Abstract
Enterococcus was designated a genus distinct from the streptococci in 1984. Enterococci cause a variety of monomicrobial and polymicrobial infections, mainly in compromised patients. These infections include bacteremia, urinary and biliary tract infections, intra-abdominal sepsis, and decubitus and diabetic foot ulcers. Enterococcal infections may be acquired from the patient’s endogenous intestinal flora or exogenously from a fecally contaminated environment. Enterococci are inherently resistant to many antimicrobial agents and readily acquire additional resistances, which is likely the reason that enterococci have become prominent nosocomial pathogens. Only the combination of a cell wall-active antibiotic to which the Enterococcus is susceptible (ie, certain β-lactams or vancomycin) plus an aminoglycoside (ie, gentamicin or streptomycin) is bactericidal, and is required for cure of endocarditis, meningitis and probably infection in neutropenic patients; bacteriostatic activity is sufficient to treat most other infections. Treatment of infections caused by strains resistant to b-lactams, glycopeptides and aminoglycosides has become problematic due the limited number of therapeutic options. No medical therapy is reliably effective for endocarditis caused by strains resistant to all cell wall-active antibiotics and all aminoglycosides. New antimicrobial agents, such as linezolid and quinupristin/dalfopristin, have recently become available, but their activity against enterococci is mainly bacterostatic.
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References and Recommended Reading
Murray PR, Baron EJ, Pfaller MA, et al.: Manual of Clinical Microbiology, edn 6. Washington, DC: ASM Press, 1995.
Murray BE: Life and time of the enterococcus. Clin Microbiol Rev 1990, 3:46–65.
Maki DG, Agger WA: Enterococcal bacteremia: Clinical features, the risk of endocarditis and management. Medicine (Baltimore) 1988, 67:248–269.
Morris JG Jr, Shay DK, Hebden JN, et al.: Enterococci resistant to multiple antimicrobial agents, including vancomycin. Establishment of endemicity in a university medical center. Ann Intern Med 1995, 123:250–259.
Boyce J, Opal SM, Chow JW, et al.: Outbreak of multidrug-resistant Enterococcus faecium with transferable van B class vancomycin resistance. J Clin Microbiol 1994, 32:1148–1153.
Murray BE, Singh KV, Heath JD, et al.: Comparison of genomic DNAs of different enterococcal isolates using restriction endonucleases with infrequent recognition sites. J Clin Microbiol 1990, 28:2059–2063.
Livornese LL Jr, Dias S, Samel C, et al.: Hospital acquired infection with vancomycin-resistant Enterococcus faecium transmitted by electronic thermometers. Ann Intern Med 1992, 117:112–116.
Rhinehart E, Smith NE, Wennersten C, et al.: Rapid dissemination of β-lactamase-producing, aminoglycoside-resistant Enterococcus faecalis among patients and staff of an infant-toddler surgical unit. N Engl J Med 1990, 323:1814–1818.
Durack DT, Beeson PB: Experimental bacterial endocarditis. II. Survival of bacteria in endocardial vegetations. Br J Exp Pathol 1972, 53:50–53.
Stevens DL, Yan S, Bryant AE: Penicillin-binding protein expression at different growth stages determines penicillin efficacy in vitro and in vivo: A explanation for the inoculum effect. J Infect Dis 1993, 167:1401–1405.
Hessen MT, Pitsakis PG, Levison ME: Post-antibiotic effect of penicillin plus gentamicin versus Enterococcus faecalis in vitro and in vivo. Antimicrob Agents Chemother 1989, 33:608–611.
Ingerman M, Pitsakis PG, Rosenberg A, Levison ME: The importance of pharmacodynamics in determining the dosing interval in therapy for experimental Pseudomonas endocarditis in the rat. J Infect Dis 1986, 153:707–714.
Thauvin C, Moellering RC Jr, et al.: Continuous ampicillin therapy of enterococcal endocarditis in rats. Antimicrob Agents Chemother 1987, 31:139–1540.
Moellering RC Jr, Korzeniowski OK, Sande M, Wennersten CB: Species-specific resistance to antimicrobial synergism in Streptococcus faecium and Streptococcus faecalis. J Infect Dis 1979, 140:203–208.
Montecalvo MA, Seiter K, Carbonaro CA: Effect of novobiocincontaining antimicrobial regimens on infection and colonization with vancomycin-resistant Enterococcus faecium. Antimicrob Agents Chemother 1995, 39:794.
Quales JM, Landman D, Mobarakai N: Treatment of experimental endocarditis due to multidrug resistant Enterococcus faecium with ciprofloxacin and novobiocin. J Antimicrob Chemother 1994, 34:797–802.
Grayson ML, Thauvin-Eliopoulos C, Eliopoulos GM, et al.: Failure of trimethoprim-sulfamethoxazole therapy in experimental enterococcal endocarditis. Antimicrob Agents Chemother 1990, 34:1792–1794.
Moellering RC Jr: The Enterococcus, a classic example of the impact of antimicrobial resistance on therapeutic options. J Antimicrob Chemother 1991, 28:1–12.
Spiegel CA, Huycke M: Endocarditis due to streptomycinsusceptible Enterococcus faecalis with high-level gentamicin resistance. Arch Intern Med 1989, 149:1873.
Lipman ML, Silva J Jr: Endocarditis due to Streptococcus faecalis with high-level resistance to gentamicin. Rev Infect Dis 1989, 11:325–328.
Fernandez-Guerrero ML, Barros C, Rodriquez Tudela JL, et al.: Aortic endocarditis caused by gentamicin-resistant Enterococcus faecalis. Eur J Clin Microbiol Infect Dis 1988, 7:525.
Rice LB, Calderwood SB, Eliopoulos GM, et al.: Enterococcal endocarditis. A comparison of prosthetic and native valve disease. Rev Infect Dis 1991, 13:1–7.
Murray BE, Church DA, Wanger A, et al.: Comparison of two b-lactamase-producing strains of Streptococcus faecalis. Antimicrob Agents Chemother 1986, 30:861–864.
Murray BE, Singh KV, Markowitz SM, et al.: Evidence for clonal spread of a single strain of β-lactamase-producing Enterococcus (Streptococcus) faecalis to six hospitals in five states. J Infect Dis 1991, 163:780–785.
Ingerman M, Pitsakis PG, Rosenberg A, et al.: β-lactamase production in experimental endocarditis due to aminoglycoside-resistant Streptococcus faecalis. J Infect Dis 1987, 155:1226–1232.
Patterson JE, Colodny SM, Zervos MJ: Serious infection due to a β-lactamase-producing Streptococcus faecalis with high-level resistance to gentamicin. J Infect Dis 1988, 158:1144–1145.
Bush LM, Calmon J, Cherney CL, et al.: High-level penicillin resistance among isolates of enterococci. Implications for treatment of enterococcal infections. Ann Intern Med 1989, 110:515–520.
Murray BE: Vancomycin-resistant enterococcal infections. N Engl J Med 2000, 342:710–721. Recent, excellent review of vancomycin resistance in enterococci.
Arthur M, Courvalin P: Genetics and mechanisms of glycopeptide resistance in enterococci. Antimicrob Agents Chemother 1993, 37:1563–1571.
Schmit JL: Efficacy of teicoplanin for enterococcal infections: 63 cases and review. Clin Infect Dis 1992, 15:1570–1575.
Caron F, Carbon C, Gutman L: Triple combination penicillin-vancomycin-gentamicin for experimental endocarditis caused by a moderately penicillin- and highly glycopeptideresistant isolate of Enterococcus faecium. J Infect Dis 1991, 164:888–893.
LeClercq R, Bingen E, Su QH, et al.: Effects of combinations of β-lactams, daptomycin, gentamicin, and glycopeptides against glycopeptide-resistant enterococci. Antimicrob Agents Chemother 1991, 35:92–98.
Johnson CC, Slavoski L, Schwartz M, et al.: In vitro activity of RP 59500 (Quinupristin/Dalfopristin) against antibiotic resistant strains of Streptococcus pneumoniae and Enterococcus. Diagn Microbiol Infect Dis 1995, 21:169–173.
Caron F, Gold HS, Wennersten CB, et al.: Influence of erythromycin resistance, inoculum growth phase, and incubation time on assessment of the bactericidal activity of RP 59500 (quinupristin-dalfopristin) against vancomycin-resistant Enterococcus faecium. Antimicrob Agents Chemother 1997, 41:2749–2753.
Winston DJ, Emmanouilides C, Kroeber A, et al.: Quinupristin/ Dalfopristin therapy for infections due to vancomycin-resistant Enterococcus faecium. Clin Infect Dis 2000, 30:790–797. Report of a clinical experience with quinupristin/dalfopristin in infections caused by vancomycin-resistant enterococci.
Furlong WB, Rakowski TA: Therapy with RP 59500 (Quinupristin/Dalfopristin) for prosthetic valve endocarditis due to enterococci with van A/van B resistance pattern. Clin Infect Dis 1997, 25:163–164.
Matsumura S, Simor AE: Treatment of endocarditis due to vancomycin-resistant Enterococcus faecium with quinupristin/ dalfopristin, doxycycline and refampin: A synergistic drug combination. Clin Ifect Dis 1998, 27:1554–1556.
Eliopoulis GM, Wennerstein CB, Gold HS, Moellering RC Jr: In vitro activity of new oxazolidinone antimicrobial agents against enterococci. Antimicrob Agents Chemother 1996, 40:1745–1747.
Chien JW, Kucia ML, Salata RA: Use of linezolid, an oxazolidinone, in the treatment of multidrug-resistant gram-positive bacterial infections. Clin Infect Dis 1999, 30:146–151. Report of clinical experience with linezolid in infections caused by vancomycin-resistant enterococci.
Foster DR, Rybak MJ: Drugs in research. Pharmacologic and bacteriologic properties of SCH-27899 (Ziracin), an investigational antibiotic from the everninomicin family. Pharmacotherapy 1999, 19:1111–1117.
Johnson CC, Taylor S, Pitsakis PG, et al.: Bactericidal activity of ramoplanin against multiple resistant Enterococcus. Antimicrob Agents Chemother 1992, 36:2341–2345.
Whitman MS, Pitsakis PG, DeJesus E, et al.: Gastrointestinal colonization with vancomycin-resistant Enterococcus faecium in an animal model. Antimicrob Agents Chemother 1996, 40:1526–1530.
Jamjian C, Biedenbach DJ, Jones RN: In vitro evaluation of a novel ketolide antimicrobial agent RU-64004. Antimicrob Agents Chemother 1997, 41:454–459.
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Levison, M.E., Mallela, S. Increasing antimicrobial resistance: Therapeutic implications for enterococcal infections. Curr Infect Dis Rep 2, 417–423 (2000). https://doi.org/10.1007/s11908-000-0068-y
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DOI: https://doi.org/10.1007/s11908-000-0068-y