Updated: 1/22/2019

Enterococci (Group D Streptococci)

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  • A 55-year-old woman is in the medical intensive care unit for treatment of intractable seizures. She was intubated and sedated with phenobarbital. On hospital day 8, her temperature is 102°F (38.9°C), blood pressure is 102/79 mmHg, and pulse is 102/min. Physical examination is notable for facial grimacing during suprapubic palpation. A Foley catheter had been placed since admission. Urine studies are obtained and a urinalysis is positive for leukocyte esterase. She is started on piperacillin-tazobactam and vancomycin. Urine culture returns positive for enterococci species susceptible to ampicillin. Her empiric antibiotic treatment was narrowed to intravenous ampicillin. (Urinary tract infection)
Introduction
  • Classification
    • gram-positive cocci
      • α- or γ-hemolytic
      • grows in 40% bile or 6.5% NaCl
      • catalase negative
      • PYR (pyrrolidonyl arylamidase) positive
    • organisms
      • Enterococcus faecium
      • E. faecalis
  • Epidemiology
    • incidence
      • a common cause of nosocomial infections in the United States
      • E. faecalis is the most common enterococci to cause endocarditis
  • Reservoir
    • normal colonic flora
  • Associated conditions
    • urinary tract infections (UTI)
    • biliary tract infections
    • subacute bacterial endocarditis
    • bacteremia
Presentation
  • Symptoms
    • UTI
      • urinary frequency or urgency
    • biliary tract infections
      • right upper quadrant pain
    • endocarditis
      • chills
      • anorexia
      • weight loss
      • patients may have tooth pain or related symptoms
  • Physical exam
    • UTI
      • dysuria
      • suprapubic pain
    • biliary tract infections
      • Murphy sign
        • arrest of inspiration secondary to pain upon right upper quadrant palpation
    • endocarditis 
      • fevers
      • new heart murmur
Studies
  • Microbiologic
    • variable hemolysis (α- or γ-hemolytic)
    • PYR positive
    • growth in 40% bile or 6.5% NaCl
Differential
  • Other causes of UTI
    • differentiating factor
      • E. coli
        • gram-negative rod
      • Staphylococcus saprophyticus
        • catalase-positive, gram-positive cocci
  • Other causes of endocarditis
    • differentiating factor
      • Streptococcus viridans 
        • α-hemolytic cocci that is optochin resistant and not bile soluble
Treatment
  • Treatment approach
    • antibiotic of choice is dependent on susceptibility testing
  • Medical
    • amoxicillin, fosfomycin, or nitrofurantoin
      • indication
        • enterococci UTI
    • ampicillin, vancomycin, or daptomycin
      • indication
        • enterococci sepsis
      • comments
        • ampicillin-resistant bacteria that are vancomycin-susceptible are treated with vancomycin or daptomycin
    • ampicillin and gentamicin
      • indication
        • endocarditis caused by enterococci
      • comments
        • other regimens
          • ceftriaxone with ampicillin
          • vancomycin with gentamicin for patients with beta-lactam allergies
    • linezolid
      • indication
        • vancomycin-resistant enterococci (VRE)
          • vancomycin resistance is gained through uptake of a resistance plasmid 

 

Complications
  • UTI
  • Biliary tract infections
  • Subacute endocarditis
  • Sepsis
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