Enterococcal infections commonly occur in people who are already ill. This can make it difficult to determine if the bacterial infection is responsible for any subsequent illness or death. Some research suggests that the outlook for people with E. Other studies have found that patients with an infection caused by strains of vancomycin-resistant Enterococcus had a higher mortality rate than those with strains susceptible to the antibiotic.
Infections caused by antibiotic-resistant bacteria tend to result in longer hospital stays, higher health care costs, and higher mortality rates when compared with infections from antibiotic-susceptible bacteria. Good hygiene practices are the best way to prevent the transmission of E. Salmonella are bacteria that can infect the intestinal tract, leading to diarrhea and other symptoms.
Learn all about the infection and what to do if…. Escherichia coli E. Most strains are not harmful, but some produce toxins that can lead to illnesses…. Dysentery is an inflammation of the intestines, especially the colon. Symptoms include stomach cramps and diarrhea with blood or mucus in the feces….
Bacteria are single-celled organisms that exist in their millions, in every environment, inside or outside other organisms. Some are harmful, but…. Clostridium difficile, now called Clostridioides difficile C. What's to know about Enterococcus faecalis?
Medically reviewed by Alana Biggers, M. What is Enterococcus faecalis? Known infections Antibiotic resistance Transmission and prevention Preventing infection Treatment Outlook Enterococcus is a type of bacteria that is typically present in the gut and bowel. Originally, this bacteria was associated with the Streptococcus.
Known infections. Share on Pinterest A urinary tract infection can be caused by E. Newer antibiotics such as linezolid, daptomycin, quinupristin-dalfopristin, tigecycline and lypoglycopeptides usually show good activity against multidrug-resistant enterococci; however, resistance to these agents has already been reported.
Epidemiology of vancomycin resistant enterococci Enterococci have become resistant to multiple antimicrobial agents e. In recent years, control of vancomycin resistant enterococci VRE in the healthcare setting has become a real challenge for epidemiologists and clinicians.
Most of infection control measures for preventing VRE are also applicable, in large, to other drug-resistant enterococci and other resistant bacteria.
Vancomycin resistant enterococci VRE can colonize the gastrointestinal tract, particularly the large bowel, and is an important cause of nosocomial and healthcare-associated infections. Isolation of VRE in person without prior hospitalization or without contact with the healthcare system is very rare.
Large differences exist among enterococcal species regarding resistance to vancomycin. Thus, the majority of VRE isolates are E. VRE bowel colonization can contaminate the skin due to fecal shedding. Patients colonized with VRE serve as a reservoir and can transmit the strains to other patients through the healthcare workers and contaminated materials.
Colonization with VRE usually anticipates infection, but not all colonized patients will become infected. Infections caused by VRE have become a difficult to treat infection in patients admitted to hospitals, long-term care facilities, or in other healthcare settings. Interestingly, several reports have demonstrated clear differences in the epidemiology of VRE between Europe and the U.
Thus, VRE infections in humans were initially reported in Europe in the late s and were associated to the widely use of avoparcin, a glycopeptide compound, as a food additive for growth promotion in animals VRE could be recovered from the bowel flora of many animals such as chicken, fowl and pigs. Thus, in Europe there was an evident link between an animal source of VRE and subsequent transmission to humans. Later on, VRE infections were detected in the U.
However, in the U. Recently, a report from Michigan showed an isolation of VRE from pigs. In humans, some enterococcal species such as E. Then, in humans the bowel colonization with high-level vancomycin resistant enterococci having van A or van B gene cluster may result from an animal source or by horizontal transfer within the hospital or other healthcare settings. Several reports have shown that VRE infections have been detected worldwide but the prevalence of these infections varies widely among countries.
Of note, in the last two decades s and s the rates of VRE infections in the U. However, in recent years VRE are increasingly reported in some European countries e. VRE have produced multiple outbreaks in hospitalized patients, particularly in severely ill or immunocompromised patients admitted to ICUs as well as in surgical wards and medical wards.
In more recent years, VRE have become endemic in many hospitals and chronic care facilities. Analyses with molecular techniques such as PFGF pulsed-field gel electrophoresis have been useful to clarify the epidemiology of VRE in the hospital setting. Thus, several reports have shown that a single VRE clone can spread within a hospital unit and produce outbreaks.
On the other hand, however, VRE strains can also transfer resistance horizontally to unrelated enterococcal strains and then many different VRE clones different PFGF profiles can be found in a single hospital and, in these circumstances, VRE may become endemic.
The epidemiology of VRE is not fully understood, but the emergence and spread of VRE may be a consequence of a complex interaction among several factors such as:.
The persistence of VRE in colonized animals and humans as well as in environmental and dietary reservoirs. The potential for the rapid spread within hospitals and healthcare facilities where debilitated and immune compromised patients are admitted. It is well known that patients with VRE colonization in the intestinal tract sever as a reservoir and it is the initial step for spreading VRE in a healthcare setting and cause VRE infections see Table V.
VRE bowel colonization is usually detected by the use of rectal or perirectal swab cultures or stool cultures. The sensitivity of rectal swab varies widely depending on the VRE density in stool. Patients with high stool densities, prior antibiotics and associated skin colonization are those with higher probability of having positive rectal swab cultures for VRE. The lack of identification of carriers because of false-negative rectal swab cultures, which may avoid the implementation of contact precautions, may increase transmission of VRE.
Transmission of VRE from colonized patients to non-colonized patients can occur directly by contaminated hands of healthcare workers or indirectly by contaminated environmental surfaces. It has been demonstrated that VRE can survive for several days in different environmental surfaces e. Several characteristics of patients have been associated with high risk of VRE such as the presence of serious underlying diseases e. Some reports have also demonstrated that patients admitted to long-term care facilities are at high risk of VRE, particularly if the colonized pressure is high in those facilities.
Often these patients have debilitating and chronic underlying conditions, suffer from decubitus ulcer, and receive multiple antibiotic treatments. Patients from nursing homes carrying VRE often introduce the strains to acute care facilities. Antibiotics may modify the normal bowel flora and predispose to colonization with resistant organisms. Thus, the use of antibiotics seems to be an important risk factor for VRE and multiple studies have demonstrated an association between prior antibiotic therapy and colonization or infection with VRE.
Thus, patients with VRE had often prior antibiotic therapy with vancomycin, cephalosporins, anti-anaerobic drugs or quinolones, often with prolonged courses of treatment.
The antibiotic selection pressure, particularly with anti-anaerobic drugs, may change the normal balance of the bowel flora and increase density of colonization with VRE. The daily point prevalence of VRE colonized patients in a specific hospital unit is a crucial risk factor for acquisition of VRE. It has been demonstrated that exposure of hospitalized patients to contaminated surfaces and medical equipment is associated with VRE colonization and outbreaks of VRE infections.
The inappropriate use of hand washing and gloves by healthcare workers may transfer VRE from contaminated surfaces to uncontaminated surfaces and to uncontaminated patients. An appropriate compliance by the housekeeping staff of the cleaning protocols to avoid or diminish environmental contamination with VRE should be mandatory.
Multiple experiences and reports have confirmed the beneficial effect of several infection control measures for preventing colonization and infection with VRE see Table IV. Once VRE have disseminated in a hospital unit, their eradication may become a very difficult issue. First, the microbiology laboratory must play an active role in the control of VRE by classifying the enterococci at the species level and determining antimicrobial susceptibilities on clinical isolates using accurate methods.
Hand hygiene is considered the most important measure of preventing spread of VRE from patient to patient through the hands of healthcare workers. The two recognized techniques for hand hygiene are hand washing with soap and water and hand rubbing with alcohol-based hand-rub formulations.
Thus, transmission of VRE may decrease when healthcare workers wear gloves properly and gown when taking care of their patients, putting them on when entering a patient room, and removing them prior to exiting. It has been demonstrated that the use of gloves and gown is more efficacious than the use of gloves alone.
It is important to clarify precisely when and how patients with VRE should be placed on contact precautions. Source control, defined as a regular bathing of patients with antiseptic agents such as chlorhexidine, can reduce the burden of skin colonization by VRE and MRSA, and is an effective measure for preventing bloodstream infections. In addition, several experiences have shown that using private rooms or closing units during outbreaks can help to reduce transmission of multidrug-resistant organisms.
Certain items of medical equipment such as thermometers, blood pressure cuffs and stethoscopes should be confined to the isolation room and not used for other patients. Patients who had been colonized or infected with VRE and are readmitted to the hospital should be placed in isolation until colonization can be ruled out e.
Active surveillance cultures facilitate identification of patients with VRE carriage to be placed on contact precautions to minimize VRE spread. Several studies have shown that performance of active surveillance cultures, on admission and periodically during hospitalization, for VRE carriage and further implementation of other control measures in patients at high risk can reduce transmission of VRE. It is well known that patients colonized with VRE, particularly those severely ill or immunocompromised, are at higher risk for developing VRE infections.
Active surveillance cultures of hospitalized patients for VRE carriage can be an effective strategy to implement rational preventive measures and should be carried out in patients at high risk. However, legislation has been introduced in some states in the U. And, the conclusion was that the intervention was not effective in reducing the transmission of MRSA and VRE, although the use of barrier precautions was not optimal.
It is important to know that patients who had an infection or were colonized with VRE may remain culture-positive for more than 1 year and therefore active surveillance cultures are not needed for most of these patients. Several decolonization strategies have been used to eradicate VRE carriage. However, current data show that intestinal decolonization with nonabsorbable oral antibiotics has not proved to be consistently effective and most authorities are not currently recommended it.
Most authorities consider that a prudent use of antibiotics is a fundamental strategy to reduce problems with antimicrobial resistance in the healthcare setting. Thus, antibiotics must be administered prudently, with appropriate doses and duration of treatment. Inappropriate and excessive use of antibiotics can lead to selection of resistant organisms. For example, the risk of MRSA colonization has been correlated with a long duration of prior antibiotic therapy and certain types of antibiotics such as quinolones.
Although the relevance of antibiotic restriction in controlling VRE has not been clearly established, most authorities agree that antibiotic restriction, particularly vancomycin, cephalosporins, and anti-anaerobic drugs, should be considered in the setting of a nosocomial outbreak of VRE.
For example, vancomycin should be avoided for routine prophylaxis unless high rates of MRSA exist. Also, vancomycin should be avoided for the treatment of coagulase-negative staphylococci bacteremia growing in a single blood culture if contamination is likely. In many circumstances transmission of VRE is related to contamination of near-patient surfaces and medical equipment.
Often the evaluation of environmental cleaning is difficult to ascertain and some reports have confirmed that most near patient surfaces are not being cleaned in accordance with existing hospital policies. After the patient is discharged or transferred, the room should be accurately cleaned and disinfected.
The cleaning process could be improved with the use of new techniques such as saturated steam vapor disinfectant systems. The CDC initiative clearly emphasizes the need for improving the environmental cleaning and encourages hospitals to implement programs for optimizing it basic or Level I program and Level II program.
The CDC initiative claims to dedicate resources for evaluating environmental hygiene by means of implementing objective monitoring methods e. However, the local hospital or healthcare institution should consider the advantages and limitations of these monitoring approaches www. Treatment of enterococcal infections remains a difficult issue. Most currently available data are derived from uncontrolled studies.
Several considerations should be taken into account and these may include:. Enterococci may harbor intrinsic antimicrobial resistance and more importantly, they have developed an escalating process of acquiring new resistant determinants.
There are some controversies related to using monotherapy versus combination therapy in enterococcal infections. Treatment options for cases with high-level resistance for both ampicillin non-betalactamase producing strains and vancomycin. Table VII summarizes the antimicrobial agents for enterococci.
Briefly, some specific treatment options for the most common enterococcal infections are summarized below:. Treatment of enterococcal bacteremia may include intravenous ampicillin as the treatment of choice and vancomycin in cases with ampicillin resistance; linezolid or daptomycin can be used in cases resistant to ampicillin and vancomycin.
Doubts exist as to whether it should be monotherapy or combination therapy, which may include ampicillin or vancomycin plus gentamicin or streptomycin, in order to obtain a synergistic effect. Most authorities favor monotherapy for most cases of enterococcal bacteremia and combination therapy in severe sepsis or critically ill patients or those with preexisting valvular disease. In general, antibiotic therapy should be given for 7 to 14 days, although the optimal duration of treatment has not been established.
In the case of catheter-related BSIs, catheter removal alone may cure the infection, and most of these patients resolve the infection after 7 days of antibiotic therapy. No randomized trials have evaluated the potential benefit of combination therapy versus monotherapy or the optimal duration of therapy.
The treatment of choice for enterococcal endocarditis is ampicillin or penicillin G plus gentamicin. The usual duration of treatment is 4 to 6 weeks; however, to avoid nephrotoxity and ototoxicity, a shorter course of aminoglycoside 2 weeks may be recommended in some cases, e.
If strains are producing beta-lactamase, the use of ampicillin-sulbactam plus gentamicin or vancomycin plus gentamicin is usually recommended. In the setting of high-level penicillin resistance, the use of vancomycin plus gentamicin is recommended; if high-level gentamicin resistance is detected, streptomycin may be the alternative.
In the setting of aminoglycoside resistant E. For multi-drug resistant E. Daptomycin is generally not recommended for enterococcal endocarditis, although high-dose daptomycin combined with other agents such as gentamicin, rifampin, or tigecycline have cured some patients with vancomycin resistant enterococcal endocarditis. Importantly, in cases with multiple resistances the treatment success is usually lower and the duration of treatment should be prolonged at least of 8 weeks.
Oral therapy for uncomplicated enterococcal UTIs may include amoxicillin, nitrofurantoin, or fosfomycin; the experience with linezolid or fluoroquinolones is limited. For complicated UTIs, intravenous ampicillin is considered the drug of choice; alternatives may include vancomycin for susceptible cases or linezolid for cases resistant to ampicillin and vancomycin. It has been suggested that empiric antibiotic therapy for most community-acquired intra-abdominal infections or peritonitis does not need to cover enterococci.
However, enterococci should be covered in selected patients with peritonitis such as those with prior antibiotics, immunocompromised host, those with valvular disease or prosthesis, as well as those with postoperative peritonitis. Antibiotics with a potential activity against enterococci, which must be confirmed with susceptibility studies, may include ampicillin, piperacillin-tazobactam, imipenem, or vancomycin. Treatment of enterococcal meningitis is a difficult issue.
Most clinicians agree that a combination of drugs to achieve synergistic therapy with systemic antibiotics i. Some patients may require an intraventricular therapy e.
Experience with multi-resistant E. Other agents such as daptomycin and tigecycline have poor CNS penetration. Guidelines to prevent transmission of VRE There is a debate on optimal infection control strategies for preventing multidrug resistant organisms and VRE.
In addition, most studies have been carried out in acute care institutions, and with lesser extent in non-acute care institutions or chronic care facilities. There have been several organizations that reported guideline recommendations to prevent transmission of multidrug resistant organisms including VRE. In brief, the SHEA guidelines include several recommendations based on the level of scientific evidence for each infection control measures that should be implemented for preventing multidrug resistant strains of Staphylococcus aureus and Enterococcus.
The U. Tier-1 includes general recommendations for routine prevention and control of multidrug resistant organisms, and Tier-2 includes recommendations for intensified multidrug resistant organisms control efforts in special situations such as an outbreak or high incidence rates. Tier-1 and Tier-2 include seven categories of intervention. However, these guidelines differ regarding the use of active surveillance cultures for detecting colonization with VRE in patients at high risk.
The UK guideline did not particularly mention active surveillance cultures as a recommended practice among the infection control measures for VRE. The SHEA guideline recommends the use of surveillance cultures in patients at high risk. All three guidelines agree that no recommendations can be made for decolonization of patients who carry VRE and the use of nonabsorbable oral antibiotics has been generally disappointing.
Also, the infection control program should identify nonadherent practices. It is important to emphasize that despite publication of detailed recommendations and guidelines, compliance remains suboptimal in many institutions.
For example, a report from three New York institutions showed that patient care staff had an adherence rates on room entry and exit of Skip to main content. National Aquatic Resource Surveys. Contact Us. Indicators: Enterococci. What are enterococci? Why is it important to evaluate enterococci? Contact Us to ask a question, provide feedback, or report a problem.
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