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Treatment of Vancomycin-Resistant Enterococcus with Quinupristin/Dalfopristin and High-Dose Ampicillin

Assistant Professor, Critical Care, Department of Pharmacy Practice, St. Louis College of Pharmacy, John Cochran Veterans Affairs Medical Center, St. Louis, MO

Christine M Walko, PharmD

Hematology/Oncology Specialty Resident; Clinical Instructor of Pharmacotherapy, University of North Carolina Hospitals, Chapel Hill, NC

Patricia A Targos, PharmD

Clinical Specialist, Oncology, Virginia Commonwealth University Health System, Medical College of Virginia Hospitals and Physicians, Richmond, VA

Reprints: Patricia A Targos PharmD, Virginia Commonwealth University Health System, Medical College of Virginia Hospitals and Physicians, 401 N. 12th St., PO Box 980042, Richmond, VA 23298-0042, fax 804/225-3920, patargos{at}hsc.vcu.edu

OBJECTIVE: To report the successful treatment of vancomycin-resistant Enterococcus (VRE) bacteremia using the combination of quinupristin/dalfopristin and high-dose ampicillin.

CASE SUMMARY: A 38-year-old African American woman with relapsed acute myeloid leukemia and neutropenic fever developed VRE bacteremia following 3 successive courses of vancomycin for methicillin-resistant staphylococcal infections. Treatment with linezolid was initiated; however, after 9 days of therapy, blood cultures continued to reveal VRE and the patient became febrile. The patient was subsequently switched to quinupristin/dalfopristin and high-dose ampicillin. The fever resolved and all subsequent blood cultures were negative after the initiation of combination therapy.

DISCUSSION: The emergence of VRE infections presents a treatment challenge in immunocompromised patients. When treating VRE infections in this patient population, the effectiveness of linezolid and quinupristin/dalfopristin is limited by their bacteriostatic activity when used as monotherapy. Recent in vitro data suggest synergistic activity with quinupristin/dalfopristin when used in combination with other antimicrobials in selected isolates of VRE.

CONCLUSIONS: Persistent VRE bacteremia was successfully treated in this neutropenic patient using the combination of high-dose ampicillin and quinupristin/dalfopristin. Case reports and in vitro data suggest that concomitant therapy with high-dose ampicillin may be an effective treatment alternative for VRE infections not responding to standard therapy.

Key Words: ampicillin, linezolid, neutropenic fever, quinupristin/dalfopristin, vancomycin-resistant enterococcus

Published Online, April 20, 2004. www.theannals.com, DOI 10.1345/aph.1D377

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