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      Molecular Characterization Of Vancomycin-Resistant Enterococcus faecalis Among Inpatients At Iranian University Hospitals: Clonal Dissemination Of ST6 And ST422


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          Over the past two decades, enterococci have emerged as an important opportunistic pathogen causing life-threatening infections in hospitals. The purpose of the present study was to examine the prevalence of genes encoding virulence factor and molecular characterization of vancomycin-resistant E. faecalis strains isolated from hospitalized patients in Isfahan, the central city of Iran.

          Patients and methods

          A total of 53 vancomycin-resistant E. faecalis isolates (VRE) obtained from clinical samples of hospitalized patients were characterized by phenotypic and genotypic methods, and 25 selected VRE isolates from internal and ICU wards were typed by multilocus sequence typing.


          The efa was the most prevalent virulence gene (100%) among isolates, followed by gelE (92.45%), asa1 (90.56%), ace (86.79%), esp (75.47%), cylA (39.62%), and hyl (18.86%). More than 80% of the isolates were HLGR. Multilocus sequence typing showed eight different sequence types including ST6, ST422, ST28, ST448, ST531, ST328, ST421, and ST495. STs were grouped into two clonal complex (CC) including CCA (ST6, ST422, ST448, ST531) and CCF (ST28, ST421) and two singletons (ST328, ST495).


          Our data indicated a high prevalence of virulence genes among STs described in this study. In addition, the molecular analysis demonstrated a relatively high genetic diversity among selected VRE strains from the ICU in comparison with the internal ward. Therefore, in order to prevent the colonization of virulent strains in the hospital environment, infection control procedures should be performed.

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          Most cited references39

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          Development of a multiplex PCR for the detection of asa1, gelE, cylA, esp, and hyl genes in enterococci and survey for virulence determinants among European hospital isolates of Enterococcus faecium.

          A multiplex PCR for the simultaneous detection of five virulence genes (asa1, gelE, cylA, esp, and hyl) in enterococci was developed. The presence of these genes was investigated in 153 clinical and 118 fecal Enterococcus faecium isolates from inpatients at an increased risk of developing infections (such as patients in intensive care units and hematology wards) from 13 hospitals in eight European countries. Of the 271 E. faecium isolates, 135 were vancomycin resistant E. faecium (VREF) isolates and 136 were vancomycin susceptible E. faecium (VSEF) isolates. Susceptibilities to ampicillin, gentamicin, streptomycin, vancomycin, teicoplanin, ramoplanin, quinupristin-dalfopristin, and linezolid were tested by the microdilution method. Overall, the prevalence of esp was significantly higher (P = 0.03) in clinical VREF isolates (92%) than in fecal VREF isolates (73%). In Italy, the prevalence of esp was significantly higher (P = 0.02) in VREF isolates (91%) than in VSEF isolates (68%), whereas in the United Kingdom, hyl was significantly more prevalent (P = 0.01) in VREF isolates (71%) than in VSEF isolates (29%). No significant differences were found for the other countries. Pulsed-field gel electrophoresis was used to check the clonality among the strains tested and showed the spread of two center-specific (esp-positive) VREF clones in Italy and one center-specific (hyl-positive) clone in the United Kingdom. These clones were resistant to ampicillin, gentamicin, and streptomycin. The multiplex PCR reported in this study is a convenient and rapid method for the simultaneous detection of the virulence genes asa1, gelE, cylA, esp, and hyl in enterococci. Molecular analysis showed the intrahospital spread of esp-positive VREF clones (in Italy) and hyl-positive VREF clones (in the United Kingdom); the role of hyl remains to be elucidated.
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            Multilocus sequence typing scheme for Enterococcus faecalis reveals hospital-adapted genetic complexes in a background of high rates of recombination.

            A multilocus sequence typing (MLST) scheme based on seven housekeeping genes was used to investigate the epidemiology and population structure of Enterococcus faecalis. MLST of 110 isolates from different sources and geographic locations revealed 55 different sequence types that grouped into four major clonal complexes (CC2, CC9, CC10, and CC21) by use of eBURST. Two of these clonal complexes, CC2 and CC9, are particularly fit in the hospital environment, as CC2 includes the previously described BVE clonal complex identified by an alternative MLST scheme and CC9 includes exclusively isolates from hospitalized patients. Identical alleles were found in genetically diverse isolates with no linkage disequilibrium, while the different MLST loci gave incongruent phylogenetic trees. This demonstrates that recombination is an important mechanism driving genetic variation in E. faecalis and suggests an epidemic population structure for E. faecalis. Our novel MLST scheme provides an excellent tool for investigating local and short-term epidemiology as well as global epidemiology, population structure, and genetic evolution of E. faecalis.
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              The multilocus sequence typing network: mlst.net

              The unambiguous characterization of strains of a pathogen is crucial for addressing questions relating to its epidemiology, population and evolutionary biology. Multilocus sequence typing (MLST), which defines strains from the sequences at seven house-keeping loci, has become the method of choice for molecular typing of many bacterial and fungal pathogens (and non-pathogens), and MLST schemes and strain databases are available for a growing number of prokaryotic and eukaryotic organisms. Sequence data are ideal for strain characterization as they are unambiguous, meaning strains can readily be compared between laboratories via the Internet. Laboratories undertaking MLST can quickly progress from sequencing the seven gene fragments to characterizing their strains and relating them to those submitted by others and to the population as a whole. We provide the gateway to a number of MLST schemes, each of which contain a set of tools for the initial characterization of strains, and methods for relating query strains to other strains of the species, including clustering based on differences in allelic profiles, phylogenetic trees based on concatenated sequences, and a recently developed method (eBURST) for identifying clonal complexes within a species and displaying the overall structure of the population. This network of MLST websites is available at

                Author and article information

                Infect Drug Resist
                Infect Drug Resist
                Infection and Drug Resistance
                25 September 2019
                : 12
                : 3039-3047
                [1 ]Department of Microbiology, School of Medicine, Isfahan University of Medical Sciences , Isfahan, Iran
                [2 ]Department of Pathobiology and Laboratory Sciences, North Khorasan University of Medical Sciences , Bojnurd, Iran
                [3 ]Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences , Isfahan, Iran
                Author notes
                Correspondence: Seyed Asghar Havaei Department of Microbiology, School of Medicine, Isfahan University of Medical Sciences , Hezar-Jerib Avenue, Isfahan81746 73461, IranTel +983137922478 Email havaei@med.mui.ac.ir
                Author information
                © 2019 Zalipour et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                : 30 May 2019
                : 05 September 2019
                Page count
                Figures: 1, Tables: 1, References: 46, Pages: 9
                Original Research

                Infectious disease & Microbiology
                enterococcus faecalis,virulence factors,vancomycin resistant,multilocus sequence typing,iran


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