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Case Reports
. 2019 Jul 2;69(2):259-265.
doi: 10.1093/cid/ciy903.

Linezolid- and Vancomycin-resistant Enterococcus faecium in Solid Organ Transplant Recipients: Infection Control and Antimicrobial Stewardship Using Whole Genome Sequencing

Lilian Abbo  1   2 , Bhavarth S Shukla  1 , Amber Giles  2 , Laura Aragon  1 , Adriana Jimenez  1 , Jose F Camargo  3 , Jacques Simkins  3 , Kathleen Sposato  1 , Truc T Tran  4 , Lorena Diaz  4   5 , Jinnethe Reyes  4   5 , Rafael Rios  5 , Lina P Carvajal  5 , Javier Cardozo  1 , Maribel Ruiz  1 , Gemma Rosello  1 , Armando Perez Cardona  6 , Octavio Martinez  6 , Giselle Guerra  7 , Thiago Beduschi  8 , Rodrigo Vianna  8 , Cesar A Arias  4   5   9
Affiliations
Case Reports

Linezolid- and Vancomycin-resistant Enterococcus faecium in Solid Organ Transplant Recipients: Infection Control and Antimicrobial Stewardship Using Whole Genome Sequencing

Lilian Abbo et al. Clin Infect Dis. .

Abstract

Background: Vancomycin-resistant enterococci are an important cause of healthcare-associated infections and are inherently resistant to many commonly used antibiotics. Linezolid is the only drug currently approved by the US Food and Drug Administration to treat vancomycin-resistant enterococci; however, resistance to this antibiotic appears to be increasing. Although outbreaks of linezolid- and vancomycin-resistant Enterococcus faecium (LR-VRE) in solid organ transplant recipients remain uncommon, they represent a major challenge for infection control and hospital epidemiology.

Methods: We describe a cluster of 4 LR-VRE infections among a group of liver and multivisceral transplant recipients in a single intensive care unit. Failure of treatment with linezolid in 2 cases led to a review of standard clinical laboratory methods for susceptibility determination. Testing by alternative methods including whole genome sequencing (WGS) and a comprehensive outbreak investigation including sampling of staff members and surfaces was performed.

Results: Review of laboratory testing methods revealed a limitation in the VITEK 2 system with regard to reporting resistance to linezolid. Linezolid resistance in all cases was confirmed by E-test method. The use of WGS identified a resistant subpopulation with the G2376C mutation in the 23S ribosomal RNA. Sampling of staff members' dominant hands as well as sampling of surfaces in the unit identified no contaminated sources for transmission.

Conclusions: This cluster of LR-VRE in transplant recipients highlights the possible shortcomings of standard microbiology laboratory methods and underscores the importance of WGS to identify resistance mechanisms that can inform patient care, as well as infection control and antibiotic stewardship measures.

Keywords: E faecium; infection control; linezolid resistance; organ transplant; whole genome sequencing.

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Figures

Figure 1.
Figure 1.
Cluster investigation timeline. Abbreviations: EMR electronic medical record; ICU, intensive care unit; LR-VRE, linezolid- and vancomycin-resistant Enterococcus faecium; PFGE, pulsed-field gel electrophoresis; VRE, vancomycin-resistant enterococci.
Figure 2.
Figure 2.
Pulsed-field gel electrophoresis results of involved isolates. Samples tested with corresponding case number: 1, standard; 2, case 2; 3, case 1; 4, case 3; 5, case 3; 6, case 4; 7, standard. The gels were run with different electrophoresis conditions to accommodate the daily workflow in the laboratory on different days; however, by running samples from case 3 along with case 4, we can see that the 2 samples match, which means that all cases have matching fingerprints, suggesting the same strain.
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References

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