Glycopeptide-resistant Enterococci Research Articles

Estimating the morbidity and mortality associated with infections due to multidrug-resistant bacteria (MDRB), France, 2012.

BackgroundA study based on 2007 data estimated that 386,000 infections due to multidrug-resistant bacteria (MDRB) occurred in Europe that year and 25,000 patients died from these infections. Our objective was to estimate the morbidity and mortality associated with these infections in France.MethodsThe MDRB considered were methicillin-resistant Staphylococcus aureus (MRSA), glycopeptide-resistant enterococci, third-generation cephalosporin-resistant (3GC-R) Escherichia coli and Klebsiella pneumoniae, carbapenem-resistant Klebsiella pneumoniae, Acinetobacter spp. and Pseudomonas aeruginosa (CR P. aeruginosa). The number of invasive infections (infections with bacteria isolated from blood or cerebrospinal fluid) due to MDRB, as reported by France to EARS-Net in 2012, was corrected for the coverage of our surveillance network and extrapolated to other body sites using ratios from the French healthcare-associated infections point prevalence survey and the literature. Mortality associated with MDRB infection was estimated using proportions from the literature. Methods and parameters were reviewed by a panel of experts.ResultsWe estimate that 158,000 (127,000 to 245,000) infections due to MDRB occurred in 2012 in France (incidence: 1.48 to 2.85 per 1000 hospital days), including 16,000 invasive infections. MRSA, 3GC-R E. coli and K. pneumoniae were responsible for 120,000 (90,000 to 172,000) infections, i.e., 75% of the total. An estimated 12,500 (11,500 to 17,500) deaths were associated with these infections, including 2,700 associated with invasive infections. MRSA, 3GC-R E. coli and CR P. aeruginosa accounted for 88% of these deaths.ConclusionThese first estimates confirm that MRSA, 3GC-R Escherichia coli and Klebsiella pneumoniae account for the largest portion of the morbidity and mortality of infections due to MDRB in France. These results are not directly comparable with the European study because the methodology used differs in many respects. The differences identified between our study and previous studies underline the need to define a standardised protocol for international assessments of the morbidity and mortality of antibiotic resistance. Estimating morbidity and mortality will facilitate communication and awareness in order to reinforce adherence and support of healthcare professionals and policy-makers to MDRB prevention programs.Electronic supplementary materialThe online version of this article (doi:10.1186/s13756-016-0154-z) contains supplementary material, which is available to authorized users.

Factors associated with acquisition of glycopeptide-resistant enterococci during a single-strain outbreak

Factors associated with acquisition of glycopeptide-resistant enterococci during a single-strain outbreak

Rapid discrimination of Enterococcus faecium strains using phenotypic analytical techniques

Clinical isolates of glycopeptide resistant enterococci (GRE) were used to compare three rapid phenotyping and analytical techniques.

Costs associated with implementation of a strict policy for controlling spread of highly resistant microorganisms in France

ObjectiveTo assess costs associated with implementation of a strict ‘search and isolate’ strategy for controlling highly drug-resistant organisms (HDRO).DesignReview of data from 2-year prospective surveillance (01/2012 to 12/2013) of HDRO.SettingThree...

TREATMENT CHALLENGES IN ENTEROCOCCUS FAECIUM SEPSIS AND CLOSTRIDIUM DIFFICILE DIARRHEA IN A PATIENT WITH B-CELL NON-HODGKIN LYMPHOMA – CASE REPORT

The risk of developing secondary infections in immunocompromised patients due to hematological malignancies and the treatments for such conditions is very well known. Fever can be the only manifestation of a serious infection among this category of patients. The degree and duration of neutropenia is directly related to the risk of multiple infectious complications. When we are dealing with severely impaired host defenses virtually any microorganism can become invasive, bacteria (gram-positive pathogens, but gram-negative as well), being the greatest immediate threat. Multiple pathogens isolated from an immunocompromised host can represent a major challenge for the clinician, especially when we have to face multidrug resistant (MDR) microorganisms, also called “superbugs”. Besides, when we confront such a patient with many comorbidities and a high risk for MDR pathogens infection, we also confront with a lot of limitations in terms of treatment options. We present a complicated case of glycopeptide-resistant Enterococcus faecium sepsis secondary to Clostridium difficile colitis in a 63 years old female patient with B-cell non-Hodgkin Lymphoma (NHL) during the R-CHOP therapy.

Maîtrise de la diffusion des entérobactéries productrices de carbapénémases : épidémiologie, stratégies de prévention et enjeux

The increasing bacterial resistance to antibiotics has become a major public health concern bringing the threat of therapeutic impasses. In this context, control of the spread of highly-resistant bacteria emerging antibiotics (BHRe), such as glycopeptide-resistant enterococci (VRE) and Enterobacteriaceae producing carbapenemases (CPE), is based on a dual strategy of reducing the prescription of antibiotics to limit the pressure selection and preventing the spread from carriers. Prevention strategy is based on three different levels such as standard precautions for all patients with a particular focus on the management of excreta, and additional precautions for BHRe carriers. What makes it difficult is that carriage is usually completely asymptomatic, enterobacteria and enterococci are normal commensal of gut microbiota. Explosive dissemination of Enterobacteriaceae producing extended spectrum beta-lactamases in hospital and community heralds the emergence of CPE whose import by patients with a history of hospitalization in abroad may be the main source of spread in France.

Introduction of highly resistant bacteria into a hospital via patients repatriated or recently hospitalized in a foreign country

We describe the prevalence of carriage and variables associated with introduction of highly drug-resistant microorganisms (HDRMO) into a French hospital via patients repatriated or recently hospitalized in a foreign country. The prevalence of HDRMO was 11% (15/132), with nine carbapenamase-producing Enterobacteriaceae, nine carbapenem-resistant Acinetobacter baumannii and six glycopeptide-resistant enterococci. Half of the admitted patients (63/132, 48%) were colonized with extended spectrum beta-lactamase-producing Enterobacteriaceae (ESBLPE). Among the four episodes with secondary cases, three involved A. baumannii.

Homogeneity of antimicrobial policy, yet heterogeneity of antimicrobial resistance: antimicrobial non-susceptibility among 108,717 clinical isolates from primary, secondary and tertiary care patients in London.

ObjectivesWe examined the 4 year trend in antimicrobial susceptibilities and prescribing across levels of care at two London teaching hospitals and their multisite renal unit, and for the surrounding community.MethodsLaboratory and pharmacy information management systems were interrogated, with antimicrobial use and susceptibilities analysed between hospitals, within hospitals and over time.ResultsA total of 108 717 isolates from 71 687 patients were identified, with significant differences (at P < 0.05) in antimicrobial susceptibility between and within hospitals. Across the 4 years, rates of ESBL-/AmpC-producing Enterobacteriaceae ranged from 6.4% to 10.7% among community isolates, 17.8% to 26.9% at ward level and 25.2% to 52.5% in critical care. Significant variations were also demonstrated in glycopeptide-resistant enterococci (ward level 6.2%–17.4%; critical care 21.9%–56.3%), MRSA (ward level 18.5%–38.2%; critical care 12.5%–47.9%) and carbapenem-resistant Pseudomonas spp. (ward level 8.3%–16.9%; critical care 19.9%–53.7%). Few instances of persistently higher resistance were seen between the hospitals in equivalent cohorts, despite persistently higher antimicrobial use in Hospital 1 than Hospital 2. We found significant fluctuations in non-susceptibility year on year across the cohorts, but with few persistent trends.ConclusionsThe marked heterogeneity of antimicrobial susceptibilities between hospitals, within hospitals and over time demands detailed, standardized surveillance and appropriate benchmarking to identify possible drivers and effective interventions. Homogeneous antimicrobial policies are unlikely to continue to be suitable as individual hospitals join hospital networks, and policies should be tailored to local resistance rates, at least at the hospital level, and possibly with finer resolution, particularly for critical care.

Les bactéries à Gram positives multirésistantes : probabilités de résistance ? Que craindre ?

Antibiotic resistance in Gram-positive bacteria already has a significant impact on morbidity and mortality. The situation is particularly alarming in the case of methicillin-resistant Staphylococcus aureus and glycopeptide-resistant Enterococcus faecium, which have shown an ability to spread to new ecological niches and to generate new clones with both increased drug resistance and increased virulence. The potential for genetic exchanges between these two species raises the specter of highly resistant and virulent S. aureus strains.

Susceptibility of Glycopeptide-Resistant Enterococci to Linezolid, Quinupristin/dalfopristin, Tigecycline and Daptomycin in a Tertiary Greek Hospital.

We investigated the antibiotic susceptibility of glycopeptide-resistant enterococci (GRE). Seventy consecutive GRE were tested. Sixty-two isolates were identified as Enterococcus faecium (88.6%), and 8 (11.4%) as Enterococcus faecalis. All strains were susceptible to linezolid and daptomycin, while 17.1% (12/70) and 11.4% (8/70) were resistant to quinupristin/dalfopristin (QD) and tigecycline, respectively. All E. faecalis isolates were resistant to QD, while 4 of 62 (6.5%) E. faecium isolates were resistant to QD. All E. faecalis isolates were susceptible to tigecycline, while 14.5% (9/62) E. faecium isolates were resistant. Continued surveillance of GRE antibiotic susceptibilities is important for combating these multi-resistant nosocomial pathogens.

Outbreak in a haematology unit involving an unusual strain of glycopeptide-resistant Enterococcus faecium carrying both vanA and vanB genes

To report an outbreak due to an unusual strain of Enterococcus faecium containing both the vanA and vanB genes, in France, where the rate of glycopeptide-resistant enterococci (GRE) is below 1%. Cases were patients infected or colonized with GRE on the haematology ward. Contact patients were screened by real-time PCR performed on rectal swabs. Clinical features were compared for GRE-positive and GRE-negative patients. GRE isolates were characterized by phenotypic and molecular methods including PFGE. Conjugation experiments were performed to identify van genetic support. After the index patient presented a bacteraemia with vanA/vanB E. faecium, 56 contact patients were screened, 7 of whom were found to be GRE positive: 6 additional cases with vanA/vanB E. faecium and 1 with GRE carrying vanA only. PFGE confirmed the clonal relationship of the seven vanA/vanB E. faecium strains, whereas the vanA isolate was distinct. Only the vanA gene could be transferred to enterococcal recipients by conjugation, and it was probably localized on a mobile genetic element. All isolates were resistant to vancomycin (MIC > 256 mg/L) and teicoplanin (MIC = 24-32 mg/L), but were susceptible to tigecycline (MIC = 0.09 mg/L), linezolid (MIC = 0.75 mg/L) and daptomycin (MIC = 1-2 mg/L). Significant differences (P < 0.001) between carriers and non-carriers of GRE were observed for the median duration of hospitalization (57 days versus 16.5 days) and of neutropenia (40 days versus 6 days), the median number of antibiotics used (5 versus 1.5) and the duration of glycopeptide treatment (14.5 days versus 0 days). vanA/vanB E. faecium strains, although rare, can emerge in the absence of previous outbreaks of vanA-GRE or vanB-GRE.

P090: Importance of the information system in the fight against multi-drug resistant bacteria

Results Overall 41 hospitals (50% of the hospitals in the region) participated in this investigation. 66% of them reported having a system of continuous monitoring of MDRB for the identification of clustered cases and 39% of the hospitals reported having a similar device for the identification of re-hospitalized cases. In addition, 63% of respondents indicated that they did not develop transmission means for the patients with MDRB to inform the hosting facility during a subsequent hospitalization. When a case of patients with MDRB occurs in a hospital, 88% of them track cases of re-hospitalized patients thanks to patient records and not via the administrative software. 57% of the hospitals reported to implement a policy of MDRB monitoring. More than half patients considered to be at risk (eg, multiple hospitalizations, previous history of antibiotic treatment) was concerned in the majority of sectors welcoming patients with emerging MDRB. The most frequently screened MDRB are respectively MRSA (46%), carbapenemase-producing Enterobacteriaceae (44%), glycopeptide-resistant Enterococci (44%) and extended-spectrum beta-lactamase-producing Enterobacteriaceae (41%). Conclusion The components of the MDRB control which are collected within the hospitals of the region have shown critical points, especially in the monitoring of patients with MDRB. Specific policy focusing MDRB should be reinforced in the region. Disclosure of interest None declared.

Rapid detection of glycopeptide-resistant enterococci: impact on decision-making and costs

BackgroundAccording to French national recommendations, the detection of a patient colonized with glycopeptide-resistant enterococci (GRE) leads to interruption of new admissions and transfer of contact patients (CPs) to another unit or healthcare facility, with weekly screening of CPs.FindingsWe evaluated the medical and economic impact of a pragmatic adaptation of national guidelines associated with a real-time PCR (RTP) (Cepheid Xpert™ vanA/vanB) as part of the strategy for controlling GRE spread in two medical wards. Screening was previously performed using chromogenic selective medium (CSM). Turn around time (TAT), costs of tests and cost of missed patient days were prospectively collected. In February 2012, the identification of GRE in one patient in the diabetology ward led to the screening of 31 CPs using CSM; one secondary case was identified in a CP already transferred to the Nephrology ward. Awaiting the results of SCM (median TAT, 70.5 h), 41 potential patient days were missed, due to interruption of admissions. The overall cost (screening tests + missing patient.days) was estimated at 14, 302.20 €. The secondary case led to screening of 22 CPs in the Nephrology ward using RTP. Because of a short median TAT of 4.6 h, we did not interrupt admissions and patients’ transfers. Among 22 CPs, 19 (86%) were negative for vanA, 2 were positive for vanB and 3 had invalid results needing CSM. The overall cost of the strategy was estimated at 870.40 € (cost of screening tests only), without missing patient days.ConclusionThe rapid PCR test for vanA-positive GRE detection both allowed rapid decision about the best infection control strategy and prevented loss of income due to discontinuation of patient transfers and admissions.

Emergence of glycopeptide resistant Enterococcus faecium in Algeria: a case report

A glycopeptide-resistant Enterococcus faecium (EFRG) was isolated from a wound in a patient hospitalized in a university hospital in Algiers. This strain was resistant to several antibiotics. This patient was carrying this strain in the digestive tract which may partly explain its origin. Genotypic comparison of the two strains by pulsed field gel electrophoresis showed that it was the same strain. Glycopeptide resistance was due to the presence of the vanA gene. Vigilance is required facing the emergence of strains of EFRG in our hospitals.

Antibiotic Resistance Mechanisms in the Intensive Care Unit

Antibiotic resistance is increasingly recognised as a major threat to global health, with few new antimicrobial agents in development. The intensive care unit provides a unique environment for the growth and spread of drug-resistant organisms. Knowledge of the pathogenesis and mechanisms of resistance of drug-resistant organisms provides a conceptual framework which underpins the clinical manifestation of infections caused by these organisms, and is crucial for the intensivist to understand. Particular importance lies in the prevention of infection and the control of drug-resistant pathogens. The major resistance mechanisms of these organisms will be highlighted, focusing on specific gram-positive (meticillin-resistant Staphylococcus aureus and glycopeptide-resistant Enterococci), gram-negative ( Pseudomonas aeruginosa, Acinetobacter baumannii and multi-drug resistant Enterobacteriaceae) organisms, and then placed in historical and clinical context.

Resistance patterns and occurrence of virulence determinants among GRE strains in southwestern Poland

The aim of this study was to determine the antimicrobial resistance and the occurrence of virulence determinants among glycopeptide-resistant enterococci (GRE) isolated in 2007-2009 from patients hospitalized in southwestern Poland. The minimal inhibitory concentrations (MICs) of antibiotics were determined by agar dilution method or by E-test®. The presence of vanA - vanG resistance and virulence genes (agg, esp, gelE and cylA, cylB, cylM) was investigated using PCR. The ability to form biofilm and the activity of gelatinase, hemolysins, lipase and DNase were tested. All the GRE strains were susceptible to linezolid, daptomycin, and tigecycline and resistant to norfloxacin. In the Enterococcus faecium group, 17 strains carried the vanA gene and 20 the vanB gene. In the Enterococcu faecalis group, 4 strains carried the vanA gene and 1 the vanB gene. There were differences in tetracycline susceptibility between the VanA (70%) and the VanB (55%) phenotypes. Only linezolid had high activity against both the VanA and the VanB phenotypes. The esp gene was present in most of the GRE strains, but only 3 E. faecalis strains produced biofilm. Lipase was produced by 10/42 examined strains, gelatinase by 4/42 and hemolysin by 3/42 isolates. Linezolid seems to be the optimal option in empirical therapy of infections caused by GRE strains because of the relationship between its activity (MIC value) and susceptibility breakpoint. There was no correlation between the prevalence of different virulence genes and resistance to the antibiotics tested.

Isolation of Enterococcus raffinosus from an ostrich chick with diarrhoea

Enterococci have been incriminated as a cause of opportunistic infections in humans and different animal species. The glycopeptide-resistant Enterococcus raffinosus has been reported as an emerging pathogen in humans recently, but the importance of E. raffinosus in animals is largely unknown. The present manuscript appears to be the first report of isolation of E. raffinosus from animal source; more importantly, the isolated organism showed resistance to vancomycin in conventional antibiotic resistance evaluation methods. The organism was isolated from a 35-day-old ostrich chick suffering from diarrhoea in pure culture. Public health and clinical significance of this emerging pathogen need further attention in veterinary and human medicine.

Antibiotic resistance in bacteria isolated from vegetables with regards to the marketing stage (farm vs. supermarket)

The aim of this study was to elucidate whether and to what extent fresh produce from Germany plays a role as a carrier and reservoir of antibiotic resistant bacteria. For this purpose, 1001 vegetables (fruit, root, bulbous vegetables, salads and cereals) were collected from 13 farms and 11 supermarkets in Germany and examined bacteriologically. Phenotypic resistance of Enterobacter cloacae (n=172); Enterobacter gergoviae (n=92); Pantoea agglomerans (n=96); Pseudomonas aeruginosa (n=295); Pseudomonas putida (n=106) and Enterococcus faecalis (n=100) against up to 30 antibiotics was determined by using the microdilution method. Resistance to ß-lactams was most frequently expressed by P. agglomerans and E. gergoviae against cefaclor (41% and 29%). Relatively high resistance rates were also observed for doxycycline (23%), erythromycin (21%) and rifampicin (65%) in E. faecalis, for spectinomycin (28%) and mezlocillin (12%) in E. cloacae, as well as for streptomycin (19%) in P. putida. In P. aeruginosa, relatively low resistance rates were observed for the aminoglycosides amikacin, apramicin, gentamicin, neomycin, netilmicin and tobramycin (<4%); 11% was resistant to streptomycin. No glycopeptide-resistant enterococci were observed. Resistance rates of bacteria isolated from farm samples were higher than those of the retail markets whenever significant differences were observed. This suggests that expressing resistance is at the expense of bacterial viability, since vegetables purchased directly at the farm are probably fresher than at the supermarket, and they have not been exposed to stress factors. However, this should not keep the customer from buying directly at the farm, since the overall resistance rates were not higher than observed in bacteria from human or animal origin. Instead, peeling or washing vegetables before eating them raw is highly recommended, since it reduces not only the risk of contact with pathogens, but also that of ingesting and spreading antibiotic resistant bacteria.

Control of a regional outbreak of vanA glycopeptide-resistant Enterococcus faecium, Eastern France, 2004–2009

At the end of 2004, an outbreak of glycopeptide-resistant enterococci (GRE) spread from the Nancy Teaching Hospital to more than 40 facilities in the Lorraine region. Because this outbreak appeared to be uninhibited, a regional task force was set up to organize and co-ordinate the management of the outbreak, visiting the affected facilities to publicize the existing recommendations and take stock of the problems encountered in the field. The task force then proposed control measures specific to the region. The proposed measures included promoting the use of alcohol-based hand-rub solutions, isolation measures, enhanced screening policies, cohorting GRE-colonized patients and contacts in special wards with dedicated staff where possible, or failing that, isolating them in single rooms with additional "contact" precautions, maintaining these precautions for GRE-colonized patients until a negative stool sample was obtained after antibiotic treatment (which is a more restrictive definition of "cleared" than usually employed), regional co-ordination of the follow-up of GRE-colonized patients with the weekly publication of a list of institutions that were or had been affected to allow isolation measures to be adopted as soon as known-GRE-colonized patient were readmitted. It was not possible to determine the efficacy of each individual measure on the course of the outbreak. Nevertheless, we observed that the number of new GRE-colonized patients started to decrease following their implementation. Ultimately, 1077 GRE colonizations were recorded in Lorraine, and the outbreak is now under control.

International Transfer of NDM-1-Producing Klebsiella pneumoniae from Iraq to France

The carbapenemase NDM-1 was initially identified in Escherichia and Klebsiella pneumoniae in Sweden from a patient transferred from India (10). Since then, it has been identified in many enterobacterial species and isolates from patients in the United Kingdom, India, and Pakistan (4). In addition, recent reports have indicated the spread of NDM-1 producers in many different countries, including Austria, Australia, Belgium, Canada, Denmark, France, Germany, Kenya, the Netherlands, Norway, the Sultanate of Oman, and the United States (6-9). Most of these reports indicated a likely source of NDM-1 producers located in the Indian subcontinent, with both hospital and community acquisition. However, a detailed analysis of the clinical cases indicated that importation of NDM-1 isolates may also have originated from Balkan countries, such as Kosovo, Serbia, Montenegro, and Bosnia and Herzegovina, which may constitute an additional reservoir for NDM-1 producers (6). A 22-year-old Iraqi male resident in Baghdad was admitted at the Bicetre Hospital (suburb of Paris) on 8 November 2010, following a direct transfer from Baghdad, Iraq. He had been a victim of a terrorist attack at the Baghdad cathedral that killed over 50 people on 31 October 2010. He had a wounded shoulder and was immediately hospitalized at the Ibn Al Nafees Hospital of Baghdad, where he was operated on and stayed for 5 days. At the Bicetre Hospital, he was screened for multidrug-resistant bacteria, including extended-spectrum β-lactamase (ESBL) and carbapenemase producers, methicillin-resistant Staphylococcus aureus, and glycopeptide-resistant enterococci. Rectal swabs grew only on ChromID ESBL culture medium (bioMerieux, La Balme-les-Grottes, France) (5). K. pneumoniae isolate IBN was obtained, which showed resistance or decreased susceptibility to all β-lactams, including carbapenems (the MICs of imipenem, ertapenem, doripenem, and meropenem were 2, 8, 2, and 3 μg/ml, respectively), according to the CLSI's updated guidelines (1). It was also resistant to gentamicin, kanamycin, tobramycin, sulfonamides, rifampin, chloramphenicol, and fluoroquinolones but remained susceptible to amikacin and fosfomycin, the MICs of tigecycline and colistin being 0.25 and 0.5 μg/ml, respectively. The patient did not develop any infection while hospitalized in France. He was neither treated with antibiotics nor decontaminated (actually not recommended for carriage of multidrug-resistant Enterobacteriaceae). PCR, sequencing, and plasmid analysis revealed that K. pneumoniae IBN harbored the blaNDM-1 carbapenemase gene, in addition to a blaCTX-M-15 ESBL gene, each located on a different plasmid (100 and 160 kb in size, respectively). Screening for additional β-lactamase genes and for 16S RNA methylase genes, as reported previously (9), showed that K. pneumoniae IBN was coharboring the blaSHV-11 and blaOXA-1 genes, but no 16S RNA methylase gene was identified. Multilocus sequence typing was performed as described worldwide (3) to evidence a possible link with other recently identified NDM-1-producing K. pneumoniae isolates, and the results were analyzed by eBURST (http://pubmlst.org). The results showed that isolate IBN belonged to the ST147 sequence type, whereas the NDM-1-positive K. pneumoniae 05-506 index strain and K. pneumoniae isolates recovered in India and in the Sultanate of Oman belonged to the ST14 type, both types differing significantly (2, 7). Interestingly, the only report of ST147-type K. pneumoniae so far corresponds to a clonal spread that has been identified in Hungary (2). This Hungarian ST147 clone was susceptible to carbapenems, but it harbored a blaCTX-M-15 plasmid and was resistant to fluoroquinolones (2), as observed for isolate IBN from Iraq. It may therefore be speculated that these isolates could be clonally related. Considering that one of the two NDM-1-producing K. pneumoniae isolates previously identified from Oman could not be traced back to the Indian subcontinent, this report provides an additional clue that the Middle East might also be a reservoir for NDM-1 producers. This result should be taken in account when taking care of any civilian or soldier hospitalized in Iraq and transferred abroad. It also suggests that the spread of NDM-1 producers is already much wider than suspected. Finally, it strengthens the value of systematic screening for multidrug-resistant bacteria for preventing the development of nosocomial outbreaks of carbapenem-resistant Enterobacteriaceae, as recommended in reference 6.