From the Guidelines
The optimal management approach for this patient is to treat the Enterococcus faecium infection as a case of infective endocarditis, given the presence of vegetations on the native mitral valve, and to start empirical antibiotic therapy promptly, as recommended by the 2015 ESC guidelines for the management of infective endocarditis 1.
Immediate Management
For immediate management, switch to daptomycin at a dose of 8-12 mg/kg daily, as recommended by the 2022 guidelines for the treatment of infections due to multidrug-resistant organisms 1, plus ampicillin-sulbactam, while awaiting blood culture results. The dosing for daptomycin should be adjusted based on renal function and therapeutic drug monitoring.
Diagnostic Evaluation
A PET-CT scan is warranted to evaluate for cardiac device infection involving the PPI leads, as this would significantly impact management decisions, potentially requiring device extraction if infected, as recommended by the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1.
Treatment Duration
Treatment duration should be at least 6 weeks given the prosthetic material, as recommended by the 2015 ESC guidelines for the management of infective endocarditis 1. Surgical evaluation is also recommended given the large vegetation size, which carries embolic risk. Regular echocardiographic monitoring is essential to assess treatment response and vegetation evolution.
Key Considerations
- The patient's immunocompromised status and previous bacteremia increase the risk of complications and require close monitoring.
- The presence of Enterococcus faecium in the urine culture, despite not being the most common cause of endocarditis, warrants full treatment for endocarditis due to the patient's clinical presentation and immunocompromised status.
- The use of daptomycin, as recommended by the 2022 guidelines for the treatment of infections due to multidrug-resistant organisms 1, is preferred due to its bactericidal activity against Enterococcus faecium.
From the Research
Patient Profile
- 78-year-old male patient with multiple comorbidities:
- Human Immunodeficiency Virus (HIV) infection
- Coronary Artery Disease (CAD) status post Coronary Artery Bypass Grafting (CABG)
- Aortic Valve Replacement (AVR) with a bioprosthetic valve
- Parkinson's disease
- Recent spine surgery
- Presents with fever, chills, and overflow incontinence
- Urine culture shows Enterococcus faecium
- Echocardiogram reveals vegetations on the native mitral valve
Management Approach
- The patient's condition is complex, with multiple comorbidities and a rare infection caused by Enterococcus faecium 2, 3, 4
- Optimal antimicrobial therapy remains undefined, but an attempt to identify bactericidal combination therapy should be sought 4
- Treatment options may include:
- Surgical intervention may be necessary, especially if the patient develops cardiac complications or if the infection is not responding to antimicrobial therapy 4, 5
- A multidisciplinary approach is crucial for optimal patient outcomes, involving cardiologists, infectious disease specialists, and surgeons 5
Considerations
- The patient's HIV status and immunocompromised state may affect the treatment approach and outcome
- The presence of a bioprosthetic valve and recent spine surgery may increase the risk of complications and affect the treatment plan
- The patient's age and underlying medical conditions may impact the decision to pursue surgical intervention 4, 5