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 same organism even after 2 weeks of therapy. The most likely organism causing infection is :

**Core Concept:**
The question is based on the identification of a bacterial infection in a critically ill patient receiving antibiotics and the process of elimination to determine the most likely causative organism. Central venous catheters are associated with increased risk of bloodstream infections, which are commonly caused by Gram-positive organisms like Staphylococcus species. However, the organism in question is catalase-negative, which narrows down the possibilities to coagulase-negative Staphylococci (e.g., Staphylococcus epidermidis) or Bacillus species. Vancomycin is a last-line antibiotic for MRSA (methicillin-resistant Staphylococcus aureus) infections.

**Why the Correct Answer is Right:**
Given that the patient is on a combination of Ceftazidime and Amikacin, the causative organism is likely resistant to these antibiotics because vancomycin was added after a week of therapy, suggesting that the organism is resistant to these drugs too. The persistence of positive blood culture even after 2 weeks of vancomycin therapy indicates that the organism is likely resistant to vancomycin, which further supports the possibility of coagulase-negative Staphylococci or Bacillus species as the causative agent.

**Why Each Wrong Option is Incorrect:**

A. **Ceftazidime:** This antibiotic is likely to be ineffective due to its combination with Amikacin, and the organism has become resistant to them after one week of treatment.

B. **Amikacin:** Similar to Ceftazidime, the organism has developed resistance to this antibiotic after one week of treatment.

C. **Vancomycin:** Although the patient was on vancomycin after the initial antibiotics, the persistence of a positive blood culture after two weeks suggests that the organism has developed resistance to vancomycin, making it an incorrect choice.

D. **Enterococcus:** This is often susceptible to vancomycin, making it less likely than the other options.

**Clinical Pearl:**

When treating a patient with a central line infection, consider coagulase-negative Staphylococci or Bacillus species as the causative organism due to the patient's history of antibiotic therapy and the persistence of positive blood culture. Vancomycin resistance should be suspected if the blood culture remains positive despite treatment with this antibiotic.

✓ Correct Answer: C. Enterococcus faecalis