Nocosomial infection with Vancomycin-dependent Enterococci
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Nocosomial infection with Vancomycin-dependent Enterococci
Michelle Nguyen
Bioc 230
10/11/04
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Preview
Cases Molecular profiling of VDE Case control study Discussion
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Case 1
32 y.o woman with h/o type 1 DM, ESRD Kidney-pancreas transplant Post-op infection with VR Enterococcus
faeciumTx with antibiotics Abdominal fluid culture VR E. faecium
that cannot grow w/o Vancomycin Refractory sepsisdeath (day 268)
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Case #2
40 y.o woman with h/o type I DM, ESRD Kidney-pancreas transplant Post-op: VRE from intraabdominal
culturesremove kidney and pancreas Antibiotic tx with IV streptogramins Refractory VREdeath
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Case #3
47 y.o woman with h/o CML Matched-unrelated donor bone marrow
transplant Post-op: severe GVHD, acute renal failure,
bacteremia with Corynebacteriumvancomycin
UTI with VREnot eradicated Death due to refractory GVHD with multiple
organ failure (day 87)
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Tip off: what are the common points Nocosomial infections Comorbidities: DM, kidney
dysfunction,tranplants post-op complications Bacteremia with VDE Broad use of antibiotics and
immunosuppressive drugs (what are the risks??)
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Characterizing VDE
Criteria VRE: growth in 6ug/ml Vancomycin, MIC>8ug/ml Vanco VDE: cannot growth without 6ug/ml Vanco with multiple
subcultures Molecular profile
Susceptibility testing: Vanco disk, D-ala-D-ala disk Resistance gene vanA and vanB: PCR Strain relation (distinct clones?): Pulsed-field gel
electrophoresis (PFGE) Spontaneous reversion from VDE to VRE: serial dilutions
of culture grown in Vanco+ broth to Vanco+/- agar plates
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Susceptibility Test Result
VDE
Revertant
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PFGE
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Molecular profile of VDE
Strain: E. faecium Resistance gene: vanA (2), vanB (1) Resistance profile: penicillins, gentamicin,
erythromycin Susceptibility: streptogramins, teicoplanin Spontaneous reversion: around 1x10-6 except
for strain 3 (2.6x10-3) Growth not supported by D-ala-D-ala
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Proposed mechanism for Vancomycin dependence Loss of D-ala-D-ala ligase in VRE strain Vancomycin induces production of D-ala-
D-lactate ligase Require prolonged exposure to
Vancomycin
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Case control study
3 patients with nocosomial VDE infection 10 patients with nocosomial VRE infection 10 at-risk patients not infected with
enterococci Matched by age and admission to same
service
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Typical case control study design
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Case study results
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Specific findings
Length of exposure to antimicrobialsVancomycin3rd generation cephalosporins
Mortality Gender Exposure to ICU
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Possible risk factors
Intense use of 3rd generation cephalosporins
Renal insufficiency Spontaneous reversionVanco
discontinuation might not be sufficient to treat VDE infection.