Population Structure of
            <i>Enterococcus faecium</i>
            Causing Bacteremia in a Spanish University Hospital: Setting the Scene for a Future Increase in Vancomycin Resistance?

Coque, Teresa M.; Willems, Rob J. L.; Fortün, Jesús; Top, Janetta; Diz, Sergio; Loza, Elena; Baquero, Fernando

doi:10.1128/aac.49.7.2693-2700.2005

Cited by 82 publications

(67 citation statements)

References 50 publications

(77 reference statements)

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“…In our institution, an ampicillin-resistant E. faecium clone (Efm-6, ST18) belonging to HrCC17 and a multiresistant E. faecalis clone (Efc-3, ST17) belonging to HrCC9 were endemic and caused several bacteremic episodes (P. Ruiz-Garbajosa et al, unpublished data). Unlike other clones, they persisted for a long time in certain wards and ICUs in our hospital (7,26). The specific role of the accessory genome involved in clonal persistence is not yet known, but in E. faecalis and E. faecium, hospital-acquired clones have been shown to be enriched in adaptive mechanisms, like the presence of putative virulence genes and novel metabolic pathways (12,13,17,19,27).…”

Section: Discussionmentioning

confidence: 99%

Longer Intestinal Persistence of Enterococcus faecalis Compared to Enterococcus faecium Clones in Intensive-Care-Unit Patients

et al. 2009

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The dynamics of intestinal colonization with enterococcal clones in intensive-care-unit (ICU) patients was evaluated. Eight patients admitted directly to the neurosurgical ICU at the Ramón y Cajal University Hospital (Madrid, Spain) from the community and with no overlapping stay during a 10-month period in 2006 were studied. Rectal swab specimens were collected on admission and daily until the patients were discharged. Clonality was determined by pulsed-field gel electrophoresis and multilocus sequence typing. Clonal colonization dynamics were estimated by using two new parameters: the clonal diversity per patient per day (CDPD) and the clonal persistence ratio (CPR). Enterococcus faecalis isolates (n ‫؍‬ 123) and Enterococcus faecium isolates (n ‫؍‬ 66) were resolved into 13 and 15 clones, respectively. The CDPD of E. faecalis steadily increased during admission, and E. faecalis showed a higher (P ‫؍‬ 0.001) CPR value than E. faecium (0.86 and 0.42, respectively). E. faecium, with the exception of an ampicillin-resistant clone belonging to clonal complex 17, frequently appeared as a short-term colonizer, even though the E. faecalis clones had significantly (P ‫؍‬ 0.03) more days under antibiotic exposure than E. faecium (77.5 and 65 days/100 colonization days, respectively). E. faecalis had a longer persistence than E. faecium, except for the CC17 ampicillin-resistant clone, and E. faecalis showed a cumulative increase in CDPD, whereas E. faecium did not. CDPD and CPR were useful for measuring the dynamics of intestinal colonization with enterococcal clones.Intensive care units (ICUs) are hospital compartments that present the highest frequencies of nosocomial infection with multiresistant bacteria due to the combination of the presence of seriously ill patients, frequent events of cross transmission, and high levels of antibiotic pressure. Enterococci have emerged as a significant cause of nosocomial infections, causing about 7% of infections among ICU patients (28). Traditionally, enterococcal infections were thought to be of endogenous origin, but modern typing systems have permitted the identification of genotypes that are well adapted to the hospital setting and that are frequently cross transmitted. Population structure studies based on multilocus sequence typing (MLST) data for Enterococcus faecalis (25) and Enterococcus faecium (14), the enterococcal species most often isolated from clinical infections, have revealed the existence of particular clonal complexes (CCs) that are frequently selected in the hospital environment. These CCs have been named high-risk CCs (HrCCs), as they are the cause of most enterococcal infections and hospital outbreaks all over the world (18).Bacterial persistence in hosts constitutes an important factor driving both bacterial transmission and infection. Different studies that have focused on the longitudinal follow-up of patients colonized with multiresistant enterococci, especially vancomycin-resistant isolates, demonstrated the prolonged persistence of vancomycin-resista...

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Section: Discussionmentioning

confidence: 99%

Longer Intestinal Persistence of Enterococcus faecalis Compared to Enterococcus faecium Clones in Intensive-Care-Unit Patients

et al. 2009

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“…Although E. faecium strains in CC17 are associated with epidemicity in hospitals, there has been a report of a CC17 strain in swine from Portugal (20). Conversely, several studies in Europe have reported finding swine-adapted E. faecium CC5 strains in humans (3,11,12,20,23,30,33).…”

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Characterization of Vancomycin-Resistant Enterococcus faecium Isolated from Swine in Three Michigan Counties

et al. 2010

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Vancomycin-resistant enterococci are a major cause of nosocomial infections but are rarely found in humans in the community and have not been identified in food animals in the United States. We evaluated a total of 360 fecal specimens from humans and their animals being raised for exhibit at three county fairs in Michigan. Fecal samples from 158 humans, 55 swine, 50 cattle, 25 horses, 57 sheep, 14 goats, and 1 llama were obtained and plated onto Enterococcosel agar containing 16 g/ml of vancomycin. Vancomycin-resistant Enterococcus faecium (VREF) was isolated from six pigs but not from humans or any animal other than pigs. All six VREF isolates had a MIC to vancomycin of >256 g/ml and contained the vanA gene. Pulsed-field gel electrophoresis (PFGE) patterns of the six VREF isolates were >80% similar. Multilocus sequence typing (MLST) revealed sequence type 5 (ST5) (n ‫؍‬ 2), ST6 (n ‫؍‬ 3), and ST185 (n ‫؍‬ 1), which are E. faecium sequence types belonging to clonal complex 5 (CC5). These findings show the dissemination of VREF strains among pigs in three Michigan counties. This is the first report of VRE found in food animals in the United States.

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“…This subpopulation belongs to a distinct genetic lineage labeled clonal complex 17 (CC17) (62) and is associated with the presence of the variant esp gene as part of a pathogenicity island (31) and resistance to ampicillin. Recently, resistance to ciprofloxacin appeared to be associated with ampicillin resistance in genotypically related E. faecium isolates from Norway (25,55,56) and Spain (7).…”

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High-Level Ciprofloxacin Resistance from Point Mutations in gyrA and parC Confined to Global Hospital-Adapted Clonal Lineage CC17 of Enterococcus faecium

et al. 2006

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To substantiate a common genetic background of ciprofloxacin-resistant Enterococcus faecium, 32 ciprofloxacin-resistant (Cip r ) and 31 ciprofloxacin-susceptible (Cip s ) isolates from outbreaks, clinical infections, surveillances, and animals from 10 different countries were genotyped by multilocus sequence typing. Additionally, susceptibilities to ampicillin and vancomycin and the presence of esp were determined and the quinolone resistance-determining regions of parC, gyrA, parB, and gyrE were sequenced. High-level Cip r (MIC > 64 g/ml) due to point mutations in the quinolone resistance-determining region was unique to a distinct hospital-adapted genetic complex in E. faecium, previously designated CC17. Low-level Cip r (MIC ‫؍‬ 4 g/ml) in non-CC17 strains is not attributable to point mutations in any subunit of the topoisomerase genes, and the mechanism of resistance remains unclear. Acquisition of mutations in parC and gyrA, leading to high-level Cip r , is, in addition to ampicillin resistance and the presence of a putative pathogenicity island, another cumulative step in hospital adaptation of CC17.Over the last two decades, enterococci have become increasingly important as nosocomial pathogens (3). These organisms are intrinsically resistant to a large number of antimicrobials and have the ability to easily acquire new resistance traits (40, 50). The emergence of nosocomial infections caused by ampicillin-, high-level aminoglycoside-, and glycopeptide-resistant Enterococcus faecium has caused clinical concern due to intraand interhospital spread and limited therapeutic options (40, 50). Glycopeptide-resistant enterococci (vancomycin-resistant enterococci [VRE]) are nowadays endemic to the United States, with ϳ30% of enterococcal infections caused by VRE (38, 43); in Europe, the epidemiology of VRE is now changing from a near absence of VRE in hospital-acquired infections at the turn of the century to a situation in which nosocomial epidemics and infections are increasingly reported (3, 13, 17). We recently described a hospital-adapted genetic subtype of E. faecium associated with epidemics and clinical infections, which has spread globally (20,32,62,65). This subpopulation belongs to a distinct genetic lineage labeled clonal complex 17 (CC17) (62) and is associated with the presence of the variant esp gene as part of a pathogenicity island (31) and resistance to ampicillin. Recently, resistance to ciprofloxacin appeared to be associated with ampicillin resistance in genotypically related E. faecium isolates from Norway (25,55,56) and Spain (7).To substantiate a common genetic background of quinoloneresistant E. faecium and association with the hospital-adapted CC17, we studied the genetic relatedness of 32 ciprofloxacinresistant and 31 ciprofloxacin-susceptible E. faecium isolates from various human and animal origins by multilocus sequence typing (MLST) and determined susceptibility to vancomycin and ampicillin and the presence of esp. Finally, we sequenced the quinolone resistance-determining regions (...

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Population Structure of Enterococcus faecium Causing Bacteremia in a Spanish University Hospital: Setting the Scene for a Future Increase in Vancomycin Resistance?

Cited by 82 publications

References 50 publications

Longer Intestinal Persistence of Enterococcus faecalis Compared to Enterococcus faecium Clones in Intensive-Care-Unit Patients

Longer Intestinal Persistence of Enterococcus faecalis Compared to Enterococcus faecium Clones in Intensive-Care-Unit Patients

Characterization of Vancomycin-Resistant Enterococcus faecium Isolated from Swine in Three Michigan Counties

High-Level Ciprofloxacin Resistance from Point Mutations in gyrA and parC Confined to Global Hospital-Adapted Clonal Lineage CC17 of Enterococcus faecium

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