Treatment options for VRE infections are limited. We defined our VRE antibiogram, and evaluated clinical responses among patients (pts) treated for VRE BSI.
Retrospective review of consecutive pts with VRE BSI (2012-15). Ampicillin susceptible (S) or E. faecalis isolates were excluded. Clinical success was defined as 30 day (d) survival with clinical improvement and absence of persistent or recurrent VRE BSI.
98 pts were enrolled. Median age was 58 years (range: 21 – 86). 60% were men. 62% were immunocompromised. At onset of VRE BSI, 73% were in an ICU, 43% required renal replacement therapy, and median Pitt Bacteremia Score (PBS) was 7 (0- 13). Portals of entry were central venous catheters in 35% and abdomen in 34%. Using microscan or Etest, 22% and 1% of VRE were daptomycin (DAP) and linezolid (LZD) NS, respectively (P<0.001). 30d survival and clinical success rates were 63% and 41%, respectively. Success rates were similar among pts treated with DAP (44% [17/39]), LZD (39% [22/56]), or quinupristin-dalfopristin (33% [1/3]). LZD success was 39% and 45% against DAP-NS and –S , respectively. LZD was utilized more often against DAP-NS than DAP-S isolates (P=0.01). By multivariate analysis, PBS was associated with failure (P=0.08). Treatment was discontinued in 5% and 21% of pts on DAP or LZD, respectively, due to adverse events or persistent infection (P=0.04). Rates of recurrent BSI (8% within 90d of initial BSI) did not vary between agents. 63% of recurrent VRE isolates were DAP-NS; 0% were LZD-NS (P=0.025). 88% and 63% of pts with recurrent BSI were previously exposed to DAP or LZD, respectively. 63% and 37% of pts with recurrent BSI were treated with the same or alternative agent, respectively. 25% of pts died during recurrent BSI treatment; another 25% had a third VRE BSI within 90 d.
Clinical success was achieved in a minority of patients treated for VRE BSI, despite the use of agents that were active in vitro. It was particularly worrisome that 22% of VRE were DAP-NS, and 21% of pts on LZD discontinued treatment. New, better-tolerated agents for VRE are needed. Microscan/Etest may assign higher DAP MICs than broth microdilution methods, but our results suggest that potential over-calling of DAP-NS did not impact outcomes.
R. V. Marini,
Astellas: Grant Investigator , Research support
L. Clarke, None
C. J. Clancy, None
M. H. Nguyen, None
J. A. Viehman, None