Impact of empiric anti-VRE therapy on survival in vancomycin-resistant enterococcal bloodstream infection.

Objectives: The aim of this study is to evaluate the benefit of early appropriate antibiotics in vancomycin-resistant Enterococcus (VRE) bloodstream infections (BSIs) amid increasing incidence and limited evidence supporting empirical VRE-active therapy.

Methods: We performed a cohort study (2010-23) involving patients with VRE BSI who received empiric Gram-positive coverage. Patients who did not receive VRE-active therapy (daptomycin or linezolid) were excluded. Based on their initial regimen, patients were classified into an empiric anti-VRE group or a glycopeptide (vancomycin or teicoplanin) group. The primary outcome was 28-day mortality.

Results: We included 134 patients: 46 in the empiric anti-VRE group and 88 in the glycopeptide group. The 28-day mortality rate was 53.7%. All glycopeptide recipients switched to daptomycin, and 29 of the 46 (63%) patients in the empiric anti-VRE group also received daptomycin. Time to VRE-active therapy was shorter in the empiric anti-VRE group (0 versus 2 days; P < 0.001), and each day's delay correlated with higher mortality (0 day: 37.0%, 1 day: 57.7%, ≥2 days: 64.5%; P = 0.02). The empiric anti-VRE group had a lower 28-day mortality rate (37.0% versus 62.5%, P = 0.006). Multivariable analysis adjusting for comorbidities, steroid use, infection focus and bacteraemia severity indicated that empiric anti-VRE therapy was independently associated with lower mortality (adjusted OR 0.41; 95% CI, 0.17-0.98; P = 0.046).

Conclusions: Among patients with VRE BSI requiring empiric Gram-positive coverage, anti-VRE therapy was associated with reduced 28-day mortality compared with glycopeptides, even both groups eventually received VRE-active antibiotics. This highlights the critical role of timely, appropriate antibiotic to improve VRE BSI outcomes.