The enterococci are the third most common agents of IE overall, causing 5-20% of cases. In a prospective analysis over a five-year period in a center in Spain, IE was found to be present in 17/116 (14.6%) patients with enterococcal bacteremia [12]. Enterococcal IE was caused by E.faecalis in 16/17 (94%)cases. Endocarditis was hospital acquired in 6/17 (35.3%) cases, and 10/17 (59%) patients had preexisting valvular abnormalities. Health-care-associated infection was also noted in an early retrospective review of 38 cases of enterococcal IE published in 1970 by Mandell et al., in which 47% of infections had developed in elderly men who had undergone GU tract procedures or in younger women following gynecological procedures [13]. In a recent publication based on the ICE merged database (1970-1999), 107 definite left-sided native valve IE cases caused by enterococci were compared to cases of other etiologies in the same database

[14]. Among the 62.6% of isolates that were fully identified, 92.5% were E. faecalis, 6.0% E. fae-cium and 1.5% E. durans. Patients with enterococcal endocarditis were older (mean age 66.4 vs. 58.2 years) and more likely to have cancer (21% vs. 8%) when compared to those with non-ente-rococcal IE. Enterococcal IE was more likely than streptococcal IE to be nosocomially acquired (15% vs. 1%). When compared to S. aureus IE, systemic embolization (26% vs. 49%) and inhospital death (11% vs. 27%) were significantly less common in the enterococcal IE cohort.

Infective endocarditis caused by vancomycin-resistant enterococci (VRE) is rare. Stevens and Edmond have reviewed the literature, finding 12 reports of native valve IE out of a total of 19 IE cases, all of which were health-care associated

[15]. The patients were 80% male with a median age of 59.5 years, and had multiple co-morbidities, including diabetes (25%), dialysis dependency (25%), cancer (25%), recent surgery (42%) and transplantation (42%). The infection involved left-sided valves in 70% of the cases and the aortic valve was involved most commonly (50%). Overall survival was 9/12 (75%), including all 3 patients that required surgical management; 2 of the 3 deaths were attributed to VRE IE.

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