Linezolid-Resistant Enterococcus faecalis Infection Following Prolonged Low-Dosage Linezolid Treatment for Multidrug-Resistant Tuberculosis
Abstract
To the Editor—Linezolid is a last-resort option for infections caused by multidrug-resistant (MDR) gram-positive pathogens, including vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus. Linezolid resistance can be mediated by chromosomal mutations in ribosomal RNA (rRNA) or protein genes (23S rRNA, rplC, rplD) altering the ribosomal target [1], and by plasmid-encoded ribosomal methylases (eg, Cfr and Cfr[B]) or ribosomal protection proteins (eg, OptrA) [1–3]. Linezolid is also recommended for infections caused by MDR and extensively drug-resistant Mycobacterium tuberculosis, administered for prolonged periods at a lower dosage (600 or even 300 mg once daily, rather than 600 mg twice daily) [1, 4, 5]. Here we report on a urinary tract infection (UTI) caused by a linezolid-resistant Enterococcus occurred in a patient that was previously treated with a linezolid-based regimen for MDR tuberculosis (TB). The patient was diagnosed with MDR pulmonary TB (resistance to rifampin, isoniazid, amikacin, ethambutol, pyrazinamide, streptomycin, and kanamycin) in October 2013. The infection was initially treated with levofloxacin, protionamide, and cycloserine (750 mg once daily, each), linezolid (600 mg twice daily), and amoxicillin-clavulanate (2.2 mg thrice daily). After 1 month, linezolid dosage was reduced to 600 mg once daily due to anemia, and amoxicillin/clavulanate was substituted with meropenem (1 g thrice daily) and then with rifabutin (300 mg once…
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