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Enterococcus

LAB WORK
  • Gram +, gamma-hemolytic (no hemolysis)

TREATMENT OPTIONS - CONSULT ID FOR ANY ENTEROCOCCUS BACTEREMIA
​
  • ​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

References
Society of Infectious Disease Pharmacists Antimicrobial Stewardship Certificate Program 2017.
  • COVID
    • INPATIENT >
      • CONSIDERATIONS & LABS
      • REMDESIVIR
      • OLUMIANT
      • ACTEMRA
      • STEROIDS
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    • Agents & Spectra
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    • By Infection Type
    • Surgical Prophylaxis >
      • By Procedure
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    • 2022 Inpatient
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