A SilencedvanAGene Cluster on a Transferable Plasmid Caused an Outbreak of Vancomycin-Variable Enterococci
ABSTRACTWe report an outbreak of vancomycin-variablevanA+enterococci (VVE) able to escape phenotypic detection by current guidelines and demonstrate the molecular mechanisms forin vivoswitching into vancomycin resistance and horizontal spread of thevanAcluster. Forty-eightvanA+Enterococcus faeciumisolates and oneEnterococcus faecalisisolate were analyzed for clonality with pulsed-field gel electrophoresis (PFGE), and theirvanAgene cluster compositions were assessed by PCR and whole-genome sequencing of six isolates. The susceptible VVE strains were cultivated in brain heart infusion broth containing vancomycin at 8 μg/ml forin vitrodevelopment of resistant VVE. The transcription profiles of susceptible VVE and their resistant revertants were assessed using quantitative reverse transcription-PCR. Plasmid content was analyzed with S1 nuclease PFGE and hybridizations. Conjugative transfer ofvanAwas assessed by filter mating. The only genetic difference between thevanAclusters of susceptible and resistant VVE was an ISL3-family element upstream ofvanHAX, which silencedvanHAXgene transcription in susceptible VVE. Furthermore, the VVE had an insertion of IS1542betweenorf2andvanRthat attenuated the expression ofvanHAX. Growth of susceptible VVE occurred after 24 to 72 h of exposure to vancomycin due to excision of the ISL3-family element. ThevanAgene cluster was located on a transferable broad-host-range plasmid also detected in outbreak isolates with different pulsotypes, including oneE. faecalisisolate. Horizontally transferable silencedvanAable to escape detection and revert into resistance during vancomycin therapy represents a new challenge in the clinic. Genotypic testing of invasive vancomycin-susceptible enterococci byvanA-PCR is advised.