This morning we discussed a patient who was recently admitted to the VA with enterococcal bacteremia. We reviewed the workup and treatment of enterococcal bacteremia. Key points to remember include:
- Enterococcus faecium is more likely to be resistant to ampicillin, while Enterococcus faecalis is more likely to be resistant to Vancomycin.
- However, remember that VRE faecalis may still be susceptible to Ampicillin! In fact, Ampicillin is the preferred treatment in the absence of resistance or allergy.
- In the absence of endocarditis, critical illness or resistance, Enterococcus bacteremia may be treated with monotherapy with Ampicillin (or Penicillin, Vancomycin, Daptomycin, or Linezolid).
- Combination therapy is indicated in cases of suspected endocarditis or critical illness. Common regimens include:
- Ampicillin + Ceftriaxone
- Ampicillin + Gentamicin
- Vancomycin + Gentamicin
However, this patient expressed that several interventions, including PIV placement and the use of IV antibiotics, were not within his goals of care. He was amenable to PO antibiotics, though. We were lucky to be joined by Dr. Looney, an expert ID physician who consulted on this case, as well as Dr. Pardee, an experienced hospitalist. They gave their valuable insight into how we can individualize care in a respectful and informed way when patients decline our treatment recommendations. Thanks for the interesting discussion!