Managing Enterococcus faecium bloodstream infection: a Delphi document on clinical recommendations and research agenda

Background: bloodstream infections (BSIs) remains debated, particularly the clinical impact of vancomycin resistance, the role of follow-up cultures, and optimal therapeutic regimens. This study aimed to reach expert consensus on these unresolved clinical domains and identify priorities for future research. Methods: BSIs, and 4) optimal antibiotic therapy for VRE-BSIs. These results informed a three-round Delphi process involving a panel of experts. An iterative approach was adopted: 16 initial questions developed from the systematic review (6-point Likert scale) were refined across rounds based on expert feedback. Consensus was defined as at least 80% agreement or disagreement. Findings: 13 statements were generated across three broader domains. Regarding clinical outcomes and diagnostics, experts agreed that mortality is heavily influenced by comorbidities; thus, therapeutic assessment should rely on clinical trends and inflammatory markers, with follow-up blood cultures used to confirm eradication. Catheter-related BSI should be managed with device removal and short-course (<7 days) antibiotics in selected uncomplicated cases. For therapeutic management, teicoplanin is preferred for vanB VRE-BSI. For vanA VRE-BSI, both linezolid and high-dose daptomycin (>9 mg/kg per day) are effective, reserving daptomycin-based combinations for challenging cases (deep-seated infections and/or high Minimum Inhibitory Concentrations). Finally, future trials evaluating the impact of antimicrobial therapy should use Desirability-of-Outcome-Ranking analysis; the in-vitro potential of oritavancin justifies targeted randomized trials to define its clinical efficacy in VRE-BSI. Interpretation: BSI while identifying crucial knowledge gaps to guide future clinical research. Funding: None.

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Journal
EClinicalMedicine
Published
2026-05-01
DOI
https://doi.org/10.1016/j.eclinm.2026.103925
Primary Topic
Central Venous Catheters and Hemodialysis
Type
article
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article

Managing Enterococcus faecium bloodstream infection: a Delphi document on clinical recommendations and research agenda

K. Thursky, Alessandra Oliva, Carlota Gudiol, Mario Venditti et al.
EClinicalMedicine
Central Venous Catheters and Hemodialysis
article

Managing Enterococcus faecium bloodstream infection: a Delphi document on clinical recommendations and research agenda

K. Thursky, Alessandra Oliva, Carlota Gudiol, Mario Venditti, Ibai Los-Arcos, Andrew Udy, S Rieg, Juan Manuel Pericàs, Winfried Vincenz Kern, Matthaios Papadimitriou-Olivgeris, Pierluigi Viale, Daniel Hornuss, Laura Escolà-Vergé, Dafna Yahav, Yin Mo, Federico Pea, Piergiorgio Cojutti, Manjunath Pai, Nuria Fernández-Hidalgo, Matteo Rinaldi, Belén Gutiérrez-Gutiérrez, Milo Gatti, Alex Soriano, Maddalena Giannella, Michele Bartoletti, Patricia Muñoz, Alessandro Russo, Luis Eduardo López-Cortés
article en

Abstract

Background: bloodstream infections (BSIs) remains debated, particularly the clinical impact of vancomycin resistance, the role of follow-up cultures, and optimal therapeutic regimens. This study aimed to reach expert consensus on these unresolved clinical domains and identify priorities for future research. Methods: BSIs, and 4) optimal antibiotic therapy for VRE-BSIs. These results informed a three-round Delphi process involving a panel of experts. An iterative approach was adopted: 16 initial questions developed from the systematic review (6-point Likert scale) were refined across rounds based on expert feedback. Consensus was defined as at least 80% agreement or disagreement. Findings: 13 statements were generated across three broader domains. Regarding clinical outcomes and diagnostics, experts agreed that mortality is heavily influenced by comorbidities; thus, therapeutic assessment should rely on clinical trends and inflammatory markers, with follow-up blood cultures used to confirm eradication. Catheter-related BSI should be managed with device removal and short-course (<7 days) antibiotics in selected uncomplicated cases. For therapeutic management, teicoplanin is preferred for vanB VRE-BSI. For vanA VRE-BSI, both linezolid and high-dose daptomycin (>9 mg/kg per day) are effective, reserving daptomycin-based combinations for challenging cases (deep-seated infections and/or high Minimum Inhibitory Concentrations). Finally, future trials evaluating the impact of antimicrobial therapy should use Desirability-of-Outcome-Ranking analysis; the in-vitro potential of oritavancin justifies targeted randomized trials to define its clinical efficacy in VRE-BSI. Interpretation: BSI while identifying crucial knowledge gaps to guide future clinical research. Funding: None.

EClinicalMedicineVol. 95
Universidad Complutense de Madrid (ES), Universitat Autònoma de Barcelona (ES), Humanitas University (IT), University of Freiburg (DE), Tel Aviv University (IL), National University of Singapore (SG), University of Michigan (US), Sheba Medical Center (IL), Policlinico Umberto I (IT), Peter MacCallum Cancer Centre (AU), University Medical Center Freiburg (DE), Instituto de Salud Carlos III (ES), Hospital de Sant Pau (ES), The Alfred Hospital (AU), Bellvitge University Hospital (ES), Hospital General Universitario Gregorio Marañón (ES), Magna Graecia University (IT), Hospital Universitario Virgen Macarena (ES), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (ES), Vall d'Hebron Institut de Recerca (ES), Victorian Comprehensive Cancer Centre (AU), Centro de Investigación Biomédica en Red (ES), Hospital Clínic de Barcelona (ES), Azienda USL di Bologna (IT), Vall d'Hebron Hospital Universitari (ES), Instituto de Biomedicina de Sevilla (ES), National University Health System (SG), Hôpital du Valais (CH), IRCCS Humanitas Research Hospital (IT), Monash University (AU), University of Bologna (IT)
Openalex Percentile: Top 5%
Central Venous Catheters and Hemodialysis
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