Empirical Treatment for Gram-Positive Cocci in Chains Bacteremia

Initial Empirical Therapy

The Infectious Diseases Society of America recommends initiating empirical therapy with vancomycin for patients with hemodynamic instability, severe sepsis, catheter-related infection, or risk factors for resistant organisms; otherwise, a beta-lactam such as cefepime, piperacillin-tazobactam, or a carbapenem is recommended 1, 2
For high-risk patients, vancomycin should be added to the initial empirical regimen when any of the following are present: hemodynamic instability or severe sepsis, positive blood cultures showing gram-positive cocci before final identification, clinically suspected catheter-related infection, known colonization with methicillin-resistant Staphylococcus aureus (MRSA) or penicillin-resistant Streptococcus pneumoniae, or severe mucositis with prior fluoroquinolone prophylaxis 1, 3

The American College of Physicians suggests that risk stratification determines initial antibiotic choice, with high-risk patients requiring vancomycin and standard-risk patients receiving beta-lactam monotherapy 1, 3
High-risk patients include those with hemodynamic instability, severe sepsis, catheter-related infection, or risk factors for resistant organisms, and should receive vancomycin in addition to a beta-lactam 1, 3

The Infectious Diseases Society of America recommends cefepime, carbapenems (imipenem, meropenem), or piperacillin-tazobactam for standard-risk patients, as these agents have excellent activity against viridans streptococci and most enterococci 1, 3
Ceftazidime should be avoided as monotherapy due to its lack of adequate gram-positive coverage 1, 3

The Infectious Diseases Society of America recommends a duration of therapy of 7-14 days for uncomplicated bacteremia with source control, and 4-6 weeks for complicated infections (persistent bacteremia, endocarditis, suppurative thrombophlebitis) 2, 5

The Infectious Diseases Society of America recommends removing long-term catheters if severe sepsis, persistent bacteremia >72 hours despite appropriate antibiotics, or evidence of endocarditis or suppurative thrombophlebitis is present 2

The American College of Physicians advises against using ceftazidime plus aminoglycoside combinations, as they lack adequate gram-positive coverage 3
The Infectious Diseases Society of America recommends against continuing empirical vancomycin beyond 48 hours if cultures are negative for resistant organisms 1, 2
The American College of Physicians advises against delaying appropriate therapy in critically ill patients, as mortality increases with treatment delays 2
The Infectious Diseases Society of America recommends against using linezolid, daptomycin, or other newer agents empirically unless specific risk factors for VRE or MRSA are present 1
The American College of Physicians advises against forgetting to adjust vancomycin and other renally cleared antibiotics in patients with renal impairment 2, 5