Prevalence of vancomycin-resistant enterococcus causing urinary tract infection in a tertiary care hospital of Eastern India

Sanjeev Das; Jayashree Konar; Manas Talukdar

doi:10.4103/bbrj.bbrj_212_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 5 | Issue : 4 | Page : 463-465

Prevalence of vancomycin-resistant enterococcus causing urinary tract infection in a tertiary care hospital of Eastern India

Sanjeev Das¹, Jayashree Konar², Manas Talukdar³
¹ Department of Microbiology, Purulia Government Medical College and Deben Mahato Hospital, Purulia, West Bengal, India
² Department of Microbiology, Dr. B. C. Roy Post Graduate Institute, Kolkata, West Bengal, India
³ Department of Pathology, Medical College and Hospital, Kolkata, West Bengal, India

Date of Submission	04-Sep-2021
Date of Acceptance	10-Nov-2021
Date of Web Publication	14-Dec-2021

Correspondence Address:
Manas Talukdar
10/1, Girish Ghosh Street, West Bengal - 700 108, Kolkata
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bbrj.bbrj_212_21

Abstract

Background: The increasing prevalence of urinary tract infection (UTI) caused by vancomycin-resistant Enterococcus (VRE) is of particular concern within many institutions because of limited treatment options. Objective: The objective of the study is to estimate the prevalence of VRE amongst the urinary pathogens along with detection of the antimicrobials effective against VRE in vitro. Materials and Methods: This hospital-based descriptive cross-sectional study was performed from January 1, 2019, to December 31, 2020, with 1037 adult patients developing symptoms of UTI. Mid-stream urine was collected in proper aseptic manner for microbiological culture to isolate and identify the bacterial pathogen. Collected urine samples were screened for pus cells and bacteria. This was followed by plating on (basal media), blood agar (enriched media), and MacConkey's agar media (differential and selective media), followed by overnight incubation at 37°C. Species confirmation and minimum inhibitory concentration value determination were done by automation. Results: Out of total 1037 collected urine samples, 693 were culture positive for bacterial etiology (66.8%). 457 urine cultures were positive for Enterococcus spp., of which 41 were vancomycin resistant (8.97%). A total of 18 Enterococcus faecalis isolates (4.72%) were vancomycin resistant, whereas significantly higher number of Enterococcus faecium, i.e., 23 isolates (30.26%) were vancomycin resistant (P < 0.01). All of 41 VRE isolates were resistant to ampicillin. No trends were observed for resistance against nitrofurantoin, tigecycline, linezolid, and daptomycin. These remained highly effective against VRE across the study period. Conclusion: Since VRE is emerging as a prevalent uropathogen with limited therapeutic options, the use of vancomycin demands judicious administration to treat UTI. Hence, antimicrobial stewardship deserves a crucial role to play.

Keywords: Enterococcus, urinary tract infections, vancomycin

How to cite this article:
Das S, Konar J, Talukdar M. Prevalence of vancomycin-resistant enterococcus causing urinary tract infection in a tertiary care hospital of Eastern India. Biomed Biotechnol Res J 2021;5:463-5

How to cite this URL:
Das S, Konar J, Talukdar M. Prevalence of vancomycin-resistant enterococcus causing urinary tract infection in a tertiary care hospital of Eastern India. Biomed Biotechnol Res J [serial online] 2021 [cited 2023 Mar 28];5:463-5. Available from: https://www.bmbtrj.org/text.asp?2021/5/4/463/332459

Introduction

Enterococci are one of the common uropathogens in nosocomial setup. Resistance to multiple antimicrobials, including vancomycin, is becoming more common nowadays, particularly in infections involving Enterococcus faecium.^[1] The increasing prevalence of urinary tract infection (UTI) caused by vancomycin-resistant enterococcus (VRE) is of particular concern within many institutions because of limited treatment options.^[2] Assessments of antibacterial efficacy against VRE is not well documented due to the lack of a comparator treatment arm (s), complex treatment options, and advanced a high case fatality ratio.^[3] The present study aimed to estimate the pooled prevalence of VRE and antimicrobial resistance profiles of Enterococcus spp. causing UTI.

Methods

This hospital-based descriptive cross-sectional study was performed from January 1, 2019, to December 31, 2020, with 1037adult patients (≥18 years) developing symptoms of UTI. Inclusion criteria were fixed as per clinical, demographic, geographical, and temporal compliance. Pyrexia, urinary hesitancy, urgency, increased frequency of and burning sensation during micturition were the symptoms for inclusion criteria. Patients who had probability to get lost during follow-up or had complications, vulnerability, or severe morbidity or having a history of treatment with antibiotic before urine collection were excluded from the study. Mid-stream urine was collected in proper aseptic manner for microbiological culture to isolate and identify the bacterial pathogen. Collected urine samples were screened for pus cells and bacteria.^[4] Pus cells ≥10/hpf in urine sample were considered significant. This was followed by plating on (basal media), blood agar (enriched media), and MacConkey's agar media (differential and selective media) for bacterial isolation. Inoculated plates were incubated aerobically overnight at 37°c. Enterococci produce small pinpoint translucent colonies on nutrient agar media and mostly nonhemolytic colonies in sheep blood agar. Discrete colonies were further studied by Gram staining, tests for motility, battery of biochemical tests for Enterococcus spp. identification according to Facklam-Collins scheme (Facklam and Collins, 1989).^[5] Enterococcus isolates were preserved in glycerol broth at 4°C until tested by VITEK 2 microbial identification system (bioMerieux) with “Advanced Expert System” (AES) to confirm the speciation and resistogram. Minimum inhibitory concentration values of the tested antibiotics were detected by VITEK 2 with “Advanced Expert System” (AES) as per CLSI guidelines. With its ability to provide accurate “fingerprint” recognition of bacterial resistance mechanisms and phenotypes, the AES is a critical component of VITEK 2 technology.^[6],[7],[8] Results were analyzed in accordance with standard statistical methods. Ethical approval from Institutional Ethics Committee (Memo No: MC/KOL/IEC/NON-SPON/1219/21).

Results

In total, out of 1037 collected urine samples, 693 were culture positive for bacterial etiology (66.8%). Four hundred and fifty-seven urine cultures were positive for Enterococcus spp., of which 41 were vancomycin resistant (8.97%). 381 Enterococcus faecalis and 76 E. faecium were identified. No other species of Enterococcus was isolated. The total number of uropathogenic Enterococci were 253 in the year 2019 and 204 in the year 2020. The proportion of vancomycin resistance among uropathogenic Enterococcus spp. varied from a low of 7.6% (19 out of 253) in 2019 to a high of 10.28% (22 out of 204) in 2020, though did not change significantly over the period (P > 0.35). A total of 18 E. faecalis isolates (4.72%) were vancomycin resistant, whereas significantly higher number [Table 1] of E. faecium, i.e., 23 isolates (30.26%) were vancomycin resistant (P < 0.00001). All VREs were reported to possess VanA type of resistance as suggested by automated system, thus sensitive to teicoplanin. All of 41 VRE isolates were resistant to ampicillin. No trends were observed for resistance against nitrofurantoin, tigecycline, linezolid, and daptomycin. These remained highly effective against VRE across the study period.

Table 1: The Fisher's exact test to show the proportion of vancomycin resistance among isolated uropathogenic Enterococcus spp.

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Discussion

The overall prevalence of enterococcal infection varies across countries and even within hospitals. Overall, Enterococcus is a difficult to treat pathogen with opportunistic spectrum.^[9] In India, Karmakar et al. carried out a study in Mumbai in which the isolation rate of Enterococci from urine samples was 10.28%.^[10] A study conducted by Kaur et al. in Haryana reported an enterococcal isolation rate of 33% from urine samples.^[11] On the other hand, few studies report low even zero prevalence of uropathogenic Enterococcus, with a Gram-negative predominance.^{[12],[13],[14]} In the present study conducted in 2019–2020, 44.06% (457 out of 1037) Enterococcus spp. isolation has been estimated which is quite a higher proportion. 8.97% vancomycin resistance has been detected in this study, whereas in a study performed by Jadhav et al. in Maharashtra, the proportion is 6.9%, almost similar to the present one.^[15] In this study, 83.36% Enterococcus isolates were E. faecalis and rest were E. faecium. No other species of Enterococcus was isolated. Similar were the findings of Jadhav et al., who reported that 79.67% of total enterococcal isolates were E. faecalis.^[15] Marothi et al. also reported E. faecalis as the most common enterococcal isolate.^[16] The proportion of vancomycin resistance among uropathogenic Enterococcus spp. varied from a low of 7.6% (19 out of 253) in 2019 to a high of 10.28% (22 out of 204) in 2020, though did not change significantly over the period (P > 0.35). A total of 18 E. faecalis isolates (4.72%) were vancomycin resistant, whereas significantly higher number [Table 1] of E. faecium, i.e. 23 isolates (30.26%) were vancomycin resistant (P < 0.00001). Jadhav et al. have also reported higher number of vancomycin-resistant E. faecium than E. faecalis.^[15] This study reports only VanA type of resistant gene whereas several other researchers including Praharaj et al. reported several other genotype of resistance with predominance of Van A.^{[17],[18],[19]} All of 41 VRE isolates were resistant to ampicillin. No trends were observed for resistance against teicoplanin, nitrofurantoin, tigecycline, linezolid, and daptomycin. These remained highly effective against VRE across the study period. Findings of Heintz et al. and Linden are similar to that of the present study.^[2],[3]

Conclusion

Since VRE is emerging as a prevalent uropathogen with limited therapeutic options, the use of vancomycin demands judicious administration to treat UTI. Hence, antimicrobial stewardship deserves a crucial role to play.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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