From the Guidelines
For VRE (Vancomycin-Resistant Enterococcus) bacteremia, linezolid and daptomycin are the primary treatment options, with linezolid administered at 600 mg IV/oral twice daily and daptomycin given at higher doses of 8-12 mg/kg IV once daily. Treatment duration is generally 14 days from the first negative blood culture, though complicated cases may require longer therapy 1.
Key Considerations
- Daptomycin dosing: High dose daptomycin at 8-12 mg/kg IV once daily is recommended for VRE bacteremia, with a treatment duration of at least 14 days 1.
- Linezolid administration: Linezolid can be administered at 600 mg IV/oral twice daily, with a treatment duration dependent on the site of infection and clinical response 1.
- Combination therapy: For severe or refractory cases, combination therapy may be considered, such as daptomycin plus ampicillin (if the isolate shows ampicillin susceptibility), or daptomycin with ceftaroline 1.
- Source control: Source control is crucial, with removal of infected devices and drainage of abscesses when possible 1.
- Infectious disease consultation: Infectious disease consultation is recommended for management of these challenging infections, and susceptibility testing should guide final antibiotic selection 1.
Alternative Options
- Tigecycline (100 mg IV loading dose followed by 50 mg IV twice daily) is an alternative but less preferred due to lower efficacy in bloodstream infections 1.
- Fosfomycin, nitrofurantoin, and ampicillin may be considered for uncomplicated urinary tract infections due to VRE 1.
From the FDA Drug Label
- 5 Vancomycin-resistant Enterococcus faecium Infections Linezolid is indicated for the treatment of vancomycin-resistant Enterococcus faecium infections, including cases with concurrent bacteremia [see Clinical Studies (14)].
Antibiotic option for VRE bacteremia:
- Linezolid (IV) is an option for the treatment of vancomycin-resistant Enterococcus faecium infections, including cases with concurrent bacteremia 2. Key points:
- Linezolid has been studied and is indicated for the treatment of VRE bacteremia.
- The recommended dosage for Linezolid formulations for the treatment of VRE infections, including concurrent bacteremia, is described in Table 1 of the drug label.
From the Research
Antibiotic Options for VRE Bacteremia
- The treatment options for vancomycin-resistant enterococcal (VRE) bacteremia include quinupristin/dalfopristin, linezolid, and daptomycin 3, 4.
- Linezolid has been shown to be effective against both vancomycin-resistant E. faecium and E. faecalis, with a clinical response rate of 70.5% and an overall response rate of 65.8% 3.
- Quinupristin/dalfopristin is a streptogramin that impairs bacterial protein synthesis, but it is not active against Enterococcus faecalis 3.
- Daptomycin is an acidic lipopeptide that has been shown to be effective against VRE bacteremia, but its use is limited by its potential for nephrotoxicity and ototoxicity 4.
Efficacy of Linezolid and Daptomycin
- A retrospective analysis of adult patients with VRE bacteremia found that linezolid and daptomycin were equally efficacious in terms of clinical and microbiologic cure rates, length of stay, and mortality 5.
- However, the study found that recurrence of VRE bacteremia was significantly higher in patients treated with daptomycin compared to linezolid 5.
- Another study found that linezolid may be the most versatile of the available drugs for VRE bacteremia, with activity against both E. faecalis and E. faecium, and a lower risk of resistance compared to other agents 4.
Safety and Tolerability
- Linezolid has been associated with thrombocytopenia, decreased leukocyte count, and increased blood pressure, but these adverse effects are generally mild and reversible 6.
- Daptomycin has been associated with nephrotoxicity and ototoxicity, but these adverse effects are rare and generally reversible 4.
- Quinupristin/dalfopristin has been associated with myalgia/arthralgia, but this adverse effect is generally mild and reversible 3.