Figure 4.

vanA VREfm cluster timeline and genomic transmission networks.

A. Timeline of vanA VREfm cases over the study periods, separated by ST and sub-cluster (cl) along the Y axis, and coloured by hospital network. Timeline is separated into pilot phase (left) and implementation phase (right); shaded timeframe shows the time between phases without sampling. Each point represents one case; only the first sample for each case in the study is included. Points have been separated vertically to allow for visualisation of closely-spaced cases. Sample sequences that did not cluster with any other study cases are shown in the ‘Singletons’ panel.

B. Network diagram of genomic and epidemiologic links between vanA VREfm cases. Each point represents one case; only the first sample for each case in the study is included, and is coloured by hospital network. The yellow circles outline genomic clusters, and lines between points represent epidemiologic links between cases (thick line, probable transmission; dotted line, possible transmission; green line, same patient. Absence of line indicates unlikely transmission by epidemiology, i.e. no known overlap between patients in space or time).

Abbreviations: VREfm, vancomycin-resistant Enterococcus faecium; ST, sequence type; cl, cluster; SNP, single-nucleotide polymorphism.