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Enterococcal Infections Follow-up

  • Author: Susan L Fraser, MD; Chief Editor: John L Brusch, MD, FACP  more...
 
Updated: Mar 17, 2016
 

Further Outpatient Care

Patients with enterococcal endocarditis or other serious enterococcal infections may receive prolonged outpatient antibiotic therapy. These patients should receive regular follow-up care to assess complications from the infection or their medical therapy. Routine weekly follow-up care should include a CBC count and serum creatinine evaluation. The erythrocyte sedimentation rate and/or C-reactive protein level are monitored by some clinicians. The normalization or stabilization of these parameters may be used to help determine the total duration of antibiotic therapy. The need for monitoring vancomycin peak and trough levels has been questioned in recent years; however, if patients are to receive prolonged courses of vancomycin, routinely check at least one trough level. In patients with enterococcal endocarditis, especially when caused by drug-resistant organisms, peaks of 30-45 mcg/mL and trough levels of 10-15 mcg/mL are recommended.

The antibiotics used to treat enterococcal infections may be associated with various adverse effects that require monitoring. Aminoglycosides may cause renal insufficiency due to acute tubular necrosis or hearing loss due to ototoxicity. Ampicillin may cause thrombocytopenia or renal insufficiency due to interstitial nephritis. Vancomycin therapy is occasionally associated with neutropenia.

Linezolid can cause myelosuppression in patients receiving therapy for more than 2 weeks and therefore need at least weekly CBC counts while on therapy.

Daptomycin can cause significant myopathy and should be discontinued in patients with signs and symptoms of myopathy along with an increase in creatine kinase of greater than 5 times the upper limits of normal or in asymptomatic patients with an increase of greater than 10 times the upper limits of normal.

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Transfer

When possible, patients with enterococcal endocarditis should be treated initially in or near a facility with personnel capable of performing open heart surgery.

Serious enterococcal infections such as endocarditis, meningitis, osteomyelitis, and prosthetic joint infections should be managed in conjunction with an infectious diseases specialist.

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Deterrence/Prevention

To prevent endocarditis, antibiotics are prescribed to some at-risk cardiac patients prior to dental or invasive oral procedures. Enterococci are a rare cause of endocarditis following genitourinary tract or gastrointestinal tract procedures. Recently published guidelines advise that the administration of antibiotics solely to prevent endocarditis is not recommended in patients who undergo a genitourinary or gastrointestinal tract procedure.[50]

In addition to medical and surgical treatment, the management of enterococcal colonization and infection also includes measures to limit the spread of VRE. In 2006, the Healthcare Infection Control Practices Advisory Committee published guidelines on the management of multidrug-resistant organisms, including VRE, in healthcare settings. This resource can be found at the Centers for Disease Control and Prevention Web site.

In 1994, the US Centers for Disease Control Hospital Infection Control Practices Advisory Committee published recommendations for preventing and controlling the spread of vancomycin resistance. Specific recommendations were made for surveillance measures to identify patients colonized or infected with VRE, for isolation measures to prevent person-to-person transmission of VRE, and for the prudent use of vancomycin.

Surveillance measures to identify patients colonized or infected with VRE include the following:

  • At hospitals where VRE has not been detected previously, clinical enterococcal isolates should be periodically screened for vancomycin resistance.
  • Once VRE is identified in a medical facility, all clinical enterococcal isolates should be tested for vancomycin resistance. Some form of surveillance for intestinal colonization is recommended because most patients harboring VRE are not identified when only clinical samples are screened.

Isolation measures to prevent person-to-person transmission include the following (also see the CDC’s Guideline for Isolation Precautions):[51]

  • Hand washing with antimicrobial soaps and hand rubs with alcohol-based solutions is critical to prevent spread of organisms.
  • Place patients with VRE infections in private rooms or in rooms with other infected patients.
  • Wear gloves when entering a VRE-colonized or VRE-infected room, and wear a gown if substantial contact with patients or their environment is anticipated.
  • Remove gloves and gown before leaving the room, and wash with antiseptic soap or with alcohol-based gel if the gloves are not visibly soiled.
  • Dedicate the use of items such as stethoscopes, blood pressure cuffs, and thermometers to a single patient (or group of patients) colonized or infected with VRE. In addition, all room surfaces should be disinfected on a regular schedule.

The above isolation measures, in combination with surveillance cultures, have been effective in eliminating small VRE outbreaks caused by dissemination of single strains of VRE. These measures may not be as effective in the setting of large polyclonal VRE outbreaks. In a study from an ICU of a hospital experiencing a large polyclonal outbreak, the use of gloves and gowns was not more effective than the use of gloves alone in preventing rectal VRE colonization. In a neonatal ICU, however, control of transmission of multiclonal VRE strains was achieved through a multifaceted approach that included active surveillance cultures of all neonates, DNA fingerprinting of all isolates, contact isolation, staff education, use of waterless hand antiseptics, and removal of electrical thermometers.[52]

One large, cluster-randomized ICU study failed to demonstrate the effectiveness of enhanced infection control precautions to prevent transmitting VRE to other patients, possibly because adherence to barrier precautions was not 100%.[53] The authors advocate that good adherence to isolation precautions is important to reduce transmission of VRE in healthcare facilities, and that reducing body site density of organisms and environmental contamination may also be helpful.

Vancomycin restriction guidelines include the following:

  • Limit use to situations in which vancomycin is clearly indicated.
  • Treat proven or possible serious infection due to susceptible pathogens in patients with serious beta-lactam allergies.
  • Treat proven or possible serious infections caused by beta-lactam–resistant, gram-positive organisms (eg, oxacillin-resistant S aureus [ORSA or MRSA] or methicillin-resistant coagulase-negative staphylococci).
  • Treat Clostridium difficile colitis that is severe or unresponsive to metronidazole therapy.
  • Use for single-dose surgical prophylaxis in patients at high risk for MRSA or methicillin-resistant S epidermidis and occasionally for endocarditis prophylaxis, as recommended by the American Heart Association.
  • Vancomycin-prescribing interventions do not always reduce VRE colonization and infection. [54] Studies have shown that other infection-control measures in addition to vancomycin-prescribing restrictions are more likely to control VRE colonization and infection. [55]

Restriction of other antibiotics includes the following:

  • In a prospective study of VRE-colonized patients, the authors have demonstrated that antianaerobic antibiotics promote persistent high-density stool colonization. Limiting the use of these agents in colonized patients may also help to limit the spread of VRE.
  • In a prospective cohort study, an enhanced infection-control strategy, including a program for reducing total antimicrobial use, resulted in reduced VRE transmission in an oncology unit compared with standard VRE infection-control practices.
  • Compared with the standard infection-control period, the use of vancomycin, imipenem-cilastatin, ceftazidime, ciprofloxacin, aztreonam, and gentamicin during the enhanced infection control period was significantly reduced.
  • The incidence of both VRE bloodstream infections and rectal colonization decreased significantly during the enhanced infection-control period.

The risk of VRE acquisition in hospitalized patients is increased when environmental culture results are positive and/or when a room has been occupied by a patient with VRE colonization or infection.[56] Adequate environmental cleaning should be a priority. Simple educational interventions directed at the housekeeping staff can improve decontamination of environmental surfaces.[57]

Bathing of hospitalized patients should reduce the bacterial burden, including drug-resistant bacteria such as VRE. Daily bathing with chlorhexidine-impregnated bathing cloths was shown to reduce colonization of patients' skin, health care workers' hands, and environmental surfaces, as well as the incidence of VRE acquisition by other patients in one intensive care unit.[58]

In conclusion, active surveillance cultures for VRE, use of isolation for colonized and infected patients, appropriate antibiotic use, adequate patient care, and environmental cleaning are important interventions that should be implemented in order to control the transmission of VRE.[59]

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Complications

Endocarditis may occur as a complication of enterococcal infection at a remote site if bacteremia occurs. For example, some cases of endocarditis are preceded by intravascular catheter infections or UTI or instrumentation.

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Prognosis

Enterococcal bacteremia tends to occur in very debilitated patients, making the exact contribution of the bacteremia to mortality difficult to determine. Nevertheless, studies have estimated the attributable mortality rate of enterococcal bacteremia to be 31-37%. Even with current therapeutic regimens, the mortality rate of enterococcal endocarditis remains approximately 20%.

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Patient Education

Direct patients to the CDC Web site for answers to some frequently asked questions about VRE.

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Contributor Information and Disclosures
Author

Susan L Fraser, MD Chief, Infectious Diseases Service, Fort Belvoir Community Hospital; 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 Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Armed Forces Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

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 and Translational Research, Infectious Diseases Society of America, Ohio State Medical Association, Society for Healthcare Epidemiology of America

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.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John L Brusch, MD, FACP Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

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: Received salary from Gilead Sciences for management position.

Acknowledgements

Julia Lim, MD Associate Program Director, Internal Medicine Residency Program, Tripler Army Medical Center

Disclosure: Nothing to disclose.

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