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. 2020 Aug 10;9:130. doi: 10.1186/s13756-020-00770-1

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© The Author(s) 2020

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

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Fig. 2 — Course of events in the epidemiology of AREfm and VREfm and the differences between the US and Europe from 1970 till 2010. In the United States (US) the increase of AREfm started around 1980 followed by an increase of VRE. In Europe, this event started 20 years later. Note the different situation between the US and Europe; in contrast to the US, Europe did have a large reservoir of VRE in the community in the 1990s, yet without suitable HA AREfm populations in hospitals to take up the van genes and become HA VREfm. This reservoir of VRE was linked to the avoparcin use in husbandry. In blue: Hospital Clade A1-VSEfm (AREfm). In red: hospital-Clade A1 VREfm. HGT: horizontal gene transfer (of van genes). Threshold: hypothetical critical number of hospital clade A1 AREfm strains needed for the introduction of van genes