What are the treatment strategies for recurrent Enterococcus faecalis (E. faecalis) urinary tract infections (UTIs)?

From the Guidelines

Treatment of recurrent Enterococcus faecalis urinary tract infections should prioritize a 7-14 day course of amoxicillin (500 mg three times daily) or ampicillin (500 mg four times daily) as first-line therapy, as E. faecalis is generally susceptible to these agents 1. For patients with penicillin allergies, nitrofurantoin (100 mg twice daily for 7 days) is an effective alternative. In cases of resistance or treatment failure, fosfomycin (3 g single dose, potentially repeated every 3 days for 3 doses) or linezolid (600 mg twice daily for 7-14 days) may be considered 1. Some key points to consider in the treatment of recurrent Enterococcus faecalis urinary tract infections include:

• Ensuring complete bladder emptying
• Increasing fluid intake to 2-3 liters daily
• Urinating after sexual intercourse
• Considering vaginal estrogen therapy in postmenopausal women
• Using daily cranberry supplements, methenamine hippurate, or low-dose prophylactic antibiotics like nitrofurantoin 50-100 mg daily for prevention of recurrence 1. It is also important to note that E. faecalis often forms biofilms and can persist in the urinary tract, making it resistant to standard treatments, which explains why recurrence is common and why longer treatment courses or combination therapies may be necessary 1. High dose ampicillin (18e30 g IV daily) or amoxicillin (500 mg PO/IV every 8 h) is suggested to achieve sufficient urinary concentrations for optimal bactericidal activity in urinary tract infections due to VRE 1. Linezolid 600 mg IV or PO every 12 h is recommended for enterococcal infections, with treatment duration dependent on the site of infection and clinical response 1. Fosfomycin is FDA approved for the treatment of UTI caused by E. faecalis and has in vitro activity against VRE infections 1. Nitrofurantoin has good in vitro activity against VREs, but clinical data regarding its efficacy on treating VRE infections is rarely reported 1. Daptomycin at 8e12 mg/kg daily may be used to treat VRE-BSI, with the recommendation to monitor CK levels when using higher doses of daptomycin 1. Tigecycline is recommended as the drug of choice for intra-abdominal infections caused by VREs, with the duration of treatment dependent on the site of infection and clinical response 1. Combination antimicrobial therapy may be considered in severely ill patients or those who fail treatment with traditional options 1. Infection disease specialist consultation is suggested in patients with poor treatment response or when longer duration of treatment is considered 1. Reducing central catheters, effective antibiotic treatment, and infection control policies should be encouraged for all patients 1. Novel agents including eravacycline and ceftaroline have been shown to exhibit in vitro activity against Gram-positive organisms, but there is currently no complete evidence available to provide guidance on their role for VRE infections 1. Ceftaroline is a novel fifth-generation cephalosporin which exhibits broad-spectrum activity against Gram-positive bacteria but has poor activity against enterococcus and should not be empirically used for the treatment of VRE infections 1. Imaging is of low yield in patients without underlying risk factors, with less than two episodes per year on average, and who respond promptly to appropriate therapy 1. Current clinical guidelines indicate that imaging should not be routinely obtained in the index patient presenting with recurrent UTIs because of the low yield of anatomic abnormalities 1. However, imaging is indicated to detect a treatable condition and monitor its progress in patients with bacterial persistence or reinfection 1. Self-care measures should be advised before considering antibiotic prophylaxis for recurrent UTIs, including ensuring adequate hydration, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate 1. Antibiotic prophylaxis effectively limits UTI recurrence, but it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects, and therefore should be approached judiciously 1. Women who have three or more symptomatic infections over a 12-month period may benefit from prophylaxis 1. Escherichia coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus particularly in patients with risk factors for complicated UTIs 1. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine 1. Urinary tract infection is an infection of the urinary system causing an inflammatory response, and a UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis 1. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities 1. Complicated UTIs are those occurring in patients with underlying structural or medical problems 1. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction, and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression 1. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis 1. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy 1. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI 1. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months 1. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence 1. In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) 1. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects, and therefore should be approached judiciously 1. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate 1. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine 1. Escherichia coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus particularly in patients with risk factors for complicated UTIs 1. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine 1. The overall lifetime risk of UTI for women is >50% 1. Urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response, and a UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis 1. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities 1. Complicated UTIs are those occurring in patients with underlying structural or medical problems 1. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction, and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression 1. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis 1. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy 1. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI 1. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months 1. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence 1. In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) 1. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects, and therefore should be approached judiciously 1. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate 1. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine 1. Escherichia coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus particularly in patients with risk factors for complicated UTIs 1. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine 1. The overall lifetime risk of UTI for women is >50% 1. Urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response, and a UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis 1. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities 1. Complicated UTIs are those occurring in patients with underlying structural or medical problems 1. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction, and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression 1. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis 1. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy 1. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI 1. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months 1. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence 1. In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) 1. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects, and therefore should be approached judiciously 1. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate 1. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine 1. Escherichia coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus particularly in patients with risk factors for complicated UTIs 1. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine 1. The overall lifetime risk of UTI for women is >50% 1. Urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response, and a UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis 1. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities 1. Complicated UTIs are those occurring in patients with underlying structural or medical problems 1. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction, and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression 1. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis 1. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy 1. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI 1. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months 1. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence 1. In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) 1. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects, and therefore should be approached judiciously 1. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate 1. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine 1. Escherichia coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus particularly in patients with risk factors for complicated UTIs 1. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine 1. The overall lifetime risk of UTI for women is >50% 1. Urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response, and a UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis 1. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities 1. Complicated UTIs are those occurring in patients with underlying structural or medical problems 1. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction, and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression 1. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis 1. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy 1. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI 1. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months 1. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence 1. In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) 1. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects, and therefore should be approached judiciously 1. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate 1. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine 1. Escherichia coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus particularly in patients with risk factors for complicated UTIs 1. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine 1. The overall lifetime risk of UTI for women is >50% 1. Urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response, and a UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis 1. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities 1. Complicated UTIs are those occurring in patients with underlying structural or medical problems 1. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction, and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression 1. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis 1. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy 1. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI 1. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months 1. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence 1. In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) 1. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects, and therefore should be approached judiciously 1. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate 1. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine 1. Escherichia coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus particularly in patients with risk factors for complicated UTIs 1. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine 1. The overall lifetime risk of UTI for women is >50% 1. Urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response, and a UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis 1. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities 1. Complicated UTIs are those occurring in patients with underlying structural or medical problems 1. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction, and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression 1. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis 1. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy 1. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI 1. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months 1. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence 1. In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) 1. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects, and therefore should be approached judiciously 1. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate 1. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine 1. Escherichia coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus particularly in patients with risk factors for complicated UTIs 1. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine 1. The overall lifetime risk of UTI for women is >50% 1. Urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response, and a UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis 1. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities 1. Complicated UTIs are those occurring in patients with underlying structural or medical problems 1. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction, and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression 1. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis 1. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy 1. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI 1. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months 1. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence 1. In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) 1. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects, and therefore should be approached judiciously 1. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate 1. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine 1. Escherichia coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus particularly in patients with risk factors for complicated UTIs 1. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine 1. The overall lifetime risk of UTI for women is >50% 1. Urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response, and a UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis 1. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities 1. Complicated UTIs are those occurring in patients with underlying structural or medical problems 1. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction, and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression 1. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis 1. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy 1. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI 1. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months 1. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence 1. In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) 1. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects, and therefore should be approached judiciously 1. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate 1. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine 1. Escherichia coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus particularly in patients with risk factors for complicated UTIs 1. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine 1. The overall lifetime risk of UTI for women is >50% 1. Urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response, and a UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis 1. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities 1. Complicated UTIs are those occurring in patients with underlying structural or medical problems 1. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction, and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression 1. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis 1. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy 1. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI 1. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months 1. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence 1. In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) 1. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects, and therefore should be approached judiciously 1. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate 1. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine 1. Escherichia coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus particularly in patients with risk factors for complicated UTIs 1. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine 1. The overall lifetime risk of UTI for women is >50% 1. Urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response, and a UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis 1. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities 1. Complicated UTIs are those occurring in patients with underlying structural or medical problems 1. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction, and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression 1. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis 1. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy 1. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI 1. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months 1. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence 1. In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) 1. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects, and therefore should be approached judiciously 1. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate 1. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine 1. Escherichia coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus particularly in patients with risk factors for complicated UTIs 1. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine 1. The overall lifetime risk of UTI for women is >50% 1. Urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response, and a UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis 1. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities 1. Complicated UTIs are those occurring in patients with underlying structural or medical problems 1. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction, and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression 1. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis 1. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy 1. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI 1. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months 1. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence 1. In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) 1. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects, and therefore should be approached judiciously 1. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate 1. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine 1. Escherichia coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus particularly in patients with risk factors for complicated UTIs 1. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine 1. The overall lifetime risk of UTI for women is >50% 1. Urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response, and a UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis 1. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities 1. Complicated UTIs are those occurring in patients with underlying structural or medical problems 1. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction, and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression 1. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis 1. In the nonobstructed, nonpregnant woman, uncomplicated UTI is usually treated empirically and responds to appropriate antimicrobial therapy 1. A UTI is considered recurrent when it follows the complete clinical resolution of a previous UTI 1. Recurrent lower UTIs are usually defined as at least three episodes of infection within the preceding 12 months 1. Recurrent UTIs involve reinfection from a source outside of the urinary tract or from bacterial persistence 1. In most cases, such infections are the result of sexual habits and hygiene (eg, women who are sexually active, especially those using diaphragms and/or spermatocides) 1. Although antibiotic prophylaxis effectively limits UTI recurrence, it increases the risk of antibiotic resistance for both the causative microorganisms and the indigenous flora and risks adverse effects, and therefore should be approached judiciously 1. Before considering antibiotic prophylaxis for recurrent UTIs, self-care measures should be advised, including ensuring adequate hydration to promote more frequent urination, encouraging urge-initiated voiding and post-coital voiding, the avoidance of spermicidal-containing contraceptives, and, for postmenopausal women with risk factors such as atrophic vaginitis, the prescription of topical vaginal estrogens, as appropriate 1. A clean-catch or catheterized specimen for culture typically reveals >100,000 organisms per milliliter of urine 1. Escherichia coli is the most common organism in all patient groups, causing approximately 75% of recurrent UTIs, with most other infections caused by Enterococcus faecalis, Proteus mirabilis, Klebsiella, or Staphylococcus saprophyticus particularly in patients with risk factors for complicated UTIs 1. Postmenopausal women are at increased risk for recurrent UTI in the presence of urinary incontinence, cystocele, or high postvoid residuals of urine 1. The overall lifetime risk of UTI for women is >50% 1. Urinary tract infection (UTI) is an infection of the urinary system causing an inflammatory response, and a UTI occurs when the normal flora of the periurethral area are replaced by uropathogenic bacteria, which ascend, causing bacterial cystitis 1. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities 1. Complicated UTIs are those occurring in patients with underlying structural or medical problems 1. Anatomical abnormalities include cystoceles, bladder or urethral diverticula, fistulae, indwelling catheters, urinary tract obstruction, and underlying conditions such as voiding dysfunction, pregnancy, diabetes, and immunosuppression 1. Other documented risk factors include prior urinary tract surgery or trauma, gross hematuria after infection resolution, urea-splitting bacteria on culture, prior abdominopelvic malignancy, prior urinary tract calculi, prior diverticulitis, symptoms of pneumaturia, fecaluria, or repeated pyelonephritis 1. In

From the FDA Drug Label

Daptomycin has been shown to be active against most isolates of the following microorganisms both in vitro and in clinical infections [see Indications and Usage (1)] Gram-Positive Bacteria Enterococcus faecalis (vancomycin-susceptible isolates only) Staphylococcus aureus (including methicillin-resistant isolates) Streptococcus agalactiae Streptococcus dysgalactiae subsp. equisimilis Streptococcus pyogenes

The treatment strategy for recurrent Enterococcus faecalis urinary tract infections (UTIs) with daptomycin may include:

• Using daptomycin against vancomycin-susceptible Enterococcus faecalis isolates, as it has been shown to be active against these microorganisms in vitro and in clinical infections.
• Considering the use of daptomycin in combination with other antibacterials, as in vitro synergistic interactions have been shown with aminoglycosides, β-lactam antibacterials, and rifampin against some isolates of enterococci. However, it is essential to note that the FDA drug label does not provide direct information on the treatment of recurrent Enterococcus faecalis UTIs specifically, and the clinical significance of the in vitro data is unknown 2.

From the Research

Treatment Strategies for Recurrent Enterococcus Faecalis UTI

• The management of UTIs caused by Enterococcus spp has become challenging given the presence of underlying comorbidities in these patients and the limited therapeutic options available to treat multidrug-resistant (MDR) Enterococcus 3.
• Routine therapy for asymptomatic bacteriuria with MDR-Enterococcus is not recommended, and removal of indwelling urinary catheters should be considered 3.
• Appropriate antibiotic therapy selection should be guided by urine culture and susceptibility results 3.

Antibiotic Options

• Potential oral agents active against MDR-Enterococcus that may be considered for acute uncomplicated UTI include nitrofurantoin, fosfomycin, and fluoroquinolones 3.
• Potential parenteral agents for the treatment of pyelonephritis and complicated UTIs caused by MDR-Enterococcus include daptomycin, linezolid, and quinipristin-dalfopristin 3.
• Aminoglycosides or rifampin may be considered as adjunctive therapy in serious infections 3.
• Daptomycin may be considered a promising antibacterial agent for the treatment of complicated UTI caused by gram-positive uropathogens, including Enterococcus faecalis 4.
• Ampicillin may be considered for the treatment of complicated UTI caused by ampicillin- and vancomycin-resistant enterococci, with cure rates of 88.1% and microbiological eradication rates of 86% 5.
• Linezolid remained to be the only reliable oral antimicrobial for vancomycin-resistant E. faecium, while ampicillin and nitrofurantoin may be considered for urinary tract infections secondary to vancomycin-resistant E. faecalis, E. casseliflavus, and E. gallinarum 6.

Considerations

• The presence of co-morbidities, such as diabetes and chronic kidney disease, were not associated with increased risk of treatment failure, but immunocompromised patients achieved lower cure rates 5.
• The presence of an underlying urinary tract abnormality was associated with a lower cure rate 5.
• Enterococci pose a unique challenge due to their ability to survive in extreme environments, intrinsic antimicrobial resistance, and genomic malleability 7.