Therapeutic and preventative options for the management of vancomycin-resistant enterococcal infections

Enterococci are naturally resistant to a wide range of antimicrobial agents. In addition, some enterococci, known as vancomycin-resistant enterococci (VRE) have become resistant to glycopeptide antibiotics. The therapeutic options for VRE infections are therefore very limited. New antimicrobials have been developed that are active against VRE, such as linezolid and quinupristin/dalfopristin. Others, e.g. tigecycline, daptomycin and oritavancin, are in the later stages of development. However, resistance has already been detected to some of these agents. Some success has been enjoyed through the application of older antibiotics against VRE. The lack of therapeutic options has led to the consideration of measures to prevent infection with VRE. In addition to standard infection control procedures such as isolation and hand washing, decolonization of the gastrointestinal tract has been investigated as a method for the prevention of VRE infection in vulnerable patient groups. Several decolonization regimens have been investigated. These include the use of ramoplanin, a new glycolipodepsipeptide antibiotic that has features that particularly suit it for decolonization. Ramoplanin is not absorbed from the gastrointestinal tract, has potent bactericidal activity against Gram-positive organisms and limited side effects. These features and current clinical evidence suggest that ramoplanin may have a role in future gastrointestinal decolonization regimens.