From the Guidelines
For a patient with Enterococcus faecalis urinary tract infection who is experiencing hypotension, high dose ampicillin (18-30 g IV daily in divided doses) is recommended as the first-line antimicrobial choice. The hypotension suggests possible progression to sepsis, so prompt initiation of antimicrobial therapy is crucial, along with appropriate fluid resuscitation and hemodynamic support. According to the guidelines 1, high dose ampicillin is suggested to achieve sufficient urinary concentrations to overcome high ampicillin MIC of ampicillin-resistant VRE and achieve the necessary drug concentration for optimal bactericidal activity in urinary tract infections.
Some key points to consider in the management of this patient include:
- The importance of differentiating colonization from true infection prior to empiric prescription of anti-VRE antimicrobial agents 1.
- The potential use of alternative antimicrobials such as linezolid, daptomycin, or tigecycline in cases of ampicillin resistance or allergy, although these options may have varying levels of evidence to support their use 1.
- The consideration of combination therapy with an aminoglycoside, such as gentamicin, for synergistic effect in severe infections or sepsis, although this should be used cautiously due to nephrotoxicity risks 1.
- The need for close monitoring of the patient's clinical response and adjustment of the antimicrobial regimen as necessary, based on urine culture results and susceptibility data 1.
It is essential to note that the choice of antimicrobial therapy should be guided by the most recent and highest quality evidence available, and that local antimicrobial resistance patterns and patient-specific factors should also be taken into consideration 1.
From the Research
Antimicrobial Options for Enterococcus faecalis UTI in Hypotensive Patients
- The choice of antimicrobial for Enterococcus faecalis urinary tract infections (UTIs) in patients who are hypotensive should be guided by susceptibility results and the severity of the infection 2, 3.
- For patients with Enterococcus faecalis UTIs, potential oral agents that may be considered include nitrofurantoin, fosfomycin, and fluoroquinolones, while potential parenteral agents include daptomycin, linezolid, and quinupristin-dalfopristin 2.
- Ampicillin is generally considered the drug of choice for ampicillin-susceptible enterococcal UTIs, including those caused by vancomycin-resistant Enterococcus faecalis (VRE) 3.
- In cases of hypotension, the choice of antimicrobial should also consider the potential for nephrotoxicity and the need for bactericidal activity, making agents like daptomycin and linezolid potential options 3, 4.
Considerations for Hypotensive Patients
- Hypotensive patients may require careful consideration of the potential for nephrotoxicity associated with certain antimicrobials, such as aminoglycosides 4.
- The combination of ampicillin and ceftriaxone has been shown to be effective and safe for treating Enterococcus faecalis endocarditis, and may be a reasonable alternative for patients with UTIs who are at increased risk for nephrotoxicity 4.
- Tigecycline has been shown to have activity against Enterococcus faecalis, including vancomycin-resistant strains, and may be a potential option for patients with UTIs who are hypotensive 5, 6.
Susceptibility Patterns
- The susceptibility patterns of Enterococcus faecalis to various antimicrobials can vary, and should be guided by local epidemiology and susceptibility results 5.
- Enterococcus faecalis has been shown to be susceptible to tigecycline, with a susceptibility rate of 100% in some studies 5, 6.
- The presence of enterocin-producing Enterococcus faecalis has been shown to enhance the antimicrobial activity of certain agents, such as arbekacin and tigecycline, against methicillin-resistant Staphylococcus aureus 6.