Snapshot 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