Treatment of VRE Wound Infections
Linezolid 600 mg IV or PO every 12 hours is the first-line treatment for VRE wound infections, with a strong recommendation (1C) from current guidelines and FDA approval for complicated skin and skin structure infections caused by vancomycin-resistant Enterococcus faecium. 1, 2, 3
Primary Treatment Approach
Linezolid as First-Line Therapy
- Linezolid 600 mg IV or PO every 12 hours for 5-7 days is the recommended treatment for VRE wound infections, with demonstrated clinical cure rates of 81.4% and microbiological cure rates of 86.4% 1, 4, 2
- The FDA specifically approves linezolid for complicated skin and skin structure infections caused by vancomycin-resistant E. faecium, including cases with concurrent bacteremia 3
- Treatment duration should be 5-7 days for most wound infections, though complicated cases may require individualized extension based on clinical response and source control 1, 2
Alternative Treatment Options
High-Dose Daptomycin
- Daptomycin 8-12 mg/kg IV daily is the preferred alternative when linezolid cannot be used, particularly at doses ≥9 mg/kg which show superior outcomes compared to lower doses 1, 4, 2, 5
- Daptomycin combined with β-lactam agents (penicillins, carbapenems, or cephalosporins other than cefotaxime and cefazolin) may improve outcomes for difficult-to-treat infections 4, 2, 6
- The combination of daptomycin plus β-lactams is especially valuable when linezolid causes bone marrow toxicity or is ineffective 6
Tigecycline
- Tigecycline 100 mg IV loading dose, then 50 mg IV every 12 hours can be considered for complicated wound infections 1, 2
- However, tigecycline should NOT be used for VRE bacteremia due to its large volume of distribution resulting in low serum levels 4, 2
Critical Clinical Considerations
Distinguish Colonization from True Infection
- VRE is part of normal colonizing flora; do not treat colonization or contamination 2, 7
- Only treat documented wound infections with clinical signs of infection (purulence, erythema, warmth, systemic symptoms) 7
Source Control is Essential
- Remove foreign bodies (catheters, hardware) and perform surgical debridement or drainage of closed-space infections to reduce treatment duration and prevent resistance emergence 7
- Inadequate source control is a common pitfall that leads to treatment failure regardless of antibiotic choice 7
Comparative Efficacy and Evidence Quality
- Meta-analyses comparing linezolid and daptomycin show conflicting results, with microbiological cure rates comparable (93% vs 91%) 4, 2
- The key distinction is that higher-dose daptomycin (≥9 mg/kg) performs similarly to linezolid, while lower doses (6-9 mg/kg) show inferior outcomes 5
- Most recommendations for VRE treatment carry weak to moderate quality evidence (Level C or D), reflecting the limited comparative trial data available 1
Common Pitfalls to Avoid
- Do not use standard daptomycin doses (6 mg/kg) for VRE infections—this is suboptimal and associated with higher mortality 5
- Avoid tigecycline for VRE bacteremia or when systemic infection is suspected 4, 2
- Do not continue linezolid beyond 14-21 days without monitoring for thrombocytopenia and bone marrow suppression 8, 6
- Ensure Gram-negative coverage is initiated if polymicrobial infection is suspected, as linezolid has no Gram-negative activity 3