question: Q:A team of intensivists working in a private intensive care unit (ICU) observe that the clinical efficacy of vancomycin is low, and proven nosocomial infections have increased progressively over the past year. A clinical microbiologist is invited to conduct a bacteriological audit of the ICU. He analyzes the microbiological reports of all patients treated with vancomycin over the last 2 years and takes relevant samples from the ICU for culture and antibiotic sensitivity analysis. The audit concludes that there is an increased incidence of vancomycin-resistant Enterococcus fecalis infections. Which of the following mechanisms best explains the changes that took place in the bacteria?? 
  {'A': 'Protection of the antibiotic-binding site by Qnr protein', 'B': 'Replacement of the terminal D-ala in the cell wall peptidoglycan by D-lactate', 'C': 'Increased expression of efflux pumps which extrude the antibiotic from the bacterial cell', 'D': 'Decreased number of porins in the bacterial cell wall leading to decreased intracellular entry of the antibiotic', 'E': 'Production of an enzyme that hydrolyzes the antibiotic'},