What can be done to prevent recurrent epididymitis infections with testicular pain in males with a urine culture positive for Enterococcus faecalis?

From the Guidelines

To prevent recurrent epididymitis infections with testicular pain in males with a urine culture positive for Enterococcus faecalis, the primary recommendation is a full course of appropriate antibiotics, typically ampicillin (500 mg four times daily) for 2-4 weeks, as it is the drug of choice for enterococcal infections, including those caused by Enterococcus faecalis 1.

The choice of antibiotic is crucial in treating Enterococcus faecalis infections. According to the most recent guidelines, ampicillin is preferred due to its bactericidal activity against Enterococcus faecalis 1. For patients who are allergic to penicillin, alternatives such as nitrofurantoin (100 mg twice daily) or fosfomycin, which is FDA-approved for the treatment of UTI caused by E. faecalis, can be considered 1.

In addition to antibiotic treatment, several measures can help prevent recurrent infections:

• Increase fluid intake to at least 2-3 liters daily to help flush bacteria from the urinary tract.
• Practice good hygiene, including urinating after sexual intercourse.
• Treat constipation promptly to prevent bacterial migration from the gastrointestinal tract to the urinary tract.
• Complete regular follow-up urine cultures to confirm the infection has cleared.
• Apply scrotal support and cold packs to reduce discomfort.
• Over-the-counter pain relievers like ibuprofen (400-600 mg every 6-8 hours) can help manage pain and inflammation.

It is essential to note that Enterococcus faecalis is part of the normal intestinal flora but can cause infection when it enters the urinary tract, often due to anatomical issues or compromised immunity, making thorough treatment essential to prevent recurrence 1.

Given the potential for antibiotic resistance, it is crucial to complete the entire prescribed course of antibiotics, even if symptoms improve quickly, and to use antibiotics judiciously to minimize the risk of resistance development 1.

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.) Ciprofloxacin Tablets USP, 250 mg, 500 mg and 750 mg is indicated for the treatment of infections caused by susceptible strains of the designated microorganisms in the conditions and patient populations listed below... Urinary Tract Infections caused by... Enterococcus faecalis

To prevent recurrent epididymitis infections with testicular pain in males with a urine culture positive for Enterococcus faecalis, treatment with ciprofloxacin may be considered, as it has been shown to be active against this microorganism. However, it is essential to note that many strains of Enterococcus faecalis are only moderately susceptible to ciprofloxacin.

• The patient should take ciprofloxacin exactly as prescribed by their healthcare provider.
• The patient should complete the full treatment course, even if they start to feel better, to ensure that all bacteria are killed and reduce the risk of resistance.
• The patient should be aware of potential side effects, such as central nervous system effects and tendon effects, and report any concerns to their healthcare provider.
• The patient should also be advised to avoid driving or operating machinery until they know how ciprofloxacin affects them and to limit their time in the sun due to the risk of photosensitivity 2, 2.

From the Research

Prevention of Recurrent Epididymitis Infections

To prevent recurrent epididymitis infections with testicular pain in males with a urine culture positive for Enterococcus faecalis, several measures can be taken:

• Identify and treat underlying conditions that may be contributing to the development of epididymitis, such as benign prostatic hyperplasia or urethral stricture disease 3, 4
• Ensure proper treatment of the initial infection, including the use of appropriate antimicrobials with adequate penetration into genital tissues 3, 5
• Consider the use of alternative antimicrobials in cases where resistance to commonly used antibiotics is a concern 3
• Practice good hygiene and safe sex practices to reduce the risk of sexually transmitted infections, which can contribute to the development of epididymitis 4, 5

Management of Urinary Tract Infections

In addition to treating the initial infection, it is also important to manage underlying urinary tract infections (UTIs) that may be contributing to the development of epididymitis:

• Urine cultures and urinalyses can help identify the presence of bacterial infections, such as Enterococcus faecalis, and guide antibiotic treatment 6
• Antibiotics should only be prescribed when there is evidence of a bacterial infection, such as an abnormal urinalysis or urine culture 6
• Indwelling urinary catheters can increase the risk of UTIs and epididymitis, and should be used judiciously and managed properly to reduce this risk 7

Biofilm Formation and Antibiotic Resistance

Enterococcus faecalis can form biofilms on urinary catheters, which can contribute to antibiotic resistance and persistent colonization of the urinary tract:

• The formation of biofilms can be facilitated by polymicrobial interactions between Enterococcus faecalis and other species, such as Proteus mirabilis 7
• These biofilms can enhance antimicrobial resistance and make treatment more challenging 7
• Further research is needed to understand the clinical significance of polymicrobial colonization of the catheterized urinary tract and to develop effective strategies for prevention and treatment 7