From the Guidelines
Daptomycin is the preferred first-line agent for managing linezolid-resistant Vancomycin-Resistant Enterococci (VRE) at doses of 8-12 mg/kg IV daily. The management of linezolid-resistant VRE requires alternative antimicrobial therapy, and the choice of treatment depends on the severity and site of infection.
Treatment Options
- For severe infections, combination therapy may be necessary, typically adding gentamicin (1 mg/kg IV every 8 hours) or ampicillin (if susceptible) 1.
- Other options include tigecycline (100 mg IV loading dose followed by 50 mg IV twice daily), quinupristin-dalfopristin (7.5 mg/kg IV every 8 hours, for E. faecium only), or fosfomycin (6-8 g IV every 8 hours) 1.
Treatment Duration
- Treatment duration typically ranges from 7-14 days depending on infection site and severity, with the definite treatment duration individualized according to infection sites, source control, the underlying comorbidities, and the initial response to therapy 1.
Additional Considerations
- Source control through drainage of abscesses or removal of infected devices is crucial.
- Infectious disease consultation is strongly recommended due to the complexity of these cases.
- Monitoring for treatment response should include clinical improvement and follow-up cultures when appropriate, with antimicrobial stewardship to prevent further resistance development. The most recent and highest quality study, published in 2022, provides recommendations for the treatment of infections due to multidrug-resistant organisms, including VRE 1. This study suggests that daptomycin is a preferred first-line agent for managing linezolid-resistant VRE, and provides guidance on treatment duration and combination therapy. Another study published in 2022 also supports the use of daptomycin as a first-line agent for VRE infections 1.
From the Research
VRE Management in Linezolid Resistant Cases
- The management of vancomycin-resistant Enterococci (VRE) infections, particularly in cases where linezolid resistance is a concern, requires careful consideration of alternative treatment options 2, 3, 4, 5, 6.
- Studies have compared the effectiveness of linezolid and daptomycin in treating VRE bloodstream infections, with some suggesting that daptomycin may be associated with better clinical outcomes 4, while others found no significant difference between the two treatments 3, 6.
- The optimization of linezolid dosing regimens is crucial to achieve favorable clinical outcomes and prevent emerging resistance, with a dosing regimen of 1,200 mg either once daily or as a divided dose every 12 h recommended for VRE isolates with documented MICs ≤1 μg/mL 2.
- In cases where linezolid resistance is suspected or confirmed, combination therapy with other antibiotics may be considered to achieve the desired pharmacokinetic/pharmacodynamic (PK/PD) targets and improve clinical outcomes 2, 5.
- The choice of treatment for VRE infections should be guided by the specific characteristics of the infecting organism, the severity of the infection, and the patient's underlying medical conditions, as well as the potential for adverse effects and the development of resistance 3, 4, 5, 6.