Do I need to treat vaginal Enterococcus faecalis?

Treatment of Vaginal Enterococcus faecalis

Treatment of vaginal Enterococcus faecalis is not recommended unless the patient is symptomatic with evidence of aerobic vaginitis or has specific risk factors.

Understanding Vaginal E. faecalis

Enterococcus faecalis is commonly found in the vaginal flora, particularly in women who have previously been treated with antibiotics. Research shows that E. faecalis can be found in approximately 17.33% of women who have not used antibiotics and up to 44% of women who have used antibiotics 1.

When NOT to Treat

• Asymptomatic colonization
• Routine vaginal cultures showing E. faecalis without symptoms
• Incidental finding during screening

When to Consider Treatment

Treatment should be considered in the following scenarios:

1. Symptomatic Aerobic Vaginitis (AV) with confirmed E. faecalis as the dominant pathogen 2

   • Symptoms include: abnormal discharge, inflammation, elevated vaginal pH (>5)
   • Signs of inflammation on examination

2. High-Risk Patients with E. faecalis in vaginal cultures:

   • Immunocompromised patients 3
   • Patients with valvular heart disease or prosthetic intravascular materials 3
   • Patients who have previously received cephalosporins or other antimicrobials selecting for Enterococcus species 3

Treatment Approach for Symptomatic Cases

If treatment is warranted based on symptoms and confirmed E. faecalis as the causative agent:

First-line Treatment Options:

• Topical antibiotic therapy targeted at E. faecalis 2
• Combination approach may include:
  • Antibacterial treatment (antiseptic and/or antibiotic)
  • Non-steroidal anti-inflammatory agents to reduce inflammation
  • Probiotics to restore normal flora

Specific Antibiotic Options:

For confirmed symptomatic infection requiring treatment, consider:

• Ampicillin (based on susceptibility testing) 3
• Piperacillin-tazobactam (based on susceptibility testing) 3
• Vancomycin (for resistant strains) 3, 4

Important Clinical Considerations

Diagnostic Approach

Before initiating treatment, confirm that E. faecalis is the causative pathogen of symptoms:

• Evaluate for other causes of vaginal symptoms (Candida, BV, Trichomoniasis)
• Consider vaginal pH (AV typically has pH >5)
• Assess for signs of inflammation

Common Pitfalls to Avoid

1. Overtreatment: Treating asymptomatic colonization can lead to disruption of normal flora and selection of resistant organisms
2. Misdiagnosis: E. faecalis may be present alongside other pathogens; ensure comprehensive testing
3. Inadequate follow-up: If symptoms persist after appropriate treatment, reevaluation is necessary

Special Populations

• Pregnant women: Limited data exists on treatment of vaginal E. faecalis during pregnancy; treatment should focus on symptomatic cases only
• Immunocompromised patients: May require more aggressive treatment approach due to higher risk of complications 3

Conclusion

The presence of E. faecalis in vaginal cultures alone is not an indication for treatment. Treatment should be reserved for symptomatic patients with evidence of infection or those with specific risk factors. This approach helps prevent unnecessary antibiotic use and development of resistance while ensuring appropriate management of clinically significant infections.