro activity of the trinem sanfetrinem (GV104326) against gram-positive organisms

The in vitro activity of the trinem sanfetrinem (formerly GV104326) (GV) was compared with that of vancomycin, ampicillin, and/or nafcillin against 287 gram-positive bacteria, including methicillin-resistant Staphylococcus aureus and multiresistant enterococci, by the agar and microbroth dilution methods. GV demonstrated 2 to 16 times more activity than ampicillin and nafcillin against the majority of these organisms. The MIC range of GV was 16 to 64 micrograms/ml for 19 Enterococcus faecium strains that were highly resistant to ampicillin (ampicillin MIC range, 64 to 512 micrograms/ml) and vancomycin resistant and 0.25 to 32 micrograms/ml for resistant Rhodococcus spp. Similar activities (+/-1 dilution) were observed by either the agar or the broth microdilution method. GV demonstrated bactericidal activity against a beta-lactamase-producing Enterococcus faecalis strain and against two methicillin-susceptible Staphylococcus aureus strains in 10(5)-CFU/ml inocula. Synergy between GV and gentamicin was observed against an E. faecalis strain that lacked high-level gentamicin resistance. The activity of GV suggests this compound warrants further study.

Activities of the semisynthetic glycopeptide LY191145 against vancomycin-resistant enterococci and other gram-positive bacteria

LY191145 is the prototype of a series of compounds with activities against vancomycin-resistant enterococci derived by modification of the glycopeptide antibiotic LY264826. LY191145 had MICs for vancomycin- and teicoplanin-resistant enterococci of < or = 4 micrograms/ml for 50% of isolates and < or = 16 micrograms/ml for 90% of isolates. Its MICs for vancomycin-resistant, teicoplanin-susceptible enterococci were 1 to 8 micrograms/ml. LY191145 retains the potent activities of its parent compound against staphylococci and streptococci. In vivo studies in a mouse infection model confirmed these activities. This compound indicates the potential of semisynthetic glycopeptides as agents against antibiotic-resistant gram-positive bacteria.

Current perspectives on glycopeptide resistance

In the last 5 years, clinical isolates of gram-positive bacteria with intrinsic or acquired resistance to glycopeptide antibiotics have been encountered increasingly. In many of these isolates, resistance arises from an alteration of the antibiotic target site, with the terminal D-alanyl-D-alanine moiety of peptidoglycan precursors being replaced by groups that do not bind glycopeptides. Although the criteria for defining resistance have been revised frequently, the reliable detection of low-level glycopeptide resistance remains problematic and is influenced by the method chosen. Glycopeptide-resistant enterococci have emerged as a particular problem in hospitals, where in addition to sporadic cases, clusters of infections with evidence of interpatient spread have occurred. Studies using molecular typing methods have implicated colonization of patients, staff carriage, and environmental contamination in the dissemination of these bacteria. Choice of antimicrobial therapy for infections caused by glycopeptide-resistant bacteria may be complicated by resistance to other antibiotics. Severe therapeutic difficulties are being encountered among patients infected with enterococci, with some infections being untreatable with currently available antibiotics.

Analysis of genes encoding D-alanine:D-alanine ligase-related enzymes in Leuconostoc mesenteroides and Lactobacillus spp

Degenerate oligodeoxyribonucleotides complementary to sequences encoding conserved amino acid (aa) motifs in D-alanine:D-alanine ligases (Ddl) were used to amplify approx. 600-bp fragments from glycopeptide-resistant strains of Leuconostoc mesenteroides (Lm), Lactobacillus plantarum, La. salivarius and La. confusus, and from a susceptible strain of La. leichmannii. Comparison of the deduced aa sequences of the PCR products revealed that the Ddl-related enzymes of resistant Lm and Lactobacillus spp. are more akin to each other (47-63% aa identity) than to that of susceptible La. leichmannii (33-37% aa identity), indicating that the Ddl-related enzymes in these intrinsically resistant species of Gram+ bacteria exhibit structural differences with those in susceptible species. The Ddl-related enzymes, VanA and VanB, implicated in acquired resistance to glycopeptides in enterococci, were not closely related to their counterparts in Lm and Lactobacillus spp., as they displayed only 26-32% aa identity.

Modification of peptidoglycan precursors is a common feature of the low-level vancomycin-resistant VANB-type Enterococcus D366 and of the naturally glycopeptide-resistant species Lactobacillus casei, Pediococcus pentosaceus, Leuconostoc mesenteroides, and Enterococcus gallinarum

The biochemical basis for the acquired or natural resistance of various gram-positive organisms to glycopeptides was studied by high-pressure liquid chromatographic analysis of their peptidoglycan UDP-MurNAc-peptide precursors. In all cases, resistance was correlated with partial or complete replacement of the C-terminal D-Ala-D-Ala-containing UDP-MurNAc-pentapeptide by a new precursor with a modified C terminus. Nuclear magnetic resonance analysis by sequential assignment showed that the new precursor encountered in Enterococcus faecium D366, a strain belonging to the VANB class, which expresses low-level resistance to vancomycin, was UDP-MurNAc-L-Ala-gamma-D-Glu-L-Lys-D-Ala-D-lactate, identical to that previously found in the VANA class, which expresses high-level resistance to vancomycin. High-pressure liquid chromatographic analyses, composition determinations, and digestion by R39 D,D-carboxypeptidase demonstrated the exclusive presence of the new precursor in Lactobacillus casei and Pediococcus pentosaceus, which are naturally highly resistant to glycopeptides. The low-level natural resistance of Enterococcus gallinarum to vancomycin was found to be associated with the synthesis of a new precursor identified as a UDP-MurNAc-pentapeptide containing a C-terminal D-serine. The distinction between low and high levels of resistance to glycopeptides appeared also to depend on the presence or absence of a substantial residual pool of a D-Ala-D-Ala-containing UDP-MurNAc-pentapeptide.

Vancomycin-resistant Leuconostoc mesenteroides and Lactobacillus casei synthesize cytoplasmic peptidoglycan precursors that terminate in lactate

The emergence of acquired high-level resistance among Enterococcus species has renewed interest in mechanisms of resistance to glycopeptide antibiotics in gram-positive bacteria. In Enterococcus faecalis and Enterococcus faecium, resistance is encoded by the van gene cluster and is due to the production of a peptidoglycan precursor terminating in D-alanyl-D-lactate, to which vancomycin does not bind. Most Leuconostoc and many Lactobacillus species are intrinsically resistant to high levels of glycopeptide antibiotics, but the mechanism of resistance has not been elucidated. To determine whether the mechanisms of resistance are similar in intrinsically resistant bacteria, cytoplasmic peptidoglycan precursors were isolated from Leuconostoc mesenteroides and Lactobacillus casei and analyzed by mass spectrometry, revealing structures consistent with UDP-N-acetylmuramyl-L-Ala-D-Glu-L-Lys-(L-Ala)-D-Ala-D-lactate and UDP-N-acetylmuramyl-L-Ala-D-Glu-L-Lys-D-Ala-D-lactate, respectively.

Enterococcus, an emerging pathogen

OBJECTIVE

To review the bacterial genus Enterococcus with respect to its epidemiology, specific infections in humans, mechanisms of resistance and tolerance, and antimicrobial treatment.

DATA SOURCES

A MEDLINE search of English-language journal articles published from 1977 to 1992 was completed. Articles published prior to 1977 were identified through Index Medicus and from references appearing in the bibliographies of other journal articles. Information also was acquired from abstracts, personal communication with infectious disease specialists with active research in the area of enterococcal infection, and conference proceedings.

STUDY SELECTION

In vitro data; animal models of enterococcal infection; case reports; and case-controlled, cohort, and randomized controlled trials in humans were evaluated for relevant information.

DATA EXTRACTION

Studies were evaluated by their methodologic strength (e.g., randomized controlled trial), reporting of clinically relevant outcomes (e.g., clinical response to antimicrobial therapy), statistical analyses, and accountability of all patients who entered the study.

DATA SYNTHESIS

The incidence of enterococcal infections has increased in recent years and enterococci are now the second most frequently reported nosocomial pathogens. Enterococcus faecalis is the pathogen responsible for most enterococcal infections seen today; it has been implicated as an important cause of endocarditis, bacteremia, urinary tract infections, and intraabdominal infections.

CONCLUSIONS

Enterococcal infection is of particular concern clinically because of its resistance to several antibiotics. Controlled comparative clinical trials of antimicrobial therapy in humans are lacking for several enterococcal infections. Therefore, the recommendations for antimicrobial therapy presented in this review are guidelines that reflect our current understanding of antibiotics used for enterococcal infection.

In vitro activity of mersacidin (M87-1551), an investigational peptide antibiotic tested against gram-positive bloodstream isolates

We measured the in vitro activity of mersacidin (formerly M87-1551) against 183 clinical isolates (vancomycin susceptible) and 12 additional vancomycin-resistant strains of Gram-positive bacteria. The activity for mersacidin increased an average twofold (range, 1.7- to 7.6-fold) in a calcium-enriched medium. The minimum inhibitory concentration (MIC)90 for mersacidin was 8-32 times higher than vancomycin for staphylococci, 4-64 times higher for enterococci, and up to 32 times higher for other organisms tested. The MIC90 for MDL 62873, a comparison compound, was less than or equal to 0.5 micrograms/ml for all species except Staphylococcus haemolyticus (MIC90, 4 micrograms/ml), and it was greater than or equal to 4-fold more active than vancomycin. Against selected vancomycin-resistant strains, mersacidin had MICs greater than or equal to 16 micrograms/ml for enterococci, 4-32 micrograms/ml for Pediococcus, and less than or equal to 2 micrograms/ml for Leuconostoc species. Mersacidin may have some clinical utility in documented infections caused by staphylococci, nonenteric streptococci, Pediococcus, and Leuconostoc.

In vitro activity of decaplanin (M86-1410), a new glycopeptide antibiotic

The in vitro activity of decaplanin (formerly M86-1410), a novel glycopeptide antimicrobial agent, was tested against 169 gram-positive bloodstream isolates from patients at the University of Iowa Hospitals and Clinics and 12 selected vancomycin-resistant strains. Enterococcus faecalis, E. faecium, Staphylococcus aureus, streptococci, bacilli, corynebacteria, and listeria were inhibited by decaplanin (MICs for 90% of the strains tested [MIC90s], 0.12 to 4 micrograms/ml). However, some rarely isolated and selected Enterococcus sp. populations had a MIC90 of 16 micrograms/ml, and S. haemolyticus strains had a MIC90 of 8 micrograms/ml. These in vitro results suggest that decaplanin may be useful against most gram-positive strains, even though some Enterococcus species and coagulase-negative staphylococci were potentially resistant (MICs, greater than or equal to 8 micrograms/ml).

In vitro activities of three semisynthetic amide derivatives of teicoplanin, MDL 62208, MDL 62211, and MDL 62873

MDL 62208, MDL 62211, and MDL 62873 are three semisynthetic amide derivatives of teicoplanin (MDL 62208 is an amide of teicoplanin aglycone, MDL 62211 is an amide of the teicoplanin A2 complex, and MDL 62873 is the corresponding derivative of peak A2-2 of the complex). The three semisynthetic glycopeptides were evaluated for in vitro antibacterial activity in comparison with the parent drug (teicoplanin) and vancomycin. A variety of gram-positive bacteria of clinical origin, whose species were carefully determined and that included 428 staphylococci (207 methicillin susceptible and 221 methicillin resistant), 41 streptococci, 82 enterococci, 43 strains of Listeria monocytogenes, 10 JK coryneform bacteria, and 67 anaerobes belonging to the genera Clostridium, Propionibacterium, Peptostreptococcus, and Eubacterium, were tested. The only resistances to MDL 62208, MDL 62211, and MDL 62873 were encountered with vancomycin- and teicoplanin-resistant enterococci. All of the other test strains, including some teicoplanin-resistant coagulase-negative staphylococci of the species Staphylococcus haemolyticus and Staphylococcus epidermidis, were highly susceptible to the three teicoplanin amides. Only minor differences in activity were observed among MDL 62208, MDL 62211, and MDL 62873, whereas the three experimental compounds were usually found to be more potent than teicoplanin or vancomycin (especially against staphylococci, with differences mostly ranging from 2- to 16-fold). The MBC-to-MIC ratios varied depending on the organisms, with the highest ratios usually observed for enterococci and listeriae. Overall, the MBC-to-MIC ratios yielded by the teicoplanin analogs were slightly greater than those yielded by teicoplanin or vancomycin.

Molecular basis for vancomycin resistance in Enterococcus faecium BM4147: biosynthesis of a depsipeptide peptidoglycan precursor by vancomycin resistance proteins VanH and VanA

Vancomycin resistance in Enterococcus faecium BM4147 is mediated by vancomycin resistance proteins VanA and VanH. VanA is a D-alanine:D-alanine ligase of altered substrate specificity [Bugg, T. D. H., Dutka-Malen, S., Arthur, M., Courvalin, P., & Walsh, C. T. (1991) Biochemistry 30, 2017-2021], while the sequence of VanH is related to those of alpha-keto acid dehydrogenases [Arthur, M., Molinas, C., Dutka-Malen, S., & Courvalin, P. (1991) Gene (submitted)]. We report purification of VanH to homogeneity, characterization as a D-specific alpha-keto acid dehydrogenase, and comparison with D-lactate dehydrogenases from Leuconostoc mesenteroides and Lactobacillus leichmanii. VanA was found to catalyze ester bond formation between D-alanine and the D-hydroxy acid products of VanH, the best substrate being D-2-hydroxybutyrate (Km = 0.60 mM). The VanA product D-alanyl-D-2-hydroxybutyrate could then be incorporated into the UDPMurNAc-pentapeptide peptidoglycan precursor by D-Ala-D-Ala adding enzyme from Escherichia coli or by crude extract from E. faecium BM4147. The vancomycin binding constant of a synthetic modified peptidoglycan analogue N-acetyl-D-alanyl-D-2-hydroxybutyrate (Kd greater than 73 mM) was greater than 1000-fold higher than the binding constant for N-acetyl-D-alanyl-D-alanine (Kd = 54 microM), partly due to the disruption of a hydrogen bond in the vancomycin-target complex, thus providing a molecular rationale for high-level vancomycin resistance.

Mechanisms and implications of glycopeptide resistance in enterococci

Glycopeptide resistance is recent in enterococci and its expression is inducible by glycopeptides. Two phenotypes can be distinguished: (a) resistance to high levels of vancomycin and teicoplanin, and (b) resistance to low levels of vancomycin only. There is no cross-resistance between glycopeptides, glycolipodepsipeptides (ramoplanin), and lipopeptides (daptomycin). The determinants conferring low-level resistance are nontransferable and presumably chromosomal. High-level resistance is plasmid-mediated and the plasmids range from 34 to 40 kb, are self-transferable, and encode various resistance combinations. All plasmids share the same glycopeptide resistance determinant, which is distinct from that conferring low-level resistance. Induction of resistance is associated with induction of about a 40 kDa protein. We have determined the sequence of the vanA gene encoding one such resistance protein designated VANA. Amino acid sequence similarity was detected between VANA and D-Ala: D-Ala ligases from Enterobacteriaceae. Complementation analysis in Escherichia coli indicated that VANA possesses D-Ala: D-Ala ligase activity and is therefore related to enzymes that catalyze synthesis of glycopeptide target, i.e., terminal D-Ala-D-Ala of peptidoglycan precursors. The contribution of VANA to synthesis of peptidoglycan in the presence of glycopeptides is unknown: VANA could bind to D-Ala-D-Ala, preventing the binding of the drugs; could modify the target of the drug; and could be a ligase with novel specificity.

Antibacterial activities and modes of action of vancomycin and related glycopeptides

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Should we vigorously try to contain and control methicillin-resistant Staphylococcus aureus?

OBJECTIVE

To review practices currently used to control transmission of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals, determine the frequency of their use, and discuss the indications for implementing such measures.

DESIGN

A questionnaire survey to determine how commonly selected control practices are used, and a literature review of the efficacy of control practices.

PARTICIPANTS

Two hundred fifty-six of 360 hospital-based members fo the Society for Hospital Epidemiology of America, Inc. (SHEA) completed the survey questionnaire.

RESULTS

Many different combinations of surveillance and control measures are used by hospitals with MRSA. Nine percent of hospitals stated that no special measures were used to control MRSA. The efficacy of commonly used control measures has not been established by controlled trials.

CONCLUSIONS

Implementing control measures is warranted when MRSA causes a high incidence of serious nosocomial infections, and is desirable when MRSA has been newly introduced into a hospital or into an intensive care unit, or when MRSA accounts for more than 10% of nosocomial staphylococcal isolates. While the value of some practices is well established, measures such as routinely attempting to eradicate carriage of MRSA by colonized patients and personnel require further evaluation.

Resistance of enterococci to glycopeptides

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