INTRODUCTION
Enterococci are Gram-positive, facultative anaerobic cocci that are normal commensals of the
human gastrointestinal tract and, to a lesser extent, the genitourinary tract. Despite their
commensal nature, enterococci have emerged over the past few decades as important
opportunistic and nosocomial pathogens, largely due to their ability to survive adverse
environmental conditions, acquire antimicrobial resistance, and express multiple virulence
determinants. Among the various species, Enterococcus faecalis and Enterococcus faecium are the
most commonly implicated in human infections.
Enterococci are responsible for a wide range of clinical infections including urinary tract infections,
bloodstream infections, infective endocarditis, intra-abdominal and pelvic infections, wound and soft
tissue infections, neonatal sepsis, and device-associated infections. They are particularly significant
in hospitalized patients, those with prolonged antibiotic exposure, immunocompromised individuals,
and patients with indwelling medical devices. Invasive infections such as bacteremia and
endocarditis caused by enterococci are associated with increased morbidity and mortality, primarily
due to limited therapeutic options.
Globally, enterococci rank among the leading causes of healthcare-associated infections,
especially in intensive care units. Surveillance data from North America and Europe indicate a high
prevalence of multidrug-resistant enterococci, including vancomycin-resistant strains. In India,
enterococci constitute a substantial proportion of nosocomial infections, with several tertiary care
centres reporting increasing isolation rates and rising antimicrobial resistance, highlighting their
growing clinical and public health importance.
The clinical significance of enterococci is largely attributed to their intrinsic and acquired resistance
to multiple antimicrobial agents. They exhibit intrinsic low-level resistance to β-lactam antibiotics,
particularly cephalosporins, due to low-affinity penicillin-binding proteins. Acquired resistance to
penicillins and ampicillin, especially among E. faecium, further limits therapeutic options. Another
major concern is the emergence of glycopeptide-resistant enterococci (VRE), mediated by van
gene clusters such as vanA and vanB, which alter the target site for glycopeptides. While VRE
prevalence is high in Western countries, Indian studies have also reported a gradual but significant
rise in VRE, posing serious treatment and infection control challenges.
In addition, enterococci demonstrate resistance to aminoglycosides. Although they possess intrinsic
low-level resistance to aminoglycosides due to reduced drug uptake, the development of high-level
aminoglycoside resistance (HLAR) abolishes the synergistic bactericidal effect achieved when
aminoglycosides are used in combination with cell wall–active agents such as penicillins or
glycopeptides. This loss of synergy is of particular concern in the management of severe infections
such as enterococcal endocarditis.
High-level aminoglycoside resistance in enterococci is primarily mediated by
aminoglycoside-modifying enzymes (AMEs), which inactivate aminoglycosides through acetylation,
phosphorylation, or adenylation. These enzymes are encoded by transferable genes, facilitating
horizontal gene transfer within hospital settings. The most commonly implicated gene is
aac(6′)-Ie-aph(2″)-Ia, responsible for high-level gentamicin resistance, while genes such as
aph(3′)-IIIa and ant(6)-Ia contribute to resistance against other aminoglycosides. Both global and
Indian studies have reported a high prevalence of these AME genes among HLAR enterococcal
isolates.
Apart from antimicrobial resistance, the pathogenicity of enterococci is associated with the
presence of multiple virulence factors, including cytolysin (hemolysin), enterococcal surface protein
(Esp), microbial surface components recognizing adhesive matrix molecules (MSCRAMMs), serine
proteases such as gelatinase, capsule, cell wall-associated polysaccharides, and oxidative stress
defense mechanisms such as superoxide dismutase. These virulence determinants contribute to
adherence, biofilm formation, tissue damage, immune evasion, and persistence of infection.
The coexistence of these virulence determinants with high-level aminoglycoside resistance,
mediated by aminoglycoside-modifying enzyme genes, may further enhance the pathogenic
potential of enterococci and contribute to adverse clinical outcomes.
Despite increasing reports on enterococcal infections, comprehensive data from India remain
limited regarding the simultaneous presence of virulence determinants and
aminoglycoside-modifying enzyme genes among high-level aminoglycoside-resistant enterococci.
Regional variation in the distribution of these factors underscores the need for local epidemiological
data. A systematic evaluation of virulence factors and aminoglycoside-modifying enzyme genes in
HLAR enterococci is therefore essential to better understand their pathogenic potential and to
support effective antimicrobial therapy, infection control measures, and antimicrobial stewardship.
Hence, the present study is undertaken to study the virulence factors and
aminoglycoside-modifying enzyme genes in high-level aminoglycoside-resistant enterococci
isolated from various clinical samples in a tertiary care centre.