From the Guidelines
For low-grade enterococcal bacteremia in the setting of TAVR, I strongly recommend prompt initiation of antibiotic therapy with a combination of penicillin G or ampicillin together with gentamicin for 4 to 6 weeks, as this regimen is supported by the highest level of evidence for treating enterococcal infections involving prosthetic material 1. This approach is crucial because enterococcal bacteremia following TAVR raises concern for prosthetic valve endocarditis, a serious complication with high mortality.
- Key considerations in managing this condition include:
- The duration of therapy, which should be longer in cases involving prosthetic material, as emphasized in the guidelines 1
- The importance of infectious disease consultation as the standard of care for managing patients with enterococcal infections, given the complexity of these cases 1
- Close monitoring of the patient's clinical response, including daily blood cultures until clearance is documented, and the performance of a transesophageal echocardiogram (TEE) to evaluate for vegetations or valve complications
- The choice of antibiotics may need to be adjusted based on susceptibility patterns and patient allergies, with vancomycin being an alternative for patients with penicillin allergies, although the primary recommendation from the guidelines involves the use of penicillin G or ampicillin together with gentamicin 1
- The timing of bacteremia relative to the TAVR procedure is also a critical factor, with bacteremia within 60 days of valve placement carrying a higher concern for device infection than later presentations, which may influence the aggressiveness and duration of the treatment approach.
From the Research
Low Grade Enterococcal Bacteremia in Setting of TAVR
- Enterococcal bacteremia is a common and challenging infection to manage, particularly in the nosocomial setting 2
- The epidemiological, clinical, and microbiological characteristics of enterococcal bacteremia, as well as factors associated with prognosis, are crucial in determining the appropriate management approach 2
- The use of echocardiography to rule out endocarditis is an important aspect of the diagnosis and work-up of enterococcal bacteremia 2
Antibiotic Management
- The choice of antibiotic therapy for enterococcal bacteremia is critical, with a focus on antimicrobial resistance and complicated bacteremia 2, 3
- Amoxicillin has been shown to be effective in the treatment of enterococcal bacteremia, with a better outcome associated with its use 3
- Combination antimicrobial therapy may be necessary for vancomycin-resistant Enterococcus faecium infections, with newer agents such as daptomycin, linezolid, and tigecycline being considered 4
Clinical Outcomes
- The duration of antibiotic therapy for enterococcal bacteremia is an important consideration, with short-course therapy potentially yielding similar clinical outcomes to prolonged-course therapy 5
- The clinical implications of enterococcal bacteremia are significant, with a high mortality rate and frequent association with other facultative and anaerobic organisms 6
- The primary sources of bacteremia, such as urinary tract, soft tissue, and intra-abdominal infections, can impact the outcome of enterococcal bacteremia 6