Management of Gram-Positive Cocci in Pairs on Blood Cultures

Initial Assessment

The Infectious Diseases Society of America recommends obtaining at least one additional set of blood cultures from peripheral sites to confirm the initial finding and rule out contamination 2, 1
If a central venous catheter is present, the Infectious Diseases Society of America suggests collecting blood cultures from each lumen of the catheter 2
Monitoring of complete blood count, renal function, electrolytes, and hepatic enzymes is recommended to assess the patient's clinical status and potential organ dysfunction 2
Evaluation for signs of severe sepsis or hemodynamic instability is necessary to determine the need for continued broad-spectrum coverage 3

The American College of Clinical Pharmacy recommends that the current regimen of cefepime and vancomycin is appropriate for empiric coverage of gram-positive cocci in pairs pending identification 3, 1
Cefepime provides excellent coverage against many strains of viridans streptococci and other gram-positive organisms, according to the Infectious Diseases Society of America 3
Vancomycin is appropriate for empiric coverage of potentially resistant gram-positive organisms, including MRSA and resistant pneumococci, as recommended by the American College of Clinical Pharmacy 3, 1

Gram-positive cocci in pairs commonly represent Streptococcus pneumoniae, according to the Infectious Diseases Society of America 3
Viridans group streptococci are also a common cause of gram-positive cocci in pairs, as noted by the American Heart Association 4
Enterococci, including Enterococcus faecium, can also cause gram-positive cocci in pairs, as recommended by the Infectious Diseases Society of America 1

If Streptococcus pneumoniae is identified, the Infectious Diseases Society of America recommends de-escalating from vancomycin to appropriate β-lactam therapy if the isolate is susceptible 1
If Viridans streptococci are identified, cefepime alone provides excellent coverage for most viridans streptococci, according to the Infectious Diseases Society of America 3
If Enterococci are identified, vancomycin should be continued for Enterococcus faecium pending susceptibility, as recommended by the Infectious Diseases Society of America 1
If Staphylococcus aureus is identified, vancomycin should be continued for MRSA, according to the Infectious Diseases Society of America 1

The American College of Clinical Pharmacy recommends monitoring vancomycin trough levels if therapy continues beyond 72 hours, especially in patients with impaired renal function 1
Reassessment of therapy is necessary when culture and susceptibility results become available, typically within 48-72 hours, as recommended by the Infectious Diseases Society of America 1
Consideration of infectious disease consultation is recommended for complicated infections or if endocarditis is suspected, according to the American Heart Association 4

The Infectious Diseases Society of America warns against continuing vancomycin unnecessarily when cultures identify organisms susceptible to narrower-spectrum antibiotics 1
The American College of Clinical Pharmacy advises against treating a single positive blood culture for coagulase-negative staphylococci without confirmation from a second culture 3
Failing to investigate for endocarditis in patients with persistent bacteremia is a common pitfall, as noted by the American Heart Association 4
Discontinuing antibiotics prematurely before complete identification and susceptibility testing is not recommended, according to the Infectious Diseases Society of America 1