Diagnosis and treatment of enterococcal endocarditis

Enterococci are frequently encountered in urinary, biliary, and gastrointestinal tract infections and are increasingly being recognized in nosocomial bacteriuria and bacteremia. Undoubtedly, however, the most serious of all enterococcal infections is endocarditis. At present, enterococci are the third most common cause of infective endocarditis (after streptococci and Staphylococcus aureus), and the incidence of the disease is likely to grow as the population ages and increasing numbers of persons are placed at risk by degenerative valve disease and by predisposition to enterococcal infections through portals such as the genitourinary tract. The case presented here exemplifies many features of enterococcal endocarditis. It also illustrates the therapeutic issues and dilemmas faced in managing this disorder. Although a transesophageal approach (Figure 1) has increased the sensitivity of echocardiography for detecting valvular abnormalities in infective endocarditis, diagnosis continues to rely on blood cultures--which raises the question of how long antimicrobial therapy should be delayed for collection of blood samples. Since enterococcal isolates are often resistant to antibiotics, therapy is based on synergistic drug combinations.