Enterococcal Infections Clinical Presentation

Updated: Jun 10, 2021
  • Author: Susan L Fraser, MD; Chief Editor: John L Brusch, MD, FACP  more...
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Urinary tract infections

The most common type of infection caused by enterococci is usually nosocomial (associated with urinary tract catheterization or instrumentation).

Cystitis and pyelonephritis are common infections.

Occasionally, prostatitis and perinephric abscesses may develop.

Occasional infections may occur in young healthy women (< 5%).


Sources of enterococcal bacteremia include the urinary tract, intra-abdominal foci, wounds, and intravascular catheters, especially catheters in femoral locations.

Community-acquired enterococcal bacteremia is more commonly associated with endocarditis (up to 36% of cases) than nosocomial bacteremia (0.8%).

Nosocomial enterococcal bacteremias may arise from various sources. Polymicrobial bacteremias including enterococci and other bowel flora should increase the index of suspicion for an intra-abdominal source. Other sources may include surgical sites and burn wound infections.

Blood cultures that grow enterococci may be positive because of contamination of the skin with these organisms. A blood culture positive for Enterococcus species in the absence of evidence of ongoing infection should raise this possibility.


Enterococci cause 5-15% of all endocarditis cases.

Enterococcal endocarditis usually occurs in older patients, particularly men.

The presentation of enterococcal endocarditis is typically subacute and infrequently associated with peripheral stigmata of endocarditis. Enterococcal endocarditis of native valves carries a relatively low short-term mortality rate.

Most cases of enterococcal endocarditis are left-sided. In two recent series of endocarditis caused by VRE, the aortic valve was involved more often than the mitral valve. [24, 25]

E faecalis causes most cases of endocarditis. Vancomycin-resistant E faecium is more likely to cause endocarditis than other VRE species, especially cases acquired nosocomially.

Risk factors for enterococcal endocarditis may include UTI or instrumentation, or occult colonic malignancy. [26, 27]

Intra-abdominal and pelvic infections

Such infections include biliary tract infection, intra-abdominal abscess, spontaneous bacterial peritonitis, endometritis, and salpingitis.

Enterococci are usually part of mixed aerobic and anaerobic flora.

Antimicrobial regimens with minimal in vitro antienterococcal activity are often effective in treating mixed infections; therefore, the pathogenicity of enterococci in this setting is questionable.

Antienterococcal bactericidal activity is recommended when blood culture results are positive for enterococci.

In more seriously ill patients, enterococcal infections have been associated with higher risk of treatment failure and mortality. Consider administering antibiotics with antienterococcal activity to immunocompromised patients at high risk for bacteremia, patients with peritonitis and valvular heart disease, patients with severe sepsis of abdominal origin who have recently received broad-spectrum antibiotics, and patients with persistent intra-abdominal fluid collections without clinical improvement. [28]

Other infections

Enterococcal wound infections often manifest as part of a mixed infection.

Enterococcal meningitis is uncommon and is usually associated with neurosurgical procedures or anatomic defects, accounting for only 0.3-6% of cases. A cell wall agent plus synergistic aminoglycoside therapy is the treatment of choice in these rare cases.

Neonatal sepsis may occur.

Respiratory tract infections can develop, especially in older debilitated patients who are receiving tube feedings. [29] However, isolation of enterococci from respiratory secretions usually represents colonization rather than infection.

Other uncommon infections caused by enterococci include osteomyelitis and septic joint infections.



Physical examination findings in patients with enterococcal infections vary widely and depend on the associated infectious syndrome; therefore, direct the examination according to the patient's symptoms and laboratory findings.

Evaluate the patient for suprapubic or flank tenderness if laboratory findings are consistent with enterococcal UTI.

If the patient has enterococcal bacteremia, carefully evaluate the patient for signs consistent with endocarditis, which include the following:

  • Fever

  • Peripheral stigmata (Janeway lesions, Osler nodes, Roth spots, petechiae, or splinter hemorrhages) 

  • New heart murmur (usually a regurgitant murmur)

Examine the abdomen carefully for signs of organ tenderness, for peritoneal signs of peritonitis, and for ascites.

Examine prosthetic devices and the local skin (eg, orthopedic, cardiac, catheter insertion sites) for signs of infection, including erythema, swelling, tenderness, and/or warmth.



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.