What is the recommended treatment for Enterococcus faecalis in urine?

Treatment of Enterococcus faecalis in Urine

For uncomplicated Enterococcus faecalis urinary tract infections, ampicillin or amoxicillin-clavulanate is the first-line treatment, with nitrofurantoin as an effective alternative. 1

First-Line Treatment Options

• Ampicillin: Standard dosing based on susceptibility testing 1
• Amoxicillin-clavulanic acid: 500/125 mg orally three times daily for 7 days 1
• Nitrofurantoin: 100mg twice daily for 5 days (for uncomplicated cases) 1

Alternative Treatment Options

• Trimethoprim-sulfamethoxazole: 160/800 mg twice daily for 3-7 days 1
• Fosfomycin: 3g single dose (particularly effective for uncomplicated UTIs) 1
• Fluoroquinolones (ciprofloxacin or levofloxacin): Consider only if susceptibility confirmed due to increasing resistance rates 1

For Resistant Strains

Penicillin-Resistant Strains

• Vancomycin: 30 mg/kg per 24h IV in 2 equally divided doses 2
• Plus Gentamicin: 3 mg/kg per 24h IV or IM in 3 equally divided doses 2

High-Level Aminoglycoside Resistant Strains

• Ampicillin + Ceftriaxone: This synergistic combination is effective for high-level aminoglycoside-resistant strains 1, 3
  • Ampicillin 2g IV every 4 hours
  • Ceftriaxone 2g IV every 12 hours

Multidrug-Resistant Strains

• Daptomycin: Shown to be active against Enterococcus faecalis, including vancomycin-resistant isolates 4
• Linezolid: Consider for resistant strains but monitor for toxicity 1

Treatment Duration

• Uncomplicated infections: 5-7 days 1
• Complicated infections: 10-14 days 1
• Pyelonephritis or severe infections: 14 days 1

Important Considerations

1. Avoid cephalosporins as monotherapy: Enterococci have minimal or no susceptibility to most cephalosporins when used alone 1

2. Renal function adjustment:

   • Nitrofurantoin should be avoided in patients with creatinine clearance <30 mL/min 1
   • Adjust aminoglycoside dosing based on renal function and drug levels

3. Synergistic combinations:

   • Beta-lactam + aminoglycoside combinations provide synergistic activity but have toxicity concerns 1
   • Ampicillin + ceftriaxone offers an effective alternative with less nephrotoxicity 3

4. Susceptibility testing: Always obtain antimicrobial susceptibility testing to guide therapy, as resistance patterns vary 1

Pitfalls to Avoid

• Monotherapy failure: E. faecalis is partially resistant to many antimicrobials, leading to treatment failures with monotherapy in serious infections 5
• Aminoglycoside toxicity: Consider alternatives to aminoglycosides in patients with renal impairment or at risk for nephrotoxicity 3
• Inadequate duration: Short treatment courses may lead to relapses, particularly in complicated infections 6
• Fluoroquinolone resistance: High rates of resistance make fluoroquinolones less reliable for empiric therapy 1

By following these evidence-based recommendations, clinicians can effectively treat Enterococcus faecalis urinary tract infections while minimizing the risk of treatment failure and antimicrobial resistance.