What is the recommended prophylactic treatment for recurrent urinary tract infections (UTIs) caused by Enterococcus faecalis (E. faecalis)?

Prophylactic Treatment for Recurrent UTI Positive for E. Faecalis

For recurrent urinary tract infections caused by Enterococcus faecalis, continuous antibiotic prophylaxis with nitrofurantoin 50-100mg daily is the recommended first-line prophylactic treatment after behavioral and non-antibiotic measures have been attempted. 1

Initial Approach

Before starting prophylactic antibiotics:

1. Confirm diagnosis of recurrent UTI (≥3 episodes in 12 months or ≥2 episodes in 6 months)
2. Ensure eradication of previous UTI with negative urine culture 1-2 weeks after treatment 1
3. Implement behavioral modifications:
   • Adequate hydration
   • Urge-initiated voiding
   • Post-coital voiding
   • Avoiding spermicidal contraceptives 1

Prophylactic Treatment Options

First-line Antibiotic Prophylaxis:

• Nitrofurantoin 50-100mg daily: Preferred for E. faecalis due to low resistance rates (only 20.2% at 3 months and 5.7% at 9 months) 1

Alternative Antibiotic Options:

• Trimethoprim-sulfamethoxazole 40/200mg daily: Consider based on susceptibility testing
• Trimethoprim 100mg daily: Consider based on susceptibility testing 1

Special Considerations:

• Post-coital prophylaxis: For infections associated with sexual activity, use low-dose antibiotic within 2 hours of intercourse 1
• Postmenopausal women: Consider vaginal estrogen with or without lactobacillus probiotics 1, 2

Non-Antibiotic Alternatives

If patient prefers to avoid antibiotics or has developed antibiotic resistance:

1. Methenamine hippurate: Strong recommendation for women without urinary tract anomalies 2
2. Lactobacillus-containing probiotics: Particularly L. rhamnosus GR-1 or L. reuteri RC-14 once or twice weekly 1
3. Cranberry products: Minimum 36mg/day proanthocyanidin A 1

Duration of Prophylaxis

• Continue prophylaxis for 6-12 months 1
• Reassess effectiveness and need for continued prophylaxis after this period

Self-Start Treatment Option

For reliable patients who can accurately self-diagnose UTI symptoms:

• Provide prescription for short-course antibiotics
• Patient initiates treatment upon symptom onset after obtaining urine specimen
• Follow-up with provider to confirm diagnosis and treatment efficacy 1, 3

Important Caveats

1. Avoid fluoroquinolones: FDA advisory warns against their use for uncomplicated UTIs due to unfavorable risk-benefit ratio 1
2. Avoid treating asymptomatic bacteriuria: This increases risk of symptomatic infection, bacterial resistance, and healthcare costs 1
3. Antibiotic stewardship: Choose antibiotics based on prior culture results, local resistance patterns, and patient-specific factors 1
4. Monitor for resistance: E. faecalis can develop resistance to multiple antibiotics; regular monitoring is essential 4

Algorithm for Management

1. Confirm diagnosis of recurrent UTI with E. faecalis
2. Implement behavioral modifications and non-antibiotic measures first
3. If unsuccessful, initiate prophylactic antibiotics:
   • Premenopausal with post-coital infections: Post-coital antibiotics
   • Postmenopausal: Vaginal estrogen ± prophylactic antibiotics
   • Others: Daily prophylactic antibiotics
4. Monitor effectiveness and reassess after 6-12 months
5. Consider self-start therapy for appropriate patients

This approach balances effective prevention of recurrent UTIs while minimizing antibiotic resistance and adverse effects.