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

Antibiotic resistant enterococci-tales of a drug resistance gene trafficker

Enterococci have been recognized as important hospital-acquired pathogens in recent years, and isolates of E. faecalis and E. faecium are the third- to fourth-most prevalent nosocomial pathogen worldwide. Acquired resistances, especially against penicilin/ampicillin, aminoglycosides (high-level) and glycopeptides are therapeutically important and reported in increasing numbers. On the other hand, isolates of E. faecalis and E. faecium are commensals of the intestines of humans, many vertebrate and invertebrate animals and may also constitute an active part of the plant flora. Certain enterococcal isolates are used as starter cultures or supplements in food fermentation and food preservation. Due to their preferred intestinal habitat, their wide occurrence, robustness and ease of cultivation, enterococci are used as indicators for fecal pollution assessing hygiene standards for fresh- and bathing water and they serve as important key indicator bacteria for various veterinary and human resistance surveillance systems. Enterococci are widely prevalent and genetically capable of acquiring, conserving and disseminating genetic traits including resistance determinants among enterococci and related Gram-positive bacteria. In the present review we aimed at summarizing recent advances in the current understanding of the population biology of enterococci, the role mobile genetic elements including plasmids play in shaping the population structure and spreading resistance. We explain how these elements could be classified and discuss mechanisms of plasmid transfer and regulation and the role and cross-talk of enterococcal isolates from food and food animals to humans.

Mobile genetic elements and their contribution to the emergence of antimicrobial resistant Enterococcus faecalis and Enterococcus faecium

Mobile genetic elements (MGEs) including plasmids and transposons are pivotal in the dissemination and persistence of antimicrobial resistance in Enterococcus faecalis and Enterococcus faecium. Enterococcal MGEs have also been shown to be able to transfer resistance determinants to more pathogenic bacteria such as Staphylococcus aureus. Despite their importance, we have a limited knowledge about the prevalence, distribution and genetic content of specific MGEs in enterococcal populations. Molecular epidemiological studies of enterococcal MGEs have been hampered by the lack of standardized molecular typing methods and relevant genome information. This review focuses on recent developments in the detection of MGEs and their contribution to the spread of antimicrobial resistance in clinically relevant enterococci.

In vitro antibacterial activity of vertilmicin and its susceptibility to modifications by the recombinant AAC6'-APH2'' enzyme

Vertilmicin is a new semisynthetic aminoglycoside with a structure similar to that of netilmicin except for a methyl group at the C-6' position. In the present study, the in vitro antibacterial activity of vertilmicin was studied, and its susceptibility to modifications by the recombinant aminoglycoside bifunctional modifying enzyme AAC(6')-APH(2'') was compared with those of verdamicin and netilmicin. A total of 1,185 clinical isolates collected from hospitals in Beijing between 2000 and 2001 were subjected to the in vitro antibacterial activity evaluations, including MIC, minimum bactericidal concentration (MBC), and time-kill curve tests. The MICs were evaluated in non-gentamicin-resistant (gentamicin-susceptible and gentamicin-intermediate) strains and gentamicin-resistant strains, respectively. For most of the non-gentamicin-resistant bacteria (except for the isolates of Pseudomonas spp.), the MIC(90)s of vertilmicin were in the range of 0.5 to 8 microg/ml, comparable to those of the reference aminoglycosides. For the gentamicin-resistant isolates, the three semisynthetic aminoglycosides (vertilmicin, netilmicin, and amikacin) demonstrated low MIC(50)s and/or MIC(90)s, as well as high percent susceptibility values. Among the study drugs, vertilmicin showed the lowest MIC(90)s, 16 microg/ml, for the gram-positive gentamicin-resistant isolates of Staphylococcus aureus and Staphylococcus epidermidis. Meanwhile, vertilmicin was a potent bactericidal agent, with MBC/MIC ratios in the range of 1 to 2 for Escherichia coli, Klebsiella pneumoniae, and S. aureus and 1 to 4 for S. epidermidis. The time-kill curve determination further demonstrated that this effect was rapid and concentration dependent. In evaluations of susceptibility to modifications by the recombinant AAC(6')-APH(2'') with maximum rate of metabolism/K(m) measurements, vertilmicin exhibited susceptibilities to both acetylation and phosphorylation lower than those of netilmicin and verdamicin.

Transposon Tn5281 is the main distributor of the aminoglycoside modifying enzyme gene among isolates of Enterococcus faecalis in Tehran hospitals

Infections with high levels of gentamicin-resistant (HLGR) isolates of Enterococcus faecalis are common in Tehran hospitals. Genes encoding such resistance are transmissible by conjugation at high frequency. The purpose of this study was to determine the existence of Tn5281 and its flanking aminoglycoside modifying enzyme gene aac(6′)-aph(2″) among 102 HLGR isolates of E. faecalis cultured from patients at three hospitals in Tehran, Iran. These isolates were detected by disks containing 120 μg of gentamicin and made 65% of all E. faecalis during the study period. DNA was extracted from HLGR isolates and subjected to PCR assays targeting aac(6′)-aph(2″) and conjugative transposon Tn5281. The amplified aac(6′)-aph(2″) gene was labeled with digoxigenin and probed with Tn5281 amplicons in dot blot hybridization assays. The aac(6′)-aph(2″) gene was detected in 91%–92% (n = 93) of the HLGR isolates. All isolates containing aac(6′)-aph(2″) were positive in long-PCR targeting Tn5281 and the probe hybridized with Tn5281 amplicons. The number of HLGR isolates of E. faecalis has increased considerably in Tehran hospitals. Tn5281 is the main cause of transmission of aac(6′)-aph(2″) to different isolates of E. faecalis in the hospitals studied.

First report of vaginal infection caused by Enterococcus raffinosus

The authors have reported the first case of vaginal infection caused by Enterococcus raffinosus. The latter is a rarely identified species, but some of the infections described in the literature should direct some attention to this, often opportunistic pathogen, and its emerging multidrug resistance.

Multidrug-resistant Enterococcus raffinosus from a decubitus ulcer: a case report

A case of decubitus ulcer infected with multidrug-resistant Enterococcus raffinosus is reported in this article. This is the first report of wound infection caused by an Enterococcus raffinosus isolate resistant to antibiotics other than beta-lactams, gentamicin, and ciprofloxacin. This case adds to the knowledge base concerning the onset of antibiotic resistance in this uncommon species and confirms the emerging role of daptomycin as a promising alternative in therapy of severe difficult-to-treat enterococcal infections.

A novel structure of Tn4001-truncated element, type V, in clinical enterococcal isolates and multiplex PCR for detecting aminoglycoside resistance genes

A multiplex polymerase chain reaction (PCR) was established for detecting aacA-aphD, aph(2'')-Ib, aph(2'')-Ic and aph(2'')-Id, encoding high-level gentamicin resistance (HLGR), and aadA and aadE, encoding high-level streptomycin resistance (HLSR), in enterococci. The assay was implemented for 419 enterococcal blood and urine isolates recovered from patients at a university hospital in Thailand. Among the isolates tested, 56.1% (235 isolates) and 58.9% (247 isolates) contained aacA-aphD and aadE, respectively. The aph(2'')-Ib, aph(2'')-Ic, aph(2'')-Id and aadA genes were not found in any isolate. Among the isolates carrying the aacA-aphD gene, 99.1% exhibited a HLGR phenotype. All 235 enterococcal isolates containing aacA-aphD were further studied by PCR to characterise the structure of the resistance determinants carrying the aacA-aphD gene. The result revealed that only 22.6% carried Tn4001-related element, whereas the remaining isolates contained Tn4001-truncated element. No Tn4001-IS257 hybrid structure was detected. The majority of isolates carrying Tn4001-related element were Enterococcus faecalis (77.4%). Among Tn4001-truncated elements detected, all previously reported types (types I-IV) were found. Furthermore, a novel Tn4001-truncated type, designated type V, was also identified.

Diversity of structures carrying the aac(6')-aph(2") gene in clinical Enterococcus faecalis and Enterococcus faecium strains isolated in Tunisia

The diversity of structures carrying the aac(6')-aph(2") gene was studied in 46 high-level gentamicin-resistant Enterococcus faecalis and Enterococcus faecium clinical strains recovered in a Tunisian hospital during the period 2000-2003. The inclusion of the aac(6')-aph(2") gene within the Tn4001 composite element or in its truncated forms (lacking the IS256 at the right, the left or at both sides of the aac(6')-aph(2") gene) was investigated by PCR and sequencing. The aac(6')-aph(2") gene was included in the composite Tn4001 element in 19 of 34 high-level gentamicin-resistant E. faecalis strains (56%) and in 1 of 12 E. faecium strains (12%). A truncated form of Tn4001 lacking IS256 at the left-hand (in 10 E. faecalis and 8 E. faecium), at the right-hand (3 E. faecalis and 2 E. faecium) or at both sides of the aac(6')-aph(2") gene (in 2 E. faecalis and 1 E. faecium) was also detected in 26 of our enterococci. The transference by conjugation of the aac(6')-aph(2") gene, associated with other resistance genes, was demonstrated in seven of the high-level gentamicin-resistant E. faecalis strains.

Effect of Hospitalization on the Antibiotic Resistance of FecalEnterococcus faecalisof Surgical Patients Over Time

The prevalence of antibiotic resistant Enterococcus faecalis was determined in fecal samples of 263 patients admitted to the surgical wards of three university-affiliated hospitals on admission, at discharge, and at 1 and 6 months after discharge. A slight increase in the prevalence of antibiotic resistance of E. faecalis was found at discharge for the antibiotics tested compared to those on admission, vancomycin excepted. At 6 months after discharge, the prevalence of resistance for amoxicillin (0%), ciprofloxacin (3%), erythromycin (47%), and oxytetracycline (60%) decreased to the level on admission (respectively 0%, 8%, 45%, and 64%). Gentamicin resistance was the same at discharge (10%) as 1 month later (12%), but decreased 6 months after discharge (8%) to the level on admission (7%). In conclusion, hospitalization resulted in the study population in a slight increase in the prevalence of resistant fecal E. faecalis isolates at discharge, which decreased again (slowly) to the level on admission 6 months after discharge. Thus, the influence of hospitalization on the prevalence of antibiotic resistance in the extramural situation disappears between 1 and 6 months after discharge in this population.

Species composition and antimicrobial resistance genes of Enterococcus spp, isolated from integrated and traditional fish farms in Thailand

Integrated fish farming uses the manure from animal husbandry as fertilisers in the fish ponds. A total of 410 enterococcal isolates, from integrated and traditional fish farms in Thailand, were collected to assess whether the input of manure from chickens receiving feed containing growth promoters and antimicrobial treatments influenced the species composition and the bacterial antimicrobial resistance in the fish pond environment. Enterococcus faecium and E. faecalis were the predominate species isolated from the integrated farms, whereas E. casseliflavus and E. mundtii isolates were most prevalent in traditional farms. Enterococcus faecalis and E. faecium demonstrated the highest prevalence of resistance, whereas E. mundtii isolates were susceptible to all antimicrobials tested. All the enterococci species isolated from the integrated farms, generally demonstrated higher resistance phenotypes to the tested antimicrobials compared with the same species from traditional farms. The erm(B) and tet(M) genes, associated with resistance to erythromycin and tetracycline, respectively, were found in 87% of the erythromycin-resistant and 95% of the oxytetracycline-resistant enterococci isolates respectively. These results suggest that the species composition and antimicrobial resistance of enterococci in tropical aquatic environments are influenced by faecal and antimicrobial pollution.

Evaluation of the revised MicroScan dried overnight gram-positive identification panel to identify Enterococcus species

The revised MicroScan Dried Overnight Gram-Positive Identification panel was evaluated for its efficacy at identifying Enterococcus species in comparison with conventional biochemical tests. Supplemental testing of ampicillin-susceptible Enterococcus faecium for motility and the ability to acidify methyl-alpha-D-glucopyranoside helped recognize E. gallinarum and increased the accuracy of the panel for identifying Enterococcus species to 98.5%.

Diversity of structures carrying the high-level gentamicin resistance gene (aac6-aph2) in Enterococcus faecalis strains isolated in France

Of 24 high-level gentamicin-resistant clinical isolates of Enterococcus faecalis, 20 carried gentamicin resistance (Gmr) plasmids. The plasmids ranged from 65.0 to 80.0 kb in size. Three of these plasmids were nonconjugative, and 17 transferred by conjugation to an E. faecalis recipient at low frequency (10(-5) to 10(-6) transconjugants per donor). The remaining four strains had a nonconjugative chromosomal Gmr determinant. On the basis of restriction enzyme and DNA-DNA hybridization profiles, Tn4001-like alpha elements were located on the chromosome and three types of Tn4001-truncated structures, I, II, and III, were found to be carried by the Gmr plasmids. Structure I lacked IS256 in the right-hand flanking extremity of Tn4001. Structure II was the same as structure I except that it also had a partial deletion of IS256 in the left-hand flanking extremity of Tn4001. Structure III lacked both the right- and left-hand flanking extremities of Tn4001. One of the wild-type strains carried the Gmr determinant both on the chromosome, as a Tn4001-like alpha element, and on a conjugative plasmid, as a Tn4001-truncated type I structure.

Resistance to antimicrobial agents used for animal therapy in pathogenic-, zoonotic- and indicator bacteria isolated from different food animals in Denmark: a baseline study for the Danish Integrated Antimicrobial Resistance Monitoring Programme (DANMAP)

This study describes the establishment and first results of a continuous surveillance system of antimicrobial resistance among bacteria isolated from pigs, cattle and broilers in Denmark. The three categories of bacteria tested were: 1) indicator bacteria (Escherichia coli, Enterococcus faecalis, Enterococcus faecium), 2) zoonotic bacteria (Campylobacter coli/jejuni, Salmonella enterica, Yersinia enterocolitica), and 3) animal pathogens (E. coli, Staphylococcus aureus, coagulase-negative staphylococci (CNS), Staphylococcus hyicus, Actinobacillus pleuropneumoniae). A total of 3304 bacterial isolates collected from October 1995 through December 1996 were tested for susceptibility to all major classes of antimicrobial agents used for therapy in Denmark. Bacterial species intrinsically resistant to an antimicrobial were not tested towards that antimicrobial. Acquired resistance to all antimicrobials was found. The occurrence of resistance varied by animal origin and bacterial species. In general, resistance was observed more frequently among isolates from pigs than from cattle and broilers. The association between the occurrence of resistance and the consumption of the antimicrobial is discussed, as is the occurrence of resistance in other countries. The results of this study show the present level of resistance to antimicrobial agents among a number of bacterial species isolated from food animals in Denmark. Thus, the baseline for comparison with future prospective studies has been established, enabling the determination of trends over time.

Gene transfer, gentamicin resistance and enterococci

Enterococci are versatile pathogens by virtue of their ability to exhibit low-level intrinsic resistance to clinically useful antibiotics and their tolerance to adverse environmental conditions. In the last 20 years these pathogens have become progressively more difficult to treat because of their aptitude for acquiring antibiotic-resistance genes. Of increasing concern is the rapid dissemination of the AAC6'-APH2" bi-functional aminoglycoside modifying enzyme. This enzyme confers high-level resistance to gentamicin and all other related aminoglycosides with the exception of streptomycin. The gene conferring this phenotype has been associated with both narrow and broad host range plasmids, and has recently been found on conjugative transposons. The nature of these conjugative elements raises the possibility of the resistance gene spreading to other pathogenic bacteria.