|Traits of Enterococcus faecium||Implications for infection control||Recommendations|
|High tenacity and intrinsic resistance to environmental stress||
- Prolonged survival in hospital environment.|
- High survival to desiccation and starvation.
- Resistance to heat and disinfection procedures.
- Intensified cleaning procedures, including intensified cleaning procedures and prolonged disinfection procedures .|
- Implementation of infection-control measures to prevent transmission of VRE, including isolation precautions for VRE-positive patients [97, 101, 103].
- Education programs for hospital staff, including hand hygiene to prevent further transmission .
- Environmental cultures in (uncontrolled) VRE outbreaks and surveillance cultures after disinfections.
|Intrinsic resistance antibiotics||
- Outgrowth under antibiotic pressure.|
- Prone to become pan-resistant.
- Antibiotic stewardship, especially prudent use of vancomycin (reduce emergence of VRE)  and metronidazole (reduce outgrowth of VRE) .|
- Surveillance and controlling of VRE-carriage in hospitals [133, 134].
- Continuously adaptation and refinement in response to environmental changes.|
- Development of resistance to newer antibiotics and disinfectants in the future.
- Continuous awareness and surveillance to detect resistance to newer antibiotics and disinfectants.|
- Further research and development of antimicrobial targets for the treatment of MDR E. faecium .
- Phenotypes of evolutionary successful HA VRE lineages that evade detection by standard recommended methods for detection of glycopeptide resistance in E. faecium|
- Difficulties in detecting VRE-carriage due to low fecal densities
- Active surveillance cultures to detect VRE-carriage in patients at high-risk units and patients transferred from foreign countries with high VRE prevalence .|
- Multiple rectal samples (four to five), are needed to detect the majority of carriers (> 90–95%) .
- Get knowledge of the local epidemiology of VRE and vancomycin MICs in own hospital.
- Early and accurate detection and reporting of VRE by clinical microbiology laboratories [75, 76].
- For rapid screening of VRE carriage, a combination of selective enrichment broths and molecular detection increases the sensitivity .
- Use of selective (chromogenic) agar in the laboratory detection of VRE .
- Vancomycin disk diffusion according to EUCAST in the detection of vancomycin-resistance in VRE .
- Genotypic testing of invasive vancomycin-susceptible enterococci by PCR .
|Common origin of hospital lineages in early twentieth century (CC-17)||- Typing difficulties during VRE outbreaks.||
- Rapid and accurate typing is needed to take adequate infection prevention measures in VRE outbreaks.|
- Preferably a highly discriminatory typing method like cgMLST or WGS, ideally combined with transposon analysis should be used in VRE outbreak analysis.