What oral (PO) antibiotic should be used to treat a male patient with Enterococcus faecalis urinary tract infection (UTI) and benign prostatic hyperplasia (BPH) with urinary retention?

From the Guidelines

For a male patient with Enterococcus faecalis UTI and BPH with urinary retention, fosfomycin (3 g single oral dose) is a recommended first-line option, as it has in vitro activity against VRE and is FDA approved for the treatment of UTI caused by E. faecalis 1. However, given the complication of BPH with urinary retention, a fluoroquinolone such as ciprofloxacin (500 mg orally twice daily for 7-14 days) or levofloxacin (750 mg orally once daily for 5-7 days) may be preferred due to better prostate penetration. Amoxicillin (500 mg orally three times daily for 7-14 days) or amoxicillin-clavulanate (875/125 mg orally twice daily for 7-14 days) are also effective options if the organism is susceptible. Treatment duration should be extended to 14 days in complicated cases, as recommended by the European Association of Urology guidelines 1. The choice should ultimately be guided by susceptibility testing, as E. faecalis can have variable resistance patterns. Additionally, the underlying urinary retention from BPH should be addressed, potentially with alpha-blockers like tamsulosin or surgical intervention if indicated, as persistent obstruction can lead to treatment failure and recurrent infections regardless of antibiotic choice. Some studies suggest that short-duration courses of antibiotics may be appropriate for the management of complicated UTI and pyelonephritis, with appropriate diagnosis based on clinical response 1. However, more data are needed in men to confirm that short-duration courses are as effective as long-duration courses for the treatment of complicated UTI. It is also important to note that the treatment of VRE infections should be guided by the most recent and highest quality evidence, and that the use of antibiotics should always be tailored to the specific needs of the patient and the susceptibility of the organism 1.

From the FDA Drug Label

Infections of the Genitourinary Tract: Amoxicillin for oral suspension is indicated in the treatment of infections due to susceptible (ONLY β-lactamase–negative) isolates of Escherichia coli, Proteus mirabilis, or Enterococcus faecalis The recommended PO antibiotic for a male patient with Enterococcus faecalis UTI and urinary retention/BPH is amoxicillin 2, provided that the isolate is β-lactamase–negative.

• Key considerations:
  • The patient's infection should be proven or strongly suspected to be caused by bacteria.
  • Culture and susceptibility information should be considered in selecting or modifying antibacterial therapy.
  • Local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy if culture and susceptibility information are not available.

From the Research

Treatment Options for Enterococcus faecalis UTI

• For the treatment of Enterococcus faecalis urinary tract infections (UTIs), several oral antibiotic options can be considered, including amoxicillin, nitrofurantoin, or fosfomycin 3.
• Fosfomycin has been shown to be effective against E. faecalis in a dynamic in vitro model, with a single dose or two doses given over two days resulting in significant growth inhibition 4.
• Amoxicillin is also a preferred option when enterococci are susceptible, and patients can tolerate it 3.
• Nitrofurantoin is another option, with all isolated strains of E. faecalis being sensitive to it in one study 5.

Considerations for Patients with BPH and Urinary Retention

• Patients with benign prostatic hyperplasia (BPH) and urinary retention may require careful consideration of antibiotic treatment options, as the risk of complications and treatment failure may be higher.
• The choice of antibiotic should be based on local susceptibility patterns and the patient's medical history, including any previous antibiotic use or resistance 6.
• It is essential to use antibiotics wisely to avoid the development of resistance, especially in patients with complicated UTIs or those who have been exposed to antibiotics recently 6.

Resistance Patterns

• E. faecalis strains have been shown to have high resistance rates to ciprofloxacin, levofloxacin, and norfloxacin, making these options less suitable for treatment 7.
• High-level resistance to aminoglycosides has also been observed in some E. faecalis and E. faecium strains, which can limit treatment options 5.
• Glycopeptides, such as vancomycin and teicoplanin, remain effective against most E. faecalis and E. faecium strains, but their use should be reserved for severe or complicated infections 5.