infections due to gram - positive bacteria are on a rise , of which those due to enterococcus spp . enterococci are reported to be the third leading cause of nosocomial infections in the world . enterococci , especially vancomycin - resistant enterococcal ( vre ) infections are becoming common and difficult to treat , appearing usually as long - lasting hospital outbreaks that present tremendous challenges for infection control . the reason for the emerging enterococcal infections is not fully understood , but an important contributory factor is probably the selection pressure from increasing consumption of cephalosporins . this promotes emergence of enterococci , which are inherently resistant to this group of antibiotics . the major infections caused by enterococci in general and vre in particular include urinary tract infections ( uti ) , wound infections , intra - abdominal infections secondary to a perforated viscus or after surgery , cholecystitis , bacteremia , endocarditis , and rarely meningitis . however , data regarding the soft tissue and wound infections due to enterococcus spp . and also its resistance pattern among trauma patients are scarce and hence the study was conducted with these lacunae in view . the study was conducted with the following aims : 
 to determine the prevalence of various enterococcal wound and soft tissue infections , to look into the factors associated with mortality and length of hospital stay ( los ) with enterococcal ( vre and vse ) wound infections , to investigate the impact of vancomycin resistance and antibiotic therapy in enterococcal soft tissue and wound infections among trauma patients , andto observe its significance . 
  to determine the prevalence of various enterococcal wound and soft tissue infections , to look into the factors associated with mortality and length of hospital stay ( los ) with enterococcal ( vre and vse ) wound infections , to investigate the impact of vancomycin resistance and antibiotic therapy in enterococcal soft tissue and wound infections among trauma patients , and to observe its significance . a cohort study was conducted from january 2011 to december 2013 at a level i trauma care center in new delhi , india , serving a reference population of 16.3 to 17.8 million inhabitants during the study period . it has 176 functional beds with an average total admission per year of 5914 during the study period . the hospital bed occupancy rate was 83% with an average bed turnover rate per day of 24 . patients with enterococcal wound and soft tissue infections were identified using the jpnatc , new delhi microbiology laboratory database . we have included all the wound swabs , pus samples and tissue sent for bacterial culture during the study period , irrespective of the diagnosis of the patients in this study . tissue and pus culture results from the trauma patients during the 3-year period were observed regarding the changes in enterococcus species distribution over time . the most frequent enterococcal species were selected for analysis of changes in antibiotic sensitivity and species distribution over the years in the study period . for every patient , an incident was defined as isolation of an enterococcus sp . in one or more samples from the same operated site or wound . if patients underwent more than one operation within 6 months and the microbiology was the same , it was included as one incident . possible risk factors like prolonged hospital stay , icu admissions , previous multiple invasive surgical interventions , prior antibiotic therapy , repeated hospital admissions , presence of indwelling devices , methicillin - resistant staphylococcus aureus co - infection etc were looked into . for the purpose of this study , recent antimicrobial use was defined as receipt of any antimicrobial agent for more than 3 consecutive days in the 3 months before the date of culture detection ; patients who received short courses of peri - operative prophylaxis were excluded by this criterion . prior icu stay of > 1 week , surgical interventions including abdominal trauma surgeries were taken as criteria for the study . also , possible outcomes like prolonging the length of stay ( los ) , increased morbidity and mortality were analyzed . microorganisms recovered from these cultures were identified using the automated vitek 2 compact systems ( biomrieux , durham , usa ) according to the manufacturer 's protocol . antibiotic sensitivity was done both by disc diffusion according to the clsi guidelines , eucast and vitek 2 in parallel . throughout the study , enterococcus faecalis atcc 29212 ( vancomycin sensitive ) , enterococcus faecalis atcc 51299 ( vancomycin resistant ) and enterococcus faecium atcc 700221 ( vancomycin resistant ) were used as controls . related information on patient demographics , antimicrobial use , repeated invasive surgical procedures , treatment of enterococcal wound and soft tissue infections and outcomes of hospitalization was collected via a review of patient medical records from the electronic hospital database . the incidence of enterococcus spp . was calculated as the number of patients with enterococcus species in tissue or pus samples per 1,000 admissions for the period 2011 - 2013 . descriptive statistics was used in most cases , but test for significance was done wherever feasible . a total of 120 consecutive isolates were noted during this study period of which 86 non - repetitive isolates and hence patients were included . it was seen that male ( 72 , 84% ) predominated over female ( 14 , 16% ) patients with respect to the number of wound and tissue infections by enterococcus sp . the clinical manifestations ranged from wound discharge ( 49% , 42/86 ) , to swelling ( 36% , 31/86 ) , redness ( 28% , 24/86 ) , pain ( 62% , 53/86 ) , abscess ( 30% , 26/86 ) , fever ( 51%,44/86 ) and loss of function ( 24% , 21/86 ) . details regarding demographics , clinical characteristics and outcomes of patients with enterococcal wound and soft tissue infections based on vancomycin susceptibility are shown in table 1 . baseline demographic data and co - morbidities of the 86 patients based on their vancomycin sensitivity during the study period a total of 32,480 samples were received , of which 11,524 consists of pus and tissue samples for culture . from these , of these , enterococcus faecium ( 48/86 , 56% ) was the most common , followed by enterococcus faecalis ( 34/86 , 40% ) and 4 ( 4% ) of enterococcus casseliflavus . the antimicrobial sensitivity pattern of different enterococcus spp . it was seen that a low level of vancomycin resistance was present in the enterococcus sp . at our center . a total of 79 ( 92% ) isolates were found to be vancomycin - sensitive enterococcus ( vse ) whereas the remaining 7 ( 8% ) were found to be vancomycin - resistant enterococcus ( vre ) . our study also observed that the number of tissue and wound infections due to e. faecalis was high ( 24/86 ) in 2011 , but was gradually overtaken by e. faecium during 2012 and 2013 ( 39/86 ) . a total of 8 polymicrobial infections were observed among these patients , of which co - infection with acinetobacter baumannii ( 5 , 63% ) was the highest followed by klebsiella pneumoniae ( 2 , 25% ) and staphylococcus aureus ( 1 , 13% ) . all these polymicrobial infections were seen in the pus / wound samples along with e. faecium ( 7 , 88% ) , except one case of co - infection of s. aureus with e. faecalis ( 1 , 13% ) in the tissue infection . its antimicrobial sensitivity pattern it was seen that longer hospital stay ( los ) , repeated surgical procedure , prior antibiotic therapy and icu stay were observed to associate with increased morbidity ( p < 0.05 ) and hence , more chances of infections with vre . other factors like female gender or age did not have significant influence ( p > 0.1 ) over the infection by enterococcus sp . this however did not influence the mortality of the admitted patients from whom enterococcus sp . , there was no significant change in the outcomes of the patient irrespective of whether they were infected with vse or vre ( p > 0.1 ) . no patient had a fatal outcome during the study period and all the patients were discharged healthy after treatment . this was seen in all the patients irrespective of whether they were admitted to icus or in other wards . in the patients having wound and soft tissue infections due to vre , 6 ( 86% ) were treated with linezolid monotherapy , whereas 2 ( 29% ) each with quinupristin - dalfopristin monotherapy or no antibiotics , respectively in the beginning . a combination of vancomycin with other antibiotics like teicoplanin , linezolid , ampicillin or benzylpenicillin was administered to 42 ( 53% ) of the vse patients either concurrently or in sequence later . however , combination therapy worked better in those patients with vre or polymicrobial infection . the overall incidence of wound and soft tissue infections with enterococcus sp . was 8.6 per 1,000 admissions . however , the incidence of infection by e. faecalis was 3.4 per 1000 admissions and that due to e. faecium was 4.8 per 1,000 admissions . prior icu stay , multiple surgical interventions and longer hospital stay was associated with increased infection with vre in our study . our study has seen a shift from a preponderance of e. faecalis to that of e. faecium in the later part of the study which also has been noted in other studies . we found a low level of vancomycin resistance among the enterococcus isolates , which is an encouraging finding . also , enterococcal wound or soft tissue infections were not a significant risk factor in our study though it influenced the morbidity and increased the los . this might be explained by the prevalence of low level of vre in our centre . our study found only 8 cases of polymicrobial infections with e. faecium and e. faecalis wound and soft tissue infections . also , longer duration of hospital stay was seen in vre patients compared to those of vse , which might support the fact that longer los is an independent risk factor for vre infections . prior icu stay was more among vre infected patients ; however , other risk factors like co - infections or co - morbidities , cost of treatment / hospitalization could not be looked into detail due to the retrospective nature of the study . in this study , a high level resistance to ampicillin was seen in both e. faecium ( 44 , 92% ) and e. faecalis ( 29 , 85% ) respectively . similar high resistance was also seen in e. faecium ( 45 , 94% ) and e. faecalis ( 26 , 76% ) to ciprofloxacin , as reported in other studies . a high level of resistance to gentamicin ( hlar ) was seen in the enterococcus spp . responsible for skin and soft tissue infections . though the number of infections due to vse among trauma patients has increased over the years in the study , it is a study of enterococcal wound and soft tissue infections on trauma patients and no such large - scale study have been reported . trauma patients generally lack underlying illness / co - morbidities and are of middle age . the incidence of wound / soft tissue infection was expressed per 1000 patient admissions instead of according to samples . the changing pattern of enterococcus sp . was clearly noted in the study and may act as a baseline data for comparison in future . also , the study tried to look into possible risk factors . first , it is the single - center study design , which makes extrapolation to other institutions difficult . second , it is not a randomized study , with the resulting risk of bias due to confounding factors . as the majority of the patients had vse wound / soft tissue infections during the study period ( 2011 to 2013 ) , matching vre and vse patients for date of admission was not possible in the study period . furthermore , we were unable to obtain the standardized data on costs of hospitalization due to enterococcal wound and soft tissue infections . enterococcal wound and soft tissue infections are prevalent in trauma care facilities , especially in the icus .
soft tissue and wound infections due to enterococcus spp . are increasing worldwide with current need to understand the epidemiology of the enterococcal infections of wounds . 
 hence , we have looked into the distribution of enterococcus spp . 
 responsible for causing wound and soft tissue infections among trauma patients , its antibiotic resistance pattern and how it affects the length of hospital stay and mortality . a laboratory cum clinical - based study 
 was performed over a period of 3 years at a level i trauma center in new delhi , india . 
 patients with enterococcal wound and soft tissue infections were identified using the hospital data base , their incidence of soft tissue / wound infections calculated , drug resistance pattern and their possible risk factors as well as outcomes analyzed . 
 a total of 86 non - repetitive enterococcus spp . 
 was isolated of which e. faecium were maximally isolated 48 ( 56% ) . 
 high level of resistance was seen to gentamicin hlar in all the species of enterococcus causing infections whereas a low level resistance to vancomycin and teicoplanin was observed among the isolates . 
 longer hospital stay , repeated surgical procedure , prior antibiotic therapy and icu stay were observed to associate with increased morbidity ( p < 0.05 ) and hence , more chances of infections with vre among the trauma patients 
 . the overall rate of wound and soft tissue infections with enterococcus sp . was 8.6 per 1,000 admissions during the study period . 
 enterococcal wound infection is much prevalent in trauma care facilities especially in the icus . here 
 , a microbiologist can act as a sentinel , help in empirical therapeutic decisions and also in preventing such infections .