GLYKOPEPTID- RESISTENS HOS ENTEROKOKKER

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GLYKOPEPTID- RESISTENS HOS ENTEROKOKKER KRISTIN HEGSTAD Wirth 1994 Eur J Biochem 222:235-46 ENTEROCOCCI (1) Gram+, normal inhabitants of the gastrointestinal tract (GIT) Arias 2012 Nat Rev Microbiol

faecium survive >90 days on hospital fabrics and plastics Intrinsic resistance to several antimicrobial agents Cephalosporins, sulphonamides, lincosamides, β-lactams and low-levels of aminoglycosides

1 GLYKOPEPTID- RESISTENS HOS ENTEROKOKKER KRISTIN HEGSTAD Wirth 1994 Eur J Biochem 222: ENTEROCOCCI (1) Gram+, normal inhabitants of the gastrointestinal tract (GIT) Arias 2012 Nat Rev Microbiol 16: Crusial role of GIT in infection and spread of enterococci Increasingly important nosocomial pathogens Survive extreme environments ph, salt, temperatures, chemical disinfectants E. faecium survive >90 days on hospital fabrics and plastics Intrinsic resistance to several antimicrobial agents Cephalosporins, sulphonamides, lincosamides, β-lactams and low-levels of aminoglycosides Acquire resistance determinants readily Successful clones have accumulated virulence factors ENTEROCOCCI (2) Species mainly causing infections E. faecalis > E. faecium Vancomycin resistant enterococci (VRE) E. faecium Effects of antibiotics on emergence of VRE; lectin Arias 2012 Nat Rev Microbiol 16:266-78

2 DEVELOPMENT AND SPREAD OF ANTIMICROBIAL RESISTANCE IN ENTEROCOCCI Mutations in pre-existing genes Acquisition of foreign DNA by conjugation Plasmids Integrative conjugative elements/conjugative transposons Genomic islands Clonal spread THREE MAJOR HOSPITAL LINEAGES (ST17, 18 AND 78) IN E. FAECIUM Hospital adapted Evolved through recombination, mutation and stress induced selection Putative pathogenicity island Accumulates Virulence genes surface proteins/adhesins Ampicillin, vancomycin and ciprofloxacin resistance Willems 2012 mbio 3:e GLYCOPEPTIDE PEPTIDOGLYCAN BINDING Glycopeptides - inhibit cell wall biosynthesis - prevent polymerisation and cross-linking of peptidoglycan Vancomycin Normal peptidoglycan peptide termini Modification of target lower affinity for binding of glycopeptide Alternative peptidoglycan peptide termini Nicas 1997 Trends Microbiol 5:240-9

FAECIUM Hospital adapted Evolved through recombination, mutation and stress induced selection Putative pathogenicity island Accumulates Virulence genes surface proteins/adhesins Ampicillin,

3 GLYCOPEPTIDE RESISTANCE IN ENTEROCOCCI Resistance Acquired Intrisic Level High Variable High Moderate Low Low Type VanA VanB VanM VanD VanE, VanG, VanL, VanN MIC mg/l: Vancomycin Teicoplanin 16 > 8 4 0,5-1 > 256 > 0, ,5 Localisation a P/C on Tn P/C, Tn/ICE? C C/ICE (VanE) C Transferable /+ (VanG) - Distribution E. faecium E. faecalis E. avium E. casseliflavus E. durans E. hirae E. mundii E. raffinosus S. aureus B. circulans O. turbata A. haemolyticum A. paenibacillus A. rhodococcus E. faecium E. faecalis E. casseliflavus E. durans E. hirae S. epidermidis Streptococcus Clostridium Ruminococcus Eggerthella E. faecium E. faecium E. faecalis E. avium E. raffinosus Nonenterococcal flora a C chromosome, P plasmid, Tn transposon, ICE integrative conjugative element E. faecalis/ E. faecium (VanN) VanG also in nonenterococcal flora VanC ,5-1 vanc1 E. casseliflavus vanc2/3 Modified Table 2 from Hegstad et al., Clin Microbiol Infect 16: VANA AND VANB CLUSTER CAN BE PART OF CONJUGATIVE PLASMIDS CONTAINING ADDICTION SYSTEMS Fig. 2 Hegstad 2010 Clin Microbiol Infect 16: Johnsen 2005 Appl Environ Microbiol 71: Bjørkeng 2011 APMIS 119: Hegstad et al. Unpublished results BRYTNINGSPUNKTER OG SCREENING AV GRE NordicASTs MIC brytningspunkter for glykopeptider: - Vankomycin R > 4 mg/l - Teikoplanin R > 2 mg/l Screening av kliniske enterokokkisolater for vankomycinresistens: - Norge spotinokulering BHI-agar med 6 mg/l vankomycin - Sverige EUCAST disk diffusjon

hirae E. mundii E. raffinosus S. aureus B. circulans O. turbata A. haemolyticum A. paenibacillus A. rhodococcus E. faecium E. faecalis E. casseliflavus E. durans E. hirae S.

4 NORDICAST STUDY COMPARING VRE DETECTION METHODS 34 Scandinavian labs participated 13 Norwegian 12 Swedish 9 Danish Methods used No. of labs Disk diffusion (6mm disks) 30 Disk diffusion (Neosensitabs) 3 BHI agar screen vanco 6 mg/l 21 VRE Chrom Agar 14 Vitek 7 Phoenix 1 NORDICAST STUDY BLINDED MATERIAL (N=30) Species van genotype Vancomycin MIC range mg/l E. faecalis B 4 24 / 4 4 E. faecalis E 16 1 E. faecalis G 16 1 E. faecalis ATCC E. faecalis ATCC B 16 3 E. faecium B 8- > No. of strains Included outbreak strains with low-level vancomycin resistance from Bergen (1996), Örebro ( ), Huddinge (2007) and Västerås (2008) 24 PFGE types 5 MLST types among 9 typed strains NORDICAST STUDY RESULTS TOTAL NUMBERS Method False susceptible samples False resistant samples Vitek 25/189 (13%) 0/21 (0%) Phoenix 4/27 (15%) 0/3 (0%) BHI vanco 6 47/567 (8,3%) 4/63 (6,3%) VRE ChromAgar 8/378 (2,1%) 6/42 (14%) Disk diffusion 6mm 53/810 (6,5%) 2/90 (2,2%) Neosensitabs 9/81 (11 %) 0/9 (0%)

Vancomycin MIC range mg/l E. faecalis B 4 24 / 4 4 E. faecalis E 16 1 E. faecalis G 16 1 E. faecalis ATCC 29212 E. faecalis ATCC 51299-3 3 B 16 3 E. faecium B 8- >256 18 No.

5 NORDICAST STUDY MIDDLE AND MEDIAN NUMBERS/LAB Method (n=no. of labs) False susceptible samples per lab (total n=27/lab) False resistant samples per lab (total n=3/lab) Number Middle Median Middle Median Vitek (n=7) 3, BHI vanco 6 (n=21) 2,2 2,0 0,19 0 VRE ChromAgar (n=14) 0,5 0 0,36 0 Disk diffusion 6mm (n=30) 1,7 1 0,067 0 Neosensitabs (n=3) 3, COMPARING RESULTS BY COUNTRIES Method Disk diffusion 6 mm disks BHI vanco 6 ChromID VRE Country (no. of labs) False susceptible samples in % False resistant samples in % Sweden (12) 1,5 0 Norway (13) 10 2,6 Denmark (5) 8,9 6,7 Sweden (1) 3,7 0 Norway (13) 7,1 0 Denmark (7) Sweden (7) 1,6 14 Norway (6) 3,1 17 Denmark (1) 0 0 VANCOMYCIN RESISTANT E. FAECIUM: EUROPE EARSS Annual Reports

0,19 0 VRE ChromAgar (n=14) 0,5 0 0,36 0 Disk diffusion 6mm (n=30) 1,7 1 0,067 0 Neosensitabs (n=3) 3,7 5 0 0 COMPARING RESULTS BY COUNTRIES Method Disk diffusion 6 mm disks BHI vanco 6 ChromID

6 VRE INFECTIONS IN SWEDEN County Blekinge Dalarna Gotland Halland Jämtland Jönköping Kalmar Kronoberg Norrbotten Skåne Stockholm Södermanland Uppsala Värmland Västernorrland Västmanland Västra Götaland Örebro Östergötland Total NATIONWIDE OUTBREAK OF A VANCOMYCIN- RESISTANT E. FAECIUM WITH VANB IN SWEDEN Majority of isolates have closely related PFGE type which contain vanb on an ICE on a conjugative plasmid with an addiction system NORM/NORM-VET 2009 VRE INFECTION AND COLONISATION IN NORWAY Country of infection Norway Unknown Abroad Total

0 0 0 0 2 0 0 1 0 Uppsala 0 3 1 0 13 7 10 0 2 Värmland 1 0 0 1 0 1 1 2 1 Västernorrland 0 0 0 0 0 2 60 37 0 Västmanland 0 0 0 0 83 133 41 2 1 Västra Götaland 1 3 4 3 4 7 8 6 16 Örebro 3 0 1 0 0 0 2 0

Epidemiology of vana gene carrier enterococci: Molecular characterisation, antibiotic sensitivity and phylogenetic relationship of Hungarian isolates

Epidemiology of vana gene carrier enterococci: Molecular characterisation, antibiotic sensitivity and phylogenetic relationship of Hungarian isolates Ágoston Ghidán Semmelweis University, Institute of