## 3 Results
### Multidrug Resistance and esp/asa1 Gene Prevalence among Enterococcus spp. Isolates
A lower frequency was reported in Europe and Canada (4%-6%) [45, 46], similar to our results (vancomycin-resistant _E. ficeium_, \(n\) = 4). However, the studies of enterococcal antimicrobial susceptibility across the world have confirmed an increase in multidrug resistance, especially to vancomycin [26, 47, 48]. All of the vancomycin-resistant _E. ficeium_ in our study showed multidrug resistance, similar to data from American authors [49, 50]. In the present study, the _vanA_ gene was detected in 17% (_n_ = 19) of the tested isolates, while all of the four vancomycin-resistant enterococci carried the gene. Similar results, 17% and 15%, respectively, were reported in Iran [51, 52]. Although 19 isolates expressed the _vanA_ gene, they were all susceptible to teicoplanin. the _VanB_ gene was not detected in any of the enterococcal isolates tested in our study, which agrees with [PERSON] et al. [26]. The _van_ genotypes determined in this study by multiplex PCR were not fully compatible with the vancomycin-/teicoplanin-resistance phenotypes, but such discrepancies have also been reported previously [53, 54, 55]. Reports of _esp_ prevalence among VRE isolates vary according to region and population [31, 35]. Three of the four _vanA_-positive MDR _E. ficeium_ in our study possessed the _esp_ gene, which is similar to previous results [31, 56]. The _esp_ gene in _E. ficeium_ is a marker of a pathogenic island that can be transmitted through conjugation to other isolates, and the _vanA_ gene is often found on plasmids [57, 58]. Therefore, the identification of isolates positive for both _esp_ and _vanA_ genes must be truly accurate in order to emphasize the infection control strategies and prevent the spread of quorum-sensing regulation genes and antimicrobial-resistance genes to other cells. In recent decades, an increasing incidence of enterococci with high rates of resistance to various antimicrobial agents has been reported, and the reason for this is thought to be horizontal gene transfer, as plasmids and transposable elements typically carry resistance determinants to more than one class of antimicrobial agents. Multidrug resistance was observed in 43 (39%) of the enterococcal strains tested in our study, with the _A-CP-G (HLAR)_ multiple-resistance profile being prevalent (60%). According to the available information, the extent of MDR among clinical enterococcal isolates varies between 32% and 100% in parts of Asia and Africa [59, 60, 58, 59, 22, 35], and this phenomenon can be explained by the overuse of antimicrobial agents and selective pressure. In contrast with our results, a much higher rate of multidrug-resistant enterococci was reported in China, India, and Egypt (60%, 63%, and 88%, respectively) [22, 38]. This situation necessitates the implementation of an effective infection control program and the regular monitoring of the antimicrobial resistance of _Enterococcus_ spp., in order to establish a rational antibiotic policy for the better management of enterococcal infections. Considering the alarming and increasing development of multidrug-resistant enteococci responsible for several infections that are difficult to treat due to the inefficaciousness of conventional antibiotics, this study is interesting, relevant, and of high importance for the design of protocols (surveillance, diagnostic, treatment) aimed at overcoming this emergency problem.