Treatment of Panresistant Enterococcus faecium Bacteremia

First-line Treatment Options

High-dose daptomycin (10-12 mg/kg/day IV) should be used as the backbone of therapy for panresistant E. faecium bacteremia 1, 2
Combination therapy with daptomycin plus ampicillin or ceftaroline is strongly recommended, especially for persistent bacteremia or strains with high MICs to daptomycin within the susceptible range 1, 2

Start with high-dose daptomycin (10-12 mg/kg/day) plus ampicillin or ceftaroline 1, 2
Treatment duration should be 7-14 days if catheter-related and removed, or if source control is achieved 3
Follow-up blood cultures should be obtained to document clearance of bacteremia 3

High-dose daptomycin (10-12 mg/kg/day) plus ampicillin or ceftaroline for at least 6 weeks 1, 2
Obtain transesophageal echocardiography (TEE) if signs/symptoms of endocarditis are present, bacteremia persists >72 hours despite appropriate therapy, or if the patient has prosthetic valves or other endovascular foreign bodies 3
Source control is critical, including removal of infected catheters or devices 3

Patients with panresistant E. faecium infections should be managed by a multidisciplinary team including specialists in infectious diseases, cardiology, cardiovascular surgery, and clinical pharmacy 1, 2
For catheter-related infections, removal of infected catheters is strongly recommended, especially for short-term catheters 3
For long-term catheters that cannot be removed, antibiotic lock therapy should be used in addition to systemic therapy 3
Persistent bacteremia (>72 hours despite appropriate therapy) should prompt removal of any retained catheters and evaluation for endocarditis or metastatic foci of infection 3

Linezolid 600 mg IV or orally every 12 hours may be used if daptomycin cannot be used, but be aware of potential bone marrow suppression and neuropathy with prolonged use 1, 4
Tigecycline 100 mg IV loading dose followed by 50 mg IV every 12 hours may be considered for intra-abdominal infections due to VRE 4
For urinary tract infections specifically, options include fosfomycin 3 g PO (single dose), nitrofurantoin 100 mg PO every 6 hours, or high-dose ampicillin (18-30 g IV daily in divided doses) 4

Obtain follow-up blood cultures to document clearance of bacteremia 3
Monitor for development of resistance during therapy, especially with daptomycin 1, 2
For linezolid therapy, monitor complete blood counts weekly due to risk of bone marrow suppression 4

Daptomycin monotherapy has been associated with treatment failures and development of resistance during therapy 1, 2
Standard doses of daptomycin (6 mg/kg/day) are inadequate for treating panresistant E. faecium; higher doses (10-12 mg/kg/day) are required 1, 2
Combination therapy with daptomycin and a β-lactam (ampicillin or ceftaroline) shows synergistic activity in vitro and may prevent the emergence of resistance 1, 2
Linezolid is bacteriostatic against enterococci, which may limit its effectiveness in endovascular infections 1
Source control is critical for successful treatment; failure to remove infected devices or drain abscesses will likely result in treatment failure 3

All statements are derived from the Clinical Infectious Diseases guideline (2010) and reinforced by Critical Care Medicine (2013) where noted.