What is the treatment for Enterococcus (E) faecium necrotizing fasciitis?

From the Guidelines

The treatment for Enterococcus faecium necrotizing fasciitis requires immediate aggressive surgical debridement combined with appropriate antibiotic therapy, prioritizing vancomycin or daptomycin plus a beta-lactam such as piperacillin-tazobactam, with adjustments based on susceptibility results 1.

Key Considerations

• Surgical intervention should include wide excision of all infected and necrotic tissue, with repeated debridements as necessary until healthy tissue margins are achieved.
• Initial empiric therapy should include vancomycin (15-20 mg/kg IV every 8-12 hours) or daptomycin (6-10 mg/kg IV daily) plus a beta-lactam such as piperacillin-tazobactam (4.5g IV every 6 hours) until susceptibility results are available.
• For confirmed vancomycin-resistant E. faecium (VRE), linezolid (600 mg IV/oral twice daily) or daptomycin (at higher doses of 8-12 mg/kg IV daily) are preferred options.
• Antibiotic therapy should continue for at least 2-4 weeks after surgical source control and clinical improvement.
• Supportive care including fluid resuscitation, pain management, and nutritional support is essential.

Management of Resistance

• E. faecium has intrinsic resistance to many antibiotics and can rapidly acquire additional resistance mechanisms, making early identification, susceptibility testing, and aggressive multidisciplinary management crucial for patient survival.
• In cases of multidrug-resistant E. faecium, consultation with specialists in infectious diseases is recommended to guide antimicrobial therapy, which may include linezolid, daptomycin, or other agents based on susceptibility patterns 1.

Clinical Approach

• The clinical approach should prioritize morbidity, mortality, and quality of life outcomes, with a focus on prompt surgical intervention and appropriate antibiotic therapy.
• The choice of antibiotic regimen should be guided by the most recent and highest quality evidence, with consideration of local resistance patterns and patient-specific factors.

From the FDA Drug Label

Daptomycin has been shown to be active against most isolates of the following microorganisms both in vitro and in clinical infections: Gram-Positive Bacteria Enterococcus faecalis (vancomycin-susceptible isolates only) Staphylococcus aureus (including methicillin-resistant isolates) Streptococcus agalactiae Streptococcus dysgalactiae subsp. equisimilis Streptococcus pyogenes The following in vitro data are available, but their clinical significance is unknown At least 90 percent of the following bacteria exhibit an in vitro minimum inhibitory concentration (MIC) less than or equal to the susceptible breakpoint for daptomycin against isolates of similar genus or organism group. However, the efficacy of daptomycin in treating clinical infections caused by these bacteria has not been established in adequate and well-controlled clinical trials Gram-Positive Bacteria Corynebacterium jeikeium Enterococcus faecalis (vancomycin-resistant isolates) Enterococcus faecium (including vancomycin-resistant isolates) Staphylococcus epidermidis (including methicillin-resistant isolates) Staphylococcus haemolyticus

The treatment for E faecium necrotizing fasciitis may include daptomycin, as it has been shown to be active against Enterococcus faecium (including vancomycin-resistant isolates) in vitro. However, the efficacy of daptomycin in treating clinical infections caused by E faecium has not been established in adequate and well-controlled clinical trials.

• Key points:
  • Daptomycin has in vitro activity against E faecium.
  • The clinical significance of this activity is unknown.
  • Daptomycin may be considered as a treatment option, but its use should be guided by clinical judgment and susceptibility testing.
  • Vancomycin-resistant E faecium infections may be treated with alternative antibiotics, such as linezolid. 2

From the Research

Treatment for E faecium Necrotizing Fasciitis

• The treatment for necrotizing fasciitis, including cases caused by Enterococcus (E) faecium, typically involves a combination of broad-spectrum antibiotic therapy and aggressive surgical débridement of affected tissue 3, 4, 5.
• Early diagnosis and prompt treatment are crucial to prevent high mortality rates associated with necrotizing fasciitis 3, 4, 5.
• For vancomycin-resistant E faecium infections, quinupristin-dalfopristin and linezolid are potential treatment options, although resistance to these antibiotics is a concern 6, 7.
• Other antibiotics such as daptomycin, tigecycline, and mupirocin may also be effective against E faecium, but their use may be limited by resistance patterns 7.
• The choice of antibiotic therapy should be guided by susceptibility testing and clinical experience 6, 7.
• Surgical débridement is a critical component of treatment, as it helps to remove necrotic tissue and prevent the spread of infection 3, 4, 5.
• Intensive general support, including management of systemic toxicity and organ dysfunction, is also essential for successful treatment 4, 5.