Enterococcus
INTRODUCTION
• α-hemolysis: It is due to partial lysis of red blood cells (RBCs), producing a small (1–2 mm)
zone of greenish discoloration surrounding the colonies. It is observed with viridans
streptococci and pneumococci.
• -hemolysis: It is due to complete lysis of RBCs and zone of lysis is wide (2–4 mm). It is
observed with S. pyogenes and other -hemolytic streptococci.
• -hemolysis: It is a misnomer, there is no hemolysis surrounding the colonies, hence no
change in color, e.g. Enterococcus.
INTRODUCTION
• Enterococci were initially grouped under group D Streptococcus, but later, it has been
reclassified as a separate genus Enterococcus.
• It is now placed under a new family; Enterococcaceae.
• Both enterococci and non-enterococcal group D streptococci give a positive bile aesculin
hydrolysis test (they grow in the presence of 40% bile and hydrolyse aesculin to
aesculetin that combines with ferric chloride to produce black coloured complex.)
Features Enterococci Non-enterococcal Group D streptococci
Group specific D Ag Present Present
Bile aesculin hydrolysis Positive Positive
In Presence of Grows Does not grow
• 6.5% NaCl
• pH 9.6
• At 45C
• At 10C
PYR test Positive Negative
Drug Resistance Marked Uncommon
Existence as normal intestinal More Common Less Common
flora
Pathogenicity Marked Less
Virulence Factors
• Enterococci are part of normal flora of human intestine, biliary tract and to lesser extent
vagina and male urethra.
• At the same time, enterococci are also becoming increasingly important agents of
human disease especially in hospitals mainly because of their resistance to antibiotics.
• E. faecalis is the most common species found in clinical specimens, whereas E. faecium
is more drug resistant than E. faecalis. They exhibit a number of virulence factors such
as:
Virulence Factors
• Cytolysin/hemolysin: They lyse the sheep and human RBCs
• Aggregation substances or pheromones: They help in clumping of adjacent cells to
facilitate plasmid exchange ( transfers drug resistance)
• Extracellular surface protein (ESP): It helps in adhesion to bladder mucosa
• Common group D lipoteichoic acid antigen: It induces cytokine release such as tumor
necrosis factor a. (TNFa.)
• Coccolysin: It inactivates endothelin, a vasoactive peptide.
Clinical Manifestations
• Enterococci are one of the major hospital acquired pathogen, produce various infections
such as:
• Urinary tract infections ( cystitis, urethritis, pyelonephritis and prostatitis)
• Bacteraemia and mitral valve endocarditis (in intravenous drug abusers)
• Intra-abdominal, pelvic and soft tissue infections
• Late-onset neonatal sepsis and meningitis
• Infection on burn surface.
Laboratory Diagnosis
• Enterococci show the following characteristics that help in their identification:
• They are gram-positive oval cocci arranged in pairs; cocci in a pair are arranged at an
angle to each other (spectacle-shaped appearance)
• Non-motile cocci (except E. gallinarum and E. casseliflavus)
• Blood agar: It produces non-haemolytic (Fig. 22.7B), translucent colonies (rarely produces
a. or β-haemolysis)
• MacConkey agar: It produces minute magenta pink colonies.
Laboratory Diagnosis
• Nutrient agar: It grows poorly
• Bile aesculin hydrolysis test is positive (Fig. 22.7C)
• PYR (Pyrrolidonyl-beta-naphthylamide) test is positive
• They can grow in presence of extremes of conditions such as- 6.5% NaCl, 40% bile, pH
9.6, 45°C and 10°c
• Heat tolerance test: They are relatively heat resistant, can survive 60°C for 30 minutes
Treatment
• Enterococci are resistant to penicillin's, aminoglycosides, sulphonamides,
cephalosporins and cotrimoxazole.
• Resistance to penicillin and aminoglycoside is overcome by combination
therapy (e.g. ampicillin plus gentamicin) due to synergistic effect and this
remains the standard therapy for life-threatening enterococcal infections.
• This combination therapy fails if the isolate is found resistant to either
ampicillin or high level aminoglycoside in vitro.
• Vancomycin is usually indicated in such cases, but resistance to vancomycin
has also been reported.
• If resistant to vancomycin: then treatment options available are linezolid,
streptogramins (active against E. faecium, but not to E. faecalis) and
daptomycin.
Vancomycin Resistant
Enterococci (VRE)
• Vancomycin resistance in enterococci has been increasingly reported now a days.
• The prevalence of VRE varies with time and place. A report in 2016 revealed that among
hospitalized patients the VRE frequency is high in America (35%) and low in Europe (4%)
and moderate (10-15%) in Asian countries. In India, the VRE rate varies from 5-10%.
• VRE is mediated by van gene, which alters the target site for vancomycin present in the cell
wall; i.e. D-alanyl-D-alanine side chain of peptidoglycan layer (which is the usual target site
for vancomycin), is altered to D-alanyl-D-serine or D-alanyl-D-lactate. This altered side
chains have less affinity for binding to vancomycin
Vancomycin Resistant
Enterococci (VRE)
• Van gene has 11 genotypes: (van A, B, Cl-C3, D, E, G, L, Mand N). The van A and van B
genotypes predominate worldwide; expressed by E. faecalis and more commonly by E.
faecium.
• All van genes are located on transposons and are inducible; except type C and N
(chromosomal and constitutive).
• Strains with van A gene show high level resistance to both glycopeptides vancomycin and
teicoplanin.
• Strains with van B gene show low level resistance to vancomycin, but sensitive to
teicoplanin.
VRE Carriers
• VRE often colonizes the intestine and poses a risk of transmitting to other
patients.
• Screening for VRE: It is recommended for high-risk patients from ICUs and
transplantation units.
• Detection: Rectal swab is collected and subjected to (i) Sodium azide agar
added with 6 µg/ml of vancomycin or (ii) chromogenic media or (iii) PCR for
detection of van gene
• Management: Ensure infection control measures such as hand hygiene and
isolation precautions (refer Chapter 53). Treatment (i.e. decolonization) is not
recommended forVRE carriers.
Thank You