Menu
Home
People
Places
Arts
History
Plants & Animals
Science
Life & Culture
Technology
Reference.org
Vancomycin-resistant Enterococcus
open-in-new
<h2 id="mechanism-of-acquired-resistance">Mechanism of acquired resistance</h2> <p>Six different types of vancomycin resistance are shown by enterococcus: Van-A, Van-B, Van-C, Van-D, Van-E and Van-G.<a class="footnote-ref" id="fnref:2" href="#fn:2"><sup>2</sup></a> The significance is that Van-A VRE is resistant to both vancomycin and <a href="/facts/Teicoplanin/sRxI5JrM">teicoplanin</a>,<a class="footnote-ref" id="fnref:3" href="#fn:3"><sup>3</sup></a> Van-B VRE is resistant to vancomycin but susceptible to teicoplanin,<a class="footnote-ref" id="fnref:4" href="#fn:4"><sup>4</sup></a><a class="footnote-ref" id="fnref:5" href="#fn:5"><sup>5</sup></a> and Van-C is only partly resistant to vancomycin. </p><p>The mechanism of resistance to vancomycin found in enterococcus involves the alteration of the <a href="/facts/Peptidoglycan/lflRRUNw">peptidoglycan</a> synthesis pathway.<a class="footnote-ref" id="fnref:6" href="#fn:6"><sup>6</sup></a> </p><p>The D-alanyl-D-lactate variation results in the loss of one <a href="/facts/Hydrogen_bond/85V86IIg">hydrogen-bonding</a> interaction (four, as opposed to five for D-alanyl-D-alanine) being possible between vancomycin and the <a href="/facts/Peptide/C4ltc7UG">peptide</a>. The D-alanyl-D-serine variation causes a six-fold loss of affinity between vancomycin and the peptide, likely due to <a href="/facts/Steric_effects/TnX5c8HG">steric hindrance</a>.<a class="footnote-ref" id="fnref:7" href="#fn:7"><sup>7</sup></a><a class="footnote-ref" id="fnref:8" href="#fn:8"><sup>8</sup></a> </p> <p>To become vancomycin-resistant, vancomycin-sensitive enterococci typically obtain new DNA in the form of <a href="/facts/Plasmids/yf59JVlA">plasmids</a> or <a href="/facts/Transposon/WbVMhuWR">transposons</a> which encode <a href="/facts/Gene/e1swwPY6">genes</a> that confer vancomycin resistance.<a class="footnote-ref" id="fnref:9" href="#fn:9"><sup>9</sup></a> This acquired vancomycin resistance is distinguished from the natural vancomycin resistance of certain enterococcal species including <a href="/facts/Enterococcus_gallinarum/PmNUF05e"><i>E. gallinarum</i></a> and <i>E. casseliflavus/flavescens</i>.<a class="footnote-ref" id="fnref:10" href="#fn:10"><sup>10</sup></a><a class="footnote-ref" id="fnref:11" href="#fn:11"><sup>11</sup></a> </p> <h2 id="screening-and-diagnosis">Screening and diagnosis</h2> <p>Screening for VRE can be accomplished in a number of ways. For inoculating peri-rectal/anal swabs or stool specimens directly, one method uses bile esculin azide agar plates containing 6 μg/ml of vancomycin. Black colonies should be identified as an enterococcus to species level and further confirmed as vancomycin resistant by an MIC method before reporting as VRE.<a class="footnote-ref" id="fnref:12" href="#fn:12"><sup>12</sup></a> </p><p>Vancomycin resistance can be determined for enterococcal colonies available in pure culture by inoculating a suspension of the organism onto a commercially available <a href="/facts/Brain_heart_infusion/sCFpoH4S">brain heart infusion agar</a> (BHIA) plate containing 6 μg/ml vancomycin. The <a href="/facts/Clinical_and_Laboratory_Standards_Institute/b5acraIz">Clinical and Laboratory Standards Institute</a> (CLSI) recommends performing a vancomycin MIC test and also motility and pigment production tests to distinguish species with acquired resistance (vanA and vanB) from those with vanC intrinsic resistance.<a class="footnote-ref" id="fnref:13" href="#fn:13"><sup>13</sup></a> Detection of vancomycin resistance by the use of PCR targeting <i>vanA</i> and <i>vanB</i> can also be performed.<a class="footnote-ref" id="fnref:14" href="#fn:14"><sup>14</sup></a><a class="footnote-ref" id="fnref:15" href="#fn:15"><sup>15</sup></a> </p><p>Once the individual has VRE, it is important to ascertain which strain.<a class="footnote-ref" id="fnref:16" href="#fn:16"><sup>16</sup></a> </p> <h2 id="treatment-of-infection">Treatment of infection</h2> <p><a href="/facts/Ceftriaxone/9NpBWG12">Ceftriaxone</a> (a third generation <a href="/facts/Cephalosporin/WeB7I75T">cephalosporin</a>) use is a risk factor for colonization and infection by VRE, and restriction of cephalosporin usage has been associated with decreased VRE infection and transmission in hospitals.<a class="footnote-ref" id="fnref:17" href="#fn:17"><sup>17</sup></a> <i>Lactobacillus rhamnosus</i> GG (LGG), a strain of <a href="/facts/Lactobacillus_rhamnosus/msxVquT6"><i>L. rhamnosus</i></a>, was used successfully for the first time to treat gastrointestinal carriage of VRE.<a class="footnote-ref" id="fnref:18" href="#fn:18"><sup>18</sup></a> In the US, <a href="/facts/Linezolid/c6kpn1Yr">linezolid</a> is commonly used to treat VRE.<a class="footnote-ref" id="fnref:19" href="#fn:19"><sup>19</sup></a> The combination of <a href="/facts/Daptomycin/ysvhcyld">daptomycin</a> and <a href="/facts/Ampicillin/oIodNyBw">ampicillin</a> is another option to treat VRE infections, especially for bacteremia.<a class="footnote-ref" id="fnref:20" href="#fn:20"><sup>20</sup></a> For invasive vancomycin-resistant <i>E. faecalis</i> infections, both ampicillin-ceftriaxone and ampicillin-<a href="/facts/Gentamicin/QXlbQH79">gentamicin</a> combinations have been used successfully, with the latter specifically showing success in treating endocarditis.<a class="footnote-ref" id="fnref:21" href="#fn:21"><sup>21</sup></a> If the VRE strain is vanB, teicoplanin and dalbavancin are suitable therapeutic options.<a class="footnote-ref" id="fnref:22" href="#fn:22"><sup>22</sup></a> Another antibiotic often used as off-label salvage therapy in systemic VRE infections is <a href="/facts/Oritavancin/CgEdJ97o">oritavancin</a>, a semisynthetic glycopeptide that has demonstrated synergic activity with <a href="/facts/Fosfomycin/pYWd2WGg">fosfomycin</a>.<a class="footnote-ref" id="fnref:23" href="#fn:23"><sup>23</sup></a> </p> <h2 id="history">History</h2> <p>High-level vancomycin-resistant <a href="/facts/Enterococcus_faecalis/66cjKlxr"><i>E. faecalis</i></a> and <a href="/facts/Enterococcus_faecium/Ek2mFsQP"><i>E. faecium</i></a> are clinical isolates first documented in Europe in 1986 and the United States in 1987.<a class="footnote-ref" id="fnref:24" href="#fn:24"><sup>24</sup></a><a class="footnote-ref" id="fnref:25" href="#fn:25"><sup>25</sup></a> In the United States, vancomycin-resistant <a href="/facts/Enterococcus_faecium/Ek2mFsQP"><i>E. faecium</i></a> was associated with 4% of healthcare-associated infections reported to the <a href="/facts/Centers_for_Disease_Control_and_Prevention/NmoJNDV5">Centers for Disease Control and Prevention</a> National Healthcare Safety Network from January 2006 to October 2007.<a class="footnote-ref" id="fnref:26" href="#fn:26"><sup>26</sup></a> VRE can be carried by healthy people who have come into contact with the bacteria, usually in a hospital<a class="footnote-ref" id="fnref:27" href="#fn:27"><sup>27</sup></a> (<a href="/facts/Nosocomial_infection/sKWTbPTq">nosocomial infection</a>),<a class="footnote-ref" id="fnref:28" href="#fn:28"><sup>28</sup></a> although it is thought that a significant percentage of <a href="/facts/Industrial_agriculture_(animals)/YabemH5u">intensively farmed chickens</a> also carry VRE.<a class="footnote-ref" id="fnref:29" href="#fn:29"><sup>29</sup></a> Other regions have noted a similar distribution, but with increased incidence of VRE. For example, a 2006 study of nosocomial VRE revealed a rapid spread of resistance among enterococci along with an emerging shift in VRE distribution in the Middle East region, such as Iran. Treatment failures in enterococcal infections result from inadequate information regarding glycopeptide resistance of endemic enterococci due to factors such as the presence of VanA and VanB. The study from Iran reported the first case of VRE isolates that carried VanB gene in enterococcal strains from Iran. This study also noted the first documented isolation of nosocomial <i>E. raffinosus</i> and <i>E. mundtii</i> in the Middle East region.<a class="footnote-ref" id="fnref:30" href="#fn:30"><sup>30</sup></a> </p> <h2 id="see-also">See also</h2> <ul><li><a href="/facts/Vancomycin-resistant_Staphylococcus_aureus/wJ0sGIVK">Vancomycin-resistant <i>Staphylococcus aureus</i></a> (VRSA)</li> <li><a href="/facts/Antibiotic_resistance/jsbAywgx">Antibiotic resistance</a></li> <li><a href="/facts/Drug_resistance/cgLruXm6">Drug resistance</a></li> <li><a href="/facts/MDR-TB/cNBgP2jb">MDR-TB</a></li></ul> <h2 id="further-reading">Further reading</h2> <ul><li>Rastall B, Gibson G (2006-05-01). <a href="https://books.google.com/books?id=ZJt03QsoaysC&q=Lactobacillus+rhamnosus+GG++treat++VRE"><i>Prebiotics: Development and Application</i></a>. John Wiley & Sons. <a href="/facts/ISBN_(identifier)/15AdSPa9">ISBN</a> 9780470023143.</li></ul> <h2 id="external-links">External links</h2> <ul><li><a href="https://www.ncbi.nlm.nih.gov/pubmed/">PubMed</a></li></ul> Wikimedia Commons has media related to Vancomycin-resistant Enterococcus. <h2 id="references">References</h2> <ol> <li id="fn:1"><p>"Vancomycin-resistant Enterococci (VRE) in Healthcare Settings". VRE in Healthcare Settings - HAI. CDC. Archived from the original on 2019-05-18. Retrieved 2015-06-09. <a href="https://www.cdc.gov/HAI/organisms/vre/vre.html" target="_blank">https://www.cdc.gov/HAI/organisms/vre/vre.html</a> <a href="#fnref:1" class="footnote-back-ref">↩</a></p></li> <li id="fn:2"><p>Fong IW, Drlica K (2007-11-15). Antimicrobial Resistance and Implications for the 21st Century. Springer Science & Business Media. ISBN 9780387724188. Archived from the original on 2023-01-14. Retrieved 2020-12-17. <a href="9780387724188" target="_blank">9780387724188</a> <a href="#fnref:2" class="footnote-back-ref">↩</a></p></li> <li id="fn:3"><p>Mendez-Vilas A (2011). Science and Technology Against Microbial Pathogens: Research, Development and Evaluation, Proceedings of the International Conference on Antimicrobial Research (ICAR2010), Valladolid, Spain 3 - 5 November 2010. World Scientific. ISBN 9789814354868. <a href="9789814354868" target="_blank">9789814354868</a> <a href="#fnref:3" class="footnote-back-ref">↩</a></p></li> <li id="fn:4"><p>Ahmad I, Aqil F (2008-11-21). New Strategies Combating Bacterial Infection. John Wiley & Sons. ISBN 9783527622948. <a href="9783527622948" target="_blank">9783527622948</a> <a href="#fnref:4" class="footnote-back-ref">↩</a></p></li> <li id="fn:5"><p>Grayson ML, Crowe SM, McCarthy JS, Mills J, Mouton JW, Norrby SR, Paterson DL, Pfaller MA (2010-10-29). Kucers' The Use of Antibiotics Sixth Edition: A Clinical Review of Antibacterial, Antifungal and Antiviral Drugs. CRC Press. ISBN 9781444147520. Archived from the original on 2023-01-14. Retrieved 2020-12-17. <a href="9781444147520" target="_blank">9781444147520</a> <a href="#fnref:5" class="footnote-back-ref">↩</a></p></li> <li id="fn:6"><p>Arias CA, Murray BE (2012). "Figure 4 : The rise of the Enterococcus: beyond vancomycin resistance : Nature Reviews Microbiology". Nature Reviews Microbiology. 10 (4): 266–278. doi:10.1038/nrmicro2761. PMC 3621121. PMID 22421879. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3621121" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3621121</a> <a href="#fnref:6" class="footnote-back-ref">↩</a></p></li> <li id="fn:7"><p>Meziane-Cherif D, Saul FA, Haouz A, Courvalin P (2012). "Structural and Functional Characterization of VanG d-Ala:d-Ser Ligase Associated with Vancomycin Resistance in Enterococcus faecalis♦". The Journal of Biological Chemistry. 287 (45): 37583–37592. doi:10.1074/jbc.M112.405522. ISSN 0021-9258. PMC 3488035. PMID 22969085. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3488035" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3488035</a> <a href="#fnref:7" class="footnote-back-ref">↩</a></p></li> <li id="fn:8"><p>Coates AR (2012-08-31). Antibiotic Resistance. Springer Science & Business Media. ISBN 9783642289507. Archived from the original on 2023-01-14. Retrieved 2020-12-17. <a href="9783642289507" target="_blank">9783642289507</a> <a href="#fnref:8" class="footnote-back-ref">↩</a></p></li> <li id="fn:9"><p>Gould D, Brooker C (2008-08-20). Infection Prevention and Control: Applied Microbiology for Healthcare. Palgrave Macmillan. ISBN 9781137045928.[permanent dead link] <a href="9781137045928" target="_blank">9781137045928</a> <a href="#fnref:9" class="footnote-back-ref">↩</a></p></li> <li id="fn:10"><p>Monticelli J, et al. (2018). "Clinical management of non-faecium non-faecalis vancomycin-resistant enterococci infection. Focus on Enterococcus gallinarum and Enterococcus casseliflavus/flavescens". J Infect Chemother. 24 (4): 237–246. doi:10.1016/j.jiac.2018.01.001. PMID 29396199. <a href="https://doi.org/10.1016%2Fj.jiac.2018.01.001" target="_blank">https://doi.org/10.1016%2Fj.jiac.2018.01.001</a> <a href="#fnref:10" class="footnote-back-ref">↩</a></p></li> <li id="fn:11"><p>"VRE and the Clinical Laboratory - HAI". Healthcare-associated Infections. CDC. Archived from the original on 2019-04-14. Retrieved 2015-06-09. <a href="https://www.cdc.gov/HAI/settings/lab/VREClinical-Laboratory.html" target="_blank">https://www.cdc.gov/HAI/settings/lab/VREClinical-Laboratory.html</a> <a href="#fnref:11" class="footnote-back-ref">↩</a></p></li> <li id="fn:12"><p>"Vancomycin-resistant Enterococci (VRE) and the Clinical Laboratory". Centers for Disease Control and Prevention. Archived from the original on 14 April 2019. Retrieved 21 May 2017. This article incorporates text from this source, which is in the public domain. <a href="https://www.cdc.gov/hai/settings/lab/vreclinical-laboratory.html" target="_blank">https://www.cdc.gov/hai/settings/lab/vreclinical-laboratory.html</a> <a href="#fnref:12" class="footnote-back-ref">↩</a></p></li> <li id="fn:13"><p>"Vancomycin-resistant Enterococci (VRE) and the Clinical Laboratory". Centers for Disease Control and Prevention. Archived from the original on 14 April 2019. Retrieved 21 May 2017. This article incorporates text from this source, which is in the public domain. <a href="https://www.cdc.gov/hai/settings/lab/vreclinical-laboratory.html" target="_blank">https://www.cdc.gov/hai/settings/lab/vreclinical-laboratory.html</a> <a href="#fnref:13" class="footnote-back-ref">↩</a></p></li> <li id="fn:14"><p>Zirakzadeh A, Patel R (April 2006). "Vancomycin-resistant enterococci: colonization, infection, detection, and treatment". Mayo Clin Proc. 81 (4): 529–36. doi:10.4065/81.4.529. PMID 16610573. Archived from the original on 2022-09-11. Retrieved 2022-09-11. The LightCycler instrument (Roche Diagnostics Corporation) is used to detect vanA and vanB using a rapid real-time PCR assay(Figure 3). This method is more sensitive and faster (~3.5 vs >72 hours) than culture for detecting VRE colonization.47 The assay detects the presence of genes associated with vancomycin resistance in enterococci, vanA and vanB. <a href="https://www.mayoclinicproceedings.org/article/S0025-6196(11)61901-0/fulltext" target="_blank">https://www.mayoclinicproceedings.org/article/S0025-6196(11)61901-0/fulltext</a> <a href="#fnref:14" class="footnote-back-ref">↩</a></p></li> <li id="fn:15"><p>Holzknecht BJ, Hansen DS, Nielsen L, Kailow A, Jarløv JO (March 2017). "Screening for vancomycin-resistant enterococci with Xpert® vanA/vanB: diagnostic accuracy and impact on infection control decision making". New Microbes New Infect. 16: 54–59. doi:10.1016/j.nmni.2016.12.020. PMC 5295639. PMID 28203378. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5295639" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5295639</a> <a href="#fnref:15" class="footnote-back-ref">↩</a></p></li> <li id="fn:16"><p>Levitus M, Rewane A, Perera TB (2022). "Vancomycin-Resistant Enterococci". StatPearls. StatPearls Publishing. PMID 30020605. Archived from the original on 27 March 2022. Retrieved 27 March 2022. <a href="https://pubmed.ncbi.nlm.nih.gov/30020605/" target="_blank">https://pubmed.ncbi.nlm.nih.gov/30020605/</a> <a href="#fnref:16" class="footnote-back-ref">↩</a></p></li> <li id="fn:17"><p>McKinnell JA, Kunz DF, Chamot E, Patel M, Shirley RM, Moser SA, Baddley JW, Pappas PG, Miller LG (2012). "Association of Vancomycin-Resistant Enterococcus Bacteremia and Ceftriaxone Usage". Infection Control and Hospital Epidemiology. 33 (7): 718–724. doi:10.1086/666331. ISSN 0899-823X. PMC 3879097. PMID 22669234. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3879097" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3879097</a> <a href="#fnref:17" class="footnote-back-ref">↩</a></p></li> <li id="fn:18"><p>Phoenix DA, Harris F, Dennison SR (2014-08-25). Novel Antimicrobial Agents and Strategies. John Wiley & Sons. ISBN 9783527676156. <a href="9783527676156" target="_blank">9783527676156</a> <a href="#fnref:18" class="footnote-back-ref">↩</a></p></li> <li id="fn:19"><p>Balli EP, Venetis CA, Miyakis S (2014). "Systematic Review and Meta-Analysis of Linezolid versus Daptomycin for Treatment of Vancomycin-Resistant Enterococcal Bacteremia". Antimicrobial Agents and Chemotherapy. 58 (2): 734–739. doi:10.1128/AAC.01289-13. ISSN 0066-4804. PMC 3910884. PMID 24247127. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3910884" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3910884</a> <a href="#fnref:19" class="footnote-back-ref">↩</a></p></li> <li id="fn:20"><p>Werth BJ, Barber KE, Tran N, Nonejuie P, Sakoulas G, Pogliano J, Rybak MJ (2015-02-01). "Ceftobiprole and ampicillin increase daptomycin susceptibility of daptomycin-susceptible and -resistant VRE". Journal of Antimicrobial Chemotherapy. 70 (2): 489–493. doi:10.1093/jac/dku386. ISSN 0305-7453. PMID 25304643. Archived from the original on 2022-05-08. Retrieved 2023-10-25. <a href="https://academic.oup.com/jac/article/70/2/489/2911200" target="_blank">https://academic.oup.com/jac/article/70/2/489/2911200</a> <a href="#fnref:20" class="footnote-back-ref">↩</a></p></li> <li id="fn:21"><p>de Oliveira Santos JV, da Costa Júnior SD, de Fátima Ramos Dos Santos Medeiros SM, Cavalcanti ID, de Souza JB, Coriolano DL, da Silva WR, Alves MH, Cavalcanti IM (April 2022). "Panorama of Bacterial Infections Caused by Epidemic Resistant Strains". Current Microbiology. 79 (6): 175. doi:10.1007/s00284-022-02875-9. PMC 9055366. PMID 35488983. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9055366" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9055366</a> <a href="#fnref:21" class="footnote-back-ref">↩</a></p></li> <li id="fn:22"><p>Riccardi N, Monticelli J, Antonello RM, Di Lallo G, Frezza D, Luzzati R, Di Bella S (2021-04-01). "Therapeutic Options for Infections Due to vanB Genotype Vancomycin-Resistant Enterococci". Microbial Drug Resistance. 27 (4): 536–545. doi:10.1089/mdr.2020.0171. ISSN 1076-6294. PMID 32799629. S2CID 221144533. <a href="https://www.liebertpub.com/doi/10.1089/mdr.2020.0171" target="_blank">https://www.liebertpub.com/doi/10.1089/mdr.2020.0171</a> <a href="#fnref:22" class="footnote-back-ref">↩</a></p></li> <li id="fn:23"><p>Di Cecco C, Monticelli J, Di Bella S, Di Maso V, Luzzati R (2023-08-21). "Vancomycin-resistant enterococcus bloodstream infection successfully managed with oritavancin and fosfomycin as sequential treatment". Journal of Chemotherapy. 36 (1): 31–34. doi:10.1080/1120009X.2023.2247205. ISSN 1120-009X. PMID 37602423. S2CID 261048377. Archived from the original on 2023-08-21. Retrieved 2023-10-25. <a href="https://www.tandfonline.com/doi/full/10.1080/1120009X.2023.2247205" target="_blank">https://www.tandfonline.com/doi/full/10.1080/1120009X.2023.2247205</a> <a href="#fnref:23" class="footnote-back-ref">↩</a></p></li> <li id="fn:24"><p>Robinson DA, Feil EJ, Falush D (2010-03-16). Bacterial Population Genetics in Infectious Disease. John Wiley & Sons. ISBN 9780470600115. <a href="9780470600115" target="_blank">9780470600115</a> <a href="#fnref:24" class="footnote-back-ref">↩</a></p></li> <li id="fn:25"><p>Murray BE (March 2000). "Vancomycin-resistant enterococcal infections". N Engl J Med. 342 (10): 710–21. doi:10.1056/NEJM200003093421007. PMID 10706902. Archived from the original on 2022-09-11. Retrieved 2022-09-11. The first reports of vancomycin-resistant enterococci (later classified as VanA type of resistance) involved strains of E. faecium that were resistant to vancomycin and teicoplanin (another glycopeptide) and that were isolated from patients in France and England in 1986. Vancomycin-resistant E. faecalis, subsequently classified as VanB type, was recovered from patients in Missouri in 1987. <a href="https://www.nejm.org/doi/10.1056/NEJM200003093421007" target="_blank">https://www.nejm.org/doi/10.1056/NEJM200003093421007</a> <a href="#fnref:25" class="footnote-back-ref">↩</a></p></li> <li id="fn:26"><p>Hidron AI, Edwards JR, Patel J, et al. (November 2008). "NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007". Infect Control Hosp Epidemiol. 29 (11): 996–1011. doi:10.1086/591861. PMID 18947320. S2CID 205988392. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:26" class="footnote-back-ref">↩</a></p></li> <li id="fn:27"><p>"Diseases and Organisms in Healthcare Settings". Healthcare-associated Infections (HAIs). CDC. Archived from the original on 2015-07-08. Retrieved 2015-06-09. <a href="https://www.cdc.gov/HAI/organisms/organisms.html" target="_blank">https://www.cdc.gov/HAI/organisms/organisms.html</a> <a href="#fnref:27" class="footnote-back-ref">↩</a></p></li> <li id="fn:28"><p>Kouchak F, Askarian M (2012). "Nosocomial Infections: The Definition Criteria". Iranian Journal of Medical Sciences. 37 (2): 72–73. PMC 3470069. PMID 23115435. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470069" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470069</a> <a href="#fnref:28" class="footnote-back-ref">↩</a></p></li> <li id="fn:29"><p>Nilsson O (2012). "Vancomycin resistant enterococci in farm animals – occurrence and importance". Infection Ecology & Epidemiology. 2 (1): 16959. Bibcode:2012InfEE...216959N. doi:10.3402/iee.v2i0.16959. PMC 3426332. PMID 22957131. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3426332" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3426332</a> <a href="#fnref:29" class="footnote-back-ref">↩</a></p></li> <li id="fn:30"><p>Fathollahzadeh B, Hashemi FB, Emaneini M, Aligholi M, Nakhjavani FA (2006). "Frequency of Vancomycin-Resistant Enterococci from Three Hospitals in Iran". Daru. 14 (3): 141–146. Archived from the original (PDF) on 2016-03-04. Retrieved 2015-12-30. <a href="https://web.archive.org/web/20160304081034/http://daru.tums.ac.ir/index.php/daru/article/download/281/281" target="_blank">https://web.archive.org/web/20160304081034/http://daru.tums.ac.ir/index.php/daru/article/download/281/281</a> <a href="#fnref:30" class="footnote-back-ref">↩</a></p></li> </ol>