What is the recommended treatment for Enterococcus (E.) faecalis prostatitis?

Treatment of Enterococcus faecalis Prostatitis

For Enterococcus faecalis prostatitis, the recommended treatment is ampicillin or penicillin G combined with gentamicin for 4-6 weeks, with the option to use a double β-lactam regimen (ampicillin plus ceftriaxone) in cases of aminoglycoside resistance or renal impairment.

Antimicrobial Selection Based on Susceptibility

First-line Treatment

• Ampicillin-susceptible E. faecalis:
  • Ampicillin 2g IV every 4 hours (or Penicillin G 18-30 million units/24h IV) 1
  • Plus Gentamicin 3 mg/kg/day IV in 3 divided doses 1
  • Duration: 4-6 weeks 1

Alternative Regimens

• For patients with high-level aminoglycoside resistance or renal impairment:

  • Double β-lactam regimen: Ampicillin 2g IV every 4 hours plus Ceftriaxone 2g IV every 12 hours 1
  • Duration: 6 weeks 1

• For penicillin-allergic patients:

  • Vancomycin 30 mg/kg/day IV in 2 divided doses plus Gentamicin 3 mg/kg/day IV in 3 divided doses 1
  • Duration: 6 weeks 1

For Multidrug-Resistant Strains

• For vancomycin-resistant E. faecalis:
  • Linezolid or Daptomycin 1
  • Consider Rifampin plus Nitrofurantoin combination for 6 weeks 2

Treatment Duration

• Standard duration: 4-6 weeks 1
• 4 weeks may be sufficient for uncomplicated cases with symptoms <3 months 1
• 6 weeks recommended for complicated cases or symptoms >3 months 1

Monitoring During Treatment

• Monitor renal function regularly when using aminoglycosides
• For gentamicin: Adjust dose to achieve 1-hour serum concentration of ≈3 μg/mL and trough <1 μg/mL 1
• Perform susceptibility testing to penicillin and vancomycin 3
• Check for high-level aminoglycoside resistance (HLAR) - if MIC >500 mg/L, aminoglycosides should not be used 1

Special Considerations

• E. faecalis strains have shown variable resistance patterns:

  • Low resistance to ampicillin (0%), fluoroquinolones (4.8-9.7%), and vancomycin (0%) 4
  • High resistance to tetracycline (97.5%), erythromycin (95%), and gentamicin (46.3%) 4

• Fluoroquinolones alone (ciprofloxacin, levofloxacin) have shown limited efficacy against E. faecalis prostatitis despite low resistance rates 5

• For chronic cases with treatment failure, consider:

  • Longer duration of therapy (up to 16 weeks) 6
  • Consultation with infectious disease specialists 3
  • Experimental approaches like phage therapy in refractory cases 7

Pitfalls and Caveats

• Do not use:

  • Quinupristin/dalfopristin (100% resistance in E. faecalis) 4
  • Tetracycline, erythromycin, or trimethoprim/sulfamethoxazole as empiric therapy due to high resistance rates 4
  • Single-agent therapy without susceptibility testing

• Important considerations:

  • E. faecalis requires bactericidal combinations for effective treatment
  • Aminoglycoside-containing regimens are cornerstone therapy but resistance is increasing 1
  • Renal toxicity is a significant concern with prolonged aminoglycoside use
  • Double β-lactam regimens (ampicillin plus ceftriaxone) show similar efficacy to aminoglycoside combinations with less nephrotoxicity 1

The treatment of E. faecalis prostatitis requires prolonged therapy with bactericidal combinations and careful monitoring of antimicrobial susceptibility patterns to ensure successful eradication.