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Updated: Jan 22 2019

Enterococci (Group D Streptococci)

  • 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
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