Prevalence of Vancomycin resistant enterococci (VRE) in Ethiopia: a systematic review and meta-analysis

High Gastrointestinal Colonization Rate of Vancomycin-Resistant Enterococci among Hospitalized Patients: Potential Source for Resistant Gene

Background

Vancomycin-resistant Enterococci (VRE) is a global health problem and responsible for healthcare-associated infections (HAIs) in patients with prolonged hospital stay, severe underlying disease, and previous broad-spectrum antibiotic therapy. These bacteria can cross-resist and transfer drug-resistant genes to other potentially pathogenic bacteria. Therefore; this study was aimed to determine the gastrointestinal colonization rate of VRE, its antimicrobial susceptibility profile, and associated factors among hospitalized patients.

Methods

Prospective cross-sectional study was conducted using stool samples from 223 patients admitted to different wards at Hawassa University Comprehensive Specialized Hospital, from April 1 to June 30, 2021. Patients admitted to the hospital for more than 48 hours for various medical conditions were included. Sociodemographic and clinical characteristics were collected using a structured questionnaire. Fecal specimens were cultured on Enterococci selective media. Enterococcus species were identified using their growth and mannitol fermentation properties. Vancomycin resistance was screened using both the Kirby-Bauer disk diffusion method and a vancomycin E-test strip. Data were entered and analyzed using SPSS version 25. Descriptive and logistic regressions were used to determine the frequency and association of factors with the VRE colonization rate. A p value of <0.05 was considered statistically significant.

Results

A total of 223 fecal specimens were collected and processed, and 141 (63.2%) them were positive for Enterococci. The predominant species was E. faecalis 65 (46.1%) followed by E. faecium 76 (53.9%). In this study, the gastrointestinal colonization rate of VRE was 15 (6.7%) and all the species belong to E. faecium. Study participants who had no formal education (AOR = 4.26, 95% CI: 1.01, 18.06), hospitalized patients for >2 weeks (AOR = 4.10, 95% CI: 1.08, 15.57), and those who had a history of treatment with vancomycin (AOR = 4.77, 95% CI: 1.26, 18.09) were more likely to be colonized with vancomycin-resistant Enterococci. More than 95% of Enterococci isolates were susceptible to linezolid, whereas 70.2%, 63.1%, 56.7%, and 53.9% were resistant to tetracycline, erythromycin, penicillin, and ampicillin, respectively. Among the total Enterococci isolated, 141 (54.6%) were multidrug resistant.

Conclusions

In our study, high proportion of vancomycin-resistant Enterococci was found. Previous exposure to antibiotics and hospital stay were significant factors for VRE gut colonization. The isolated Enterococci showed variable degrees of resistance to commonly prescribed antibiotics which leads to a worldwide problem multidrug resistance. Therefore, periodic surveillance on antimicrobial resistance pattern, adhering to rational use of antibiotics, and implementing infection prevention protocols may reduce colonization by VRE.

Potential of Selected African Medicinal Plants as Alternative Therapeutics against Multi-Drug-Resistant Bacteria

Antimicrobial resistance is considered a "One-Health" problem, impacting humans, animals, and the environment. The problem of the rapid development and spread of bacteria resistant to multiple antibiotics is a rising global health threat affecting both rich and poor nations. Low- and middle-income countries are at highest risk, in part due to the lack of innovative research on the surveillance and discovery of novel therapeutic options. Fast and effective drug discovery is crucial towards combatting antimicrobial resistance and reducing the burden of infectious diseases. African medicinal plants have been used for millennia in folk medicine to cure many diseases and ailments. Over 10% of the Southern African vegetation is applied in traditional medicine, with over 15 species being partially or fully commercialized. These include the genera Euclea, Ficus, Aloe, Lippia. And Artemisia, amongst many others. Bioactive compounds from indigenous medicinal plants, alone or in combination with existing antimicrobials, offer promising solutions towards overcoming multi-drug resistance. Secondary metabolites have different mechanisms and modes of action against bacteria, such as the inhibition and disruption of cell wall synthesis; inhibition of DNA replication and ATP synthesis; inhibition of quorum sensing; inhibition of AHL or oligopeptide signal generation, broadcasting, and reception; inhibition of the formation of biofilm; disruption of pathogenicity activities; and generation of reactive oxygen species. The aim of this review is to highlight some promising traditional medicinal plants found in Africa and provide insights into their secondary metabolites as alternative options in antibiotic therapy against multi-drug-resistant bacteria. Additionally, synergism between plant secondary metabolites and antibiotics has been discussed.

Antimicrobial Resistance Patterns of Staphylococcus aureus and Enterococcus Species at the Ethiopian Public Health Institute, Ethiopia: A Five-Year Retrospective Analysis

Purpose

The study aimed to investigate the antimicrobial resistance patterns of Staphylococcus aureus and Enterococcus species isolated from clinical specimens over a period of five years, including resistance to methicillin and vancomycin.

Patients and Methods

Bacterial identification and antimicrobial susceptibility testing reports from 2017 to 2021 at the Ethiopian Public Health Institute were used for this retrospective study. The organisms were identified using either BD Phoenix M50, Vitek 2 compact, or conventional biochemical methods, whichever was available at the time of testing. The antimicrobial susceptibility profiles of the isolates were determined using either Kirby-Bauer disc diffusion, BD phoenix M50, or Vitek 2 compact. WHONET software was used to analyze the antimicrobial resistance patterns of both organisms. The p-values of ≤0.05 were considered statistically significant.

Results

During the study period, a total of 315 Staphylococcus aureus and 92 Enterococcus species were isolated. Out of 315 Staphylococcus aureus isolates, 27% and 5.1% were methicillin and vancomycin resistant, respectively. Staphylococcus aureus showed very high resistance to Penicillin G (86.7%). Out of 92 Enterococcus species recovered, 8.7% were vancomycin-resistant. Enterococcus species showed very high resistance to Penicillin G (71.4%) and tetracyclines (83.3%). Methicillin-resistant Staphylococcus aureus shows 100% resistance to penicillin followed by ciprofloxacin (50%), erythromycin (45.6%), and tetracycline (44.2%) and lower resistance to vancomycin (18.8%). All vancomycin-resistant isolates of both organisms were fully resistant (100%) to all antibiotics tested, except for linezolid and daptomycin, to which they were susceptible.

Conclusion

This study found a high prevalence of methicillin and vancomycin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus species between 2017 and 2021. However, there were no statistically significant changes in the prevalence of these organisms during the study period. This suggests that larger and more representative nationwide data is needed to show trends of these pathogens.

Prevalence of vancomycin-resistant Enterococci in India between 2000 and 2022: a systematic review and meta-analysis

BACKGROUND

Vancomycin-resistant Enterococci (VRE) infections are recurrently reported in different parts of India in the last two decades. However, an up-to-date, countrywide information concerning the prevalence and the rate of VRE in India is limited and hence this study aimed to estimate the pooled prevalence of VRE in India.

METHODS

A literature search was performed using various databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed throughout. Cross-sectional studies reporting the prevalence of VRE in India from human samples whereby at least two Enterococci were isolated between 1 January 2000 and 31 December 2022 were sought for inclusion. Data were extracted and analysed using Microsoft Excel and Comprehensive Meta-analysis version 4, respectively.

RESULTS

Nineteen studies were included in the analyses. A collective total of 3683 Enterococci isolates were examined, of which 368 were VRE strains. The pooled prevalence of VRE in India was calculated at 12.4% (95% CI: 8.6-17.5; Q = 189.69; I2 = 90.51%; p = < 0.001). E. faecalis was the most frequently isolated species (1450 [39.37%]) followed by E. faecium (724 [19.66%]). Amongst the VRE strains, E. faecium was the most prevalent (214 [58.15%]) followed by E. faecalis (134 [36.41%]). An upsurge in the rate of VRE infections was observed in India over time: VRE prevalence was estimated at 4.8% between 2000 and 2010 and 14.1% between 2011 and 2020.

CONCLUSION

This study presents the most up-to-date information on the rate of VRE infections in India. Though lower than the findings for some less developed countries, VRE prevalence in India is notable and on the rise.

Bringing resistance modulation to methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) strains using a quaternary ammonium compound coupled with zinc oxide nanoparticles

Nowadays, there are concerns about the inadequacy of new antimicrobials and the rise of antimicrobial resistance. Hence, novel antibacterial agents need to be discovered. In this respect, the use of nanoparticles (NPs) seems promising. Zinc oxide nanoparticles (ZnONPs) are functional and inexpensive NPs that possess antimicrobial characteristics, stability, microbial selectivity, and an easy manufacturing procedure. Imidazolium is one of the quaternary ammonium compounds (QACs) frequently employed as antimicrobial materials in industrial and clinical fields. The present study successfully employed imidazolium to couple with ZnONPs to improve their antimicrobial properties. The antimicrobial activities of ZnONPs doped with imidazolium (IM@ZnONPs) compared to ZnONPs and zinc (Zn) ions against some pathogen microorganism species including Streptococcus aureus (S. aureus), Enterococcus faecalis (E. faecalis), methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Candida albicans (C. albicans) were evaluated by the microdilution method. The minimum inhibitory concentration (MIC) results revealed that the antimicrobial activities of Zn ions, ZnONPs, and IM@ZnONPs were concentration-dependent. Moreover, we found that the nanoparticulate forms of Zn had considerably stronger antibacterial activities, particularly against VRE and MRSA, compared to Zn ions which failed to restrain the microbial strains at the tested microdilutions of this experiment (MIC: ≥512 µg/mL). Interestingly, the incorporation of imidazolium into ZnONPs resulted in significant inhibition of microbial growth in antimicrobial-resistant pathogens at low concentrations (MIC: 32 µg/mL) and effectively improved the monodispersity of the final coated NPs in terms of size and morphology. To sum up, IM@ZnONPs can be a favorable substitute for conventional antimicrobial agents to combat antimicrobial resistance in many fields, including pharmaceuticals, dental materials, and cosmetic products.

Vancomycin and Linezolid-Resistant Enterococcus Isolates from a Tertiary Care Center in India

INTRODUCTION

There is increasing development of antibiotic resistance among the Enterococcus species.

OBJECTIVES

This study was performed to determine prevalence and characterize the vancomycin-resistant and linezolid-resistant enterococcus isolates from a tertiary care center. Moreover, the antimicrobial susceptibility pattern of these isolates was also determined.

MATERIALS AND METHODS

A prospective study was performed in Medical College, Kolkata, India, over a period of two years (from January 2018 to December 2019). After obtaining clearance from the Institutional Ethics Committee, Enterococcus isolates from various samples were included in the present investigation. In addition to the various conventional biochemical tests, the VITEK 2 Compact system was used to identify the Enterococcus species. The isolates were tested for antimicrobial susceptibility to different antibiotics using the Kirby-Bauer disk diffusion method and VITEK 2 Compact to determine the minimum inhibitory concentration (MIC). The Clinical and Laboratory Standards Institute (CLSI) 2017 guidelines were used to interpret susceptibility. Multiplex PCR was performed for genetic characterization of the vancomycin-resistant Enterococcus isolates and sequencing was performed for characterization of the linezolid-resistant Enterococcus isolates.

RESULTS

During the period of two years, 371 isolates of Enterococcus spp. were obtained from 4934 clinical isolates showing a prevalence of 7.52%. Among these isolates, 239 (64.42%) were Enterococcus faecalis, 114 (30.72%) Enterococcus faecium, and others were Enterococcus durans, Enterococcus casseliflavus, Enterococcus gallinarum, and Enterococcus avium. Among these, 24 (6.47%) were VRE (Vancomycin-Resistant Enterococcus) of which 18 isolates were Van A type and six isolates of Enterococcus casseliflavus and Enterococcus gallinarum were resistant VanC type. There were two linezolid-resistant Enterococcus, and they were found to have the G2576T mutation. Among the 371 isolates, 252 (67.92%) were multi-drug resistant.

CONCLUSION

This study found an increasing prevalence of vancomycin-resistant Enterococcus isolates. There is also an alarming prevalence of multidrug resistance among these isolates.

Vancomycin Resistance in Enterococcus and Staphylococcus aureus

Enterococcus faecalis, Enterococcus faecium and Staphylococcus aureus are both common commensals and major opportunistic human pathogens. In recent decades, these bacteria have acquired broad resistance to several major classes of antibiotics, including commonly employed glycopeptides. Exemplified by resistance to vancomycin, glycopeptide resistance is mediated through intrinsic gene mutations, and/or transferrable van resistance gene cassette-carrying mobile genetic elements. Here, this review will discuss the epidemiology of vancomycin-resistant Enterococcus and S. aureus in healthcare, community, and agricultural settings, explore vancomycin resistance in the context of van and non-van mediated resistance development and provide insights into alternative therapeutic approaches aimed at treating drug-resistant Enterococcus and S. aureus infections.

Prevalence and multidrug resistance of Enterococcus species isolated from chickens at slaughterhouses in Nakhon Ratchasima Province, Thailand

Background and Aim

Enterococcus is a commensal bacteria found in humans and animals, which can cause human nosocomial infections. One of the most contaminated enterococcal sources is poultry meat. Therefore, this study estimated the prevalence and antimicrobial resistance (AMR) profile of Enterococcus from chickens and their meat products at local slaughterhouses in Nakhon Ratchasima Province, Thailand.

Materials and Methods

From January 2021 to March 2022, 558 samples from 279 cloacal swabs and breast meat were collected from 31 local slaughterhouses in the area. Then, the samples were screened for Enterococcus using modified de Man, Rogosa, and Sharpe agar. Next, selected Gram-positive, catalase-negative, and cocci-shaped colonies were investigated for enterococcal confirmation using Enterococcosel Agar (EA). We also cultivated the samples directly on EA. However, the disk diffusion method was used to investigate positive Enterococcus resistance profiles to 16 antimicrobial agents. Finally, selected phenotypic multidrug-resistant (MDR) Enterococcus isolates were further assessed to identify AMR genes by polymerase chain reaction.

Results

Investigations showed that the prevalence of Enterococcus isolates from the chicken cloacal swabs and meat samples were 29.75% (83/279) and 28.32% (78/279), respectively. Most Enterococcus positive isolates were resistant to colistin, followed by cefoxitin, cephalexin, and streptomycin. These isolates also showed a prevalence of MDR species (65.22%; 105/161) and 66 patterns. Furthermore, selected MDR Enterococcus (MDRE) from cloacal swabs and breast meat were positive for the resistant extended-spectrum beta-lactamase TEM genes at 71.43% (20/28) and 78.26% (18/23), respectively, whereas other AMR genes detected in the selected MDR enterococci from the cloacal swabs and breast meat were beta-lactamase TEM (bla _TEM [0%, 1.96%]), Class 1 integrase (intI1 [14.28%, 0%]), colistin (mrc-1 [3.57%, 0%]), and vancomycin (vanA [14.28%, 0%]).

Conclusion

This study indicated that phenotypic MDRE correlated with extended-spectrum beta-lactamase TEM gene presence, leading to an AMR reservoir that can be transferred to other bacteria.

Antimicrobial Resistance and Its Drivers-A Review

Antimicrobial resistance (AMR) is a critical issue in health care in terms of mortality, quality of services, and financial damage. In the battle against AMR, it is crucial to recognize the impacts of all four domains, namely, mankind, livestock, agriculture, and the ecosystem. Many sociocultural and financial practices that are widespread in the world have made resistance management extremely complicated. Several pathways, including hospital effluent, agricultural waste, and wastewater treatment facilities, have been identified as potential routes for the spread of resistant bacteria and their resistance genes in soil and surrounding ecosystems. The overuse of uncontrolled antibiotics and improper treatment and recycled wastewater are among the contributors to AMR. Health-care organizations have begun to address AMR, although they are currently in the early stages. In this review, we provide a brief overview of AMR development processes, the worldwide burden and drivers of AMR, current knowledge gaps, monitoring methodologies, and global mitigation measures in the development and spread of AMR in the environment.

Meta-analysis of the global prevalence of Enterococcus spp. in foods: Antibiotic resistance profile of Enterococcus faecalis and Enterococcus faecium

Aim: The objective of this study was to evaluate the prevalence and diversity of Enterococcus spp. and antibiotic-resistant Enterococcus faecalis and Enterococcus faecium isolates in different foods worldwide.

Method and Result: This study used meta-analytical methods. Besides, Web of Science (n= 705), Medline (n= 6), and Scopus (n= 1.338) were searched for studies in the years 1995-2021 using related keywords. Results showed that the pooled prevalence for Enterococcus spp. and antibiotic-resistant of E. faecalis and E. faecium isolates were found 0.41 (95% C.I. 0.34-0.47), 0.25 (95% C.I. 0.13-0.38), respectively. According to the results of the subgroup analysis, the lowest and highest prevalence of Enterococcus spp. in food types were calculated for red meat (0.56), and fermented foods (0.29). Also, as a result of subgroup analyses by country the highest prevalence of Enterococcus spp. was calculated in studies conducted in Slovakia (0.74). In contrast, the lowest prevalence was calculated in studies conducted in Georgia (0.07).

Conclusion: The meta-analyses improved our understanding of the prevalence of Enterococcus spp. and the antibiotic resistance of E. faecalis and E. faecium isolates in different foods and provided results that can be useful as input for quantitative microbiological risk evaluation modeling.

Significance and Impact of Study: We demonstrated the antibiotic resistance of E. faecalis and E. faecium in foods and gaps that could be addressed in the future. Therefore, it is believed that the results compiled herein will contribute to the epidemiological surveillance of the presence and antibiotic resistance of E. faecalis and E. faecium in foods.

Physiologically based pharmacokinetic modeling of daptomycin dose optimization in pediatric patients with renal impairment

Background and Objective: Daptomycin is used to treat Gram-positive infections in adults and children and its dosing varies among different age groups. We focused on the pharmacokinetics of daptomycin in children with renal impairment, which has not been evaluated.

Methods: A physiologically based pharmacokinetic (PBPK) model of daptomycin was established and validated to simulate its disposition in healthy populations and adults with renal impairment, along with a daptomycin exposure simulated in pediatric patients with renal impairment.

Results: The simulated PBPK modeling results for various regimens of intravenously administered daptomycin were consistent with observed data according to the fold error below the threshold of 2. The Cmax and AUC of daptomycin did not differ significantly between children with mild-to-moderate renal impairment and healthy children. The AUC increased by an average of 1.55-fold and 1.85-fold in severe renal impairment and end-stage renal disease, respectively. The changes were more significant in younger children and could reach a more than 2-fold change. This scenario necessitates further daptomycin dose adjustments.

Conclusion: Dose adjustments take into account the efficacy and safety of the drug; however, the steady-state Cmin of daptomycin may be above 24.3 mg/L in a few instances. We recommend monitoring creatine phosphokinase more than once a week when using daptomycin in children with renal impairment.

Drug Utilization Evaluation (DUE) of vancomycin: A cross-sectional study

Objective

Evaluating the use of antibiotics leads to identifying drug problems, preventing antibiotic resistance, and controlling the cost of medication. The aim of this study was to Drug Utilization Evaluation (DUE) of vancomycin.

Methods

This study was a descriptive retrospective cross-sectional study. Sampling method was the census. The information was collected through a checklist and referring to patients' files.

Results

170 children and 120 adults who received vancomycin were studied. The dose of vancomycin in the studied adults was 40.6% and 61% was in accordance with the Uptodate guideline. Also, the duration of treatment in the studied children was 10.6% and 15.3% according to the Uptodate guideline and in adults 30%, 39.2% was in accordance with the Uptodate guideline. Also, the indication for vancomycin in children was 14.1% and 18.8% in accordance with the Uptodate guideline, and in adults 40% and 52.5% was in accordance with the Uptodate guideline. The highest initial diagnosis in children was RDS 54.1%, seizure 9.4%, jaundice 9.4% and pneumonia 8.2%, and in adults 30% CRF and 11.7% catheter. In children, the most common complications were related to shortness of breath 41.2%, fever 18.8% and jaundice 11.8%, and in adults were related to fever 32.5%, lethargy 26.7% and shortness of breath 20%, respectively.

Conclusion

It is recommended to improve the administration and rational use of antibiotics and prevent the occurrence of microbial resistance, to follow the treatment patterns based on international standards in hospitals.

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Evaluating the use of antibiotics leads to identifying drug problems.

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Preventing antibiotic resistance, and controlling the cost of medication.

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It is recommended to improve the administration and rational use of antibiotics and prevent.

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DUE is a practical and continuous method, which evaluates the quality and economics of drug use.

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This type of study be carried out with a larger sample size and in different populations.

Burden of Antibiotic Resistance at Wolaita Sodo University Comprehensive Specialized Hospital

Background

Antibiotic resistance is a serious threat to the human population everywhere. However, less attention is given to its concern in sub-Saharan Africa including Ethiopia. There is an information gap concerning antibiotic resistance and its pattern in Wolaita Sodo University Teaching Referral Hospital. This study is aimed at investigating the prevalence of antimicrobial resistance in the study area.

Methods

Five-year retrospective data of cultures and records of 581 patients were utilized to analyze the pattern of antibiotic resistance. The statistical software including SPSS version 25 and Microsoft excel 2013 were used. Laboratory records with incompletely registered age, sex, culture isolation, or drug susceptibility test data were excluded.

Results

Out of the total of 581 samples extracted from the microbiology laboratory, 237 (40.8%) samples were culture positive for bacteria. From positive culture growth, 165 (69.6%) were gram-positive bacteria whereas 72 (30.4%) were gram negative. Staphylococcus aureus was the most prevalent isolate among gram-positive isolates as Escherichia coli was for gram-negative isolates. Overall antibiotic resistance of gram-positive isolates was 57.2% whereas that of gram-negative bacteria was 58.8%.

Conclusion

S. aureus and E. coli were found to be the most prevalent pathogenic isolates among gram-positive and gram-negative bacteria, respectively. Most of the isolated pathogens showed high resistance towards the commonly prescribed antibiotic agents. The overall antibiotic resistance in this study was 57.7%, and the overall MDR prevalence was 72.2%.

Antimicrobial resistance trend of bacterial uropathogens at the university of Gondar comprehensive specialized hospital, northwest Ethiopia: A 10 years retrospective study

Urinary tract infection and antimicrobial resistance remains the major problem, with significant health and socioeconomic burden, particularly in developing countries. This infection is commonly caused by Gram-negative bacteria, principally by Escherichia coli. So, this study aimed to determine bacterial isolates and antimicrobial resistance trend among patients with urinary tract infection at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. A retrospective study was conducted from January 1^st to February 28^th. A ten years (2010–2019) record of urine culture results, the biochemical test and antimicrobial susceptibility test results of isolates were collected from the medical microbiology laboratory register using a checklist. Data quality was checked, entered, and analyzed using SPSS version 23. We have presented results through descriptive tables and graphs. The overall prevalence of urinary tract infection among 4441 patients was 24.1%. Escherichia coli (37.7%), Klebsiella pneumoniae (11.4%), and Staphylococcus aureus (9.1%) were the predominant uropathogens. The infection rate was nearly similar across both sexes but highest in the age group above 60 years. Above 75% of Gram-negative isolates were resistant to ampicillin (92.5%), amoxicillin-clavulanate (80.1%), tetracycline (79.3%), cefuroxime (79.2%), and Trimethoprim-sulfamethoxazole (78.3%). Over 2/3 of Gram-positive isolates also showed increased resistance to tetracycline (84.8%) and penicillin (71.6%). Moreover, more than 44% of the isolates were multidrug-resistant (MDR). We have seen an inconsistent trend of antimicrobial resistance, with an overall resistance rate of above 50%. In conclusion, the overall prevalence of urinary tract infection was high and elderly patients were most affected. More than 70% of both Gram positive and gram-negative isolates were resistant to penicillin, ampicillin, amoxicillin-clavulanate, tetracycline, cefuroxime, Trimethoprim-sulfamethoxazole. Above than 44% of the isolates were multidrug-resistant (MDR). The increasing rate of antimicrobial resistance calls for routine diagnosis and antimicrobial susceptibility testing. A prospective multicenter study indicating the status of resistance should be encouraged.

Novel linear plasmids carrying vanA cluster drives the spread of vancomycin resistance in Enterococcus faecium in India

OBJECTIVES

The genetic basis for the spread of vancomycin resistance in E. faecium is largely unexplored in India. The present study aimed to investigate the plasmid diversity and variation of Tn1546 associated with vanA harbouring VREfm isolates.

METHODS

A total of 122 VREfm isolates collected from blood cultures were included in this study. MLST analysis was performed on all isolates and they were also screened for the presence of vanA and vanB genes. Whole genome sequencing was performed for a subset of fifteen VREfm isolates belonging to ST1643.

RESULTS

All of the 122 VREfm isolates carried the vanA gene. Twenty four different sequence types were seen, of these ST1643, ST80 and ST17 were predominant. Whole genome sequencing was performed on fifteen VREfm isolates belonging to ST1643. For eight isolates the vanA gene was found on pRUM like circular plasmids, and for the remaining seven isolates, the vanA gene was found in linear plasmids. Novel Tn1546 variants carrying vanA were found on both circular and linear plasmids. Interestingly, co-presence of vanA and optrA were seen in the backbone of three linear plasmids.

CONCLUSION

Multiple vanA carrying plasmids and Tn1546 like elements were involved in the dissemination of vancomycin resistance in VREfm. The co-occurrence of Tn1546 carrying vanA and Tn554 family transposon carrying optrA on the backbone of plasmids is worrisome. The dissemination of such plasmids may pose treatment and infection control challenges.

Reagentless Sensing of Vancomycin Using an Indium Tin Oxide Electrode Grafted with Molecularly Imprinted Polymer including Ferrocenyl Group

Vancomycin (VCM) is a first-line antimicrobial agent against methicillin-resistant Staphylococcus aureus, a cause of nosocomial infections. Therapeutic drug monitoring is strongly recommended for VCM-based chemotherapy. The authors attempted to develop a simple VCM sensor based on molecularly imprinted polymer (MIP), which can be used with simple operations. Methacrylic acid (MAA), acrylamide, methylenebisacrylamide, and allylamine carboxypropionate-3-ferrocene (ACPF) were copolymerized in the presence of VCM and grafted from the surface of indium-tin oxide (ITO) to obtain MIP-coated electrodes. The MIP-grafted ITO electrode was used for differential pulse voltammetry (DPV) measurements in a buffer solution containing VCM or whole bovine blood. The obtained current depends on the VCM concentration with high linearity. The dynamic range covered the therapeutic range (20–40 μg/mL) of the VCM but was almost insensitive to teicoplanin, which has a similar structure to VCM. The ITO electrodes grafted by the same procedure except for omitting either VCM or APCF were not sensitive to VCM. The sensitivity of the MIP electrodes to VCM in whole blood and buffered saline, but the background current in blood was higher than that in saline. This high background current was also seen in the deproteinized plasma. Thus, the current is probably originated from the oxidation of low molecular weight reducing agents in the blood. The MIP-grafted ITO electrode using ACPF as a functional monomer would be a promising highly selective sensor for real-time monitoring of VCM with proper correction of the background current.

Utility of Minimum Inhibitory Concentration values and Antibiotyping for Epidemiological study of Vancomycin Resistant Enterococci in a Tertiary Care Hospital

Vancomycin-resistant enterococci (VRE) have emerged as an important nosocomial infection. Three important vancomycin resistance types namely, VanA, VanB, VanC are very commonly found in enterococci. VanA and VanB are plasmid-encoded, transferable types of resistance and VanC is chromosomally mediated nontransferable resistance. So for infection control purpose, it is important to know the type of vancomycin resistance to prevent the spread of drug resistance. Enterococci isolated from clinical samples were tested for vancomycin resistance by disc diffusion and macro broth dilution (MIC) method. Vancomycin resistance gene was detected by the polymerase chain reaction (PCR) method. Antimicrobial susceptibility for penicillin, erythromycin, ciprofloxacin, high-level gentamicin, nitrofurantoin, tetracycline, teicoplanin and linezolid was performed by disc diffusion method. Antibiotyping of VRE strains was done based on their antimicrobial susceptibility pattern. Over a period of one year out of 246 clinical isolates of enterococci, seven (2.8%) isolates showed vancomycin resistance. Based on MICs and PCR, all the isolates demonstrated VanA type of resistance. Analysis of antibiogram showed three different antibiotype patterns for VRE labelled as 1,2,3. The majority of VRE isolates (72%) belonged to “Pattern 1”. Also clustering of cases of “Pattern 1” was observed in medicine ICU and medicine ward. These areas were identified as a potential reservoir for VRE infection and appropriate infection control measures were taken to curtail the spread of infection. The present study recommends a macro broth dilution method for detection of the type of vancomycin resistance in enterococci and “antibiotyping” as a basic typing method for VRE in resource-poor health care settings specifically in outbreak situations.

Review on the Antibacterial Mechanism of Plant-Derived Compounds against Multidrug-Resistant Bacteria (MDR)

Microbial resistance has progressed rapidly and is becoming the leading cause of death globally. The spread of antibiotic-resistant microorganisms has been a significant threat to the successful therapy against microbial infections. Scientists have become more concerned about the possibility of a return to the pre-antibiotic era. Thus, searching for alternatives to fight microorganisms has become a necessity. Some bacteria are naturally resistant to antibiotics, while others acquire resistance mainly by the misuse of antibiotics and the emergence of new resistant variants through mutation. Since ancient times, plants represent the leading source of drugs and alternative medicine for fighting against diseases. Plants are rich sources of valuable secondary metabolites, such as alkaloids, quinones, tannins, terpenoids, flavonoids, and polyphenols. Many studies focus on plant secondary metabolites as a potential source for antibiotic discovery. They have the required structural properties and can act by different mechanisms. This review analyses the antibiotic resistance strategies produced by multidrug-resistant bacteria and explores the phytochemicals from different classes with documented antimicrobial action against resistant bacteria, either alone or in combination with traditional antibiotics.

Anti-enterococcal and anti-oxidative potential of a thermophilic cyanobacterium, Leptolyngbya sp. HNBGU 003

Enterococci, the opportunistic pathogens, pose several serious and life-threatening infections such as urinary tract infections, sepsis, and endocarditis. The situation is worsening due to the development of drug resistance in these pathogens against several antibiotics. The addition of anti-enterococcal compounds with antioxidant activity in fermented and packaged food may help prevent the transmission of food-borne enterococcal infections. Scientists are in continuous search of such compounds from various sources. Hence, the present study has tested the diethyl ether extracts of thermophilic cyanobacteria, selected based on a previous study, against the multidrug-resistant and -sensitive strains of Enterococcus faecium. Out of the eleven tested extracts, 72% have shown anti-enterococcal activity against both strains. Among the extracts with anti-enterococcal activity, the diethyl ether extract of Leptolyngbya sp. (DEEL-3) inhibited the growth of VRE in a dose-dependent manner with a minimum inhibitory concentration of 2.0 mg mL^-1. The DEEL-3 has also shown its antioxidant potential in terms of DPPH scavenging with an IC₅₀ of 3.16 mg mL^-1. The organism was named Leptolyngbya sp. HNBGU 003 based on 16SrRNA sequence homology analysis and morphological features. Further, the GC–MS analysis of the DEEL-3 has revealed the predominance of two phenolic compounds, phenol, 2,4-bis(1,1-dimethylethyl)-, phosphite (3:1) and tris(2,4-di-tert-butylphenyl) phosphate, in it. Thus, the anti-enterococcal and antioxidant activity of DEEL-3 may be attributed to these phenolics, which may be isolated and developed as food additives.

Prevalence, Antimicrobial Susceptibility Patterns, and Risk Factors Associated with Enterococci among Pediatric Patients at Dessie Referral Hospital, Northeastern Ethiopia

BACKGROUND

Enterococcus species, which is previously considered as medically not important, now becomes one of the leading causes of nosocomial infections. Even though it becomes the most public health concern and emerging multidrug-resistant pathogen, there is no enough data in the study area.

OBJECTIVE

To determine the prevalence, antimicrobial resistance pattern, and associated risk factors of enterococci infection in pediatric patients.

METHODS

A hospital-based cross-sectional study was conducted from February to May 2019 at Dessie Referral Hospital, Northeastern Ethiopia. A total of 403 pediatric patients were included in the study, and a pretested structured questionnaire was used to collect sociodemographic and risk factor-related data. Clinical samples such as urine, blood, wound swabs, discharges, and other body fluids were collected aseptically and inoculated on to Bile Esculin Azide Agar, and colony characteristics, Gram stain, catalase, salt, and temperature tolerance tests were employed for bacterial identification. Antimicrobial sensitivity tests were performed using the modified Kirby-Bauer disk diffusion method. Data was entered into SPSS software version 25 and descriptive statistics; bivariate and multivariate logistic regression analyses were performed. In all cases, a P value ≤ 0.05 with corresponding 95% confidence interval were considered as statistically significant.

RESULT

The overall prevalence of enterococci was 2.7% (11/403). Of which, the highest number of enterococci infection was recovered from urine sample (54.5%) followed by blood (27.3%), wound swab (9.1%), and other body fluids (9%). The overall multidrug resistance rate was 54.5%. Higher drug resistance pattern was observed against tetracycline, chloramphenicol, and amoxicillin/clavulanate. Having history of invasive procedure (P < 0.001), chronic illness (P < 0.001) and previous admission history of the children (P < 0.001) were statistically significant associated risk factors for pediatrics enterococci infection.

CONCLUSION

The prevalence of enterococci from pediatric patients in this study was relatively low compared to other studies. Significant rates of MDR and VRE were identified, and the risk of infection became high when children had a history of different chronic illnesses and history of admission and underwent invasive treatment procedures. Therefore, efforts should be made to prevent enterococci infections and spread of multidrug-resistant enterococci.

Adverse events associated with administration of vasopressor medications through a peripheral intravenous catheter: a systematic review and meta-analysis

BACKGROUND

It is unclear whether vasopressors can be safely administered through a peripheral intravenous (PIV). Systematic review and meta-analysis methodology was used to examine the incidence of local anatomic adverse events associated with PIV vasopressor administration in patients of any age cared for in any acute care environment.

METHODS

MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials, and the Database of Abstracts of Reviews of Effects were searched without restriction from inception to October 2019. References of included studies and related reviews, as well as relevant conference proceedings were also searched. Studies were included if they were: (1) cohort, quasi-experimental, or randomized controlled trial study design; (2) conducted in humans of any age or clinical setting; and (3) reported on local anatomic adverse events associated with PIV vasopressor administration. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials or the Joanna Briggs Institute checklist for prevalence studies where appropriate. Incidence estimates were pooled using random effects meta-analysis. Subgroup analyses were used to explore sources of heterogeneity.

RESULTS

Twenty-three studies were included in the systematic review, of which 16 and 7 described adults and children, respectively. Meta-analysis from 11 adult studies including 16,055 patients demonstrated a pooled incidence proportion of adverse events associated with PIV vasopressor administration as 1.8% (95% CI 0.1-4.8%, I² = 93.7%). In children, meta-analysis from four studies and 388 patients demonstrated a pooled incidence proportion of adverse events as 3.3% (95% CI 0.0-10.1%, I² = 82.4%). Subgroup analyses did not detect any statistically significant effects associated with stratification based on differences in clinical location, risk of bias or design between studies, PIV location and size, or vasopressor type or duration. Most studies had high or some concern for risk of bias.

CONCLUSION

The incidence of adverse events associated with PIV vasopressor administration is low. Additional research is required to examine the effects of PIV location and size, vasopressor type and dose, and patient characteristics on the safety of PIV vasopressor administration.

Frequency and co-colonization of vancomycin-resistant Enterococci and Candida in ICU-hospitalized children

In the time span between January 2018 and September 2020, 205 patients were enrolled in a prospective cohort study at Mofid Children's Hospital. Demographic information and clinical data on all the participating children were collected and rectal swabs were performed for the sampling method. All samples were analysed so as to identify the presence of Enterococcus and Candida colonization by the use of conventional biochemical tests. Resistance to vancomycin in Enterococcus isolates was phenotypically identified using an E-test kit and MIC value, interpreted according to the CLSI criteria. The presence of vanA and vanB genes, which encode the resistance to vancomycin, was screened by PCR assay. Candida species were detected in 21.5% of rectal swab samples. Candida glabrata (56.8%) and Candida albicans (43.2%) were the only Candida species detected. Enterococcus species were detected in 29.3% of rectal swab samples. Out of 60 Enterococcus isolates, 33 (55%) were resistant to vancomycin. Moreover, vanA was detected in 84.8% and vanB was detected in 3% of the 33 vancomycin-resistant Enterococcus isolates. Enterococcus and Candida species were frequently detected in the <1 year and 1–3 years age groups, respectively. Central venous access catheter and brain tumour were the main reasons for hospital admissions, 32.2% and 20.1% of total admissions, respectively. Furthermore, it must be noted that the most frequent underlying medical conditions in participating patients were esophageal atresia and hydrocephalus. The results of the present study demonstrated the necessity of determining the susceptibility of Enterococcus isolates to vancomycin before prescribing antibiotics.

Vancomycin-resistant enterococci and coagulase-negative staphylococci prevalence among patients attending at Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, Ethiopia

Background

Vancomycin resistant enterococci (VRE) and vancomycin resistance coagulase negative staphylococci (VRCoNS) are common pathogens causing difficult to treat health care associated infections (HAI). Hence, the World Health Organization listed VRE as one of the high priority pathogens for new antibiotic discovery and antimicrobial resistance surveillance. Despite this, data on the prevalence of VRE and VRCoNS in Ethiopia is scarce. Thus, the present study determined prevalence of VRE and VRCoNS among patients attending Felege-Hiwot comprehensive specialized hospital, Ethiopia.

Methods

A hospital based cross-sectional study was conducted on 384 patients selected conveniently from February to March 2020. Data on demographic and clinical variables were collected using a structured questionnaire by face-to-face interview. Simultaneously urine, venous blood and wound swab were collected and processed following standard bacteriological technique. Antimicrobial susceptibility test was performed by minimum inhibitory concentration method using E-test for vancomycin and Kirby-Bauer disc diffusion method for other classes of antibiotics. Data was entered and analyzed using SPSS version 23. Logistic regression was performed to identify factors associated with VRE infection. P. value < 0.05 was considered as statistically significant.

Results

The prevalence of enterococci and CoNS were 6.8% and 12% respectively. The prevalence of VRE was 34.61% (9/26), while all CoNS (46 isolates) were susceptible to vancomycin. The majority (66.7%) of VRE was isolated from blood samples. Furthermore all VRE (100%), 58.8% of vancomycin susceptible enterococci and 45.7% of CoNS were multidrug resistant (MDR). Having educational level of secondary school and below (AOR = 12.80, CI = 1.149–142.5), previous exposure to catheterization (AOR = 56.0, CI = 4.331–724.0) and previous antibiotic use practice (AOR = 26.25, CI = 3.041–226.2) were a significant associated explanatory factor for VRE infection.

Conclusions

The prevalence of vancomycin resistance enterococci, which is also multidrug resistant, was significantly high. Though no vancomycin resistance CoNS detected, the MDR level of CoNS was high. Thus to limit enterococci and CoNS infections and MDR development, focused infection prevention measures should be implemented.

Global Prevalence of Vancomycin-Resistant Enterococci in Food of Animal Origin: A Meta-Analysis

Vancomycin-resistant enterococci (VRE) are a leading cause of nosocomial infections in patients worldwide. VRE contamination in food of animal origin may create a risk for human health. This study was conducted to estimate the pooled prevalence of VRE in food of animal origin worldwide, to assess the result heterogeneity, and to determine cumulative evidence and the trend of the prevalence over time. Relevant studies were retrieved from PubMed, Scopus, and Web of Science. A random-effects model was used to calculate the pooled prevalence of VRE in food of animal origin. Subgroup meta-analysis was used to assess the heterogeneity of the results. A cumulative meta-analysis and meta-regression were conducted to determine cumulative evidence and the trend of the prevalence of VRE in food of animal origin over time, respectively. Of the 1352 retrieved studies, 50 articles were included. The pooled prevalence of VRE in food of animal origin was 11.7% (95% confidence interval [95% CI] = 8.4 to 16.0). Subgroup meta-analyses showed a significant difference in the prevalence of VRE for two characteristics. First, for the source of food, the prevalence of VRE was highest in aquatic food (43.4% [95% CI = 28.4 to 59.7]) and lowest in dairy food (4.1% [95% CI = 1.7 to 9.8]). Second, for continents, the prevalence of VRE was highest in Africa (18.5% [95% CI = 12.8 to 26.1]) and lowest in North America (0.3% [95% CI = 0.1 to 1.1]). Cumulative evidence showed two distinct features in two different periods. The pooled prevalence of VRE rapidly decreased from 79.3% in 1998 to 13.1% in 2003; it has slightly fluctuated between 10.5% and 20.5% since 2004. The results of the meta-regression indicated that the prevalence gradually decreased over time. In conclusion, the estimate of overall VRE prevalence worldwide in food of animal origin was ∼12%, indicating the burden of VRE contamination in food of animal origin.

Prevalence of vancomycin-resistant enterococci in Asia-A systematic review and meta-analysis

WHAT IS KNOWN AND OBJECTIVE

The rise of vancomycin-resistant enterococci (VRE) has been a major health problem in most countries of the world including Asia, since its discovery. There is a paucity of data on VRE in many countries of Asia as well as limited pooled estimates. Therefore, we performed a systematic review and meta-analysis to estimate a pooled prevalence of VRE in Asia.

METHODS

A literature search in electronic databases like PubMed, Embase and Google Scholar and manual searching of references and grey literature, comprising the information on the prevalence of VRE with at least two species of enterococci, conducted in different countries of Asia from January 1, 2000, to September 20, 2020, was done. The random-effect model and 95% CIs was used to calculate the pooled prevalence. Subgroup, sensitivity and meta-regression analyses were performed to address heterogeneity while Egger's test for publication bias.

RESULTS AND DISCUSSIONS

We identified 39 studies, comprising a total of 11,875 enterococcal isolates. The result of the analysis showed that the pooled prevalence of VRE in Asia was 8.10% (95% CI; 7-9; I²  = 93.79%; p < 0.001). Resistance to vancomycin was greater among strains of E. faecium compared to the strains of E. faecalis (22.40% vs. 3.70%). Amongst various regions of Asia, the highest prevalence of VRE was found in the Western Asian region and the lowest in the South-east Asian region. Moreover, the rate of VRE was higher than most European countries and lower than USA.

WHAT IS NEW AND CONCLUSIONS

With an upsurge of VRE in Asia in recent years, efficient infection control programmes, robust surveillance systems and adherence to antibiotic stewardship are paramount to halt the further rise of VRE.

The Prevalence of Virulent and Multidrug-Resistant Enterococci in River Water and in Treated and Untreated Municipal and Hospital Wastewater

The aim of this study is to describe the drug resistance and virulence of enterococci in river water sampled downstream (DRW) and upstream (URW) from the wastewater discharge point, to determine the pool of virulent and drug-resistant enterococci in untreated wastewater (UWW) and the extent to which these bacteria are eliminated from hospital wastewater (HWW) and municipal wastewater treated (TWW) by biological and mechanical methods in a wastewater treatment plant (WWTP). A total of 283 strains were identified with the use of culture-dependent methods and PCR, including seven different species including E. faecalis and E. faecium which were predominant in all analyzed samples. Majority of the strains were classified as multidrug resistant (MDR), mostly on streptomycin and trimethoprim. Strains isolated from wastewater and DRW harbored van genes conditioning phenotypic resistance to vancomycin, the highest percentage of vancomycin-resistant strains (57.0%), mostly strains harboring vanC1 genes (27.6%), was noted in TWW. More than 65.0% of the isolated strains had different virulence genes, the highest number of isolates were positive for cell wall adhesin efaA and sex pheromones cob, cpd, and ccf which participate in the induction of virulence. Many of the strains isolated from TWW were resistant to a higher number of drugs and were more virulent than those isolated from UWW and HWW. The enterococci isolated from DRW and wastewater were characterized by similar multidrug resistance and virulence profiles, and significant correlations were observed between these groups of isolates. These findings suggest that pathogenic enterococci are released with TWW and can spread in the river, pose a serious epidemiological threat and a risk to public health.

A systematic review and meta-analysis on the prevalence of vancomycin-resistant enterococci (VRE) among Nigerians

BACKGROUND

Enterococci are opportunistic pathogens and are one of the most important bacteria in hospital-acquired infections. Their resistance to antibiotics such as vancomycin has led to life-threatening and difficult-to-treat nosocomial infections. The true prevalence in clinical settings in Nigeria is not well known due to the lack of a comprehensive antibiotic surveillance system. This study aims to estimate the prevalence of vancomycin-resistant enterococci (VRE) in clinical infections in Nigeria.

METHODS

Databases (PubMed, African Journal Online, and Google scholar) were searched following the Preferred Reporting Items for Systematic review and meta-analysis protocols (PRISMA-P) 2015 statements for articles reporting VRE prevalence, and were published before August 5, 2020. Data from the studies were extracted and analyzed using Microsoft Excel and Comprehensive Meta-Analysis (CMA 3.0), respectively. The pooled prevalence of VRE was estimated with the random-effects model and the 95% confidence interval (CI). The heterogeneity level was assessed using Cochran Q and I 2 tests.

RESULTS

A total of 35 articles were scanned for eligibility, among which 7 were included in the study after fulfilling the eligibility criteria. The studies analyzed a total of 832 enterococci isolates and 90 VRE strains. The prevalence of Enterococcus faecium and E faecalis in this study are 361 (59.3%) and 248 (40.7%), respectively, among which 41 (63.1%) of the E faecium and 24 (36.9%) of the E faecalis were vancomycin resistant. The pooled prevalence of VRE was estimated at (95% CI; 10.0-53.9%; I 2 = 93.50%; P < .001). The highest prevalence of VRE was reported from western Nigeria, 14.6% (95% CI; I 2 = 97.27; P < .001).

CONCLUSION

The prevalence of VRE in Nigeria according to the reports from this study is relatively high. The report of this study should help policymakers to put in place measures that will help curb the spread of VRE and associated resistant genes to other important clinical pathogens like Staphylococcus aureus.

Vancomycin-Resistant Enterococci (VRE) in Nigeria: The First Systematic Review and Meta-Analysis

Vancomycin-Resistant Enterococci (VRE) are on the rise worldwide. Here, we report the first prevalence of VRE in Nigeria using systematic review and meta-analysis. International databases MedLib, PubMed, International Scientific Indexing (ISI), Web of Science, Scopus, Google Scholar, and African journals online (AJOL) were searched. Information was extracted by two independent reviewers, and results were reviewed by the third. Two reviewers independently assessed the study quality using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. OpenMeta analyst was used. The random effect was used, and publication bias was assessed using a funnel plot. Between-study heterogeneity was assessed, and the sources were analysed using the leave-one-out meta-analysis, subgroup analysis, and meta-regression. Nineteen studies met the eligibility criteria and were added to the final meta-analysis, and the study period was from 2009–2018. Of the 2552 isolates tested, 349 were VRE, and E. faecalis was reported the most. The pooled prevalence of VRE in Nigeria was estimated at 25.3% (95% CI; 19.8–30.8%; I² = 96.26%; p < 0.001). Between-study variability was high (t² = 0.011; heterogeneity I² = 96.26% with heterogeneity chi-square (Q) = 480.667, degrees of freedom (df) = 18, and p = 0.001). The funnel plot showed no publication bias, and the leave-one-out forest plot did not affect the pooled prevalence. The South-East region had a moderate heterogeneity though not significant (I² = 51.15%, p = 0.129). Meta-regression showed that all the variables listed contributed to the heterogeneity except for the animal isolate source (p = 0.188) and studies that were done in 2013 (p = 0.219). Adherence to proper and accurate antimicrobial usage, comprehensive testing, and continuous surveillance of VRE are required.