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 login to view 1 more bullet 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 login to view 1 more bullet Staphylococcus saprophyticus login to view 1 more bullet Other causes of endocarditis differentiating factor Streptococcus viridans login to view 1 more bullet Treatment Treatment approach antibiotic of choice is dependent on susceptibility testing Medical amoxicillin, fosfomycin, or nitrofurantoin indication login to view 1 more bullet ampicillin, vancomycin, or daptomycin indication login to view 1 more bullet comments login to view 1 more bullet ampicillin and gentamicin indication login to view 1 more bullet comments login to view 3 more bullets linezolid indication login to view 2 more bullets Complications UTI Biliary tract infections Subacute endocarditis Sepsis