title: Multilevel population genetic analysis of vanA and vanB Enterococcus faecium causing nosocomial outbreaks in 27 countries (1986-2012).
abstract: Vancomycin-resistant Enterococcus faecium (VREfm) have been increasingly reported since the 1980s. Despite the high number of published studies about VRE epidemiology, the dynamics and evolvability of these microorganisms are still not fully understood. A multilevel population genetic analysis of VREfm outbreak strains since 1986, representing the first comprehensive characterization of plasmid content in E. faecium, was performed to provide a detailed view of potential transmissible units.
  
  
  
  From a comprehensive MeSH search, we identified VREfm strains causing hospital outbreaks (1986-2012). In total, 53 VanA and 18 VanB isolates (27 countries, 5 continents) were analysed and 82 vancomycin-susceptible E. faecium (VSEfm) were included for comparison. Clonal relatedness was established by PFGE and MLST (goeBURST/Bayesian Analysis of Population Structure, BAPS). Characterization of van transposons (PCR mapping, RFLP, sequencing), plasmids (transfer, ClaI-RFLP, PCR typing of relaxases, replication-initiation proteins and toxin-antitoxin systems, hybridization, sequencing), bacteriocins and virulence determinants (PCR, hybridization, sequencing) was performed.
  
  
  
  VREfm were mainly associated with major human lineages ST17, ST18 and ST78. VREfm and VSEfm harboured plasmids of different families [RCR, small theta plasmids, RepA_N (pRUM/pLG1) and Inc18] able to yield mosaic elements. Tn1546-vanA was mainly located on pRUM/Axe-Txe (USA) and Inc18-pIP186 (Europe) plasmids. The VanB2 type (Tn5382/Tn1549) was predominant among VanB strains (chromosome and plasmids).
  
  
  
  Both strains and plasmids contributed to the spread and persistence of vancomycin resistance among E. faecium. Horizontal gene transfer events among genetic elements from different clonal lineages (same or different species) result in chimeras with different stability and host range, complicating the surveillance of epidemic plasmids.
authors.affiliation: UCIBIO/REQUIMTE, Departamento de Ciências Biológicas, Laboratório de Microbiologia, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal.|Servicio de Microbiología, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain.
authors.forename: Ana R
authors.initials: AR
authors.lastname: Freitas
authors.affiliation: Servicio de Microbiología, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain.|CIBER en Epidemiología y Salud Pública (CIBER-ESP), Madrid, Spain.|Unidad de Resistencia a Antibióticos y Virulencia Bacteriana (RYC-CSIC), Madrid, Spain.
authors.forename: Ana P
authors.initials: AP
authors.lastname: Tedim
authors.affiliation: Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla (IDIVAL), Santander, Spain.
authors.forename: Maria V
authors.initials: MV
authors.lastname: Francia
authors.affiliation: Division of Food Microbiology, National Food Institute, Danish Technical University, Copenhagen V, Denmark.
authors.forename: Lars B
authors.initials: LB
authors.lastname: Jensen
authors.affiliation: UCIBIO/REQUIMTE, Departamento de Ciências Biológicas, Laboratório de Microbiologia, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal.
authors.forename: Carla
authors.initials: C
authors.lastname: Novais
authors.affiliation: UCIBIO/REQUIMTE, Departamento de Ciências Biológicas, Laboratório de Microbiologia, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal.
authors.forename: Luísa
authors.initials: L
authors.lastname: Peixe
authors.affiliation: Servicio de Microbiología, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain.
authors.forename: Antonio
authors.initials: A
authors.lastname: Sánchez-Valenzuela
authors.affiliation: Research group for Host-microbe Interactions, Department of Medical Biology, Faculty of Health Science, UiT - The Arctic University of Norway, Tromsø, Norway.|Norwegian National Advisory Unit on Reference Centre for Detection of Antimicrobial Resistance, Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway.
authors.forename: Arnfinn
authors.initials: A
authors.lastname: Sundsfjord
authors.affiliation: Research group for Host-microbe Interactions, Department of Medical Biology, Faculty of Health Science, UiT - The Arctic University of Norway, Tromsø, Norway.|Norwegian National Advisory Unit on Reference Centre for Detection of Antimicrobial Resistance, Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway.
authors.forename: Kristin
authors.initials: K
authors.lastname: Hegstad
authors.affiliation: Division of Nosocomial Pathogens and Antibiotic Resistance, Department of Infectious Diseases, Robert Koch Institute, Wernigerode Branch, Wernigerode, Germany.
authors.forename: Guido
authors.initials: G
authors.lastname: Werner
authors.affiliation: National Medicines Institute, Warsaw, Poland.
authors.forename: Ewa
authors.initials: E
authors.lastname: Sadowy
authors.affiliation: Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark.
authors.forename: Anette M
authors.initials: AM
authors.lastname: Hammerum
authors.affiliation: Centre de Recerca en Sanitat Animal (CReSA), UAB-IRTA, Campus de la Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Lourdes
authors.initials: L
authors.lastname: Garcia-Migura
authors.affiliation: Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Rob J
authors.initials: RJ
authors.lastname: Willems
authors.affiliation: Servicio de Microbiología, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain.|CIBER en Epidemiología y Salud Pública (CIBER-ESP), Madrid, Spain.|Unidad de Resistencia a Antibióticos y Virulencia Bacteriana (RYC-CSIC), Madrid, Spain.
authors.forename: Fernando
authors.initials: F
authors.lastname: Baquero
authors.affiliation: Servicio de Microbiología, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain mariateresa.coque@salud.madrid.org teresacoque@gmail.com.|CIBER en Epidemiología y Salud Pública (CIBER-ESP), Madrid, Spain.|Unidad de Resistencia a Antibióticos y Virulencia Bacteriana (RYC-CSIC), Madrid, Spain.
authors.forename: Teresa M
authors.initials: TM
authors.lastname: Coque
mesh_terms: D001426:Bacterial Proteins / Q000235:genetics*; D001430:Bacteriocins / Q000032:analysis; D019729:Carbon-Oxygen Ligases / Q000235:genetics*; D003428:Cross Infection / Q000453:epidemiology / Q000382:microbiology; D004251:DNA Transposable Elements; D004196:Disease Outbreaks; D016521:Electrophoresis, Gel, Pulsed-Field; D016984:Enterococcus faecium / Q000145:classification* / Q000235:genetics / Q000302:isolation & purification; D022761:Gene Transfer, Horizontal; D014644:Genetic Variation; D005828:Genetics, Population; D005838:Genotype; D014943:Global Health; D016908:Gram-Positive Bacterial Infections / Q000453:epidemiology* / Q000382:microbiology; D006801:Humans; D058885:Multilocus Sequence Typing; D010957:Plasmids / Q000032:analysis; D065507:Vancomycin-Resistant Enterococci / Q000145:classification* / Q000235:genetics / Q000302:isolation & purification; D037521:Virulence Factors / Q000235:genetics
chemical_list: D001426:Bacterial Proteins; D001430:Bacteriocins; D004251:DNA Transposable Elements; C071437:VanA ligase, Bacteria; C079913:VanB protein, Enterococcus; D037521:Virulence Factors; D019729:Carbon-Oxygen Ligases