High-Level, Multiresistant Enterococci Associated with Systemic Disease: A Report of Two Cases

Abstract

SMH Qadri, ME Ellis, F Al-Rabiah, P Ernst, S Ingemansson, High-Level, Multiresistant Enterococci Associated with Systemic Disease: A Report of Two Cases. 1996; 16(6): 682-685 We describe two patients who died from enterococcal systemic disease. The organisms were identified as Enterococcus faecium. One isolate was resistant to all available antimicrobials and the other was sensitive only to chloramphenicol. The recent emergence of multiple-resistant enterococcal species reflects the critically fragile status of antimicrobial therapeutics. The clinical implications and possible means of their control are discussed.Although the term "enterocoque" was first used almost 100 years ago to emphasize the intestinal origin of these bacteria, 1 until recently they were classified in the genus Streptococcus, mainly because of their morphological resemblance and common biochemical tests. However, in 1984 it was shown by nucleic acid hybridization studies that S. faecalis and S. faecium were so distantly related to streptococci that they should be transferred to a new genus called Enterococcus.2 These bacteria also differ significantly in their antimicrobial susceptibility patterns from other streptococci. Recently these organisms have drawn much attention, not only because of their increasing role in hospital-acquired infections but because of their increasing resistance to antimicrobial agents. Their intrinsic resistance or relative resistance to β-lactams, clindamycin and aminoglycosides, and ability to acquire resistance to ciprofloxacin, erythromycin and tetracycline is well known.3-6 The most recent and most disturbing trait to emerge is resistance to vancomycin.7 Three years ago we had reported the first case of wound infection caused by vancomycin-resistant Enterococcus.7 In this paper we report two cases in which multiresistant enterococci were associated with systemic disease. Case 1A 15-year-old male patient with acute myelogenous leukemia and neutropenia developed fever and was treated with ceftazidime 40 mg/kg q8h intravenously, amikacin 15 mg/kg daily, vancomycin 15 mg/kg q12h and amphotericin B 0.5 mg/kg daily for four weeks. He eventually defervesced, but no organisms were isolated. He then received a regimen which included busulphan and total body irradiation for refractory relapsed acute leukemia prior to bone marrow transplantation. Although he was afebrile at the time of transplantation, he was profoundly neutropenic with a white count of <0.1 x 10 9 /L, and was therefore continued on the same broad spectrum antimicrobials. On the sixth day after the bone marrow transplant, he again became febrile; blood cultures taken 14 days post-transplantation grew Enterococcus, which was identified as E. faecium. Clinical management included catheter and line change, with the administration of imipenem 20 mg/kg q6h intravenously. The patient continued to be unwell, developing peritonitis and right lower lobe pneumonia in the presence of persistent neutropenia. Bone marrow examination showed a hypocellular marrow....

Vancomycin-Resistant Enterococci (VRE) as Intestinal Flora from Poultry in Riyadh

“…To our knowledge, only six cases of VRE infections and some colonization have been seen or reported. 4,5,7,10 As the prudent use of antimicrobials by clinicians is effective in lowering the emergence of resistant isolates in humans, animal husbandries and poultry farms should be discouraged to use avoparcin and other antimicrobial agents as feed supplement, in order to minimize acquisition of resistant flora.…”

“…1 Since then, these organisms have been reported to have caused human infections in the USA, UK, Germany, The Netherlands, Spain and Saudi Arabia. [2][3][4][5] The number of cases infected with VRE, as reported by the US Centers for Disease Control and Prevention, had jumped from 99 in 1992 to 278 in 1994, with a rapid increase in colonization, and a fecal carriage rate of 86%. 6 Since colonized patients as well as domestic animals and environment can serve as significant reservoirs for human acquisition of VRE, we determined the presence of these organisms in sewage and fecal samples of poultry, camels, goats and sheep in Riyadh and its vicinity.…”