review · BMC Infectious Diseases
Enterococcus faecalis is an important cause of healthcare-associated infections, frequently persisting and resisting medical treatment through the formation of biofilms. A comprehensive review and meta-analysis of 56 studies published between 2015 and 2024 evaluated 3,739 clinical isolates to determine the global scale of this issue. Across all evaluated data, the global pooled prevalence of biofilm-forming Enterococcus faecalis was estimated at 68.68 per cent. Biofilm formation rates varied significantly across clinical sources and geographic regions, with isolates recovered from urine exhibiting the highest prevalence at 80.47 per cent. Furthermore, nearly half of all biofilm-positive isolates were categorised as strong producers, with higher overall prevalence observed in studies conducted between 2021 and 2024 compared to earlier years. These insights highlight the widespread nature of biofilm-producing pathogens in hospital settings.
Biofilms protect bacteria from standard antibiotic therapies and immune responses, leading to persistent hospital infections that are exceptionally hard to clear. Establishing that over two thirds of clinical Enterococcus faecalis isolates form biofilms worldwide underscores the challenge facing infection control and guides the need for updated clinical management protocols.
This meta-analysis provides epidemiological baseline evidence rather than a product, highlighting demand for standardised diagnostic protocols and novel anti-biofilm therapies. Diagnostic developers and pharmaceutical firms could utilise these findings to target treatment pathways for urinary and healthcare-associated infections, though the work itself remains at an analytical, non-applied stage.
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BACKGROUND: Enterococcus faecalis (E. faecalis) is a major cause of healthcare-associated infections (HAIs). It exhibits a strong biofilm-forming ability, which contributes to treatment resistance and persistence. Despite its clinical relevance, the global prevalence of biofilm-forming E. faecalis remains poorly defined. This study aimed to estimate the pooled prevalence of biofilm-forming E. faecalis in clinical isolates worldwide. METHODS: Following PRISMA 2020 guidelines, we systematically searched PubMed, Scopus, ScienceDirect, Google Scholar, and institutional repositories for studies published between 2015 and 2024. A total of 56 studies involving 3,739 clinical isolates met the inclusion criteria. We used a random-effects model to estimate pooled prevalence and conducted subgroup analyses based on WHO region, continent, publication year, specimen type, and biofilm detection method. Meta-regression and sensitivity analyses assessed heterogeneity and robustness. Publication bias was evaluated using Egger's test and corrected with trim-and-fill analysis. RESULTS: The global pooled prevalence of biofilm-forming E. faecalis was 68.68% (95% CI: 61.33-76.02%), with significant heterogeneity (I² = 99.30%). By WHO region, prevalence ranged from 57.93% (95% CI: 41.01-71.85%) in South-East Asia to 73.66% (95% CI: 63.40-83.92%) in the Eastern Mediterranean. By continent, South America (all from Brazil) showed the highest prevalence at 89.79% (95% CI: 73.02-106.56%). Studies from 2021 to 2024 reported higher prevalence (76.18%, 95% CI: 66.25-86.11%) than those from 2015 to 2020. Among specimens, urine showed the highest prevalence (80.47%, 95% CI: 61.17-99.77%). Among biofilm-positive isolates, 47.92% (95% CI: 39.34-56.51%) were strong producers. Meta-regression identified WHO region (p = 0.005) and specimen type (p = 0.043) as significant sources of heterogeneity. Egger's test indicated publication bias (p = 0.0066), but trim-and-fill analysis yielded a consistent adjusted prevalence of 68.08%. CONCLUSION: Biofilm formation is highly prevalent in E. faecalis clinical isolates globally, with substantial regional and specimen-based variation. These findings highlight the urgent need for standardized biofilm detection protocols, improved infection prevention and control, tailored antibiotic stewardship, and the development of anti-biofilm therapies to mitigate biofilm-associated resistance and enhance patient outcomes.
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DOI: 10.1186/s12879-025-11399-z
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