Resistance by Default

A 58-year-old man with Child-Pugh B alcoholic cirrhosis and type 2 diabetes is admitted with a 2-day history of fever, rigors, and progressive confusion. He has not been hospitalized in over 8 months. He takes furosemide, spironolactone, and lactulose at home. He denies recent antibiotic use, foreign travel, or new dietary changes.

On examination he is febrile to 38.7°C with a heart rate of 108 beats per minute and blood pressure of 102/68 mmHg. He is jaundiced with scleral icterus, has mild asterixis, and is oriented only to person. Abdominal examination reveals a distended abdomen with shifting dullness and mild diffuse tenderness without peritoneal signs. Spider angiomata are present on the chest. There is 2+ pitting edema of the lower extremities bilaterally. No focal skin or soft tissue findings are identified. Cardiopulmonary examination is unremarkable.

Laboratory data show white blood cell count 14,800/μL with 82% neutrophils, hemoglobin 10.2 g/dL, and platelets 88,000/μL. Comprehensive metabolic panel shows total bilirubin 4.2 mg/dL, ALT 58 U/L, AST 74 U/L, alkaline phosphatase 186 U/L, creatinine 1.6 mg/dL, and albumin 2.8 g/dL. INR is 1.9. Urinalysis is unremarkable. Diagnostic paracentesis is performed and shows 180 white blood cells/mm³ with 52% neutrophils.

Two sets of blood cultures are drawn from separate peripheral sites. Both become positive at 18 hours with gram-positive cocci in pairs and short chains. The organism is identified as Enterococcus gallinarum by MALDI-TOF mass spectrometry. The automated susceptibility system reports the following: ampicillin susceptible (MIC 0.5 μg/mL), vancomycin resistant (MIC 8 μg/mL), teicoplanin susceptible (MIC 0.5 μg/mL), linezolid susceptible, and daptomycin susceptible. The laboratory automatically flags the result as "vancomycin-resistant enterococcus (VRE)" and notifies the infection control team. The covering team calls you, the infectious diseases fellow on call, asking whether to start linezolid and initiate VRE contact precautions.