First Glycopeptide-Resistant Enterococcus faecium Isolate from Blood Culture in Ankara, Turkey.

To the Editor: Glycopeptide-resistant enterococci infections are a major problem in hospitals. Infection or colonization by vancomycin-resistant enterococci was first reported in France (1) and the United Kingdom (2); since then, these organisms have been reported throughout the world. In Turkey, vancomycin and teicoplanin have been used to treat serious methicillin-resistant Staphylococcus aureus and ampicillin-resistant enterococci infections.

We describe the case of an acute myelocytic leukemia patient with vancomycin-resistant enterococci bloodstream infection. This is the first glycopeptide-resistant Enterococcus faecium isolate from our hospital and from Ankara, Turkey. The patient had not been cared for at another institution.

A 68-year-old man, hospitalized with acute myelocytic leukemia, had fever episodes during the neutropenia following three courses of remission-induction chemotherapy (daunorubicin+cytosine arabinoside). A combination of antibiotics including vancomycin, ceftazidime (sometimes imipenem), and amikacin was administered with different regimens during the 5 months of hospitalization. Blood, urine, and rectal swab cultures during this period were positive for different Enterobacteriaceae spp. but always negative for vancomycin-resistant enterococci. For long-term hospitalizations, our center routinely performs surveillance rectal swab cultures. At the end of month 5, E. faecium was isolated from the blood cultures, just 1 day before the patient's death.

The strain was identified by conventional methods, commercial automatic systems (API Strep-Biomerieux, France), and polymerase chain reaction. Susceptibility patterns showed that the isolate was resistant to all antibiotics except ciprofloxacin and levofloxacin. When the E-test was used, MIC levels for vancomycin, teicoplanin, ciprofloxacin, and levofloxacin were 256 [micro]g/mL, 64 [micro]g/mL, 0.75 [micro]g/mL, and 1.5 [micro]g/ mL, respectively. VAN-A1 and Van-A2 type resistance genes were detected by polymerase chain reaction. Hacettepe University microbiology laboratories confirmed these results (3,4).

After this strain was isolated, 1,266 stool and 176 rectal swab samples were taken from hospital personnel in three sessions [is greater than or equal to] 1 week apart, and patients were tested for vancomycin-resistant enterococci. Swab cultures from all environmental surfaces (bed rails, bedside commodes, carts, charts, doorknobs, faucet handles) were also examined. We injected all samples with 5% sheep blood agar with vancomycin (6 mg/L); vancomycin-resistant E. faecium was not identified in any sample.

This was the first case of high-level vancomycin-resistant enterococci with a class A phenotype isolated from a person in our hospital or in Ankara, Turkey. To prevent the organism's spread, we implemented the recommendations of the Hospital Infection Control Practices Advisory Committee (5).

Ahmet Basustaoglu,(*) Hakan Aydogan,(*) Cengiz Beyan,(*) Atilla Yalcin,* Serhat Unal([dagger])

(*) Gulhane Military Medical Academy, Etlik Ankara, Turkey; ([dagger]) Hacettepe University, Ankara, Turkey

References

(1.) Leclercq R, Derlot E, Duval J, Courvalin P. Plasmid-mediated resistance to vancomycin and teicoplanin in Enterococcus faecium. N Engl J Med 1988;319:157-61.

(2.) Uttley AH, George RC, Naidoo J, Woodford N, Johnson AP, Collins CH, et al. High level vancomycin-resistant enterococci causing hospital infection. Epidemiol Infect 1989; 103:173-81.

(3.) Dutka-Malen S, Evers S, Courvalin P. Detection of glycopeptide resistance genotypes and identification of the species level of clinically relevant enterococci by PCR. J Clin Microbiol 1995;33:24-7.

(4.) Handwerger S, Skoble J, Discotto LF, Pucci MJ. Heterogeneity of the VanA gene clusters in clinical isolates of enterococci from the northeastern United States. Antimicrob Agents Chemother 1995;39:362-8.

(5.) Hospital Infection Control Practices Advisory Committee (HICPAC). Recommendations for preventing the spread of vancomycin resistance. Infect Control Hosp Epidemiol 1995;16:105.