This document discusses a study on the prevalence of vancomycin resistant enterococcal species (VRE) in clinical isolates from a tertiary care hospital in Ahmedabad, India from July 2015 to October 2016. The study found that 8.88% of Enterococcus isolates were resistant to vancomycin. Of the VRE isolates identified, 80.5% were Enterococcus faecium. VRE isolation was highest from urine samples at 55%. The results indicate an increasing prevalence of VRE in this region, highlighting the need for prudent antibiotic use and infection control practices.

1. PREVALENCE OF VANCOMYCIN RESISTANT
ENTEROCOCCAL SPECIES (VRE) IN VARIOUS
CLINICAL ISOLATES AT TERTIARY CARE
HOSPITAL, AHMEDABAD

2. INTRODUCTION
• Enterococci, leading causes of nosocomial
bacteremia, surgical wound infection, and urinary
tract infection, are becoming resistant to many and
sometimes all standard therapies .
• Prevalence of vancomycin resistant enterococci (VRE)
has dramatically increased worldwide. Emergence of
vancomycin resistant enterococci is of great concern
because of its epidemic potential and scanty
therapeutic options.

3. AIM
Enterococci have become prominent cause of
nosocomial infection as a result of their
multiple antibiotic resistance. Here the
present study was undertaken to
determine the prevalence of vancomycin
resistant enterococci isolated from various
clinical specimens which pose as an emerging
health risk.

4. MATERIALS AND METHODS
• The study conducted over a period from July
2015 to October 2016 in department of
Microbiology, B.J.Medical College, Ahmedabad.
• Enterococcal strains were isolated from various
clinical samples (urine, blood, swab, CSF, body
fluids and others), total 50,483. Identification of
enterococci was based on their growth
characteristics on blood agar, chocolate agar,
nutrient agar, gram staining, catalase reaction,
ability to grow in 6.5% NaCl broth & bile esculin
hydrolysis ( standard biochemical methods).

5. MATERIALS AND METHODS
• Antibiotic sensitivity test was performed by
modified Kirby-Bauer disc diffusion method
and subjected to VRE screening by
vancomycin (30mcg) antimicrobial disc and
also screened for High Level Aminoglycoside
Resistance (HLAR), and later confirmed by
epsilometer strip (E-strip) minimum
inhibitory concentration (MIC) test for
vancomycin.
.

6. Biochemical reactions positive
Bile Esculin
positive
Raffinose
sugar
positive
Arabinose
sugar
positive
PYR
reagent

7. RESULTS AND DISCUSSION
DISTRIBUTION OF ENTEROCOCCUS SPP.
Enterococcus spp .
405
E. faecium
279 (68.88%) )
E.faecalis
118 (29.13%)

8. ISOLATION OF ENTEROCOCCUS spp. FROM
CLINICAL SPECIMENS
Urine, 55%Blood, 33%
CSF, 3%
Pus, 2%
Swab, 4%
Others, 3%
Above diagram shows that highest isolation of
Enterococci were from urine (55%), followed by
blood (33%) and swab(4%).

9. ATCC ENTEROCOCCUS 29212 E-TEST
E. FECALIS ATCC 29212
Sensitivity of vancomycin by E-Strip with ATCC E.FECALIS 29212.
MIC value (S ≤4mcg/ml, I 8 -16mcg/ml, R≥32mcg/ml) as per CLSL guidline.
(S-susceptible ,I-intermediate, R- resistant)

10. VRE by E-TEST
Minimum inhibitory concentration (MIC) of Vancomycin by E-test with a
concentration range 0.016-256 mcg/ml, (HiMedia, India) . The isolated VRE
MIC >256 ug/ml was found.(resistant breakpoint is ≥ 32 ug/ml as per CLSI
creteria.

11. ANTIMICROBIAL SUSCEPTIBILITY PATTERN OF
ENTEROCOCCUS SPP
77 80.2
67 62.8
28.4
84.5
39
50.5
25.5 25
57.7
8.88 1.92 0
0
20
40
60
80
100
120
Sensitive Resistant

12. RESULT AND DISCUSSION
• Graph shows that out of 405 enterococci,369(91.12%) isolates
were sensitive to vancomycin and 36(8.88%) were resistant to
vancomycin. So, prevalence of vancomycin resistant
enterococci (VRE) was 8.88%. The vancomycin MIC of
enterococci isolates ≥ 256 mcg/ml by E-strip and among VRE,
29(80.5%) E.faecium was Indentified.
• Out of 405 enterococci 233 (57.7%) show resistant to high level
Gentamycin (HLAR) but out of 36 VRE, 7 (19.44%) HLAR were
also seen.
• Out of 36 VRE, 15(41.66%) were resistant and 21(58.33%) were
sensitive to Teicoplanin, so they would be of VanA and VanB
phenotype respectively.
• All isolates were sensitive to Linezolid.

13. RESULT AND DISCUSSION
• Same study was done Western, India by Modi
G.B., et al. (2012), according to them 4%
enterococci isolates were resistant to
Vancomycin by disc diffusion and 1.2%
showed intermediate resistance and 2.8% high
level resistance to vancomycin by MIC
according to CLSI guidelines.
• Another study was done in northern india by
Mathur P.,et al.(2003) , Vancomycin resistance
was found in 1% isolates of enterococci.

14. Role of the Microbiology Laboratory
in the Detection, Reporting, and Control of VRE
• The microbiology laboratory is the first line of
defence against the spread of VRE in the hospital.
• The laboratory’s ability to promptly and accurately
identify Enterococci and detect Vancomycin
resistance is essential for recognizing VRE
colonization and infection and avoiding complex,
costly containment efforts that are required when
recognition of the problem is delayed.
• In addition, cooperation and communication
between the laboratory and the infection-control
program will facilitate control efforts.

15. PREVENTIVE & CONTROL
Early detection
Strict antibiotics policy
Timely implementation of strict infection
control practices
antibiotic resistance surveillance
programs

16. CONCLUSION
• The finding of this study can serve as an alert to the
clinician for emergence of infection by VRE and it can
encourage the implementation of appropriate
infection control measure for and judicious use of
Vancomycin in order to prevent rise in VRE
prevalence and also to all laboratories should have
effective detection methods which can be helpful in
treatment of VRE.

17. REFERENCES
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enterococcus: An Emerging nosocomial pathogen. Indian J Med Microbiol 2009 ;27:301-5.
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faecal is at a tertiary care centre of northern India. Indian J Med Res 2003; 118 : 25-
• A De, A Bindlish, S Kumar, M Mathur
Vancomycin resistant enterococci in a tertiary care hospital in Mumbai,Department of
Microbiology, L.T.M. Medical College, Sion, Mumbai - 400 022, India
• CDC. Nosocomial enterococci resistant to vancomycin—United States, 1989–1993.
MMWR,1993;42:597–9.
• Modi G.B., et al. (2012) Prevalenace of Vancomycin Resistant Enterococci in Tertiary Care
Hospital, Western, India. International Journal of Microbiology Research, ISSN: 0975-5276 &
E-ISSN:0975-9174, Volume 4, Issue 2, pp.-182-185