Optimizing Therapy for Vancomycin-resistant Enterococcal Bacteremia in Children

Pranita D. Tamma; Alice J. Hsu


Curr Opin Infect Dis. 2014;27(6):517-527. 

In This Article


A limited number of antimicrobials are available for the treatment of VRE bacteremia. If ampicillin susceptibility is retained, ampicillin remains the mainstay of therapy. When ampicillin is no longer an option, acceptable alternatives include quinupristin-dalfopristin, linezolid, and daptomycin.

Several practical issues complicate the use of quinupristin-dalfopristin. First, it should be given by a central venous catheter to avoid venous irritation. Second, there are significant drug–drug interactions with medications metabolized via cytochrome P450 enzymes. In addition, more than a negligible portion of patients will experience myalgias and/or arthralgias that can be severe enough to require dose reduction or administration of opiate analgesics. There have been no pharmacokinetic studies specific in the pediatric population. Despite these challenges, the drug has been used successfully in children for the treatment of VRE bacteremia.

Although daptomycin is generally better tolerated for prolonged periods of time compared with quinupristin-dalfopristin and linezolid, observational data in adults suggest poorer outcomes with this agent compared with linezolid. Additionally, optimal dosing for the treatment of VRE bacteremia is unknown particularly in young children who have enhanced clearance of daptomycin.

If one considers the properties of all the agents, linezolid, despite its bacteriostatic activity against VRE, may be the most versatile of the drugs. Its antibacterial spectrum is at least as broad as that of quinupristin-dalfopristin and daptomycin, and it is active against both E. faecalis and E. faecium. It can be given orally, with the potential to enhance patient comfort and decrease costs and risks of i.v. therapy. The clinical pharmacokinetics of linezolid have been well described in children. The most notable concerns with linezolid, however, are toxicities associated with prolonged use. Until more prospective data are available, we favor linezolid as first-line therapy for the treatment of VRE bacteremia in children.