title: Single center experience of a vancomycin resistant enterococcal endocarditis cohort.
abstract: OBJECTIVE
  Vancomycin resistant enterococcus (VRE) infective endocarditis (IE) is an increasing nosocomial problem. We describe the clinical management and outcomes of a cohort of patients with VRE IE at a tertiary endocarditis referral center.
  
  
  METHODS
  Retrospective review of all proven cases of VRE IE, from July 2000 through January 2008 was performed. Demographics, comorbidities and therapeutic details were collected and analyzed to assess for risk factors and clinical outcomes.
  
  
  RESULTS
  Fifty cases of VRE IE were identified: 26 (52%) were Enterococcus faecium and 24 were Enterococcus faecalis. Vancomycin resistant E. faecalis IE was associated with the presence of a central venous line, liver transplantation, and mitral valve infection while VR E. faecium IE was significantly associated with tricuspid valve infection (p=0.03). The median duration of bacteremia was 14 days for E. faecium and 4 days for E. faecalis, respectively (p=0.002). Factors associated with mortality on bivariate analysis were hemodialysis via a catheter with VR E. faecium (OR=11.7. CI 1.1-122, p=0.02) and liver transplantation with both species. Combination antimicrobial therapy (OR=0.5 CI=0.06-3.2, p=0.1) and valve surgery (OR 1.3 CI 0.8-20, p=0.02) trended toward improved survival with E. faecalis on bivariate analysis. On multivariate analysis, none of the associations were significant.
  
  
  CONCLUSIONS
  Hemodialysis and liver transplantation were factors associated with acquisition of VRE IE. There was a higher mortality and prolonged bacteremia with VR E. faecium IE than VR E. faecalis IE. Although not significant, combination antimicrobial therapy and surgical intervention trended toward improved survival.
authors.affiliation: Division of Infectious Diseases, Portland VA Medical Center, 3710 SW US Veterans Hospital Road, P3-ID, Portland, OR 97239, USA. forrestg@ohsu.edu
authors.forename: Graeme N
authors.initials: GN
authors.lastname: Forrest
authors.forename: Ryan S
authors.initials: RS
authors.lastname: Arnold
authors.forename: James S
authors.initials: JS
authors.lastname: Gammie
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Gilliam
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003428:Cross Infection / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology; D004697:Endocarditis, Bacterial / Q000188:drug therapy* / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality; D013293:Enterococcus faecalis / Q000187:drug effects* / Q000302:isolation & purification; D016984:Enterococcus faecium / Q000187:drug effects* / Q000302:isolation & purification; D005260:Female; D016908:Gram-Positive Bacterial Infections / Q000188:drug therapy* / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome; D020713:Vancomycin Resistance