Abstract
Enterococci are an increasingly important cause of nosocomial infections. While the clinical impact of enterococci in cases of bacteremia and super-infections in selected patient populations has been well-established, their role as primary pathogens in polymicrobial intra-abdominal infections remains controversial. While it has been suggested that the presence of enterococci increases the rate of infectious post-operative complication, it has also been demonstrated that polymicrobial intra-abdominal infections involving enterococci can be treated successfully with appropriate surgical drainage and antibiotics, such as cephalosporins, that are not active against enterococci. Therefore, the question arises of whether or not antibiotic coverage against enterococci should be included in the empirical treatment of peritonitis in certain high-risk patient populations. An extensive literature review revealed some evidence arguing in favour of using empirical therapy with enterococcal coverage for intra-abdominal infections in the following cases: (i) immunocompromised patients with nosocomial, post-operative peritonitis; (ii) patients with severe sepsis of abdominal origin who have previously received cephalosporins and other broad-spectrum antibiotics selecting for Enterococcus spp.; (iii) patients with peritonitis and valvular heart disease or prosthetic intravascular material, which place them at high risk of endocarditis. The ideal therapeutic regimen for these high-risk patients remains to be determined, but empirical therapy directed against enterococci should be considered.
Similar content being viewed by others
References
Skau T, Nystrom PO, Carlsson C (1985) Severity of illness in intra-abdominal infection. A comparison of two indexes. Arch Surg 120:152–158
Bohnen JM (1992) Operative management of intra-abdominal infections. Infect Dis Clin North Am 6:511–523
Gorecki PJ, Schein M, Mehta V, Wise L (2000) Surgeons and infectious disease specialists: different attitudes towards antibiotic treatment and prophylaxis in common abdominal surgical infections. Surg Infect (Larchmt) 1:115–123; discussion 125–126
Harbarth S, Ferriere K, Hugonnet S, Ricou B, Suter P, Pittet D (2002) Epidemiology and prognostic determinants of bloodstream infections in surgical intensive care. Arch Surg 137:1353–1359
Bohnen J, Boulanger M, Meakins JL, McLean AP (1983) Prognosis in generalized peritonitis. Relation to cause and risk factors. Arch Surg 118:285–290
Mulier S, Penninckx F, Verwaest C, et al (2003) Factors affecting mortality in generalized postoperative peritonitis: multivariate analysis in 96 patients. World J Surg 27:379–384
Dougherty SH (1984) Role of enterococcus in intraabdominal sepsis. Am J Surg 148:308–312
Barie PS, Christou NV, Dellinger EP, Rout WR, Stone HH, Waymack JP (1990) Pathogenicity of the enterococcus in surgical infections. Ann Surg 212:155–159
Nichols RL, Muzik AC (1992) Enterococcal infections in surgical patients: the mystery continues. Clin Infect Dis 15:72–76
Gorbach SL (1993) Intraabdominal infections. Clin Infect Dis 17:961–965
Rohrborn A, Wacha H, Schoffel U, et al (2000) Coverage of enterococci in community acquired secondary peritonitis: results of a randomized trial. Surg Infect (Larchmt) 1:95–107
Sotto A, Lefrant JY, Fabbro-Peray P, et al (2002) Evaluation of antimicrobial therapy management of 120 consecutive patients with secondary peritonitis. J Antimicrob Chemother 50:569–576
Sitges-Serra A, Lopez MJ, Girvent M, Almirall S, Sancho JJ (2002) Postoperative enterococcal infection after treatment of complicated intra-abdominal sepsis. Br J Surg 89:361–367
Solomkin JS, Mazuski JE, Baron EJ, et al (2003) Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clin Infect Dis 37:997–1005
Thadepalli H, Gorbach SL, Broido PW, Norsen J, Nyhus L (1973) Abdominal trauma, anaerobes, and antibiotics. Surg Gynecol Obstet 137:270–276
Berne TV, Yellin AW, Appleman MD, Heseltine PN (1982) Antibiotic management of surgically treated gangrenous or perforated appendicitis. Comparison of gentamicin and clindamycin versus cefamandole versus cefoperazone. Am J Surg 144:8–13
Berne TV, Yellin AE, Appleman MD, Gill MA, Chenella FC, Heseltine PN (1987) Surgically treated gangrenous or perforated appendicitis. A comparison of aztreonam and clindamycin versus gentamicin and clindamycin. Ann Surg 205:133–137
Berne TV, Yellin AE, Appleman MD, Heseltine PN, Gill MA (1993) A clinical comparison of cefepime and metronidazole versus gentamicin and clindamycin in the antibiotic management of surgically treated advanced appendicitis. Surg Gynecol Obstet 177 (Suppl):18–22
Solomkin JS, Reinhart HH, Dellinger EP, et al (1996) Results of a randomized trial comparing sequential intravenous/oral treatment with ciprofloxacin plus metronidazole to imipenem/cilastatin for intra-abdominal infections. The Intra-Abdominal Infection Study Group. Ann Surg 223:303–315
Quinn JP (1997) Rational antibiotic therapy for intra-abdominal infections. Lancet 349:517–518
Jaccard C, Troillet N, Harbarth S, et al (1998) Prospective randomized comparison of imipenem-cilastatin and piperacillin-tazobactam in nosocomial pneumonia or peritonitis. Antimicrob Agents Chemother 42:2966–2972
Zanetti G, Harbarth SJ, Trampuz A, et al (1999) Meropenem (1.5 g/day) is as effective as imipenem/cilastatin (2 g/day) for the treatment of moderately severe intra-abdominal infections. Int J Antimicrob Agents 11:107–113
Teppler H, McCarroll K, Gesser RM, Woods GL (2002) Surgical infections with enterococcus: outcome in patients treated with ertapenem versus piperacillin-tazobactam. Surg Infect (Larchmt) 3:337–349
Vergis EN, Hayden MK, Chow JW, et al (2001) Determinants of vancomycin resistance and mortality rates in enterococcal bacteremia. A prospective multicenter study. Ann Intern Med 135:484–492
Carmeli Y, Eliopoulos G, Mozaffari E, Samore M (2002) Health and economic outcomes of vancomycin-resistant enterococci. Arch Intern Med 162:2223–2228
Onderdonk AB, Bartlett JG, Louie T, Sullivan-Seigler N, Gorbach SL (1976) Microbial synergy in experimental intra-abdominal abscess. Infect Immun 13:22–26
Dupont H, Montravers P, Mohler J, Carbon C (1998) Disparate findings on the role of virulence factors of Enterococcus faecalis in mouse and rat models of peritonitis. Infect Immun 66:2570–2575
Montravers P, Mohler J, Saint Julien L, Carbon C (1997) Evidence of the proinflammatory role of Enterococcus faecalis in polymicrobial peritonitis in rats. Infect Immun 65:144–149
Dougherty SH, Flohr AB, Simmons RL (1983) ‘Breakthrough’ enterococcal septicemia in surgical patients. Arch Surg 118:232–238
Burnett RJ, Haverstock DC, Dellinger EP, et al (1995) Definition of the role of enterococcus in intraabdominal infection: analysis of a prospective randomized trial. Surgery 118:716–721
Fernandez-Guerrero ML, Herrero L, Bellver M, Gadea I, Roblas RF, Gorgolas M de (2002) Nosocomial enterococcal endocarditis: a serious hazard for hospitalized patients with enterococcal bacteraemia. J Intern Med 252:510–515
Lautenbach E, Bilker WB, Brennan PJ (1999) Enterococcal bacteremia: risk factors for vancomycin resistance and predictors of mortality. Infect Control Hosp Epidemiol 20:318–323
Carmeli Y, Samore MH, Huskins C (1999) The association between antecedent vancomycin treatment and hospital-acquired vancomycin-resistant enterococci: a meta-analysis. Arch Intern Med 159:2461–2468
Harbarth S, Cosgrove S, Carmeli Y (2002) Effects of antibiotics on nosocomial epidemiology of vancomycin-resistant enterococci. Antimicrob Agents Chemother 46:1619–1628
Pallares R, Pujol M, Pena C, Ariza J, Martin R, Gudiol F (1993) Cephalosporins as risk factor for nosocomial Enterococcus faecalis bacteremia. A matched case-control study. Arch Intern Med 153:1581–1586
Gray J, Marsh PJ, Stewart D, Pedler SJ (1994) Enterococcal bacteraemia: a prospective study of 125 episodes. J Hosp Infect 27:179–186
Noskin GA, Peterson LR, Warren JR (1995) Enterococcus faecium and Enterococcus faecalis bacteremia: acquisition and outcome. Clin Infect Dis 20:296–301
Mainous MR, Lipsett PA, O’Brien M (1997) Enterococcal bacteremia in the surgical intensive care unit. Does vancomycin resistance affect mortality? Arch Surg 132:76–81
Barrall DT, Kenney PR, Slotman GJ, Burchart KW (1985) Enterococcal bacteremia in surgical patients. Arch Surg 120:57–63
Patel R, Badley AD, Larson-Keller J, et al (1996) Relevance and risk factors of enterococcal bacteremia following liver transplantation. Transplantation 61:1192–1197
Harbarth S, Samore MH, Lichtenberg D, Carmeli Y (2000) Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Circulation 101:2916–2921
Harbarth S, Garbino J, Pugin J, Romand J, Lew D, Pittet D (2003) Inappropriate initial antimicrobial therapy and its effect on survival in a clinical trial of immunomodulating therapy for severe sepsis. Am J Med 115:529–535
Harbarth S, Albrich W, Goldmann DA, Huebner J (2001) Control of multiply resistant cocci: do international comparisons help? Lancet Infect Dis 1:251–261
Author information
Authors and Affiliations
Corresponding author
Additional information
This work was presented in part at the 43rd Annual Interscience Conference on Antimicrobial Agents and Chemotherapy in Chicago, USA, September 2003 (Abstract #2079)
Rights and permissions
About this article
Cite this article
Harbarth, S., Uckay, I. Are there Patients with Peritonitis Who Require Empiric Therapy for Enterococcus?. Eur J Clin Microbiol Infect Dis 23, 73–77 (2004). https://doi.org/10.1007/s10096-003-1078-0
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10096-003-1078-0