Table 2 Recommendations for infection control and detection methods of VRE

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 [132].

- 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 [106].

- 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) [106] and metronidazole (reduce outgrowth of VRE) [106].

- Surveillance and controlling of VRE-carriage in hospitals [133, 134].

Genome plasticity

- 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 [106].

Diagnostic evasion

- 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 [135].

- Multiple rectal samples (four to five), are needed to detect the majority of carriers (> 90–95%) [106].

- 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 [106].

- Use of selective (chromogenic) agar in the laboratory detection of VRE [82].

- Vancomycin disk diffusion according to EUCAST in the detection of vancomycin-resistance in VRE [136].

- Genotypic testing of invasive vancomycin-susceptible enterococci by PCR [137].

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.