Clin Infect Dis, 1992 Nov, 15 Suppl 1, S43 - 52 Evaluation of new anti-infective drugs for the treatment of acute pelvic infections in hospitalized women . Infectious Diseases Society of America and the Food and Drug Administration; Hemsell DL et al.; This set of guidelines deals with evaluation of anti-infective drugs for treatment of acute pelvic infections in hospitalized women . The clinical entities include infectious complications of cesarean section; elective hysterectomy; and septic, incomplete abortion . Conditions including endomyometritis, cuff cellulitis, pelvic cellulitis, parametritis, phlegmon, and pelvic abscesses may arise due to a variety of bacterial species, both aerobic and anaerobic, that comprise the endogenous flora of the lower reproductive tract . Anaerobic bacteria have assumed particular importance, and therapy should be directed against such organisms . The roles of enterococci, chlamydiae, and mycoplasmas remain uncertain . Culture samples must be obtained under conditions assuring minimal vaginal contamination . Before a new drug may be used for treatment of human pelvic infections, considerable information is necessary about its antimicrobial spectrum as well as its safety and efficacy . Placebo-controlled trials are considered unethical . Historical controls may be used, but concurrent active control comparative trials are preferred . Parenteral administration is recommended for at least the initial 4 days of therapy, but orally administered drugs may be evaluated for completion of longer courses . The expected cure rate is approximately 90% . Uncomplicated infections should be treated for at least 4 days; more complicated infections may require prolonged therapy . Although clinical cure is paramount, microbiologic response must also be taken into account . In the final assessment, outcome will be classified as cure, failure, or indeterminate. J Clin Microbiol, 1992 Nov, 30(11), 2757 - 61 Molecular typing of ampicillin-resistant, non-beta-lactamase-producing Enterococcus faecium isolates from diverse geographic areas; Donabedian SM et al.; Molecular typing methods were compared by using 66 ampicillin-resistant, non-beta-lactamase-producing Enterococcus faecium clinical isolates from diverse geographic areas . Whole-plasmid analysis, restriction enzyme analysis of plasmid DNA with EcoRI and HindIII, and contour-clamped homogeneous electric field electrophoresis with digestion by SmaI and ApaI were performed on all isolates . Whole-plasmid analysis identified 47 different groups . Restriction enzyme analysis of plasmid DNA identified 50 groups when EcoRI was used and 51 groups when HindIII was used . Results with EcoRI and HindIII differed in 9 of 66 isolates . Grouping results with whole-plasmid analysis differed from results of restriction enzyme analysis of plasmid DNA (combining EcoRI and HindIII) in 20 of 66 isolates . Contour-clamped homogeneous electric field electrophoresis identified 46 groups when SmaI was used and 44 groups when ApaI was used . Results with SmaI and ApaI differed in 3 of 66 isolates . Grouping results with contour-clamped homogeneous electric field electrophoresis (combining SmaI and ApaI) differed from results of restriction enzyme analysis of plasmid DNA (combining EcoRI and HindIII) in 17 of 66 isolates . The combined use of whole-plasmid analysis, restriction enzyme analysis of plasmid DNA with two enzymes, and contour-clamped homogeneous electric field electrophoresis with two restriction enzymes should be considered when E . faecium is typed for epidemiologic investigation. Gene, 1992 Oct 12, 120(1), 111 - 4 Sequence of the vanY gene required for production of a vancomycin-inducible D,D-carboxypeptidase in Enterococcus faecium BM4147; Arthur M et al.; Cloning and nucleotide sequencing identified the vanY gene as a member of the vancomycin-resistance van gene cluster of enterococcal plasmid, pIP816 . The vanY gene was necessary for synthesis of the vancomycin-inducible D,D-carboxypeptidase activity previously proposed to be responsible for glycopeptide resistance . However, this activity was not required for peptidoglycan synthesis in the presence of glycopeptides . The deduced product of vanY did not display significant similarity with other D,D-carboxypeptidases. Antimicrob Agents Chemother, 1992 Oct, 36(10), 2342 - 5 Bactericidal activity of ramoplanin against antibiotic-resistant enterococci; Johnson CC et al.; Ramoplanin, a new lipoglycodepsipeptide antibiotic, was uniformly active against 65 strains of enterococci, including strains highly resistant to vancomycin, penicillin G, and gentamicin . MBCs were usually within a fourfold dilution of the MICs . In time-kill studies, ramoplanin alone demonstrated dose-dependent bactericidal activity against enterococcal strains that resisted killing by vancomycin or penicillin in combination with gentamicin. Infect Immun, 1992 Sep, 60(9), 3635 - 40 Contributions of complement and immunoglobulin to neutrophil-mediated killing of enterococci; Harvey BS et al.; Enterococci have become a frequent causative agent in neonatal sepsis . The relative contributions of antibody and complement and their interactions in the neutrophil-mediated bacterial killing of 11 Enterococcus strains from neonates were investigated . Polymorphonuclear leukocytes (PMNL) from adult and term newborn infants were tested with normal human serum, adult hypogammaglobulinemic serum, and normal newborn serum in a neutrophil bactericidal assay . Neutrophil bactericidal activity for enterococci was not influenced by the serum source but was essentially ablated after heat inactivation of complement in all sera . No differences were observed in the killing capacity of healthy newborn versus adult PMNL regardless of serum source . Representative Enterococcus strains were then tested with agammaglobulinemic serum or C4-deficient serum, resulting in neutrophil bactericidal activities consistently exceeding 90% . A neutrophil bactericidal assay performed with normal rabbit serum and hyperimmune rabbit serum against enterococci showed that antibodies to enterococci enhanced neutrophil-mediated killing of this organism . Thus, neutrophil killing of enterococci appears to be mediated primarily by complement, with antibody playing a less essential but potentially important role . PMNL from adult and healthy term infants functioned with equal efficiency in the neutrophil killing of enterococci. Antimicrob Agents Chemother, 1992 Sep, 36(9), 2005 - 8 Vancomycin resistance gene vanC is specific to Enterococcus gallinarum; Leclercq R et al.; Nearly all strains of Enterococcus gallinarum are resistant to low levels of vancomycin . The glycopeptide resistance gene vanC from E . gallinarum BM4174 has recently been cloned and sequenced . A probe specific for vanC hybridized with a 2.7-kb EcoRI and a 4.5-kb HindIII fragment of total DNA from the 42 strains of E . gallinarum studied . No homology was detected with DNA of strains belonging to other species intrinsically resistant to vancomycin, including Enterococcus casseliflavus, a species that expresses a vancomycin resistance phenotype similar to that of E . gallinarum . No hybridization with DNA of enterococcal strains with acquired resistance to high or low levels of vancomycin was observed . The specificity of the vanC probe allowed us to distinguish E . gallinarum from 12 other species of enterococci, indicating that this probe is a useful tool for species identification within the genus Enterococcus. Ann Intern Med, 1992 Jul 15, 117(2), 112 - 6 Hospital-acquired infection with vancomycin-resistant Enterococcus faecium transmitted by electronic thermometers; Livornese LL Jr et al.; OBJECTIVES: To describe an epidemic of vancomycin-resistant Enterococcus faecium causing bacteremia and bacteriuria, to identify the source of infection, to delineate risk factors associated with acquisition of the organism, and to determine antibiotic sensitivities for the organism . DESIGN: Investigation of an epidemic, including a case-control study . SETTING: Medical-surgical intensive care unit and ward in a university medical center . PATIENTS: Nine patients infected or colonized with vancomycin-resistant Enterococcus faecium and 20 noninfected controls . MEASUREMENTS: Clinical data, environmental surveillance cultures, and in-vitro microbiologic studies . RESULTS: Colonization or infection by vancomycin-resistant E . faecium was associated with an increased duration of treatment with ceftazidime, 13.2 compared with 4.6 days, and a greater number of nonisolated days of hospitalization in the intensive care unit, 19.9 compared with 6.4 days for infected and noninfected patients, respectively (P less than 0.05) . Environmental surveillance cultures recovered the organism repeatedly from the rectal probe handles of three electronic thermometers used exclusively on nonisolated patients in the intensive care unit . Restriction endonuclease analysis of plasmid DNA showed that all clinical and environmental isolates were identical . Infection control measures, including isolation of colonized or infected patients and removal of the rectal thermometer probes suspected to be responsible for transmission, resulted in termination of the outbreak . In-vitro, time-kill studies showed that the combination of ciprofloxacin, rifampin, and gentamicin resulted in bactericidal activity against the organism . CONCLUSIONS: This nosocomial outbreak of infection due to a highly vancomycin-resistant strain of Enterococcus is the first epidemic in which an electronic thermometer has been implicated as the vehicle of transmission for an infectious agent. FEMS Microbiol Lett, 1992 Jul 1, 73(1-2), 161 - 3 The putative Na+/H+ antiporter (NapA) of Enterococcus hirae is homologous to the putative K+/H+ antiporter (KefC) of Escherichia coli; Reizer J et al.; Two monovalent ion porters, the putative Na+/H+ antiporter (NapA) of Enterococcus hirae and the putative K+/H+ antiporter (KefC) of Escherichia coli, are similar in sequence throughout their hydrophobic domains . These two proteins, which comprise a novel family of transporters unrelated to the previously characterized Na+/H+ exchangers of E . coli (NhaA and NhaB) are proposed to function by essentially the same mechanism. Clin Infect Dis, 1992 Jul, 15(1), 72 - 6 Enterococcal infections in surgical patients: the mystery continues; Nichols RL et al.; The frequency of isolation of enterococci from surgical patients has increased significantly during the past decade, although the role of these organisms as pathogens in mixed infections remains a mystery . Bacteremia and other infections in which enterococci are the only pathogens frequently result in high morbidity and mortality among patients unless specific antimicrobial therapy is initiated promptly . Debate continues concerning the necessity for treatment with such agents when this organism is isolated as a component of a polymicrobial infecting flora . Our recent data indicate that enterococci are rarely isolated in postoperative infections after penetrating abdominal trauma if no gastrointestinal perforation has occurred . However, they were found in 56% of postoperative infections of patients with gastrointestinal perforation . In contrast, enterococci were isolated in only 9% of cultures of specimens from patients with secondary suppurative peritonitis . The occurrence of superinfection after therapy with a cephalosporin appears to be an important factor in this finding . Future studies are necessary to evaluate the efficacy of antibiotic treatment of enterococcal infections and to assess the need for prophylaxis against enterococci. FEMS Microbiol Lett, 1992 Jul 1, 73(1-2), 195 - 200 Modified peptidoglycan precursors produced by glycopeptide-resistant enterococci; Messer J et al.; Cytoplasmic precursors of the peptidoglycan biosynthetic pathway were purified from vancomycin-treated, glycopeptide-sensitive and -resistant strains of Enterococcus faecium . Resistance was due to production of a modified precursor, UDP-MurNAc-L-Ala-D-Glu-L-Lys-D-Ala-D-lactate, where lactate was identified on the basis of mass of the precursor and on its ability to act as a substrate for D-lactate dehydrogenase after release from the precursor . The presence of the D-lactate residue instead of D-alanine in the terminal position would hinder formation of a vancomycin-precursor complex, without preventing incorporation of the precursor into mature peptidoglycan. Antimicrob Agents Chemother, 1992 Jul, 36(7), 1563 - 6 Inconsistent bactericidal activity of triple-combination therapy with vancomycin, ampicillin, and gentamicin against vancomycin-resistant, highly ampicillin-resistant Enterococcus faecium; Fraimow HS et al.; Combination therapy with ampicillin, vancomycin, and gentamicin in vitro against several clinical isolates of vancomycin-resistant, highly ampicillin-resistant Enterococcus faecium, including VanA and VanB strains, was evaluated . The MICs of ampicillin were not significantly decreased by induction with vancomycin, and the combination of ampicillin and vancomycin was not inhibitory for any strain . Triple-combination therapy was least active against highly resistant VanA isolates, achieving a reduction of less than 1 log CFU at 24 h, but demonstrated slightly more activity against VanB strains. Antimicrob Agents Chemother, 1992 Jul, 36(7), 1514 - 8 Characterization of vanY, a DD-carboxypeptidase from vancomycin-resistant Enterococcus faecium BM4147; Wright GD et al.; VanY is a protein with a molecular mass of 34.8 kDa encoded by vanY, a member of the high-level vancomycin resistance gene cluster found on plasmid pIP816 in Enterococcus faecium BM4147 . Extracts from Escherichia coli JM83 bearing plasmid pAT383, which contains the vanY gene, were examined for enzymatic hydrolysis of peptidoglycan precursors . VanY was associated with the cell membranes and cleaved the C-terminal D-alanine residue of UDP-muramyl-pentapeptide but did not display transpeptidase or beta-lactamase activities . The DD-carboxypeptidase activity was not inhibited by beta-lactam antibiotics . VanY released the C-terminal D-hydroxy acid from depsipeptides produced by the vancomycin resistance protein VanA . These results demonstrate that VanY should contribute in vivo to the hydrolysis of both the D-alanyl-D-alanine- and the depsipeptide-containing peptidoglycan precursors. Antimicrob Agents Chemother, 1992 Jul, 36(7), 1487 - 90 Analysis of peptidoglycan precursors in vancomycin-resistant enterococci; Billot-Klein D et al.; Analysis by high-pressure liquid chromatography of the cytoplasmic peptidoglycan precursors of a high- and a low-level vancomycin-resistant Enterococcus spp . was performed before and after induction of resistance . This analysis showed a decrease of the D-Ala-D-Ala and UDP-MurNac-pentapeptide pools, an increase of the UDP-MurNac-tripeptide pool, and the appearance of new UDP-MurNac-containing material . These results lead us to suggest that the vancomycin-induced carboxypeptidase activity cleaves the D-Ala-D-Ala (L . Gutmann, D . Billot-Klein, S . Al-Obeid, I . Klare, S . Francoul, E . Collatz, and J . van Heijenoort, Antimicrob . Agents Chemother . 36:77-80, 1992), which in turn would prevent formation of the normal UDP-MurNac-pentapeptide and thereby of the vancomycin target . The novel UDP-MurNac-containing material is thought to correspond to peptidoglycan precursors which might be synthesized by an alternate pathway (T . D . H . Bugg, G . D . Wright, S . Dutka-Malen, M . Arthur, P . Courvalin, and C . T . Walsh, Biochemistry 30:10408-10415, 1991) and which would be unable to bind vancomycin in glycopeptide-resistant enterococci. Antimicrob Agents Chemother, 1992 Jul, 36(7), 1392 - 9 Vancomycin resistance in Enterococcus gallinarum; Vincent S et al.; The vancomycin resistance expressed by several strains of Enterococcus gallinarum was studied . Resistance was expressed constitutively, as demonstrated by analysis of growth and inhibition of peptidoglycan synthesis . E . gallinarum strains were moderately resistant to vancomycin (MIC, 16 micrograms/ml) but were as susceptible as vancomycin-susceptible enterococci to the glycopeptides, teicoplanin, A35512B, A47934, A4103A, and A41030E and the glycopeptide actaplanins A1, B2, and C1 . Vancomycin resistance in E . gallinarum was inhibited by beta-lactam antibiotics at concentrations that saturated penicillin-binding protein 6 (PBP 6), as demonstrated by binding competition experiments . Spontaneous mutants (frequency, 10(-8)) were two- to fourfold more resistant to beta-lactam inhibition of vancomycin resistance than the parent strain . PBP binding competition experiments suggested that PBP 6 in the mutants bound less cefotaxime, while binding of penicillin and cefoxitin was unaffected . Both a bioassay method and high-performance liquid chromatography showed that E . gallinarum membranes have enzymatic activity which modifies a model pentapeptide yielding a product that is thought to be a tetrapeptide . This activity could be a D,D-carboxypeptidase . In both the parent E . gallinarum strain and its derivatives that were resistant to the synergistic drug combination, the activity was inhibited by beta-lactams at concentrations which correlated with those that inhibit vancomycin resistance and those that saturate PBP 6 . These results suggest the possibility that PBP 6 may be involved in the vancomycin resistance of E . gallinarum and that the putative D,D-carboxypeptidase activity seen in E . gallinarum membranes may be attributable to PBP 6. Int J Syst Bacteriol, 1992 Jul, 42(3), 365 - 9 Enterococcus flavescens sp . nov., a new species of enterococci of clinical origin; Pompei R et al.; Four yellow-pigmented group D enterococci of uncertain taxonomic position were isolated from several humans with severe infections . The results of DNA composition, DNA-DNA hybridization, fatty acid content, and biochemical property studies demonstrated that these organisms were slightly related to other previously described yellow-pigmented enterococcal species and constitute a new species, for which we propose the name Enterococcus flavescens . The type strain of E . flavescens is strain CCM 4239 {corrected}. Antimicrob Agents Chemother, 1992 May, 36(5), 1032 - 9 Emergence and nosocomial transmission of ampicillin-resistant enterococci; Boyce JM et al.; Between 1986 and 1988, the incidence of ampicillin-resistant enterococci increased sevenfold at a university-affiliated hospital . Forty-three patients acquired nosocomial infections with ampicillin-resistant enterococci, most of which were also resistant to mezlocillin, piperacillin, and imipenem . An analysis of plasmid and chromosomal DNAs of isolates revealed that the increase was due to an epidemic of 19 nosocomial infections that yielded closely related strains of Enterococcus faecium and to a significant increase in the incidence of nonepidemic, largely unrelated strains of ampicillin-resistant enterococci . The nonepidemic strains were identified as E . faecium, E . raffinosus, E . durans, and E . gallinarum . A logistic regression analysis revealed that patients with nonepidemic resistant strains were 16 times more likely than controls to have received preceding therapy with imipenem . In our institution, the increase in the incidence of ampicillin-resistant enterococci appears to be due to the selection of various strains of resistant enterococci by the use of imipenem and to the nosocomial transmission of E . faecium and E . raffinosus. J Hosp Infect, 1992 May, 21(1), 1 - 14 Antibiotic-resistant enterococci; Gray JW et al.; Enterococci have emerged as an important cause of nosocomial infection . Successful antibiotic treatment of serious enterococcal infection usually depends on the synergistic bactericidal effect achieved by the combination of a cell wall-active agent, such as ampicillin or a glycopeptide, and an aminoglycoside . However, the prevalence of enterococci resistant to one or more of these antibiotics is increasing, and has resulted in serious therapeutic difficulties . The mechanisms of antibiotic resistance, and the epidemiology, laboratory diagnosis and management of infection with antibiotic-resistant enterococci are discussed. South Med J, 1992 Apr, 85(4), 430 - 1 Acute pancreatitis associated with ketoprofen; Cobb TK et al.; An 80-year-old man had acute pancreatitis during the fourth week of antibiotic therapy for enterococcal endocarditis and 12 days after initiation of ketoprofen therapy for osteoarthritis of the hip . Pancreatitis resolved after discontinuance of ketoprofen therapy and while continuing antibiotic therapy for endocarditis . Common causes of pancreatitis were excluded by laboratory testing . Ketoprofen may have been the cause of pancreatitis in this case; we have suggested two possible mechanisms related to prostaglandin inhibition. Nippon Koshu Eisei Zasshi, 1992 Apr, 39(4), 223 - 7 {Comparative evaluation of membrane filter methods for enumeration of enterococci in water}; Koujima I; Many laboratory methods for the assay of viable counts of enterococci in water have been reported, but the evaluation or verification of the methods have yet to be reported . The three most commonly used membrane filter methods were selected and compared in terms of the verification of enterococci counts in environmental water . The verified percentages, i.e . identified enterococci count versus apparent enterococci count, assayed by each method, were as follows: KF.MF (membrane filter cultured on KF agar) method 64.5%; mENT.MF (membrane filter cultured on mENT agar) method 80.7%; and mE.MF (membrane filter cultured on mE agar) method 63.4% . The AC.MF (membrane filter cultured on AC agar) method which we reported previously (Koujima I, et al . Jap J Bact, 1989; 44: 813-816) consistently gives 100% verification and therefore is the most consistent method and superior in accuracy to the other three methods. Infect Control Hosp Epidemiol, 1992 Apr, 13(4), 195 - 200 A cluster of vancomycin-resistant Enterococcus faecium in an intensive care unit; Karanfil LV et al.; OBJECTIVE: To describe the epidemiology of a cluster of vancomycin-resistant Enterococcus faecium (VAREC) in a cardiothoracic surgery intensive care unit . DESIGN: A case series of patients identified through review of surveillance data on nosocomial infections, review of microbiologic records, and culture survey of patients in the unit . RESULTS: Six patients in the cardiothoracic surgery intensive care unit had VAREC with identical antimicrobic susceptibility patterns over a 6-month period . Four patients were identified with VAREC through prospective surveillance and 2 through retrospective review . Prior vancomycin use was seen more commonly in patients with VAREC (6/6, 100%) than in those without VAREC (3/12, 25%) (Fisher's exact test, p = .01) . Six of the 7 patients with prior infection developed VAREC (85.7%) . A prior nosocomial infection and prior exposure to vancomycin were found to be important variables in a logistic regression analysis . VAREC also was isolated from the environment . A combination of cohorting of patients and staff, and modifications of standard contact isolation practices eliminated the presence of VAREC from the cardiothoracic surgery intensive care unit . CONCLUSIONS: The results suggest that prior administration of vancomycin, especially in the patient who develops nosocomial infection, can influence the acquisition of vancomycin-resistant enterococci and that VAREC may be transmitted from patient to patient . Using a modification of the standard infection control practice of isolation, we were able to control the spread of this resistant strain of E faecium. J Bacteriol, 1992 Apr, 174(8), 2582 - 91 The VanS-VanR two-component regulatory system controls synthesis of depsipeptide peptidoglycan precursors in Enterococcus faecium BM4147; Arthur M et al.; Plasmid pIP816 of Enterococcus faecium BM4147 confers inducible resistance to vancomycin and encodes the VanH dehydrogenase and the VanA ligase for synthesis of depsipeptide-containing peptidoglycan precursors which bind the antibiotic with reduced affinity . We have characterized a cluster of five genes of pIP816 sufficient for peptidoglycan synthesis in the presence of vancomycin . The distal part of the van cluster encodes VanH, VanA, and a third enzyme, VanX, all of which are necessary for resistance . Synthesis of these enzymes was regulated at the transcriptional level by the VanS-VanR two-component regulatory system encoded by the proximal part of the cluster . VanR was a transcriptional activator related to response regulators of the OmpR subclass . VanS stimulated VanR-dependent transcription and was related to membrane-associated histidine protein kinases which control the level of phosphorylation of response regulators . Analysis of transcriptional fusions with a reporter gene and RNA mapping indicated that the VanR-VanS two-component regulatory system activates a promoter used for cotranscription of the vanH, vanA, and vanX resistance genes. Antimicrob Agents Chemother, 1992 Apr, 36(4), 867 - 9 Evidence for in vivo incorporation of D-lactate into peptidoglycan precursors of vancomycin-resistant enterococci; Arthur M et al.; The VanA ligase encoded by the vancomycin resistance plasmid pIP816 of Enterococcus faecium BM4147 condenses D-alanine with various D-2-hydroxy and D-2-amino acids in vitro . D-Lactate added to the culture medium restored the vancomycin resistance of a strain that does not produce the VanH dehydrogenase and therefore appears to be a substrate of VanA in vivo. Antimicrob Agents Chemother, 1992 Apr, 36(4), 783 - 7 Overproduction of a penicillin-binding protein is not the only mechanism of penicillin resistance in Enterococcus faecium; Klare I et al.; In 1989 and 1990, a large number of ampicillin-resistant strains of Enterococcus faecium were isolated from infected patients treated at intensive care units in Berlin, Germany . Twenty-five clinical isolates, including five different biotypes as classified by acid production from various sugars and a wide range of susceptibilities to ampicillin (MICs between 0.5 and 128 micrograms/ml), were selected for a detailed analysis of penicillin-binding proteins (PBPs) . All strains contained a slowly reacting PBP with low penicillin affinity known to be present in enterococci . Overproduction of this PBP relative to susceptible isolates was noted, especially in all strains for which the MIC of ampicillin was 8 micrograms/ml, to a lesser degree in the more resistant strains, but not at all in the three highly resistant isolates for which the MIC was 128 micrograms/ml . In these three strains, this PBP appears to have a reduced affinity for beta-lactams . The results suggest that overproduction of PBP 6 correlates only with intermediate resistance levels and that higher resistance is mediated by yet another, still unknown mechanism, probably including reduction of beta-lactam affinity in one or more PBPs. FEMS Microbiol Lett, 1992 Apr 1, 71(1), 11 - 4 Insertional inactivation of a gene which controls expression of vancomycin resistance on plasmid pHKK100; Handwerger S et al.; Expression of inducible high level vancomycin resistance (Vmr) in enterococci appears to require other plasmid-encoded genes in addition to the previously described structural genes vanA and vanH . Tn917 mutagenesis was used to identify such a region in the Vmr plasmid pHKK100 . Insertional inactivation of a 693-bp open reading frame upstream from vanH resulted in complete loss of Vmr . This putative 26,642-Da protein has been designated VanR. J Biol Chem, 1992 Mar 15, 267(8), 5396 - 400 Cloning and disruption of a putative NaH-antiporter gene of Enterococcus hirae; Waser M et al.; When growing in a sodium-rich environment, wild-type Enterococcus hirae extrudes sodium by two mechanisms, ATP-driven sodium extrusion, and NaH-antiport . Mutant 7683 is unable to grow on sodium-rich media . This is due to two mutations, one inactivating ATP-driven sodium transport and a second rendering NaH-antiport inoperative . 7683 was transformed by electroporation with a gene bank, derived from E . hirae, in an Escherichia coli-E . hirae shuttle vector . Transformants which had regained the ability to grow on sodium-rich media were selected for and the transforming plasmids analyzed . A gene able to restore NaH-antiport activity in 7683 was identified . This gene was named napA . It codes for an extremely hydrophobic protein of 383 amino acids . Hydropathy analysis of this protein indicates that it probably forms 12 transmembraneous helices . In a mutant, possessing only the NaH-antiporter, the napA gene was disrupted by homologous recombination . The resultant strain failed to grow in sodium-rich media, and vesicles isolated from these cells exhibited a defect in sodium proton antiport activity . We conclude that the napA gene codes for a NaH-antiporter . The NapA protein does not exhibit significant homology to any protein in the EMBL genetic data bank. Gene, 1992 Mar 1, 112(1), 53 - 8 Sequence of the vanC gene of Enterococcus gallinarum BM4174 encoding a D-alanine:D-alanine ligase-related protein necessary for vancomycin resistance; Dutka-Malen S et al.; The amplification product obtained with DNA from vancomycin-resistant (VmR) Enterococcus gallinarum BM4174 and a pair of degenerate oligodeoxyribonucleotides that correspond to conserved amino acid (aa) motifs in Escherichia coli D-alanine (D-Ala):D-Ala ligases and in En . faecium VmR protein (VanA) was used as a probe to clone the vanC gene of that strain . The vanC product, with a calculated Mr of 37,504, exhibits 29 to 38% aa identity with VanA and E . coli ligases . Insertional inactivation of vanC led to Vm sensitivity of BM4174 suggesting that the gene may encode a D-Ala:D-Ala ligase of altered specificity. Am J Gastroenterol, 1992 Mar, 87(3), 375 - 8 Enterococcus avium bacteremia in association with ulcerative colitis; Mellman RL et al.; The enterococci are common human pathogens . Enterococcus avium is a rare cause of infection in humans . A variety of immunological alterations in the intestinal mucosa of patients with ulcerative colitis may predispose them to unusual organisms . We report the first case of E . avium bacteremia in a patient with ulcerative colitis. FEMS Microbiol Lett, 1992 Feb 1, 70(1), 79 - 84 Replacement of the essential penicillin-binding protein 5 by high-molecular mass PBPs may explain vancomycin-beta-lactam synergy in low-level vancomycin-resistant Enterococcus faecium D366; al-Obeid S et al.; The mechanism of synergy between vancomycin and penicillin, as well as other beta-lactam antibiotics, was examined in a penicillin-resistant E . faecium (D366) expressing an inducible low-level resistance to vancomycin . It was demonstrated that penicillin per se was not able to reduce the inducible expression of the 39.5-kDa protein (VANB) or the carboxypeptidase activity which are involved in the mechanism of vancomycin resistance of this strain . Assays of competition between 3H-benzylpenicillin and diverse beta-lactam antibiotics suggested as the most likely explanation of the synergy that, once vancomycin resistance has been induced, the high-molecular mass penicillin-binding proteins (PBPs), and possibly PBP1 in particular, which have a high affinity for beta-lactam antibiotics, take over the role of the low-affinity PBP5 which is, in the non-induced strain, responsible for beta-lactam resistance. J Chemother, 1992 Feb, 4(1), 9 - 11 High-level aminoglycoside resistance among enterococci: evaluation of an agar screen susceptibility test; Nicastri E et al.; Seventy-five enterococci from infected (63 isolates) and colonized (12 isolates) patients hospitalized in various divisions of the Policlinico Umberto I, University of Rome, were in vitro studied for high-level resistance (HLR) to gentamicin (HLRG) and streptomycin (HLRS) with adoption of a standard broth dilution and an agar screen test . The employed procedures provided equal results for 100% of the 75 isolates . Of these, 21 (28%) showed HLRG and 43 (57%) HLRS . Combined HLRG and HLRS were found in 18 (24%) isolates, whereas HLRS or HLRG alone were found in 25 (33%) and 3 (4%) isolates respectively . It is concluded that HLR to aminoglycosides may represent a major problem in Italian institutions . Along with other established procedures, the agar screen test employed in the study may be used to detect this antibiotic resistance in enterococci. Br J Surg, 1992 Jan, 79(1), 27 - 8 Bacteriology of anal fistulae; Seow-Choen F et al.; Anal fistulae are said to arise from cryptoglandular infection of the anal glands, which lie within the intersphincteric space . The type and virulence of the micro-organism responsible may determine whether an anal fistula develops . The microbiology of chronic anal fistulae has not been reported previously . Twenty-five consecutive anal fistulae were studied prospectively (eight intersphincteric fistulae, 12 trans-sphincteric fistulae, two suprasphincteric fistulae, one extrasphincteric fistula, one superficial fistula, one anovaginal fistula) . There were 18 men and seven women, with a median age of 42 (range 22-71) years . Patients with Crohn's disease or acute anorectal suppuration were excluded . In 18 patients, 0.1 ml granulation tissue from the track of the fistula was obtained and processed within 4 h using standard microbiological techniques . Sixty-nine isolates representing at least 17 species were obtained . The predominant organisms were Escherichia coli (22 per cent), Enterococcus spp . (16 per cent) and Bacteroides fragilis (20 per cent) . The majority of the growths were obtained only from enrichment . Bacteria from only one patient grew at a dilution of 10(3) . Granulation tissue from 25 patients was processed for mycobacterial culture, and Mycobacterium tuberculosis was grown from one patient . No other mycobacterium was isolated . The chronic inflammation in anal fistulae does not seem to be maintained by either excessive numbers of organisms or organisms of an unusual type. Antimicrob Agents Chemother, 1992 Jan, 36(1), 77 - 80 Inducible carboxypeptidase activity in vancomycin-resistant enterococci; Gutmann L et al.; Vancomycin was found to coinduce DD-carboxypeptidase activity, together with resistance, in eight low- or high-level glycopeptide-resistant strains of enterococci . The constitutively resistant mutant (MT10) of a low-level-resistant strain of Enterococcus faecium (D366) spontaneously expressed a level of carboxypeptidase similar to that of the induced strain D366 . Pentapeptide, UDP-MurNac-pentapeptide, as well as D-alanyl-D-alanine were in vitro substrates for the carboxypeptidase which was not inhibited by penicillin . The level of vancomycin resistance correlated roughly with the level of carboxypeptidase activity . We infer from these results that the carboxypeptidase is one component of the glycopeptide resistance mechanism. J Hosp Infect, 1992 Jan, 20(1), 35 - 42 Clinical isolates of enterococci with high-level resistance to currently available aminoglycosides; Ismaeel NA; Enterococci isolated from different body sites were tested for high-level gentamicin resistance . A total of 139 enterococcal isolates were screened for resistance (minimum inhibitory concentration {MIC} greater than 2000 mg l-1) by a broth-tube method . Twenty-five (18%) were found to exhibit resistance and this was confirmed by agar screening (1000 mg l-1) and agar dilution MIC determinations . The majority of isolates also showed high-level resistance to kanamycin and streptomycin . The remaining isolates showed high-level resistance to gentamicin and kanamycin but not streptomycin . A retrospective clinical review was performed . Most patients had a source of definite or likely infection (78%) . Serious infections such as endocarditis or meningitis were not observed during the course of this study . Retrospective clinical data suggest that in cases not involving endocarditis or meningitis, neither infection refractory to therapy nor relapse of infection is a common sequel to infection with gentamicin-resistant enterococci in hospitalized patients. J Clin Microbiol, 1991 Dec, 29(12), 2884 - 6 Characterization of yellow-pigmented enterococci from severe human infections; Pompei R et al.; Four strains of yellow-pigmented enterococci that resembled the species Enterococcus casseliflavus were isolated from patients who had undergone surgical treatment . They were substantially homologous in terms of biochemical properties, antibiotic susceptibilities, and plasmid DNA profiles . Yellow-pigmented enterococci could be another potentially important cause of nosocomial infection in surgical units. J Clin Microbiol, 1991 Dec, 29(12), 2752 - 7 DNA fingerprinting of Enterococcus faecium by pulsed-field gel electrophoresis may be a useful epidemiologic tool; Miranda AG et al.; Pulsed-field gel electrophoresis was used to compare 34 isolates of Enterococcus faecium from six different geographic locations . This procedure generated an average of 13 discernible fragment bands per isolate (range, 10 to 19 fragment bands) of 34 to 485 kb . The resulting restriction endonuclease digestion patterns were quite heterogeneous and were able to differentiate 27 of 34 isolates from each other, as defined by one or more mismatched fragment bands . Five patterns were shared by two or more isolates, and each set of isolates with matching patterns (shared pattern) originated in the same medical center, suggesting a common epidemiologic background, including highly penicillin resistant isolates in Richmond and Philadelphia . We conclude that pulsed-field gel electrophoresis of DNA digested with low-frequency-cleavage restriction enzymes offers a relatively simple method of comparing E . faecium for the purpose of epidemiologic study. South Med J, 1991 Dec, 84(12), 1435 - 7 Endovascular infections caused by enterococci highly resistant to ampicillin; Chirurgi VA et al.; Enterococci frequently cause endocarditis and are the most common gram-positive isolates in polymicrobial bacteremia . We report three cases of polymicrobial endovascular infections at a single institution during a 12-month period; the enterococcal isolates were highly resistant to penicillins . These cases comprised 18% of all enterococcal endovascular isolates during the same 12-month period . Previous use of antibiotics, presence of endovascular catheters, and nosocomial acquisition of the organism occurred in all three cases . Clinicians should be aware of enterococcal resistance to penicillins and should exercise care in designing appropriate regimens for serious enterococcal infections. Eur J Clin Microbiol Infect Dis, 1991 Dec, 10(12), 1062 - 5 Bactericidal activity of daptomycin against vancomycin-resistant Enterococcus faecium in an in vitro pharmacokinetic model; Bingen E et al.; A dynamic in vitro model was used to determine the killing kinetics of daptomycin against 15 vancomycin-resistant clinical isolates of Enterococcus faecium . Concentration profiles simulating those observed in serum following administration of both low-dose (2 mg/kg) and high-dose (6 mg/kg) daptomycin were bactericidal within 5.5 and 2.8 h, respectively . In contrast, when albumin was added to the growth medium, the corresponding bacterial killing times were slowed to greater than 24 h and 7 h; these results suggest that in the clinical setting, daptomycin dosages of approximately 6 mg/kg are required to achieve bactericidal activity against vancomycin-resistant Enterococcus faecium. Antimicrob Agents Chemother, 1991 Nov, 35(11), 2180 - 4 Increasing resistance to beta-lactam antibiotics among clinical isolates of Enterococcus faecium: a 22-year review at one institution; Grayson ML et al.; To identify any change in the antibiotic resistance of Enterococcus faecium, we examined the antibiotic susceptibilities of clinical strains (n = 84) isolated at one institution during the 22 years since 1968 . A significant increase in resistance to penicillin was observed during the study period: the MICs of penicillin for 50 and 90% of isolates tested were 16 and 64 micrograms/ml, respectively, from 1969 to 1988 (n = 48; geometric mean MIC, 14 micrograms/ml) , whereas they were 256 and 512 micrograms/ml, respectively, from 1989 to 1990 (n = 36; geometric mean MIC, 123 micrograms/ml) (P less than 0.001) . A comparable increase in resistance to ampicillin was also noted (P less than 0.001) . No strains produced detectable beta-lactamase . In contrast, susceptibilities to vancomycin, teicoplanin, and ciprofloxacin remained stable . High-level resistance to gentamicin was observed in none of 48 isolates from 1969 to 1988, but was present in 22 of 36 strains (61%) from 1989 to 1990 (P less than 0.001) and was significantly associated with resistance (MIC, greater than or equal to 128 micrograms/ml) to penicillin (P less than 0.001) . To assess the potential evolution of antibiotic resistance in this species, clinical isolates (n = 24) were compared with strains isolated in 1968 from a human population in the Solomon Islands that was never exposed to antibiotics . Solomon Island isolates were significantly more susceptible than all clinical strains to penicillin, ampicillin, and vancomycin (P less than 0.001 for each), but they exhibited no differences in susceptibility to teicoplanin or ciprofloxacin . The penicillin-binding affinity of penicillin-binding protein 5 (PBP 5) in penicillin-resistant clinical strains (MIC, 512 micrograms/ml) was notably lower than that in strains with more typical susceptibilities, suggesting an alteration in this PBP as a possible mechanism for increased penicillin resistance . Solomon Island strains most susceptible to penicillin demonstrated a prominent PBP 5* and the absence of PBP 5 . These changes in the antibiotic resistance of E . faecium emphasize the importance of identifying this species in patients with serious enterococcal infections and the necessity of assessing its susceptibility to both beta-lactams and aminoglycosides if effective therapy is to be identified. FEBS Lett, 1991 Nov 4, 292(1-2), 64 - 8 Primary structure of the alpha-subunit of vacuolar-type Na(+)-ATPase in Enterococcus hirae . Amplification of a 1000-bp fragment by polymerase chain reaction; Kakinuma Y et al.; A 1000-bp fragment of Enterococcus hirae genomic DNA was amplified by the polymerase chain reaction method, using the oligonucleotide primers designed from amino acid sequences of both amino-terminal and a tryptic fragment of the Na(+)-ATPase alpha-subunit in this organism . DNA sequencing of this product revealed that the amino acid sequence of Na(+)-ATPase alpha-subunit is highly homologous to the corresponding sequences of large (alpha) subunits of vacuolar (archaebacterial) type H(+)-ATPases, supporting our proposal {Kakinuma, Y . and Igarashi, K . (1990) FEBS Lett . 271, 97-101} that the Na(+)-ATPase of this organism belongs to the vacuolar-type ATPase. J Infect Dis, 1991 Nov, 164(5), 888 - 93 Triple-combination penicillin-vancomycin-gentamicin for experimental endocarditis caused by a moderately penicillin- and highly glycopeptide-resistant isolate of Enterococcus faecium; Caron F et al.; An in vitro bacteriostatic synergy between beta-lactam and glycopeptide antibiotics has been recently described against isolates of Enterococcus faecium moderately resistant to penicillin and highly resistant to vancomycin . The relevance of this synergy in a rabbit endocarditis model was evaluated . Penicillin was tested at low- (LoD) and high-dose (HiD) regimens, alone or combined with vancomycin and/or gentamicin . Compared with controls, after a 5-day treatment: LoD penicillin, vancomycin, gentamicin, LoD penicillin plus gentamicin or vancomycin, and vancomycin-gentamicin were not effective; LoD penicillin-vancomycin caused a small reduction of bacterial titers in vegetations that was strongly enhanced by adding gentamicin; HiD penicillin-gentamicin, the most effective regimen, was not significantly better than LoD penicillin-vancomycin-gentamicin . These results suggest that the relative in vivo inefficacy of penicillin-vancomycin might be related to the fact that this combination was poorly bactericidal, and the triple combination of LoD penicillin-vancomycin-gentamicin or the combination of HiD penicillin-gentamicin should be considered in the treatment of serious infections due to beta-lactam- and glycopeptide-resistant enterococci. An Esp Pediatr, 1991 Nov, 35(5), 319 - 21 {Vulvovaginitis in premenarche girls . A preliminary study}; Jimenez Fernandez F et al.; The study population consisted of 832 premenarcheal girls . Vaginal cultures are performed on 40 premenarcheal girls suffering from vulvovaginitis . All were less than 7 years old . This patients were seen in primary cares . In 23 cases (57.5%) E . coli was isolated, Enterococcus (30%), mixed flora (10%) and G . vaginalis (2.5%) . Common clinical characteristics were pruritus (97.5%), vaginal discharge (67.5%) . Dysuria and abdominal pain constituted accompanying symptoms . Only in one case masturbation was observed. J Clin Microbiol, 1991 Nov, 29(11), 2663 - 5 Ampicillin-resistant Enterococcus raffinosus in an acute-care hospital: case-control study and antimicrobial susceptibilities; Chirurgi VA et al.; A prospective study identified 9 (32%) of 28 ampicillin-resistant (MIC greater than or equal to 16 micrograms/ml) enterococcus isolates as Enterococcus raffinosus . A case-control study found no significant differences with respect to underlying diseases, catheterization, or surgery between patients with ampicillin-resistant E . raffinosus and those with ampicillin-susceptible Enterococcus spp . Prior treatment with antibiotics and prolonged hospitalization were more frequent among patients with ampicillin-resistant E . raffinosus . Patients with the same strain (determined by plasmid analysis) were frequently hospitalized concurrently. J Clin Microbiol, 1991 Oct, 29(10), 2335 - 7 Vancomycin susceptibility and identification of motile enterococci; Vincent S et al.; Thirty-seven clinical isolates of Enterococcus gallinarum and Enterococcus casseliflavus and three type or reference strains of the species were studied with respect to vancomycin susceptibility and key identification characteristics . With the exception of one clinical isolate of E . casseliflavus (MIC, 4 micrograms/ml), MICs of vancomycin were 8 to 32 micrograms/ml . The type strain of E . gallinarum, NCDO 2313, and five of the clinical isolates had similar penicillin-binding protein profiles and shared 90 to 100% DNA homology . Two isolates, identified as E . gallinarum by conventional tests, were shown to be non-pigment-producing E . casseliflavus on the basis of penicillin-binding protein profile and DNA homology . The type and reference strains of E . casseliflavus, ATCC 25788 and ATCC 25789, were nonmotile in our experiments . However, both shared 65 to 100% DNA homology with each other and with five clinical isolates of E . casseliflavus . These data suggest that the MICs of vancomycin observed for strains of E . gallinarum and E . casseliflavus are higher than those usually associated with other enterococci and may be a common property of these species . Additionally, pigment production and motility may occasionally be misleading criteria for definitive identification of these organisms. Am J Hosp Pharm, 1991 Oct, 48(10), 2150 - 4 Therapeutic interchange of ampicillin-sulbactam for cefoxitin; Lawrenz CA et al.; A therapeutic interchange program based on microbial patterns within an institution is described . A change in anaerobic susceptibility patterns, increased prevalence of enterococcal infections, and cost factors provided the rationale for the therapeutic interchange of ampicillin-sulbactam for cefoxitin . Ampicillin-sulbactam was recommended for prophylaxis in intraabdominal or gynecological surgery as well as for treatment for gynecological infections . Cefoxitin was restricted to penicillin-allergic patients and women who were pregnant or breast-feeding . The transition from cefoxitin to ampicillin-sulbactam proceeded smoothly as a result of preliminary education of pharmacists and physicians . Pharmacists participated in continuing-education programs and received concise guidelines for the interchange and follow-up instructions; physicians learned of the program from the drug newsletter published by the pharmacy department . Three months after the program began, only one physician was resistant to the interchange . After the program began, 11 antimicrobials, including cefoxitin, were used less frequently and ampicillin-sulbactam use increased . No adverse clinical consequences from the interchange were detected . A therapeutic interchange program based on institution-specific microbial patterns and educational efforts by the pharmacy department produced a change in physician prescribing. Zentralbl Hyg Umweltmed, 1991 Sep, 192(1), 33 - 44 {A simple apparatus for the determination of the resistance of bioindicators to saturated steam at temperatures less than 100 degrees C., tested with Enterococcus faecium as test microbe}; Spicher G et al.; An apparatus is described by means of which the resistance of microbiological indicators to water vapor at temperatures below 100 degrees C can be determined . The apparatus can be assembled from parts generally available in laboratories . The principle of the apparatus consists in the production of water vapor of the desired temperature under conditions of reduced pressure and its recondensation to water after having passed a special chamber . Accordingly, the device consists of a heated round-bottom flask serving as steam generator, an exposure chamber (B), and a condenser (D) attached to a receiver (E) . The bioindicators are exposed to the water vapor in the exposure chamber . A bypass located between the steam generator and the condenser allows for continuous operation even when the exposure chamber is opened . The reduced pressure was achieved by means of a waterjet pump and adjusted by two tandem-joined pressure-regulating valves as needed . The apparatus was tested using water vapor of 73, 75 and 77 degrees C, respectively, and bioindicators containing Enterococcus faecium as test organism . In the range of exposure periods in which bioindicators change from the status "all indicators having surviving test organisms" to the status "all indicators free from surviving test organisms" the bioindicators showed D values of 5.7, 4.4 and 2.9 min, respectively . For the temperature dependence of resistance a z value of 12.5 Kelvin resulted. Nippon Geka Gakkai Zasshi, 1991 Sep, 92(9), 1284 - 7 {Study of the host factors in the occurrence of the postoperative infections--special reference to the pathogenicity of the Enterococcus and MRSA}; Kodama T et al.; A study of the pathogenicity of the Enterococcus and Methicillin resistant S . aureus (MRSA) was made of 781 cases with gastroenterological surgery . The results obtained were summarized as follows . In this study 215 strains were isolated from clinical specimens . In these strains 13% was isolated from the postoperative mixed infection and only 7% occurred in single infection . Most of the single infections by the Enterococcus occurred in the cases with changes in host resistance, such as terminal cancer, disorder of the glucose tolerance, malnutrition and/or organ failures . Seventy-three strains were isolated from clinical specimens . In these strains 10% were the postoperative mixed infection and 40% were single infection . Incidence of the infection by the MRSA was significantly high compared with that by the Enterococcus . Single infection by the MRSA occurred even in the cases with normal host resistance . Strains producing enterotoxin C (single or plus A) were frequently isolated in MRSA enteritis or pneumonia . However, 60 percent of the patients in whom MRSA were detected in their abdominal drains had no signs of infection . These results suggest that the occurrence and severity of the MRSA infection relate with site of the infection and production of the exotoxin. J Clin Microbiol, 1991 Sep, 29(9), 1888 - 92 Evidence for the genetic unrelatedness of nosocomial vancomycin-resistant Enterococcus faecium strains in a pediatric hospital; Bingen EH et al.; Vancomycin-resistant enterococci are now found with increasing frequency . Up to now, epidemiological studies of enterococci have been limited by the lack of convenient and accessible methods for comparing strains . In this study, we report an epidemiological investigation on 16 nosocomial vancomycin-resistant Enterococcus faecium strains isolated from 15 patients in four different wards of a children's hospital over a period of 17 months . Analysis of restriction fragment length polymorphism (RFLP) of total DNA and of ribosomal DNA regions (ribotyping) was used as a typing approach . Each strain produced a different total DNA RFLP pattern after HindIII and PvuII digestion, except for two strains that were isolated from a single patient and that gave indistinguishable patterns . In our system, ribotyping was less discriminative than RFLP of total DNA . This approach, therefore, shows the genetic unrelatedness of the nosocomial strains studied and excludes patient-to-patient strain transmission either in the same ward or between wards. FEMS Microbiol Lett, 1991 Aug 1, 66(2), 119 - 23 Mode of membrane insertion and sequence of a 32-amino acid peptide stretch of the penicillin-binding protein 4 of Enterococcus hirae; Jacques P et al.; Analysis of water-soluble derivatives of the Enterococcus hirae 75-kDa membrane-bound penicillin-binding protein 4 (PBP4) has yielded the amino acid sequence of a 32-amino acid polypeptide stretch . This peptide is similar to peptide segments known to occur in the N-terminal domain of high-Mr PBPs of class B . The E . hirae PBP4 probably belongs to the same class . It is anchored in the membrane at the N-terminus of the polypeptide chain. Antimicrob Agents Chemother, 1991 Aug, 35(8), 1570 - 5 Influence of low-level resistance to vancomycin on efficacy of teicoplanin and vancomycin for treatment of experimental endocarditis due to Enterococcus faecium; Fantin B et al.; Emergence of vancomycin-resistant strains among enterococci raises a new clinical challenge . Rabbits with aortic endocarditis were infected with Enterococcus faecium BM4172, a clinical strain resistant to low levels of vancomycin (MIC, 16 micrograms/ml) and susceptible to teicoplanin (MIC, 1 micrograms/ml), and against its susceptible variant E . faecium BM4172S obtained in vitro by insertional mutagenesis (MICs, 2 and 0.5 micrograms/ml, respectively) . Control animals retained 8 to 10.5 log10 CFU/g of vegetation . We evaluated in this model the efficacy of vancomycin (30 mg/kg of body weight; mean peak and trough serum levels, 27 and 5 micrograms/ml, respectively), teicoplanin (standard dose, 10 mg/kg; mean peak and trough levels, 23 and 9 micrograms/ml, respectively; and high dose, 20 mg/kg; mean peak and trough levels, 63 and 25 micrograms/ml, respectively), gentamicin (6 mg/kg; mean peak and trough levels, 8.6 and less than 0.1 micrograms/ml, respectively), alone or in combination, given every 12 h intramuscularly for 5 days . Teicoplanin standard dose was as active as vancomycin against both strains . Vancomycin was not effective against E . faecium BM4172 but was highly effective against E . faecium BM4172S (7.5 +/- 1.1 log10 CFU/g of vegetation versus 4.9 +/- 1.0 log10 CFU/g of vegetation for vancomycin against E . faecium BM4172 and E . faecium BM4172S, respectively; P = 0.0012) . A high dose of teicoplanin was more effective than vancomycin against E . faecium BM4172 (4.4 +/- 1.8 log10 CFU/g of vegetation versus 7.5 +/- 1.1 log10 CFU/g of vegetation for teicoplanin high dose and vancomycin, respectively; P less than 0.05) . Against E . faecium BM4172 glycopeptide-gentamicin combinations were the most effective regimens in vitro and in vivo (2.8 +/- 0.7 and 3.5 +/- 1.3 log10 CFU/g of vegetation for vancomycin plus gentamicin and teicoplanin standard dose plus gentamicin, respectively; P < 0.05 versus single-drug regimens) . We concluded that high-dose teicoplanin or the combination of a glycopeptide antibiotic plus gentamicin was effective against experimental infection due to E . faecium with low-level resistance to vancomycin. Gene, 1991 Jul 15, 103(1), 133 - 4 Structural relationship between the vancomycin resistance protein VanH and 2-hydroxycarboxylic acid dehydrogenases; Arthur M et al.; Sequencing upstream from the vanA gene of enterococcal plasmid pIP816 that confers Vm resistance revealed the presence of an ORF which could code for a protein of 322 aa designated VanH . Extensive aa similarity was detected between VanH and 2-hydroxycarboxylic acid dehydrogenase . We discuss possible roles for VanH in the synthesis of a novel type of peptidoglycan precursors with lower affinity for Vm. Antimicrob Agents Chemother, 1991 Jul, 35(7), 1408 - 12 Comparison of Enterococcus raffinosus with Enterococcus avium on the basis of penicillin susceptibility, penicillin-binding protein analysis, and high-level aminoglycoside resistance; Grayson ML et al.; We reidentified our laboratories' collections of 57 enterococcal isolates previously classified as Enterococcus avium by the API Rapid Strep identification system (Analytab Products, Plainview, N.Y.) with the identification criteria recommended by Facklam and Collins (R . R . Facklam and M . D . Collins, J . Clin . Microbiol . 27: 731-734, 1989) . Thirty isolates were identified as true E . avium, 25 isolates were identified as E . raffinosus, and 2 isolates were identified as E . pseudoavium . E . raffinosus could be differentiated from E . avium on the basis of penicillin susceptibility, as follows: MIC for 50% of E . raffinosus isolates tested (MIC50), 32 micrograms/ml; MIC90, 64 micrograms/ml (range, 4 to 64 micrograms/ml); E . avium MIC50, 1 microgram/ml; MIC90, 2 micrograms/ml (range, 0.5 to 2 micrograms/ml) . No strains produced detectable beta-lactamase . Penicillin-binding protein (PBP) analysis of all E . raffinosus isolates demonstrated the unique pattern reported previously (M . D . Collins, R . R . Facklam, J . A . E . Farrow, and R . Williamson, FEMS Microbiol . Lett . 57:283-288, 1989); however, a number of newly identified PBPs were noted . Of 25 isolates, 13 had an additional PBP of 77 kDa (designated PBP 6*), while all isolates possessed a 52-kDa PBP (PBP 7) and a 46-kDa PBP (PBP 8) . The presence or absence of PBP 6* did not correlate with penicillin susceptibility; however, PBP 7 demonstrated many features suggestive of low penicillin-binding affinity and may represent a possible mechanism for the relative resistance of this species to penicillin, although this hypothesis remains speculative since attempts to develop a penicillin-hypersusceptible E . raffinosus mutant were unsuccessful . E . raffinosus isolates were significantly more likely to exhibit high-level resistance to kanamycin than E . avium strains were (P < 0.001; chi-square); however, no strains demonstrated high-level resistance to gentamicin . No trend toward increasing penicillin resistance was noted among this collection of E . avium and E . raffinosus isolates collected over the past 35 and 14 years, respectively . Relative resistance to penicillin may be a helpful differentiating feature between E . avium and E . raffinosus when assessment of raffinose metabolism is not possible or is indeterminant. Rev Infect Dis, 1991 Jul-Aug, 13(4), 600 - 5 Enterococcal bacteremia: to treat or not to treat, a reappraisal; Hoge CW et al.; The treatment of enterococcal bacteremia not associated with endocarditis has been controversial . We retrospectively reviewed 81 episodes of enterococcal bacteremia and categorized them as to their clinical significance, using a strict case definition . Of the 81 episodes, 41 met our criteria for clinical significance . Mortality was 51% among the 41 patients with clinically significant bacteremia and 50% among the 40 patients with bacteremia of uncertain clinical significance . Despite these equivalent overall mortality figures, antibiotic therapy specific for Enterococcus species was associated with reduced in-hospital mortality among patients with clinically significant infections (relative risk {RR} = 0.46, 95% confidence interval {CI} = 0.27-0.77); mortality was also reduced in the first 7 days after the detection of bacteremia, when death was relatively likely to be directly due to the bacteremic episode (RR = 0.17, CI = 0.04-0.74) . The association between appropriate antibiotic therapy and reduced mortality remained statistically significant when adjustments were made for a number of other factors related to mortality, including age, underlying conditions, prior use of antibiotics, nosocomial acquisition, polymicrobial etiology, prior surgery, and source of infection . Thus enterococcal isolates from the blood, even when of doubtful clinical significance, are poor prognostic markers associated with high mortality . However, when the clinical significance of bacteremia is defined by strict criteria, specific therapy against Enterococcus species is associated with improved outcome. Int J Syst Bacteriol, 1991 Jul, 41(3), 406 - 9 Enterococcus seriolicida sp . nov., a fish pathogen; Kusuda R et al.; The properties and taxonomic position of bacterial strains isolated from diseased specimens of cultured yellowtail and eels were examined . The isolates were gram-positive, short-chain-forming, catalase-negative, facultatively anaerobic cocci . Growth at 10 and 45 degrees C in 6.5% NaCl (pH 9.6) with 40% bile and in 0.1% methylene blue-milk were both positive . The isolates could be distinguished from other species of the genus Enterococcus by several biochemical characteristics and by Lancefield's group antigen . Guanine-plus-cytosine content of DNA was 44 mol% as determined by the thermal melting temperature . The value for DNA-DNA hybridization was sufficiently low to warrant distinguishing this species from reported . Enterococcus species . The name Enterococcus seriolicida is proposed . The type strain is YT-3 (=ATCC 49156). J Clin Microbiol, 1991 Jun, 29(6), 1258 - 9 Comparison of the new MicroScan Pos MIC Type 6 panel and AMS-Vitek Gram Positive Susceptibility Card (GPS-TA) for detection of high-level aminoglycoside resistance in Enterococcus species; Szeto S et al.; We compared the MicroScan Pos MIC Type 6 panel and AMS-Vitek Gram Positive Susceptibility Card (GPS-TA) to agar dilution screen plates for the detection of high-level aminoglycoside resistance in 182 enterococcal isolates . The specificity of the two commercial systems was 100%, with the exception of one susceptible isolate found to be streptomycin resistant by the Vitek system . The MicroScan and Vitek systems had comparable sensitivities for the detection of gentamicin resistance (90 and 95% respectively) and streptomycin resistance (85 and 78%, respectively) . These results suggest that screening tests such as agar dilution screen plates, broth dilution, or disk diffusion should continue to be used to detect high-level gentamicin and streptomycin resistance. J Infect Dis, 1991 Jun, 163(6), 1358 - 61 Synergistic bactericidal activity of rat serum with vancomycin against enterococci; Gold MJ et al.; Animal models of infectious diseases may not predict clinical efficacy when species-related factors come into play . Recently, unexpected bactericidal activity of vancomycin alone against enterococci was observed in a rat model of endocarditis . A factor or factors in rat serum, but not rabbit or human serum, enhanced in vitro killing by vancomycin in four of five clinical isolates of enterococci . Bactericidal activity was maintained on dilution of rat serum to 5.0% and after exposure of serum to 56 degrees C for 30 min . Activity was lost by heating at 60 degrees C for 2 h, ultrafiltration, or absorption with bentonite or heat-killed bacteria . Rat serum appears to contain a factor or factors that contribute bactericidal activity to vancomycin, a drug normally bacteriostatic for these enterococci . The mechanism by which this factor enhances killing of enterococci by vancomycin is unknown. Vet Med (Praha), 1991 Jun, 36(6), 335 - 40 {Lactic acid production and urease activity in strains of Enterococcus faecium found in the rumen and their genetic stability}; Laukova A et al.; Lactic acid production, urease activity and genetic stability were investigated in five selected rumen strains of Enterococcus faecium . The average value of urease activity in the tested strains was 16.5 +/- 0.953 nkat per ml, two strains were urease-negative . The values of E . faecium strains produced lactic acid ranged from 1.087 +/- 0.134 to 1.787 +/- 0.213 mmol per 1 l . Cultivation of the strains in ethidium bromide (EB) eliminated urease activity of these strains already in the first subculture, but the elimination effects of sodium dodecyl sulphate (SDS) and acridine orange (AO) were manifested later on (1-8 subcultures) . Lactic acid production was eliminated in all strains from 1st to 8th subculture after cultivation in SDS, EB and also AO. J Clin Microbiol, 1991 May, 29(5), 1075 - 7 Isolation of Enterococcus mundtii from normally sterile body sites in two patients; Kaufhold A et al.; Enterococcus mundtii, a recently described nonmotile, yellow-pigmented enterococcal species, was isolated from a chronic thigh abscess and from operatively obtained sinus mucosa . It is emphasized that this species may be encountered in clinical specimens and that the correct species identification may be missed when commercially available identification systems are relied on. Zentralbl Hyg Umweltmed, 1991 Mar, 191(2-3), 265 - 76 {Ergotropic effects through the nutritive use of organic acids}; Kirchgessner M et al.; Experimental data showed a significant improvement of growth rate and efficiency of feed utilization of young animals (piglets) by the dietary inclusion of organic acids . These ergotropic effects were mainly observed with citric acid, fumaric acid and formic acid as well as with Ca and Na formate . The merely dietary pH lowering with an inorganic acid (ortho-phosphoric acid) failed to show a nutritive efficacy . Studies on the mode of action of organic acids indicated a higher protein and energy digestibility, a lower stomach pH and reduced levels of NH3 and lactic acid in the stomach and duodenal digesta . Furthermore, the duodenum mainly contained a significant lower bacterial population for E . coli and enterococci . By this way the burden of metabolism of the host may be reduced which results in a higher overall performance. J Antimicrob Chemother, 1991 Mar, 27(3), 263 - 71 Effect of non-beta-lactam antibiotics on penicillin-binding protein synthesis of Enterococcus hirae ATCC 9790; Grossato A et al.; Fosfomycin, bacitracin and vancomycin in combination with penicillin exhibit a synergic effect against Enterococcus hirae ATCC 9790 . This strain, when incubated in presence of the MIC of non-beta-lactam antibiotics, showed an alternated pattern of PBPs . Bacitracin and vancomycin caused a decrease in the density of all PBPs while fosfomycin only reduced that of PBP 6 . It is suggested that the observed synergy is a consequence of the inhibition of PBP synthesis by antibiotics which act on the early stages of peptidoglycan synthesis prior to the formation of cross-links. Diagn Microbiol Infect Dis, 1991 Mar-Apr, 14(2), 141 - 5 The bactericidal activity of ampicillin, daptomycin, and vancomycin against ampicillin-resistant Enterococcus faecium; el-Mady A et al.; Ampicillin, daptomycin, and vancomycin, alone and in combination with gentamicin, were examined for bactericidal effects on ampicillin-resistant Enterococcus faecium using broth dilution minimum inhibitory concentrations (MICs) and time-kill studies . We tested 12 ampicillin-resistant isolates and demonstrated the following MICs and MBCs, respectively: ampicillin, greater than or equal to 32 micrograms/ml and greater than 256 micrograms/ml; daptomycin, less than or equal to 4 micrograms/ml and less than or equal to 16 micrograms/ml; and vancomycin, less than or equal to 4 micrograms/ml and greater than 64 micrograms/ml . Time-kill studies demonstrated that daptomycin alone had marked activity against the ampicillin-resistant E . faecium and that the addition of gentamicin resulted in synergistic killing . In addition, ampicillin and vancomycin were not bactericidal for the ampicillin-resistant isolates without the addition of gentamicin . The present study supports the consideration of daptomycin alone or in combination with an aminoglycoside as an alternative therapy for ampicillin-resistant enterococci, although additional clinical experience is now necessary. Lett Appl Microbiol, 1991 Mar, 12(3), 95 - 8 Enterococcus dispar sp . nov . a new Enterococcus species from human sources; Collins MD et al.; The partial 16S rRNA sequences of two unknown human enterococcal isolates were determined by reverse transcription in an attempt to clarify their taxonomic position . The sequence data indicate that they belong to a hitherto unknown species of Enterococcus, for which the name Enterococcus dispar sp . nov . is proposed . The type strain is NCIMB 13000. Biochemistry, 1991 Feb 26, 30(8), 2017 - 21 Identification of vancomycin resistance protein VanA as a D-alanine:D-alanine ligase of altered substrate specificity; Bugg TD et al.; High-level glycopeptide resistance in Enterococcus faecium BM4147 is mediated by a 38-kDa protein VanA, whose amino acid sequence is related to Gram-negative D-alanine:D-alanine (D-Ala-D-Ala) ligases {Dutka-Malen, S., Molinas, C., Arthur, M., & Courvalin, P . (1990) Mol . Gen . Genet . 224, 364-372} . We report purification of VanA and demonstrate that it has D-Ala-D-Ala ligase activity but has substantially modified substrate specificity, compared with Gram-negative D-Ala-D-Ala ligases . VanA preferentially condenses D-Ala with D-Met or D-Phe, raising the possibility that its cellular role is to synthesize a modified cell-wall component, which is subsequently not recognized by vancomycin. Zhonghua Min Guo Wei Sheng Wu Ji Mian Yi Xue Za Zhi, 1991 Feb, 24(1), 36 - 43 Effect of glucose concentration, agar, and amount of inoculum on the 6.5% sodium chloride tolerance test for presumptive identification of enterococci; Chang JC; The 6.5% NaCl tolerance test is simple and commonly used for presumptive identification of enterococci; however, it is not strictly standardized . The effect of glucose concentration, types of media and the size of inocula on the growth of enterococci have been evaluated . The results showed that broth was superior to agar media for enterococcal growth at any amount of inoculum . The media containing 1.0% glucose also showed superiority to media containing 0.1% glucose . It is suggested that broth containing 1.0% glucose be the medium of choice for 6.5% NaCl tolerance test. Infection, 1991, 19 Suppl 3, S138 - 40 Complement C3, coeruloplasmin and PMN-elastase in the ejaculate in chronic prostato-adnexitis and their diagnostic value; Blenk H et al.; The clinical differential of chronic prostatitis and psycho-vegetative urogenital syndrome with objective laboratory tests is very difficult . 265 ejaculates with possible chronic prostatitis were bacteriologically examined (including the search for STD agents) . To verify an inflammatory process in the prostate and adnexae, we tested the C3 complement, coeruloplasmin and PMN-elastase levels in ejaculate . In addition, semiquantitative leucocyte counts in stained smears of the ejaculate were carried out . 185 of 265 patients had C3 complement below detection levels or in the normal range excluding inflammation of prostate or adnexae . 16.8% of the C3-negative ejaculates showed an elevated PMN-elastase level associated with urethritis anterior and/or posterior caused by STD agents . 80 patients showed elevated C3 levels; 38.8% with elevated coeruloplasmin and PMN-elastase levels . The semiquantitative leucocyte count in the stained smear proved the least sensitive method for verifying an inflammation . Enterococci (55.3%), Mycoplasma (18.8%) and Escherichia coli (16.5) were the dominant pathogens of chronic prostatitis present in number of 10(2) cfu/ml or greater than 10(5) cfu/ml . A correlation to the intensity of the inflammation was not found . These results show how important it is to realise a complete bacteriological examination as well as to determine the C3 complement, coeruloplasmin and PMN elastase. Pharmacotherapy, 1991, 11(2 ( Pt 2)), 64S - 71S Monotherapy versus combination antimicrobial therapy: a review; Barriere SL; In view of the newer antibiotics that can cover the spectrum of organisms in mixed infections, single agents are now a viable option for antimicrobial therapy . In addition, monotherapy is relatively nontoxic and possibly less costly than combination therapy . Combinations may be more effective in preventing the emergence of resistance, however, and can also provide synergistic effects . They are a necessity in mycobacterial infections, enterococcal endocarditis, and deep-seated pseudomonal infections, as well as in patients with gram-negative bacillary infection with profound granulocytopenia. Clin Ther, 1991 Jan-Feb, 13(1), 58 - 80 Clindamycin in the treatment of obstetric and gynecologic infections: a review; Zambrano D; The spectrum of clindamycin's activity includes anaerobes and gram-positive aerobes other than enterococci . No inactivation or incompatibility of clindamycin phosphate has been shown in intravenous solutions usually used clinically . After oral administration, clindamycin is almost completely absorbed, with mean peak serum levels reached in 45 to 60 minutes . Clindamycin is widely distributed in many body fluids and tissues . Its normal half-life is two to three hours, and thus it can be given at six-hour intervals . Because of its excellent coverage against anaerobes, gram-positive cocci, and Chlamydia trachomatis, clindamycin is the preferred antimicrobial agent for serious infections of the female genital tract . Clindamycin plus tobramycin or an aminoglycoside is effective treatment for pelvic inflammatory disease, particularly when a tubo-ovarian abscess is present . In post-cesarean section endometritis, clindamycin plus gentamicin has been shown to be more effective than any other treatment . Clindamycin (alone or with an aminoglycoside) has been used successfully in posthysterectomy vaginal cuff infections and, with an aminoglycoside, in septic abortions . Clindamycin has been well tolerated in studies of animals and human subjects; its most significant side effects develop in the gastrointestinal system. Surg Gynecol Obstet, 1991, 172 Suppl, 57 - 64 Role of newer antimicrobial agents in the treatment of mixed aerobic and anaerobic infections; Karam GH et al.; Mixed infections with aerobic and anaerobic bacteria are being recognized with increasing frequency in clinical practice . Several concepts regarding such infections are clinically significant for the physician . These include the presence and significance of species in the Bacteroides fragilis group at clinical sites of infection, the facilitation of B . fragilis virulence by beta-lactamase producing aerobic bacteria and the role of enterococci in such infections . In response to the need for new forms of therapy for mixed aerobic and anaerobic infections, several new classes of antimicrobial agents have been introduced . Some of these allow for the potential option of monotherapy in certain clinical settings . In addition to clinical and microbiologic efficacy, safety and cost-effectiveness are factors that must be addressed with regard to these agents. Rev Infect Dis, 1991 Jan-Feb, 13(1), 1 - 7 Enterococcal endocarditis: a comparison of prosthetic and native valve disease; Rice LB et al.; Between 1973 and 1987, 36 patients with 41 episodes of enterococcal endocarditis were seen at our institution . There were 22 episodes of native valve endocarditis (NVE) and 19 episodes of prosthetic valve endocarditis (PVE) . The overall mortality before completion of therapy was 15% (18% due to NVE and 11% due to PVE) . Among patients with NVE, involvement of the aortic valve was significantly associated with death or complicated illness (defined as the need for valve replacement before completion of antibiotic therapy or relapse of endocarditis after completion of therapy) . Among patients who survived episodes of PVE, 69% were cured without surgical intervention . Gentamicin was administered in combination with a penicillin or vancomycin in the majority of episodes (mean duration of therapy with aminoglycosides: 5 weeks) . Renal dysfunction occurred in 44% of patients who received gentamicin and occurred more frequently in patients with elevated serum creatinine levels before treatment . Our results suggest that enterococcal PVE can often be successfully treated with antibiotics alone, and they confirm the efficacy of gentamicin when it is administered in combination with cell wall-active agents for the treatment of endocarditis due to enterococci that lack high-level resistance to this agent. Chemotherapy, 1991, 37(1), 6 - 14 Antimicrobial activity of intravenous quinolones on the intestinal microflora in dogs; Thadepalli H et al.; The antimicrobial activity of intravenously given quinolones on the intestinal microflora was unknown and therefore studied in dogs with a surgically isolated loop of the jejunum . Ciprofloxacin, enoxacin and norfloxacin were actively excreted by the intestinal mucosa and achieved therapeutic levels within the lumen of this isolated jejunal loop . Also the total counts of enterococci and Escherichia coli decreased in this loop of the jejunum as well as in the stool . All three quinolones, when given intravenously, decreased the total counts of anaerobic bacteria including Bacteroides fragilis. Kinderarztl Prax, 1991 Jan-Feb, 59(1-2), 35 - 7 {Candida parapsilosis infection as a complication of long-term parenteral nutrition}; Buttenberg S et al.; In case of short bowel syndrome in infancy the total parenteral nutrition was complicated by catheter-associated Candida parapsilosis septicemia based on generalized enterococci infection . Specific problems in antifungal treatment are discussed. Adv Perit Dial . 1991;7:96. Recurrent abdominal pain caused by a toothpick in a CAPD patient; Konig PS et al.; A 27-year-old patient on CAPD presented with febrile illness and abdominal pain suggestive of peritonitis . Dialysis fluid culture yielded Enterococcus . Response to treatment was slow, with pain persisting . Laparotomy revealed a toothpick, which was causing peritoneal irritation . It was unclear how the foreign object entered the peritoneum. Adv Perit Dial, 1991, 7, 135 - 7 Sensitivity of CAPD/IPD peritonitis organisms to ciprofloxacin; Pylypchuk GB et al.; Studies have suggested that oral quinolones may be useful in the treatment of peritonitis in peritoneal dialysis . We undertook a study of organisms causing peritonitis in our IPD and CAPD populations to determine if these organisms would be susceptible in vitro to Cipro . We determined the minimal inhibitory concentrations (MIC) of 62 non-duplicate isolates from episodes of peritonitis to Cipro by standard broth microdilution . Serial dilutions were done with Cipro and MIC50 and MIC90 were determined . The isolates were as follows: S, epidermidis (17), S . aureus (14), coliforms (11), Pseudomonas (8), Enterococci (8), Diphtheroids (4) . The MIC50 and MIC90 for each of the isolate groups and overall are shown below. J Chemother, 1990 Dec, 2(6), 351 - 4 Comparative in-vitro activity of fourteen antibiotics against clinical isolates of enterococci; Abd-Elalim Eltahawy AT et al.; The in-vitro antibacterial activities of fourteen antimicrobial agents, including ampicillin, amikacin, Augmentin, ceftazidime, cefotaxime, ceftriaxone, ciprofloxacin, erythromycin, gentamicin, penicillin G, piperacillin, rifampicin, streptomycin and vancomycin, were compared against 195 enterococcal strains isolated from clinical specimens received at the King Abdulaziz University Hospital in Saudi Arabia . The antibacterial susceptibility was determined by the minimal inhibitory concentration (MIC) using an agar dilution method . Ampicillin, Augmentin and vancomycin exhibited the greatest activity, inhibiting 90% of the tested strains (MIC90) at 2 micrograms/ml, followed by penicillin G and piperacillin with MIC90 of 4 micrograms/ml . Erythromycin, third generation cephalosporins, aminoglycosides and rifampicin, on the other hand, had poor activity against enterococci with MIC90s well above the obtainable serum concentrations . The clinical implications of resistance to aminoglycosides and the alternative antimicrobial therapy in serious enterococcal infections are discussed in the text. Dtsch Stomatol, 1990 Nov, 40(11), 462 - 3 {Antibacterial efficiency and toxicity of hydrogen peroxide and other antiseptics}; Glockmann E et al.; The results suggest a relatively favourable relation between minimum bactericidal concentration (enterococci) and toxic agent concentration (chicken embryos) of hydrogen peroxide in comparison with chlorhexidin-digluconate, sodium-tosylchloramide and peracetic acid . For chlorhexidin-digluconate a somewhat more favourable relation between minimum bacteriostatic and toxic concentration of the agent was established. J Antimicrob Chemother, 1990 Nov, 26(5), 613 - 8 Modification of penicillin-binding proteins of penicillin-resistant mutants of different species of enterococci; al-Obeid S et al.; Mutants resistant to penicillin G were selected in a stepwise manner from nine different species of enterococci . Mutants with the highest level of resistance showed cross-resistance to all beta-lactams tested . For eight of the nine species, resistance correlated with increased production of a low molecular weight penicillin-binding protein (PBP) . Two of these species produced a new PBP of low molecular weight, while two other species produced an additional PBP of high molecular weight . With the exception of Enterococcus faecium, no difference was observed in terms of lysis or bactericidal effect when the sensitive strains and their resistant mutants were tested at ten times their respective MICs of penicillin G . With E . faecium an increased lytic and bactericidal effect was observed for the resistant mutant. J Antimicrob Chemother, 1990 Nov, 26(5), 619 - 26 Bactericidal activity of vancomycin, daptomycin, ampicillin and aminoglycosides against vancomycin-resistant Enterococcus faecium; Bingen E et al.; Daptomycin, vancomycin, ampicillin and aminoglycosides, alone or in combination, were tested for their bactericidal activity against 15 isolates of vancomycin-resistant Enterococcus faecium from immunocompromised children . The kill-kinetic studies at clinically achievable concentrations demonstrated that daptomycin alone or in combination with ampicillin had the greatest bactericidal activity. Antimicrob Agents Chemother, 1990 Oct, 34(10), 1901 - 7 Correlation of penicillin-induced lysis of Enterococcus faecium with saturation of essential penicillin-binding proteins and release of lipoteichoic acid; al-Obeid S et al.; Clinical isolates of Enterococcus faecium that had a range of susceptibilities to penicillin were found to differ significantly in their responses to the antibiotic . In the penicillin-susceptible group (MIC, less than or equal to 4 micrograms/ml), the cessation of growth (bacteriostasis) at 10 x the MIC of penicillin appeared to correlate with the inhibition of penicillin-binding protein (PBP) 5*, whereas the onset of lysis (bactericidal effect) at higher antibiotic concentrations (100 x the MIC) was concomitant with the inhibition of the lower-affinity PBP 5 . In contrast, in the resistant (MIC, greater than or equal to 8 micrograms/ml) group (in which most of the strains did not contain PBP 5*), the degree of saturation of PBP 5 seemed to determine the physiological response to the antibiotic: low levels of saturation caused growth inhibition, whereas almost complete saturation correlated with lysis . The penicillin-induced cell lysis of both penicillin-susceptible and -resistant strains was attributed, at least in part, to the extensive loss of acylated lipoteichoic acid into the growth medium. Biochem Med Metab Biol, 1990 Oct, 44(2), 135 - 41 The relation of diabetic control to in vivo pH of soft tissue abscesses; Bessman AN et al.; It has been shown that induced soft tissue abscesses have a lower intra-abscess pH in the uncontrolled diabetic host than in the nondiabetic control . These differences were felt to be secondary to alterations in white cell metabolism . The current study compares the intra-abscess pH in three groups of mice: (I) nondiabetic, (II) untreated diabetic, and (III) insulin-treated diabetic . Diabetes was induced with streptozotocin in male white mice . The bacteria used to induce the abscesses were a combination of B . fragilis and Enterococcus . The blood glucose values of groups I, II, and III were 189 mg% (+/- 20.3), 256 mg% (+/- 121.9), and 712.8 mg% (+/- 169.7), respectively . None of the animals were ketotic, and peritoneal pH (reflecting systemic pH) showed no significant differences between groups . There were no significant differences in colony counts between any groups . The intra-abscess pH values of groups I, II, and III were 6.97 (+/- 0.26), 6.85 (+/- 0.41), and 6.08 (+/- 0.70) . The differences in intra-abscess pH and blood glucose levels were all significantly different from each other when all three groups were compared . The insulin-treated mice tended to return to normality but had the widest spread of values . Since a decrease in intra-abscess pH has been felt to be a reflection of white cell activity, our studies may be the first to demonstrate an in vivo effect of insulin on white cell activity. Microbiologica, 1990 Oct, 13(4), 329 - 32 Microbiological study of Enterococcus faecium SF68: post-antibiotic effect and growth curves; Lo Bue AM et al.; We studied the microbiological characteristics of Enterococcus faecium SF 68 (an oral vaccine) assessing post-antibiotic effect of ampicillin and growth curves in different media . Results showed a good resistance of the microorganism tested which has important implications in clinical practice . The growth ability of Enterococcus faecium SF 68 was similar on all media tested. Antimicrob Agents Chemother, 1990 Sep, 34(9), 1800 - 2 Efficacy of ampicillin versus trimethoprim-sulfamethoxazole in a mouse model of lethal enterococcal peritonitis; Chenoweth CE et al.; Lethal enterococcal peritonitis in mice was used to compare trimethoprim-sulfamethoxazole (TMP-SMX) therapy with ampicillin therapy . Peritoneal fluid showed a 10(3)-CFU decrease in enterococci with ampicillin compared with TMP-SMX . Mortality of the untreated mice was 100%, compared with 40% for ampicillin and 95% for TMP-SMX, despite adequately measured levels in serum and peritoneal fluid. Antimicrob Agents Chemother, 1990 Sep, 34(9), 1792 - 4 Failure of trimethoprim-sulfamethoxazole therapy in experimental enterococcal endocarditis; Grayson ML et al.; To assess the potential efficacy of trimethoprim-sulfamethoxazole (TMP-SMX) against serious enterococcal infections, we used a rat enterococcal endocarditis model comparing TMP-SMX therapy (500 mg of TMP plus 2,500 mg of SMX per kg of body weight per day given every 8 h by intragastric gavage) with intravenous ampicillin therapy (1,000 mg/kg per day) . Despite concentrations of active drug in serum well in excess of the MIC and MBC, the mean residual vegetation bacterial titer in TMP-SMX-treated rats was similar to that in untreated controls (8.4 +/- 1.1 versus 8.6 +/- 1.3 log10 CFU/g) and significantly higher than that in the ampicillin-treated group (3.6 +/- 1.5 log10 CFU/g; P less than or equal to 0.001) . This demonstrates discordance between in vitro activity and in vivo efficacy of TMP-SMX in serious enterococcal infection. Kansenshogaku Zasshi, 1990 Aug, 64(8), 1037 - 44 {Investigation on the etiology of sepsis by using experimental mouse model with leukocytopenia . 3 . The role of Kupffer cells in the etiology of bacteremia}; Hirakata Y et al.; In the previous report, we showed that the reticuloendothelial system (RES), especially the liver, played an important role in the etiology of bacteremia or sepsis as the major protective system . In this study, to investigate the role of Kupffer cells in the etiology of bacteremia, we isolated and cultured murine Kupffer cells using a technique involving perfusion with collagenase and DNase . We compared the adherence and phagocytosis rate of two groups of isolated bacteria from bacteremic mice by these cells . One group was bacteria causing systemic bacteremia consisted of P . aeruginosa and M . morganii, and the other was bacteria causing portal bacteremia consisted of E . coli, E . cloacae, K . pneumoniae and Enterococci . As a consequence, the following facts were revealed . 1 . The bacterial phagocytosis and adherence rate by Kupffer cells were significantly higher in bacteria causing portal bacteremia than in bacteria causing systemic bacteremia . These data were correlated to each blood clearance rate from mice . 2 . Blood clearance rate reflected mainly adherence of Kupffer cells to bacteria, and it was suggested that these adherence were one of the most important factor to protect the hosts from the advance of bacteremia from the portal to the systemic . 3 . In the case of using peritoneal macrophage, we couldn't find the same correlation, so the possibility was suggested that the above phenomenon was specific to Kupffer cells. J Infect, 1990 Jul, 21(1), 43 - 53 Ileal and jejunal absorptive function in patients with AIDS and enterococcidial infection; Kapembwa MS et al.; Small intestinal absorptive function was investigated in six patients with the acquired immunodeficiency syndrome (AIDS) who had diarrhoea and weight loss . Proximal function was assessed by {14C}Triolein test of fat absorption . Distal function was determined by a test of bile acid absorption in which the loss of radio-labelled synthetic bile acid, 75seleno-23-homocholic acid-taurine ({75Se}HCAT), from the enterohepatic circulation was quantified by abdominal gamma-scanning and by a vitamin B12-intrinsic factor absorption test . Concurrently indirect tests of small intestinal bacterial overgrowth ({14C}glycocholate and breath hydrogen) were carried out . In addition, jejunal histological examination and stool microscopy and culture for enteropathogens were performed . Fat absorption was reduced in all six patients, four of whom had jejunal villous atrophy . Bile acid and vitamin B12 absorption were normal in four subjects . Enteropathogens were not detected in any of the four subjects with normal terminal ileal absorptive function . In contrast, reduced bile acid and vitamin B12 absorption were detected in two of six subjects . Both patients had an enteropathogen (Cryptosporidium spp . and Isospora belli) present on stool and jejunal histological examination . Neither subject had evidence of small-intestinal bacterial overgrowth . AIDS patients therefore may have normal ileal absorptive function in the presence of jejunal disease . Infection with Cryptosporidium spp . or I . belli may however, be associated with severe ileal dysfunction. FEMS Microbiol Lett, 1990 Jul, 58(2), 167 - 70 Induction of vancomycin resistance in Enterococcus faecium by inhibition of transglycosylation; Handwerger S et al.; Vancomycin resistance has recently been recognized among clinical isolates of enterococci . Resistance is inducible, and associated with production of a novel 39 kDa membrane protein . The mechanism by which exposure to vancomycin, which does not penetrate the cell membrane, induces resistance is unknown . In the vancomycin resistant strain Enterococcus faecium 228, resistance was also inducible by moenomycin, suggesting that inhibition of the transglycosylation step in peptidoglycan synthesis may be required for induction of resistance . Cytoplasmic pools of peptidoglycan precursors were increased after exposure to vancomycin or moenomycin, representing a potential means for regulation of induction. Clin Podiatr Med Surg, 1990 Jul, 7(3), 467 - 81 Microbiology and antimicrobial therapy of diabetic foot infections; Joseph WS et al.; Infections of the foot in the person with diabetes are the result of a complex myriad of pathophysiologic alterations . Neuropathy, vascular disease, and host immune alterations all interact to present a fertile ground for significant microbiologic invasion . When infection occurs, it is commonly due to a mixed flora of aerobic and anaerobic organisms, although "pure" aerobic or anaerobic infections are sometimes seen . Treatment of these infections requires a broad approach, including surgery, local care, and antibiotics . Most often, treatment against aerobic and anaerobic pathogens will be necessary . These infections can be divided into two categories based on clinical appearance . Severe life- or limb-threatening infections can present with massive cellulitis of the foot and leg, high fever, significantly elevated white blood count, septicemia, and tissue gas . Appropriate antibiotics in this setting include either combination or single-agent therapy . Imipenem/cilastatin offers coverage of all usual pathogens along with potentially lower toxicity and lower cost than combinations . Combinations containing clindamycin and aztreonam or ciprofloxacin may be useful for patients allergic to beta-lactam antibiotics . Less severe infections can usually be treated with a single-agent antibiotic such as ticarcillin/clavulanic acid or ampicillin/sulbactam . Cephalosporins with anaerobic activity, including cefoxitin, cefotaxime, and ceftizoxime, can be used in areas where enterococci are not a major problem. Biochim Biophys Acta, 1990 Jun 26, 1017(3), 221 - 8 Electrogenic transport by the Enterococcus hirae ATPase; Apell HJ et al.; A transport ATPase from Enterococcus hirae was reconstituted in lipid vesicles and its electrogenic action investigated with the fluorescent dye oxonol VI as membrane potential probe . Reconstitution in bacterial and in soybean phospholipid mixtures led to transport-active vesicle preparations . Inside-out oriented ATPase molecules were activated by the addition of ATP to the extravesicular medium, generating in all experiments an intravesicularly positive potential . The extravesicular pH strongly influenced the initial pumping rate and the duration of the pumping activity . At neutral pH, transient pumping activity was observed, lasting for 1-2 min, while at pH 5.6, pumping was continuous . The transport activity was not dependent on the ionic composition of the buffer on either side of the membrane . These findings can be interpreted as the action of a proton ATPase, regulated by the cytoplasmic proton concentration and electrogenically translocating protons from the cytoplasm to the extracellular space. J Clin Microbiol, 1990 Jun, 28(6), 1484 - 6 Spontaneous peritonitis caused by Enterococcus faecium; Pascual J et al.; Three cases of spontaneous peritonitis caused by Enterococcus faecium are presented . The underlying condition was alcoholic cirrhosis in each case . This enterococcal species has never before been reported as a cause of spontaneous bacterial peritonitis . Two patients responded to therapy . The development of enterococcal peritonitis and the cases documented in the literature are briefly reviewed . Taxonomic problems with pathogenic, clinical, and therapeutic implications are discussed. Stomatol DDR, 1990 Jun, 40(6), 268 - 9 {Influence factors on progression and result of the treatment of periapical inflammation}; Glockmann E; The removal of the root canal infection was rendered more difficult with initially present communication of the root canal with the oral cavity, the involvement of relatively resistant microorganisms (enterococci, candida spec . and others) in the infection, and the extensive destructions of the periodontium . Some reduction of the chance of success could be established in case of extensive lesions of the marginal, lateral and apical periodontium after a control period of three years . This indicates the role of the relations between periodontium and endodontium for the result of the therapy of periapical inflammations. J Surg Res, 1990 May, 48(5), 444 - 7 Selective bowel decontamination results in gram-positive translocation; Jackson RJ et al.; Colonization by enteric gram-negative bacteria with subsequent translocation is believed to be a major mechanism for infection in the critically ill patient . Selective bowel decontamination (SBD) has been used to control gram-negative infections by eliminating these potentially pathogenic bacteria while preserving anaerobic and other less pathogenic organisms . Infection with gram-positive organisms and anaerobes in two multivisceral transplant patients during SBD led us to investigate the effect of SBD on gut colonization and translocation . Methods: Twenty-four rats received enteral polymixin E, tobramycin, amphotericin B, and parenteral cefotaxime for 7 days (PTA + CEF); 23 received parenteral cefotaxime alone (CEF), 19 received the enteral antibiotics alone (PTA), 21 controls received no antibiotics . Cecal homogenates, mesenteric lymph node (MLN), liver, and spleen were cultured . Results: Only 8% of the PTA + CEF group had gram-negative bacteria in cecal culture vs 52% CEF, 84% PTA, and 100% in controls . Log Enterococcal colony counts were higher in the PTA + CEF group (8.0 + 0.9) vs controls (5.4 + 0.4) P less than 0.01 . Translocation of Enterococcus to the MLN was significantly increased in the PTA + CEF group (67%) vs controls (0%) P less than 0.01 . SBD effectively eliminates gram-negative organisms from the gut in the rat model . Overgrowth and translocation of Enterococcus suggests that infection with gram-positive organisms may be a limitation of SBD. J Clin Microbiol, 1990 May, 28(5), 1051 - 3 Evaluation of a commercial microtiter system (MicroScan) using both frozen and freeze-dried panels for detection of high-level aminoglycoside resistance in Enterococcus spp; Fuller SA et al.; The MicroScan system was compared with agar dilution screen plates for the detection of high-level aminoglycoside resistance in 182 enterococcal isolates . Both the frozen Gram-Positive Combo Type 2 and the freeze-dried Type 5 panels were evaluated . The specificity of both panels for the detection of streptomycin and gentamicin resistance was 100% . However, the sensitivities for the detection of gentamicin and streptomycin resistance were 84 and 31%, respectively, for the Type 2 panels and 90 and 41%, respectively, for the Type 5 panels . The sensitivities of these panels for the detection of enterococcal high-level aminoglycoside resistance are inadequate for routine use. Infection, 1990 May-Jun, 18(3), 146 - 51 Infections after auxiliary partial liver transplantation . Experiences in the first ten patients; van Zeijl JH et al.; In ten auxiliary partial liver transplant recipients selective bowel decontamination (SBD) was used to reduce infections due to gram-negative microorganisms and fungi . During SBD no gram-negative infections occurred . Candida peritonitis was observed in one patient . After discontinuation of SBD serious infections of gram-negative origin did occur and three fungal infections were seen . SBD seems to have a favourable effect in reducing infections by gram-negative microorganisms and fungi . Most striking was the number of enterococcal infections that occurred . Five out of ten patients developed enterococcal infections which in two cases contributed to a fatal outcome . These infections occurred after increase of the number of enterococci in faeces and concomitant positive cultures of bile, ascites or wound drains . This increase could be due to the use of SBD . Also, the kind of biliary anastomosis may play an important role in the relatively high incidence of enterococcal infections . In the postoperative period, recurrence of hepatitis B infection in the liver graft was observed in all patients with cirrhosis due to this virus . Problems caused by other viral infections or protozoal infections remained limited in these ten patients. Biochimie, 1990 Apr, 72(4), 279 - 83 Efficient electrotransformation of Enterococcus hirae with a new Enterococcus-Escherichia coli shuttle vector; Solioz M et al.; In the present study, an Enterococcus-Escherichia coli shuttle vector, pC3, was constructed that allows efficient transformation by electroporation of Enterococcus hirae ATCC9790 . 5 x 10(6) transformants per microgram of plasmid DNA were obtained, using a commercial capacitor discharge device with an improved circuitry and a home-made electrode assembly, delivering pulses of 24 kV/cm across the cell suspension . The transformants were stable without selective pressure and plasmid DNA reisolated from transformed cells displayed no alterations in restriction enzyme analysis . Chromosomal DNA from E coli or E hirae, carried by pC3, was stably maintained in E hirae, making cloning and genetic manipulation in this organism feasible. J Antimicrob Chemother, 1990 Apr, 25(4), 551 - 60 Synergy between penicillin and gentamicin against enterococci; Winstanley TG et al.; The role of active uptake in aminoglycoside activity against penicillin-treated enterococci was studied by viable counts and ATP determinations . Penicillin and gentamicin gave synergistic bactericidal and post-antibiotic effects (PAEs) which were partially reduced by sodium azide, an electron transport inhibitor, and totally blocked in the presence of both sodium azide and EDTA, which chelates divalent cations . EDTA and gentamicin showed marked synergy in both 'killing curve' and PAE experiments . This synergy was completely inhibited by sodium azide . The data indicate that the activity of gentamicin against enterococci that have been damaged by penicillin or EDTA is energy-dependent . This is consistent with present theories of gentamicin uptake via transportation drive by a protonmotive force. South Med J, 1990 Apr, 83(4), 458 - 60 Gentamicin-resistant enterococcal endocarditis: the need for routine screening for high-level resistance to aminoglycosides; Libertin CR et al.; We have reported a case of high-level gentamicin-resistant enterococcal endocarditis as a complication of intravenous narcotic abuse . Because routine screening of enterococcal blood isolates for high-level aminoglycoside resistance was not done, the patient possibly received suboptimal therapy . This case amplifies the necessity of a systematic screening program for enterococcal blood isolates to detect high-level resistance to gentamicin and streptomycin in clinical laboratories. J Antimicrob Chemother, 1990 Mar, 25(3), 423 - 33 A randomized clinical study of cefoperazone and sulbactam versus gentamicin and clindamycin in the treatment of intra-abdominal infections; Jauregui LE et al.; This report summarizes the experience of investigators in four medical centres who compared the combination of cefoperazone/sulbactam against gentamicin/clindamycin in the treatment of intra-abdominal infections . One hundred and fifty-two patients were enrolled in the study and all were evaluable for safety and tolerance, 110 were evaluable for efficacy . Of the 76 patients (49 male, 27 female) treated with cefoperazone/sulbactam 66 (86.8%) were cured, five (6.6%) improved and five (6.6%) failed to respond to treatment . Of 34 patients treated with gentamicin/clindamycin, 21 (61.8%) were cured, four (11.8%) improved and nine (26.4%) failed . Cure rates for patients receiving cefoperazone/sulbactam were significantly higher than those of patients receiving gentamicin/clindamycin (P less than 0.006) . Failures in both groups were attributable in part to pseudomonal and enterococcal infection and abscess formation . The addition of sulbactam to cefoperazone rendered cefoperazone-resistant organisms susceptible to cefoperazone in 11 of the 76 cases (14.4%) and thus permitted treatment with this agent . The present study confirms the safety and clinical efficacy of cefoperazone/sulbactam and suggests that this combination is a viable alternative to an aminoglycoside plus clindamycin for intra-abdominal infections. J Reprod Med, 1990 Mar, 35(3 Suppl), 343 - 7 Ticarcillin/clavulanate in the treatment of pelvic infections; Lucas MJ et al.; Ticarcillin/clavulanate was used to treat 130 women with pelvic infections . The 129 who completed an initial course of treatment with ticarcillin/clavulanate were analyzed according to type and clinical severity of infection, and pretreatment and posttreatment endometrial bacteriology . There were 26 cases of pelvic inflammatory disease and 103 puerperal infections, 61 of which occurred in women who had delivered by cesarean section (46 elective with no antibiotic prophylaxis at the time of surgery) . Of the 129 patients treated, 124 were clinically cured, and one improved (97%) . There were four treatment failures, all of which were among a total of 20 cases classified as clinically severe . All the patients designated as treatment failures required prolonged treatment with other antibacterials to achieve a clinical cure, but a longer duration of treatment with ticarcillin/clavulanate might have effected a clinical resolution even in these cases . In vitro examination of endometrial isolates revealed a significant reduction of the minimum inhibitory concentrations (MICs) of beta-lactamase-producing bacteria with the addition of clavulanate to ticarcillin . The relationship of non-beta-lactamase-producing enterococci having relatively high MICs to clinical failure was examined. Eur J Clin Microbiol Infect Dis, 1990 Feb, 9(2), 80 - 9 The epidemiology of enterococci; Chenoweth C et al.; The enterococci are emerging as a significant cause of nosocomial infections, accounting for approximately 10% of hospital acquired infections . They are found as normal inhabitants of the human gastrointestinal tract, but may also colonize the oropharynx, vagina, perineal region and soft tissue wounds of asymptomatic patients . Until recently, evidence indicated that most enterococcal infections arose from patients' own endogenous flora . Recent studies, however, suggest that exogenous acquisition may occur and that person-to-person spread, probably on the hands of medical personnel, may be a significant mode of transmission of resistant enterococci within the hospital . The use of broad-spectrum antibiotics, especially cephalosporins, is another major factor in the increasing incidence of enterococcal infections . These findings suggest that barrier precautions, as applied with other resistant nosocomial pathogens, along with more judicial use of antibiotics may be beneficial in preventing nosocomial spread of resistant enterococci. Eur J Clin Microbiol Infect Dis, 1990 Feb, 9(2), 118 - 26 Therapy of enterococcal infections; Eliopoulos GM et al.; Because enterococci are typically tolerant of the bactericidal effects of cell wall-active antimicrobial agents, bactericidal therapy has required use of these agents in combination with aminoglycosides . For strains which do not demonstrate high-level aminoglycoside resistance, either streptomycin or gentamicin can be used in combination with penicillin, ampicillin or vancomycin . At some centers, as many as 50% of isolates display high-level gentamicin resistance . A minority of such isolates will not be highly streptomycin-resistant, and the latter drug can be used in combination with a cell wall-active drug . Optimal treatment of serious infections due to strains highly resistant to both streptomycin and gentamicin is unknown . While no agent is predictably bactericidal against such isolates, ampicillin, penicillin or vancomycin alone would be expected to cure some patients . Other drugs or drug combinations do not offer any predictable therapeutic advantages. Eur J Clin Microbiol Infect Dis, 1990 Feb, 9(2), 90 - 102 Movable genetic elements and antibiotic resistance in enterococci; Clewell DB; The enterococci possess genetic elements able to move from one strain to another via conjugation . Certain enterococcal plasmids exhibit a broad host range among gram-positive bacteria, but only when matings are performed on solid surfaces . Other plasmids are more specific to