A patient admitted to an ICU is on central venous line for the last one week. He is on ceftazidime and amikacin. After 7 days of antibiotics he develops a spike of fever and his blood culture is positive for gram positive cocci in chains, which are catalase negative. Following this, vancomycin was started but the culture remained positive for the same organism even after 2 weeks of therapy. The most likely organism causing infection is-

**Core Concept**
Vancomycin-resistant Enterococci (VRE) are a type of gram-positive cocci that can cause infections in patients receiving prolonged antibiotic therapy, especially vancomycin. These bacteria are often resistant to multiple antibiotics and can be difficult to treat.

**Why the Correct Answer is Right**
The patient's symptoms and lab results suggest a vancomycin-resistant Enterococci (VRE) infection. The organism was initially identified as a gram-positive coccus in chains, which are catalase-negative, consistent with Enterococci. The patient was on vancomycin for two weeks, which should have cleared the infection if it was susceptible. However, the culture remained positive, indicating resistance to vancomycin. VRE typically exhibit high-level resistance to vancomycin, making it ineffective against this organism.

**Why Each Wrong Option is Incorrect**
**Option A:** Staphylococcus aureus - This is incorrect because Staphylococcus aureus is a gram-positive coccus, but it is catalase-positive, unlike the organism described. Additionally, vancomycin is generally effective against Staphylococcus aureus.

**Option B:** Streptococcus pneumoniae - This is incorrect because Streptococcus pneumoniae is a gram-positive coccus, but it typically exhibits alpha-hemolysis on blood agar and is catalase-negative. However, it is typically susceptible to vancomycin.

**Option C:** Coagulase-negative Staphylococci - This is incorrect because these organisms are typically catalase-positive and are often susceptible to vancomycin.

**Clinical Pearl / High-Yield Fact**
When treating infections with vancomycin, it's essential to monitor for signs of resistance, such as persistent fever or positive cultures despite therapy. Vancomycin-resistant Enterococci can spread through contaminated medical devices and personnel, highlighting the need for strict infection control measures.

**Correct Answer: C. Coagulase-negative Staphylococci

✓ Correct Answer: C. Enterococcus faecalis