What is the best practice antibiotic treatment for a patient with sepsis, potential sources including aspiration pneumonia (ASP), urinary tract infection (UTI), or colitis, and a history of Vancomycin-Resistant Enterococcus (VRE) in the urine?

From the Guidelines

For a patient with sepsis potentially due to aspiration pneumonia, UTI, or colitis, with a history of VRE in urine, the recommended empiric antibiotic regimen should include broad-spectrum coverage with attention to resistant organisms, starting with a combination of piperacillin-tazobactam 4.5g IV every 6 hours (or meropenem 1g IV every 8 hours if beta-lactam allergy), plus linezolid 600mg IV every 12 hours (to cover VRE), as recommended by recent guidelines 1.

Key Considerations:

• The choice of empiric antimicrobial therapy depends on complex issues related to the patient’s history, clinical status, and local epidemiologic factors, as noted in 1.
• The presence of VRE history specifically necessitates linezolid rather than vancomycin for gram-positive coverage, as vancomycin-resistant enterococci are a concern 1.
• Duration of therapy typically ranges from 7-14 days depending on the identified source and clinical response, with the possibility of shorter or longer courses based on patient-specific factors, as suggested in 1 and 1.

Additional Recommendations:

• Add azithromycin 500mg IV daily for atypical pneumonia coverage, considering the potential sources of sepsis.
• If colitis is strongly suspected, add oral vancomycin 125mg every 6 hours for possible C. difficile, but be cautious of the potential for vancomycin-resistant organisms.
• Obtain cultures from blood, urine, sputum, and stool before starting antibiotics, but do not delay treatment, as emphasized in 1 and 1.
• Reassess the regimen within 48-72 hours based on culture results and clinical response, and narrow therapy accordingly, following the principles outlined in 1 and 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. Table 15. Cure Rates at the Test-of-Cure Visit for ITT Adult Patients with Documented Vancomycin-Resistant Enterococcal Infections at Baseline Source of InfectionCured ZYVOX600 mg q12hn/N (%)ZYVOX200 mg q12hn/N (%) Any site39/58 (67)24/46 (52) Any site with associated bacteremia10/17 (59)4/14 (29) Bacteremia of unknown origin5/10 (50)2/7 (29) Skin and skin structure9/13 (69)5/5 (100) Urinary tract12/19 (63)12/20 (60) Pneumonia 2/3 (67)0/1 (0) Other*11/13 (85)5/13 (39)

The best practice antibiotic treatment for a patient with sepsis, potential sources including aspiration pneumonia (ASP), urinary tract infection (UTI), or colitis, and a history of Vancomycin-Resistant Enterococcus (VRE) in the urine is Linezolid (ZYVOX) 600 mg every 12 hours.

• The cure rate for urinary tract infections was 63% for the 600 mg dose.
• The cure rate for pneumonia was 67% for the 600 mg dose.
• The cure rate for any site of infection was 67% for the 600 mg dose. 2

From the Research

Best Practice Antibiotic Treatment for Sepsis with Potential Sources of ASP, UTI, or Colitis and History of VRE in Urine

• The patient's history of Vancomycin-Resistant Enterococcus (VRE) in the urine is a crucial factor in determining the best practice antibiotic treatment 3, 4.
• For VRE urinary tract infections (UTIs), linezolid has been shown to have a clinical cure rate of 71.4%, although no significant difference was found compared to non-linezolid treatment options 3.
• Daptomycin has been compared to linezolid for the treatment of VRE bacteraemia, with similar clinical and microbiological outcomes, but a lower incidence of thrombocytopenia 4.
• In the context of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia, linezolid has been shown to have increased clinical cure and microbiological eradication rates compared to vancomycin 5, 6.
• The effectiveness and safety of linezolid versus vancomycin, teicoplanin, or daptomycin against MRSA bacteremia have been evaluated, with comparable primary and secondary effectiveness outcomes and no difference in adverse event incidence 6.

Considerations for Antibiotic Treatment

• The potential sources of sepsis, including aspiration pneumonia (ASP), urinary tract infection (UTI), or colitis, should be considered when selecting an antibiotic treatment.
• The history of VRE in the urine suggests that the patient may be at risk for VRE infections, and antibiotic treatment should be chosen accordingly.
• The use of linezolid, daptomycin, or other antibiotics should be based on the specific clinical scenario and the patient's individual needs, taking into account the potential benefits and risks of each treatment option 3, 4, 5, 6.