Clinical outcomes and molecular epidemiology of vancomycin-resistant Enterococcus faecium bloodstream infection: The importance of appropriate therapy and ST17 predominance

BACKGROUND: Vancomycin-resistant Enterococcus faecium (VREfm) bloodstream infection (BSI) remains associated with substantial mortality, and timely active therapy may be critical. We evaluated factors associated with 14-day mortality, focusing on anti-VRE therapy, and described contemporaneous molecular epidemiology and biofilm capacity. METHODS: We randomly selected 150 VREfm blood isolates (50/year) from a tertiary medical center in Northern Taiwan, 2021-2023. Resistance genes were detected by PCR; multilocus sequence typing (MLST) and biofilm assays were performed. The primary outcome was 14-day all-cause mortality, analysed primarily among patients who survived at least three days from BSI onset to mitigate immortal-time bias. RESULTS: 0.79 vs 0.44; P < 0.001), but neither ST17 status nor biofilm production was associated with 14-day mortality. In the primary outcome analysis (n = 137), multivariable analysis showed mortality was independently associated with no anti-VRE therapy (adjusted odds ratio [aOR] 10.44, 95% confidence interval [CI] 1.07-101.86; P = 0.04), higher Pitt bacteraemia score (aOR 1.27; P = 0.003), autoimmune disease (aOR 21.90; P = 0.02), and lower platelet count (aOR 0.92; P = 0.003). Compared with no anti-VRE therapy, daptomycin (aOR 0.11, 95% CI 0.01-1.03; P = 0.05) and linezolid (aOR 0.05, 95% CI 0.003-0.84; P = 0.04) were associated with reduced mortality. Findings were consistent in the 150-patient sensitivity analysis. CONCLUSIONS: Mortality in VREfm BSI was primarily associated with host factors, illness severity, and receipt of anti-VRE therapy. ST17 predominated and showed enhanced biofilm formation, but was not independently associated with mortality.