Enterococcus faecalis harbors a virulence-associated surface protein encoded by the esp gene. This gene has been shown to be part of a 150-kb putative pathogenicity island. A gene similar to esp has recently been found in Enterococcus faecium isolates recovered from hospitalized patients. In the present study we analyzed the polymorphism in the esp gene of E. faecium, and we investigated the association of esp with neighboring chromosomal genes. The esp gene showed considerable sequence heterogeneity in the regions encoding the nonrepeat N-and C-terminal domains of the Esp protein as well as differences in the number of repeats. DNA sequencing of chromosomal regions flanking the esp gene of E. faecium revealed seven open reading frames, representing putative genes implicated in virulence, regulation of transcription, and antibiotic resistance. These flanking regions were invariably associated with the presence or absence of the esp gene in E. faecium, indicating that esp in E. faecium is part of a distinct genetic element. Because of the presence of virulence genes in this gene cluster, the lower G؉C content relative to that of the genome, and the presence of esp in E. faecium isolates associated with nosocomial outbreaks and clinically documented infections, we conclude that this genetic element constitutes a putative pathogenicity island, the first one described in E. faecium. Except for the presence of esp and araC, this pathogenicity island is completely different from the esp-containing pathogenicity island previously disclosed in E. faecalis.Enterococci are common inhabitants of the gastrointestinal tracts of humans and animals, and although they have been recognized as pathogens able to cause endocarditis, they were generally considered second-rate pathogens. Recent estimates, however, indicate that enterococci are now among the leading causes of nosocomial infections (57). Of all enterococcal species, Enterococcus faecalis accounted for the most infections in humans (26). However, during the past decade, the incidence of bloodstream infections caused by Enterococcus faecium increased, an increase which has been linked to the emergence of antibiotic resistance in this species (26,40).Little is known about virulence determinants in E. faecium (20). Recently, however, three potential virulence genes, esp, hyl, and acm, have been described for E. faecium. They were all found more frequently in clinical isolates than in fecal isolates or nonhuman isolates (13,41,44,65).Of these three putative virulence genes, only the esp gene is also found in E. faecalis (51). The Esp protein in E. faecalis is expressed as a large surface-exposed protein with a molecular mass of approximately 202 kDa. In E. faecalis, Esp is thought to be an adhesin contributing to colonization of urinary tract epithelial cells and biofilm formation (50, 59). Although detailed experimental evidence is not yet available, the higher prevalence of the E. faecium esp gene in clinical isolates suggests a role of Esp in the pathogenesis of E. faeci...