Global Prevalence of Vancomycin-Resistant Enterococcus faecium and Enterococcus faecalis Isolated From Clinical and Environmental Sources: A Systematic Review and Meta-Analysis.

Abstract

Vancomycin-resistant enterococci (VRE) are an increasing public health concern. However, the contribution of environmental reservoirs to the global epidemiology of vancomycin resistance remains unclear. This meta-analysis estimated the prevalence of Vancomycin-resistant Enterococcus faecalis (VREfs) and vancomycin-resistant Enterococcus faecium (VREfm) from clinical and environmental specimens worldwide. We conducted a systematic literature search in PubMed, Web of Science, Embase, and Scopus up to 26 April 2025. Statistical analysis was performed using the meta and metaphor packages in R, and heterogeneity was evaluated using I². We assessed potential publication bias using Egger's test. A total of 349 eligible studies were included. The pooled prevalence of VREfm was 25%, and VREfs was 5%. The prevalence of both VREfs and VREfm increased significantly during the last two decades. The highest prevalence of VREfm and VREfs was found in rectal swabs (76%), hospital environmental samples (74%), environmental water (26%), and animal stool (40%). By integrating clinical and environmental data, the present study highlights the possible role of non-clinical reservoirs in the persistence and dissemination of VRE. Our results support the One Health approach for VRE surveillance and emphasize the need for environmental surveillance in infection prevention and antimicrobial resistance control strategies.