Management of vancomycin‐resistant Enterococci and daptomycin‐resistant Enterococci infections in liver transplant recipients in a single academic center

Introduction Vancomycin‐resistant Enterococci (VRE) infections cause significant morbidity and mortality in liver transplant (LT) recipients. Management is challenging, especially in the setting of daptomycin resistance (DR). Methods Single‐center retrospective review of patients who underwent LT between January 1, 2020, and December 31, 2022, and developed VRE infections. Descriptive statistics were used and Kaplan‐Meier curves estimated freedom from treatment failure and survival. Results Forty‐two patients (median age 58; 64% female; 67% white) were included. Alcohol‐related cirrhosis (48%) and metabolic dysfunction‐associated steatohepatitis (31%) were the most common indications for LT, and most were from deceased donors (86%). VRE infection occurred at a median of 21 days after LT, and 16% had known prior VRE colonization. Common infection sites were blood (45%, n = 19), intraabdominal (36%, n = 15), and urine (36%, n = 15). Most were initially treated with daptomycin alone (64%) or in combination with other agents (21%); 7% received linezolid alone. Twelve (29%) developed breakthrough infections during treatment and 11 (26%) had recurrent infections after discontinuation of treatment. All‐cause mortality was 36% (n = 15) at a median of 90 days after VRE infection diagnosis and was nearly twice as high in patients with DR (63%). Conclusion VRE infection in LT recipients relapsed or recurred in over 25%. Mortality was high, especially in cases with DR. More data is needed to establish an optimal treatment approach, particularly for relapse and DR. Vancomycin‐resistant Enterococci infections carry high mortality in liver transplant recipients, especially in the setting of daptomycin resistance. Infection relapsed or recurred in over 25% despite standard‐of‐care therapy. Source control is critical and more data is needed to establish an optimal treatment approach.