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PubMed2003

Treatment of multifocal vancomycin-resistant Enterococcus faecium osteomyelitis in sickle cell disease: a preliminary report.

Repeat episodes of musculoskeletal infarction coupled with immunosuppression predispose sickle cell patients to infectious complications throughout their lives. Osteomyelitis is a familiar complication of sickle cell disease, and it may result in significant morbidity, especially when occurring in multiple sites. Staphylococcus and Salmonella remain the most common causes of osteomyelitis in sickle cell patients. Vancomycin-resistant enterococcus (VRE) infections have been reported mainly in connection with bacteremias and infections outside of the musculoskeletal system. To our knowledge, only a few cases of VRE long bone osteomyelitis have been reported in the literature. A few antimicrobial agents are available to treat VRE infections. The occurrence of VRE osteomyelitis is a major clinical concern, especially in an immunocompromised host, such as a sickle cell patient. We present a case of multiple long bone vancomycin-resistant Enterococcus faecium (mixed organisms) osteomyelitis in a sickle cell patient, and we report on a new method of using quinupristin-dalfopristin as part of the management plan to treat a complicated VRE infection successfully. We discuss the mechanism of action of anti-VRE drugs and the future direction to combat VRE in orthopedic infections.

Anemia, Sickle Cell↗

PubMed2001

Cost of hospitalization for and risk factors associated with vancomycin-resistant Enterococcus faecium infection and colonization.

The increase in costs of hospitalization for patients with drug-resistant infection may be associated with drug resistance itself or with the severity of the underlying illness that predisposes patients to acquire the drug-resistant infection. To address this issue, risk factors and cost of hospitalization were compared for patients infected or colonized with vancomycin-susceptible Enterococcus faecium (VSEF) or vancomycin-resistant E. faecium (VREF) in a large tertiary-care hospital in New York City. From January 1995 through December 1996, 157 patients with VSEF and 262 patients with VREF were identified. CMI (case-mix index) was assigned to each patient as a measure of severity of illness, with a CMI of 1 considered to represent illness of average severity. For all patients who were assigned a CMI of <3, the cost per day of hospitalization for patients with VREF was significantly greater than that for patients with VSEF. However, for patients with a CMI of >3, there was no difference between cost of hospitalization for patients with VREF and that for patients with VSEF. These observations indicate that, although vancomycin resistance is associated with an increased cost of hospitalization for less severely ill patients with VREF, patients with severe underlying illness, regardless of vancomycin resistance, incur similar hospitalization costs.

Adolescent↗

PubMed2001

In vitro activity of trovafloxacin against Bacteroides fragilis in mixed culture with either Escherichia coli or a vancomycin- resistant strain of Enterococcus faecium determined by an anaerobic time-kill technique.

To determine the efficacy of trovafloxacin as a possible treatment for intra-abdominal abscesses, we have developed an anaerobic time-kill technique using different inocula to study the in vitro killing of Bacteroides fragilis in pure culture or in mixed culture with either Escherichia coli or a vancomycin-resistant strain of Enterococcus faecium (VREF). With inocula of 5 x 10(5) CFU/ml and trovafloxacin concentrations of </=2 microg/ml, a maximum observed effect (E(max)) of >/=6.1 (log(10) CFU/ml) was attained with all pure and mixed cultures within 24 h. With inocula of 10(8) CFU/ml, a similar E(max) and a similar concentration to produce 50% of E(max) (EC(50)) for B. fragilis were found in both pure cultures and mixed cultures with E. coli. However, to produce a similar killing of B. fragilis in the mixed cultures with VREF, a 14-fold increase in the concentration of trovafloxacin was required. A vancomycin-susceptible strain of E. faecium and a trovafloxacin-resistant strain of E. coli were also found to confer a similar "protective" effect on B. fragilis against the activity of trovafloxacin. Using inocula of 10(9) CFU/ml, the activity of trovafloxacin was retained for E. coli and B. fragilis and was negligible against VREF. We conclude that this is a useful technique to study the anaerobic killing of mixed cultures in vitro and may be of value in predicting the killing of mixed infections in vivo. The importance of using mixed cultures and not pure cultures is clearly shown by the difference in the killing of B. fragilis in the mixed cultures tested. Trovafloxacin will probably be ineffective in the treatment of infections involving large numbers of enterococci. However, due to its ability to retain activity against large cultures of B. fragilis and E. coli, trovafloxacin could be beneficial in the treatment of intra-abdominal abscesses.

Anaerobiosis↗

PubMed2005

Vancomycin for multi-drug resistant Enterococcus faecium cholangiohepatitis in a cat.

A 12-year-old, neutered male domestic shorthair cat was evaluated with a life-long history of intermittent, predominantly small bowel diarrhea and a 3 day history of hematochezia. At presentation, the cat had increased liver enzyme activities and an inflammatory leukogram. Histopathology demonstrated inflammatory bowel disease (IBD), cholangiohepatitis and pancreatitis. The cholangiohepatitis was associated with a multi-drug resistant Enterococcus faecium. Gallbladder agenesis was also documented. Treatment with vancomycin was safely instituted for 10 days. Clinical signs resolved, however, cure of the bacterial cholangiohepatitis was not achieved. The risk of vancomycin resistant enterococci (VRE) in human and veterinary medicine is discussed.

Animals↗

PubMed2004

Competitive exclusion of a glycopeptide-resistant Enterococcus faecium in the presence of vancomycin but not equivalent concentrations of tylosin or gentamicin.

The effect of subtherapeutic concentrations of antibiotics (10.0 and 40.0 microg/mL of vancomycin, gentamicin, and tylosin) on the efficacy of a mixed anaerobe culture of chicken microflora (CCF) was studied in a continuous-flow fermentation system. Efficacy of CCF posttreatment was assessed by challenge with glycopeptide-resistant Enterococcus faecium (GRE) at 6.0 log10 cfu/mL. Bacterial enumeration of endogenous CCF isolates, volatile fatty acid (VFA) analysis, and challenge with GRE indicated that CCF efficacy was affected by all antibiotic treatments. Although CCF treated with 10.0 microg/mL of vancomycin eliminated GRE13 at a rate of 0.61 log10 cfu/ mL per day, it was unable to eliminate E. coli, a gram-negative challenge organism. All other antibiotic treatments allowed GRE persistence at approximately 2.0 to 6.5 log10 cfu/mL. All antibiotic-treated cultures had decreased concentrations of acetic and propionic acids. Our data suggest that low concentrations of antimicrobials may adversely affect the microbial ecology of gut microflora with respect to its ability to exclude exogenous bacteria. Moreover, gentamicin had an adverse effect on the inhibitory stringency of CCF even though it showed little anti-anaerobic activity against CCF strict anaerobes in pure culture. Verification of the results in live animals will be necessary to determine if antimicrobial treatment could compromise the effectiveness of normal microflora to serve as a natural host defense against infection.

Animals↗

PubMed2005

Global spread of vancomycin-resistant Enterococcus faecium from distinct nosocomial genetic complex.

Vancomycin-resistant enterococci (VRE) have caused hospital outbreaks worldwide, and the vancomycin-resistance gene (vanA) has crossed genus boundaries to methicillin-resistant Staphylococcus aureus. Spread of VRE, therefore, represents an immediate threat for patient care and creates a reservoir of mobile resistance genes for other, more virulent pathogens. Evolutionary genetics, population structure, and geographic distribution of 411 VRE and vancomycin-susceptible Enterococcus faecium isolates, recovered from human and nonhuman sources and community and hospital reservoirs in 5 continents, identified a genetic lineage of E. faecium (complex-17) that has spread globally. This lineage is characterized by 1) ampicillin resistance, 2) a pathogenicity island, and 3) an association with hospital outbreaks. Complex-17 is an example of cumulative evolutionary processes that improved the relative fitness of bacteria in hospital environments. Preventing further spread of this epidemic E. faecium subpopulation is critical, and efforts should focus on the early disclosure of ampicillin-resistant complex-17 strains.

Africa↗

PubMed1996

Epidemiology of an outbreak due to glycopeptide-resistant Enterococcus faecium on a leukaemia unit.

The clinical and molecular epidemiology of two clusters of colonization and infection of patients by glycopeptide-resistant enterococci (GRE) on a leukaemia and bone marrow transplantation unit was studied over a two-and-a half-year period. Thirty-five patients became colonized, of whom six developed clinical infections. Of the 53 isolates of GRE, 49 were Enterococcus faecium, multiply-resistant to vancomycin and ampicillin. DNA fingerprinting of 48 E. faecium isolates by pulsed-field gel electrophoresis identified six DNA types. One strain of VanB phenotype E. faecium predominated during the initial outbreak, and an unrelated strain of the VanA phenotype was present in a second cluster. Environmental and patient isolates of E. faecium were indistinguishable by DNA typing. The VanA phenotype enterococci probably arose by transfer from the renal ward at a nearby hospital, and a patient with persistent diarrhoea may have contributed to contamination and cross-infection. GRE may cause significant infections in immunocompromised patients, and are readily transmitted between them. GRE were controlled, but not eradicated on the unit; infection control measures included improved environmental cleaning and modification of antibiotic use. In order to control GRE, it is necessary to educate healthcare workers and implement the traditional, effective values of good personal hygiene and environmental cleanliness.

Adult↗

PubMed2005

Prevention of febrile neutropenia in cancer patients by probiotic strain Enterococcus faecium M-74. Pilot study phase I.

Febrile neutropenia (FN) remains a potentially life-threatening complication of anticancer chemotherapy. Bacterial translocation via intestinal mucosa is a significant mechanism of FN development. Competitive inhibition of bowel colonization by pathogenic microorganisms by lactic acid bacteria could be a useful prevention of FN. The aim of the study was the evaluation of dose and safety of probiotic strain Enterococcus faecium M-74 enriched with organic selenium in patients with solid and hematological malignancies. Eleven (9 M/2F) patients were included in the study. In the first phase six patients with germ cell tumors treated by chemotherapy were included. They received prophylaxis by nonpathogenic strain E. faecium M-74 during 2 cycles of chemotherapy. The planned daily dose was 6 x 10(9) bacteria. Regarding the insufficient colonization of the gut, the dose was further increased up to 18 x 10(9) tid. After safety evaluation, five patients were included with relapse of acute leukemia. In patients with germ cell cancer, severe neutropenia G3/4 was noted in 10 of 12 cycles of chemotherapy. The febrile episode was not observed in any of the patients. The gut colonization by enterococci reaches 10(6) CFU/g stool. In 5 patients with acute leukemia during 127 days of severe neutropenia 12 febrile episodes occurred. There was not noted any febrile episode or infection provoked by the tested strain. Tolerance of therapy was excellent without significant undesirable effects. Optimal dose was assessed and safety of probiotic strain was evaluated in neutropenic patients with solid, or hematological malignancies. Based on these results we plan phase II study to evaluate the effectiveness of this strain in FN prophylaxis.

Administration, Oral↗

PubMed2004

Linkage of a novel mercury resistance operon with streptomycin resistance on a conjugative plasmid in Enterococcus faecium.

It has been shown that the mercury in dental amalgam and other environmental sources can select for mercury resistant bacteria and that this can lead to an increase in resistance to antibiotics. To understand more about this linkage we have investigated the genetic basis for mercury and antibiotic resistance in a variety of oral bacteria. In this study we have cloned and sequenced the mer operon from an Enterococcus faecium strain which was resistant to mercury, tetracycline, and streptomycin. This strain was isolated, in a previous investigation, from a cynomolgus monkey post-installation of amalgam fillings. The mer operon was contained within a putative transposon (Tnmer1) of the ISL3 family. This element was located on a streptomycin resistant plasmid, pPPM1000, which shares homology with pRE25.

Amino Acid Sequence↗

PubMed2001

Sequencing of the ddl gene and modeling of the mutated D-alanine:D-alanine ligase in glycopeptide-dependent strains of Enterococcus faecium.

Glycopeptide dependence for growth in enterococci results from mutations in the ddl gene that inactivate the host D-Ala:D-Ala ligase. The strains require glycopeptides as inducers for synthesis of resistance proteins, which allows for the production of peptidoglycan precursors ending in D-Ala-D-Lac instead of D-Ala-D-Ala. The sequences of the ddl gene from nine glycopeptide-dependent Enterococcus faecium clinical isolates were determined. Each one had a mutation consisting either in a 5-bp insertion at position 41 leading to an early stop codon, an in-frame 6-bp deletion causing the loss of two residues (KDVA243-246 to KA), or single base-pair changes resulting in an amino acid substitution (E13 --> G, G99 --> R, V241 --> D, D295 --> G, P313 --> L). The potential consequences of the deletion and point mutations on the 3-D structure of the enzyme were evaluated by comparative molecular modeling of the E. faecium enzyme, using the X-ray structure of the homologous Escherichia coli D-Ala:D-Ala ligase DdlB as a template. All mutated residues were found either to interact directly with one of the substrates of the enzymatic reaction (E13 and D295) or to stabilize the position of critical residues in the active site. Maintenance of the 3-D structure in the vicinity of these mutations in the active site appears critical for D-Ala:D-Ala ligase activity.

Amino Acid Sequence↗

PubMed1990

[The conjugative transfer of beta-hemolysin plasmid in Enterococcus faecalis to Enterococcus faecium].

The conjugative transfer by using a filter mating method in 109 cases of combinations between 20 strains of beta-hemolytic Enterococcus faecalis and 28 strains of alpha-hemolytic Enterococcus faecium was tried. A stable transconjugation was observed in two cases: from E. faecalis No. 170 to E. faecium No. 49 and from E. faecalis No. 500 to E. faecium No. 48. From the results, it was proved that the beta-hemolysin plasmid of E. faecalis is transferred by conjugation to E. faecium. The virulence (LD50) of E. faecium No. 17049, No. 50048 (heterogeneous transconjugant) and E. faecalis No. 17067, No. 50067 (homologous transconjugant) in mice was compared with their parent strains. The virulence of E. faecalis transconjugants was more marked than that of the recipients. However, the virulence of E. faecium transconjugants was not enhanced. This fact suggests that, only in E. faecalis, does beta-hemolysin play a role in its pathogenicity in mice. beta-Hemolysin in E. faecium transconjugants does not participate in pathogenicity in mice. It may be due to the fact that it takes more time to cause beta-hemolysis on blood agar plate or beta-hemolysin production in B-YEG broth by E. faecium transconjugants than by E. faecalis transconjugants.

Animals↗

PubMed2005

Community-acquired vancomycin-resistant Enterococcus faecium: a case report from Malaysia.

Vancomycin-resistant enterococci (VRE) are formidable organisms renowned for their ability to cause infections with limited treatment options and their potential for transferring resistance genes to other Gram-positive bacteria. Usually associated with nosocomial infections, VRE are rarely reported as a cause of community-acquired infection. Presented here is a case of community-acquired infection due to vancomycin-resistant Enterococcus faecium. The patient had been applying herbal leaves topically to his cheek to treat a buccal space abscess, resulting in a burn of the overlying skin. From pus aspirated via the skin a pure culture of E. faecium was grown that was resistant to vancomycin with a MIC of >256 microg ml-1 by the E test and resistant to teicoplanin by disc diffusion, consistent with the VanA phenotype. The organism was suspected of contaminating the leaf and infecting the patient via the burnt skin. This case highlights the need for further studies on the community prevalence of VRE among humans and animals to define unrecognized silent reservoirs for VRE, which may pose a threat to public health.

Abscess↗

PubMed2004

Eradication of a large outbreak of a single strain of vanB vancomycin-resistant Enterococcus faecium at a major Australian teaching hospital.

OBJECTIVE: To demonstrate that nosocomial transmission of vancomycin-resistant enterococci (VRE) can be terminated and endemicity prevented despite widespread dissemination of an epidemic strain in a large tertiary-care referral hospital. INTERVENTIONS: Two months after the index case was detected in the intensive care unit, 68 patients became either infected or colonized with an epidemic strain of vanB vancomycin-resistant Enterococcus faecium despite standard infection control procedures. The following additional interventions were then introduced to control the outbreak: (1) formation of a VRE executive group; (2) rapid laboratory identification (30 to 48 hours) using culture and polymerase chain reaction detection of vanA and vanB resistance genes; (3) mass screening of all hospitalized patients with isolation of carriers and cohorting of contacts; (4) environmental screening and increased cleaning; (5) electronic flagging of medical records of contacts; and (6) antibiotic restrictions (third-generation cephalosporins and vancomycin). RESULTS: A total of 19,658 patient and 24,396 environmental swabs were processed between July and December 2001. One hundred sixty-nine patients in 23 wards were colonized with a single strain of vanB vancomycin-resistant E. faecium. Introducing additional control measures rapidly brought the outbreak under control. Hospital-wide screening found 39 previously unidentified colonized patients, with only 7 more nonsegregated patients being detected in the next 2 months. The outbreak was terminated within 3 months at a cost of dollar 2.7 million (Australian dollars). CONCLUSION: Despite widespread dissemination of VRE in a large acute care facility, eradication was achievable by a well-resourced, coordinated, multifaceted approach and was in accordance with good clinical governance.

Cohort Studies↗

PubMed1997

Assessment of the synergistic interactions of levofloxacin and ampicillin against Enterococcus faecium by the checkerboard agar dilution and time-kill methods.

Multidrug-resistant enterococci have become increasingly difficult to eradicate in a growing number of nosocomial infections. With the emergence of vancomycin-resistant enterococci, the use of synergistic antibiotic combinations has become one of the only remaining therapeutic options. Levofloxacin, the active l-isomer of ofloxacin, is a new oral and intravenous fluoroquinolone with a broad spectrum of activity against numerous Gram-positive, Gram-negative, and atypical organisms. The in vitro activity of levofloxacin, alone and in combination with ampicillin, against recent clinical isolates of Enterococcus faecium was assessed for synergistic interactions using the checkerboard agar dilution technique and time-kill methodology. Against all strains, the static technique of checkerboard agar dilution demonstrated indifferent or additive effects for the ampicillin + levofloxacin combination. With the dynamic time-kill technique, synergy was demonstrated for ampicillin (16 micrograms/ml) + levofloxacin (2 micrograms/ml) combination against three levofloxacin-sensitive, ampicillin-resistant isolates. At 24 h, the combination yielded a > or = 2-log10 decrease in CFU/ml compared to levofloxacin alone, while ampicillin had negligible effects. Against both a levofloxacin-intermediate, ampicillin-resistant isolate, and a highly levofloxacin-resistant, ampicillin-resistant isolate, none of the ampicillin+levofloxacin combinations tested demonstrated a synergistic interaction. The time-kill method suggested synergy for the ampicillin+levofloxacin combination against some strains of E. faecium.

Ampicillin↗

PubMed2004

Evaluation of Vitek system for susceptibility testing of Enterococcus faecium isolates.

Although imipenem is not a first-line drug for treating enterococcal infection, it could well become a useful drug for treating mixed infections that include enterococci. However, there is no NCCLS guideline for susceptibility testing of imipenem versus enterococci. Moreover, there are no statements to indicate that in vitro susceptibility results for other antimicrobial agents can be used to predict the in vitro activity of imipenem against enterococci. In this study, 52 Enterococcus faecium isolates were collected from patients hospitalized at Kangnam St. Mary's Hospital between March 2002 and December 2002. The sources of the isolates were mainly urine specimens and wounds. For ampicillin, the "major" and "very major" error rates observed with the Vitek system were 0% and 2.0%, respectively. For penicillin, the major and very major error rates observed with the Vitek system were both 0%. For imipenem, the major and very major error rates observed with the Vitek system were 0% and 36.5%, respectively. The MICs of ampicillin and penicillin obtained using the Vitek system were reliable, but that of imipenem was unreliable. In the 52 E. faecium isolates, the in vitro activity of penicillin and ampicillin versus enterococci accurately predicted that of imipenem. Therefore, the MIC of imipenem obtained with the Vitek system must be retested by the agar dilution method, when it disagrees with those of penicillin and ampicillin.

Ampicillin↗

PubMedDate not supplied

Use of antimicrobial growth promoters in food animals and Enterococcus faecium resistance to therapeutic antimicrobial drugs in Europe.

Supplementing animal feed with antimicrobial agents to enhance growth has been common practice for more than 30 years and is estimated to constitute more than half the total antimicrobial use worldwide. The potential public health consequences of this use have been debated; however, until recently, clear evidence of a health risk was not available. Accumulating evidence now indicates that the use of the glycopeptide avoparcin as a growth promoter has created in food animals a major reservoir of Enterococcus faecium, which contains the high level glycopeptide resistance determinant vanA, located on the Tn1546 transposon. Furthermore, glycopeptide-resistant strains, as well as resistance determinants, can be transmitted from animals to humans. Two antimicrobial classes expected to provide the future therapeutic options for treatment of infections with vancomycin-resistant enterococci have analogues among the growth promoters, and a huge animal reservoir of resistant E. faecium has already been created, posing a new public health problem.

Animal Feed↗

PubMed2001

In vivo efficacy of trovafloxacin against Bacteroides fragilis in mixed infection with either Escherichia coli or a vancomycin-resistant strain of Enterococcus faecium in an established-abscess murine model.

The pharmacodynamic and pharmacokinetic properties of trovafloxacin were studied in a standardized murine model of established subcutaneous abscesses. Daily dosing regimens of 37.5 to 300 mg/kg every 8 h (q8h) or every 24 h (q24h) were started 3 days after inoculation with mixtures containing either Bacteroides fragilis-Escherichia coli-autoclaved cecal contents (ACC) or B. fragilis-vancomycin-resistant Enterococcus faecium (VREF)-ACC. Treatment was continued for 3 or 5 days. The efficacy of treatment was determined by the decrease in abscess bacterial counts and abscess weights, as well as by the reduction in inflammation (biodistribution of (99m)Tc-HYNIC immunoglobulin G) compared to saline-treated controls. Trovafloxacin showed a significant dose-response effect on the bacterial counts, weight, and inflammation of B. fragilis-E. coli abscesses after 3 and/or 5 days of treatment. A maximum 3.4 and 3.1 log(10) reduction in CFU/abscess in the respective B. fragilis and E. coli bacterial counts was attained after 5 days of treatment with daily doses of 300 mg/kg. The peak serum concentration was more predictive for effect than the area under the concentration-time curve. The C(max) was the pharmacodynamic index most predictive for success, and the efficacy of the q24h regimens was significantly better than the q8h regimens. The antibiotic was ineffective against the VREF in mixed infection with B. fragilis, while the killing of the anaerobe in the same combination was significantly less than in the E. coli combination (P < 0.05). We conclude that this is a useful model for studying the activity of antimicrobials for the treatment of small (<1-cm), undrainable, mixed-infection abscesses. In addition, we have shown for the first time that a decrease in bacterial numbers also leads to a reduction in both abscess weight and inflammation.

Abscess↗

PubMed1998

Carbamate kinase from Enterococcus faecalis and Enterococcus faecium--cloning of the genes, studies on the enzyme expressed in Escherichia coli, and sequence similarity with N-acetyl-L-glutamate kinase.

Carbamate kinase (CK) catalyzes the reversible reaction NH2COO- + ATP <--> NHCOOPO3(2-) + ADP, serving to synthesize ATP from carbamoyl phosphate in those microorganisms that derive energy from anaerobic arginine degradation via the arginine dihydrolase pathway. We report here the cloning and sequencing of the CK gene from Enterococcus faecalis and Enterococcus faecium and we demonstrate that the amino acid sequence of CK is identical in the two species. The enzyme, expressed and isolated from Escherichia coli using simple purification procedures, was used to generate crystals suitable for X-ray studies and to investigate the utilization by CK of bicarbonate and other carbamate analogs. CK had a bicarbonate-dependent ATPase activity and, therefore, is able to synthesize carboxyphosphate, an unstable compound that is an intermediate in the reactions catalyzed by carbamoyl-phosphate synthetase (CPS) and by biotin carboxylase. Other functional similarities with CPS include the utilization of acetate by CK with a similarly high Km and the similar Km values of CK for carbamate and of CPS for bicarbonate. Enterococcal CK was inhibited by adenosine(5')pentaphospho(5')adenosine (Ap5A) and Ap6A and, less powerfully, by Ap4A, whereas Ap3A is essentially non-inhibitory. Thus, inhibition by Ap5A seems not to be a valid criterion to differentiate between CK and CPS, for the two enzymes can be inhibited by Ap5A. All these results support the relatedness of CK and CPS. Finally, we used limited proteolysis: (a) to localize the epitopes for monoclonal antibodies obtained against CK; (b) to demonstrate the importance of the C-terminus for enzyme activity; and (c) to show that Arg158 is highly exposed and may be essential for activity. Comparison of the sequence of CK with known protein sequences demonstrates considerable similarity of CK with bacterial N-acetylglutamate kinases, strongly suggesting that these two enzymes may share a similar structure and the same catalytic mechanism.

Amino Acid Sequence↗