Version May 2024
| Regimen | Dose and route |
| Isolate is ampicillin susceptible and vancomycin resistant | |
| Preferred agents | |
| Ampicillin | 1 to 2 g IV every 4 to 6 hours |
| Penicillin G¶ | 18 to 30 million units IV per 24 hours either continuously or in 6 equally divided doses |
| Alternate agents | |
| DaptomycinΔ | 8 to 12 mg/kg IV every 24 hours |
| Linezolid (alternative agent to daptomycin) | 600 mg IV every 12 hours |
| Isolate is ampicillin resistant and vancomycin susceptible | |
| Preferred agents | |
| Vancomycin◊ | Initially 15 mg/kg/dose IV every 12 hours, not to exceed 2 g per dose; subsequent dosing guided by serum trough concentration or AUC monitoring§ |
| DaptomycinΔ (alternative agent to vancomycin) | 8 to 12 mg/kg IV every 24 hours |
| Linezolid (alternative agent to daptomycin) | 600 mg IV every 12 hours |
| Alternate agents | |
| High-dose ampicillin (if ampicillin MIC is ≤32 mcg/mL) | 3 to 4 g IV every 4 hours |
| Ampicillin-sulbactam (if ampicillin resistance is due to beta-lactamase production) | 3 g IV every 6 hours |
| Isolate is ampicillin resistant and vancomycin resistant | |
| Preferred agents | |
| DaptomycinΔ | 8 to 12 mg/kg every 24 hours |
| Linezolid (alternative agent to daptomycin) | 600 mg IV every 12 hours |
| Alternate agents | |
| High-dose ampicillin (if ampicillin MIC is ≤32 mcg/mL) | 18 to 30 g per day |
| Ampicillin-sulbactam (if ampicillin resistance is due to beta-lactamase production) | 3 g IV every 6 hours |
IV: intravenously; MIC: minimum inhibitory concentration; AUC: area under the 24-hour time-concentration curve.
* For patients with enterococcal bacteremia in the absence of critical illness or suspected endocarditis, an empiric monotherapy (bacteriostatic) regimen is appropriate.
¶ Isolate susceptibility to penicillin should be confirmed prior to using penicillin.
Δ Many favor use of daptomycin for treatment of infections due to isolates that are resistant to approved agents (including vancomycin-resistant Enterococcus faecalis and E. faecium). Higher doses of daptomycin (10 to 12 mg/kg) have been associated with increased probability of achieving pharmacodynamic targets (free drug AUC/MIC ratio) and improved clinical outcomes in large retrospective studies, especially with E. faecium, and could be considered for life-threatening vancomycin-resistant enterococcal infections with relatively high MICs. High-dose daptomycin was not associated with dose dependent increases in myopathy from these retrospective studies, however serial measurements of serum creatinine kinase should be monitored on daptomycin therapy.
◊ Teicoplanin (where available) may be used in place of vancomycin for treatment of infection due to isolates with MIC ≤2 mg/L; for vancomycin-resistant strains (very common with Enterococcus faecium), teicoplanin should not be used (even if susceptible in vitro) because of concern about emergence of resistance. Teicoplanin loading and maintenance doses vary depending on the site and severity of infection. Loading doses range from 400 mg (approximately 6 mg/kg per dose) intravenously every 12 hours for 3 doses to 800 mg (approximately 12 mg/kg per dose) every 12 hours for 3 to 5 doses; maintenance doses range from 6 to 12 mg/kg/day. Therapeutic drug monitoring may be warranted; refer to local product information.
§ There is limited information on pharmacologic targets for vancomycin dosing in vancomycin susceptible enterococcal bloodstream infections. An AUC/MICEtest ratio of ≥389 was associated with reduced mortality in one small single-center study[1], but not in another[2]. Vancomycin trough levels above 15 mg/L are likely excessive for enterococci and have been associated with higher rates of acute kidney injury. The authors generally aim for a trough of 10 to 15 mg/L. A loading dose and/or higher pharmacologic targets may be considered as guided by the overall condition of the patient or a concern for concurrent infection due to another pathogen (eg, methicillin-resistant Staphylococcus aureus). Refer to the UpToDate topic on vancomycin dosing for discussion of AUC-guided and trough-guided vancomycin dosing.آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
