Vancomycin-resistant enterococci (VRE) in hospital settings across European borders: a scoping review comparing the epidemiology in the Netherlands and Germany

Abstract

The rising prevalence of vancomycin-resistant enterococci (VRE) is a matter of concern in hospital settings across Europe without a distinct geographical pattern. In this scoping review, we compared the epidemiology of vancomycin-resistant Enterococcus spp. in hospitals in the Netherlands and Germany, between 1991 and 2022. We searched PubMed and summarized the national antibiotic resistance surveillance data of the two countries. We included 46 studies and summarized national surveillance data from the NethMap in the Netherlands, the National Antimicrobial Resistance Surveillance database in Germany, and the EARS-Net data. In total, 12 studies were conducted in hospitals in the Netherlands, 32 were conducted in German hospitals, and an additional two studies were conducted in a cross-border setting. The most significant difference between the two countries was that studies in Germany showed an increasing trend in the prevalence of VRE in hospitals, and no such trend was observed in studies in the Netherlands. Furthermore, in both Dutch and German hospitals, it has been revealed that the molecular epidemiology of VREfm has shifted from a predominance of vanA towards vanB over the years. According to national surveillance reports, vancomycin resistance in Enterococcus faecium clinical isolates fluctuates below 1% in Dutch hospitals, whereas it follows an increasing trend in German hospitals (above 20%), as supported by individual studies. This review demonstrates that VRE is more frequently encountered in German than in Dutch hospitals and discusses the underlying factors for the difference in VRE occurrence in these two neighboring countries by comparing differences in healthcare systems, infection prevention control (IPC) guidelines, and antibiotic use in the Netherlands and Germany.

Keywords: Antibiotic resistance; Dutch-German cross-border region; Epidemiology; Germany; Prevalence; The Netherlands; VRE; Vancomycin-resistant enterococci.

Fig. 1

Summary of the literature search and selection process

Fig. 2

Publication dates of the included articles

Fig. 3

Summary of the number of VREfm outbreaks (blue boxes) and VREfm proportion (orange boxes) in clinical isolates in Dutch hospitals between 2003 and 2021 (NethMap reports) [81]. The data in the boxes represent the temporal distribution of VRE data over the years. (VREF: vancomycin resistant E. faecalis, VREfm: vancomycin- resistant E. faecium)

Fig. 4

VREfm as the proportion (%) of all E. faecium isolates from inpatients’ blood cultures between 2008 and 2021 in Germany (ARS-RKI Statistics) [85]. (VREfm: vancomycin- resistant E. faecium)

Fig. 5

The percentage of VREfm in clinical (invasive) E. faecium isolates in the Netherlands and Germany between 2001 and 2021. EU/EAA average was only reported between 2013 and 2020. Data from the ECDC Surveillance Atlas [92]