Prevalence and Antibiotic Resistance of Enterococcus spp.: A Retrospective Study in Hospitals of Southeast Romania
, Eliza-Andreea Zaharia 1,5,†, Dana Tutunaru 6,7,†, Nicoleta-Maricica Maftei 5,6,*, Lucian-Daniel Peptine 1,5,†, George Țocu 6,7,† and Gabriela Gurău 1,5,†
Round 1
Reviewer 1 Report
Dear authors,
Beta-lactamases, (β-lactamases) is correct wording.
I was lost in numbers of isolated strains - total 26,699 isolated bacterial strains and you found 86 strains of Enterococcus spp., meaning 0.7%. 0,7% from 26699 is 186. Pls check your numbers and explain discrepancies within article.
Author Response
Response to Reviewer 1 Comments
Point 1: Beta-lactamases, (β-lactamases) is correct wording.
Response 1:
We revised.
Point 2: I was lost in numbers of isolated strains - total 26,699 isolated bacterial strains and you found 86 strains of Enterococcus spp., meaning 0.7%. 0,7% from 26699 is 186. Pls check your numbers and explain discrepancies within article.
Response 2:
We corrected.
Thank You.
Reviewer 2 Report
Enterococcal infection, in my opinion, is one of the most significant healthcare challenges facing most developing and undeveloped nations. Another major cause for concern over the past few decades has been the emergence of antibiotic-resistant pathogens. Therefore, this topic should be addressed with clinical evidence in order to improve the prescriptions given to patients. The article, on the other hand, has a significant amount of room for improvement before it can be considered for publication. Please see my suggestions to improve this article as follows:
1.The introduction needs to be rewritten in light of a few key considerations, such as: What is the prevalence of enterococcal infections in the Southeastern region of Romania? What are the major sources and causes of enterococcal infection?, What are the most commonly prescribed antibiotics for enterococcal infections?, Which antibiotics were replaced within three years without solid research information?, then authors can justify that this research was undertaken to address those issues.
2. Although the authors claim to have performed some univariate statistical analysis, this is not borne out by the results section.
3. The expansion of the table 1 is not convincing and improve with some statistical information
4. Finally, please justify, what results are the authors using to convince their readers? what kind of novel aspects were investigated in this study.
Consider revising the sentences, 104 -105, 173-177, 289-292, 318-319
Line 122 - on what basis the isolates are suspected?
Line 227 change to sensitive
Please change the fig 1 and 2 in colour, its hard to differentate the variations between bacterial members.
Author Response
Response to Reviewer 2 Comments
Point 1: The introduction needs to be rewritten in light of a few key considerations, such as: What is the prevalence of enterococcal infections in the Southeastern region of Romania? What are the major sources and causes of enterococcal infection?, What are the most commonly prescribed antibiotics for enterococcal infections?, Which antibiotics were replaced within three years without solid research information?, then authors can justify that this research was undertaken to address those issues.
Response 1:
We completed the introduction.
“There are not previous studies on AMRE from the South-East of Romania.”
According to our knowledges, this is the first study of AMRE in hospitals from our region. The reported national data to ECDC are the result of AMRE colected from hemocultures of patients with invasive infections from few santinels hospital, but South-Region is not represented. The results of our study evidenced that most Enterococcus spp are isolated from the blood, urine, purulent secretions. Source of infections coud be endogene or exogenous. We have not specific data about the treatment of enterococcal infections in our hospitals, but the surveillance data on antimicrobial drugs national consumption evidenced that the most used antibiotics are beta-lactams, macrolides and quinolones, that could influence the AMRE of endogen or exogenous sources (ingestion of contaminated food or water, hospital associated procedures, contamination from community environment) of Enterococcus spp.
The identification of Enterococcus spp become available in our hospitals during the last three years. We have a small number of analyzed samples because not all the strains were identified to species. These first report is considered for the hospitals’ protocols of antibiotic use right now.
Point 2: Although the authors claim to have performed some univariate statistical analysis, this is not borne out by the results section
Response 2:
We have corrected.
Point 3: The expansion of the table 1 is not convincing and improve with some statistical information
Response 3:
We have extended the Results section, adding the subsection “3.3. Comparative of Enterococcus spp. in three hospitals from South-East of Romania”, including table 2 with statistical results.
Point 4: Finally, please justify, what results are the authors using to convince their readers? what kind of novel aspects were investigated in this study.
The novel aspect is the first report of antibiotic resistance of Enterococcus spp from our region an this is a landmark and a piece of the puzzle of national antibiotic resistance. Globally, antibiotic resistance has no border.
Consider revising the sentences, 104 -105, 173-177, 289-292, 318-319
Response 4:
104 -105 - We revised
173-177- We revised
289-292 - We revised
318-319- We revised
Point 5: Line 122 - on what basis the isolates are suspected?
Response 5: We revised.
Point 6: Line 227 change to sensitive
Response 6: We revised.
Point 7: Please change the fig 1 and 2 in colour, its hard to differentate the variations between bacterial members.
Response 7: We revised.
Thank you.
Author Response File: 
Author Response.docx
Round 2
Reviewer 1 Report
Dear authors,
thanks for new manuscript. Now, numbers are corect.
Author Response
Thank you for the revised observations for improve the manuscript.
Reviewer 2 Report
Although the authors claim this is the first study on the prevalence of enterococcal infections in the South-East of Romania, they are still able to outline relevant data from different parts of the world. Furthermore, the study's rationale remains unconvincing. Authors updated tables to include statistical data, but the text doesn't reflect statistical analysis, and the figures don't replicate any statistical findings.
The results-based discussion lacks clarity; further language editing is required. In general, I do not think the improved version is satisfactory.
Author Response
Dear Reviewer,
Thank you for your observations in order to improve our manuscript.
The English language will be revised by native English editors, as part of the processing the manuscript and the communication of the content will be more clear.
We revised the second version, considering your request.
Regarding the observation that "Although the authors claim this is the first study on the prevalence of enterococcal infections in the South-East of Romania, they are still able to outline relevant data from different parts of the world" we confirm that are not published previous local reports on this topic.
Antibiotic stewardship and antibiotic resistance surveillance are increasing national and local interest in Romania, but the identification methods of enterococcal species became available in hospitals from our region just in the last 2-3 years. This fact explains why there are no previous studies on antibiotic resistance of enterococcal species. We mention (table A1) that are 230 enterococcal isolates (Enterococcus spp), although there are analyzed only a number of 86, that are completely identified as species (E. faecium, E. faecalis, others).
The aim of our manuscript is to signal the local situation of AMRE in our region as a step for developping efficient microbiological diagnostic and antibiotic stewardship programmes.
We added a section on „Limits of the study”.
We revised the conclusions.
