Should a low amount of Enterococcus faecalis detected in a vaginal Polymerase Chain Reaction (PCR) swab be treated?

Management of Low Amounts of Enterococcus faecalis in Vaginal PCR Swabs

Treatment is not recommended for low amounts of Enterococcus faecalis detected in vaginal PCR swabs unless the patient is symptomatic with clinical signs of infection.

Understanding Enterococcus faecalis in Vaginal Flora

• Enterococcus faecalis can be part of the vaginal microbiome, especially in women who have previously received antibiotic treatment 1
• Studies show E. faecalis is present in approximately 17% of women who have not been treated with antibiotics and up to 44% of women who have used antibiotics 1
• The mere presence of E. faecalis in low amounts without symptoms does not necessarily indicate pathology requiring treatment 2

Clinical Decision Algorithm

When NOT to Treat:

• Asymptomatic patients with incidental finding of low amounts of E. faecalis 2
• No signs of mucopurulent cervicitis (MPC) or vaginal inflammation 2
• Normal vaginal pH (<4.5) 2
• Predominance of normal lactobacilli in vaginal flora 2

When to Consider Treatment:

• Presence of symptoms (abnormal discharge, itching, burning, odor) 2
• Clinical signs of aerobic vaginitis (AV) or mucopurulent cervicitis 3
• Elevated vaginal pH (>4.5) 2
• Significant inflammation on microscopy 2
• Immunocompromised status or planned invasive gynecological procedures 2

Diagnostic Considerations

• PCR testing alone may detect non-viable or colonizing organisms that don't require treatment 2, 4
• Quantitative PCR is more sensitive than culture techniques for detecting E. faecalis 4
• Clinical diagnosis should include:
  • Assessment of vaginal pH (>4.5 suggests potential infection) 2
  • Microscopic examination for inflammatory cells 2
  • Evaluation for symptoms and signs of infection 2

Treatment Recommendations (When Indicated)

If treatment is deemed necessary based on symptoms and clinical findings:

• First-line treatment for symptomatic infection: 2, 3

  • Ampicillin 500 mg orally four times a day for 7 days
  • OR Amoxicillin-clavulanate 875/125 mg orally twice daily for 7 days

• For penicillin-allergic patients: 2, 5

  • Vancomycin (appropriate dosing based on patient factors)

• Consider adjunctive therapy: 3

  • Topical anti-inflammatory agents to reduce inflammation
  • Probiotics to restore normal vaginal flora

Special Considerations

• E. faecalis has been associated with aerobic vaginitis (AV), which differs from bacterial vaginosis and requires different treatment approaches 3
• Some research suggests a potential association between persistent E. faecalis and increased risk for HPV infection and cervical lesions, though this relationship requires further study 3
• Antibiotic resistance is a concern with enterococci; sensitivity testing may be warranted in recurrent cases 5

Common Pitfalls to Avoid

• Overtreatment of asymptomatic colonization, which can disrupt normal vaginal flora 2
• Failure to distinguish between true infection and colonization 2
• Not considering other causes of vaginal symptoms (candidiasis, trichomoniasis, bacterial vaginosis) 2
• Treating based solely on PCR results without clinical correlation 2, 4