MSD MANUAL

Professional Version
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Enterococcal Infections
By Larry M. Bush , MD, FACP, Charles E. Schmidt College of Medicine, Florida Atlantic University;
Maria T. Perez , MD, Wellington Regional Medical Center, West Palm Beach
Last full review/revision June 2019 by Larry M. Bush, MD, FACP; Maria T. Perez, MD

Enterococci are gram-positive, facultative anaerobic organisms. Enterococcus faecalis and E. faecium cause a
variety of infections, including endocarditis, urinary tract infections, prostatitis, intra-abdominal infection,
cellulitis, and wound infection as well as concurrent bacteremia.

Enterococci are part of the normal intestinal flora. They used to be classified as group D streptococci but are now
considered a separate genus. There are > 17 species, but E. faecalis and E. faecium most commonly cause infections in
humans.
Enterococci typically cause
Urinary tract infections

Bacteremia

Endocarditis

Intra-abdominal and pelvic infections

Skin, soft tissue, and wound infections

Treatment
Varies by site of infection and susceptibility testing

(See also the American Heart Association's Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and
Management of Complications.)
Enterococci associated with endocarditis are difficult to eradicate unless a combination of certain cell wall–active drugs (eg,
penicillin, ampicillin, amoxicillin, piperacillin, vancomycin) plus an aminoglycoside (eg, gentamicin, streptomycin) is used to
achieve bactericidal activity. However, some cell wall–active drugs have limited or no activity against enterococci; they
include nafcillin, oxacillin, ticarcillin, ertapenem, most cephalosporins, and aztreonam. E. faecium are more resistant to
penicillin than E. faecalis. When an aminoglycoside cannot be used, the combination of penicillin or ampicillin plus
ceftriaxone is an effective alternative for the treatment of E. faecalis endocarditis. Imipenem and, to a lesser degree,
meropenem are active against E. faecalis.
For complicated skin infections due to vancomycin-susceptible enterococci, daptomycin, linezolid, tedizolid, tigecycline,
and omadacycline are effective treatment options.
Piperacillin/tazobactam, imipenem or meropenem, and eravacycline are recommended for complicated intra-abdominal
infections when enterococci are known or presumed to be involved.
Urinary tract infections do not require bactericidal therapy and, if the causative organism is sensitive, are usually treated
with a single antibiotic such as ampicillin. Nitrofurantoin and fosfomycin are often effective against vancomycin-resistant
enterococcal urinary tract infection.

Resistance
In the past several decades, resistance to multiple antimicrobial drugs has increased rapidly, especially among E. faecium.
Resistance to aminoglycosides (eg, gentamicin, streptomycin), particularly with E. faecium, continues to emerge.
Vancomycin-resistant enterococci (VRE) may also be resistant to other glycopeptides (eg, teicoplanin), aminoglycosides,
and cell wall–active beta-lactams (eg, penicillin G, ampicillin). When identified, infected patients are strictly isolated.
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Recommended treatment includes streptogramins (quinupristin/dalfopristin for E. faecium only) and oxazolidinones
(linezolid, tedizolid). Daptomycin, tigecycline, and eravacycline have in vitro activity against VRE and may be off-label
treatment options.
Beta-lactamase–producing enterococci are occasionally problematic, particularly when large numbers of organisms are
present in tissues (eg, in endocarditis vegetation). Resistance may be present clinically even though the organism appears
susceptible based on standard testing. Vancomycin or combination beta-lactam/beta-lactamase inhibitor antibiotics (eg,
piperacillin/tazobactam, ampicillin/sulbactam) can be used.

More Information
Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications

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