**7. Bacteremia**

There is a high prevalence of blood stream infections caused by Gram-positive bacteria and 45% are caused by Enterococci. Bacteremia is a common manifestation of vancomycin resistant Enterococci. Due to use of intravascular and urinary catheters these nosocomial infections are acquired. *E. faecium* in the blood stream is associated with increased mortality due to high levels of resistance. Risk factors identified with VRE bacteremia include intestinal colonization, long term antibiotic use, severity of illness, bone marrow transplant, hematologic malignancy, indwelling urinary catheters, corticosteroid treatment, chemotherapy and parenteral nutrition [34]. Studies have shown that bacteremia caused by vancomycin resistant Enterococci strains carry higher mortality rates (2.5-fold increase) as compared to bacteremia caused by vancomycin sensitive strains. In one such study the prognosis of VRE bacteremia was not much changed even with the availability of antimicrobial agents with greater potency. *E. faecalis* sigma factor Sig V that regulates gene expression in response to stress conditions has been implicated in enterococci survival and colonization in systemic infection. Absence of sig V in systemic infection in mice resulted in attenuation of bacterial translocation reducing colonization of kidney and liver. Virulence factors like Bgs A and Bgs B have also been implicated in colonization of endocarditic lesions and bacteremia. BgsA and Bgs B are now being used to treat enterococcal infections by using them as drug targets [35]. Similarly gene Asr has been implicated in *E. faecium* pathogenesis in systemic infections. Nosocomial enterococcal bacteremia have been associated with urinary catheters, intra-abdominal, burn wound, pelvic, biliary and bone sources. VRE bacteremia results in 2.5-fold increase in mortality as compared to vancomycin sensitive (VSE) bacteremia [18].
