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A patient with native valve endocarditis caused by a vancomycin "heteroresistant" strain of Enterococcus faecium experienced failure of daptomycin monotherapy without evidence of daptomycin resistance. The infecting organism exhibited in vivo emergence of a vancomycin-susceptible subpopulation lacking vanA. Treatment with a combination of high-dose daptomycin, gentamicin, and high-dose ampicillin cleared the infection.

clinical infectious diseases/clinical infectious diseases (online. university of chicago. press)

Failure of Daptomycin Monotherapy for Endocarditis Caused by an Enterococcus faecium Strain with Vancomycin-Resistant and Vancomycin-Susceptible Subpopulations and Evidence of In Vivo Loss of the vanA Gene Cluster