What is the recommended treatment for Enterococcus faecalis infections?

From the Guidelines

The recommended treatment for Enterococcus faecalis infections is linezolid 600 mg IV or PO every 12 hours, as recommended by the most recent guidelines 1.

Treatment Options

• For uncomplicated urinary tract infections, options include:
  • Fosfomycin 3 g PO as a single dose 1
  • Nitrofurantoin 100 mg PO every 6 hours 1
  • High dose ampicillin (18-30 g IV daily in divided doses) or amoxicillin 500 mg PO/IV every 8 hours 1
• For more severe infections like bacteremia or endocarditis, combination therapy with ampicillin plus gentamicin may be considered, but linezolid 600 mg IV or PO every 12 hours is the preferred option for vancomycin-resistant enterococci (VRE) 1.
• Daptomycin 8-12 mg/kg IV daily may also be used for VRE infections, particularly for bloodstream infections 1.

Important Considerations

• Susceptibility testing is crucial as E. faecalis can develop resistance to multiple antibiotics 1.
• Treatment duration varies by infection site: 7-14 days for UTIs, 2-4 weeks for bacteremia, and 4-6 weeks for endocarditis 1.
• Infection disease specialist consultation is suggested in patients with poor treatment response or when longer duration of treatment is considered 1.

From the Research

Treatment Options for Enterococcus faecalis Infections

• The recommended treatment for Enterococcus faecalis infections depends on the severity and location of the infection, as well as the antibiotic resistance pattern of the strain 2, 3.
• For uncomplicated urinary tract infections, ampicillin/sulbactam may be a suitable option, especially for ciprofloxacin-resistant strains 4.
• For more severe infections, such as endocarditis, daptomycin, vancomycin, and ampicillin-gentamicin combinations have shown efficacy 2, 3, 5.
• High-dose daptomycin (12 mg/kg IV q 24 hours) has been successfully used to treat vancomycin-tolerant E. faecalis bacteremia 5.
• The addition of gentamicin to daptomycin has been shown to improve bactericidal activity against biofilm-forming E. faecalis 6.

Antibiotic Resistance and Treatment

• Enterococcus faecalis strains can exhibit resistance to various antibiotics, including vancomycin, aminoglycosides, and fluoroquinolones 2, 3, 4.
• The emergence of high-level aminoglycoside resistance (HLAR) and vancomycin resistance limits treatment options for E. faecalis infections 3.
• Daptomycin and linezolid have been shown to be effective against vancomycin-resistant E. faecalis and E. faecium strains 2, 6.

Combination Therapy

• Combination therapy with daptomycin and gentamicin has been shown to be effective against biofilm-forming E. faecalis 6.
• The addition of rifampin to daptomycin or linezolid may antagonize their activities against E. faecalis and VRE 6.
• Further studies are needed to determine the optimal combination therapy regimens for E. faecalis infections 3, 6.