LAB WORK

• Gram +, gamma-hemolytic (no hemolysis)

TREATMENT OPTIONS - CONSULT ID FOR ANY ENTEROCOCCUS BACTEREMIA
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• ​Penicillins (Drug of choice for susceptible strains only!)
  • ​ampicillin, amoxicillin, Pen VK/G, piperacillin
  • DO NOT USE nafcillin or oxacillin (anti-staph penicillins as a group), not active enough
• ​​Vancomycin (does not cover VRE, vancomycin-resistant enterococcus)
  • ​Typically second line if enterococcus is resistant to penicillins and sensitive to vancomycin​
• Resistant to cephalosporins (due to inner penicillin binding proteins that lead to low affinity and weak binding of certain beta lactams)
• Resistant to Bactrim (even if in vitro testing shows susceptibility, in vivo enterococcus can use exogenous folic acid and bypass folate synthesis blockade)​
• Nitrofurantoin (only for uncomplicated cystitis and only in patients with CrCl > 60 mL/min, though some data supports possible use in CrCl/eGFR of 30-60 mL/min)
  

BROADER COVERAGE TREATMENT OPTIONS

• ​Carbapenems
  • ​Inactive against E. faecium, so useful only for E. faecalis​
  • Do not use ertapenem (Invanz)​, no activity against Enterococcus
• Linezolid
  • ​Active vs. VRE
• Daptomycin
  • Active vs. VRE
• Tigecycline
  • Active vs. VRE
  • Avoid in bacteremia due to low blood concentrations
• Gentamicin/Streptomycin
  • Only effective in combination with a cell wall agent like a penicillin or vancomycin! "(S)" on cultures is only as synergy
• Quinupristin/dalfopristin (Synercid)
  • Active against E. faecium only, no activity against E. faecalis

CLINICAL NOTES

• E. faecalis more common, typically less resistant (may be penicillin-sensitive even if vancomycin-resistant)
• E. faecium less common, more resistant (possible resistance to BOTH penicillin and vancomycin), majority of VRE strains ​ 
• Normal flora of GI tract

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References
Society of Infectious Disease Pharmacists Antimicrobial Stewardship Certificate Program 2017.