Clinical Infectious Diseases
STATE-OF-THE-ART REVIEW
Executive Summary: State-of-the-Art Review: Persistent
Enterococcal Bacteremia
Ralph Rogers and Louis B. Rice
Division of Infectious Diseases and Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
Keywords. enterococcus; bacteremia; persistence; duration; review.
Persistent enterococcal bacteremia is a commonly encountered
and morbid syndrome without a strong evidence base for opti-
mal management practices. Here we highlight reports on the
epidemiology of enterococcal bacteremia to better describe
and define persistent enterococcal bacteremia, discuss factors
specific to Enterococcus species that may contribute to persis-
tent infections, and describe a measured approach to diagnostic
and therapeutic strategies for patients with these frequently
complicated infections.
The diagnosis of persistent enterococcal bacteremia is typi-
cally clinically evident in the setting of repeatedly positive blood
culture results; instead, the challenge is to determine in an accu-
rate, cost-effective, and minimally invasive manner whether any
underlying nidus of infection (eg, endocarditis or undrained ab-
scess) is present and contributing to the persistent bacteremia
(Figure 1).
Received 03 October 2023; published online 29 November 2023
Correspondence: R. Rogers, Division of Infectious Diseases and Department of Medicine,
Warren Alpert Medical School of Brown University, 593 Eddy St, Providence, RI 02903
(rrogers@lifespan.org); L. B. Rice, Division of Infectious Diseases and Department of
Medicine, Warren Alpert Medical School of Brown University, 593 Eddy St, Providence, RI
02903 (lrice@lifespan.org).
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Clinical outcomes for patients with persistent enterococcal
bacteremia remain suboptimal. Beyond addressing host im-
mune status if relevant and pursuing source control for all pa-
tients, management decisions primarily involve the selection of
the proper antimicrobial agent(s). Options for antimicrobial
therapy are often limited in the setting of intrinsic and acquired
antimicrobial resistance among enterococcal clinical isolates.
The synergistic benefit of combination antimicrobial therapy
has been demonstrated for enterococcal endocarditis, but it is
not clear at present whether a similar approach will provide
any clinical benefit to some or all patients with persistent en-
terococcal bacteremia.
Note
Potential conflicts of interest. The authors: No reported conflicts of in-
terest. Both authors have submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest.
Clinical Infectious Diseases®
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https://doi.org/10.1093/cid/ciad613
Persistent Enterococcal Bacteremia • CID • 1
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Figure 1. Diagnostic considerations for persistent enterococcal bacteremia. Abbreviations: CRBSI, catheter-related bloodstream infection; CT, computed tomography;
DENOVA, endocarditis diagnostic score; FDG, fluorodeoxyglucose; GI, gastrointestinal; NOVA, endocarditis diagnostic score; PET, positron emission tomography; WBC, white
blood cell; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography.

2 • CID • Rogers and Rice