eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Enterococcal Infection: Treatment & Medication
Updated: Nov 12, 2009
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Treatment
Medical Care
The following are guidelines for antimicrobial therapy in patients with enterococcal infections. Adjust based on antibiotic susceptibility.
- Ampicillin/penicillins are the drugs of choice if the Enterococcus is susceptible.
- Ampicillin alone can be used to treat minor localized infections in an otherwise healthy host.
- Antibiotics containing beta-lactamase inhibitors (eg, clavulanate, sulbactam) can be used if resistance is due to production of beta-lactamase.
- Single drug therapy is effective treatment for urinary tract infection (UTI) and enterococcal bacteremia without endocarditis. Nitrofurantoin is an alternative to penicillins for uncomplicated UTIs. Penicillin or ampicillin plus aminoglycoside (for synergism to produce bactericidal activity) are to be used in the following:
- Neonatal septicemia
- Endocarditis
- Meningitis
- Guidelines from the Infectious Diseases Society of America (IDSA) on intra-abdominal infections do not recommend empiric enterococcal coverage for community-acquired infections.11 However, for hospital-acquired abdominal infections, if enterococci are isolated, antibiotic coverage is recommended.
- For strains with high-level resistance to beta-lactams, aminoglycosides, and glycopeptides, quinupristin/dalfopristin (Synercid) or linezolid (Zyvox) may be used.
- A 7-month-old formerly premature infant with ventriculitis secondary to E faecium who was successfully treated with a 3-week course of linezolid at a dose of 10 mg/kg/dose 3 times a day has been reported. Therapy was well tolerated. Resistance to linezolid can develop after prolonged antibiotic therapy (>21 days).
- Quinupristin/dalfopristin inhibits bacterial protein synthesis and is approved for patients older than 16 years for serious or life-threatening infections associated with vancomycin-resistant E faecium bacteremia.
- Synercid is not effective against E faecalis.
- Endocarditis is treated as follows:
- Treatment of endocarditis due to susceptible strains of enterococci consists of combination therapy with parenteral ampicillin (or penicillin G) plus parenteral gentamicin (or streptomycin) for a minimum of 4-6 weeks (4 wk if symptoms are present <3 mo vs 6 wk if symptoms are present >3 mo).
- Patients with severe penicillin allergy should be treated with vancomycin plus gentamicin or streptomycin.
- Endocarditis due to enterococci highly resistant to beta-lactams (usually E faecium) may be treated with vancomycin plus an aminoglycoside.
- Endocarditis caused by beta-lactamase–producing strains of E faecalis can be treated with ampicillin-sulbactam plus an aminoglycoside.
- Endocarditis caused by Van B strains of enterococci can be treated with high-dose ampicillin plus an aminoglycoside if resistance to these agents is not present; otherwise, teicoplanin (investigational drug in the United States) plus an aminoglycoside should be used.
- For endocarditis of native or prosthetic valve due to multiple drug–resistant vancomycin-resistant E faecium, 8 weeks of linezolid is recommended. For endocarditis of native or prosthetic valve due to vancomycin-resistant E faecalis, a combination of imipenem and ampicillin or cephalosporin and ampicillin for 8 weeks is recommended.
- High-dose continuous infusion ampicillin (200-300 mg/kg/d) may be an option to dosing every 4-6 hours in the treatment of nonsynergistic enterococcal endocarditis.
- Doses of gentamicin for treatment of enterococcal endocarditis are aimed to reach a serum concentration peak of only 3-5 mcg/mL. The dose is 3 mg/kg/d instead of the usual 6-7.5 mg/kg/d.
- Streptomycin is not usually given unless gentamicin resistance and synergism for streptomycin are present.
- Meningitis and septicemia should be treated with bactericidal regimens. With meningitis, the duration of therapy is usually 2-3 weeks. If an underlying predisposing cutaneous defect is present, such as congenital cutis aplasia, 3-4 weeks of therapy may be required.
- In a study of 98 adult patients with VRE bacteremia, 30 were treated with daptomycin, and 68 were treated with linezolid.12 Daptomycin was noted to be as effective as linezolid. No elevation of creatine kinase levels or rhabdomyolysis was noted.
Surgical Care
- Catheter-associated sepsis: Remove promptly catheter.
- Infected ventriculoperitoneal (VP) shunt: An infected VP shunt should be removed promptly and an external ventricular drain placed (ventriculostomy).
- Endocarditis due to aminoglycoside-nonsynergistic strains: Valve replacement may be necessary.
Consultations
- Treat patients with enterococcal infections in consultation with an infectious disease consultant.
Medication
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Ampicillin (Omnipen, Polycillin, Principen)
Interferes with bacterial cell wall synthesis during active multiplication, causing cell wall death and resultant bactericidal activity against susceptible bacteria.
Adult
1-2 g IV q4-6h
Pediatric
100-200 mg/kg/d IV/IM divided q6h; alternatively, 8.3-12.5 mg/kg/h IV continuous infusion, not to exceed 12 g/d
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives or atenolol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Cross-allergy to cephalosporin antibiotics; adjust dose in renal failure
Gentamicin (Garamycin)
Inhibits protein synthesis by irreversibly binding to bacterial 30S and 50S ribosomes.
Adult
1.5-1.8 mg/kg/dose IV/IM q8h
Pediatric
3 mg/kg/d IV/IM divided q8h
Increased risk of renal failure with coadministration with other nephrotoxic drugs (eg, aminoglycosides, cephalosporins, penicillins, amphotericin B, furosemide, cyclosporine); because aminoglycosides enhance effects of neuromuscular blocking agents, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Possible association of nephrotoxicity and ototoxicity with prolonged elevated trough concentrations; monitor drug levels to minimize risk of toxicity and optimize therapy; adjust dosing intervals according to CrCl
Vancomycin (Vancocin)
Inhibits cell wall synthesis by binding to carboxyl units on peptide subunits containing free D -alanyl-D-alanine. Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in treatment of septicemia and skin structure infections.
Adult
30-50 mg/kg/d IV divided q12h; generally 2 g/d
Pediatric
40 mg/kg/d IV divided q8h
Possible increased risk of nephrotoxicity with concurrent use of aminoglycosides; possible erythema, histaminelike flushing, and anaphylactic reactions with coadministration of anesthetic agents; may potentiate neuromuscular blockade when used concurrently with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure and neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose is administered IV over 2 h or as PO or IP administration; red man syndrome is not an allergic reaction; monitor levels to minimize risk of toxicity and to optimize therapy
Linezolid (Zyvox)
Inhibits formation of initiation complex in protein synthesis by preventing formation of tRNA-mRNA-70S and 30s subunit ternary complex. Binds to the 23S ribosomal RNA of the 50S subunit to prevent complex formation.
Bacteriostatic against enterococci and staphylococci and bactericidal against most strains of streptococci. Used as alternative in patients allergic to vancomycin and for treatment of VRE.
Adult
600 mg PO/IV q12h
Pediatric
Preterm neonate <7 days: 10 mg/kg PO/IV q12h
Term neonates-12 years: 10 mg/kg PO/IV q8h
>12 years: Administer as in adults
May cause hypertension when used concomitantly with adrenergic agents (eg, tyramine-containing foods, pseudoephedrine, sympathomimetic agents, vasopressors, dopaminergic agents); serotonin syndrome may occur if used concomitantly with serotonergic agents (eg, TCAs, meperidine, dextromethorphan, trazodone, venlafaxine, SSRIs)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Has mild MAOI properties and has potential to have same interactions as other MAOIs; caution in uncontrolled hypertension, pheochromocytoma, carcinoid syndrome, and untreated hyperthyroidism; caution in patients who are at increased risk of bleeding, have preexisting thrombocytopenia, receive concomitant medications that may decrease platelet count or function, and who may require >2 wk of therapy (monitor platelet counts); unnecessary use may lead to resistance
Quinupristin and dalfopristin (Synercid)
First of a class of antimicrobial agents known as streptogramins. Works by irreversibly binding to 50S and 70S ribosomes, which results in inhibition of protein synthesis. Used to treat serious or life-threatening bacteremia associated with vancomycin-resistant E faecium.
Adult
7.5 mg/kg IV q8h
Pediatric
<1 month: Not established
1 month to 16 years: Limited data suggest 7.5 mg/kg IV q8h or q12h
>16 years: Administer as in adults
Potent inhibitor of CYP450 3A4; may decrease elimination and increase serum concentrations of 3A4 isoenzyme substrates (eg, amlodipine, cisapride, carbamazepine, cyclosporine, docetaxel, paclitaxel, vinca alkaloids, midazolam, diazepam, HMG-CoA reductase inhibitors, nifedipine, verapamil, diltiazem, quinidine, lidocaine, delavirdine, nevirapine, indinavir); incompatible with saline solutions
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in hepatic dysfunction (decrease dose); venous irritation may occur; dilute in at least 250 mL D5W for peripheral infusion (at least 100 mL for infusion via central line); arthralgia and myalgia may occur; decreasing administration frequency to q12h may prevent recurrence of arthralgia and myalgia; may cause hyperbilirubinemia (25%)
Penicillin G (Pfizerpen)
Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Adult
5-24 million U/d IV divided q4-6h
Pediatric
250,000-400,000 U/kg/d IV divided q4-6h
Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
Nitrofurantoin (Macrobid, Furadantin, Macrodantin)
Nitrofurantoin is an alternative to penicillins for uncomplicated UTIs. Synthetic nitrofuran that interferes with bacterial carbohydrate metabolism by inhibiting acetylcoenzyme A. Bacteriostatic at low concentrations (5-10 mcg/mL) and bactericidal at higher concentrations.
Adult
50-100 mg/dose PO q6h
Pediatric
>1 month: 5-7 mg/kg/d PO divided q6h; not to exceed 400 mg/d
Long-term therapy: 1-2 mg/kg/d divided 12-24h; not to exceed 100 mg/d
Anticholinergics may delay gastric emptying and increase absorption, increasing nitrofurantoin bioavailability; antacids made of magnesium salts may decrease effects of nitrofurantoin, decreasing absorption; high doses of probenecid concurrently with nitrofurantoin decrease renal clearance and increase nitrofurantoin toxicity
Documented hypersensitivity; renal insufficiency ( <60 mL/min CrCl), anuria, or oliguria
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause severe and irreversible peripheral neuropathy that can be fatal; renal impairment, diabetes, electrolyte imbalance, anemia, and vitamin B deficiency increase risk of adverse effects; prolonged use of antibiotics may result in fungal or bacterial overgrowth of resistant or nonsusceptible organisms
More on Enterococcal Infection |
| Overview: Enterococcal Infection |
| Differential Diagnoses & Workup: Enterococcal Infection |
 Treatment & Medication: Enterococcal Infection |
| Follow-up: Enterococcal Infection |
| Multimedia: Enterococcal Infection |
| References |
| « Previous Page | Next Page » |
References
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Further Reading
Keywords
enterococcal infection, group D streptococcal infection, enterococci, vancomycin-resistant VRE, peritonitis, urinary tract infection, endocarditis, upper respiratory tract infection, hospital-acquired infection, bacteremia, early onset septicemia, treatment, diagnosis
