Oral Bacitracin: A Consideration for Suppression of Intestinal Vancomycin-Resistant Enterococci (VRE) and for VRE Bacteremia From an Apparent Gastrointestinal Tract Source.

TO THE EDITOR—Intestinal colonization with vancomycin-resistant Enterococcus faecium (VRE) is considered the major risk factor for VRE infection and transmission. Bacitracin was previously shown to decrease VRE colonization burden during its administration. Here, we describe a neutropenic patient with VRE bacteremia, which persisted despite multiple combination therapies until decolonization was initiated with oral bacitracin. A 25-year-old patient with leukemia and neutropenia after chemotherapy presented with Klebsiella pneumoniae and Escherichia coli bacteremia, successfully treated with doripenem. Subsequently, VRE resistant to ampicillin and daptomycin (minimum inhibitory concentration [MIC], 12 μg/mL) but susceptible to linezolid and quinupristin-dalfopristin were isolated from the patient’s blood. Catheters were changed multiple times, but blood cultures continued to grow VRE despite combinations of tigecycline, rifampin, quinupristin-dalfopristin, linezolid, and ampicillin; transthoracic echocardiography was normal and an indium white blood cell scan revealed uptake consistent with focal pericecal colitis. A perirectal swab grew VRE. Based on previous reports [1–5], oral bacitracin 25 000 U/125 mL 4 times a day was begun. Forty-eight hours later, stool cultures were negative for VRE as were blood cultures for the first time in 17 days. Unfortunately, the patient later died from other causes. Intestinal domination by VRE has been reported to precede bloodstream infections in patients with neutropenia after hematopoietic stem cell transplant [6, 7]. Recent attempts to decrease VRE bacteremia in neutropenic patients report the use of parenteral daptomycin or of