Treatment of Enterococcus Faecalis Bacteremia

First-Line Treatment

The American Heart Association recommends ampicillin plus gentamicin as the first-line treatment for vancomycin-sensitive Enterococcus faecalis bacteremia in patients with normal renal function, with ampicillin 2g IV every 4 hours and gentamicin 3 mg/kg/day IV in 3 divided doses 1
This double β-lactam combination is particularly valuable for patients with normal or impaired renal function, or those with abnormal cranial nerve function 1

For patients unable to tolerate penicillin or ampicillin, the American Heart Association recommends vancomycin plus gentamicin, with vancomycin 30 mg/kg/day IV in 2 divided doses and gentamicin 3 mg/kg/day IV in 3 divided doses, although this combination has increased risk of ototoxicity and nephrotoxicity compared to penicillin-gentamicin combinations 1
For vancomycin-resistant E. faecalis, Linezolid 600 mg IV/PO every 12 hours is recommended by the American College of Emergency Physicians and the World Journal of Emergency Surgery 2, 3
For vancomycin-resistant E. faecalis, Daptomycin 8-12 mg/kg/day (higher doses for serious infections) is recommended by the American Heart Association and Infectious Diseases Society of America 3, 4
For vancomycin-resistant E. faecalis with intra-abdominal infections, Tigecycline is recommended by the World Journal of Emergency Surgery 3
For penicillin-allergic patients, Vancomycin (30 mg/kg/day IV in 2 divided doses) is recommended by the American Heart Association 1

For bloodstream infections, the treatment duration is 10-14 days for uncomplicated bacteremia, and 4-6 weeks if endocarditis is suspected or confirmed, with native valve with symptoms <3 months requiring 4 weeks, native valve with symptoms >3 months requiring 6 weeks, and prosthetic valve requiring a minimum of 6 weeks 1
The European Society for Medical Oncology recommends treatment duration of 10-14 days for bloodstream infections with central venous catheters 5
Uncomplicated infections typically require 7-14 days of treatment, while bloodstream infections with central venous catheters require 10-14 days of treatment, and a longer treatment course (e.g., 37 days) may be warranted in patients with complex surgical histories or recent intra-abdominal abscesses 1, 6, 4

Catheter removal is generally recommended for catheter-related infections, as suggested by the European Society for Medical Oncology and Infectious Diseases Society of America 5, 4
Infected catheters should be removed immediately for enterococcal bloodstream infections, and new catheter placement should only occur after blood cultures clear, as recommended by the Clinical Infectious Diseases guidelines and Infectious Diseases Society of America 4, 1
Infection control measures should be evaluated on a case-by-case basis, and enhanced precautions may be needed for epidemic outbreaks or isolates suspected of harboring transmissible resistance elements, as recommended by the Infectious Diseases Society of America 7

Weekly renal function tests are recommended with aminoglycoside therapy, and weekly complete blood counts are recommended with linezolid therapy, and follow-up blood cultures should be performed to ensure clearance of bacteremia 1
Weekly creatine kinase (CK) levels should be monitored to detect potential myopathy, and a transesophageal echocardiogram (TEE) should be considered if there is persistent fever or bacteremia beyond 72 hours of appropriate therapy, new murmur or embolic phenomena, or presence of prosthetic valves or other endovascular devices 1, 4

E. faecalis is intrinsically resistant to cephalosporins (monotherapy), trimethoprim-sulfamethoxazole, clindamycin, and aminoglycosides (low-level resistance), and using cephalosporins as monotherapy is a common mistake, as it is ineffective against E. faecalis due to intrinsic resistance 6
The European Society of Cardiology recommends against using Ceftin (cefuroxime) as monotherapy for treating Enterococcus faecalis infections due to intrinsic resistance to cephalosporins, with a strength of evidence supporting alternative treatments 3
Infectious disease consultation is strongly recommended for serious or complicated enterococcal infections, especially endocarditis or VRE infections, to guide optimal therapy, as recommended by the American Heart Association and Infectious Diseases Society of America 8, 1