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Treatment of infections caused by vancomycin-resistant enterococci [Article de Revue]

 
[Traitement des infections dûes à des entéroscopes résistants à la vancomycine]
MUDER RR
Current treatment options in infectious diseases. 2003/09; 5 : 431-439
Summary: Cette revue présente les facteurs de risque d'acquisition d'entérocoques résistants à la vancomycine et souvent multirésistants et les différents traitements antibiotiques.La maîtrise de ERV demande une coordination dans la surveillance destinée à déceler les porteurs sains, l'isolement adapté, les précautions barrière et hygiène des mains, ces mesures permettant une diminution nette de la transmission des ERV.

Vancomycin-resistant enterococci (VRE) have emerged as major nosocomial pathogens.VRE are typically resistant to multiple antimicrobials; ampicillin resistance and high-level aminoglycoside resistance are common. The primary therapeutic options for patients with VRE infection include quinupristin/dalfopristin, which is active against most strains of Enterococcus faecium, and linezolid, which is active against E. faccium and Enterococcus faecalis. In noncomparative trials of treatment of VRE infections, quinupristin/dalfopristin and linezolid appear to be effective. Both agents have an acceptable safety profile. The major toxicity of quinupristin/dalfopristin is musculoskeletal pain. Linezolid causes reversible anemia and thrombocytopenia.Because comparative data are extremely limited, the optimal treatment of patients with VRE infection is uncertain. Some VRE strains (most often E.faecalis) are susceptible to ampicillin. Ampicillin is the preferred therapy in these cases, based on experience and low cost. Linezolid should be considered first-line therapy for patients with ampicillin-resistant E. faecalis. Quinupristin/dalfopristin or linezolid is reasonable as first-line therapy for patients with E. faecium infection. Susceptibility to quinupristin/dalfopristin or linezolid should not be assumed but should be confirmed by susceptibility testing.Emergence of resistance to either agent may occur during therapy. Certain VRE infections pose particular therapeurtic problems. Optimal treatment of endocarditis requires bactericidal antimicrobial therapy. Quinupristin/dalfopristin and linezolid are bacteriostatc in vitro. Limited in vitro data indicated synergistic bactericidal activity when quinupristin/dalfopristin is combined with linezolid, doxycycline, or ampicillin. Synergy appears to be isolate-specific. One rational approach for treatment of patients with VRE endocarditis would be to test the isolate against combinations of antimicrobial agents reported to interact synergistically by kill-curve determination and select one with bactericidal activity in vitro.Surgical intervention is needed if VRE bacteria cannot be cleared. Data on treatment of central nervous system infection caused by VRE are extremely limited.Quinupristin/dalfopristin does not reach cerebrospinal fluid levels adequately to treat patients with VRE meningitis; there are a limited number of reports of successful treatment with entrathecal administration. Linezolid reaches adequate cerebrospinal fluid livels; there is a case report of successful treatment of E. faecium menungitis with ingravenous linezolid. Control of VRE in hospitals requires a coordinatie approach that combines surveillance to detect asymptomatic carriers, appropriate isolation, barrier precautions, and hand hygiene. Vigorous applications of these measures can result in a marked reduction in transmission of VRE.
Publication
2003/09

Pages
431-439

Language
Anglais

Number of ref
54

Published in
Current treatment options in infectious diseases

ID notice
319204

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33076 Bordeaux
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