Infection

Antibiotic(s) primary: alternative

Comments

Urinary tract infection

Intraadominal infection

Ampicillin:

Vancomycin

Nitrofurantoin Fosfomycin

Ampicillin: Beta lactamase inhibitors, Vancomycin

Nitrofurantoin only for (cystitis) with isolates susceptible, not in sepsis or renal failure, usual duration 7-10d

Not essential to treat for Enterococcus in all intraabdominal infection, unless organisms cultured, patient severely ill, duration 10-14d

Endocarditis

Ampicillin or Penicillin plus Gentamicin: Streptomycin, vancomycin (Penicillin allergy)

To be used in combination  for the treatment of enterococcal endocarditis caused by organisms susceptible in vitro to either agent; streptomycin is used when gentamicin cannot be used because of high level resistance. Ampicillin plus gentamicin for 4-6 weeks is treatment of choice for endocarditis

Intravenous Catheter Bacteremia

Ampicillin: Vancomycin

Duration 10-14d, some patients (single positive blood culture will respond to removal of the line alone

Antibiotic(s) primary

Dose, Duration

Comments

Ampicillin

12g/d IV

For rare ampicillin-susceptible isolates of Enterococcus faecium;vancomycin resistant E. faecalis are usually susceptible

Gentamicin or streptomycin

1 mg/kg q 8 hrs to achieve serum peaks of 3-4 mg/ml and trough <1 mg/ml for endocarditis, treat for at least 4-6 weeks

To be used in combination with ampicillin for the treatment of enterococcal endocarditis caused by organisms susceptible in vitro to either agent; streptomycin is used when gentamicin cannot be used because of resistance

Linezolid

600 mg PO or IV q 12 hr

For linezolid-susceptible isolates of E faecium and E faecalis.  An agent of choice for serious enterococcal VREF infections

Daptomycin

Use dose of 6 mg/kg/24 hrs for serious enterococcal infection; 6-8 weeks for endocarditis.

Not approved for treatment of VRE infection. Not approved for treatment of endocarditis. Limited clinical information for VREF, but bactericidal activity makes therapy with this is agent a consideration for serious infections

Antibiotic(s) alternative

Dose, Duration

Comments

Doxycycline

100 mg PO or IV q 12 hr

Not a first line therapy. For susceptible isolates, not bacteremia or endocarditis

Nitrofurantoin

100 mg PO Q 6 hr

For urinary tract infections (cystitis) with isolates susceptible to nitrofurantoin, not indicated in renal failure

Fosfomycin

3 g X1

For urinary tract infections (cystitis) with isolates susceptible to fosfomycin

Chloramphenicol

50 mg/kg/d IV (in q 6hr divided doses)

For chloramphenicol-susceptible isolates of E faecium and E. faecalis. Not a first-line therapy

Tigecycline

100 mg IV then 50 mg IV q 12 hrs

Not indicated for VRE, approved in US for skin soft tissue infection, excellent in-vitro activity vs VRE

Quinupristin/dalfopristin

7.5 mg/kg Q8hr IV

For-susceptible isolates of E faecium only

1. Appropriate use of vancomycin

a. Treatment of infection due to B-lactam resistant gram-positive organisms. 

b. Treatment of infection due to gram-positive organisms in patients with serious beta-lactam allergy.

c. Treatment of antibiotic associated colitis in cases of metronidazole failure or potentially life threatening illness. 

d. Endocarditis prophylaxis, as recommended by the American Heart Association (Dajani). 

e. Prophylaxis for surgical procedures involving implantation of a prosthesis in institutions with a high rate of infection due to MRSA or methicillin-resistant S. epidermidis.

2. Education Program

a. Include physicians, nurses, pharmacy and laboratory personnel, students, and all other direct patient care providers. 

b. Program should include information on epidemiology of VRE and impact of VRE on cost and outcome of patient care.

3. Role of the Microbiology Laboratory

a. Laboratory should be able to identify and speciate enterococci.

b. Fully automated methods of testing enterococci for susceptibility testing are unreliable; disk diffusion, gradient disk diffusion, agar dilation, or manual broth dilution are acceptable. 

c. Vancomycin resistance should be confirmed by repeating one of the above tests, or by streaking onto brain heart infusion containing 6 ug/ml of vancomycin. Preliminary and confirmatory identification of VRE should be immediately reported to patient care personnel and infection control. 

d. Screening for VRE should be conducted periodically in hospitals where VRE has not been previously detected.

4. Prevention and control of nosocomial transmission of VRE

a. For all hospitals, including those with no or infrequent isolation of VRE: 

1. Notify appropriate staff immediately when VRE are detected. 

2. Educate clinical staff about hospital policies regarding VRE colonized or infected patients so that appropriate procedures can be implemented immediately. 

3. Establish systems for monitoring process and outcome measures. 

4. Isolation precautions to prevent patient to patient transmission of VRE: REFER TO TABLE 2.

b. In Hospitals with endemic VRE of continued VRE transmission despite implementation of above measures: 

a. Focus initial control efforts on critical care units and other areas where VRE transmission rates are highest. 

b. Where feasible cohort staff caring for VRE-positive and VRE-negative patients. 

c. Carriage of enterococci by hospital staff are rarely implicated in transmission. Investigation and culturing of hospital staff should be at the direction of infection control staff. 

d. Verify that environmental disinfection procedures are adequate, and that procedures are correctly performed. 

e. Consider sending representative VRE isolates to reference laboratories for strain typing as an aid in identifying reservoirs and patterns of transmission.

1. Place VRE colonized or infected patients in single rooms, or cohort with other patients with VRE.

2. Wear gloves when entering the room of a VRE-infected or colonized patient.

3. Wear a gown when entering the room of a VRE-infected or colonized patient if:

a. Substantial contact with the patient or environmental surfaces in the room is anticipate. 

b. The patient is incontinent 

c. The patient has an ileostomy, colostomy or wound drainage not contained by dressing.

4. Remove gloves and gown before leaving the patient’s room and wash hands immediately with an antiseptic soap or waterless antiseptic agent. 

5. Dedicate the use of non-critical items, such as stethoscope, sphygmomanometer or rectal thermometer to a single patient or cohort of isolated patients. Devices must be disinfected before used on other patients.

6. Obtain stool or rectal swab cultures of roommates of patients newly found to be infected of colonized with VRE. Perform additional patient screening at the discretion of the infection control staff.

7. Adopt a policy for determining when patients infected or colonized with VRE can be removed from isolation precautions. As VRE colonization may be prolonged, negative cultures from multiple sites on 3 separate occasions at least one week apart is recommended.

8. The hospital should adopt a system by which infected and colonized patients can be recognized and placed into isolation promptly on transfer or re-admission.

9. Develop a plan, in consultation with public health authorities, for discharge or transfer of colonized or infection patients to other health facilities, including nursing homes and home health care.