Pediatric Enterococcal Infection Treatment & Management

  • Author: Meera Varman, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Nov 12, 2009
 

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.
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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.
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Consultations

  • Treat patients with enterococcal infections in consultation with an infectious disease consultant.
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Contributor Information and Disclosures
Author

Meera Varman, MD  Associate Professor, Department of Pediatrics, Section of Pediatric Infectious Diseases, Creighton University Medical Center

Meera Varman, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: phamaceutical companies Honoraria Speaking and teaching; phamaceutical companies Grant/research funds clinical trials

Coauthor(s)

Archana Chatterjee, MD, PhD  Professor of Pediatrics, Medical Microbiology and Immunology, and Pharmacy, Division of Pediatric Infectious Diseases, Chief of Division of Pediatric Infectious Diseases, Creighton University School of Medicine; Hospital Epidemiologist and Medical Director of Infection Control, Children's Hospital

Archana Chatterjee, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, International Society for Infectious Diseases, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Walid Abuhammour, MD, FAAP  Professor of Pediatrics, Michigan State University College of Medicine; Director of Pediatric Infectious Disease, Department of Pediatrics, Hurley Medical Center

Walid Abuhammour, MD, FAAP is a member of the following medical societies: American Medical Association, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

José Rafael Romero, MD  Director of Pediatric Infectious Diseases Fellowship Program, Associate Professor, Department of Pediatrics, Combined Division of Pediatric Infectious Diseases, Creighton University/University of Nebraska Medical Center

José Rafael Romero, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, New York Academy of Sciences, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Larry I Lutwick, MD  Professor of Medicine, State University of New York Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus

Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi Pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Warren C Johnson III, MD, to the development and writing of this article.

References

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This photomicrograph reveals cocci-shaped Enterococcus species bacteria taken from a patient with pneumonia.
 
 
 
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