From the Guidelines
Ciprofloxacin (Cipro) is not effective in treating Enterococcus faecalis urinary tract infections (UTIs) in males due to high resistance rates. The provided evidence does not directly address the effectiveness of ciprofloxacin against Enterococcus faecalis, but it does mention that fluoroquinolone resistance levels are a concern in treating UTIs 1. Given the intrinsic resistance of E. faecalis to quinolones, including ciprofloxacin, with resistance rates often exceeding 30-40%, alternative treatment options are recommended.
Treatment Options
- Ampicillin (1-2g IV every 6 hours or 500mg orally four times daily) or amoxicillin (500mg orally three times daily) for 7-14 days, depending on infection severity, are more effective treatment options.
- For patients with penicillin allergies, nitrofurantoin (100mg orally twice daily for 5-7 days) may be used for uncomplicated lower UTIs, while vancomycin is an option for more severe infections.
Important Considerations
- Male UTIs often require longer treatment courses than female UTIs due to concerns about prostate involvement.
- Before starting treatment, urine culture and susceptibility testing should be performed to guide antibiotic selection, as local resistance patterns can vary 1. The ineffectiveness of ciprofloxacin against E. faecalis stems from the bacterium's natural ability to alter drug binding sites and utilize efflux pumps that remove the antibiotic from bacterial cells.
From the FDA Drug Label
Ciprofloxacin has been shown to be active against most strains of the following microorganisms, both in vitro and in clinical infections... Aerobic gram-positive microorganisms Enterococcus faecalis (Many strains are only moderately susceptible.) The MIC values should be interpreted according to the following criteria: For testing aerobic microorganisms other than Haemophilus influenzae , Haemophilus parainfluenzae, and Neisseria gonorrhoeaea: MIC (μg/mL)Interpretation ≤ 1 Susceptible (S) 2 Intermediate (I) ≥ 4 Resistant (R)
Effectiveness of Ciprofloxacin against Enterococcus faecalis UTI in Males:
- Ciprofloxacin has in vitro activity against Enterococcus faecalis, but many strains are only moderately susceptible.
- The susceptibility of Enterococcus faecalis to ciprofloxacin can be determined using MIC values, with ≤ 1 μg/mL indicating susceptible and ≥ 4 μg/mL indicating resistant.
- Given that many strains of Enterococcus faecalis are only moderately susceptible to ciprofloxacin, it is uncertain whether ciprofloxacin will be effective in treating Enterococcus faecalis UTIs in males.
- A conservative clinical decision would be to exercise caution when using ciprofloxacin to treat Enterococcus faecalis UTIs in males, as the effectiveness of the treatment is uncertain 2.
From the Research
Effectiveness of Ciprofloxacin in Treating Enterococcus faecalis UTIs in Males
- The effectiveness of ciprofloxacin (Cipro) in treating Enterococcus faecalis urinary tract infections (UTIs) in males is a concern due to increasing resistance rates 3, 4.
- A study published in the Korean journal of urology in 2013 found that 47% of E. faecalis strains isolated from male patients with complicated UTIs were resistant to ciprofloxacin 3.
- Another study published in Przeglad lekarski in 2004 found that 57% of E. faecalis strains isolated from urine samples were sensitive to ciprofloxacin, indicating a significant resistance rate 4.
- The treatment of UTIs caused by Enterococcus spp. has become challenging due to the presence of underlying comorbidities and limited therapeutic options available to treat multidrug-resistant (MDR) Enterococcus 5.
Alternative Treatment Options
- Alternative treatment options for Enterococcus faecalis UTIs include nitrofurantoin, fosfomycin, and fluoroquinolones, although resistance rates to these antibiotics are also increasing 5, 6.
- A study published in the Journal of infection and public health in 2019 found that pivmecillinam, fosfomycin, and nitrofurantoin were effective against ESBL-producing Enterobacteriaceae, including E. coli and Klebsiella species 6.
- However, the effectiveness of these alternative treatment options against Enterococcus faecalis UTIs specifically is not well established, and further research is needed to determine the best treatment approach 7.
Resistance Rates and Risk Factors
- The risk factors for ciprofloxacin resistance in E. faecalis UTIs include hospital-acquired infection, treatment in a urological department, and transfer from healthcare centers 3.
- The increasing resistance rates to ciprofloxacin and other antibiotics highlight the need for accurate and reproducible antimicrobial susceptibility testing methods to guide appropriate treatment of patients with deep-seated enterococcal infections 7.