Treating infections that caused by Vanomycin-Resistant Enterococci (VRE)

 Treating infections caused by Vancomycin-Resistant Enterococci (VRE) poses a significant clinical challenge due to limited treatment options and the potential for adverse patient outcomes. Enterococci, particularly Enterococcus faecalis and Enterococcus faecium, are common inhabitants of the human gastrointestinal tract and can cause a variety of infections, including urinary tract infections, bloodstream infections, and surgical site infections. The emergence of vancomycin resistance among enterococcal strains, often mediated by the acquisition of van genes encoding altered cell wall synthesis, has rendered vancomycin, a key antibiotic in the treatment of enterococcal infections, ineffective against VRE.

To effectively manage infections caused by VRE, several strategies are employed:

1. Antibiotic Stewardship: Antibiotic stewardship programs play a crucial role in optimizing the use of antibiotics to prevent the emergence and spread of antimicrobial resistance, including VRE. These programs promote the judicious use of antibiotics, encourage appropriate antibiotic selection based on local resistance patterns and patient-specific factors, and emphasize the importance of de-escalation and discontinuation of antibiotic therapy when appropriate.

2. Enhanced Surveillance: Surveillance of VRE prevalence and antimicrobial resistance patterns is essential for guiding empirical treatment decisions and implementing infection control measures. Surveillance data provide valuable insights into the epidemiology of VRE, allowing healthcare providers to monitor trends, detect outbreaks, and tailor treatment strategies accordingly.

3. Alternative Antibiotics: Infections caused by VRE often necessitate the use of alternative antibiotics that are active against vancomycin-resistant strains. Linezolid, daptomycin, tigecycline, and newer lipoglycopeptides such as telavancin and oritavancin are among the antibiotics that may be considered for the treatment of VRE infections. However, the choice of antibiotic depends on factors such as the site of infection, antimicrobial susceptibility testing results, and patient-specific considerations.

4. Combination Therapy: Combination antibiotic therapy, involving the simultaneous or sequential use of multiple antibiotics with different mechanisms of action, may be considered in severe infections caused by VRE, particularly when monotherapy is deemed inadequate or when targeting polymicrobial infections. However, the optimal choice and duration of combination therapy remain subject to debate, and careful consideration of potential side effects, drug interactions, and emergence of resistance is necessary.

5. Infection Prevention and Control Measures: Implementing infection prevention and control measures, such as hand hygiene, contact precautions, environmental cleaning, and antimicrobial stewardship interventions, is crucial for preventing the transmission of VRE within healthcare facilities and the community. Strict adherence to infection control protocols can help contain outbreaks, reduce the spread of multidrug-resistant organisms, and protect vulnerable patient populations.

In conclusion, addressing infections caused by VRE requires a multifaceted approach involving antibiotic stewardship, enhanced surveillance, appropriate antibiotic selection, combination therapy when necessary, and rigorous infection prevention and control measures. Collaboration between healthcare providers, microbiologists, infection control specialists, and public health authorities is essential to mitigate the impact of antimicrobial resistance and ensure optimal patient outcomes.

References:

• Arias, C. A., & Murray, B. E. (2012). The rise of the Enterococcus: beyond vancomycin resistance. Nature Reviews Microbiology, 10(4), 266-278.
• Boucher, H. W., Talbot, G. H., Bradley, J. S., Edwards Jr, J. E., Gilbert, D., Rice, L. B., ... & Bartlett, J. (2009). Bad bugs, no drugs: no ESKAPE! An update from the Infectious Diseases Society of America. Clinical Infectious Diseases, 48(1), 1-12.
• Van Hal, S. J., & Paterson, D. L. (2016). Systematic review and meta-analysis of the significance of heterogeneous vancomycin-intermediate Staphylococcus aureus isolates. Antimicrobial Agents and Chemotherapy, 60(6), 3150-3156.