What is the treatment for a moderate load of Escherichia coli (E. coli) and Enterococcus faecalis (not enterococcus fasciculus, as it is not a valid medical term) with a bacterial load between 100,000 and 10 million colony-forming units per milliliter (CFU/mL) on a vaginal swab?

From the Research

For a medium bacterial load of E. coli and Enterococcus faecalis in a vaginal swab (between 100,000 and 10 million CFU), I recommend treatment with local antibiotics, specifically kanamycin, due to its broad-spectrum coverage of enteric gram-positive and gram-negative aerobes, as suggested by the most recent and relevant study 1. The treatment of aerobic vaginitis, which is often characterized by the presence of E. coli and other enteric bacteria, requires a comprehensive approach that addresses both the infectious and inflammatory components of the condition.

• Local antibiotics, such as kanamycin, are preferred due to their broad-spectrum coverage and minimal absorption, reducing the risk of systemic side effects.
• The use of oral antibiotics, such as amoxicillin-clavulanate or moxifloxacin, may be considered in cases of severe symptoms or deep dermal vulvitis and colpitis infections, but their use should be discouraged in general due to the risk of promoting antibiotic resistance 1.
• Vaginal rinsing with povidone iodine may provide rapid relief of symptoms, but it does not offer long-term reduction of bacterial loads, and its use should be limited to adjunctive therapy 1.
• The role of vaginal swabs in altering empirical clinical management is context-specific and variable, and the majority of swabs performed do not impact upon empirical management, as noted in a recent study 2.
• The increasing concern of antimicrobial resistance in E. coli, as highlighted in a 2018 study 3, underscores the need for judicious use of antibiotics and consideration of alternative treatment options, such as local antibiotics and probiotics.
• Probiotics containing Lactobacillus may be considered to help restore normal vaginal flora after antibiotic treatment, although their effectiveness in this context is not well established.
• It is essential to follow up with a healthcare provider if symptoms persist after completing the antibiotic course, as antibiotic resistance testing may be needed to guide further treatment.