title: Nosocomial outbreak of vancomycin-resistant Enterococcus faecium in a paediatric unit at a Turkish university hospital.
abstract: BACKGROUND
  Despite growing concern about vancomycin-resistant enterococci (VRE) as nosocomial pathogens, especially in the USA, they have been rarely isolated in Turkish hospitals. After initial description in 2001 of unrelated VRE isolates, we report now the molecular characterization of a nosocomial outbreak at the Akdeniz University Hospital, Antalya, Turkey.
  
  
  METHODS
  VRE isolates were from either clinical or rectal swab specimens. Identification, susceptibility testing and molecular characterization were performed according to standard techniques. Virulence genes (encoding aggregation substance, gelatinase, cytolysin, enterococcal surface protein and hyaluronidase) were sought by PCR.
  
  
  RESULTS
  Thirty-six VRE were isolated from 10 patients between June and October 2005 in the Department of Paediatrics. Six patients were only carriers, two had urinary tract infections and two had bloodstream infections. All isolates were Enterococcus faecium, of vanA genotype and belonged either to a main pulsotype (A) or to three minor pulsotypes (B, C and D). The epidemic strain A, found in eight patients, expressed high-level glycopeptide resistance (MIC of vancomycin 256 mg/L and MIC of teicoplanin 64 mg/L) and was of multilocus sequence typing sequence type (ST) 31, whereas the minor strain D, found in two patients, expressed heterogeneous glycopeptide resistance (MIC of vancomycin 8 to 256 mg/L) and was ST18. Strains B and C were only found in single patients either with strain A or alone. The two epidemic strains A and D were esp gene-positive. Their vanA genes were located on transposons similar to Tn1546, except for deletion of the transposition genes and the presence of IS1542, inserted upstream of the vanA operon, and IS1216, inserted at the 3' end of the vanX gene. VRE outbreak was contained by early identification and implementation of measures for patient isolation and of stringent hand and environmental disinfection policies.
  
  
  CONCLUSIONS
  This work underlines the emergence in Turkey of epidemic VRE clones that belong to the clonal complex-17 (CC-17) and that are esp-positive.
authors.affiliation: Medical Microbiology Department, Akdeniz University School of Medicine, Antalya, Turkey.
authors.forename: Ayla
authors.initials: A
authors.lastname: Ergani-Ozcan
authors.forename: Thierry
authors.initials: T
authors.lastname: Naas
authors.forename: Betil Ozhak
authors.initials: BO
authors.lastname: Baysan
authors.forename: Dilara
authors.initials: D
authors.lastname: Ogunc
authors.forename: Dilara
authors.initials: D
authors.lastname: Inan
authors.forename: Dilek
authors.initials: D
authors.lastname: Colak
authors.forename: Patrice
authors.initials: P
authors.lastname: Nordmann
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000494:pharmacology*; D002648:Child; D002675:Child, Preschool; D003428:Cross Infection / Q000453:epidemiology / Q000382:microbiology*; D004196:Disease Outbreaks; D016984:Enterococcus faecium / Q000187:drug effects*; D005260:Female; D016908:Gram-Positive Bacterial Infections / Q000453:epidemiology / Q000382:microbiology*; D006757:Hospital Units; D006785:Hospitals, University; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D014421:Turkey / Q000453:epidemiology; D014640:Vancomycin / Q000494:pharmacology*; D020713:Vancomycin Resistance
chemical_list: D000900:Anti-Bacterial Agents; D014640:Vancomycin