Mohammad Sholeh ¹ Samane Moradi ² Mahya Abedi Moghadam ² Zahra Teymouri ² Faezeh Motallebi Tabaei ² Masoumeh Beig ^1*

• ¹ Pasteur Institute of Iran (PII), Tehran, Iran
• ² Golestan University of Medical Sciences, Gorgan, Golestan, Iran

This review examines antibacterial resistance in Enterococcus faecalis beyond clinical settings, highlighting the presence of resistance in animals, food, and the environment. Using a "One Health" approach that links human, animal, and environmental health, it assesses resistance patterns in non-clinical isolates across different regions and time periods, with a focus on how geography affects these patterns. Between 2003 and 2022, we meticulously searched various databases, such as Scopus, PubMed, Web of Science, and EMBASE. Quality assessment was performed using the Joanna Briggs Institute Checklist. Resistance proportions were estimated using a random-effects model with additional analyses, including meta-regression, subgroup evaluation, and identification of outliers and influential studies. Statistical analysis was performed using R programming language and metaphor package for thorough data management. This systematic review and meta-analysis examined data from 34 studies conducted between 2003 and 2022 across 17 countries. Significant variability in resistance among non-clinical E. faecalis isolates was observed, with differences attributed to antibacterial agents, geographic regions, time periods, and isolation sources. Resistance rates varied considerably, with the highest rate observed for rifampicin at 75.3% (95% CI: 40.5%, 93.2%) and the lowest for teicoplanin at 3.1% (95% CI: 1.4%, 6.9%). Notable resistance rates included 66.5% for doxycycline, 53.5% for tetracycline, and 48.2% for quinupristin/dalfopristin. Additional resistance rates were as follows: 14.9% for linezolid, 10.5% for gentamicin, 8.7% for ampicillin, 8.6% for tigecycline, 7.3% for nitrofurantoin, 4.3% for daptomycin, and 4.0% for vancomycin. Geographic variations and sources of isolate significantly influenced these resistance patterns. A key limitation of this study is its limited sample of 17 countries, which may not fully represent global resistance patterns. However, with data spanning 6 continents, it provides a broad geographical perspective. This study highlights the urgent need for a collaborative One Health approach to tackle antibacterial resistance in E. faecalis, integrating human, animal, and environmental health sectors.