Enterococcus

{{Short description|Genus of bacteria}} {{cs1 config|name-list-style=vanc|display-authors=6}} {{Distinguish|Enterobacter}} {{Automatic taxobox | image = Enterococcus_histological_pneumonia_01.png | image_caption = ''Enterococcus sp.'' infection in pulmonary tissue | taxon = Enterococcus | authority = (''ex'' Thiercelin & Jouhaud 1903)<br />Schleifer & Kilpper-Bälz 1984 | subdivision_ranks = Species | subdivision_ref = <ref name=Eremococcus /> | subdivision = * ''E. alcedinis''<ref name=Eremococcus>{{cite web| vauthors = Parte AC |title=Enterococcus| work = List of Prokaryotic names with Standing in Nomenclature (LPSN) |url=https://lpsn.dsmz.de/genus/enterococcus}}</ref> * ''E. aquimarinus''<ref name=Eremococcus/> * ''E. asini''<ref name=Eremococcus/> * ''E. avium''<ref name=Eremococcus/> * ''E. bulliens''<ref name=Eremococcus/> * ''E. burkinafasonensis''<ref name=Eremococcus/> * ''E. caccae''<ref name=Eremococcus/> * ''E. camelliae''<ref name=Eremococcus/> * ''E. canintestini''<ref name=Eremococcus/> * ''E. canis''<ref name=Eremococcus/> * ''E. casseliflavus''<ref name=Eremococcus/> * ''E. cecorum''<ref name=Eremococcus/> * ''E. columbae''<ref name=Eremococcus/> * ''E. crotali''<ref name=Eremococcus/> * ''E. devriesei''<ref name=Eremococcus/> * ''E. diestrammenae''<ref name=Eremococcus/> * ''E. dispar''<ref name=Eremococcus/> * ''E. durans''<ref name=Eremococcus/> * ''E. eurekensis''<ref name=Eremococcus/> * ''E. faecalis''<ref name=Eremococcus/> * ''E. faecium''<ref name=Eremococcus/> *  * ''E. gallinarum''<ref name=Eremococcus/> * ''E. gilvus''<ref name=Eremococcus/> * ''E. haemoperoxidus''<ref name=Eremococcus/> * ''E. hermanniensis''<ref name=Eremococcus/> * ''E. hirae''<ref name=Eremococcus/> * ''E. hulanensis''<ref name=Eremococcus/> * ''E. innesii''<ref name=Eremococcus/> * ''E. italicus''<ref name=Eremococcus/> * ''E. lactis''<ref name=Eremococcus/> * ''E. lemanii''<ref name=Eremococcus/> * ''E. malodoratus''<ref name=Eremococcus/> * ''E. massiliensis''<ref name=Eremococcus/> * ''E. mediterraneensis''<ref name=Eremococcus/> * ''E. moraviensis''<ref name=Eremococcus/> * ''E. mundtii''<ref name=Eremococcus/> * ''E. olivae''<ref name=Eremococcus/> * ''E. pallens''<ref name=Eremococcus/> * ''E. phoeniculicola''<ref name=Eremococcus/> * ''E. plantarum''<ref name=Eremococcus/> *  * ''E. pseudoavium''<ref name=Eremococcus/> * ''E. quebecensis''<ref name=Eremococcus/> * ''E. raffinosus''<ref name=Eremococcus/> * ''E. ratti''<ref name=Eremococcus/> * ''E. rivorum''<ref name=Eremococcus/> * ''E. rotai''<ref name=Eremococcus/> * ''E. saccharolyticus''<ref name=Eremococcus/> *  *  * ''E. saigonensis''<ref name=Eremococcus/> * ''E. silesiacus''<ref name=Eremococcus/> * ''E. sulfureus''<ref name=Eremococcus/> * ''E. solitarius'' * ''E. songbeiensis''<ref name=Eremococcus/> * ''E. termitis''<ref name=Eremococcus/> * ''E. thailandicus''<ref name=Eremococcus/> * ''E. ureasiticus''<ref name=Eremococcus/> * ''E. ureilyticus''<ref name=Eremococcus/> * ''E. viikkiensis''<ref name=Eremococcus/> * ''E. villorum''<ref name=Eremococcus/> * ''E. wangshanyuanii''<ref name=Eremococcus/> * ''E. xiangfangensis''<ref name=Eremococcus/> * ''E. xinjiangensis''<ref name=Eremococcus/> }}

'''''Enterococcus''''' is a large genus of lactic acid bacteria of the phylum Bacillota. Enterococci are Gram-positive cocci that often occur in pairs (diplococci) or short chains, and are difficult to distinguish from streptococci on physical characteristics alone.<ref name=Gilmore_2002>{{cite book | title=The Enterococci: Pathogenesis, Molecular Biology, and Antibiotic Resistance | publisher = ASM Press | location=Washington, D.C. | year=2002 | editor=Gilmore MS | isbn=978-1-55581-234-8|display-editors=etal}}</ref> Two species are common commensal organisms in the intestines of humans: ''E. faecalis'' (90–95%) and ''E. faecium'' (5–10%). Rare clusters of infections occur with other species, including ''E. durans'',<ref name=":0">{{Cite journal |last1=Karlsson |first1=Philip A. |last2=Zhang |first2=Taoran |last3=Järhult |first3=Josef D. |last4=Joffré |first4=Enrique |last5=Wang |first5=Helen |date=2025-06-12 |editor-last=Ponraj |editor-first=Vittal Prakash |title=Heterogeneity and metabolic diversity among Enterococcus species during long-term colonization |journal=Microbiology Spectrum |volume=13 |issue=8 |article-number=e03160-24 |language=en |doi=10.1128/spectrum.03160-24 |doi-access=free|pmid=40503823 |pmc=12323598 |issn=2165-0497}}</ref> ''E. casseliflavus'', ''E. gallinarum'', and ''E. raffinosus''.<ref name="Gilmore_2002" />

== Physiology and classification == Enterococci are facultative anaerobic organisms, i.e., they are capable of cellular respiration in both oxygen-rich and oxygen-poor environments.<ref name=Fischetti_2000>{{cite book | veditors = Fischetti VA, Novick RP, Ferretti JJ, Portnoy DA, Rood JI | title = Gram-Positive Pathogens | publisher = ASM Press | year = 2000 | isbn = 1-55581-166-3}}</ref> Though they are not capable of forming spores, enterococci are tolerant of a wide range of environmental conditions: extreme temperature (10–45 °C), pH (4.6–9.9), and high sodium chloride concentrations.<ref name=Fisher>{{cite journal | vauthors = Fisher K, Phillips C | title = The ecology, epidemiology and virulence of Enterococcus | journal = Microbiology | volume = 155 | issue = Pt 6 | pages = 1749–1757 | date = June 2009 | pmid = 19383684 | doi = 10.1099/mic.0.026385-0 | doi-access = free }}</ref>

''E. faecium'' and ''E. faecalis'' can be differentiated based on their carbohydrate metabolism: ''E. faecium'' consistently metabolizes lactose but not melezitose or inositol, whereas ''E. faecalis'' reliably metabolizes sorbitol and sucrose but lacks the ability to utilize L-arabinose, melibiose, or raffinose. Less is known of other species; ''E. durans'' share most of the important carbohydrate metabolism with ''E. faecium''.<ref name=":0" />

Enterococci exhibit variable hemolysis on blood agar. Differences occur between species, and between strains of species. More virulent organisms are more likely to exhibit alpha (partial) or beta (complete) hemolysis than less virulent specimens of ''Enterococcus'', which frequently exhibit gamma (absent) hemolysis.<ref>{{cite journal | vauthors = Semedo T, Almeida Santos M, Martins P, Silva Lopes MF, Figueiredo Marques JJ, Tenreiro R, Barreto Crespo MT | title = Comparative study using type strains and clinical and food isolates to examine hemolytic activity and occurrence of the cyl operon in enterococci | journal = Journal of Clinical Microbiology | volume = 41 | issue = 6 | pages = 2569–2576 | date = June 2003 | pmid = 12791882 | pmc = 156526 | doi = 10.1128/jcm.41.6.2569-2576.2003 }}</ref>

=== History ===

Members of the genus ''Enterococcus'' (from Greek έντερο, ''éntero'' 'intestine' and κοκκος, ''coccos'' 'granule') were classified as group D ''Streptococcus'' until 1984, when genomic DNA analysis indicated a separate genus classification would be appropriate.<ref>{{cite journal |vauthors=Schleifer KH, Kilpper-Balz R | title = Transfer of ''Streptococcus faecalis'' and ''Streptococcus faecium'' to the genus ''Enterococcus'' nom. rev. as ''Enterococcus faecalis'' comb. nov. and ''Enterococcus faecium'' comb. nov. | journal= Int. J. Syst. Bacteriol.| year= 1984 | volume= 34 | pages= 31–34 | doi = 10.1099/00207713-34-1-31 | doi-access= free }}</ref>

==Evolution==

This genus appears to have evolved {{ma|425}} to {{Ma|500}}.<ref name=Lebreton2017>{{cite journal | vauthors = Lebreton F, Manson AL, Saavedra JT, Straub TJ, Earl AM, Gilmore MS | title = Tracing the Enterococci from Paleozoic Origins to the Hospital | journal = Cell | volume = 169 | issue = 5 | pages = 849–861.e13 | date = May 2017 | pmid = 28502769 | pmc = 5499534 | doi = 10.1016/j.cell.2017.04.027 }}</ref>

== Pathology ==

Important clinical infections caused by ''Enterococcus'' include urinary tract infections (see ''Enterococcus faecalis''), bacteremia, bacterial endocarditis, diverticulitis, meningitis, and spontaneous bacterial peritonitis.<ref name="Fisher" /><ref name="Sherris">{{cite book | veditors = Ryan KJ, Ray CG | title = Sherris Medical Microbiology | edition = 4th | pages = 294–5 |publisher = McGraw Hill | year = 2004 | isbn = 0-8385-8529-9 }}</ref><ref>{{cite journal | vauthors = Fiore M, Maraolo AE, Gentile I, Borgia G, Leone S, Sansone P, Passavanti MB, Aurilio C, Pace MC | title = Current concepts and future strategies in the antimicrobial therapy of emerging Gram-positive spontaneous bacterial peritonitis | journal = World Journal of Hepatology | volume = 9 | issue = 30 | pages = 1166–1175 | date = October 2017 | pmid = 29109849 | pmc = 5666303 | doi = 10.4254/wjh.v9.i30.1166 | doi-access = free }}</ref> Sensitive strains of these bacteria can be treated with ampicillin, penicillin and vancomycin.<ref name="Baron">{{cite book | vauthors = Pelletier Jr LL | chapter = Microbiology of the Circulatory System|title= Baron's Medical Microbiology | veditors = Albrecht T, Baron S | edition = 4th | publisher = Univ of Texas Medical Branch | year = 1996 | pmid = 21413321| url = https://www.ncbi.nlm.nih.gov/books/NBK8290/ | isbn = 0-9631172-1-1 }}</ref> In catheterized patients receiving intensive care, ''Enterococcus'' spp., have been reported the dominant cause of urinary tract infections, particularly in patients treated with cephalosporin antibiotics.<ref>{{Cite journal |last1=Karlsson |first1=Philip A. |last2=Pärssinen |first2=Julia |last3=Danielsson |first3=Erik A. |last4=Fatsis-Kavalopoulos |first4=Nikos |last5=Frithiof |first5=Robert |last6=Hultström |first6=Michael |last7=Lipcsey |first7=Miklos |last8=Järhult |first8=Josef D. |last9=Wang |first9=Helen |date=2023-02-07 |title=Antibiotic use during coronavirus disease 2019 intensive care unit shape multidrug resistance bacteriuria: A Swedish longitudinal prospective study |journal=Frontiers in Medicine |language=English |volume=10 |article-number=1087446 |doi=10.3389/fmed.2023.1087446 |doi-access=free |issn=2296-858X |pmc=9941185 |pmid=36824610}}</ref><ref>{{Cite journal |last1=Karlsson |first1=Philip A. |last2=Bolin |first2=Christian |last3=Spång |first3=Labolina |last4=Frithiof |first4=Robert |last5=Hultström |first5=Michael |last6=Lipcsey |first6=Miklos |last7=Wang |first7=Helen |last8=Järhult |first8=Josef D. |date=2025-03-04 |title=Bacteriuria and antibiotic use during the third wave of COVID-19 intensive care in Sweden |url=https://www.tandfonline.com/doi/full/10.1080/23744235.2024.2423884 |journal=Infectious Diseases |language=en |volume=57 |issue=3 |pages=284–293 |doi=10.1080/23744235.2024.2423884 |pmid=39509144 |issn=2374-4235|doi-access=free }}</ref> Recent work has shown that multiple genetically distinct ''Enterococcus'' sequence types, including antibiotic resistant and high risk clones, can coexist in the same urine sample from a single ICU patient, with the more virulent lineage often present only as a minority subpopulation - undetectable by standard diagnostics.<ref name=":0" /> Urinary tract infections can be treated specifically with nitrofurantoin, even in cases of vancomycin resistance.<ref name="pmid11120989">{{cite journal | vauthors = Zhanel GG, Hoban DJ, Karlowsky JA | title = Nitrofurantoin is active against vancomycin-resistant enterococci | journal = Antimicrobial Agents and Chemotherapy | volume = 45 | issue = 1 | pages = 324–326 | date = January 2001 | pmid = 11120989 | pmc = 90284 | doi = 10.1128/AAC.45.1.324-326.2001 }}</ref> thumb|left|Example of a workup algorithm of possible bacterial infection in cases with no specifically requested targets (non-bacteria, mycobacteria etc.), with most common situations and agents seen in a New England community hospital setting. ''Enterococcus'' is included near bottom-center.

=== Meningitis === {{Main|Meningitis}} Enterococcal meningitis is a rare complication of neurosurgery. It is often treated with intravenous or intrathecal vancomycin, yet it is debatable as to whether its use has any impact on outcome. The removal of any neurological devices is a crucial part of the management of these infections.<ref name="Guardado_2006">{{cite journal | vauthors = Guardado R, Asensi V, Torres JM, Pérez F, Blanco A, Maradona JA, Cartón JA | title = Post-surgical enterococcal meningitis: clinical and epidemiological study of 20 cases | journal = Scandinavian Journal of Infectious Diseases | volume = 38 | issue = 8 | pages = 584–588 | year = 2006 | pmid = 16857599 | doi = 10.1080/00365540600606416 | s2cid = 24189202 }}</ref> New epidemiological evidence has shown that enterococci are major infectious agent in chronic bacterial prostatitis.<ref>{{cite web | title = Enterococcus sp rRNA [Presence] in Specimen by Probe | url = https://loinc.org/5001-3 | id = 5001-3 | work = Logical Observation Identifiers Names and Codes (LOINC) | publisher = Regenstrief Institute, Inc. }}</ref> Enterococci are able to form biofilm in the prostate gland, making their eradication difficult.{{citation needed|date=February 2023}} Cases of enterococcal meningitis, in the absence of trauma or surgery, should raise suspicion of an underlying intestinal pathology (e.g., strongyloidiasis).<ref>{{cite journal | vauthors = Cosimi L, Di Bella S, Luzzati R, Simeth CT, Pinamonti M, Cominotto F, Sisto UG | title = Enterococcal meningitis associated with ''Strongyloides'' infection: a case report and literature review | journal = Le Infezioni in Medicina | volume = 31 | issue = 4 | pages = 583–590 | date = 2023-12-01 | pmid = 38075422 | pmc = 10705849 | doi = 10.53854/liim-3104-18 }}</ref>

=== Bloodstream infections === {{Main|Bloodstream infections}} ''Enterococcus'' species are frequent causes of hospital-acquired bloodstream infections (BSIs). They ranked as the second most common cause of ICU-acquired BSIs in Europe in 2019. Enterococcal BSIs have high mortality rates, typically around 20–30%.<ref>{{Cite journal |last1=Scharloo |first1=Fenna |last2=Cogliati Dezza |first2=Francesco |last3=López-Hernández |first3=Inmaculada |last4=Martínez Pérez-Crespo |first4=Pedro María |last5=Goikoetxea Aguirre |first5=Ane Josune |last6=Pérez-Rodríguez |first6=María Teresa |last7=Fernandez-Suarez |first7=Jonathan |last8=León Jiménez |first8=Eva |last9=Morán Rodríguez |first9=Miguel Ángel |last10=Fernández-Natal |first10=Isabel |last11=Reguera Iglesias |first11=José María |last12=Natera Kindelán |first12=Clara |last13=Fariñas Álvares |first13=Maria Carmen |last14=Boix-Palop |first14=Lucía |last15=Lopez-Cortes |first15=Luis Eduardo |date=2024 |title=Clinical characteristics, predisposing factors and outcomes for Enterococcus faecalis versus Enterococcus faecium bloodstream infections: a prospective multicentre cohort study |journal=European Journal of Clinical Microbiology & Infectious Diseases |language=en |volume=43 |issue=10 |pages=2011–2022 |doi=10.1007/s10096-024-04917-5 |issn=0934-9723 |pmc=11405461 |pmid=39112668}}</ref> Outcomes tend to be worse for ''E. faecium'' infections, which often exhibit higher antibiotic resistance (e.g. high rates of vancomycin resistance). The incidence of vancomycin-resistant ''Enterococcus'' infections has been rising globally. In a 2014–2021 cohort study of 584 patients with enterococcal BSI, the 30-day mortality was 27.5%. Mortality was significantly higher when the infection was caused by vancomycin-resistant ''E. faecium'' (36.6%) or vancomycin-susceptible ''E. faecium'' (31.8%) than when caused by ''E. faecalis'' (23.2%).<ref>{{Cite journal |last1=Zerbato |first1=Verena |last2=Pol |first2=Riccardo |last3=Sanson |first3=Gianfranco |last4=Suru |first4=Daniel Alexandru |last5=Pin |first5=Eugenio |last6=Tabolli |first6=Vanessa |last7=Monticelli |first7=Jacopo |last8=Busetti |first8=Marina |last9=Toc |first9=Dan Alexandru |last10=Crocè |first10=Lory Saveria |last11=Luzzati |first11=Roberto |last12=Di Bella |first12=Stefano |date=2024-06-27 |title=Risk Factors for 30-Day Mortality in Nosocomial Enterococcal Bloodstream Infections |journal=Antibiotics |language=en |volume=13 |issue=7 |pages=601 |doi=10.3390/antibiotics13070601 |doi-access=free |issn=2079-6382 |pmc=11273391 |pmid=39061283}}</ref> Enterococcal bacteremia can also lead to infective endocarditis.

== Antibacterial resistance == From a medical standpoint, an important feature of this genus is the high level of intrinsic antibiotic resistance. Some enterococci are intrinsically resistant to β-lactam-based antibiotics (penicillins, cephalosporins, carbapenems), as well as many aminoglycosides.<ref name="Sherris" /> In the last two decades, particularly virulent strains of ''Enterococcus'' that are resistant to vancomycin (vancomycin-resistant ''Enterococcus'', or VRE) have emerged in nosocomial infections of hospitalized patients, especially in the US.<ref name="Fisher" /> Other developed countries, such as the UK, have been spared this epidemic, and, in 2005, Singapore managed to halt an epidemic of VRE.<ref>{{cite journal | vauthors = Kurup A, Chlebicki MP, Ling ML, Koh TH, Tan KY, Lee LC, Howe KB | title = Control of a hospital-wide vancomycin-resistant Enterococci outbreak | journal = American Journal of Infection Control | volume = 36 | issue = 3 | pages = 206–211 | date = April 2008 | pmid = 18371517 | pmc = 7115253 | doi = 10.1016/j.ajic.2007.06.005 }}</ref> Although quinupristin/dalfopristin (Synercid) was previously indicated for treatment of VRE in the USA, the FDA approval for this indication has since been retracted.<ref>{{cite journal | vauthors = Batts DH, Lavin BS, Eliopoulos GM | title = Quinupristin/dalfopristin and linezolid: spectrum of activity and potential roles in therapy--a status report | journal = Current Clinical Topics in Infectious Diseases | volume = 21 | pages = 227–251 | date = 2001 | pmid = 11572153 }}</ref> The rationale for the retraction of Synercid's indication for VRE was based upon poor efficacy in ''E. faecalis'', which is implicated in the vast majority of VRE cases.<ref>{{cite journal | vauthors = Collins LA, Malanoski GJ, Eliopoulos GM, Wennersten CB, Ferraro MJ, Moellering RC | title = In vitro activity of RP59500, an injectable streptogramin antibiotic, against vancomycin-resistant Gram-positive organisms | journal = Antimicrobial Agents and Chemotherapy | volume = 37 | issue = 3 | pages = 598–601 | date = March 1993 | pmid = 8460927 | pmc = 187713 | doi = 10.1128/aac.37.3.598 }}</ref><ref>{{cite journal | vauthors = Singh KV, Weinstock GM, Murray BE | title = An Enterococcus faecalis ABC homologue (Lsa) is required for the resistance of this species to clindamycin and quinupristin-dalfopristin | journal = Antimicrobial Agents and Chemotherapy | volume = 46 | issue = 6 | pages = 1845–1850 | date = June 2002 | pmid = 12019099 | pmc = 127256 | doi = 10.1128/AAC.46.6.1845-1850.2002 | doi-access = free }}</ref> Tigecycline has also been shown to have antienterococcal activity, as has rifampicin.<ref>{{cite web | title = Enterococcus sp DNA [Presence] by NAA with probe detection in Positive blood culture | url = https://loinc.org/92784-8 | id = 92784-8 | work = Logical Observation Identifiers Names and Codes (LOINC) | publisher = Regenstrief Institute, Inc. }}</ref> However, resistance to these last-resort antibiotics, including linezolid and daptomycin, is increasingly being reported, involving complex genetic mechanisms that pose new challenges for treatment.<ref>{{Cite journal |last=Lu |first=Zhaoxiang |last2=Mclnnes |first2=Ross S |last3=Allen |first3=Freya |last4=Gadar |first4=Kavita |last5=van Schaik |first5=Willem |date=2025-01-14 |editor-last=Banin |editor-first=Ehud |title=Resistance to last-resort antibiotics in enterococci |url=https://academic.oup.com/femsre/article/doi/10.1093/femsre/fuaf057/8317236 |journal=FEMS Microbiology Reviews |language=en |volume=49 |doi=10.1093/femsre/fuaf057 |issn=1574-6976 |pmc=12641126 |pmid=41206754}}</ref>

''Bacillus haynesii'' CD223 and ''Advenella mimigardefordensis'' SM421 can inhibit the growth of ''Enterococcus'' spp.<ref>{{cite journal | vauthors = Rahman MM, Paul SI, Rahman A, Haque MS, Ador MA, Foysal MJ, Islam MT, Rahman MM | title = Suppression of Streptococcosis and Modulation of the Gut Bacteriome in Nile Tilapia (''Oreochromis niloticus'') by the Marine Sediment Bacteria Bacillus haynesii and Advenella mimigardefordensis | journal = Microbiology Spectrum | volume = 10 | issue = 6 | pages = e0254222 | date = December 2022 | pmid = 36453920 | pmc = 9769507 | doi = 10.1128/spectrum.02542-22 | doi-access = free| veditors = Rogovskyy AS, Weththasinghe P, Rodriguez-Estrada U | article-number = e02542-22 }}</ref>

== Water quality ==

In bodies of water, the acceptable level of contamination is very low; for example in the state of Hawaii, and most of the United States, the limit for water off its beaches is a five-week geometric mean of 35 colony-forming units per 100 ml of water, above which the state may post warnings to stay out of the ocean.<ref name=Hawaii_DOH>{{cite web|title=Clean Water Branch |work=Hawaii State Department of Health |url=http://gen.doh.hawaii.gov/sites/har/AdmRules1/11-54.pdf |access-date=2012-05-18 |url-status=dead |archive-url=https://web.archive.org/web/20111111031411/http://gen.doh.hawaii.gov/sites/har/AdmRules1/11-54.pdf |archive-date=2011-11-11 }}</ref> In 2004, measurement of enterococci took the place of fecal coliforms as the new American federal standard for water quality at public saltwater beaches and alongside ''Escherichia coli'' at freshwater beaches.<ref>{{cite journal|title=Water Quality Standards for Coastal and Great Lakes Recreation Waters; Final Rule|journal=Federal Register|date=16 November 2004|volume=69|issue=220|pages=67218–67243|url=https://www.federalregister.gov/articles/2004/11/16/04-25303/water-quality-standards-for-coastal-and-great-lakes-recreation-waters|access-date=26 November 2014}}</ref> It is believed to provide a higher correlation than fecal coliform with many of the human pathogens often found in city sewage.<ref name=Jin_2004>{{cite journal | vauthors = Jin G, Jeng HW, Bradford H, Englande AJ | title = Comparison of E. coli, enterococci, and fecal coliform as indicators for brackish water quality assessment | journal = Water Environment Research | volume = 76 | issue = 3 | pages = 245–255 | year = 2004 | pmid = 15338696 | doi = 10.2175/106143004X141807 | bibcode = 2004WaEnR..76..245J | s2cid = 35780753 }}</ref>

== References == {{Reflist|2}}

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Category:Enterococcus Category:Bacteria genera Category:Gram-positive bacteria Category:Pathogenic bacteria

Enterococcus

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