Antimicrobial resistance in gram-positive bacteria

doi:10.1016/j.ajic.2006.05.220

American Journal of Infection Control

Volume 34, Issue 5, Supplement, June 2006, Pages S11-S19

https://doi.org/10.1016/j.ajic.2006.05.220 Get rights and content

Gram-positive bacteria are common causes of bloodstream and other infections in hospitalized patients in the United States, and the percentage of nosocomial bloodstream infections caused by antibiotic-resistant gram-positive bacteria is increasing. Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are of particular concern. In the United States, approximately 60% of staphylococcal infections in the intensive care unit are now caused by MRSA, and percentages continue to rise. Outbreaks of hospital-acquired MRSA (HA-MRSA) are typically the result of clonal spread by MRSA being transferred from patient to patient, frequently using healthcare personnel as intermediaries. HA-MRSA strains are generally multidrug resistant. Vancomycin is the standard treatment for serious MRSA infections, but a few cases of vancomycin-resistant S aureus (VRSA) have recently emerged in the United States. Community-acquired MRSA (CA-MRSA) is also increasing. Soft tissue infections are the most frequent presentations of CA-MRSA, but life-threatening invasive infections occur as well, including necrotizing pneumonia. The mechanisms of methicillin resistance are the same for CA-MRSA and HA-MRSA, but susceptibilities to non–â-lactam antibiotics often differ. CA-MRSA exhibits broader antibiotic susceptibility than does HA-MRSA. The proportion of enterococci resistant to vancomycin continues to rise in the hospital setting, with the overwhelming majority of infections due to Enterococcus faecium. Clonal spread of VRE has been documented, but polyclonal outbreaks associated with antimicrobial use are also common. The relations between antibiotic use and VRE colonization are complex and related to the antienterococcal activity, biliary excretion, and antianaerobic activity of the antibiotic. Recent results show a decline in invasive pneumococcal disease (IPD) since the introduction of 7-valent pneumococcal conjugate vaccine, and suggest that, where available, vaccines may be useful in the battle to slow the spread of resistant gram-positive cocci.

Section snippets

Methicillin-resistant Staphylococcus aureus

Virtually all S aureus strains were susceptible to penicillin G when the latter was initially introduced in the early 1940s, but by 1944 the first reports of penicillin-resistant S aureus had already appeared, and today virtually all strains of S aureus are resistant to natural penicillins, aminopenicillins, and antipseudomonal penicillins.4, 5 Resistance to these drugs occurs because of the acquisition of genes that encode drug-inactivating enzymes, initially known as penicillinases and now

Multidrug-resistant enterococcal species

Despite the fact that vancomycin has been in clinical use since the late 1950s, VRE were not observed until the mid-1980s, and in the United States, VRE were virtually nonexistent as recently as 1989 (Fig 1).⁴⁴ During the 1990s, however, a dramatic rise in VRE occurred—first in ICUs, then essentially throughout hospitals. The latest NNIS report indicated that nearly 30% of all enterococci isolated from patients infected in ICUs are now resistant to vancomycin.¹⁰

Perhaps an even more remarkable

Penicillin-resistant pneumococci and vaccines

Penicillin resistance is common in Streptococcus pneumoniae, and many strains of S pneumoniae are resistant to other antibiotics as well.⁵⁹ Resistance has been linked to use of several different antibiotic classes. Invasive disease caused by antibiotic-resistant S pneumoniae is a particular concern, and the incidence of invasive S pneumoniae infections in the United States is highest among children aged <2 years.⁶⁰ To address these concerns, a 7-valent pneumococcal conjugate vaccine (PCV7) was

Summary

Antibiotic resistance in gram-positive cocci is a persistent problem. Both infection control and antibiotic selective pressure are important factors in its spread. In some cases, as with HA-MRSA, infection control measures appear to be the most important mechanisms for limiting spread. In others, such as VRE, both infection control and antimicrobial exposures are important. Unfortunately, different antibiotics may exert different effects depending on the preexisting colonization state of the

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Antimicrobial resistance in gram-positive bacteria

Section snippets

Methicillin-resistant Staphylococcus aureus

Multidrug-resistant enterococcal species

Penicillin-resistant pneumococci and vaccines

Summary

Clin Lab Med

Lancet Infect Dis

Lancet Infect Dis

Trends Microbiol

Semin Pediatr Infect Dis

Nosocomial bloodstream infections in United States hospitals: a 3-year analysis

Clin Infect Dis

Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study

Clin Infect Dis

Nosocomial bloodstream infections in pediatric patients in United States hospitals: epidemiology, clinical features, and susceptibilities

Pediatr Infect Dis J

The changing epidemiology of Staphylococcus aureus?

Emerg Infect Dis

The crisis in antibiotic resistance

Science

Methicillin-resistant Staphylococcus aureus at Boston City Hospital: bacteriologic and epidemiologic observations

N Engl J Med

Methicillin-resistant Staphylococcus aureus in US hospitals, 1975–1991

Infect Control Hosp Epidemiol

Survey of infections due to Staphylococcus species: frequency of occurrence and antimicrobial susceptibility of isolates collected in the United States, Canada, Latin America, Europe, and the Western Pacific region for the SENTRY Antimicrobial Surveillance Program, 1997–1999

Clin Infect Dis

Data summary from January 1992 through June 2004, issued October 2004

Am J Infect Control

The evolutionary history of methicillin-resistant Staphylococcus aureus (MRSA)

Proc Natl Acad Sci U S A

Staphylococcus aureus infections

N Engl J Med

A cloud adult: the Staphylococcus aureus-virus interaction revisited

Ann Intern Med

Role of an altered penicillin-binding protein in methicillin- and cephem-resistant Staphylococcus aureus

Antimicrob Agents Chemother

A new UK strain of epidemic methicillin-resistant Staphylococcus aureus (EMRSA-17) resistant to multiple antibiotics

J Antimicrob Chemother

Rapid development of ciprofloxacin resistance in methicillin-susceptible and -resistant Staphylococcus aureus

J Infect Dis

Fluoroquinolones and the risk for methicillin-resistant Staphylococcus aureus in hospitalized patients

Emerg Infect Dis

Methicillin-resistant Staphylococcus aureus clinical strain with reduced vancomycin susceptibility

J Antimicrob Chemother

Emergence of vancomycin resistance in Staphylococcus aureus

N Engl J Med

Staphylococcus aureus with reduced susceptibility to vancomycin—Illinois, 1999

MMWR Morb Mortal Wkly Rep

The development of vancomycin resistance in a patient with methicillin-resistant Staphylococcus aureus infection

N Engl J Med

Cell wall thickening is a common feature of vancomycin resistance in Staphylococcus aureus

J Clin Microbiol

Vancomycin-resistant Staphylococcus aureus isolate from a patient in Pennsylvania

Antimicrob Agents Chemother

Infection with vancomycin-resistant Staphylococcus aureus containing the vanA resistance gene

N Engl J Med

Vancomycin-resistant Staphylococcus aureus—New York, 2004

MMWR Morb Mortal Wkly Rep

Genetic analysis of a high-level vancomycin-resistant isolate of Staphylococcus aureus

Science

Methicillin-resistant Staphylococcus aureus: epidemiologic observations during a community-acquired outbreak

Ann Intern Med

Community-acquired methicillin-resistant Staphylococcus aureus infections: a new source for nosocomial outbreaks

Ann Intern Med