When is vancomycin indicated for treatment of enterococcal infections?

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

If vancomycin is used in the course of treatment for endocarditis, a 6-week rather than 4-week course of therapy is recommended. Combination therapy is also recommended to treat enterococcal meningitis, usually for at least 2-3 weeks. Intravenous linezolid or intravenous plus intraventricular quinupristin-dalfopristin have also been used to successfully treat meningitis. Intrathecal or intraventricular therapy can be considered in refractory cases.

The emergence of enterococcal strains with multidrug-resistant determinants has significantly complicated the management of enterococcal infections. Vancomycin should be used to treat infections with strains that exhibit high-level resistance to ampicillin. Test strains with high-level gentamicin resistance for high-level streptomycin resistance. For gentamicin-resistant strains, the only alternative is streptomycin, as tobramycin and amikacin are not active. Treatment options are limited for endocarditis caused by strains that exhibit high-level resistance to all aminoglycosides. For E faecalis infection, prolonged therapy with high doses of ampicillin plus imipenem-cilastatin or ampicillin plus ceftriaxone may be considered. [41] For E faecium infection, either linezolid or daptomycin may be effective, and quinupristin-dalfopristin, tigecycline, omadacycline, eravacycline or oritavancin could be considered. Surgical approaches may be necessary.


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