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Background  Vancomycin-resistant isolates of  E. faecalis  and  E. faecium  are of special concern and patients at risk of acquiring a VRE colonization/infection include also intensively-cared neonates. We describe here an ongoing high prevalence of VanB type  E. faecium  in a neonatal ICU hardly to identify by routine diagnostics.    Methods  During a 10 months’ key period 71  E. faecium  isolates including 67  vanB -type isolates from 61 patients were collected non-selectively. Vancomycin resistance was determined by different MIC methods (broth microdilution, Vitek® 2) including two Etest® protocols (McFarland 0.5/2.0. on Mueller-Hinton/Brain Heart Infusion agars). Performance of three chromogenic VRE agars to identify the  vanB  type outbreak VRE was evaluated (Brilliance TM  VRE agar, chromID TM  VRE agar, CHROMagar TM  VRE). Isolates were genotyped by  Sma I- and  Ceu I-macrorestriction analysis in PFGE, plasmid profiling,  vanB  Southern hybridisations as well as MLST typing.    Results  Majority of  vanB  isolates (n = 56, 79%) belonged to a single ST192 outbreak strain type showing an identical PFGE pattern and analyzed representative isolates revealed a chromosomal localization of a  vanB2 -Tn 5382  cluster type. Vancomycin MICs in cation-adjusted MH broth revealed a susceptible value of ≤4 mg/L for 31 (55%) of the 56 outbreak VRE isolates. Etest® vancomycin on MH and BHI agars revealed only two  vanB  VRE isolates with a susceptible result; in general Etest® MIC results were about 1 to 2 doubling dilutions higher than MICs assessed in broth and values after the 48 h readout were 0.5 to 1 doubling dilutions higher for  vanB  VRE. Of all  vanB  type VRE only three, three and two isolates did not grow on Brilliance TM  VRE agar, chromID TM  VRE agar and CHROMagar TM  VRE, respectively. Permanent cross contamination via the patients’ surrounding appeared as a possible risk factor for permanent VRE colonization/infection.    Conclusions  Low level expression of  vanB  resistance may complicate a proper routine diagnostics of  vanB  VRE and mask an ongoing high VRE prevalence. A high inoculum and growth on rich solid media showed the highest sensitivity in identifying  vanB  type resistance.

antimicrobial resistance and infection control

Vancomycin-resistant vanB-type Enterococcus faecium isolates expressing varying levels of vancomycin resistance and being highly prevalent among neonatal patients in a single ICU