Analysis of a persistent outbreak with vancomycin resistant Enterococcus faecium (VREfm) revealed the need for an adapted diagnostic algorithm

Abstract

Our setting was challenged with an outbreak of different vancomycin resistant Enterococcus faecium (VREfm) including vanA and/or vanB containing isolates. Remarkably, it was observed that screening by use of a vanA and vanB real-time PCR on overnight enriched specimens from time to time tested positive for VanB with very low Ct-values, whereas VREfm-specific enrichment cultures remained negative. Here, we describe the analysis of the diagnostic results leading to adaptation of the diagnostic algorithm. Per specimen of each patient, results of the vanA and vanB screening PCR and of the VREfm-specific culture (Brilliance VRE) were collected and combined with genotyping data of the identified VREfm isolates. During the outbreak, a second VREfm-specific culture medium (CHROMagar VRE) was introduced, and results were compared to the results obtained with Brilliance VRE agar. Thirty-five patients were identified as VREfm-carrier, in which four different strains were identified comprising vanA (STnew-CT7088) and/or vanB (ST80-CT1065, ST117-CT7117 and ST117-CT7118). Complementing results of PCR, culture and genotyping revealed that culture with Brilliance VRE agar was inadequate for detection of the vanB ST117 isolates identified, irrespective of vancomycin MIC values. In contrast, CHROMagar VRE was able to correctly detect these vanB ST117 isolates and other tested isolates. Our data showed that the vanB ST117 containing isolates were inadequately detected by the VREfm-specific culture media, possibly contributing to unnoticed spread of VREfm. For this reason, CHROMagar VRE was evaluated during the outbreak and subsequently implemented in routine diagnostics, replacing Brilliance VRE agar.