Successful treatment of complicated infective endocarditis due to Enterococcus faecium in a patient with substance use disorder using Oritavancin as sequential maintenance therapy.

We have read with great interest the article written by Wurcel et al. [ [1] Wurcel A.G. DeSimone D.C. Marks L. Baddour L.M. Sendi P. Which trial do we need? Long-acting glycopeptides versus oral antibiotics for infective endocarditis in patients with substance use disorder. Clin Microbiol Infect. 2023 Aug; 29: 952-954https://doi.org/10.1016/j.cmi.2023.04.005 Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar ] published in Clin Microbiol Infect. We completely agree with the necessity to design randomized clinical trials to investigate the use of long-acting glycopeptides (LGPs) such as those for the treatment of infective endocarditis, which are now allowed off-label use, in comparison with oral therapy in people who inject drugs (PWIDs). We recently managed a 35-years-old man, who was addicted to heroin intravenously and who presented at our Emergency Department for fever and dyspnoea. Blood tests documented leukocytosis and increased levels of inflammatory markers, such as C-reactive protein (CRP). A chest X-ray showed lung consolidation with ground glass opacities, and blood cultures were positive for Enterococcus faecium resistant to ampicillin, high-level resistant to gentamicin, and susceptible to glycopeptides and oxazolidinones. Vancomycin therapy was promptly initiated, and a transthoracic echocardiographic examination revealed pedunculated and strongly mobile vegetation of the tricuspid valve, 0.6 × 0.5 cm in diameter, causing double jet valve insufficiency with a Coandă effect (i.e. blood flow adhering to the atrial wall) which was estimated to be moderate. The findings were confirmed by transesophageal echocardiography. A total body CT scan revealed numerous pulmonary nodules suggestive of septic emboli and the presence of a left coxofemoral joint effusion suggestive of septic arthritis. Finally, due to reported breast pain, an ultrasound examination of skin and soft tissue was performed, which showed the presence of a septic collection in the left mammary gland, interpreted as further embolic-septic localization. Forty-height hours after the start of vancomycin therapy, control blood cultures were negative, and therapy was continued for four weeks, during which the patient experienced significant improvement in clinical symptoms, stable defervescence, and a reduction in inflammatory markers. No surgical procedure involving drainage of the septic collections was performed.