Praxis Medical Insights

Introduction to Management

The American College of Radiology recommends that for a catheter-related infection with positive blood culture for Enterococcus faecalis, systemic ampicillin (or vancomycin if resistant) should be initiated, and the catheter may be retained if there are no complications, with antibiotic treatment for 10-14 days plus antibiotic lock therapy if the catheter is retained 1, 2.

The Infectious Diseases Society of America recommends removal of the catheter in all cases of Enterococcus infection 3, 4.
A new catheter should be placed at a different site after removal 3.
The catheter may be retained if all the following conditions are met: no infection of the insertion site or tunnel 4, no suppurative thrombophlebitis 4, no severe sepsis 4, no endocarditis 4, no persistent bacteremia 4, and no metastatic infection [4] [1, 2, 5].

The American College of Cardiology recommends ampicillin as the antibiotic of choice for susceptible E. faecalis 1, 2, 3, 4, 5, 6.
Vancomycin should be used if the isolate is resistant to ampicillin 1, 2, 3, 4, 5, 6.

The American College of Radiology recommends 10-14 days of systemic antibiotics plus antibiotic lock therapy if the catheter is retained 1, 2, 3, 4, 5, 6.
If the catheter is removed without complications, 7-14 days of systemic antibiotics are recommended 1, 2, 3, 4, 7.

The American Heart Association recommends transesophageal echocardiography (TEE) if there are signs or symptoms of endocarditis, persistent bacteremia or fever >72 hours despite appropriate antibiotics, radiographic evidence of septic pulmonary emboli, or presence of prosthetic valve or other endovascular devices 1, 2, 3, 4, 6.

The Infectious Diseases Society of America recommends obtaining follow-up blood cultures at 72 hours after starting appropriate antibiotics 3, 4, 6.
If the catheter is retained and blood cultures remain positive >72 hours, the catheter should be removed immediately 3, 4, 6.

The role of combination therapy (cell-wall active antibiotic + aminoglycoside) for enterococcal bacteremia without endocarditis is not resolved 3, 4.
Combination therapy may be considered if attempting to salvage the catheter, but there is no solid evidence of superiority over monotherapy in the absence of endocarditis 3, 4, 5.