Open Access Research article

Dynamics of ampicillin-resistant Enterococcus faecium clones colonizing hospitalized patients: data from a prospective observational study

Maja Weisser127*, Evelien A Oostdijk26, Rob JL Willems2, Marc JM Bonten23, Reno Frei4, Luigia Elzi1, Jörg Halter5, Andreas F Widmer1 and Janetta Top2

Author Affiliations

1 Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland

2 Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands

3 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands

4 Division of Clinical Microbiology, University Hospital Basel, Basel, Switzerland

5 Division of Hematology, University Hospital Basel, Basel, Switzerland

6 Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands

7 Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Petersgraben 4, CH- 4031 Basel, Switzerland

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BMC Infectious Diseases 2012, 12:68  doi:10.1186/1471-2334-12-68

Published: 22 March 2012

Abstract

Background

Little is known about the dynamics of colonizing Enterococcus faecium clones during hospitalization, invasive infection and after discharge.

Methods

In a prospective observational study we compared intestinal E. faecium colonization in three patient cohorts: 1) Patients from the Hematology Unit at the University Hospital Basel (UHBS), Switzerland, were investigated by weekly rectal swabs (RS) during hospitalization (group 1a, n = 33) and monthly after discharge (group 1b, n = 21). 2) Patients from the Intensive Care Unit (ICU) at the University Medical Center Utrecht, the Netherlands (group 2, n = 25) were swabbed weekly. 3) Patients with invasive E. faecium infection at UHBS were swabbed at the time of infection (group 3, n = 22). From each RS five colonies with typical E. faecium morphology were picked. Species identification was confirmed by PCR and ampicillin-resistant E. faecium (ARE) isolates were typed using Multiple Locus Variable Number Tandem Repeat Analysis (MLVA). The Simpson's Index of Diversity (SID) was calculated.

Results

Out of 558 ARE isolates from 354 RS, MT159 was the most prevalent clone (54%, 100%, 52% and 83% of ARE in groups 1a, 1b, 2 and 3, respectively). Among hematological inpatients 13 (40%) had ARE. During hospitalization, the SID of MLVA-typed ARE decreased from 0.745 [95%CI 0.657-0.833] in week 1 to 0.513 [95%CI 0.388-0.637] in week 3. After discharge the only detected ARE was MT159 in 3 patients. In the ICU (group 2) almost all patients (84%) were colonized with ARE. The SID increased significantly from 0.373 [95%CI 0.175-0.572] at week 1 to a maximum of 0.808 [95%CI 0.768-0.849] at week 3 due to acquisition of multiple ARE clones. All 16 patients with invasive ARE were colonized with the same MLVA clone (p < 0.001).

Conclusions

In hospitalized high-risk patients MT159 is the most frequent colonizer and cause of invasive E. faecium infections. During hospitalization, ASE are quickly replaced by ARE. Diversity of ARE increases on units with possible cross-transmission such as ICUs. After hospitalization ARE are lost with the exception of MT159. In invasive infections, the invasive clone is the predominant gut colonizer.