Treatment of Vancomycin-Resistant Enterococci (VRE) Endocarditis

First-line Treatment Options

The American College of Cardiology recommends linezolid 600 mg IV every 12 hours as the strongly recommended first-line therapy for VRE endocarditis with strong evidence (Level 1C) 1, 2
Cardiac surgery combined with antimicrobial therapy should be considered for the treatment of infective endocarditis, according to the American Heart Association 1, 3
Treatment duration should be individualized according to clinical response, but typically requires at least 10-14 days of therapy, often longer for endocarditis, as suggested by the Infectious Diseases Society of America 2

Daptomycin 8-12 mg/kg IV daily is an alternative option (Level 2C), with higher doses (≥11 mg/kg) showing improved survival in patients with VRE bloodstream infections, particularly for isolates with higher MICs, according to the European Society of Clinical Microbiology and Infectious Diseases 2, 4
Combination therapy with daptomycin plus beta-lactams may be considered for VRE bloodstream infections with high daptomycin MIC (3-4 mg/mL), as recommended by the Society for Healthcare Epidemiology of America 2, 4

Monitor creatine kinase levels when using higher doses of daptomycin, as doses ≥11 mg/kg are associated with a higher rate (3.9%) of significantly elevated creatine kinase (>2000 U/L), according to the American College of Clinical Pharmacy 4

Daptomycin with ampicillin and gentamicin is a reported successful combination for multi-drug resistant VRE endocarditis with treatment failure, as suggested by the International Society for Antimicrobial Chemotherapy 4
Linezolid with tigecycline is another reported successful combination for salvage therapy, according to the European Society of Clinical Microbiology and Infectious Diseases 4

Definitive treatment duration should be individualized according to infection site, source control, underlying comorbidities, and initial response to therapy, as recommended by the Infectious Diseases Society of America 1, 2
For endocarditis, longer treatment courses (4-6 weeks) are typically required, according to the American Heart Association 4
Infectious disease specialist consultation is strongly recommended for VRE endocarditis due to the complexity of management, as suggested by the Society for Healthcare Epidemiology of America 2

Tigecycline should not be used for the treatment of VRE bacteremia or endocarditis due to its large volume of distribution and low serum levels, according to the European Society of Clinical Microbiology and Infectious Diseases 4, 5
Avoid monotherapy with cephalosporins as they have poor activity against enterococci, as recommended by the American College of Clinical Pharmacy 4
Do not delay cardiac surgery evaluation in patients with VRE endocarditis, as combined medical and surgical therapy often provides the best outcomes, according to the American College of Cardiology 3
Recognize that VRE endocarditis has a high mortality rate and early aggressive therapy is essential, as suggested by the Infectious Diseases Society of America 4, 6