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Rogers LA, Strong K, Cork SC, McAllister TA, Liljebjelke K, Zaheer R, Checkley SL. The Role of Whole Genome Sequencing in the Surveillance of Antimicrobial Resistant Enterococcus spp.: A Scoping Review. Front Public Health 2021; 9:599285. [PMID: 34178909 PMCID: PMC8222819 DOI: 10.3389/fpubh.2021.599285] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 05/04/2021] [Indexed: 12/19/2022] Open
Abstract
Enterococcus spp. have arisen as important nosocomial pathogens and are ubiquitous in the gastrointestinal tracts of animals and the environment. They carry many intrinsic and acquired antimicrobial resistance genes. Because of this, surveillance of Enterococcus spp. has become important with whole genome sequencing emerging as the preferred method for the characterization of enterococci. A scoping review was designed to determine how the use of whole genome sequencing in the surveillance of Enterococcus spp. adds to our knowledge of antimicrobial resistance in Enterococcus spp. Scoping review design was guided by the PRISMA extension and checklist and JBI Reviewer's Guide for scoping reviews. A total of 72 articles were included in the review. Of the 72 articles included, 48.6% did not state an association with a surveillance program and 87.5% of articles identified Enterococcus faecium. The majority of articles included isolates from human clinical or screening samples. Significant findings from the articles included novel sequence types, the increasing prevalence of vancomycin-resistant enterococci in hospitals, and the importance of surveillance or screening for enterococci. The ability of enterococci to adapt and persist within a wide range of environments was also a key finding. These studies emphasize the importance of ongoing surveillance of enterococci from a One Health perspective. More studies are needed to compare the whole genome sequences of human enterococcal isolates to those from food animals, food products, the environment, and companion animals.
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Affiliation(s)
- Lindsay A Rogers
- Department of Ecosystem and Public Health, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Kayla Strong
- Department of Ecosystem and Public Health, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Susan C Cork
- Department of Ecosystem and Public Health, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Tim A McAllister
- Lethbridge Research and Development Centre, Agriculture and Agri-Food Canada, Lethbridge, AB, Canada
| | - Karen Liljebjelke
- Department of Ecosystem and Public Health, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Rahat Zaheer
- Lethbridge Research and Development Centre, Agriculture and Agri-Food Canada, Lethbridge, AB, Canada
| | - Sylvia L Checkley
- Department of Ecosystem and Public Health, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
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Incidence of genes encoding vanA/vanB vancomycin resistance in rectal swabs of patients with diagnosed cancer, on the day of admission to hospital, in a non-epidemic period. GASTROENTEROLOGY REVIEW 2020; 15:220-224. [PMID: 33005267 PMCID: PMC7509899 DOI: 10.5114/pg.2020.98537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/20/2019] [Indexed: 11/17/2022]
Abstract
Introduction Rapid diagnosis is important for preventing infections due to vancomycin-resistant enterococci. Aim To evaluate the status of gastrointestinal colonisation with strains containing vanA/vanB genes in oncological patients. Material and methods A total of 167 samples of rectal swabs taken from 161 patients (mean age: 63, range: 29-93 years) were examined, including 113 patients from surgical wards (70.2%) and 48 patients from non-surgical wards (29.8%), with diagnosed cancer. The tests were carried out within 24 h of admitting the patient to the department, using the Cepheid Xpert vanA/vanB test, with a CE marked GeneXpert® Instrument Systems analyser. Samples with positive vanB gene results were additionally seeded on chromogenic media. Results The presence of the vanA gene was found in 2.7% and 6.3% of the examined patients, respectively, from the surgical and non-surgical departments, which accounted for 3.7% of all the patients examined. The presence of the vanB gene was detected in 21.1% of the patients, but in no case was there any growth of vancomycin-resistant enterococci on the chromogenic medium. Conclusions Patients admitted to non-surgical wards were more often colonised with vanA/vanB genes than were patients admitted to surgical wards, but the differences were not statistically significant.
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Janes VA, Notermans DW, Spijkerman IJ, Visser CE, Jakobs ME, van Houdt R, Willems RJ, de Jong MD, Schultsz C, Matamoros S. Amplified fragment length polymorphism and whole genome sequencing: a comparison of methods in the investigation of a nosocomial outbreak with vancomycin resistant enterococci. Antimicrob Resist Infect Control 2019; 8:153. [PMID: 31572571 PMCID: PMC6757385 DOI: 10.1186/s13756-019-0604-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 08/30/2019] [Indexed: 12/19/2022] Open
Abstract
Background Recognition of nosocomial outbreaks with antimicrobial resistant (AMR) pathogens and appropriate infection prevention measures are essential to limit the consequences of AMR pathogens to patients in hospitals. Because unrelated, but genetically similar AMR pathogens may circulate simultaneously, rapid high-resolution molecular typing methods are needed for outbreak management. We compared amplified fragment length polymorphism (AFLP) and whole genome sequencing (WGS) during a nosocomial outbreak of vancomycin-resistant Enterococcus faecium (VRE) that spanned 5 months. Methods Hierarchical clustering of AFLP profiles was performed using unweighted pair-grouping and similarity coefficients were calculated with Pearson correlation. For WGS-analysis, core single nucleotide polymorphisms (SNPs) were used to calculate the pairwise distance between isolates, construct a maximum likelihood phylogeny and establish a cut-off for relatedness of epidemiologically linked VRE isolates. SNP-variations in the vanB gene cluster were compared to increase the comparative resolution. Technical replicates of 2 isolates were sequenced to determine the number of core-SNPs derived from random sequencing errors. Results Of the 721 patients screened for VRE carriage, AFLP assigned isolates of 22 patients to the outbreak cluster. According to WGS, all 22 isolates belonged to ST117 but only 21 grouped in a tight phylogenetic cluster and carried vanB resistance gene clusters. Sequencing of technical replicates showed that 4-5 core-SNPs were derived by random sequencing errors. The cut-off for relatedness of epidemiologically linked VRE isolates was established at ≤7 core-SNPs. The discrepant isolate was separated from the index isolate by 61 core-SNPs and the vanB gene cluster was absent. In AFLP analysis this discrepant isolate was indistinguishable from the other outbreak isolates, forming a cluster with 92% similarity (cut-off for identical isolates ≥90%). The inclusion of the discrepant isolate in the outbreak resulted in the screening of 250 patients and quarantining of an entire ward. Conclusion AFLP was a rapid and affordable screening tool for characterising hospital VRE outbreaks. For in-depth understanding of the outbreak WGS was needed. Compared to AFLP, WGS provided higher resolution typing of VRE isolates with implications for outbreak management.
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Affiliation(s)
- Victoria A. Janes
- Amsterdam UMC, University of Amsterdam, Medical Microbiology, Amsterdam, The Netherlands
| | - Daan W. Notermans
- Amsterdam UMC, University of Amsterdam, Medical Microbiology, Amsterdam, The Netherlands
| | - Ingrid J.B. Spijkerman
- Amsterdam UMC, University of Amsterdam, Medical Microbiology, Amsterdam, The Netherlands
| | - Caroline E. Visser
- Amsterdam UMC, University of Amsterdam, Medical Microbiology, Amsterdam, The Netherlands
| | - Marja E. Jakobs
- Amsterdam UMC, University of Amsterdam, Clinical Genetics, Core Facility Genomics, Amsterdam, The Netherlands
| | - Robin van Houdt
- Amsterdam UMC, Vrije Universiteit, Medical Microbiology, Amsterdam, The Netherlands
| | - Rob J.L. Willems
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Menno D. de Jong
- Amsterdam UMC, University of Amsterdam, Medical Microbiology, Amsterdam, The Netherlands
| | - Constance Schultsz
- Amsterdam UMC, University of Amsterdam, Medical Microbiology, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Global Health - Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, The Netherlands
| | - Sébastien Matamoros
- Amsterdam UMC, University of Amsterdam, Medical Microbiology, Amsterdam, The Netherlands
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Molecular analysis and epidemiological typing of Vancomycin-resistant Enterococcus outbreak strains. Sci Rep 2019; 9:11917. [PMID: 31417140 PMCID: PMC6695431 DOI: 10.1038/s41598-019-48436-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 08/05/2019] [Indexed: 12/14/2022] Open
Abstract
Outbreaks of multidrug resistant bacteria including vancomycin-resistant enterococci (VRE) in healthcare institutions are increasing in Norway, despite a low level of resistance compared to other European countries. In this study, we describe epidemiological relatedness of vancomycin-resistant Enterococcus faecium isolated during an outbreak at a Norwegian hospital in 2012–2013. During the outbreak, 9454 fecal samples were screened for VRE by culture and/or PCR. Isolates from 86 patients carrying the vanA resistance gene were characterized using pulsed-field gel electrophoresis (PFGE), MALDI-TOF mass spectrometry and single nucleotide polymorphism typing. PFGE revealed two main clusters, the first comprised 56 isolates related to an initial outbreak strain, and the second comprised 21 isolates originating from a later introduced strain, together causing two partly overlapping outbreaks. Nine isolates, including the index case were not related to the two outbreak clusters. In conclusion, the epidemiological analyses show that the outbreak was discovered by coincidence, and that infection control measures were successful. All typing methods identified the two outbreak clusters, and the experiment congruence between the MALDI-TOF and the PFGE clustering was 63.2%, with a strong correlation (r = 72.4%). Despite lower resolution compared to PFGE, MALDI-TOF may provide an efficient mean for real-time monitoring spread of infection.
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Flipse J, von Wintersdorff CJH, van Niekerk JM, Jamin C, van Tiel FH, Hasman H, van Alphen LB. Appearance of vanD-positive Enterococcus faecium in a tertiary hospital in the Netherlands: prevalence of vanC and vanD in hospitalized patients. Sci Rep 2019; 9:6949. [PMID: 31061446 PMCID: PMC6502811 DOI: 10.1038/s41598-019-42824-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 02/14/2019] [Indexed: 02/06/2023] Open
Abstract
Vancomycin-resistant enterococci (VRE) can rapidly spread through hospitals. Therefore, our hospital employs a screening program whereby rectal swabs are screened for the presence of vanA and vanB, and only PCR-positive broths are cultured on VRE selection agar. Early November 2016, a clinical vanA-/vanB-negative VRE isolate was detected in a vanA/vanB-screening-negative patient, giving the possibility that an undetected VRE might be spreading within our hospital. Whole-genome-sequencing of the isolate showed that resistance was vanD-mediated and core genome multilocus sequence typing showed it was a rare type: ST17/CT154. To determine the prevalence of vanA/B/C/D-carrying enterococci, we designed a real-time PCR for vanC1/2/3 and vanD and screened rectal swabs from 360 patients. vanD was found in 27.8% of the patients, yet culture demonstrated only E. faecium from vanA-positive broths and E. gallinarum from vanC1-positive broths. No vanD-positive VRE were found, limiting the possibility of nosocomial spread of this VRE. Moreover, the high prevalence of non-VRE vanD in rectal swabs makes it unfeasible to include the vanD PCR in our VRE screening. However, having validated the vanC1/2/3 and vanD PCRs allows us to rapidly check future vanA/B-negative VRE for the presence of vanC and vanD genes.
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Affiliation(s)
- Jacky Flipse
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center+, Maastricht, The Netherlands. .,Laboratory for Medical Microbiology and Infectious Diseases, Isala Clinics, Zwolle, The Netherlands.
| | - Christian J H von Wintersdorff
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Julius M van Niekerk
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Casper Jamin
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Frank H van Tiel
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Henrik Hasman
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Lieke B van Alphen
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center+, Maastricht, The Netherlands.
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Dziri R, El Kara F, Barguellil F, Ouzari HI, El Asli MS, Klibi N. Vancomycin-ResistantEnterococcus faeciumin Tunisia: Emergence of Novel Clones. Microb Drug Resist 2019; 25:469-474. [DOI: 10.1089/mdr.2018.0158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Raoudha Dziri
- Laboratory of Microorganisms and Active Biomolecules, Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Feriel El Kara
- Service of Microbiology, Military Hospital of Tunis HMPIT, Tunis, Tunisia
- Department of Microbiology, Faculty of Pharmacy, University of Monastir, Tunisia
| | - Farouk Barguellil
- Service of Microbiology, Military Hospital of Tunis HMPIT, Tunis, Tunisia
- Department of Microbiology, Faculty of Pharmacy, University of Monastir, Tunisia
| | - Hadda-Imen Ouzari
- Laboratory of Microorganisms and Active Biomolecules, Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Mohamed Selim El Asli
- Service of Microbiology, Military Hospital of Tunis HMPIT, Tunis, Tunisia
- Department of Microbiology, Faculty of Pharmacy, University of Monastir, Tunisia
| | - Naouel Klibi
- Laboratory of Microorganisms and Active Biomolecules, Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Burcham ZM, Schmidt CJ, Pechal JL, Brooks CP, Rosch JW, Benbow ME, Jordan HR. Detection of critical antibiotic resistance genes through routine microbiome surveillance. PLoS One 2019; 14:e0213280. [PMID: 30870464 PMCID: PMC6417727 DOI: 10.1371/journal.pone.0213280] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 02/18/2019] [Indexed: 12/29/2022] Open
Abstract
Population-based public health data on antibiotic resistance gene carriage is poorly surveyed. Research of the human microbiome as an antibiotic resistance reservoir has primarily focused on gut associated microbial communities, but data have shown more widespread microbial colonization across organs than originally believed, with organs previously considered as sterile being colonized. Our study demonstrates the utility of postmortem microbiome sampling during routine autopsy as a method to survey antibiotic resistance carriage in a general population. Postmortem microbial sampling detected pathogens of public health concern including genes for multidrug efflux pumps, carbapenem, methicillin, vancomycin, and polymixin resistances. Results suggest that postmortem assessments of host-associated microbial communities are useful in acquiring community specific data while reducing selective-participant biases.
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Affiliation(s)
- Zachary M. Burcham
- Department of Biological Sciences, Mississippi State University, Starkville, MS, United States of America
| | - Carl J. Schmidt
- Department of Pathology, University of Michigan, Ann Arbor, MI, United States of America
| | - Jennifer L. Pechal
- Department of Entomology, Michigan State University, East Lansing, MI, United States of America
| | - Christopher P. Brooks
- Department of Biological Sciences, Mississippi State University, Starkville, MS, United States of America
| | - Jason W. Rosch
- Department of Infectious Disease, St. Jude Children’s Research Hospital, Memphis, TN, United States of America
| | - M. Eric Benbow
- Department of Entomology, Michigan State University, East Lansing, MI, United States of America
- Department of Osteopathic Medical Specialties, Michigan State University, East Lansing, MI, United States of America
| | - Heather R. Jordan
- Department of Biological Sciences, Mississippi State University, Starkville, MS, United States of America
- * E-mail:
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Morfin-Otero R, Perez-Gomez HR, Gonzalez-Diaz E, Esparza-Ahumada S, Rodriguez-Noriega E. Enterococci as Increasing Bacteria in Hospitals: Why Are Infection Control Measures Challenging for This Bacteria? CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0166-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Frakking FNJ, Bril WS, Sinnige JC, Klooster JEV, de Jong BAW, van Hannen EJ, Tersmette M. Recommendations for the successful control of a large outbreak of vancomycin-resistant Enterococcus faecium in a non-endemic hospital setting. J Hosp Infect 2018; 100:e216-e225. [PMID: 29475013 DOI: 10.1016/j.jhin.2018.02.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 02/14/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND A large outbreak of three epidemic vancomycin-resistant Enterococcus faecium (VRE) clones affected the study hospital for almost two years. AIM To describe the strategy to successfully control this outbreak and eradicate VRE from the study hospital. METHODS Infection control interventions started after detection of VRE in three patients. Hospital-wide surveillance was started after ongoing transmission despite isolation precautions, cleaning and contact tracing. Hygiene education and discipline were enhanced. Despite these interventions, additional measures were required to control the outbreak, such as ward disinfection with hydrogen peroxide vapour and the introduction of a VRE quarantine ward. Ultimately, ciprofloxacin prophylaxis for haematological patients on chemotherapy was abandoned. FINDINGS Over a 22-month period, 242 VRE carriers were identified. Of these, 128 (53%) patients were detected by hospital-wide surveillance alone. Three epidemic clones were detected: ST494-vanA (N = 160), ST78-vanA (N = 23) and ST117-vanB (N = 32). In total, 5614 possible contacts were identified. VRE transmission occurred on 13 out of 23 wards. VRE was cultured from clinical specimens in 22 patients (seven with bacteraemia). Since January 2014, no further transmission of these VRE clones has been observed. CONCLUSION Infection control measures according to international guidelines were insufficient to expose the outbreak to its full extent and control it. Its full extent only became apparent after sustained hospital-wide screening. Successful control of this hospital-wide VRE outbreak was feasible, but required great effort. Final containment and eradication of the epidemic clones was achieved by environmental decontamination with hydrogen peroxide vapour, strict isolation precautions, a VRE quarantine ward and antimicrobial stewardship.
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Affiliation(s)
- F N J Frakking
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein and Utrecht, The Netherlands; Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - W S Bril
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein and Utrecht, The Netherlands
| | - J C Sinnige
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein and Utrecht, The Netherlands; Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J E Van't Klooster
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein and Utrecht, The Netherlands
| | - B A W de Jong
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein and Utrecht, The Netherlands
| | - E J van Hannen
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein and Utrecht, The Netherlands
| | - M Tersmette
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein and Utrecht, The Netherlands
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Both A, Franke GC, Mirwald N, Lütgehetmann M, Christner M, Klupp EM, Belmar Campos C, Büttner H, Aepfelbacher M, Rohde H. Two-tier approach combining molecular and culture-based techniques for optimized detection of vancomycin-resistant enterococci. Diagn Microbiol Infect Dis 2017; 89:253-257. [DOI: 10.1016/j.diagmicrobio.2017.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/15/2017] [Accepted: 08/17/2017] [Indexed: 11/29/2022]
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Garvey M, Bradley C, Casey A, Clewer V, Holden E. Using a vanA polymerase chain reaction to detect environmental contamination during a vancomycin-resistant enterococci outbreak. J Hosp Infect 2017; 97:419-421. [DOI: 10.1016/j.jhin.2017.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 08/16/2017] [Indexed: 10/19/2022]
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Ahmed MO, Baptiste KE. Vancomycin-Resistant Enterococci: A Review of Antimicrobial Resistance Mechanisms and Perspectives of Human and Animal Health. Microb Drug Resist 2017; 24:590-606. [PMID: 29058560 DOI: 10.1089/mdr.2017.0147] [Citation(s) in RCA: 220] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Vancomycin-resistant enterococci (VRE) are both of medical and public health importance associated with serious multidrug-resistant infections and persistent colonization. Enterococci are opportunistic environmental inhabitants with a remarkable adaptive capacity to evolve and transmit antimicrobial-resistant determinants. The VRE gene operons show distinct genetic variability and apparently continued evolution leading to a variety of antimicrobial resistance phenotypes and various environmental and livestock reservoirs for the most common van genes. Such complex diversity renders a number of important therapeutic options including "last resort antibiotics" ineffective and poses a particular challenge for clinical management. Enterococci resistance to glycopeptides and multidrug resistance warrants attention and continuous monitoring.
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Affiliation(s)
- Mohamed O Ahmed
- 1 Department of Microbiology and Parasitology, Faculty of Veterinary Medicine, University of Tripoli , Tripoli, Libya
| | - Keith E Baptiste
- 2 Department of Veterinary Medicine, Danish Medicines Agency , Copenhagen South, Denmark
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