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PubMed1998

Colonization with vancomycin-resistant enterococci in chronic hemodialysis patients.

Vancomycin-resistant enterococcus (VRE) has been identified with increased frequency in dialysis populations, but the risk factors for VRE colonization are not well defined in hemodialysis patients. Patients from a university-affiliated outpatient dialysis center had surveillance stool or rectal cultures for VRE during April 1994 and January 1996. The combined cohort of 168 patients was followed-up for all-cause mortality, subsequent hospitalization, and VRE infection. Demographic and risk factor information, including age, gender, race, diabetes, coronary artery disease (CAD), and human immunodeficiency virus (HIV) infection, were collected on all patients. Sixteen patients had surveillance cultures grow vancomycin-resistant Enterococcus faecium or E faecalis (VREF), and nine additional patients had clinical cultures positive for VREF. The median follow-up time for patients with positive surveillance or clinical cultures for VREF was 421 days versus 423 days for those without VREF. Patients with positive surveillance cultures for VREF had less time on hemodialysis before screening (median = 207 days v 822 days; P < 0.01), and more hospitalization in the year before screening (median = 19 days v 3 days, P < 0.01) compared with those without VREF. Patients with VREF colonization were more likely to develop infection with VREF (25% v 1%, P < 0.01) than those without VREF colonization. However, adjusting for age, diabetes, coronary artery disease, and acquired immune deficiency syndrome (AIDS) using Cox-proportional hazards models, the presence of VREF on screening culture was not associated with increased risk of death (RR = 1.1, P = 0.86). Thus after adjusting for other comorbidities, VREF colonization was not associated with increased mortality. Patients with end-stage renal disease (ESRD) on hemodialysis who are hospitalized are more likely to have VREF, but longer duration on hemodialysis was not associated with presence of this organism. This suggests that VRE transmission occurs predominantly in the inpatient setting.

Adult↗
PubMed2000

Risk factors for acquisition of vancomycin-resistant enterococci among patients on a renal ward during a community hospital outbreak.

BACKGROUND: During an outbreak of vancomycin-resistant enterococcal (VRE) infection and colonization at a community hospital in Indianapolis, Indiana, we performed a case-control study of patients on the hospital's renal unit to determine risk factors for acquisition of VRE among this potentially high-risk patient population. METHODS: Twenty-four renal patients with VRE colonization/infection (ie, case-patients) were compared by univariate and multivariate analyses with 29 renal patients with nosocomially acquired vancomycin-susceptible enterococcal infection and colonization (ie, controls). RESULTS: Age and length of hospitalization were similar between the VRE case-patients and the vancomycin-susceptible enterococcal control-patients, but case-patients had higher Acute Physiology and Chronic Health Evaluation II scores and received significantly greater numbers of antimicrobials and significantly more days of antimicrobials during the 60 days preceding the first positive enterococcal culture. In an assessment of the appropriateness of vancomycin use, one third of vancomycin orders were found to be inappropriate in both patient groups. CONCLUSIONS: Our data show that among renal patients, those who are severely ill and receive multiple and prolonged courses of antimicrobials are at greatest risk for acquiring VRE infection or colonization. The Centers for Disease Control and Prevention recommends that hospitals develop a comprehensive plan to prevent and control infection and colonization of patients with VRE. This plan should include prompt identification of affected patients, initiation of isolation precautions to prevent patient-to-patient transmission of VRE, and prudent use of antimicrobials, including vancomycin.

APACHE↗
PubMed2000

Epidemiology of bacteriuria caused by vancomycin-resistant enterococci--a retrospective study.

BACKGROUND: The epidemiology of vancomycin-resistant enterococcal (VRE) bacteriuria has not been previously described. Our objectives are to describe the frequency of VRE bacteriuria, to use strict definitions to distinguish symptomatic urinary tract infection (UTI) versus urine colonization without pyuria versus asymptomatic bacteriuria with pyuria, and to describe the outcomes of each group. METHODS: We used a retrospective analysis of patients with VRE bacteriuria in an academic medical center. RESULTS: During the 18-month study period, 98 of the 107 patients (92%) with urine cultures positive for VRE (23/10,000 admissions), had charts that were available for review. In 94 of 98 patients, the organism was Enterococcus faecium, and in only 4 was Enterococcus faecalis recovered. Thirty-seven patients were colonized with VRE; 21 patients had asymptomatic bacteriuria, and the status of 27 patients was not ascertainable. Thirteen patients had VRE UTIs with two associated bacteremias and one death. Patients with UTI versus patients without UTI were more likely to have an underlying malignancy (39% vs 9%, P =.014). CONCLUSION: The majority of urine cultures yielding VRE do not represent true infection, rather colonization or asymptomatic bacteriuria.

Adolescent↗
PubMed2003

Role of fecal incontinence in contamination of the environment with vancomycin-resistant enterococci.

BACKGROUND: We tested the hypothesis that patients with vancomycin-resistant Enterococcus (VRE) stool colonization who are continent of feces contaminate the environment less frequently than patients who are colonized and incontinent. METHODS: We prospectively examined the frequency of environmental VRE contamination in the rooms of 15 patients who were continent and 15 who were incontinent and VRE-colonized. Broth-enrichment cultures of bed rails, bedside table, and call buttons were performed at baseline, and 2 and 5 days after environmental disinfection. The numbers of VRE colonies isolated after directly plating environmental swabs onto agar were compared for the continent and incontinent groups. RESULTS: The percentages of patients with 1 or more positive environmental cultures for VRE were not significantly different for the groups of patients who were continent and incontinent at baseline (60% vs 73%, P =.45) or 2 days after disinfection (60% vs 80%, P =.24). The numbers of VRE colonies isolated by direct plating were not significantly different for the continent and incontinent groups (P =.42). CONCLUSIONS: Environmental contamination occurs frequently in the rooms of patients who are continent, and those who are incontinent and VRE-colonized. Our findings suggest that similar infection control measures should be implemented for patients who are continent and incontinent.

Chi-Square Distribution↗
PubMed2000

The molecular basis of vancomycin resistance in clinically relevant Enterococci: crystal structure of D-alanyl-D-lactate ligase (VanA).

d-alanine-d-lactate ligase from Enterococcus faecium BM4147 is directly responsible for the biosynthesis of alternate cell-wall precursors in bacteria, which are resistant to the glycopeptide antibiotic vancomycin. The crystal structure has been determined with data extending to 2.5-A resolution. This structure shows that the active site has unexpected interactions and is distinct from previous models for d-alanyl-d-lactate ligase mechanistic studies. It appears that the preference of the enzyme for lactate as a ligand over d-alanine could be mediated by electrostatic effects and/or a hydrogen-bonding network, which principally involve His-244. The structure of d-alanyl-d-lactate ligase provides a revised interpretation of the molecular events that lead to vancomycin resistance.

Bacterial Proteins↗
PubMed2002

Molecular analysis of streptogramin resistance in enterococci.

The new semi-synthetic streptogramin antibiotic combination quinupristin/dalfopristin (Synercid) is a promising alternative for a treatment of infections with multiple resistant gram-positive pathogens, e.g. glycopeptide- and multi-resistant Enterococcus faecium. Streptogramins consist of two unrelated compounds, a streptogramin A and B, which act synergistically when given in combination. Mechanisms conferring resistance against both components are essential for resistance against the combination in E. faecium. In this species resistance to streptogramin A compounds is mediated via related acetyltransferases VatD and VatE. Resistance against streptogramins B is either encoded by the widespread ermB gene cluster conferring resistance to macrolide-lincosamide-streptogramin B antibiotics or via expression of the vgbA gene, which encodes a staphylococcal-type lactonase. E. faecalis is intrinsically resistant to streptogramins. Due to a wide use of streptogramins (virginiamycins S/M) in commercial animal farming a reservoir of streptogramin-resistant E. faecium isolates had already been selected. Determinants for streptogramin resistance are localized on plasmids that can be transferred into an E. faecium recipient both in vitro in filter-matings and in vivo in the digestive tracts of rats. Hybridization and sequencing experiments revealed a linkage of resistance determinants for streptogramins A and B on definite plasmid fragments.

Anti-Bacterial Agents↗
PubMed2004

Characterization of streptococci and enterococci associated with septicaemia in broiler parents with a high prevalence of endocarditis.

Increased mortality due to septicaemia, where 29% of the affected birds had developed valvular endocarditis, was observed in a flock of broiler parents affected by myelocytomatosis. Bacterial investigations resulted in isolation of streptococci, the classification of which was unknown according to present taxonomy. Strains were isolated from the liver, spleen, heart and salpinx in clinical cases of septicaemia from the affected flock of Ross broiler parents aged between 26 and 56 weeks. Phenotypic characterization followed by genotypic investigation by ribotyping with HindIII and pulsed-field gel electrophoresis (PFGE) with SmaI demonstrated three ribotypes and six different PFGE profile types, respectively. Ribotype A with variant A1, together with the PFGE profile type represented by the three subtypes Ia, Ib and Ic, dominated the outbreak constituting 85% of the strains investigated, indicating clonality. 16S rRNA sequencing of strains representing this genotype demonstrated the occurrence of a recently described new Streptococcus sp., Streptococcus gallinaceus. Sequence analysis of the other genotypes demonstrated in the outbreak, resulted in identical 16S rRNA sequences to the type strain of Enterococcus faecalis. S. gallinaceus appears to represent a new opportunistic pathogen within the poultry industry.

Animals↗
PubMed1992

In vitro activity of cefpirome (HR 810) against enterococci and staphylococci.

The inhibitory activity of cefpirome (HR 810), a new cephalosporin derivative for parenteral use, was tested by agar dilution methods against Enterococcus faecalis (100 strains), Staphylococcus aureus (40 strains) and coagulase-negative staphylococcal species (60 strains) in comparison with other beta-lactam antibiotics. For E. faecalis, the cefpirome minimum inhibitory concentration (MIC) range was 2-128 micrograms/ml, with an MIC50 of 8 micrograms/ml, and an MIC90 of 64 micrograms/ml. The optimal bactericidal activity against strains with MICs of < or = 8 micrograms/ml occurred at 2-4 times the MIC, and the reduction in the initial inoculum was 99.9-99.7% after 24 h incubation at these concentrations. Mec gene-negative staphylococci (both S. aureus and coagulase-negative species) had cefpirome MICs of 0.25-2 micrograms/ml (MIC50 0.5 microgram/ml, MIC90 1 microgram/ml). Mec gene-positive strains had MICs of 0.5-128 micrograms/ml (MIC50 2 micrograms/ml, MIC90 32 micrograms/ml). Strains with borderline resistance to oxacillin which did not harbor the mec gene and which were susceptible to cefpirome maintained their susceptibility even when high-density inocula were used and after several passages in media containing the antibiotic. These studies present some potential advantages of cefpirome over other cephalosporins in the inhibitory activity against Gram-positive cocci.

Anti-Bacterial Agents↗
PubMed1993

Activity of daptomycin against enterococci and coagulase-negative staphylococci (CNS): relationship between CNS susceptibility and slime production.

We compared the in vitro activity of daptomycin, a new lipopeptide antibiotic, with that of vancomycin and other selected agents against 95 coagulase negative staphylococci (CNS) isolates causing septicemia or foreign-body infections in immunocompromised patients. These strains were classified as follows: 51 methicillin-susceptible CNS (23 slime producers); 44 methicillin-resistant CNS (23 slime producers). We also investigated the activity of daptomycin against 50 Enterococcus faecalis isolates. Minimal inhibitory concentrations (MICs) were determined by the broth microdilution method. Daptomycin at a concentration of 2 mg/L was inhibitory for all the evaluated strains. Vancomycin and ciprofloxacin showed good activity: 90% of the strains were inhibited by these agents at 8 mg/L. The activity of netilmicin, rifampin and trimethoprim-sulfamethoxazole was instead limited. Resistance to the antimicrobial agents tested was seen with increased frequency among slime producing strains. Daptomycin and teicoplanin were the most active agents tested against E. faecalis (MIC90 0.25 mg/L and 0.12 mg/L).

Anti-Bacterial Agents↗