Centers for Disease Control and Prevention

Antimicrobial Resistance Threats Report

Vancomycin-resistant Enterococcus

Threat Level: SERIOUS

In the United States in 2023:

CDC changed methodologies and data sources to produce the most comprehensive AR Threats Report to date. Direct comparison of this threat's data to previous reports is not recommended.

What you need to know

Enterococcus bacteria are normally found in the intestines of people and animals. They can also be found in the environment, including in soil and water. These bacteria normally live on or in our bodies without causing problems, but they can cause infections in the urinary tract, blood, or other parts of the body.

Some Enterococcus bacteria are resistant to vancomycin, a powerful antibiotic that is given by IV to treat serious infections. These vancomycin-resistant Enterococcus (VRE) bacteria tend to cause infections in patients who have frequent exposures to health care. VRE bacteria spread through contact with contaminated surfaces or objects, particularly in healthcare settings. The bacteria can also spread from person to person, especially when hands are contaminated.

Patients at high risk for VRE infections include those who have been on antibiotics, have been in an intensive care unit, or have medical devices such as ventilators and catheters. VRE infections are especially concerning for some of our most vulnerable populations, including those in long-term acute care hospitals, patients undergoing treatment for some types of cancer, and patients with organ transplants.

Vancomycin-resistant Enterococcus data

In 2023, there were an estimated 65,204 cases of vancomycin-resistant Enterococcus (VRE) in hospitalized patients and 6,536 people who died due to their VRE infection. CDC estimates that VRE cases were responsible for nearly $725 million in healthcare costs in 2023. VRE bacteria tend to cause infections in patients with serious underlying illnesses. A severe VRE infection could lead to delays in treatment for those conditions.

Number of vancomycin-resistant Enterococcus (VRE) cases in hospitalized patients (N=65,204) by location of onset and specimen type in 2023 in the U.S.

In 2023, 38% of the VRE cases in hospitalized patients were hospital-onset, and 62% were community-onset. Hospital-onset cases occur when specimens (samples) taken from patients on or after day four of hospitalization test positive for VRE. Community-onset cases occur when specimens taken from patients immediately before or within the first three days of hospitalization test positive for VRE. Community-onset cases may be in patients with recent healthcare exposure prior to their hospitalization, including nursing home residents.

Fourteen percent of hospital-onset VRE cases and 12% of community-onset VRE cases were invasive. Invasive cases mean VRE bacteria are found in normally sterile (free from germs) body sites, such as blood or cerebrospinal fluid. Non-invasive cases mean VRE bacteria are found in non-sterile sites, such as the urinary tract, the respiratory tract, or wounds.

Most reported VRE cases are non-invasive. Non-invasive infections can be mild or severe, and some non-invasive infections, like infections involving the upper urinary tract, can be deadly. Invasive infections are very serious and can be deadly, often resulting in significant healthcare needs, antibiotic use, and an increased risk for sepsis. Preventing VRE infections, whether they are invasive or non-invasive, is critically important, since they can be difficult to treat.

For the first time, data from the National Healthcare Safety Network (NHSN) Antimicrobial Use and Resistance Module were used to estimate the burden of VRE as shown in the figure above.

For the figure below, CDC used data from large electronic health databases to review changes in the rates of patient hospitalizations with VRE from 2012 to 2022.

Incidence rates of patient hospitalizations with vancomycin-resistant Enterococcus (VRE) by year and location of onset in the U.S.

A previously published CDC analysis, shown in the figure above, demonstrates that preventing VRE infections is possible. Between 2012 and 2017, the estimated rate of hospitalizations with community-onset and hospital-onset VRE declined. The estimated rates of community-onset VRE then stabilized from 2017 to 2022 [1]. The estimated rate of hospitalizations with hospital-onset VRE increased during 2020 through 2022 compared to 2019, likely for reasons related to the COVID-19 pandemic, including sicker patients with longer hospital stays [2]. The credible intervals (range of values likely to include the true value) overlap for the hospital-onset VRE yearly estimates during 2019 to 2022, suggesting that assessment of changes from year to year should be made cautiously.

Continued close monitoring, especially of hospital-onset VRE cases, along with infection control and antibiotic stewardship, are important to protect patients at risk for VRE infections.

From tragedy to advocacy: Mary and Mo's story and the fight for safer health care

Mary and Mo's Story

In this video, Mary and Mo share the story of losing their mother to a drug-resistant infection and the importance of infection prevention in protecting patients and saving lives.

Mary, a dialysis patient, chose to have an arteriovenous (AV) graft placed for her hemodialysis treatments. An AV graft is a synthetic tube surgically placed under the skin to connect an artery to a vein to enable dialysis. Grafts provide a safer alternative to a dialysis catheter, which carries a higher risk of infection. Despite choosing the safer approach, Mary got an infection and developed sepsis, a life-threatening condition where the body's extreme response to an infection begins to damage its own tissues and organs.
Mary was rushed to the hospital with confusion and fever, and she was quickly treated with antibiotics. Her condition rapidly deteriorated when her colon perforated (tore), spilling infectious contents into her abdomen and leading to overwhelming septic shock (the most severe stage of sepsis). Too weak for surgery, Mary passed away on Mother's Day.
The germ that caused Mary's first infection was identified as vancomycin-resistant Enterococcus, which can spread by contaminated hands or surfaces. Unfortunately, she probably got the infection during her regular dialysis care, which started a domino effect of reactions in her body.
Mary's preventable death inspired two of her children to become infection preventionists—healthcare professionals dedicated to preventing the spread of infections in various settings, ensuring the safety of patients, staff, and visitors. They believe rigorous hand hygiene and meticulous environmental cleaning could have saved their mother's life.
Mary's children advocate for healthcare systems to focus on foundational infection prevention, consistent training, accountability, illustrating the real-life impact and cost of infection, and championing appropriate antibiotic use. Their mission is to prevent other families from experiencing devastating loss.

How CDC combats vancomycin-resistant Enterococcus

  • Tracking infections

    CDC's National Healthcare Safety Network identifies and measures healthcare-associated infections, including those caused by vancomycin-resistant Enterococcus (VRE), in healthcare facilities nationwide to inform antibiotic stewardship and infection prevention efforts, and alert experts to new resistance trends.

  • Collaborating through partnerships

    CDC works closely with health departments, other federal agencies, healthcare facilities and providers, and patients to prevent infections caused by VRE and stop the spread of resistant bacteria.

Vancomycin-resistant Enterococcus resources

Illustration of Vancomycin-resistant Enterococcus