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Clinical Considerations in the Approach to Vancomycin-Resistant Enterococci: A Narrative Review




Vancomycin-resistant enterococci, Enterococcus faecalis, Enterococcus faecium, Vancomycin resistance, Healthcare-associated infection, Nosocomial infection


Vancomycin-Resistant Enterococci (VRE) increasingly colonize and infect assorted patient populations throughout the world, maintaining a continual reservoir of opportunistic pathogens with varying antibiotic resistance. Here we present the current general epidemiology and classification of these pathogens within the scope of healthcare-associated infections (HAIs). Risk factors for colonization and conditions for subsequent infection are reviewed, along with infection characteristics. Current infection control protocols and their effectiveness, selected evidence-based medical therapies, and ongoing research into alternative therapies are summarized.


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Ramsey AM, Zilberberg MD. Secular Trends of Hospitalization with Vancomycin-Resistant Enterococcus Infection in the United States, 2000–2006. Infect Control Hosp Epidemiol. 2009;30(2):184-186.

Uttley AH, Collins CH, Naidoo J, George RC. Vancomycin-resistant enterococci. Lancet Lond Engl. 1988;1(8575-6):57-58.

Weiner LM, Fridkin SK, Aponte-Torres Z, Avery L, Coffin N, Dudeck MA, et al. Vital Signs: Preventing Antibiotic-Resistant Infections in Hospitals — United States, 2014. 2016;65(9):7.

Osei Sekyere J, Mensah E. Molecular epidemiology and mechanisms of antibiotic resistance in Enterococcus spp., Staphylococcus spp., and Streptococcus spp. in Africa: a systematic review from a One Health perspective. Ann N Y Acad Sci. 2020;1465(1):29-58.

European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in Europe 2016. Annual Report of the European Antimicrobial Resistance Surveillance Network (EARS-Net). Eur Cent Dis Control. Published online 2017.

Centers for Disease Control and Prevention (U.S.). Antibiotic Resistance Threats in the United States, 2019. Centers for Disease Control and Prevention (U.S.); 2019.

Molton JS, Tambyah PA, Ang BSP, Ling ML, Fisher DA. The global spread of healthcare-associated multidrug-resistant bacteria: a perspective from Asia. Clin Infect Dis Off Publ Infect Dis Soc Am. 2013;56(9):1310-1318.

Smith JR, Barber KE, Raut A, Aboutaleb M, Sakoulas G, Rybak MJ. B-Lactam combinations with daptomycin provide synergy against vancomycin-resistant Enterococcus faecalis and Enterococcus faecium. J Antimicrob Chemother. Published online February 1, 2015:dkv007.

Mazuski JE. Vancomycin-Resistant Enterococcus: Risk Factors, Surveillance, Infections, and Treatment. Surg Infect. 2008;9(6):567-571.

Wade JJ, Uttley AH. Resistant enterococci--mechanisms, laboratory detection and control in hospitals. J Clin Pathol. 1996;49(9):700-703.

Boyce JM, Opal SM, Chow JW, Zervos MJ, Potter-Bynoe G, Sherman CB, et al. Outbreak of multidrug-resistant Enterococcus faecium with transferable vanB class vancomycin resistance. J Clin Microbiol. 1994;32(5):1148-1153.

Leclercq R, Derlot E, Duval J, Courvalin P. Plasmid-mediated resistance to vancomycin and teicoplanin in Enterococcus faecium. N Engl J Med. 1988;319(3):157-161.

Crank C, O’Driscoll T. Vancomycin-resistant enterococcal infections: epidemiology, clinical manifestations, and optimal management. Infect Drug Resist. Published online July 2015:217.

Arthur M, Courvalin P. Genetics and mechanisms of glycopeptide resistance in enterococci. Antimicrob Agents Chemother. 1993;37(8):1563-1571.

Kang M, Xie Y, He C, Chen ZX, Guo L, Yang Q, et al. Molecular characteristics of vancomycin-resistant Enterococcus faecium from a tertiary care hospital in Chengdu, China: Molecular characteristics of VRE in China. Eur J Clin Microbiol Infect Dis. 2014;33(6):933-939.

Holzknecht BJ, Hansen DS, Nielsen L, Kailow A, Jarløv JO. Screening for vancomycin-resistant enterococci with Xpert® vanA/vanB: diagnostic accuracy and impact on infection control decision making. New Microbes New Infect. 2017;16:54-59.

Paule SM, Trick WE, Tenover FC, Lankford M, Cunningham S, Stosor V, et al. Comparison of PCR Assay to Culture for Surveillance Detection of Vancomycin-Resistant Enterococci. J Clin Microbiol. 2003;41(10):4805-4807.

Avery R, Kalaycio M, Pohlman B, Sobecks R, Luczkowski E, Andresen S, et al. Early vancomycin-resistant enterococcus (VRE) bacteremia after allogeneic bone marrow transplantation is associated with a rapidly deteriorating clinical course. Bone Marrow Transplant. 2005;35(5):497-499.

Baethge C, Goldbeck-Wood S, Mertens S. SANRA-a scale for the quality assessment of narrative review articles. Res Integr Peer Rev. 2019;4:5.

Manchikanti L. Evidence-based medicine, systematic reviews, and guidelines in interventional pain management, part I: introduction and general considerations. Pain Physician. 2008;11(2):161-186.

Hamel M, Zoutman D, O’Callaghan C. Exposure to hospital roommates as a risk factor for health care–associated infection. Am J Infect Control. 2010;38(3):173-181.

Kaki R, Yu Y, O’Neill C, Lee C, Mertz D, Hamilton Health Sciences Infection Prevention and Control Team. Vancomycin-Resistant Enterococcus (VRE) Transmission and Risk Factors in Contacts of VRE Carriers. Infect Control Hosp Epidemiol. 2014;35(7):876-879.

Ziakas PD, Thapa R, Rice LB, Mylonakis E. Trends and Significance of VRE Colonization in the ICU: A Meta-Analysis of Published Studies. Ratner AJ, ed. PLoS ONE. 2013;8(9):e75658.

Decker BK, Lau AF, Dekker JP, Spalding CD, Sinaii N, Conlan S, et al. Healthcare personnel intestinal colonization with multidrug-resistant organisms. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2018;24(1):82.e1-82.e4.

Freedberg DE, Zhou MJ, Cohen ME, Annavajhala MK, Khan S, Moscoso DI, et al. Pathogen colonization of the gastrointestinal microbiome at intensive care unit admission and risk for subsequent death or infection. Intensive Care Med. 2018;44(8):1203-1211.

Zacharioudakis IM, Zervou FN, Ziakas PD, Rice LB, Mylonakis E. Vancomycin-Resistant Enterococci Colonization Among Dialysis Patients: A Meta-analysis of Prevalence, Risk Factors, and Significance. Am J Kidney Dis. 2015;65(1):88-97.

Calfee DP, Giannetta ET, Durbin LJ, Germanson TP, Farr BM. Control of Endemic Vancomycin-Resistant Enterococcus among Inpatients at a University Hospital. Clin Infect Dis. 2003;37(3):326-332.

CDC. Recommendations for preventing the spread of Vancomycin resistance: Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). Recomm Rep. 1995;44(12):1-13.

Cheah ALY, Cheng AC, Spelman D, Nation RL, Kong DCM, McBryde ES. Mathematical modelling of vancomycin-resistant enterococci transmission during passive surveillance and active surveillance with contact isolation highlights the need to identify and address the source of acquisition. BMC Infect Dis. 2018;18(1):511.

Zirakzadeh A, Gastineau DA, Mandrekar JN, Burke JP, Johnston PB, Patel R. Vancomycin-resistant enterococcal colonization appears associated with increased mortality among allogeneic hematopoietic stem cell transplant recipients. Bone Marrow Transplant. 2008;41(4):385-392.

Archuleta S, Murphy B, Keller MJ. Successful treatment of vancomycin-resistant Enterococcus faecium endocarditis with linezolid in a renal transplant recipient with human immunodeficiency virus infection. Transpl Infect Dis. 2004;6:117-119.

Satlin MJ, Walsh TJ. Multidrug-resistant Enterobacteriaceae, Pseudomonas aeruginosa, and vancomycin-resistant Enterococcus: Three major threats to hematopoietic stem cell transplant recipients. Transpl Infect Dis. 2017;19(6):e12762.

Edmond MB, Ober JF, Dawson JD, Weinbaum DL, Wenzel RP. Vancomycin-Resistant Enterococcal Bacteremia: Natural History and Attributable Mortality. Clin Infect Dis. 1996;23(6):1234-1239.

Brennen C, Wagener MM, Muder RR. Vancomycin-resistant Enterococcus faecium in a long-term care facility. J Am Geriatr Soc. 1998;46(2):157-160.

Zaas AK, Song X, Tucker P, Perl TM. Risk factors for development of vancomycin-resistant enterococcal bloodstream infection in patients with cancer who are colonized with vancomycin-resistant enterococci. Clin Infect Dis Off Publ Infect Dis Soc Am. 2002;35(10):1139-1146.

Hachem R, Afif C, Gokaslan Z, Raad I. Successful Treatment of Vancomycin-Resistant Enterococcus Meningitis with Linezolid. Eu Jou CLin Micro & Inf Dis.:4.

Song IJ, Seo JW, Kwon YE, Kim YL, Lim TS, Kang EW, et al. Successful Treatment of Vancomycin-Resistant Enterococcus Peritonitis Using Linezolid Without Catheter Removal in a Peritoneal Dialysis Patient. Perit Dial Int. 2014;34(2):235-239.

Diekema D. Use of Active Surveillance Cultures to Control Vancomycin-Resistant Enterococcus. Clin Infect Dis. 2003;37:1399-1400.

He YH, Ruan GJ, Hao H, Xue F, Ma YK, Zhu SN, et al. Real-time PCR for the rapid detection of vanA, vanB and vanM genes. J Microbiol Immunol Infect. 2020;53(5):746-750.

Messler S, Klare I, Wappler F, Werner G, Ligges U, Sakka SG, et al. Reduction of nosocomial bloodstream infections and nosocomial vancomycin-resistant Enterococcus faecium on an intensive care unit after introduction of antiseptic octenidine-based bathing. J Hosp Infect. 2019;101(3):264-271.

Montecalvo MA, Jarvis WR, Uman J, Shay DK, Petrullo C, Rodney K, et al. Infection-Control Measures Reduce Transmission of Vancomycin-Resistant Enterococci in an Endemic Setting. Ann Intern Med. 1999;131(4):269.

Slaughter S. A Comparison of the Effect of Universal Use of Gloves and Gowns with That of Glove Use Alone on Acquisition of Vancomycin-Resistant Enterococci in a Medical Intensive Care Unit. Ann Intern Med. 1996;125(6):448.

Rubin MA, Samore MH, Harris AD. The Importance of Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci. JAMA. 2018;319(9):863.

Harris AD, Pineles L, Belton B, Johnson JK, Shardell M, Loeb M, et al. Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial. JAMA. 2013;310(15):1571-1580.

Morgan DJ, Murthy R, Munoz-Price LS, Barnden M, Camins BC, Johnston BL, et al. Reconsidering contact precautions for endemic methicillin-resistant Staphylococcus aureus and vancomycin-resista.nt Enterococcus. Infect Control Hosp Epidemiol. 2015;36(10):1163-1172.

Eichel VM, Boutin S, Frank U, Weigand MA, Heininger A, Mutters NT, et al. Impact of discontinuing contact precautions and enforcement of basic hygiene measures on nosocomial vancomycin-resistant Enterococcus faecium transmission. J Hosp Infect. 2022;121:120-127.

Stelfox HT. Safety of Patients Isolated for Infection Control. JAMA. 2003;290(14):1899.

Siegel JD, Rhinehart E, Cic R, Jackson M. Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006. Published online 2006:75.

Narayanan N, Rai R, Vaidya P, Desai A, Bhowmick T, Weinstein MP. Comparison of linezolid and daptomycin for the treatment of vancomycin-resistant enterococcal bacteremia. Ther Adv Infect Dis. 2019;6:2049936119828964.

Kelly J, Tysall L, Dewar S. Daptomycin susceptibility testing and therapeutic use in enterococcal bloodstream infection (EBSI) in a setting with high rates of vancomycin-resistant Enterococcus faecium (VREfm). J Antimicrob Chemother. Published online February 15, 2022:dkac042.

McComb MN, Collins CD. Comparative cost-effectiveness of alternative empiric antimicrobial treatment options for suspected enterococcal bacteremia. Pharmacotherapy. 2014;34(6):537-544.

Birmingham MC, Rayner CR, Meagher AK, Flavin SM, Batts DH, Schentag JJ. Linezolid for the treatment of multidrug-resistant, gram-positive infections: experience from a compassionate-use program. Clin Infect Dis Off Publ Infect Dis Soc Am. 2003;36(2):159-168.

Gallagher JC, Perez ME, Marino EA, LoCastro LG, Abrardo LA, MacDougall C. Daptomycin therapy for vancomycin-resistant enterococcal bacteremia: a retrospective case series of 30 patients. Pharmacotherapy. 2009;29(7):792-799.

Patel JJ, Antony A, Herrera M, Lipchik RJ. Daptomycin-induced acute eosinophilic pneumonia. WMJ Off Publ State Med Soc Wis. 2014;113(5):199-201.

Balli EP, Venetis CA, Miyakis S. Systematic review and meta-analysis of linezolid versus daptomycin for treatment of vancomycin-resistant enterococcal bacteremia. Antimicrob Agents Chemother. 2014;58(2):734-739.

Chuang YC, Chen PY, Lin CY, Chen YC, Wang JT, Chang SC. A retrospective clinical comparison of daptomycin vs daptomycin and a beta-lactam antibiotic for treating vancomycin-resistant Enterococcus faecium bloodstream infections. Sci Rep. 2018;8(1):1632.

Karlowsky JA, Steenbergen J, Zhanel GG. Microbiology and Preclinical Review of Omadacycline. Clin Infect Dis Off Publ Infect Dis Soc Am. 2019;69(Suppl 1):S6-S15.

Yim J, Smith JR, Rybak MJ. Role of Combination Antimicrobial Therapy for Vancomycin-Resistant Enterococcus faecium Infections: Review of the Current Evidence. Pharmacotherapy. 2017;37(5):579-592.

Mercuro NJ, Davis SL, Zervos MJ, Herc ES. Combatting resistant enterococcal infections: a pharmacotherapy review. Expert Opin Pharmacother. 2018;19(9):979-992.

Antao EM, Vincze S, Hanke R, KlimmekL, Suchecka K, Lubke-Becker A, et al. Antibiotic resistance, the 3As and the road ahead. Gut Pathog. 2018;10(1):52.

Shreiner AB, Kao JY, Young VB. The gut microbiome in health and in disease: Curr Opin Gastroenterol. 2015;31(1):69-75.

Borgmann S, Rieß B, Siegmund R, Werner G, Klare I. Treatment with Saccharomyces boulardii and Escherichia coli Nissle is safe and associated with reduced nosocomial transmission of vanB vancomycin-resistant Enterococcus faecium on an early rehabilitation ward in Germany: a retrospective analysis. Ther Clin Risk Manag. 2019;Volume 15:343-354.

Li M, Lee K, Hsu M, Nau G, Mylonakis E, Ramratnam B. Lactobacillus-derived extracellular vesicles enhance host immune responses against vancomycin-resistant enterococci. BMC Microbiol. 2017;17(1):66.

Davido B, Batista R, Fessi H, Michelon H, Escaut L, Lawrence C, et al. Fecal microbiota transplantation to eradicate vancomycin-resistant enterococci colonization in case of an outbreak. Médecine Mal Infect. 2019;49(3):214-218.

Wasilewska E, Zlotkowska D, Wroblewska B. Yogurt starter cultures of Streptococcus thermophilus and Lactobacillus bulgaricus ameliorate symptoms and modulate the immune response in a mouse model of dextran sulfate sodium-induced colitis. J Dairy Sci. 2019;102(1):37-53.

Kim SG, Becattini S, Moody TU, Shliaha PV, Littmann ER, Seok R, et al. Microbiota-derived lantibiotic restores resistance against vancomycin-resistant Enterococcus. Nature. 2019;572(7771):665-669.

Davido B, Batista R, Fessi H, Salomon J, Dinh A. Impact of faecal microbiota transplantation to eradicate vancomycin-resistant enterococci (VRE) colonization in humans. J Infect. 2017;75(4):376-377.

Baxter M, Colville A. Adverse events in faecal microbiota transplant: a review of the literature. J Hosp Infect. 2016;92(2):117-127.


2022-04-25 — Updated on 2022-06-30


How to Cite

Beale, J. W., & Durward-Diioia, M. (2022). Clinical Considerations in the Approach to Vancomycin-Resistant Enterococci: A Narrative Review. International Journal of Medical Students, 10(2), 202–209.