Bulletin of the Transilvania University of Braşov eries VI: Medical ciences Vol. 9 (58) No. 1-2016 THE EVLUTION OF THE THOGENI OLE ND NTIMIOBIL EITNE OF ENTEOOU EIE M.E. IDOMI 1.D. NEULOIU 2 bstract: The aim of the study consisted in the evaluation of the pathogenic role and resistance to antibiotics of enterococcal strains isolated in a 3 years period (2013-2015) from hospitalized patients. The spectrum of enterococcal infections in hospitalized patients was large and relative constant in the studied period, being dominated by urinary tract infections (38.8%), wound infections (30.1%) and intraabdominal and pelvic abscesses (10.9%). The highest level of resistance were recorded to macrolides and fluoroquinolones. The Enterococcus strains had high sensitivity to glycopeptides. Key words: Enterococcus, infections, antimicrobial resistance. 1. Introduction Enterococcus genre includes gram positive catalase negative cocci, natural residents of human intestine. Due to the disruption of the commensal relationship with the host, Enterococcus can be involved in urinary and biliary tract infections, endocarditis, intra-abdominal and pelvic infections, wounds infections, rarely meningitis. [4], [7], [9] Enterococcus represent an important cause of nosocomial infections and can determine sporadic outbreaks in some hospital wards. In the hospitals, enterococci are considered the second most common cause of urinary tract and wounds infections and the third most common cause of bacteriemia. [4], [7] Urinary infections are the most common location in hospitalized patients (cystitis, pyelonephritis, prostatitis, renal abscesses) and are frequently associated with structural abnormalities or local catheterization. [4], [7] Enterococcus sp. are intrinsically resistant to cephalosporins. The sensitivity to other antibiotics varies widely. The acquisition of high-level resistance to aminoglycosides and the emergence of vancomycin resistant strains are the most concerning problem in our days. The resistance to β-lactams is due to β- lactamases or structural changes of the B (penicillin binding protein). [3], [5], [7], [9] 1 Faculty of Medicine, Transilvania University of Braşov 2 linical ounty Emergency Hospital of Braşov * orrespondent author: midomir@yahoo.com
14 Bulletin of the Transilvania University of Braşov eries VI Vol. 9 (58) No. 1-2016 Enterococcus genre shows a low level of natural resistance to aminoglycosides but with gentamicin being active. t the wild strains of Enterococcus the synergy with β- lactams and glycopeptides is present. Due to chromosomal mutations, HL (High el minoglycosides esistant) strains are being selected case in which the synergy with β-lactams is lost. The enterococi resistance to glycopeptides is associated with changes in the bacterial wall (due to the synthesis of a new precursor of the peptidoglycan). [3], [5], [7], [9] 2. Material and Methods The study was retrospective, descriptive and was conducted in the linical ounty Emergency Hospital of Braşov in the period 1.01.2013-31.12.2015. The aim of the study was to evaluate the pathogenic role of these germs and to determine the level of antibiotic resistance of the enterococci isolated from the hospitalized patients. The objectives of the study have consisted in the evaluation of the etiologic spectrum of enterococcal infections and the study of the resistance patterns of the isolates strains in order to optimize the prescription of antibiotics. The processing of the biological samples was performed in the linical laboratory of this medical unit. During the study there were considered as having ethiopathogenic significance the enteroocci isolated from the samples with inflammatory characteristics (purulent, with polymorphonuclear neutrophil leukocytes on the gram smear). For the isolation of enterococci there were used olumbia gar with 5% sheep blood, Mac onkey gar and Brilliance UTI gar, incubated aerobically at 37 for 24 hours. The genre identification of the isolates was based on morphological, cultural and biochemical characteristics (esculin Bile gar), being confirmed in certain clinical situations by VITEK 2 ompact system. The routine antibiotic susceptibility testing of the Enterococcus sp. was performed by Kirby-Bauer diffusion method, interpreted according to the.l..i. guideline (linical and Laboratory tandards Institute) from 2013, 2014, respectively 2015. The antimicrobials that have been tested for Enterococcus strains were ampicillin (), ciprofloxacin (ip), cloramphenicol (), eryhtromycin (E), linezolid (), levo-floxacin (), norfloxacin (), penicillin (), riphampicin (), teicoplanin () and vancomycin (). For detection of the HL strains 120 µg gentamicin disks have been used. 3. esults and Discussions The first objective of the study was to assess the involvement in pathology of the enterococci isolated from the hospitalized patients. Figure 1 shows the dynamics of the number of enterococci in the studied period. 700 600 500 400 300 200 100 0 453 424 2013 2014 2015 No. enterococci 616 Fig. 1. The dynamics of the number of Enterococcus strains in the studied period
M.E. IDOMI et al: The Evaluation of the athogenic ole and ntimicrobial esistance... 15 Figure 2 shows the spectrum of infections caused by Enterococcus sp. during the study. 4.2% 8.4% 3.7% 4.0% 10.9% 38.8% 30.1% espiratory secretions erous fluids Fig. 2. The spectrum of infections with Enterococcus sp. in the studied period The analyzed serous fluids were peritoneal (52), pleural (3), pericardic (3) and sinovial fluids (1). biological samples from which Enterococcus sp. has been isolated were blood, bile, genital secretions and catheters fragments. We have also analyzed the spectrum of the infections with Enterococcus sp. in each year of the study to see if there have been significant differences, as shown in Figures 3 5. 2.6% 3.1% 9.3% 5.1% 11.0% 3.5% 5.4% 11.1% 5.7% 8.7% 23.2% 45.7% 27.6% 38.0% espiratory secretions erous fluids espiratory secretions erous fluids Fig. 3. Enterococcus infections in 2013 Fig. 4. Enterococcus infections in 2014 4.5% 3.6% 5.8% 2.6% 12.2% 37.0% 34.3% espiratory secretions erous fluids Fig. 5. Enterococcus infections in 2015
16 Bulletin of the Transilvania University of Braşov eries VI Vol. 9 (58) No. 1-2016 From the results it can be observed that the spectrum of infections with Enterococcus was relatively constant during the study. The second objective of the retrospective study was to analyze the level of antibiotic resistance of Enterococcus sp. The results 0.1 83.4 16.5 99.2 99.2 16.6 40.0 1.5 43.3 58.7 39.8 53.3 20.9 99.5 0.4 46.3 E 23.0 8.1 56.1 ip 45.3 46.6 2.2 73.2 24.6 0.1 83.5 16.4 of the antibiograms during the studied period are illustrated in Figure 6. In Figures 7-9 are presented the results obtained for the antibiotic susceptibility tests for each year of study. I Fig. 6. esistance to antimicrobials of Enterococcus sp. in the studied period During the study, higher level of resistance were recorded to macrolides (erythromycin - 56.1%), fluoroquinolones (ciprofloxacin 46.6%, levofloxacin 46.3%, norfloxacin 39.9%) and riphampicin (43.3%). The isolates strains had high sensitivity to glycopeptides (vancomycin 99.2%; teicoplanin 99.2%). There were also observed various levels of resistance to the other tested antibiotics. E ip 36.4 3.0 23.2 15.4 50.0 21.9 41.5 81.1 18.9 21.2 42.4 73.3 98.9 0.8 1 73.7 62.7 49.2 48.3 3.5 23.3 81.8 18.2 Fig. 7. esistance to antimicrobials of Enterococcus sp. in 2013 1.1 I
M.E. IDOMI et al: The Evaluation of the athogenic ole and ntimicrobial esistance... 17 E ip 34.5 1.3 23.9 17.2 89.6 10.4 99.1 0.7 99.1 0.7 22.2 43.3 99.8 74.8 49.6 50.4 24.0 58.8 7.3 42.3 50.4 2.4 7 27.1 88.7 11.3 I Fig. 8. esistance to antimicrobials of Enterococcus sp. in 2014 0.3 80.8 18.9 11.4 44.6 43.9 1.1 77.6 21.3 0.3 99.7 0.3 57.9 41.7 17.5 E 35.7 46.9 7.3 ip 49.6 43.1 0.9 74.8 24.3 81.5 18.4 I Fig. 9. esistance to antimicrobials of Enterococcus sp. in 2015 During the study it was also analyzed the dynamics of the number of HL strains, knowing that these strains represent a major infections control challenge and an important cause of nosocomial infections. The results are shown in Figure 10. The pathogenic role of HL strains for the entire studied period are illustrated in Figure 11.
18 Bulletin of the Transilvania University of Braşov eries VI Vol. 9 (58) No. 1-2016 250 200 150 185 177 223 17.3% 3.9% 1.2% 4.1% 8.7% 3.4% 100 50 61.4% 0 2013 2014 2015 No. HL strains espiratory secretions erous fluids Fig. 10. The dynamics of the number of HL strains in the studied period Fig. 11. The spectrum of infections with HL strains in the studied period The pathogenic role of HL strains for each year of the studied period are illustrated in Figures 12-14. 17.3% 1.6% 2.7% 2.2% 3.8% 6.5% 65.9% espiratory secretions erous fluids Fig. 12. Infections with HL strains in 2013 6.2% 4.5% 4.0% 1.7% 7.3% 17.9% 1.8% 5.4% 4.0% 0.4% 11.7% 16.4% 59.9% 58.7% espiratory secretions erous fluids espiratory secretions erous fluids Fig. 13. Infections with HL strains in 2014 Fig. 14. Infections with HL strains in 2015
M.E. IDOMI et al: The Evaluation of the athogenic ole and ntimicrobial esistance... 19 It was also analyzed the resistance to antibiotics of the HL strains, which is an important aspect in the evaluation of the therapeutical options for these infections. The results for the entire period and for each year is illustrated in Figures 15-18. 2.6 4.4 42.2 70.3 29.7 98.6 98.6 23.3 97.4 95.6 34.4 E 13.9 6.1 79.9 3.9 ip 95.6 3.9 70.0 26.1 72.8 27.2 0.9 0.9 0.7 I 3.4 E 5.5 40.4 1 8.4 81.0 4.6 0.7 ip 94.8 66.8 33.2 75.5 98.9 98.9 29.5 96.6 98.9 94.5 74.4 25.6 5.7 30.1 18.9 1.1 I Fig. 15. esistance to antimicrobials of HL strains in the studied period Fig. 16. esistance to antimicrobials of HL strains in 2013 1.0 4.1 39.3 85.8 14.2 97.7 1.7 97.7 1.7 31.5 29.2 99.0 99.4 95.9 E 13.6 5.8 8 5.4 ip 94.6 5.6 63.4 31.0 84.6 15.4 Fig. 17. esistance to antimicrobials of HL strains in 2014 I During the study it was recorded an increase of the number of Enterococcus strains, especially in the last year. The results regarding the pathogenic role of Enterococcus sp. were similar to those obtained in previous studies in the same medical unit, these germs being most commonly involved in the urinary tract infections and wound infections of the hospitalized patients. [1], [2], [6] s in other studies conducted in the same hospital, the isolated strains have presented resistance to all tested antibiotics, especially to fluoroquinolones. 3.2 3.7 E 20.7 2.3 ip 0.9 45.0 2.2 60.8 39.2 99.0 99.0 14.8 96.8 99.5 96.3 96.8 77.2 4 66.4 33.6 61.9 38.1 Fig. 18. esistance to antimicrobials of HL strains in 2015 I lso these germs have retained their sensitivity to glycopeptides. [1], [2], [6] The levels of resistance to antibiotics of Enterococcus species resulting from this study falls within the data published by the European E-Net surveillance system in 2014. The HL strains share (39.85%) was lower than the percentage for omania (76.5% - E. faecalis; 84.2% - E. faecium) but greater than the percentage for Europe (28.8%) in 2014. The resistance to vancomycin was very low (0,8%) compared to the national percentage (3.9% - E. faecalis, 25% - E. faecium) [8], [9]
20 Bulletin of the Transilvania University of Braşov eries VI Vol. 9 (58) No. 1-2016 4. onclusions The spectrum of enterococcal infections in hospitalized patients was large and relatively constant in the studied period, being dominated by urinary tract infections (38.8%), wound infections (30.1%) and intraabdominal and pelvic abscesses (10.9%). During the studied period, higher level of resistance was recorded to macrolides and fluoroquinolones. The Enterococcus sp. had high sensitivity to glycopeptides. There were obtained various levels of resistance to the other tested antibiotics. The share of HL strains was relatively high (39.85%) and constant during the study. The results of the study sustain the importance of the identification of the species and of the resistance phenotypes in case of these germs in order to optimize the etiological therapy. eferences 1. Gavrilă, G., Idomir, M.E.: tudy of some Enterococcus sp. strains isolated from different pathological products. In: ibiul Medical, vol. 16, No. 3, 2005, p. 113-116. 2. Idomir, M.E., irău,., Nemet,., Bandac, M.: Evaluation of microbiological spectrum of burn wound infections. In: Bulletin of Transilvania University series VI, vol. 5(54), No. 1, 2012, p. 7-12. 3. Jehl, F., homarat, M., Weber, M., Gerard,.: De la antibiogramă la prescripţie, ediţia a III-a. Bucureşti. Editura Orizonturi, 2010, p. 86-88. 4. Kilian, M.: treptococcus and Enterococcus. In: Medical microbiology seventeenth edition, hurchill Livingstone Elsevier, 2007. 5. Kristich,.J., ice, L.B., rias,..: Enterococcal Infection Treatment and ntibiotic esistance Enterococci. In: From ommensals to Leading auses of Drug esistant Infection, Massachusetts Eye and Ear Infirmary, Boston, 2014. 6. Mateescu, G.G., Idomir, M.E., Nemet,.: Ethiological and therapeutical particularities of urinary infections in urological patients. In: Bulletin of Transilvania University (2014) Vol. vol. 7(56), eries VI, No. 1, p. 19-24. 7. Winn, W., llen,., Janda, W., Koneman, E., rocop, G., chreckenberger,., Woods, G.: Koneman's olor tlas and Textbook of diagnostic microbiology, sixth edition. Lippincott Williams&Wilkins, 2006. 8. *** nnual epidemiological report. ntimicrobial resistance and healthcare-associated infections 2014. ecdc.europa.eu/en/publications/ublica tions/antimicrobial-resistance-annualepidemiological-report.pdf 9. *** nnual report of the European ntimicrobial esistance urveillance Network (E-Net). ecdc.europa.eu /en/publications/ublications/antimicr obial-resistance-europe-2014.pdf