From the Guidelines
Linezolid 600 mg IV or PO every 12 h is recommended for enterococcal infections, with high dose daptomycin 8-12 mg/kg IV daily or in combination with beta-lactams as an alternative for vancomycin-resistant enterococci (VRE) bacteremia. The treatment duration is dependent on the site of infection and clinical response 1. For uncomplicated urinary tract infections caused by Enterococcus faecalis, amoxicillin 500mg three times daily for 5-7 days is typically sufficient. More serious infections like bacteremia or endocarditis require intravenous therapy, often with ampicillin 2g every 4-6 hours, sometimes combined with gentamicin for synergistic effects, as recommended in the 2015 ESC guidelines for the management of infective endocarditis 1.
- Key considerations for treating Enterococcus infections include:
- Proper antibiotic selection, as enterococci are naturally resistant to many antibiotics, including cephalosporins and trimethoprim-sulfamethoxazole
- Susceptibility testing to guide treatment, as resistance patterns vary significantly between strains and geographic regions
- Treatment duration varies by infection site, with 7-14 days for uncomplicated infections and 4-6 weeks for endocarditis or osteomyelitis
- Alternative treatment options for VRE infections include:
- Tigecycline 100 mg IV loading dose then 50 mg IV q12 h for intraabdominal infections
- A single dose of fosfomycin 3 g PO for uncomplicated urinary tract infections
- Nitrofurantoin 100 mg PO every 6 h for uncomplicated urinary tract infections
- High dose ampicillin (18-30 g IV daily in divided doses) or amoxicillin 500 mg IV or PO every 8 h daily for uncomplicated urinary tract infections 1.
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
Good antibiotics for Enterococcus include:
- Linezolid, as shown in the study 2, which demonstrated cure rates for vancomycin-resistant enterococcal infections.
- Daptomycin, as shown in the study 3, which has been shown to be active against most isolates of Enterococcus faecalis (vancomycin-susceptible isolates only) and Enterococcus faecium (including vancomycin-resistant isolates).
From the Research
Effective Antibiotics for Enterococcus Infections
- Ampicillin plus ceftriaxone is a good option for Enterococcus faecalis infections caused by high-level aminoglycosides resistance (HLAR) strains 4
- Vancomycin, daptomycin, and linezolid are recommended by major guidelines for the treatment of enterococcal infections, but their efficacy is limited by the emergence of resistance 4, 5
- Amoxicillin is associated with a better outcome in patients with enterococcal bacteraemia 6
- Other antibiotics such as piperacillin, piperacillin/tazobactam, imipenem, meropenem, and tigecycline may also be effective against Enterococcus spp. 6
Treatment Challenges
- Enterococci are resistant to many antibiotics, including cephalosporins and aminoglycosides, making treatment challenging 5, 6
- The emergence of vancomycin-resistant enterococci (VRE) and high-level aminoglycoside-resistant strains has limited treatment options 4, 5
- Multidrug resistance is a significant concern in enterococcal infections, and antibiotic misuse has contributed to this problem 5, 7
Specific Infections
- Enterococcal endocarditis is a serious infection that requires prompt treatment, and ampicillin plus ceftriaxone may be a good option for HLAR strains 4
- Urinary tract infections caused by enterococci are common, and treatment recommendations should follow the most recent guidelines 7
- Bloodstream infections and wound infections caused by enterococci also require prompt treatment with effective antibiotics 5, 8