To treat these conditions, oral antibiotic therapy is given with proper local wound care and sometimes the pump is also removed. • Corticosteroids use in COVID-19 may increase the risk of bacterial co-infection. Although the mechanism of action of FMT is far from clear, it is proposed that restoring the intestinal microbiota to a prior, healthier state helps to counterbalance the CDI. and Citrobacter spp., and MDR in Pseudomonas aeruginosa, Acinetobacter spp., and Stenotrophomonas maltophilia.11 Across ICUs, the most important resistant microorganisms in the ICU are currently methicillin-resistant Staphylococcus aureus, (MRSA) and vancomycin-resistant enterococci (VRE). In spite of this potential wekaness, the APACHE-II score has outlasted earlier criticism of not being specific enough for grading IAI. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. Methicillin Resistant Staphylococcus Aureus, Microbiologic Considerations in the Intensive Care Patient, Principles of Antibiotic Prescription in Intensive Care Unit Patients and Patients With Acute Renal Failure, Hunter's Tropical Medicine and Emerging Infectious Disease (Ninth Edition), Understanding, Controlling, and Preventing Infectious Diseases, Principles and Practice of Pediatric Infectious Diseases (Fourth Edition), Computer-Based Approaches to Improving Healthcare Quality and Safety at LDS Hospital, Clinical Decision Support (Second Edition), Current and Emerging Technologies for the Diagnosis of Microbial Infections, Gaia, Casati, & Tonolla, 2011; Lasch et al., 2014; Rezzonico, Vogel, Duffy, & Tonolla, 2010, Dieckmann, Helmuth, Erhard, & Malorny, 2008, Cherkaoui et al., 2010; Dieckmann et al., 2008; Lartigue et al., 2009, 2011; Williamson et al., 2008, Emonet, Shah, Cherkaoui, & Schrenzel, 2010; Murray, 2010, Ghyselinck, Van, Hoste, Heylen, & de, 2011; Tanigawa, Kawabata, & Watanabe, 2010, Use and Evaluation of Vancomycin Serum Drug Level, Decision Making in Medicine (Third Edition), Pediatric Gastrointestinal and Liver Disease (Sixth Edition), Assessment of Severity and Prognosis in Surgical Patients with Secondary Peritonitis, These conditions have differences in management and outcome. So as to treat this infection, she was treated with amikacin i.v. This study confirmed the multi-antibiotic resistant in bacterial bioaerosol in a landfill and in the surrounding area. Multi-resistant Gram-negative bacilli (MRGN) Carbapenemase-producing Enterobacterales (formerly known as Carbapenemase-producing Enterobacteriaceae) Candida auris; Prevention. This procedure increases the morbidity, hospitalization time, and cost (Boviatsis et al., 2004). Meta-analysis of case reports and clinical trials have demonstrated that more than 90% of patients with rCDI who have failed multiple courses of antibiotics can be cured with a single FMT.13,29 In the first randomized controlled trial of FMT for rCDI, van Nood et al. Sequence-based methods such as single- or multi-locus sequence analysis (MLSA, MLST, spa-typing) (de Bruijn, 1992; Killgore et al., 2008) have also been described. • Review novel multi-drug resistant organisms (N-MDROs) • Describe the epidemiology of and response efforts to N-MDROs • Discuss the role of infection preventionists in detecting, reporting, and containing novel MDROs 1. Especially alarming is the rapid global spread of multi- and pan-resistant bacteria (also known as “superbugs”) that cause infections that are not treatable with existing antimicrobial medicines such as antibiotics. Clostridium Difficile. You just studied 22 terms! Potential for the emergence of multi-resistant bacteria is high, with the concomitant contamination of adjacent natural aquatic habitats used for irrigation and drinking water, impairing in turn human health system. The global problem of antibiotic resistance is fast becoming one of the major scientific issues of modern times. These infection symptoms are local inflammation and intraoperative traces of infection. Another matter that caught our attention was their usefulness for individual prognosis and for decision making for relaparotomy. Even within these defined categories there may be differences. Multi-resistant organisms (MROs) are bacteria that are not destroyed by a number of different antibiotics. Drug resistant and multidrug resistant bacteria have emerged as major concerns both inside and outside the hospital environment. The place around the pump showed the sign of local inflammation and serous discharge. During the validation process of this version, all 12 physiological measurements were available for only 87% of the 5,815 patients studied. coli Nissle 1917” are still being studied.3, In modern history, the first documented use of feces for the treatment of a specific disease was in 1958. Patient-specific parameters such as renal function, age, weight, site of infection, comorbidities, and route of administration should be included in VSDL evaluations (see Use and Evaluation of Serum Drug Levels for more details). Bacteria that are resistant to many antibiotics are known as multi-resistant organisms (MRO). • MDROs were detected from 28% (13/47) among patients with culture data. Multi-drug resistant organisms present significant clinical, and infection prevention and control challenges in health care provider settings. Serial dilutions of the water and sediment samples were carried out in sterile physiological solution (0.9 g/L NaCl). �����{W_Pe΋�k��M-5��Q���r��;rN�)���+�T��ٱ%�i��. Short-term therapy is not likely to require VSDL monitoring unless renal function is impaired. To address this issue, we automated a MRSA risk stratification algorithm and send alerts to notify nurses and infection control practitioners when high-risk patients are admitted and need to be tested for MRSA carriage (Evans 2008). Global action plan on antimicrobial resistance. Patients receiving continuous renal replacement therapy (CRRT), hemodialysis, or other renal alteration therapies should be evaluated individually. The Multi-Drug Resistant Organism Network will form the basis of practice-changing studies in antimicrobial resistance for years to come. A healthcare-acquired-IAI, for example, has a worse prognosis than a community-acquired one, due to the underlying health status and the likelihood of infection by multi-drug resistant organisms.20–21. Pump was cleaned and disinfected thoroughly with povidone-iodine solution and vancomycin solution and then placed again in deeper position. endobj Not all patients operated on for IAI are sent to ICUs, so in this scenario, the measurement of all variables is improbable. Multidrug-resistant (MDR) Gram-negative bacteria (GNB) are bacteria (or germs) that remain susceptible to only one or two antibiotics. Jane D. Siegel, in Principles and Practice of Pediatric Infectious Diseases (Fourth Edition), 2012, Guideline for Disinfection and Sterilization in Health-Care Facilities, 2008, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007, Management of Multi-Drug Resistant Organisms (MDROs) in Healthcare Settings, 2006, Guidelines for Environmental Infection Control in Health-Care Facilities, 2003, Guidelines for Hand Hygiene in Healthcare Settings, 2002, Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011, Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 2009, Guideline for Preventing Healthcare-Associated Pneumonia, 2003, Guideline for the Prevention of Surgical Site Infection, 1999, Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, 2011, R. Scott Evans, in Clinical Decision Support (Second Edition), 2014. 2 and . The library-based approach is the most commonly used method for the identification of bacteria and fungi on the species level and has been adopted by several researchers to distinguish strains on subspecies level. <> In one of the cases, a lady was having cerebral palsy at the age of 26. Multi-resistant organisms (MROs) are micro -organisms (usually bacteria) that are not susceptible to multiple classes of antimicrobial agents. While it isn’t a massive threat to humanity currently, this bacteria will become an increasing threat over the next few years. These researches have shown that there is a sign that bacteriophages will be able to restore antibiotic sensitivity in antibiotic resistant bacteria, such as multidrug-resistant P. aeruginosa 12,13. Described as ‘opportunistic’ because it primarily affects humans that are already critically ill, this bacteria can cause serious complications in the treatment of AIDS, cancer or cystic fibrosis patients. Other risk factors are recent surgery and previous multi-drug–resistant organism (MDRO) colonization.7–9 Infections resulting from MDRO in the ICU can affect up to 50% of patients10 and are associated with high mortality.11,12. A number of drug resistant organisms, including Enterobacteriaceae (CRE), Campylobacter and Candida, show continually increasing levels of resistance. Further, genetic mutations within the organism have contributed to increased drug resistance in N. gonorrhoeae. After 6 months till now, he has refilled the pump twice and the port of pump was explanted through the surgical scars; because of this, the patient has become febrile. When using vancomycin empirically, it is important to consider the probable organism, local susceptibility patterns, and nationally recognized guidelines. Hygiene interventions with decontamination or separation of patients carrying MDRs are pertinent measures to diminish the risk of transmission of MDRs to other patients. The length of optimal treatment is uncertain; many authorities treat for a minimum of 4 weeks after clinical resolution (Fig. A recent article underlines that AMR is one of the greatest challenges for public health and highlights the high impact of healthcare-associated infections (HAIs) due to antimicrobial resistant bacteria in terms of number of cases, attributable deaths, and disability-adjusted life-years. Early detection of multi-drug resistant organisms (MDRO) carriage upon admission could allow timely implementation of infection control measures and the appropriate selection of empiric antimicrobial therapy [].Few nationwide surveys investigated real-life MDRO screening practices upon admission [2,3,4,5].In 2010, an unpublished survey conducted in Swiss intensive care units (ICUs) … Welcome to the NCBI National Database of Antibiotic Resistant Organisms (NDARO), a collaborative, cross-agency, centralized hub for researchers to access AMR data to facilitate real-time surveillance of pathogenic organisms. When a single bacterium is resistant to more than one antibiotic it is said to be Some examples are; MRSA (Methicillin-Resistant Staphylococcus Aurous); VRE (Vancomycin-resistant enterococci), However, resistance has been heavily … and ciprofloxacin orally. Gram-negative bacteria usually live in the gut (or in the environment), where they do no harm, but can appear and cause infection at other body sites that normally lack any bacteria, for example in the bladder or blood. Serious infections caused by Gram-positive bacteria are currently difficult to treat because many of these pathogens are now resistant to standard antimicrobial agents. in 2010.30 He reported on the successful treatment of rCDI in a 2-year-old girl using donor feces infused via a nasogastric (NG) tube. Vancomycin-resistant Enterococcus (VRE) is an example of a GP MDRO that commonly causes disease in the ICU. Each day, infection control personnel at all hospitals receive an e-mail report that contains a list of all patients admitted to their hospital with previous MRSA or VRE. Making multi resistant bacteria susceptible to already existing antibiotics (again) is an emerging approach which gains traction through new insights on the molecular level. S. capitis, E. coli, and P. mirabilis can be found in blood, S. epidermidis in CSF, and multi-drug-resistant organism such as methicillin-resistance S. aureus, S. epidermidis, P. aeruginosa, and enterobacteriacea (E.coli, K. pneumoniae and M. morgagnii) can be seen on catheter tips (Stempien and Tsai, 2000). These bacteria have become resistant to a large number of antibiotics, including carbapenems and third generation cephalosporins – the best available antibiotics for treating multi-drug resistant bacteria. They pose very little risk to healthy people and some are carried as part of the normal bacteria in their bodies or on their skin. 1. World Health Organization. Antibiotic resistance often occurs following frequent antibiotic use or frequent exposure to a health care setting. Studies involving both specific bacterial combinations and, surprisingly, even nonbacterial components of the stool have also effectively treated rCDI.36, Rodolfo Leonel Bracho-Riquelme, in Microbiology for Surgical Infections, 2014, Prognosis in IAI is difficult to establish because it includes a variety of different pathological conditions.18 The spectrum of IAI includes primary peritonitis, secondary peritonitis, tertiary peritonitis and intra-abdominal abscesses as well as focal infections such as diverticulitis, appendicitis and cholangitis-cholecystitis.19 These conditions have differences in management and outcome. C. difficile (Clostridium difficile) C. difficile is a pathogen infecting the colon of patients following antibiotic treatment. published on their use of fecal enemas to treat pseudomembranous colitis.4 Although at the time, the underlying pathogen, Clostridium difficile, was unknown to them, their treatment was a success. Prevention is hand hygiene. Further serious complications include infection, overdose, skin necrosis, tissue damage, sensitivity reactions, CSF leak, and even epileptic seizures and acute withdrawal syndrome (Kofler et al., 1994; Siegfried et al., 1992). This resistance develops when potentially harmful bacteria change in a way that reduces or eliminates the effectiveness of antibiotics. Culture of AB multi-resistant bacteria and isolation of pure cultures were carried out on Nutrient Agar plates (Himedia, India), with an additional 1% NaCl (purum, Himedia, India). ESBLs) recent international travel to areas with a high prevalence of multidrug-resistant Gram-negative organisms (eg within 6 months) prolonged hospitalisation; residence in a long-term care facility Organisms that display multidrug resistance can be pathologic cells, including bacterial and neoplastic cells. In case of undernourished patients, because of poor nutrition healing is impaired due to which wounds break down and the infection spreads (Stallings et al., 1993a, b). Also, the MDRO alerts are a good example of a new framework we have developed that is dependent on the clinical use of the enterprise-wide data in the EDW (Evans et al., 2012). As to the decision for relaparatomy, this is a medical act, based on experience and good medical judgment. Susceptibility to fluoroquinolones is variable. VSDL monitoring commonly consists of trough levels and occasionally peak levels. In contrast, a number of reports have demonstrated the suitability of MALDI-TOF MS for typing applications. It is believed that Nefertiti and her Pharaoh husband Akhenaten both died from tuberculosis in around 1330 BC, and documents remain from ancient Egypt that talk of the dangers of the disease. The emergence of multiple antibiotic resistant strains in the environment, particularly in a densely populated market is a problem to the infection management. The extent of the resistance will influence the control measures required to prevent spread and the treatment options available in the event of infection. Other clinical causes of these parameters should be considered. These include organisms that are intrinsically resistant and readily acquire additional resistance mechanisms and become multi-drug resistant (eg, carbapenem-resistant Acinetobacter). For clinical examination, the pump puncture was avoided to prevent the possibility of iatrogenic contamination. The limits of the taxonomic resolution of MALDI-TOF MS profiling may largely be due to the nature of the particular bacterium profiled, as some bacteria are remarkably different genetically at the subspecies levels, whereas others are almost indistinguishable (Ghyselinck, Van, Hoste, Heylen, & de, 2011; Tanigawa, Kawabata, & Watanabe, 2010). APACHE,7 SAPS10 and SOFA16 were not intended for individual outcome estimation or decision making, but for classifying groups of patients to compare outcomes in clinical studies. There are two different species of Enterococcus known as frequent pathogens in humans: Enterococcus faecium and Enterococcus faecalis. The focus of this chapter is on the current literature and recent developments of MALDI-TOF MS as a tool for strain typing of Gram-positive and Gram-negative bacteria as well as certain fungi. She was suffering from pharmaceutically intractable spasticity located in the lower extremities from the age of 17. This course details the clinical significance, risk factors, and laboratory detection of these multi-drug resistant organisms: methicillin resistant Staphylococcus aureus , vancomycin resistant Enterococcus species, Clostridium difficile , and carbapenem-resistant Enterobacteriaceae . We use cookies to help provide and enhance our service and tailor content and ads. This omission occurred in spite of the fact that there was a training process and supervision of the participant centers in the validation study, and that it was “mandatory” to measure all study variables.7,11, In everyday surgical practice, this flaw in the score is very real. Particularly dangerous to humans with preexisting lung conditions such as Cystic Fibrosis, scientists have been developing new ways to fight the bacteria as it evolves an increasing resistance to antibiotics. 3 0 obj The infectious organism causing infection in a study was found to be methicillin-sensitive Staphylococcus aureus, Pseudomonas aureus, coagulase-negative Staphylococcus, enterobacteriacea like Escherichia coli, K. pneumoniae and M. morgagnii, S. capitis, P. mirabilis, and S. epidermidis. In some instances VREs can be susceptible to ampicillin, in which case that will be the drug of choice for treatment. multi-drug resistant Gram-negative organisms is of particular concern because: • Enterobacteriaceae cause infections at a high frequency and CRE infections are associated with 1a high mortality. Some bacteria are naturally resistant to some antibiotics. Most infection-causing bacteria can become resistant to at least some antibiotics. Bacteria that are resistant to many antibiotics are known as multi-resistant organisms (MRO). With its improved safety profile and the increasing incidence of multi–drug-resistant organisms, vancomycin use in both empiric and organism-specific treatment has increased. Multi-drug resistant organisms (MDRO) are common bacteria (germs) that have developed resistance to multiple types of antibiotics. Multi-Drug Resistance Bacterial Infections in Critically Ill Patients Admitted with COVID-19 . C. krusei is intrinsically resistant to fluconazole, whereas C. glabrata, parapsilosis, and tropicalis can become resistant. Non-resistant bacteria receive the new DNA and become resistant to drugs. These infection-causing organisms can be isolated from pump, blood, and catheter. These infections are defined as small infections involving the suture, without pump exteriorization and small collections in pump pocket. Multi-drug resistant infection about to evolve within cystic fibrosis patients. When contacted during the evaluation, the infection control practitioner at the hospital immediately had that patient moved to a private room and placed in isolation. Severe CDI-related complications, including toxic megacolon, perforation, and the need for a surgical intervention, occurred in fewer than 2% of pediatric patients with CDI.27,28, Fecal transplantation has been performed, reported, and studied in hundreds of adult patients with chronic CDI. The Longitude Prize aims to tackle growing levels of antimicrobial resistance, but what exactly are we up against? There are not only pressures for selection and emergence of resistance of these organisms but also the highest risks of transmission of drug-resistant pathogens.8. It even protects the organisms from the endogenous bactericidal compounds such as lysozymes. Increasingly important as a nosocomial infection. A high level of resistance to antibiotics has been found across several strains of E.coli and while it is rare to find these strains causing illness, it is another concerning example of a bacteria that has the potential to cause problems if our use of antibiotics goes unchecked. By providing rapid results regarding the species identification, MALDI-TOF MS stimulated the desire for further fast diagnostic results such as strain typing (Murray, 2010). This University of Western Australia project, led by Professor Alice Vrielink, researches new therapeutics to treat multidrug resistant bacteria. Multi-drug resistant organisms (MDRO) were isolated from 8.6% of COVID-19 pneumonia. Jason M. Rominski PharmD, Kathryn R. Matthias PharmD, in Decision Making in Medicine (Third Edition), 2010. The species identification using MALDI-TOF MS relies on the detection of protein peaks which are shared by members of the same species. Alternatively, if signs and symptoms of vancomycin toxicity are evident, such as leukopenia, thrombocytopenia, ototoxicity, or nephrotoxicity, an alternative antimicrobial should be considered. Specific goals were to validate the MRSA risk stratification algorithm and evaluate the alert system’s usability. The identification of species relies on the detection of proteins, most of which belong to highly abundant ribosomal proteins. Multidrug-resistant organisms … Multiple drug resistance or Multidrug resistance is a condition enabling a disease-causing organism to resist distinct drugs or chemicals of a wide variety of structure and function targeted at eradicating the organism. Further, this layer acts as a barrier which protects the bacteria from the host defense mechanism and antibiotics which are given systemically. 3.5 Other Multi-Drug resistant organisms (MDROs) - Other multi-drug resistant Gram-negative bacteria and, indeed other organisms such as resistant fungi, exist with a range of resistance mechanisms. These bacteria are present on the bodies of many people, including on the skin, in the nose or other moist areas of the body, and in secretions. reported on 16 adult subjects who underwent donor feces infusion via a nasoduodenal (ND) tube.9 Of those 16 subjects, 13 had resolution of symptoms after one infusion. Francisco Vega-López, in Hunter's Tropical Medicine and Emerging Infectious Disease (Ninth Edition), 2013. Raju Saka, ... Wahid Khan, in Brain Targeted Drug Delivery System, 2019. Multi-Drug Resistant Organism Network - MDRO Network: Actual Study Start Date : June 16, 2016: Actual Primary Completion Date : May 30, 2020: Actual Study Completion Date : May 30, 2020: Resource links provided by the National Library of Medicine. Illness Caused: Diarrhoea. They help fight infections that are caused by bacteria. To remove a pump from brain, the patient has to go through two operations, that is, one for removal of the pump and second for pump replacement after eradicating the infection. Spasticity patients have increased risk for preoperative infection, even without wound breakdown. Penny Lynn Sappington, in Critical Care Nephrology (Third Edition), 2019, Multi-drug–resistant (MDR) organisms are microorganisms that have become resistant to multiple antibiotics. Multidrug-resistant organisms are bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria. Many of the resistance genes apparently have their evolutionary origins in the antibiotic-producing … Thus, MS spectrum quality, data richness, reproducibility, and mass accuracy must typically exceed levels necessary for species-level profiling (Dieckmann, Helmuth, Erhard, & Malorny, 2008). Treatment medications. These are the devices which are implanted to various sites of brain like intrathecal perfusion devices (baclofen perfusion), Giladel wafers, and catheters to deliver the drug at the site of action. However, that program does not identify previous MRSA or VRE patients when they are readmitted or have had MRSA or VRE identified at different hospitals. The bacteria can survive in harsh conditions for long periods of time so are often difficult to deal with in weaker patients, and coupled with increasing resistance presents a tough challenge when encountered by doctors. A patient's clinical response to vancomycin therapy is more important than whether a VSDL is within a standard therapeutic range (see Use and Evaluation of Serum Drug Levels for more details). So, for the purpose classifying groups of patients to compare outcomes in clinical studies and for the prediction of individual mortality in IAI, of the indexes discussed, the best estimators are APACHE-II, SAPS-II and MPI. The small hairs or ‘pili’ on the bacteria act like hooks that are used to move the cell and attach it to other healthy cells. ?\E������o����]�8+���Wy�q��uTTi\��d��ͻ���TG�藷o��OWQ��T&@ei\:Py\�(Kb�#U�I^y�Jػ��fv�L6 y��4���]���M��绛����?��٢��څ]�� }T�R8���F�U�L�iT�%�"����XմU��o����?���y������f��%$h�X-QQ��yZGyQ��+�=��j��ͯ�LcƊG�dv�F�� eĢ�m(�+�!ףu4֣�v\�&����ϲє��2zn��=��=� ��V� C���d4��yJ��Z��>�~��[RZ��؞T}�. A patient can be evaluated by this system and have no infectious process at all, let alone an IAI. Drug-resistant TB cases in 2017: 847. Australian Commission on Safety and Quality … If multiple VSDLs are obtained and a pharmacokinetic evaluation is desired, consider consulting a clinical pharmacy specialist. Certain strains of the bacteria have shown resistance to antibiotics and have mutated over the course of 50 years or so, slowly adapting different resistances as doctors change their approach by using different antibiotics to counter the disease. The main reason that doctors worry about multi-resistant organisms is that if a person colonised with a multi-resistant organism gets sick, we often have to start treatment with powerful, expensive antibiotics, which may have more side-effects, instead of our preferred antibiotics. Multi-drug-resistant Gram-negative bacteria Journal of Chemotherapy 2017VOL. How can we stop them developing? It is also relevant that in 1987 the Surgical Infection Society proposed that the APACHE-II system be used for grading the severity of the infection and the stratification of patient risk of mortality.22–24 The fact that the score had been used in 5,815 intensive care admissions from 13 hospitals appeared to be sufficient support for its proposal. Each of these approaches has been shown to have sufficiently high resolution to discern microbial strains from one another. But of these admissions, only 106 according to the data available in the article clearly had IAI due to gastrointestinal perforation or obstruction. β-lactamase-mediated resistance is the most important and efficient method of β-lactam resistance for Gram-negative bacteria. Infections without removal of pumps can be treated with therapeutic aspirations, pump disinfection, and local and systemic antibiotic treatment. In view of the rise of multi-drug-resistant organisms (MDRs), which are increasingly difficult to treat by antimicrobials, the spread of these organisms between patients in health-care settings becomes a major issue. Multi-drug resistant organisms present significant clinical, and infection prevention and control challenges in health care provider settings. Groups and Cohorts. Multi-drug resistant organism (MDRO): An umbrella term for bacteria and other microorganisms that are resistant to antibiotics and other drugs designed to kill them. Infection resulting from MDR organisms in critically ill patients presents particular challenges to clinicians, given the lack of a pipeline of new antibiotics active against these resistant strains. Several significant outbreaks of C.difficile have made the news in the UK and despite a major effort in improving hygiene in hospitals, the bacteria is responsible for a significant number of deaths globally. Each patient within Intermountain Healthcare receives a unique enterprise number during their first admission. Due to its high levels of resistance, it is common in the US to perform tests to identify which strain is present in a patient to better inform doctors of how to treat them. The main reason for pump infection is breakdown of skin over device in spasticity patients. The small hairs or ‘pili’ on the bacteria act like hooks that are used to move the cell and attach it to other healthy cells. So why would we expect a score intended to be used for classifying severity to predict an individual’s outcome? serovar); (ii) strain differentiation, which facilitates the discrimination of single strains from another based on similarity levels of their profiles; and (iii) strain identification, based on creation of a reference library consisting of known strains, which enables the identification of yet unidentified strains. Both species can become MDROs, but E. faecium is more likely to do so; high-level resistant strains of E. faecium are associated with 30% mortality.