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Applied and Environmental Microbiology, December 2003, p. 7414-7419, Vol. 69, No. 12
0099-2240/03/$08.00+0 DOI: 10.1128/AEM.69.12.7414-7419.2003
Copyright © 2003, American
Society for
Microbiology. All Rights Reserved.
Natalia Vargas,1 Marco Luis Herrera,2 Álvaro Vargas,2 Magaly Caballero,3 and Fernando García1*
Centro de Investigación en Enfermedades Tropicales, Facultad de Microbiología, Universidad de Costa Rica,1 Hospital Nacional de Niños, San José,2 Programa de Investigación en Enfermedades Tropicales, Escuela de Medicina Veterinaria, Universidad Nacional, Heredia,Costa Rica3
Received 2 April 2003/ Accepted 10 September 2003
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Resistance to vancomycin and other glycopeptides is heterogeneous. Three phenotypes, VanA, VanB, and VanC, have been well described (9, 38), but three additional phenotypes, VanD, VanE, and VanG, have recently been reported (19, 22, 30, 34). Both vanA and vanB determinants are transferable by conjugation among enterococci, including E. faecalis, E. faecium, E. avium, and E. raffinosus (9, 20, 38). The vanA gene cluster is located on a mobile DNA element, Tn1546, and consists of seven genes denominated vanR, vanS, vanH, vanA, vanX, vanY, and vanZ (9, 38). The heterogeneity of Tn1546 has previously been reported (39), including the insertion of IS1251 in the vanSH intergenic region (24) and of IS1476 in the vanXY intergenic region (5). A similar gene structure has been described for the vanB determinant located on Tn1547 in E. faecalis V583 (20). In contrast, vanC1, vanC2, and vanC3 are normally occurring genes present in E. gallinarum, E. casseliflavus, and E. flavescens, respectively, and are considered not to be transferable (9, 38).
Supplementing animal food with antimicrobial agents to enhance growth has been a common practice for more than 30 years. This usage is estimated to constitute more than half the total antimicrobials used worldwide. Previous studies have shown that the use of antimicrobial growth promoters may select resistant bacteria among the normal intestinal flora of animals that can be transmitted to humans (2, 3, 6). Several studies in European countries indicate that the use of avoparcin as a growth promoter has contributed to the creation of a major reservoir of several species of Enterococcus carrying the vanA determinant in food animals and that vancomycin-resistant enterococci (VRE) can be transmitted from animals to humans (9). Avoparcin has never been approved for use in the United States by federal authorities. Although several studies have been conducted in industrialized countries of VRE in hospitals, communities, and food animals, little is known about the epidemiology and dissemination of VRE in developing countries. Notwithstanding the experiences in the United States and Europe, the use of avoparcin for growth promotion in poultry and pigs was unrestricted in Costa Rica until Roche voluntary withdrew avoparcin from the market by the first quarter of 2000. This study was undertaken to determine the occurrence of VRE in food animal settings in Costa Rica during 1998 and 1999, prior to the withdrawal of avoparcin from the market. The results presented in this paper show that the vanA determinant is predominant among enterococcal species from poultry and pigs, but not from cattle, a situation similar to that in European countries before the use of avoparcin was forbidden, and that food animals may represent an important reservoir of VRE in Costa Rica.
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Fecal samples.
For broilers, a total of 413 cloacal
samples were collected by using swabs during three different visits to
a national poultry slaughterhouse receiving chickens from all around
the country. The chickens were on average 5 to 6 weeks old. In
addition, 130 cecal samples were collected from adult dairy cows at
three different farms. A total of 350 cecal samples were collected from
swine at four different farms by using rectal swabs (Table
1). Swine fecal samples were collected from newly weaned (5 to 10 kg),
growing (20 to 60 kg), and finishing (60 to 100 kg) pigs, as well as
from gestating and lactating sows. An equal number of samples were
collected from each group of pigs at a particular farm. In all
samplings, animals were randomly selected from the entire flock or
herd. The number of samples collected from cattle and swine represented
approximately 5% in each herd, whereas those from poultry
represented approximately 2.5% of each flock. Samples from
poultry were collected during 1998, whereas samples from pigs and
cattle were collected during 1999. Precise information about avoparcin
use in the poultry flocks and swine herds sampled for this study was
not available. However, avoparcin was not used for the three bovine
herds sampled.
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TABLE 1. Isolation
of VRE from animal fecal samples in Costa Rica
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Determination of
MIC.
The MIC of vancomycin
(Sigma) was determined by the agar dilution method approved by the
NCCLS (32). Each isolate
was grown on blood agar plates without antibiotics for 18 h
at 35°C and suspended in sterile saline solution to a density
of 0.5 MacFarland standard. A 1:100 dilution from each suspension was
prepared in sterile saline solution. Ten microliters from each
dilution, containing approximately 104 CFU per ml, was
spotted on brain heart infusion agar plates containing different
concentrations of vancomycin. The inoculated plates were incubated in
the dark for 24 h at
35°C.
Other tests.
ß-Lactamase production and
high-level aminoglycoside resistance (HLR) to gentamicin and
streptomycin were assessed as described previously
(26,
27).
DNA
isolation and PCR analysis of van genotypes.
DNA was isolated by using a
previously described procedure
(21) and was stored at
-20°C until use. The van genotypes were
determined by PCR analysis by using the following primers
(21): vanA-F,
5'-GCTATTCAGCTGTACTC-3'; vanA-R,
5'-CAGCGGCCATCATACGG-3'; vanB-F,
5'-CATCGCCGTCCCCGAATTTCAAA-3';
vanB-R,
5'-GATGCGGAAGATACCGTGGCT-3';
vanC1-F, 5'-GGTATCAAGGAAACCTC-3';
vanC1-R, 5'-CTTCCGGCCATCATAGCT-3';
vanC2-F, 5'-CTCCTACGAATTCTCTTG-3';
and vanC2-R,
5'-CGAGCAAGACCTTTAAG-3'.
Amplification reactions were performed in a
solution containing 20 mM Tris-HCl (pH 8.3), 50 mM KCl, 1.5 mM
MgCl2, 0.01% (wt/vol) gelatin, and 0.05%
(wt/vol) Tween 20 supplemented with 100 µM (each)
deoxynucleoside triphosphate, 0.4 µM (each) primer, and 1.5 U
of recombinant Taq DNA polymerase (AmpliTaq; Roche Molecular
Systems, Inc., Branchburg, N.J.) in a final volume of 50 µl.
Each sample was subjected to 30 cycles, each consisting of 1 min at
94°C, 1 min at 56°C, and 1 min at 72°C, with a
final extension at 72°C for 5 min in a GeneAmp PCR System 2400
(Perkin-Elmer Corporation, Norwalk, Conn.). Amplification products were
visualized on 1.5% agarose gels stained with ethidium bromide.
The sizes of the amplification and digestion products were estimated by
comparison with DNA size markers (123-bp ladder; Sigma). All PCR
analyses were performed in duplicate. In order to analyze the
heterogeneity of the vanA determinant, the vanSH and
vanXY intergenic regions were amplified by PCR as previously
described (29). According
to this procedure, amplification products of 2,337 and 1,947 bp,
respectively, were expected when no insertion sequence elements were
inserted in the vanSH and vanXY intergenic regions.
Amplification products of a higher size are expected when insertion
sequence elements are inserted in these intergenic
regions.
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TABLE 2. Isolation
of VRE from poultry, swine, and cattle fecal samples in Costa Rica
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TABLE 3. Identification
of VRE isolates from poultry, swine, and bovine fecal samples
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16 µg/ml. The MIC
of vancomycin for all E. casseliflavus isolates
recovered from cattle was 8 µg/ml. The two S.
equinus isolates analyzed in this study required MICs of
vancomycin of >512 µg/ml. The MICs of vancomycin at
which 50% of the strains are inhibited (MIC50s) and
the MIC90s for the VRE isolates are shown in Table
4. The presence of the different van determinants was assessed by
PCR. The vanA determinant was observed among various
enterococcal species, including E. casseliflavus,
E. durans, E. faecalis, E.
faecium, E. gallinarum, and E.
hirae (Table
5). The vanA determinant was also observed in the two S.
equinus isolates recovered in this study. The vanA
genotype was detected in all isolates obtained from poultry samples
with a MIC of vancomycin of
128 µg/ml and in all swine
isolates with a MIC of
512 µg/ml but was not detected
among vancomycin-resistant E. casseliflavus isolates
of bovine origin. The vanA determinant was found in all
E. faecium isolates recovered in this study (Table
5). The diversity of the
vanA determinant of the isolates was assessed by the detection
of insertions of IS1251 in the vanSH intergenic
region and of IS1476 in the vanXY intergenic region.
However, in none of the 154 vanA+ isolates
recovered in this study were these insertions detected (data not
shown), since all amplification product sizes from the vanSH
and vanXY intergenic regions of these isolates were
approximately 2,340 and 1,950 bp, respectively. Amplification products
of similar size were also detected in E. faecium
strain A256. The vanC determinant was detected in 10 out of 69
(14.5%) isolates from swine samples, including two E.
casseliflavus (vanC-2) and eight E.
gallinarum isolates (vanC-1), and in all E.
casseliflavus (vanC-2) isolates from bovine samples
(Table 5). Interestingly,
the vanB genotype was not observed among the 185 isolates
analyzed in this
study. |
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TABLE 4. MICs
of vancomycin and percentage of VRE van genotypes isolated
from fecal samples from poultry, swine, and cattle that were
vanA or vanC
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TABLE 5. Distribution
of van determinants among enterococcal species of animal
origin
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E. faecium was the most frequently isolated VRE species, being predominant among the poultry and swine isolates, but it was not recovered from the bovine samples. E. casseliflavus was the only species obtained from bovine samples, but it was not found among the avian isolates. The second-most-frequently-isolated species from poultry and swine, respectively, were E. durans and E. faecalis. However, E. durans was not identified among the swine and bovine isolates. The distribution of the enterococcal species found among the different animal species correlates with previous reports, but some differences were observed (13-17, 28). In fact, E. faecium is the predominant species reported in fecal samples collected from poultry and swine, whereas E. hirae, a species recovered in this study only from swine samples, has been reported as a species frequently present in the feces of poultry (14, 28). In addition, it has been reported that in the feces of adult dairy cows there are hardly any enterococcal species present and that the main part of the flora consists of Streptococcus bovis (15, 17). However, in this study, we recovered E. casseliflavus vanC-2 isolates from the fecal bovine samples. Finally, E. cecorum, reported to be a predominant species in fecal samples from ruminant calves and pigs (14, 15, 16), was not recovered in the samples analyzed in this study, since this species requires CO2 for growth and does not grow on enterococcus-selective media. However, to our knowledge, no isolate of E. cecorum has been reported to show resistance to glycopeptides or to carry van determinants. Thus, the differences observed in the species recovered from the animals could be due to the isolation method.
The vanA determinant was detected among various
enterococcal species, including E. casseliflavus,
E. durans, E. faecalis, E.
faecium, E. gallinarum, and E.
hirae, as well as in S. equinus, supporting
the evidence that the vanA gene cluster located on mobile
elements is able to disseminate between different species. The
vanA determinant was detected mostly in isolates of poultry
and swine origin, but it was absent among the bovine isolates. All
isolates carrying the vanA determinant showed MICs of
vancomycin of
128 µg/ml, and most of the
vanA+ isolates from swine showed MICs of
vancomycin of
512 µg/ml. These data correlate well
with the use of avoparcin in Costa Rica as a growth promoter in poultry
and swine but not in cattle. Thus, whereas most of these species, with
the exceptions of E. faecalis and E.
faecium, are considered of reduced virulence for animals and
humans, they constitute an important reservoir for the vanA
determinant that can eventually be transmitted to enterococcal strains
colonizing the human gastrointestinal and genitourinary tracts. The
vanC determinant was detected in eight E.
gallinarum (vanC-1) and two E.
casseliflavus (vanC-2) isolates recovered from swine
samples and in all E. casseliflavus (vanC-2)
isolates from bovine samples. The vanB determinant was not
observed among the enterococcal isolates recovered in this study. As
has previously been reported, vanA-type resistance is widely
distributed and is by far the predominant type of resistance reported
in Europe. While vanB-type resistance is fairly common among
enterococcal isolates in the United States, vanA-type
resistance still predominates
(10). In addition, the
vanA gene cluster has been found among other gram-positive
bacteria, including the genera Streptococcus,
Lactococcus, Oerskovia, Arcanobacterium, and
Bacillus (9,
20,
38), and it can be
transferred by conjugation under laboratory conditions to
Streptococcus pyogenes, viridans group streptococci,
Listeria monocytogenes, and Staphylococcus aureus
(12,
33). In contrast, the
vanB determinant has been found primarily in E.
faecium and E. faecalis
(9,
20,
38), although a
vanB-related gene sequence has been found in Streptococcus
bovis (35). The
difference in the dissemination of these determinants may be related to
the observation that the vanA gene cluster is often located on
a Tn1546-like transposon, which can be part of a conjugative
plasmid (5,
9,
22,
23). Although the
vanB gene cluster may be carried on a plasmid, it is usually
on the chromosome, and its dissemination can occur by the transfer of
large genetic elements which contain the transposon Tn1547
(36,
37).
The heterogeneity of Tn1546 can be useful for epidemiological studies (39). In this work, the heterogeneity of the vanA gene cluster was assessed by the presence of insertions of IS1251 in the vanSH intergenic region (24) and of IS1476 in the vanXY intergenic region (5). However, these insertions were not detected among the 154 vanA+ isolates analyzed in this study or in vanA+ reference strain E. faecium A256. These results suggest either predominance of a single clone or a low discriminatory power for this typing strategy. Additional studies are presently being undertaken in our laboratory to characterize the vanA gene cluster in the animal isolates.
Two additional traits, ß-lactamase activity and HLR phenotype, were assessed among VRE isolates. ß-Lactamase was detected in only eight vanA+ isolates (4.3%), including six isolates from poultry and two isolates from swine. The HLR phenotype for streptomycin resistance was detected in 110 isolates (59.5%), all carrying the vanA determinant, whereas susceptibility to streptomycin was observed in 44 vanA+ isolates (23.8%) and in 31 isolates lacking vanA (16.7%). A single poultry E. durans vanA+ isolate showed the HLR phenotype for both gentamicin and streptomycin resistance, but no ß-lactamase activity was detected in this isolate. Thus, while ß-lactamase production and the HLR phenotype for gentamicin resistance are infrequent characteristics in VRE isolates analyzed in the study, the HLR phenotype for streptomycin resistance is a rather common trait among animal vanA+ VRE.
The use of subtherapeutic levels of antibiotics in animal husbandry as growth promoters constitutes a selective pressure for the prevalence and dissemination of resistance determinants among bacterial populations. Avoparcin, a glycopeptide with a chemical structure which is very similar to that of vancomycin or teicoplanin, had been widely used in several European Union and developing countries for animal growth promotion but had never been approved for use in United States. Due to its association with a high prevalence of VRE in different settings, the use of avoparcin was banned in all European Union countries in April 1997. In spite of the experiences in the United States and Europe, no ban has been imposed in Costa Rica on the use of avoparcin and other antibiotics for animal growth promotion. In fact, avoparcin was used in Costa Rica for several years, until the first quarter of 2000, when it was no longer available on the market. According to the register of the Ministry of Agriculture of Costa Rica, during 1999, 15,000 kg of Avotan100, containing 100 g of avoparcin in each kg of product, was imported to Costa Rica. Once avoparcin was withdrawn, a reduction in the prevalence and dissemination of VRE similar to that described by several studies performed in Denmark, Germany, The Netherlands, and Italy was expected. However, the ban of avoparcin as a growth promoter could not be immediately translated to a reduction in the prevalence of VRE in food animals. In fact, although the use of avoparcin was banned in Denmark in 1995, data from the Danish antimicrobial resistance monitoring program showed a marked reduction in VRE from broilers, but no significant change occurred in pigs (4, 7, 8). The persistence of VRE in pigs could be attributed to coselection resulting from continued use of tylosin, because genes encoding resistance to macrolides and glycopeptides are linked among isolates from pigs (1). Thus, genetic linkage and coselection could weaken the impact of the restrictive use of antibiotics on the prevalence and dissemination of antimicrobial resistance determinants in bacterial populations.
In conclusion, the vanA determinant is predominant among diverse enterococcal species from poultry and pigs but not from cattle, a situation similar to that in European countries before the use of avoparcin was banned. Food animals may represent an important reservoir for VRE in Costa Rica and appear to play an important role in the prevalence, acquisition, and dissemination of antibiotic resistance determinants.
We gratefully acknowledge D. Utzinger for her technical assistance, G. Bonilla and J. R. Molina for their assistance in the collection of the swine samples, and H. Raventós for critical reading of the manuscript.
Present
address: Instituto Costarricense de Acueductos y Alcantarillados,
Puntarenas, Costa Rica. ![]()
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