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What do you use for treatment for endocarditis caused by HLAR +ve Enterococcus faecalis?
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Lets talk about #Enterococcus #bacteremia 🧵
2 important species - E.faecalis, E faecium
E.faecium is generally more resistant, but lower risk of endocarditis
E.faecalis, usually S to Ampicillin, but IR to Quinopristin-Dalfopristin
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Also, note- Enterococcus is IR to Cephalosporins, Aminoglycosides
Bacteremia source - Indwelling catheter, GI, Urinary tract
DOC for bacteremia - Ampicillin/Penicillin if S
If, Ampi R - Vanco/Teico
Combination therapy in case of suspicion of endocarditis or septic shock
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When to suspect Enterococcus Endocarditis?
DENOVA score can be used
•Duration of symptoms ≥7 days
•Evidence of embolization
•Number of positive blood cultures (>/=2)
•Unknown origin of bacteremia
•Prior heart valve disease
•Auscultation of a heart murmur
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What combination therapy to be given?
Though Enterococcus is IR to Aminoglycosides, combination of cell wall active agent like bat-lactam can be used with Aminoglycosides - Synergy+
Synergy is determined by Susceptibility to high level Aminoglycoside (HLAR)
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If HLAR - S, Beta-lactam - S - then synergy will be present
Combination of choice depends on the presence or absence of synergy
Ampicillin+ Ceftriaxone can be used in presence or absence of synergy and relatively renal safe
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Treatment of VRE - Depends on species & AST
Determine Van type
Ampicillin S E.faecalis - Ampicillin
Ampicillin R, E.faecium - Daptomycin based combination
Alternative - Linezolid
Van B - Teicoplanin
Duration of therapy
Uncomplicated bacteremia - 14 days
Complicated - 4 weeks
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Further reading - clinicalmicrobiologyandinfection.com/article/S1198-…