What is the best antibiotic regimen for a patient with a nephrostomy (nephrostomy tube) and an Enterococcus faecalis urinary tract infection (UTI) without available antibiotic sensitivities?

From the Guidelines

For a patient with a nephrostomy tube and an Enterococcus faecalis UTI without available antibiotic sensitivities, the recommended empiric antibiotic regimen is high dose ampicillin (18-30 g IV daily in divided doses) or amoxicillin 500 mg IV or PO every 8 h daily for 7-14 days, as recommended by recent guidelines 1.

Key Considerations

• The presence of a nephrostomy tube represents a complicated UTI, which typically requires a longer treatment duration (10-14 days) compared to uncomplicated UTIs.
• Enterococcus faecalis is generally susceptible to ampicillin, which is why it remains the first-line therapy.
• The bacterium has intrinsic resistance to cephalosporins and trimethoprim-sulfamethoxazole, making these antibiotics ineffective choices.
• Alternative options, such as linezolid, daptomycin, and tigecycline, may be considered in cases of penicillin allergy or resistance, but are not the first-line choice for uncomplicated UTIs due to Enterococcus faecalis.
• Fosfomycin and nitrofurantoin may also be considered for uncomplicated UTIs, but their use is limited by the severity of the infection and the patient's renal function.

Treatment Duration and Monitoring

• The treatment duration should be based on the clinical response and the severity of the infection.
• Urine cultures should be repeated after completing therapy to ensure resolution of the infection.
• The nephrostomy tube should be exchanged if possible during treatment to remove the biofilm that may harbor bacteria.

Additional Recommendations

• Infection disease specialist consultation is suggested in patients with poor treatment response or when longer duration of treatment is considered 1.
• Combination antimicrobial therapy may be considered in severely ill patients or those who fail treatment with traditional options 1.

From the Research

Treatment Options for E. faecalis UTI in Patients with Nephrostomy Tubes

• The treatment of Enterococcus faecalis urinary tract infections (UTIs) in patients with nephrostomy tubes can be challenging, especially when antibiotic sensitivities are not available 2, 3.
• In the absence of antibiotic sensitivities, the choice of antibiotic regimen should be based on the severity of the infection, the presence of underlying medical conditions, and the potential for antibiotic resistance 3, 4.
• Ampicillin is generally considered the drug of choice for ampicillin-susceptible enterococcal UTIs, including those caused by E. faecalis 3, 4.
• For patients with vancomycin-resistant E. faecalis (VRE) UTIs, alternative antibiotics such as linezolid, daptomycin, and nitrofurantoin may be considered 2, 3.
• The use of antibiotic combinations, such as ampicillin plus an aminoglycoside, may also be effective in treating VRE UTIs, although the clinical evidence for this approach is limited 3.

Considerations for Patients with Nephrostomy Tubes

• Patients with nephrostomy tubes are at increased risk of developing UTIs, including those caused by E. faecalis 5, 6.
• The presence of a nephrostomy tube can also increase the risk of antibiotic resistance, making treatment more challenging 5, 6.
• In patients with nephrostomy tubes, it is essential to monitor for signs of infection, such as fever, chills, and flank pain, and to obtain urine cultures to guide antibiotic therapy 5, 6.
• The management of UTIs in patients with nephrostomy tubes should involve a multidisciplinary approach, including urology, infectious diseases, and nursing care 5, 6.

Antibiotic Regimens for E. faecalis UTI in Patients with Nephrostomy Tubes

• Ampicillin (1-2 g IV every 6 hours) may be considered as an initial antibiotic regimen for E. faecalis UTIs in patients with nephrostomy tubes, although the effectiveness of this approach may be limited by antibiotic resistance 4.
• Linezolid (600 mg IV every 12 hours) may be an alternative antibiotic regimen for VRE UTIs, although its use should be reserved for severe or complicated infections 2, 3.
• Daptomycin (4-6 mg/kg IV every 24 hours) may also be considered for the treatment of VRE UTIs, although its use should be guided by antibiotic susceptibility testing and clinical experience 3.
• Nitrofurantoin (100-200 mg PO every 12 hours) may be an effective oral antibiotic regimen for uncomplicated E. faecalis UTIs in patients with nephrostomy tubes, although its use should be guided by antibiotic susceptibility testing and clinical experience 3.