Should we treat an elderly patient with symptomatic Enterococcus (E.) faecalis urinary tract infection (UTI) and significant leukocyturia?

Management of Symptomatic Enterococcus faecalis UTI in Elderly Patients

Yes, this elderly symptomatic patient with Enterococcus faecalis bacteriuria (49,000 colony count) and significant leukocyturia should be treated with appropriate antibiotics.

Diagnostic Confirmation

The patient meets criteria for symptomatic UTI requiring treatment based on:

• Significant bacteriuria (49,000 colony count of E. faecalis)
• Presence of leukocyturia (large amount of leukocytes)
• Symptomatic presentation
• Elderly status (higher risk for complications)

Treatment Recommendations

First-line Options:

• Ampicillin/sulbactam: Preferred option due to low resistance rates in E. faecalis 1
  • Dosing: Adjust based on renal function
  • Duration: 7 days for uncomplicated UTI; 10-14 days if delayed response

Alternative Options (if penicillin allergic or unavailable):

• Nitrofurantoin (if GFR >30 mL/min)

  • Dosing: 100 mg twice daily
  • Duration: 7 days
  • Caution: Contraindicated if GFR <30 mL/min 2

• Fosfomycin

  • Dosing: 3g single oral dose
  • Particularly useful in patients with renal impairment 2, 3

For Severe Infection/Systemic Symptoms:

• Consider parenteral therapy with:
  • Ampicillin ± gentamicin (if susceptible)
  • Daptomycin or linezolid (for resistant strains) 3

Important Considerations

Resistance Patterns

• E. faecalis generally has low resistance to ampicillin/sulbactam and nitrofurantoin 1, 4
• High resistance rates to fluoroquinolones (47% for ciprofloxacin) make them poor empiric choices 1
• Vancomycin resistance is rare in E. faecalis but should be checked 4

Special Considerations for Elderly Patients

• Elderly patients often present with atypical UTI symptoms, including altered mental status, functional decline, and falls 2
• Longer treatment duration may be needed in elderly males due to possible prostate involvement 2
• Monitor renal function during treatment and ensure adequate hydration 2

Monitoring and Follow-up

• Assess clinical response within 48-72 hours
• Consider urological evaluation if recurrent infections occur
• If treatment fails, obtain repeat urine culture with susceptibility testing 2

Important Distinctions

It's crucial to distinguish between asymptomatic bacteriuria (which should NOT be treated) and symptomatic UTI (which requires treatment):

• Asymptomatic bacteriuria in elderly patients should NOT be treated, even with pyuria 5
• Non-specific symptoms like falls or delirium alone should not trigger antibiotic treatment without other UTI symptoms 5
• In this case, the patient is described as symptomatic with significant bacteriuria and pyuria, warranting treatment

Potential Pitfalls

• Avoid fluoroquinolones as first-line therapy due to high resistance rates in E. faecalis and increased risk of adverse effects in elderly patients 2, 1
• Do not attribute non-specific symptoms solely to UTI without considering other causes 2
• Avoid unnecessary prolonged treatment, which increases risk of resistance and adverse effects
• Remember that catheter-associated UTI requires catheter removal or change before collecting specimens 5

By following these recommendations, you can effectively treat this elderly patient's symptomatic E. faecalis UTI while minimizing risks of treatment failure and adverse effects.