THE glycopeptide antibiotic agents vancomycin and teicoplanin are useful in the treatment of severe infections due to gram-positive bacteria.1 2 3 Staphylococci, streptococci, and enterococci are a...

Plasmid-mediated resistance to vancomycin and teicoplanin in Enterococcus faecium.

The etiologic diagnosis of infective endocarditis is easily made in the presence of continuous bacteremia with gram-positive cocci. However, the blood culture may contain a bacterium rarely associated with endocarditis, such as Lactobacillus spp., Klebsiella spp., or nontoxigenic Corynebacterium, Salmonella, Gemella, Campylobacter, Aeromonas, Yersinia, Nocardia, Pasteurella, Listeria, or Erysipelothrix spp., that requires further investigation to establish the relationship with endocarditis, or the blood culture may be uninformative despite a supportive clinical evaluation. In the latter case, the etiologic agents are either fastidious extracellular or intracellular bacteria. Fastidious extracellular bacteria such as Abiotrophia, HACEK group bacteria, Clostridium, Brucella, Legionella, Mycobacterium, and Bartonella spp. need supplemented media, prolonged incubation time, and special culture conditions. Intracellular bacteria such as Coxiella burnetii cannot be isolated routinely. The two most prevalent etiologic agents of culture-negative endocarditis are C. burnetti and Bartonella spp. Their diagnosis is usually carried out serologically. A systemic pathologic examination of excised heart valves including periodic acid-Schiff (PAS) staining and molecular methods has allowed the identification of Whipple9s bacillus endocarditis. Pathologic examination of the valve using special staining, such as Warthin-Starry, Gimenez, and PAS, and broad-spectrum PCR should be performed systematically when no etiologic diagnosis is evident through routine laboratory evaluation.

Endocarditis Due to Rare and Fastidious Bacteria

Several new genera and species of gram-positive, catalase-negative cocci that can cause infections in humans have been described. Although these bacteria were isolated in the clinical laboratory, they were considered nonpathogenic culture contaminants and were not thought to be the cause of any diseases. Isolation of pure cultures of these bacteria from normally sterile sites has led to the conclusion that these bacteria can be an infrequent cause of infection. This review describes the new bacteria and the procedures useful for clinical laboratories to aid in their identification. The clinical relevance and our experience with the various genera and species are reviewed and discussed.

Identification, classification, and clinical relevance of catalase-negative, gram-positive cocci, excluding the streptococci and enterococci.

Lactic acid bacteria and human clinical infection

Enterococcus faecium BM4165 and BM4178, isolated from immunocompromised patients, one treated with vancomycin, were inducibly resistant to high levels of the glycopeptide antibiotics vancomycin and teicoplanin but susceptible to the new lipopeptide daptomycin (LY146032). Strain BM4165 was also resistant to macrolidelincosamide-streptogramin B-type (MLS) antibiotics. The genes conferring resistance to glycopeptides and to MLS antibiotics in strain BM4165 were carried on plasmids pIP819 and pIP821, respectively; pIP819 also carried genes that encoded resistance to MLS antibiotics. The two plasmids, which were distinct although related, were self-transferable to other E. faecium strains. Plasmid pIP819 could also conjugate to E. faecalis, Streptococcus sanguis, S. pyogenes, S. lactis, and Listeria monocytogenes, in which it conferred inducible glycopeptide resistance, but not to S. aureus. Glycopeptide-inactivating activity was not detected, and the biochemical mechanism of resistance remains unknown. Based on this first report of transferable resistance to glycopeptides, we anticipate dissemination of resistance to these antibiotics in gram-positive cocci and bacilli in which it can be phenotypically expressed.

Transferable vancomycin and teicoplanin resistance in Enterococcus faecium.

Two strains of gram-positive cocci highly resistant to vancomycin (MICs of 512 and 1,024 micrograms/ml) were isolated from blood cultures in two compromised patients. These organisms were identified as Leuconostoc spp. Leuconostoc spp. are gram-positive cocci found in vegetables and dairy products; they had not been isolated previously from clinical specimens. The susceptibility of eight Leuconostoc spp. strains, including the two clinical isolates, to 23 antimicrobial agents was determined.

Vancomycin-resistant streptococci or Leuconostoc sp.

Gemella haemolysans, a member of the family Streptococcacae, was isolated from patients with subacute endocarditis. The minimal inhibitory concentrations of 21 antimicrobial agents for five strains of the organism were determined. All strains were highly sensitive to penicillin G and ampicillin. Cefotaxime was the most active cephalosporin tested. All strains were sensitive to vancomycin, chloramphenicol and rifampin. Four strains were sensitive to tetracycline and erythromycin. All strains demonstrated a low level of resistance to aminoglycosides and were highly resistant to sulfonamides and trimethoprim. Killing curves and checker-board titration demonstrated synergism between penicillin G and streptomycin or gentamicin, and also between vancomycin and streptomycin or gentamicin. The results suggest that penicillin G combined with an aminoglycoside can be recommended for the treatment of subacute endocarditis caused by Gemella haemolysans.

A. Buu-Hoi

Papers

Vancomycin-resistant streptococci or Leuconostoc sp.

Antimicrobial susceptibility of Gemella haemolysans isolated from patients with subacute endocarditis.

Vancomycin-Resistant Streptococci or sp.