Enterococcal bacteraemia

Publication: 22/07/2014  --
Last review: 23/03/2020  
Next review: 23/03/2023  
Clinical Guideline
CURRENT 
ID: 3907 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Department of Microbiology Bacteraemia guideline

Enterococcal bacteraemia

Quick reference guide to the management of Enterococcal bacteraemia

This document provides guidelines for doctors on the management of patients with confirmed bacteraemias (blood cultures).  This document is supplementary to, and should be used in conjunction with, the antimicrobial guidelines.

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Species: Enterococcus

Aim

The aim of this guideline is to:

  • Provide education to junior microbiology registrars
  • Support communication of blood culture results from microbiologists to ward doctors
  • Support ward doctors in treating and investigating bacteraemic patients

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Background

The blood culture process: Timings of culture, identification, susceptibility tests and clinical liaison.
How to use this guideline: This guideline should be used to help in the management of patients with a confirmed bacteraemia. The guideline should be used to support interaction with specialist advice e.g.  Microbiology.

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About Enterococcus

Enterococci are gram-positive organisms, oval in shape and can be seen as single cells, pairs, short or long chains.

Most clinical infections are produced by two species (Enterococcus faecalis and Enterococcus faecium).

Enterococci have developed mechanisms to survive in the gastrointestinal tract of humans. One of the main effects that antibiotics have in the human gut is to alter the colonization in favor of enterococci. Other factors including increased stomach pH (use of PPIs) may also play a role in the overgrowth of enterococci3

Vancomycin Resistant Enterococci (VRE) are among the causes of nosocomial infections.  Most VRE isolates are E. faecium (>90%).  Risk factors associated with increased VRE colonization include: immunosuppression, diabetes, renal failure, increased hospital stay, residence in long-term care facility, broad spectrum antibiotics or Vancomycin.  After a patient becomes colonized with VRE, the risk of developing bloodstream infection appears to increase4

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Antimicrobial susceptibilities

  • Enterococci are always resistant to Cephalosporins, Ertapenem and Clindamycin.
  • β-Lactam antibiotics (excluding cephalosporins): The most potent activity is observed with Aminopenicillins (Ampicillin, Amoxicillin). Resistance to Amoxicillin indicates concurrent resistance to all β-Lactams e.g. Piperacillin/Tazobactam,Carbapenems) is usually found in clinical isolates of E. faecium but less commonly in E. faecalis. In certain infections like endocarditis combination with aminoglycosides (Gentamicin) may be recommended for its synergistic effect.
  • Glycopeptides: Vancomycin and Teicoplanin are used in the treatment of amoxicillin resistant Enterococcal infections. However , the increased prevalence of Vancomycin resistance may  reduce the clinical use of these compounds
  • Antibiotics for the treatment of VRE infections: Daptomycin, Linezolid and Tigecycline can be used for the treatment of VRE infections after discussion with Microbiology/Infectious Diseases. The use of these antibiotics requires consideration of the site of infection as these drugs cannot be used for all indications e.g. tigecycline is poorly excreted in the urine.

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Clinical differential diagnosis

The differential diagnosis of enterococcal bacteremia includes:

  • Urinary tract Infections
  • Intra-Abdominal and Pelvic Infections
  • Endocarditis
  • Long Line Infections
  • Spontaneous Bacterial Peritonitis
  • Peritoneal Dialysis Associated Peritonitis

Of note: Patients with a community-acquired Enterococcal bacteraemia should be assessed for a possible diagnosis of endocarditis.

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Antimicrobial treatment

  • Antibiotic therapy should always be reviewed with speciation of the bacteria, and with results of sensitivity tests

History of the following are important to determine appropriate antimicrobial therapy

  • Previous enterococcal infections (including Vancomycin Resistant Enterococci -VREs)
  • Colonization with VRE
  • Source of infection
  • Allergy status

The table below outlines some of the common infections associated with Enterococcal bacteraemia.

Table 1: Common infections associated with Enterococcal bacteraemia.

Clinical diagnosis

Antimicrobial therapy

Urinary Tract Infections

See guideline

Intra-abdominal Infections

See guideline

Endocarditis

See guideline

Spontaneous Bacterial Peritonitis

See guideline

Peritoneal dialysis associated peritonitis

See guideline

Long Line Infections

See guideline
Other Discuss with Microbiology

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Supplementary Investigations

Consider further investigations as appropriate to source of infection, please see relevant guidelines.

Further Action: Source Isolation of patients with VRE infection/colonization

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Provenance

Record: 3907
Objective:
Clinical condition:

Bacteraemia

Target patient group:
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

  1. BNF
  2. EMC
  3. Stiefel U,et al. Suppresion of gastric acid production by Proton Pump Inhibitor facilitates colonization of the large intestine by Vancomycin-Resistant Enterococcus and Klebsiella pneumonia in Clindamycin-treated mice. Antimicrob. Agents Chemother. November 2006 vol. 50 no. 11 3905-3907
  4. Weinstock DM,et al. Colonization, bloodstream infection and mortality caused by Vancomyci-Resistant Enterococcus early after allogenic stem cell transplant. Biol Blood Marrow Transplant. 2007;13:615-21

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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