Does cefuroxime (Cefuroxime) cover Enterococcus faecalis in urine?

Cefuroxime Does Not Cover Enterococcus faecalis in Urine

Cefuroxime should not be used for urinary tract infections caused by Enterococcus faecalis as it has no activity against this organism. 1 The FDA drug label explicitly states that "most strains of enterococci, e.g., Enterococcus faecalis (formerly Streptococcus faecalis), are resistant to cefuroxime."

Evidence for Enterococcal Resistance to Cefuroxime

Cefuroxime is a second-generation cephalosporin with good activity against many gram-positive and gram-negative organisms, but it has significant limitations:

• The FDA drug label clearly indicates that enterococci, including E. faecalis, are resistant to cefuroxime 1
• Cephalosporins as a class have poor activity against enterococci, which is a well-established microbiological principle
• In a 7-year surveillance study of urinary pathogens, E. faecalis was the second most common uropathogen (18% of isolates), highlighting the importance of appropriate coverage 2

Appropriate Antibiotic Options for E. faecalis UTIs

For urinary tract infections where E. faecalis is confirmed or suspected, the following options are recommended based on current guidelines:

First-line options:

• Ampicillin or amoxicillin: High-dose ampicillin (18-30g IV daily in divided doses) or amoxicillin (500mg PO/IV every 8h) is recommended for uncomplicated urinary tract infections due to VRE and remains effective for susceptible E. faecalis 3
• Nitrofurantoin: 100mg PO every 6h is recommended for uncomplicated UTIs due to enterococci 3
• Fosfomycin: A single 3g oral dose is effective for uncomplicated UTIs caused by E. faecalis 3

For resistant strains:

• Linezolid: 600mg IV or PO every 12h is recommended for enterococcal infections, particularly vancomycin-resistant strains 3
• Daptomycin: At high doses (8-12 mg/kg/day) for serious enterococcal infections 3

Clinical Implications and Pitfalls

When treating urinary tract infections, several important considerations should guide antibiotic selection:

1. Empiric therapy pitfall: Starting empiric therapy with cefuroxime for a suspected UTI may lead to treatment failure if E. faecalis is the causative organism

2. Identification importance: Laboratory identification of the specific enterococcal species and antimicrobial susceptibility testing are crucial for appropriate therapy 3

3. Resistance patterns: E. faecalis has shown increasing resistance to various antibiotics, making culture and susceptibility testing essential 2

4. Uncomplicated vs. complicated UTI: For uncomplicated UTIs caused by E. faecalis, oral options like nitrofurantoin, fosfomycin, or amoxicillin are appropriate; for complicated infections, parenteral therapy may be necessary

Algorithm for UTI Treatment When E. faecalis is Suspected

1. Obtain urine culture before starting antibiotics when possible
2. If empiric therapy is needed and E. faecalis is suspected (healthcare-associated infection, recent antibiotics, etc.):
   • Choose nitrofurantoin, fosfomycin, or amoxicillin rather than cefuroxime
3. For confirmed E. faecalis UTI:
   • Use susceptibility results to guide therapy
   • For uncomplicated lower UTI: nitrofurantoin, fosfomycin, or amoxicillin/ampicillin
   • For complicated UTI or pyelonephritis: ampicillin IV or alternative based on susceptibilities

In conclusion, cefuroxime has no place in the treatment of E. faecalis urinary tract infections due to intrinsic resistance of this organism to cefuroxime and other cephalosporins.