Open access peer-reviewed chapter

Mobile Genetic Elements in Vancomycin-Resistant Enterococcus faecium Population

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Gastón Delpech, Leonardo García Allende and Mónica Sparo

Submitted: April 4th, 2019 Reviewed: July 3rd, 2019 Published: August 12th, 2019

DOI: 10.5772/intechopen.88389

From the Edited Volume

Pathogenic Bacteria

Edited by Sahra Kırmusaoğlu and Sonia Bhonchal Bhardwaj

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Abstract

Horizontal gene transfer constitutes a key driving force in bacterial evolution. The ability to acquire mobile genetic elements encoding antimicrobial resistance has contributed to the emergence of Enterococcus faecium as one of the main human nosocomial opportunistic pathogens. The deep analysis of the vancomycin-resistant E. faecium (VREfm) population’s mobilome, as the architecture and evolution of the core genome enables to observe VREfm plasticity and power of adaptation in animals, plants, environment and food. The persistence of VREfm is facilitated by the exchange of plasmids, phages and conjugative transposons that have allowed them to achieve a rapid adaptation to changes in environmental conditions. They can acquire resistance determinants from several species and transfer resistance genes to other potentially pathogenic bacteria such as methicillin-resistant Staphylococcus aureus strains.

Keywords

  • E. faecium
  • vancomycin
  • resistance
  • mobile genetic elements

1. Introduction

Enterococcus faeciumis a main bacterial agent of healthcare-associated infections in immunocompromised as well as severely ill patients, with a worldwide distribution [1, 2].

In 1988, vancomycin-resistant E. faecium(VREfm) was reported for the first time. Along the 1990s, a fast increase of infectious diseases due to this bacterium was detected in the United Kingdom hospitals, linking its emergence with the employment of the glycopeptide avoparcin in animal husbandry for food industry. In addition, at U.S hospitals it was observed the emergence of VREfm, but with not proved association to the use of avoparcin in animals [3, 4, 5].

The World Health Organization’s global priority pathogens list of antibiotic-resistant bacteria has categorized VREfm as of high priority. For infectious diseases produced by VREfm, it has been reported that the therapeutic options are more limited, altogether with higher mortality rates and financial costs for the Health system when compared with vancomycin-susceptible enterococci [6, 7].

Food chain can be considered as one possible way of VREfm spread or for the transfer of its antimicrobial resistance genes to humans, as it has been reported for cattle, pork and poultry meat [5, 8].

In the European Union, despite the avoparcin ban 18 years ago, VREfm circulation in the environment has continued. A likely cause of vancomycin-resistance plasmid genes persistence is the co-selection of other antimicrobials used in animals, such as macrolides or narasin, as it has been suggested by the presence of ermBtype transporter genes (macrolide-lincosamide-streptogramin B resistance), as well as ABC type transporter genes and the presence of a toxin/anti-toxin system. Other possibilities which can relate with VREfm spread is their persistence in food farms, slaughterhouses or their environments due to poor hygienic conditions or through avian transmission [9, 10, 11].

It is important to highlight that, enterococci, as part of human and animal intestinal microbiota, are able to acquire resistance genes from other commensal bacteria, which can be spread as well to other pathogenic bacteria [12, 13].

Evolution of E. faeciumfrom intestinal commensal bacteria to opportunistic pathogen is a complex and sequential process, in which seem to have been involved different factors, such as resistance and virulence determinants acquisition and persistence. Their expression is assumed to give an adaptive advantage since these factors facilitate the colonization of different epithelial cells (urinary, oral or intestinal), and at the same time, the bacterial adhesion to a wide variety of extracellular matrix proteins.

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2. VREfm: natural and acquired antimicrobial resistance

E. faeciumis intrinsically resistant to penicillin, ampicillin, cephalosporins and other β-lactams by mutations in the penicillin-binding protein PBP5 that is encoded by a horizontally transferred gene. Globally, enterococci are in vivoresistant to clindamycin (efflux pumps), trimethoprim-sulfamethoxazole (missing target) and the majority of aminoglycosides (enzymatic degradation). Furthermore, E. faeciumhas been acquiring resistance to quinolones, rifampicin and chloramphenicol, through mutations or by horizontal gene transfer [14, 15, 16, 17, 18].

In regard with vancomycin resistance, only the vanAand vanBgenotypes are epidemiologically relevant in clinical isolates. In this sense, the vanAcluster is the most prevalent glycopeptide resistance determinant in clinical settings. Recently, the presence of vanBcluster has increased in Europe, while is the main vancomycin resistance mechanism in Australia. These genotypes are associated with mobile genetic elements. The vanAgene cluster is generally part of the Tn3-family transposon Tn1546. Among vanBcluster, vanB2is the most frequent subtype and constitutes an integral part of the integrative conjugative element Tn1549/5382[19, 20, 21, 22, 23].

2.1 The VREfm-mobilome

The mobilome is defined as all the mobile genetic elements (MGEs) able to move around within or between genomes. MGEs contribute to genome plasticity and dissemination of antimicrobial resistance and pathogenicity bacterial genes. In E. faecium, the acquisition of exogenous DNA is involved in the change of a commensal bacterium for becoming a pathogenic strain [24].

Horizontal gene transfer (HGT) allows the exchange of genetic material between bacteria. The most important HGT mechanism is conjugation, where the type IV secretion systems create channels between bacterial cells for transferring DNA.

The others mechanisms involved in HGT are transformation, in which bacteria are able to internalize naked DNA located in their immediate environment, and transduction, in which DNA is trapped within bacteriophages that have infected a bacterial cell and, then, is released and inserted into the genome of a new cell after bacteriophage transmission. Other gene transfer mechanisms as nanotubes, micro-vesicles and gene-transfer agents have not been described in enterococci yet [25, 26].

There have been described three mechanisms of attack and defense interacting with HGT, toxin-antitoxin (T/A) systems, restriction/modification (R/M) systems and Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)-Cas enzymes.

  • T/A systems are small elements conformed by a toxin gen and its related antitoxin. Plasmid-encoded TA elements are important for plasmid maintenance. There are five types of T/A systems but only type 2 is prevalent in enterococci. In E. faecium, type 2 T/A systems comprise Axe/Txe and omega/epsilon/zeta. These plasmid-located T/A systems are enriched in clinical multi-drug resistant isolates [26, 27, 28].

  • R/M systems, in which a restriction enzyme cleaves in a specific unmethylated DNA site and other enzyme links a methyl group to the same site; thus, DNA cleavage is blocked. This system contributes with the regulation of gene exchange in E. faecium[29].

  • CRISPR-Cas systems constitute endogenous barriers to HGT in bacteria. A set of genes (cas) encoding nucleases are located near the CRISPR. Nosocomial clade of E. faeciumis in great measure deficient of the CRISPR-Cas systems [30]. This fact is associated with the increased presence of MGEs. Conversely, commensal E. faecaliscontain type II CRISPR-Cas systems, but multi-drug resistant (MDR) strains not carry complete CRISPR systems. Thus, MDR E. faecalisare prone for acquiring antibiotic resistance genes [31].

Among enterococci, different types of DNA arrangements and/or MGEs can be found, such as insertion sequences (IS), pathogenicity islands (PAIs), transposons (Tn) and plasmids.

IS are DNA segments (0.5–2 kb) able to autonomously move and to be found integrated in any replicon, in chromosomes as well as in plasmids. When IS appear in the middle of genes, they can interrupt the encoding sequence and inactivate the gene expression.

PAIs are fractions of a microorganism’s genomic DNA linked with encoding sequences for virulence traits, such as adhesins, host immune evasion factors, toxins, cell components lytic enzymes, among others. Usually, PAIs are included in plasmids and their origin is associated with horizontal transfer of genetic material.

Tn are genetic elements that are directly movable as DNA and can harbor adaptive functions such as an antimicrobial resistance mechanism.

Plasmids are small extrachromosomal DNAs that can replicate independently (replicons). In enterococci, these genetic elements are wide-spread. Plasmid size is variable and is reflected in the number of genes they contain and the range of encoded functions. Plasmids are able to include antimicrobial resistance genes, stability modules and conjugation modules. In addition, are termed conjugative plasmids when they encode the type IV secretion system (T4SS) and are mobilizable if they contain the origin of transfer (oriT) and the relaxase protein, type IV coupling protein T4CP. In enterococci, plasmid replication proteins may be classified by mode of replication, sequence similarity and subdomains present within the translated gene. Replication proteins replicate the plasmids by unidirectional leading strand Rolling Circle Replication (RCR) and by bi-directional Theta (q) replication. RCR plasmids are frequently small, cryptic and unstable over a 10–15 kb size.

A plasmid typing method based on the replication regions from various plasmid incompatibility groups was described in enterococci and other Gram-positive bacteria, and 19 replicon families (rep-family) and some unique replicons were found [32].

The q plasmids are subdivided into replicon families: Rep_3, Inc18 and RepA_N:

  • Rep_3 plasmids: narrow host range of similar size to RCR plasmids and often cryptic.

  • Inc18 plasmids: often conjugative (25–50 kb) broad host-range plasmids; most of them harbor resistance determinants.

  • RepA_N plasmids (10–300 kb): prevalent in low G + C content Gram positive bacteria with a narrow host range.

This scheme can be modified by recombination, leading to mosaic structures [26, 33, 34, 35, 36].

The pheromone-responsive plasmids have been described mainly in E. faecalis; pAD1 and pCF10 were the first described.

Different plasmid diversity between VREfm and E. faecalisstrains producers of nosocomial infections can be observed. VREfm, mainly CC17, show many reptypes as rep11 (pB82), rep14 (pRI1), rep18 (pEF418), repunique (pC1Z2) rep1 and rep2 (Inc18), rep17 (pRUM), repunique (pHTβ) were found. Vancomycin-resistant E. faecaliscarry a lower diversity of plasmid, generally associated with rep9 type (pheromone responsive pAD1), rep1 and rep2 (Inc-18 type) as well [34].

The presence of big transferable plasmids, also known as megaplasmids (>150 kb) is common among clinical isolates of E. faecium, and can have a role related with their virulence. Often, these plasmids contain genes linked with different carbohydrates metabolism, such as hylEfm gene. Initially, it was suggested that this gene encoded for a hyaluronidase. Nevertheless, more recent sequencing studies showed that, actually, this gene encodes for a glycosyltransferase which allows the utilization of complex carbohydrates. Furthermore, it has been proven that the transfer of these MGEs to non-carrying plasmid commensal strains of E. faecium, will increase their virulence and their gastrointestinal colonization capability [19, 33, 37].

Worldwide, most of the VREfm strains recovered in clinical settings were included into the clonal complex 17 (CC17). Afterwards, they were divided into three lineages (17, 18 and 78), using multilocus sequence typing studies (MLST). More recently, the Bayesian Analysis of Population Structure (BAPS), applied to MLST data established two nosocomial groups: 2–1 (lineage 78) and 3–3 (lineages 17/18). All CC17 E. faeciumstrains contain many exogenously acquired genes such as IS, phages, and Tn encoding antimicrobial resistance. Furthermore, hospital-adapted VREfm are ciprofloxacin and ampicillin-resistant, with virulence traits also found in theirs genomes. VREfm strains have cell surface protein genes, regulatory genes, putative PAIs, plasmids, IS and integrated phages, which promote their adaptation to the healthcare-associated environment. The IS16and the espgene are carried by an integrative conjugative element (ICEEfm1) with the intAintegrase gene, and are considered as markers of nosocomial E. faeciumstrains [5, 17, 29].

In E. faeciumCC17, the location of hylEfm gene was described in a large conjugative plasmid, pLG1 (281.02 kb), in association with the vanAoperon, the ermBgene (macrolide-lincosamide-streptogramin B resistance) and the tcrYAZBoperon (heavy metal resistance). The hylEfm gene, an important factor involved in enterococcal colonization and adhesion, it has also been described as part of a genomic island. The dissemination of the multi-resistant megaplasmid pLG1, carrying hylEfm could explain the spread of the so frequently isolated hospital-associated E. faeciumCC17 genotype [33].

Transposable elements contribute with the genome plasticity by different mechanisms. They are substrates for homologous recombination within and between different DNA elements and rearrangements are carried out in chromosome and plasmid DNA [38].

In glycopeptide-resistant enterococci, vancomycin resistance is classified into eight acquired gene clusters: vanA, vanB, vanD, vanE, vanG, vanL, vanMand vanN. VanA- and VanB-type vancomycin-resistant enterococci (VRE) constitute the majority of VRE in clinical settings. VanA-type VRE shows high-level resistance to vancomycin (Minimum Inhibitory Concentration, MIC = 64–100 mg/L) and teicoplanin (MIC = 16–512 mg/L), while VanB-type VRE is susceptible to teicoplanin (MIC = 0.5–1 mg/L) and expresses different levels of resistance to vancomycin (MIC = 4–1000 mg/L). Also, it can be mentioned the intrinsic vanCgenotype, found in E. gallinarumand E. casseliflavus[39, 40]. The main phenotypic and genotypic features of glycopeptide resistant enterococci are shown in Table 1.

PhenotypeVanAVanBVanDVanEVanGVanLVanMVanNVanC
ResistanceAcquiredAcquiredAcquiredAcquiredAcquiredAcquiredAcquiredAcquiredIntrinsic
MICvan16–>10004–>100016–1288–32168>256162–32
MICtei16–5120.25–22–640.50.50.5960.50.12–2
ExpressionIICIIIICI, C
MobiltiyYesYesNoNoYesNoYesYesNo
PrecursorAla-LacAla-LacAla-LacAla-SerAla-SerAla-SerAla-LacAla-SerAla-Ser
OperonvanAvanBvanDvanEvanGvanLvanMvanNvanC
SubtypesN/AB1-B3D1-D5N/AG1-G2N/AN/AN/AC1-C4
Required genes for expressionvanH, vanA, vanXvanHB, vanB, vanXBvanHD, vanD, vanXDvanE, vanXYE, vanTEvanG, vanXYG, vanTGvanL, vanXY1, vanTm, vanTr1vanHM, vanM, vanXMvanN, vanXYN, vanTNvanC, vanXYC, vanT

Table 1.

Main phenotypic and genotypic features of glycopeptide-resistant enterococci.

MIC, minimum inhibitory concentration (mg/L); van, vancomycin; tei, teicoplanin; I, inducible; C, constitutive; N/A, not applies. Adapted from [39, 40].

The vanBgene cluster consists of a two-component regulatory system (vanRB, vanSB) and five resistance genes (vanYB, vanW, vanHB, vanB, vanXB). Conversely to the highly conserved resistance genes, the amino acid sequences of VanSB and VanRB show less similarity to those of VanSA and VanRA. These differences could be responsible for the characteristics of VanB-type resistance [41].

Furthermore, low-level vancomycin resistant E. faeciumcan turn into high-level vancomycin resistant during antibiotic therapy. This variant was named vancomycin-variable E. faecium[20, 39, 42]. A schematic diagram of vanoperon is shown in Figure 1.

Figure 1.

Schematic diagram ofvanoperon. Adapted from [40].

Tn1546carries the vanAgene, and is often located on a plasmid belonging to the broad host range Inc18 family, involved in the vanAtransfer from enterococci to Staphylococcus aureus. Typically, the vanAoperon is associated with Tn, such as Tn1546, implicating two genes for the transposition of the element (orf1and orf2), and one gene involved with teicoplanin resistance (vanZ). The vanAgene cluster includes seven open reading frames transcribed from two separate promoters. The regulatory apparatus is encoded by the vanR(response regulator) and vanS(sensor kinase) two-component system. Both are transcribed from one promoter, while the remaining genes are transcribed from other promoter. vanH(dehydrogenase that converts pyruvate to lactate) and vanA(ligase that forms D-Ala-D-Llac dipeptide) modify the production of peptidoglycan precursors. The production of the normal ending D-Ala-D-Ala of the pentapeptide does not continue. The products of vanX(encodes a dipeptidase that cleaves D-Ala-D-Ala) and vanY(encodes a D, D-carboxypeptidase) genes hydrolyze, interrupt the production of the pentapeptides and cleave the pentapeptides that can still be produced. The variations in the composition of this vancomycin resistance operon is due to the insertion of IS elements. The vanBoperon is carried by Tn1547, Tn1549and Tn5382. Tn1549conjugative Tn, is mainly located in large conjugative chromosomal elements and less frequently integrated in conjugative plasmids. This conjugative vanBTn is widely prevalent among VanBtype enterococci and other Gram-positive bacteria. The vanBoperon has a similar genetic organization to the vanAbecause vanBoperon contains two distinct promoters transcribing seven open reading frames. But vanBencodes a two-component signaling system (named vanRBand vanSB) that is considerably different from that encoded in vanA. Furthermore, vanBencodes homologs of vanHand the D-Ala-D-Ala ligase, and the peptidases (vanXand vanY). In addition, vanBlacks a homolog of vanZ, and instead encodes a protein vanW, with a role not totally explained. vanBgene (ligase) has been divided in three subtypes, vanB1-3, based on nucleotidic sequence differences. vanB2subtype is the most commonly spreaded in clinical enterococci. Also, is part of conjugative Tn, Tn1549/Tn5382-like. The first description of a vanB2-Tn1549-like element in pheromone responsive plasmids (pCF10-like) carried by E. faecaliswas reported at Japan. vanB1has only been described for certain isolates as part of composite Tn or an integrative conjugative element [21, 43, 44, 45, 46, 47, 48].

It has been described that some vanAgenotype isolates had a new type F Tn1546Tn associated with two insertion sequences: IS1216Vand IS1251[49].

The vanMcluster is similar to vanA, vanB, and vanD, while vanLand vanNare similar to vanC. The vanMoperon has been described in VREfm isolates and showed a close genetic arrangement to vanDand in vitrotransferable resistance by conjugation. The vanNoperon is the most recently identified gene cluster described in E. faeciumand is a similar operon to vanG, but can be transferred by MGEs only in this enterococcal species. The IS elements can produce structural alterations in the genes, and as a consequence leads to changes of resistance phenotype. The vanAgene cluster is prone to IS-mediated alterations, modifying sometimes the vancomycin resistance phenotype, as being susceptible to glycopeptides but with possibility to revert to a resistant phenotype. These bacteria were named vancomycin-variable enterococci (VVE), which could cause serious clinical issues because of their possibility to escape of detection and surveillance as well as facilitating the horizontal transfer of vancomycin resistance [50, 51, 52].

An additional operon (vanF) was described but only in Paenibacillus popilliae. This vanFcluster has a high similarity to the amino acid sequences of the vanAoperon, and P. popilliaehas been proposed as a possible origin for vancomycin resistance in enterococci [53].

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3. Conclusions

The massive use of glycopeptides (vancomycin and teicoplanin) and non-glycopeptide agents such as extended-spectrum cephalosporins in clinical settings have been implicated in the emergence of VREfm. Delayed effective antimicrobial therapy more than 48 h after the beginning of VRE bacteremia is associated with higher mortality rates.

The core genes bring a phylogenomic reconstruction of the E. faeciumpopulation structure; the main contribution of accessory genes includes the adaptation of this species to nosocomial environments. It was observed that the plasmid component drives host specificity, while their whole genome and chromosome share a common evolutionary history.

The clinical isolates’ mobilome are quite different from the other hosts. In VREfm the plasmid component of the pan-genome plays an important role in adaptation and its emergence as a nosocomial pathogen.

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Conflict of interest

Authors declare no conflicts of interest.

References

  1. 1. Cattoir V, Leclercq R. Twenty-five years of shared life with vancomycin-resistant enterococci: Is it time to divorce? Journal of Antimicrobial Chemotherapy. 2013;68:731-742. DOI: 10.1093/jac/dks469
  2. 2. Sievert DM, Ricks P, Edwards JR, Schneider A, Patel J, Srinivasan A, et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: Summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010. Infection Control and Hospital Epidemiology. 2013;34:1-14. DOI: 10.1086/668770
  3. 3. Leclercq R, Derlot E, Duval J, Courvalin P. Plasmid-mediated resistance to vancomycin and teicoplanin inEnterococcus faecium. New England Journal of Medicine. 1988;319:157-161
  4. 4. Reacher MH, Shah A, Livermore DM, Wale MCJ, Graham C, Johnson AP, et al. Bacteraemia and antibiotic resistance of its pathogens reported in England and Wales between 1990 and 1998: Trend analysis. BMJ. 2000;320:213-216
  5. 5. Sparo M, Delpech G, García Allende N. Impact on public health of the spread of high-level resistance to gentamicin and vancomycin in enterococci. Frontiers in Microbiology. 2018;9:3073. DOI: 10.3389/fmicb.2018.03073
  6. 6. Cheah AL, Spelman T, Liew D, Peel T, Howden BP, Spelman D, et al. Enterococcal bacteraemia: Factors influencing mortality, length of stay and costs of hospitalization. Clinical Microbiology and Infection. 2013;19:E181-E189. DOI: 10.1111/1469-0691.12132
  7. 7. World Health Organization. Global Priority List of Antibiotic-Resistant Bacteria to Guide Research, Discovery, and Development of New Antibiotics. Geneva, Switzerland: WHO; 2017
  8. 8. Delpech G, Pourcel G, Schell C, De Luca M, Basualdo J, Bernstein J, et al. Antimicrobial resistance profiles ofEnterococcus faecalisandEnterococcus faeciumisolated from artisanal food of animal origin in Argentina. Foodborne Pathogens and Disease. 2013;9:939-944. DOI: 10.1089/fpd.2012.1192
  9. 9. Aarestrup FM. Characterization of glycopeptide-resistantEnterococcus faecium(GRE) from broilers and pigs in Denmark: Genetic evidence that persistence of GRE in pig herds is associated with coselection by resistance to macrolides. Journal of Clinical Microbiology. 2000;38:2774-2777
  10. 10. Garcia-Migura L, Liebana E, Jensen LB, Barnes S, Pleydell E. A longitudinal study to assess the persistence of vancomycin-resistantEnterococcus faecium(VREF) on an intensive broiler farm in the United Kingdom. FEMS Microbiology Letters. 2007;275:319-325
  11. 11. Nilsson O, Greko C, Bengtsson B, Englund S. Genetic diversity among VRE isolates from Swedish broilers with the coincidental finding of transferrable decreased susceptibility to narasin. Journal of Applied Microbiology. 2012;112:716-722. DOI: 10.1111/j.1365-2672.2012.05254.x
  12. 12. Sparo M, Urbizu L, Solana MV, Pourcel G, Delpech G, Confalonieri A, et al. High-level resistance to gentamicin: Genetic transfer betweenEnterococcus faecalisisolated from food of animal origin and human microbiota. Letters in Applied Microbiology. 2012;54:119-125. DOI: 10.1111/j.1472-765X.2011.03182.x
  13. 13. Weigel LM, Clewell DB, Gill SR, Clark NC, McDougal LK, Flannagan SE, et al. Genetic analysis of a high-level vancomycin-resistant isolate ofStaphylococcus aureus. Science. 2003;302:1569-1571
  14. 14. Deshpande LM, Fritsche TR, Moet GJ, Biedenbach DJ, Jones RN. Antimicrobial resistance and molecular epidemiology of vancomycin resistant enterococci from North America and Europe: A report from the SENTRY antimicrobial surveillance program. Diagnostic Microbiology and Infectious Disease. 2007;58:163-170
  15. 15. Miller WR, Munita JM, Arias CA. Mechanisms of antibiotic resistance in enterococci. Expert Review of Anti-Infective Therapy. 2014;12:1221-1236. DOI: 10.1586/14787210.2014.956092
  16. 16. Murray BE. The life and times of theEnterococcus. Clinical Microbiology Reviews. 1990;3:46-65
  17. 17. Pourcel G, Sparo M, Corso A, Delpech A, Gagetti P, de Luca MM, et al. Molecular genetic profiling of clinical and foodborne strains of enterococci with high level resistance to gentamicin and vancomycin. Clinical Microbiology Open Access. 2017;6:1. DOI: 10.4172/2327-5073.1000272
  18. 18. Werner G, Fleige C, Ewert B, Laverde-Gomez JA, Klare I, Witte W. High-level ciprofloxacin resistance among hospital-adaptedEnterococcus faecium(CC17). International Journal of Antimicrobial Agents. 2010;35:119-125. DOI: 10.1016/j.ijantimicag.2009.10.012
  19. 19. Arias CA, Murray BE. The rise of theEnterococcus: Beyond vancomycin resistance. Nature Reviews Microbiology. 2012;10:266-278. DOI: 10.1038/nrmicro2761
  20. 20. Courvalin P. Vancomycin resistance in gram-positive cocci. Clinical Infectious Diseases. 2006;42(suppl 1):S25-S34
  21. 21. Dahl KH, Lundblad EW, Røkenes TP, Olsvik O, Sundsfjord A. Genetic linkage of thevanB2gene cluster to Tn5382in vancomycin-resistant enterococci and characterization of two novel insertion sequences. Microbiology. 2000;146:1469-1479
  22. 22. Guzman Prieto AM, van Schaik W, Rogers MR, Coque TM, Baquero F, Corander J, et al. Global emergence and dissemination of enterococci as nosocomial pathogens: Attack of the clones? Frontiers in Microbiology. 2016;7:788. DOI: 10.3389/fmicb.2016.00788
  23. 23. Howden BP, Holt KE, Lam MM, Seemann T, Ballard S, Coombs GW, et al. Genomic insights to control the emergence of vancomycin-resistant enterococci. MBio. 2013;4:e00412-e00413. DOI: 10.1128/mBio.00412-13.
  24. 24. Willems RJ, van Schaik W. Transition ofEnterococcus faeciumfrom commensal organism to nosocomial pathogen. Future Microbiology. 2009;4:1125-1135. DOI: 10.2217/fmb.09.82
  25. 25. Clewell DB, Francia MV. Conjugation in gram-positive bacteria. In: Funnal BE, Philips GJ, editors. Plasmid Biology. Washington, DC: ASM Press; 2004. pp. 227-256
  26. 26. Clewell DB, Weaver KE, Dunny GM, Coque TM, Francia MV, Hayes F. Extrachromosomal and mobile elements in enterococci: Transmission, maintenance, and epidemiology. In: Gilmore MS, Clewell DB, Ike Y, Shankar N, editors. Enterococci: From Commensals to Leading Causes of Drug Resistant Infection. Boston, MA: Massachusetts Eye and Ear Infirmary; 2014. pp. 1-84
  27. 27. Grady R, Hayes F. Axe-Txe, a broad-spectrum proteic toxin-antitoxin system specified by a multidrug-resistant, clinical isolate ofEnterococcus faecium. Molecular Microbiology. 2003;47:1419-1432
  28. 28. Meinhart A, Alonso JC, Sträter N, Saenger W. Crystal structure of the plasmid maintenance system epsilon/zeta: Functional mechanism of toxin zeta and inactivation by epsilon 2 zeta 2 complex formation. Proceedings of the National Academy of Sciences of the United States of America. 2003;100:1661-1666
  29. 29. Lebreton F, van Schaik W, McGuire AM, Godfrey P, Griggs A, Mazumdar V, et al. Emergence of epidemic multidrug-resistantEnterococcus faeciumfrom animal and commensal strains. MBio. 2013;4:e00534-e00513. DOI: 10.1128/mBio.00534-13
  30. 30. Palmer KL, Gilmore MS. Multidrug-resistant enterococci lack CRISPR-cas. MBio. 2010;1:e00227-e00210. DOI: 10.1128/mBio.00227-10
  31. 31. Hullahalli K, Rodrigues M, Thy Nguyen U, Palmer K. An attenuated CRISPR-Cas system inEnterococcus faecalispermits DNA acquisition. MBio. 2018;9:e00414-e00418. DOI: 10.1128/mBio.00414-1
  32. 32. Jensen LB, Garcia-Migura L, Valenzuela AJ, Lehr M, Hasman H, Aarestrup FM. A classification system for plasmids from enterococci and other gram-positive bacteria. Journal of Microbiological Methods. 2010;80:25-43. DOI: 10.1016/j.mimet.2009.10.012
  33. 33. Freitas AR, Tedim AP, Novais C, RuizGarbajosa P, Werner G, Laverde-Gomez JA, et al. Global spread of thehylEfm colonization-virulence gene in megaplasmids of theEnterococcus faeciumCC17 polyclonal subcluster. Antimicrobial Agents and Chemotherapy. 2010;54:2660-2665. DOI: 10.1128/AAC.00134-10
  34. 34. Freitas AR, Tedim AP, Francia MV, Jensen LB, Novais C, Peixe L, et al. Multilevel population genetic analysis ofvanAandvanB Enterococcus faeciumcausing nosocomial outbreaks in 27 countries (1986-2012). Journal of Antimicrobial Chemotherapy. 2016;71:3351-3366
  35. 35. Lilly J, Camps M. Mechanisms of theta plasmid replication. Microbiology Spectrum. 2015;3:PLAS-0029-2014. DOI: 10.1128 /microbiolspec.PLAS-0029-2014
  36. 36. Smillie C, Garcillán-Barcia MP, Francia MV, Rocha EP, de la Cruz F. Mobility of plasmids. Microbiology and Molecular Biology Reviews. 2010;74:434-452. DOI: 10.1128/MMBR.00020-10
  37. 37. Rice LB, Laktičová V, Carias LL, Rudin S, Hutton R, Marshall SH. Transferable capacity for gastrointestinal colonization inEnterococcus faeciumin a mouse model. Journal of Infectious Diseases. 2009;199:342-349. DOI: 10.1086/595986
  38. 38. Rice LB, Carias LL, Marshall S, Rudin SD, Hutton-Thomas R. Tn5386, a novel Tn916-like mobile element inEnterococcus faeciumD344R that interacts with Tn916to yield a large genomic deletion. Journal of Bacteriology. 2005;187:6668-6677
  39. 39. Cercenado E.Enterococcus: Phenotype and genotype resistance and epidemiology in Spain. Enfermedades Infecciosas y Microbiología Clínica. 2011;29(Suppl. 5):59-65. DOI: 10.1016/S0213-005X(11)70045-3
  40. 40. Ahmed MO, Baptiste KE. Vancomycin-resistant enterococci: A review of antimicrobial resistance mechanisms and perspectives of human and animal health. Microbiology Drug Resistance. 2018;24:590-606. DOI: 10.1089/mdr.2017.0147
  41. 41. Evers S, Courvalin P. Regulation of VanB-type vancomycin resistance gene expression by the VanS(B)-VanR(B) two-component regulatory system inEnterococcus faecalisV583. Journal of Bacteriology. 1996;178:1302-1309
  42. 42. Coburn B, Low DE, Patel SN, Poutanen SM, Shahinas D, Eshaghi A, et al. Vancomycin-variableEnterococcus faecium:In vivoemergence of vancomycin resistance in a vancomycin-susceptible isolate. Journal of Clinical Microbiology. 2014;52:1766-1767. DOI: 10.1128/JCM.03579-13
  43. 43. Arthur M, Molinas C, Depardieu F, Courvalin P. Characterization of Tn1546, a Tn3-related transposon conferring glycopeptide resistance by synthesis of depsipeptide peptidoglycan precursors inEnterococcus faeciumBM4147. Journal of Bacteriology. 1993;175:117-127
  44. 44. Clark NC, Cooksey RC, Hill BC, Swenson JM, Tenover FC. Characterization of glycopeptide-resistant enterococci from U.S. hospitals. Antimicrobial Agents and Chemotherapy. 1993;37:2311-2317
  45. 45. Garnier F, Taourit S, Glaser P, Courvalin P, Galimand M. Characterization of transposon Tn1549, conferring VanB-type resistance inEnterococcusspp. Microbiology. 2000;146:1481-1489
  46. 46. Perichon B, Courvalin P. VanA-type vancomycin-resistantStaphylococcus aureus. Antimicrobial Agents and Chemotherapy. 2009;53:4580-4587. DOI: 10.1128/AAC.00346-09
  47. 47. Sarti M, Campanile F, Sabia C, Santagati M, Gargiulo R, Stefani S. Polyclonaldiffusion of Beta-lactamase-producingEnterococcus faecium. Journal of Clinical Microbiology. 2012;50:169-172. DOI: 10.1128/JCM.05640-11
  48. 48. Zheng B, Tomita H, Inoue T, Ike Y. Isolation of VanB-typeEnterococcus faecalisstrains from nosocomial infections: First report of the isolation and identification of the pheromone-responsive plasmids pMG2200, encoding VanB-type vancomycin resistance and a Bac41-type bacteriocin, and pMG2201, encoding erythromycin resistance and cytolysin (Hly/Bac). Antimicrobial Agents and Chemotherapy. 2009;53:735-747. DOI: 10.1128/AAC.00754-08
  49. 49. Khan MA, Shorman M, Al-Tawfiq JA, Hays JP. New type F lineage-related Tn1546and avanA/vanBtype vancomycin-resistantEnterococcus faeciumisolated from patients in Dammam, Saudi Arabia during 2006-2007. Epidemiololgy and Infection. 2013;141:1109-1114. DOI: 10.1017/S0950268812001574
  50. 50. Kohler P, Eshaghi A, Kim HC, Plevneshi A, Green K, Willey BM, et al. Toronto invasive bacterial diseases network (TIBDN). Prevalence of vancomycin-variableEnterococcus faecium(VVE) amongvanA-positive sterile site isolates and patient factors associated with VVE bacteremia. PLoS ONE. 2018;13:e0193926. DOI: 10.1371/journal.pone.0193926
  51. 51. Lebreton F, Depardieu F, Bourdon N, Fines-Guyon M, Berger P, Camiade S, et al. D-Ala-d-Ser VanN-type transferable vancomycin resistance inEnterococcus faecium. Antimicrobial Agents and Chemotherapy. 2011;55:4606-4612. DOI: 10.1128/AAC.00714-11
  52. 52. Partridge SR, Kwong SM, Firth N, Jensen SO. Mobile genetic elements associated with antimicrobial resistance. Clinical Microbiology Reviews. 2018;31:e00088-e00017. DOI: 10.1128/CMR.00088-17
  53. 53. Patel R, Piper K, Cockerill FR 3rd, Steckelberg JM, Yousten AA. The biopesticidePaenibacillus popilliaehas a vancomycin resistance gene cluster homologous to the enterococcal VanA vancomycin resistance gene cluster. Antimicrobial Agents and Chemotherapy. 2000;44:705-709

Written By

Gastón Delpech, Leonardo García Allende and Mónica Sparo

Submitted: April 4th, 2019 Reviewed: July 3rd, 2019 Published: August 12th, 2019