Treatment of Vancomycin-Resistant Enterococcus Infections

Introduction to Treatment Guidelines

The American College of Microbiology recommends linezolid 600 mg IV or PO every 12 hours as the first-line treatment for most serious VRE infections, with strong guideline support (1C evidence) across pneumonia, bloodstream infections, and complicated intra-abdominal infections 1

For uncomplicated VRE cystitis, the Infectious Diseases Society of America recommends fosfomycin 3 g PO as a single dose (2D evidence) or nitrofurantoin 100 mg PO every 6 hours for 5-7 days (2D evidence) 1, 3
For complicated VRE UTI or pyelonephritis, the European Society of Clinical Microbiology and Infectious Diseases recommends linezolid 600 mg IV or PO every 12 hours for 10-14 days (1C evidence) 1, 3
For VRE bloodstream infections, the American College of Microbiology recommends high-dose daptomycin ≥9 mg/kg/day, which is associated with significantly lower mortality (adjusted OR 0.26, 95% CI 0.09-0.74) compared to standard dosing 2
For VRE pneumonia, the Infectious Diseases Society of America recommends linezolid 600 mg IV every 12 hours for at least 7 days (1C evidence) 1
For VRE complicated intra-abdominal infections, the European Society of Clinical Microbiology and Infectious Diseases recommends linezolid 600 mg IV every 12 hours (1C evidence) or tigecycline 100 mg IV loading dose, then 50 mg IV every 12 hours (2D evidence) 1, 4

The American College of Microbiology recommends monitoring for serotonin syndrome symptoms every 4-6 hours during the first 72 hours when using linezolid, due to significant risk when combined with SSRIs, SNRIs, tricyclic antidepressants, or bupropion 6
The European Society of Clinical Microbiology and Infectious Diseases recommends monitoring creatine kinase (CK) levels when using high-dose daptomycin, though meta-analysis showed no significantly increased risk with high-dose regimens 2

The Infectious Diseases Society of America recommends differentiating VRE colonization from true infection before prescribing anti-VRE antimicrobials, as unnecessary treatment drives resistance and increases costs 5, 2
The American College of Microbiology recommends obtaining susceptibility testing, as approximately 60% of E. faecium are vancomycin-resistant with variable ampicillin susceptibility 2
The European Society of Clinical Microbiology and Infectious Diseases recommends removing central venous catheters or other foreign bodies and ensuring adequate surgical drainage of closed-space infections 2, 1

The Infectious Diseases Society of America recommends avoiding tigecycline for VRE bacteremia or suspected upper tract infection due to poor serum concentrations despite large volume of distribution 3
The American College of Microbiology recommends avoiding ceftaroline for VRE infections due to poor activity against enterococcus 5
The European Society of Clinical Microbiology and Infectious Diseases recommends considering cardiac surgery and combination antibiotic therapy for VRE endocarditis, as it improves survival outcomes 5