About what percentage of VRE isolates are E. faecium?

A 52-year-old man presented with a painful, red, purulent port site and fevers. He had pancreatic cancer and an implanted port for chemotherapy, but his last cycle was over 3 months ago. On exam, the port site was erythematous, with a central area of fluctuance and some visible purulence. His temperature was 37.2°C, his heart rate was 98 beats/min, and his blood pressure was 108/64 mm Hg.

Investigations:

Neutrophil count: 7.2 × 109/L

Alkaline phosphatase (ALP): 95 U/L

Blood cultures were taken, and empiric antibiotic therapy was started while plans were made for his port to be removed.

What antibiotic is an essential component of empirical treatment?

A 65-year-old male presented with fatigue, subjective fever and chills, and poor appetite. He had a history of hypertension, hyperlipidemia, diabetes, and chronic kidney disease (CKD) stage 4. He had no known drug allergies. On examination he was found to have a new diastolic murmur. He was started empirically on vancomycin.

Investigations:

4/4 blood cultures positive for fully sensitive Enterococcus faecalis

Echocardiogram: a 5 mm vegetation of the aortic valve

Creatinine clearance: 15 mL/min

What is the most appropriate treatment?

Infectious endocarditis and bacteremia caused by ________ are highly associated with gastrointestinal malignancy.

True or False?

E. faecium typically exhibit high MICs for ampicillin, and a large proportion of clinical isolates are carbepenem resistant.

What is the preferred therapy for severe infections caused by E. faecalis?

True or False?

Daptomycin is not approved by the FDA for the treatment of E. faecium (regardless of susceptibility) or for VRE infections.

A 65-year-old female was admitted with tachycardia and fever. She had a history of colon cancer, diabetes mellitus, acute on chronic kidney disease (AKI/CKD), and depression. She was taking citalopram and had a severe penicillin allergy (anaphylaxis).

Investigations:

• Creatinine: 2.9 mg/dL (baseline SCr 1.8 mg/dL)

• Total white cell count: 16.2 cells/μL

• CXR: normal

• Transthoracic echocardiogram: no evidence of endocarditis

• Three sets of blood cultures: positive for Enterococcus faecalis:

• Ampicillin: sensitive

• Vancomycin: sensitive

• Daptomycin: sensitive

• Linezolid: sensitive

• High-level gentamicin resistance: present

• High-level streptomycin resistance: results pending

What is the most appropriate treatment?

Which of the following organisms lacks the ability to produce detectable nitrites on urine dip stick testing?

True or False?

The simultaneous presence of vancomycin-resistant E. faecalis and S. aureus in diabetic wound infections has been associated with the transfer of the vanA gene cluster (encoding proteins necessary for vancomycin resistance) from enterococcus to S. aureus.

 A 72-year-old male was brought to the emergency department after being found on the floor in his nursing home. He had a low-grade fever with mild tachycardia, and he was dehydrated. He gave a history of 2 months of general malaise and fevers. He had lost 2% of his body weight. He was rehydrated with IV fluids, and blood tests including cultures were taken. He had a past medical history of diverticular disease and hypertension. Initial blood tests showed mild leucocytosis and a raised C-reactive protein at 78 mg/dL. His renal function and creatinine kinase were within normal limits. He was admitted for observation.

His blood cultures grew E. faecalis (ampicillin and gentamicin susceptible). This organism was repeatedly grown on subsequent cultures. The medical team were concerned about the possibility of endocarditis, and subsequent ­transthoracic echocardiography showed a small mobile vegetation on his aortic valve. The microbiology team called for his antibiogram. The Enterococcus was fully sensitive to the antibiotics tested.

What is the most appropriate treatment course?