Important Gram-positive Pathogens Research Articles

Immunoproteomic analysis of the antibody response obtained in Nile tilapia following vaccination with a Streptococcus iniae vaccine

Streptococcus iniae is one of the most economically important Gram-positive pathogens in cultured fish species worldwide. The USDA-ARS Aquatic Animal Health Research Unit developed a modified (contains concentrated culture supernatant) S. iniae bacterin that has been demonstrated to be efficacious, and protection is mediated by specific anti-S. iniae antibodies. Although effective, the specific vaccine components important for efficacy are not known. In the present study, an immunoproteomic approach was utilized to identify whole-cell lysate proteins of S. iniae that stimulated specific antibody production in Nile tilapia (Oreochromis niloticus) following vaccination. Groups of tilapia were vaccinated by intraperitoneal injection with the modified S. iniae bacterin or were mock-vaccinated, and at 30d post-vaccination sera samples were obtained from individual fish. Vaccination of tilapia with the S. iniae vaccine stimulated significantly elevated specific antibody responses against proteins of the bacterium and passive immunization of tilapia with this serum demonstrated the antibodies were highly protective. Whole-cell lysate proteins of S. iniae were separated by 2D-PAGE and were probed with a pooled serum sample from vaccinated tilapia. A total of eleven unique immunogenic proteins were positively identified by mass spectrometry. Based on research conducted on homologous proteins in other Streptococcus spp., antibodies specific for three of the identified proteins, enolase, glyceraldehyde-3-phosphate dehydrogenase, and fructose-bisphosphate aldolase, are likely involved in protection from streptococcosis caused by S. iniae.

Prophylactic and therapeutic targeting of the neurokinin-1 receptor limits neuroinflammation in a murine model of streptococcal meningitis (161.7)

Abstract Bacterial meningitis is a rapid, severe and highly damaging infection of the central nervous system (CNS) that is accompanied with high degree of inflammation. We have previously determined an important role for the neuropeptide substance P (SP) in the initiation and progression of bacterially-induced CNS inflammation. In the present study, we provide evidence that SP augments inflammatory glial responses to the important Gram-positive CNS pathogen Streptococcus pneumoniae, and show that endogenous SP/NK-1 receptor interactions play a critical role in the development of neuroinflammation and neurological damage in a mouse model of streptococcal meningitis. Moreover, we show that therapeutic intervention with a systemically delivered NK-1 receptor antagonist attenuates increases in inflammatory cytokine levels and decreases in immunosuppressive cytokine production within the CNS associated with an established in vivo S. pneumoniae infection. Furthermore, we have shown that treatment with an NK-1 receptor antagonist reverses infection-associated pathology in the absence of effects on bacterial burden within the CNS. These results provide the first demonstration that the therapeutic targeting of SP/NK-1 receptor interactions can limit progressive neuroinflammation and neurological damage associated with bacterial infections of the CNS. NK-1 receptor antagonists could, therefore, represent a new strategy for the treatment of potentially lethal CNS inflammation.

Role of VltAB, an ABC Transporter Complex, in Viologen Tolerance in Streptococcus mutans

Streptococcus mutans, a Gram-positive organism, is the primary causative agent in the formation of dental caries in humans. To persist in the oral cavity, S. mutans must be able to tolerate rapid environmental fluctuations and exposure to various toxic chemicals. However, the mechanisms underlying the ability of this cariogenic pathogen to survive and proliferate under harsh environmental conditions remain largely unknown. Here, we wanted to understand the mechanisms by which S. mutans withstands exposure to methyl viologen (MV), a quaternary ammonium compound (QAC) that generates superoxide radicals in the cell. To elucidate the essential genes for MV tolerance, screening of ∼3,500 mutants generated by ISS1 mutagenesis, revealed 15 MV-sensitive mutants. Among them, five and four independent insertions had occurred in SMU.905 and SMU.906 genes, respectively. These two genes are appeared to be organized in an operon and encode a putative ABC transporter complex; we designated the genes as vltA and vltB, for viologen transporter. To verify our results, vltA was deleted by using an antibiotic resistance marker; the mutant was just as sensitive to MV as the ISS1 insertion mutants. Furthermore, vltA and vltB mutants were also sensitive to other viologen compounds such as benzyl and ethyl viologens. Complementation assays were also carried out to confirm the role of VltA and VltB in viologen tolerance. Sensitivity to various drugs, including a wide range of QACs, was evaluated. It appears that a functional VltA is also required for full resistance toward acriflavin, ethidium bromide, and safranin; all are well-known QACs. These results indicate that VltA/B constitute a heterodimeric multidrug efflux pump of the ABC family. BLAST-P analysis suggests that homologs of VltA/B are widely present in streptococci, enterococci, and other important Gram-positive pathogens.

Molecular analysis of Streptococcus pyogenes strains isolated from Chinese children with pharyngitis

Streptococcus pyogenes is an important gram-positive bacterial pathogen that causes various human diseases, of which streptococcal pharyngitis is the most common. In this work, a total of 185 S. pyogenes isolated from Chinese children with pharyngitis was analyzed by superantigen (SAg) genes, emm genotyping, and pulsed-field gel electrophoresis (PFGE). Fifty-eight (31.4%) isolates were also typed by multilocus sequence typing (MLST). The results indicate that most of the emm1 isolates possessed speA (88.5%) and speJ (83.6%), and few isolates possessed speI gene (13.1%). In contrast, none of the emm12-type isolates possessed speJ; few isolates possessed speA (5.2%); and most of the isolates possessed speI (91.7%). PFGE analysis revealed 25 different clusters, and MLST was performed for 2 predominant emm-type isolates; emm12 isolates belonged to ST36 while emm1 isolates belonged to ST28. As far as this collection is concerned, emm1 and emm12 are the prevalent genotypes among S. pyogenes strains associated with children's pharyngitis in China. Most of the pharyngitis strains can be covered by a 26-valent vaccine. A strong correspondence is found only in the direction of emm type for both SAg profiles and PFGE types but not in the reverse direction.

Genomic organization, structure, regulation and pathogenic role of pilus constituents in major pathogenic Streptococci and Enterococci

Oligocomponent pilus structures, recently discovered in many important Gram-positive pathogens, represent a new class of virulence factors with adhesive and matrix protein-binding activity. Some of these proteins have emerged as very promising lead components of protein-based vaccines against Streptococci. These extended surface structures play key roles in host cell and tissue adherence, paracellular translocation, and biofilm formation of major Gram-positive pathogens such as Streptococcus pyogenes, S. agalactiae, S. pneumoniae as well as in opportunistic and nosocomial pathogens like Enterococci. Here, we discuss the similarities and differences of: (1) the genomic organization of the various regions encoding pilus proteins, (2) the number, type, and assembly of the proteins constituting the pili, (3) their expression and regulation mechanisms, (4) their role in bacterial virulence, and (5) their potential as vaccine candidate antigens.

MOLECULAR STRUCTURAL STUDIES OF LICHEN SUBSTANCES WITH ANTIMICROBIAL, ANTIPROLIFERATIVE, AND CYTOTOXIC EFFECTS FROM Parmelia subrudecta

Lecanoric acid (1), orsellinic acid methyl ester (2), orcinol (3), and usnic acid (4) were isolated from the lichen Parmelia subrudecta, collected on Palma of the Canary Islands, Spain. Compounds 1, 2, 3, and 4 were purified by solvent extraction, silica gel column chromatography, and preparative high-performance liquid chromatography (HPLC) consecutively. The structures of the four compounds were elucidated by one- and two-dimensional nuclear magnetic resonance (NMR) experiments and mass spectrometric investigations. These compounds showed activity against important gram-positive and gram-negative pathogens like mycobacteria and multiresistant staphylococci. This activity is combined with antiproliferative activity and cytotoxicity.

Human Transferrin Confers Serum Resistance against Bacillus anthracis

The innate immune system in humans consists of both cellular and humoral components that collaborate to eradicate invading bacteria from the body. Here, we discover that the gram-positive bacterium Bacillus anthracis, the causative agent of anthrax, does not grow in human serum. Fractionation of serum by gel filtration chromatography led to the identification of human transferrin as the inhibiting factor. Purified transferrin blocks growth of both the fully virulent encapsulated B. anthracis Ames and the non-encapsulated Sterne strain. Growth inhibition was also observed in serum of wild-type mice but not of hypotransferrinemic mice that only have approximately 1% circulating transferrin levels. We were able to definitely assign the bacteriostatic activity of transferrin to its iron-binding function: neither iron-saturated transferrin nor a recombinant transferrin mutant unable to bind iron could inhibit growth of B. anthracis. Additional iron could restore bacterial growth in human serum. The observation that other important gram-positive pathogens are not inhibited by transferrin suggests they have evolved effective mechanisms to circumvent serum iron deprivation. These findings provide a better understanding of human host defense mechanisms against anthrax and provide a mechanistic basis for the antimicrobial activity of human transferrin.

A new pathway for the synthesis of α-ribazole-phosphate in Listeria innocua.

The genomes of Listeria spp. encode all but one of 25 enzymes required for the biosynthesis of adenosylcobalamin (AdoCbl; coenzyme B(12) ). Notably, all Listeria genomes lack CobT, the nicotinamide mononucleotide:5,6-dimethylbenzimidazole (DMB) phosphoribosyltransferase (EC 2.4.2.21) enzyme that synthesizes the unique α-linked nucleotide N(1) -(5-phospho-α-D-ribosyl)-DMB (α-ribazole-5'-P, α-RP), a precursor of AdoCbl. We have uncovered a new pathway for the synthesis of α-RP in Listeria innocua that circumvents the lack of CobT. The cblT and cblS genes (locus tags lin1153 and lin1110) of L. innocua encode an α-ribazole (α-R) transporter and an α-R kinase respectively. Results from in vivo experiments indicate that L. innocua depends on CblT and CblS activities to salvage exogenous α-R, allowing conversion of the incomplete corrinoid cobinamide (Cbi) into AdoCbl. Expression of the L. innocua cblT and cblS genes restored AdoCbl synthesis from Cbi and α-R in a Salmonella enterica cobT strain. LinCblT transported α-R across the cell membrane, but not α-RP or DMB. UV-visible spectroscopy and mass spectrometry data identified α-RP as the product of the ATP-dependent α-R kinase activity of LinCblS. Bioinformatics analyses suggest that α-R salvaging occurs in important Gram-positive human pathogens.

In vitro activity of tigecycline and comparators on Acinetobacter spp. isolates collected from patients with bacteremia and MIC change during the Tigecycline Evaluation and Surveillance Trial, 2004 to 2008

The Tigecycline Evaluation and Surveillance Trial is a global surveillance study established in 2004 to monitor the activity of tigecycline, a new glycylcycline, and several comparators against an array of important Gram-positive and Gram-negative pathogens. In this study, we examined 1591 isolates of Acinetobacter from blood samples collected from 352 centers globally between 2004 and 2008. Tigecycline showed an MIC 90 (1 μg/mL) globally, with a maximum regional value of 4 μg/mL (Middle East) reported. Antimicrobial susceptibility was notably higher among nonintensive care unit (non-ICU) isolates than isolates collected from ICUs. Carbapenem-resistant Acinetobacter were more prevalent in the Middle East, Latin America, and Asia/Pacific rim than in Europe or North America. Tigecycline creep was noted between 2004 and 2007, corresponding closely to changes in MIC 90.

Linezolid treatment of shunt-related cerebrospinal fluid infections in children

The emergence of multidrug-resistant bacteria as a cause of ventriculoperitoneal (VP) shunt infection is a disconcerting phenomenon that often requires the use of alternative antimicrobial agents due to resistance against commonly used medications. Linezolid, a member of a new class of antimicrobial agents, has good activity against virtually all important gram-positive pathogens, including multidrug-resistant gram-positive pathogens. The object of this article is to report a single-center experience with linezolid treatment in 6 young patients with VP shunt infections caused by drug-resistant strains. The authors reviewed the records of 6 pediatric patients who developed VP shunt infection and in whom initial antimicrobial treatment regimens, including vancomycin, either failed or were associated with vancomycin-resistant enterococcus. All 6 patients were treated at their hospital between July 1, 2008, and June 29, 2009. The patients' demographic and clinical characteristics, underlying diseases, clinical manifestations, laboratory results, and various treatment modalities used before linezolid therapy were evaluated. The 6 patients included were 2 boys and 4 girls with a mean (+/- SD) age of 11.83 +/- 12 months (range 4-36 months). Five patients had acquired an infection within 4 months (mean 7.50 +/- 13.51 months, range 1-35 months) after shunt insertion. Four patients were treated with external ventricular drainage. Two patients' parents refused to allow shunt removal and placement of an external ventricular drain. The CSF was clear of bacterial growth within a mean of 3.67 +/- 1.36 days (range 2-6 days) after initiation of linezolid treatment. The mean duration of linezolid treatment was 18.17 +/- 3.31 days (range 14-21 days). Microbiological clearance of CSF and clinical cure were achieved in all patients. No laboratory or clinical side effects were observed during the treatment period. The mean length of hospital stay was 22.8 +/- 4.96 days (range 17-28 days). Linezolid could be an appropriate treatment alternative in children with ventriculostomy-related CSF infections caused by drug-resistant strains, including cases in which shunt removal is not an option. Well-designed prospective studies providing additional information on linezolid levels in plasma and CSF are necessary to confirm the authors' observations.

The 4.5S RNA component of the signal recognition particle is required for group A Streptococcus virulence

The signal recognition particle (SRP) is a ribonucleoprotein complex that targets proteins for secretion in a co-translational manner. While originally thought to be essential in all bacteria, recent data show that the SRP is dispensable in at least some streptococcal species. The SRP from the human pathogen group A Streptococcus (GAS, Streptococcus pyogenes) is predicted to be composed of protein Ffh and 4.5S RNA. Deletion of ffh alters the secretion of several GAS proteins, and leads to a severe reduction in virulence. Here, we report that mutation of the gene encoding 4.5S RNA results in phenotypes both similar to and distinct from that observed following ffh mutation. Similarities include a reduction in secretion of the haemolysin streptolysin O, and attenuation of virulence as assessed by a murine soft tissue infection model. Differences include a reduction in transcript levels for the genes encoding streptolysin O and NAD-glycohydrolase, and the reduced secretion of the SpeB protease. Several differences in transcript abundance between the parental and mutant strain were shown to be dependent on the sensor-kinase-encoding gene covS. Using growth in human saliva as an ex vivo model of upper respiratory tract infection we identified that 4.5S RNA mutation leads to a 10-fold reduction in colony-forming units over time, consistent with the 4.5S RNA contributing to GAS growth and persistence during upper respiratory tract infections. Finally, we determined that the 4.5S RNA was essential for GAS to cause lethal infections in a murine bacteraemia model of infection. The data presented extend our knowledge of the contribution of the SRP to the virulence of an important Gram-positive pathogen.

Pharmacokinetic-Pharmacodynamic Modeling of the In Vitro Activities of Oxazolidinone Antimicrobial Agents against Methicillin-ResistantStaphylococcus aureus

Linezolid is the first FDA-approved oxazolidinone with activity against clinically important gram-positive pathogens, including methicillin (meticillin)-resistant Staphylococcus aureus (MRSA). RWJ-416457 is a new oxazolidinone with an antimicrobial spectrum similar to that of linezolid. The goal of the present study was to develop a general pharmacokinetic (PK)-pharmacodynamic (PD) model that allows the characterization and comparison of the in vitro activities of oxazolidinones, determined in time-kill curve experiments, against MRSA. The in vitro activities of RWJ-416457 and the first-in-class representative, linezolid, against MRSA OC2878 were determined in static and dynamic time-kill curve experiments over a wide range of concentrations: 0.125 to 8 microg/ml (MIC, 0.5 microg/ml) and 0.25 to 16 microg/ml (MIC, 1 microg/ml), respectively. After correction for drug degradation during the time-kill curve experiments, a two-subpopulation model was simultaneously fitted to all data in the NONMEM VI program. The robustness of the model and the precision of the parameter estimates were evaluated by internal model validation by nonparametric bootstrap analysis. A two-subpopulation model, consisting of a self-replicating, oxazolidinone-susceptible and a persistent, oxazolidinone-insusceptible pool of bacteria was appropriate for the characterization of the time-kill curve data. The PK-PD model identified was capable of accounting for saturation in growth, delays in the onsets of growth and drug-induced killing, as well as naturally occurring bacterial death. The simultaneous fit of the proposed indirect-response, maximum-effect model to the data resulted in concentrations that produced a half-maximum killing effect that were significantly (P < 0.05) lower for RWJ-416457 (0.41 microg/ml) than for linezolid (1.39 microg/ml). In combination with the appropriate PK data, the susceptibility-based two-subpopulation model identified may provide valuable guidance for the selection of oxazolidinone doses or dose regimens for use in clinical studies.

New and emerging treatment of Staphylococcus aureus infections in the hospital setting

Methicillin-resistant Staphylococcus aureus (MRSA), both hospital-acquired and community-acquired, is a dangerous pathogen that is involved in an increasing number of serious infections with high risk for morbidity and mortality. Community-acquired MRSA strains have epidemic potential and can be particularly virulent. Vancomycin has been the standard hospital treatment for the past 40 years, but vancomycin-resistant isolates of S. aureus have emerged in the USA, and vancomycin-intermediate isolates are increasingly being reported worldwide. New antimicrobial agents with activity against multidrug-resistant S. aureus and other resistant pathogens are urgently needed. Despite great strides, further advances in our understanding of the molecular and biochemical mechanisms responsible for antimicrobial resistance are still required. Several agents have been recently approved for the treatment of serious Gram-positive infections, including linezolid, daptomycin, and tigecycline. The novel investigational cephalosporin, ceftobiprole, is one of the first penicillinase-resistant agents to target penicillin-binding protein 2a (or PBP2a), an acquired PBP with low beta-lactam-affinity that confers intrinsic beta-lactam resistance to S. aureus and other staphylococci. This mechanism of PBP binding, including inhibition of PBP2a, confers broad-spectrum activity against clinically important Gram-negative and Gram-positive pathogens, including MRSA. Phase III clinical trials comparing ceftobiprole with vancomycin alone and in combination with ceftazidime for the treatment of complicated skin and skin structure infections showed ceftobiprole to have efficacy similar to the efficacy of these comparators as evidenced by non-inferior clinical cure and microbiological eradication rates.

The Mga virulence regulon: infection where the grass is greener

Co-ordinate regulation of virulence gene expression in response to different host environments is central to the success of the group A streptococcus (GAS, Streptococcus pyogenes) as an important human pathogen. Mga represents a ubiquitous stand-alone virulence regulator that controls genes (Mga regulon) whose products are necessary for adherence, internalization and host immune evasion. Mga highly activates a core set of virulence genes, including its own gene, by directly binding to their promoters. Yet, Mga also influences expression of over 10% of the GAS genome, primarily genes and operons involved in metabolism and sugar utilization. Expression of the Mga regulon is influenced by conditions that signify favourable growth conditions, presumably allowing GAS to take advantage of promising new niches in the host. The ability of Mga to respond to growth signals clearly involves regulation of mga expression via global regulatory networks such as RALPs, Rgg/RopB and the catabolite control protein CcpA. However, the presence of predicted PTS regulatory domains (PRDs) within Mga suggests an intriguing model whereby phosphorylation of Mga by the PTS phosphorelay might link growth and sugar utilization with virulence in GAS. As Mga homologues have been found in several important Gram-positive pathogens, the Mga regulon could provide a valuable paradigm for increasing our understanding of global virulence networks in bacteria.

Redesigning β-lactams to combat resistance: summary and conclusions

The relentless emergence and spread of antimicrobial resistance warrant an increased awareness of the problem and improved coordination and standardisation of surveillance systems, as well as resistance control strategies. Moreover, this underscores the urgent need for new antibiotics active against the emerging resistant pathogens. Ceftobiprole is a new β-lactam molecule engineered for bactericidal activity against methicillin-resistant staphylococci that also exhibits an extended broad spectrum of activity covering the most clinically important Gram-positive (methicillin-susceptible staphylococci, penicillin-susceptible and -resistant pneumococci, other streptococci and ampicillin-susceptible enterococci) and Gram-negative (Enterobacteriaceae, Pseudomonas aeruginosa, Acinetobacter spp., Haemophilus spp. and Moraxella spp.) pathogens. Results from studies with experimental infections and from clinical trials support a role for ceftobiprole in treating complicated skin and skin structure infections caused by Gram-positive pathogens, including methicillin-resistant staphylococci, and suggest a potential role for this drug in treating other types of serious infection caused by Gram-positive and Gram-negative pathogens.

An anti-infective peptide that selectively modulates the innate immune response

We show that an innate defense-regulator peptide (IDR-1) was protective in mouse models of infection with important Gram-positive and Gram-negative pathogens, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus and Salmonella enterica serovar Typhimurium. When given from 48 h before to 6 h after infection, the peptide was effective by both local and systemic administration. Because protection by IDR-1 was prevented by in vivo depletion of monocytes and macrophages, but not neutrophils or B- and T-lymphocytes, we conclude that monocytes and macrophages are key effector cells. IDR-1 was not directly antimicrobial: gene and protein expression analysis in human and mouse monocytes and macrophages indicated that IDR-1, acting through mitogen-activated protein kinase and other signaling pathways, enhanced the levels of monocyte chemokines while reducing pro-inflammatory cytokine responses. To our knowledge, an innate defense regulator that counters infection by selective modulation of innate immunity without obvious toxicities has not been reported previously.

Pili mediate specific adhesion of Streptococcus pyogenes to human tonsil and skin

Very little is known about the biological functions of pili that have recently been found to be expressed by important Gram-positive pathogens such as Corynebacterium diphtheriae, Streptococcus agalacticae, S. pneumoniae and S. pyogenes. Using various ex vivo tissue and cellular models, here we show that pili mediate adhesion of serotype M1 S. pyogenes strain SF370 to both human tonsil epithelium and primary human keratinocytes, which represent the two main sites of infection by this human-specific pathogen. Mutants lacking minor pilus subunits retained the ability to express cell-surface pili, but these were functionally defective. In contrast to above, pili were not required for S. pyogenes adhesion to either immortalized HEp-2 or A549 cells, highlighting an important limitation of these extensively used adhesion/invasion models. Adhering bacteria were internalized very effectively by both HEp-2 and A549 cells, but not by tonsil epithelium or primary keratinocytes. While pili acted as the primary adhesin, the surface M1 protein clearly enhanced adhesion to tonsil, but surprisingly, had the opposite effect on adhesion to keratinocytes. These studies provide clear evidence that S. pyogenes pili display an adhesive specificity for clinically relevant human tissues and are likely to play a critical role in the initial stages of infection.

Telavancin: a novel lipoglycopeptide for serious Gram-positive infections

Telavancin, a once-daily dosing lipoglycopeptide derived from vancomycin, has a broad-spectrum microbiologic activity against Gram-positive bacteria, including vancomycin-resistant staphylococci. Telavancin displays a dual mode of action and a rapid bactericidal killing. The in vitro activity of telavancin is superior to vancomycin and comparable with, or greater than, linezolid, daptomycin and other novel lipoglycopeptides. Telavancin is effective against Gram-positive pathogens in animal models of soft tissue infections and deep-seated infections including endocarditis, pneumonia and bacteremia. Clinical experience with telavancin in Phase II and III studies for complicated skin and skin structure infections have demonstrated similar efficacy and tolerability compared with standard anti-staphylococcal β-lactams and vancomycin. Telavancin is in Phase III studies for nosocomial pneumonia. Telavancin seems to be promising as a novel agent for empiric therapy or as an alternative agent in serious infections caused by clinically important resistant Gram-positive pathogens such as methicillin-resistant Staphylococcus aureus, vancomycin intermediate-susceptible S. aureus, vancomycin-resistant S. aureus and vancomycin-resistant enterococci.

Appropriateness of Empiric Gentamicin and Vancomycin Therapy for Bacteremias in Chronic Dialysis Outpatient Units in the Era of Antibiotic Resistance

Bacteremias in inpatient chronic HD units have been described, but there is little information on bacteremias in ambulatory HD units. To determine the frequency of bacteremia and pathogen distribution in ambulatory chronic HD units, we retrospectively reviewed our experience with 107 bacteremias in 5 chronic ambulatory HD units over a 3 year period. The object of the study was twofold. The first objective was to determine if bacteremias in ambulatory HD setting were substantially different in frequency or type than in the inpatient HD setting. Secondly, febrile patients suspected of having bacteremia in chronic HD patients are often empirically treated with vancomycin and gentamicin.Chronic HD patients require repeated and frequent venous access for HD. Bacteremias are common in chronic HD patients and may be primary or secondary and are often related to venous access site infections. The distributions of bacteremia pathogens in chronic HD patients are predominantly reflective of skin flora, i.e., staphylococci and to lesser extent aerobic Gram-negative bacilli. After S. aureus (MSRA/MSSA) and coagulase-negative staphylococcus (CoNS), enterococci are the next most important Gram-positive pathogens in bacteremic HD patients. Most strains of E. faecalis are sensitive to vancomycin and for practical purposes should be considered as vancomycin sensitive enterococci (VSE). In contrast, most strains of E. faecium are resistant to vancomycin and should be considered as vancomycin resistant enterococci (VRE).We retrospectively reviewed 107 patients on chronic ambulatory HD to determine the adequacy of empiric vancomycin and gentamicin prophylaxis. We found amikacin is preferred to gentamicin and that meropenem is an effective alternate substitution for gentamicin and vancomycin combination therapy.

Assessment of Two Commercial Susceptibility Test Methods for Determination of Daptomycin MICs

Daptomycin is a lipopeptide antibiotic with activity against several important gram-positive bacterial pathogens, including drug-resistant staphylococci and enterococci. Because the mechanism of action of daptomycin is calcium-dependent depolarization of the cell membrane, susceptibility testing requires medium supplemented with a physiological level of calcium. This study assessed two Food and Drug Administration-cleared commercial test devices for determination of daptomycin MICs, Etest and JustOne. A collection of 220 selected isolates, including Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus faecalis, E. faecium, E. avium, E. durans, E. casseliflavus, and E. gallinarum, were tested by both methods. Included in the collection were 22 S. aureus and 14 Enterococcus sp. isolates that were recovered from patients and were nonsusceptible on the basis of the daptomycin MICs. As the reference method for comparison, all isolates were tested by the Clinical and Laboratory Standards Institute broth microdilution method incorporating cation-adjusted Mueller-Hinton broth with 50 microg/ml calcium. Daptomycin MICs agreed, within 1 twofold dilution, for 97% of the isolates by Etest and for 100% by JustOne. However, daptomycin MICs determined by Etest were 1 dilution lower than the reference MICs for 65% of the Enterococcus sp. isolates tested. This resulted in 28.5% very major (VM) errors (4/14) with enterococci (all E. faecium) but none (0/22) with staphylococci. Use of JustOne yielded MICs that were 1 dilution lower than the reference MICs for 69% of the staphylococci and 25% of the enterococci. This resulted in 13.6% VM errors (3/22) with staphylococci and 14.3% VM errors (2/14) with enterococci. The manufacturer-recommended JustOne inoculum preparation resulted in mean colony counts of only 5 x 10(4) to 1 x 10(5) CFU/ml in the wells of the strip. Increasing the inoculum to 3 x 10(5) to 4 x 10(5) CFU/ml eliminated two of five VM errors upon retesting. No major interpretive errors occurred with either device. In summary, daptomycin MICs generated by the Etest or JustOne method generally agreed within 1 dilution of the reference daptomycin MICs. However, both devices produced slightly lower MICs that resulted in some VM errors.