What is the treatment for Vancomycin-Resistant Enterococci (VRE) infections?

From the Guidelines

Treatment of Vancomycin-Resistant Enterococci (VRE) infections typically involves using alternative antibiotics, with linezolid and daptomycin being the primary options. The recommended first-line treatment is linezolid, 600 mg orally or intravenously every 12 hours for 7-14 days, depending on the severity and site of infection 1. For patients who cannot tolerate linezolid or in cases of linezolid resistance, daptomycin is an alternative, given at 8-12 mg/kg intravenously once daily 1.

Key Considerations

• The choice of antibiotic is based on the organism's susceptibility to these alternatives and the patient's specific condition.
• Treatment duration may be extended for severe infections like endocarditis or osteomyelitis.
• Infection control measures are essential to prevent VRE spread, including contact precautions, hand hygiene, and environmental cleaning.
• Combination therapy may be necessary in some cases, such as daptomycin plus ampicillin or linezolid plus rifampin.

Antibiotic Options

• Linezolid: inhibits protein synthesis
• Daptomycin: disrupts bacterial cell membranes
• Other options: quinupristin-dalfopristin (for E. faecium only), tigecycline, and fosfomycin

Important Notes

• Obtain cultures and susceptibility testing to guide therapy.
• Consult with an infectious disease specialist for complex cases or treatment failures.
• Monitor for potential side effects, such as thrombocytopenia and CK elevation, especially with high-dose daptomycin 1.

From the FDA Drug Label

The cure rates for the ITT population with documented vancomycin-resistant enterococcal infection at baseline are presented in Table 15 by source of infection. These cure rates do not include patients with missing or indeterminate outcomes. The cure rate was higher in the high-dose arm than in the low-dose arm, although the difference was not statistically significant at the 0. 05 level.

The treatment for Vancomycin-Resistant Enterococci (VRE) infections is linezolid (600 mg every 12 hours), which has been shown to have a cure rate of 67% in patients with documented VRE infections 2.

• The cure rates vary by source of infection, with the highest cure rate of 85% observed in patients with other sources of infection, such as hepatic abscess, biliary sepsis, and pericolonic abscess.
• The cure rate for patients with bacteremia of unknown origin was 50%.
• The cure rate for patients with skin and skin structure infections was 69%.
• The cure rate for patients with urinary tract infections was 63%.

From the Research

Treatment Options for Vancomycin-Resistant Enterococci (VRE) Infections

• Available agents without specific VRE approval include chloramphenicol, doxycycline, high-dose ampicillin or ampicillin/sulbactam, and nitrofurantoin (for lower urinary tract infection) 3
• Novel antimicrobial agents that have emerged as approved therapeutic options for vancomycin-resistant Enterococcus faecium include quinupristin/dalfopristin and linezolid 3, 4
• Quinupristin/dalfopristin has bacteriostatic activity against vancomycin-resistant E. faecium, but is not active against Enterococcus faecalis 3
• Linezolid has bacteriostatic activity against both vancomycin-resistant E. faecium and E. faecalis 3
• Other treatment options include daptomycin, tigecycline, and teicoplanin, although their use may be limited by resistance or lack of approval for VRE infections 5, 6, 7

Efficacy of Treatment Options

• Quinupristin/dalfopristin has been shown to have a clinical response rate of 70.5% and an overall response rate of 65.8% in patients with VRE infections 3
• Linezolid has been shown to have a cure rate of 92.6% in patients with VRE infections, although the dose-response relationship is not well established 3
• Daptomycin has been shown to have in vitro bactericidal activity against VRE isolates, although its clinical efficacy is still being evaluated 6

Challenges and Future Perspectives

• The emergence of resistance to available antimicrobial agents is a significant challenge in the treatment of VRE infections 3, 5, 6
• Therapeutic drug monitoring (TDM) may play a role in optimizing antimicrobial therapy for VRE infections, although further research is needed 7
• The development of new antimicrobial agents and the evaluation of combination therapies are critical to addressing the limited treatment options for VRE infections 3, 5, 6