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Enterococcal Infections: Differential Diagnoses & Workup

Author: Susan L Fraser, MD, Infectious Diseases Service, Walter Reed Army Medical Center; Chairman, Infection Control Committee; Associate Professor of Medicine, Uniformed Services University of the Health Sciences
Coauthor(s): Julia Lim, MD, Associate Program Director, Internal Medicine Residency Program, Tripler Army Medical Center; Curtis J Donskey, MD, Chairman of Infection Control, Instructor, Department of Internal Medicine, Section of Infectious Diseases, Stokes Cleveland VA Medical Center, Case Western Reserve University; Robert A Salata, MD, Chief and Clinical Program Director of Division of Infectious Diseases, Vice Chair for International Affairs, Professor, Department of Medicine, Case Western Reserve University School of Medicine
Contributor Information and Disclosures

Updated: Aug 25, 2008

Differential Diagnoses

Acalculous Cholecystitis
Septic Arthritis
Infective Endocarditis
Urinary Tract Infection, Females
Liver Abscess
Urinary Tract Infection, Males
Pelvic Inflammatory Disease
Wound Infection
Peritonitis and Abdominal Sepsis
Pyogenic Hepatic Abscesses
Sepsis, Bacterial

Workup

Laboratory Studies

  • The appropriate laboratory studies depend on the potential clinical syndrome present. Ideally, before administering empirical antibiotic therapy, obtain cultures from sites suspected to be infected, including blood, urine, peritoneal fluid, joint fluid, CSF, and/or pyogenic fluid collections in soft tissue.
  • Blood cultures are usually indicated in patients with possible infection who also require hospitalization. If endocarditis is suspected, obtain 3 sets of blood cultures over 1 hour or longer.
    • A blood culture positive for Enterococcus species in a patient with a polymicrobial infection from an intra-abdominal source indicates the need for antimicrobial therapy, including activity against enterococci.
    • A blood culture positive for Enterococcus species (especially if multiple cultures are positive) also warrants an evaluation for endocarditis if clinical features suggest this diagnosis. Echocardiography should be performed to help evaluate for cardiac vegetations.
  • Susceptibility testing is essential for all enterococcal isolates that require antimicrobial therapy.
  • Stool specimens, perirectal cultures that grow resistant Enterococcus, or both are the criterion standard for evaluating vancomycin-resistant enterococci (VRE) colonization.

Imaging Studies

  • Echocardiography
    • Echocardiography should be performed when enterococcal endocarditis is suggested.
    • Transthoracic echocardiography is often performed as an initial screening test; if endocarditis is strongly suggested and the transthoracic echocardiography findings are negative, transesophageal echocardiography should be performed.
  • Abdominal CT scanning
    • A CT scan of the abdomen is indicated if symptoms or signs indicate a renal or gastrointestinal source of infection or if no clear focus of infection is evident elsewhere.
    • In elderly and/or immunocompromised patients, an intra-abdominal source of infection may manifest as minimal localizing signs or symptoms.
    • The scan may be ordered to include images of the pelvis in patients with suspected sigmoid or rectal disease, pelvic inflammatory disease (PID), or prostatic infection.
  • Ultrasonography: Ultrasonography of the kidneys, liver, and/or pelvis may be useful in determining whether an abscess is present and may be performed before CT scan or as an adjunct to CT scanning in selected cases.

Other Tests

  • Susceptibility testing
    • Blood isolates of enterococci should be tested for susceptibility. Routine testing should include penicillin or ampicillin, vancomycin, and high-level aminoglycosides. The Clinical and Laboratory Standards Institute (CLSI), formerly the National Committee for Laboratory Standards (NCCLS), recommends screening enterococci for high-level resistance to both gentamicin and streptomycin.
    • Urine isolates should be tested for susceptibility to ampicillin and nitrofurantoin.
    • For VRE isolates associated with infection, susceptibility testing should include a formal MIC determination for ampicillin and an assessment of beta-lactamase production in selected isolates. In addition, susceptibility testing should be requested for linezolid and may be considered for daptomycin, tigecycline, and quinupristin-dalfopristin, although not all of these antibiotics are FDA-approved for VRE infections. CLSI interpretive criteria are not available for non–FDA-approved indications or for certain organisms, so results must be interpreted using expert microbiological and clinical infectious-disease advice.

Procedures

Surgical incision and drainage of skin or soft-tissue abscesses or radiology-guided aspiration of abscess material may be required in certain enterococcal infections. In many cases, removal of prosthetic devices, such as vascular catheters, shunts, and prosthetic cardiac valves or orthopedic devices, is necessary to facilitate cure of the infection. Some vascular catheters may be exchanged over a wire and antibiotic lock therapy can be attempted, but the device should be permanently removed if failure occurs.

More on Enterococcal Infections

Overview: Enterococcal Infections
Differential Diagnoses & Workup: Enterococcal Infections
Treatment & Medication: Enterococcal Infections
Follow-up: Enterococcal Infections
References
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Further Reading

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Keywords

enterococcal infections, VRE, vancomycin-resistant enterococci, Enterococcus faecalis, E faecalis, Enterococcus faecium, E faecium, vancomycin-resistant Enterococcus, cocci, coccus, enterococci, enterococcal bacteremia, enterococcal endocarditis, enterococci infection, enterococcal urinary tract infection, enterococcal UTI, enterococcal wound infection, enterococcal intra-abdominal infection, enterococcal intraabdominal infection, enterococcal pelvic infection, enterococcal catheter-associated infection, enterococcal cystitis, enterococcal pyelonephritis, enterococcal prostatitis, group D streptococci, Enterococcus avium, Enterococcus gallinarum, Enterococcus casseliflavus, Enterococcus durans, Enterococcus raffinosus, Enterococcus mundtii, E avium, E gallinarum, E casseliflavus, E durans, E raffinosus, E mundtii

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Contributor Information and Disclosures

Author

Susan L Fraser, MD, Infectious Diseases Service, Walter Reed Army Medical Center; Chairman, Infection Control Committee; Associate Professor of Medicine, Uniformed Services University of the Health Sciences
Susan L Fraser, MD is a member of the following medical societies: American College of Physicians, American Liver Foundation, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Armed Forces Infectious Diseases Society, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Julia Lim, MD, Associate Program Director, Internal Medicine Residency Program, Tripler Army Medical Center
Disclosure: Nothing to disclose.

Curtis J Donskey, MD, Chairman of Infection Control, Instructor, Department of Internal Medicine, Section of Infectious Diseases, Stokes Cleveland VA Medical Center, Case Western Reserve University
Curtis J Donskey, MD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Nothing to disclose.

Robert A Salata, MD, Chief and Clinical Program Director of Division of Infectious Diseases, Vice Chair for International Affairs, Professor, Department of Medicine, Case Western Reserve University School of Medicine
Robert A Salata, MD is a member of the following medical societies: American Association of Immunologists, American Federation for Medical Research, American Medical Association, Central Society for Clinical Research, Infectious Diseases Society of America, Ohio State Medical Association, and Society for Healthcare Epidemiology of America
Disclosure: Nothing to disclose.

Medical Editor

David Hall Shepp, MD, Program Director, Fellowship in Infectious Diseases, Department of Medicine, North Shore University Hospital; Associate Professor, New York University School of Medicine
David Hall Shepp, MD is a member of the following medical societies: Infectious Diseases Society of America
Disclosure: Gilead Sciences Salary Management position

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist  Speaking and teaching

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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