What is the treatment for chronic prostatitis caused by Enterococcus faecalis?

Treatment of Chronic Prostatitis Caused by Enterococcus faecalis

For chronic prostatitis caused by Enterococcus faecalis, levofloxacin 500 mg orally once daily for 28 days is the recommended first-line treatment based on its proven efficacy and favorable resistance profile.

First-Line Treatment Options

• Levofloxacin 500 mg orally once daily for 28 days is FDA-approved for chronic bacterial prostatitis due to Enterococcus faecalis and has shown high clinical and microbiological success rates 1, 2
• Ciprofloxacin 500 mg orally twice daily for 28 days is an effective alternative with comparable efficacy to levofloxacin 2
• Fluoroquinolones are preferred due to their excellent prostatic tissue penetration and low resistance rates against E. faecalis (only 4.8-9.7% resistance reported for levofloxacin and ciprofloxacin) 3, 2

Treatment Algorithm

1. Confirm diagnosis:

   • Obtain expressed prostatic secretions (EPS) or post-massage urine (VB3) using the Meares-Stamey technique 1, 2
   • Verify significant E. faecalis growth in culture 3

2. First-line therapy:

   • Levofloxacin 500 mg orally once daily for 28 days 1, 2
   • Monitor for clinical improvement (reduction in pain, voiding symptoms, sexual dysfunction) 2, 4

3. Alternative if fluoroquinolone contraindicated or resistant:

   • Ampicillin-based regimen (if susceptible) 5
   • For aminoglycoside-susceptible strains: combination therapy with ampicillin plus gentamicin 5

Special Considerations

For Fluoroquinolone-Resistant E. faecalis

• If susceptible to penicillin/ampicillin: Ampicillin 2g IV every 4 hours plus ceftriaxone 2g IV every 12 hours for 6 weeks 5
• This double β-lactam regimen is effective against aminoglycoside-resistant enterococci 5

For Penicillin-Allergic Patients

• Vancomycin combined with gentamicin for 6 weeks (if aminoglycoside-susceptible) 5
• Monitor renal function closely when using aminoglycosides 5

Monitoring and Follow-Up

• Clinical evaluation at 5-18 days after completion of therapy 1, 2
• Long-term follow-up at 24-45 days after completion 1, 2
• Consider repeat cultures if symptoms persist or recur 3, 2

Potential Pitfalls and Caveats

• Avoid empiric use of tetracycline, erythromycin, and trimethoprim/sulfamethoxazole due to high resistance rates (97.5%, 95%, and 31.5% respectively) 3
• E. faecalis strains show 100% resistance to quinupristin/dalfopristin, making it ineffective 3
• Aminoglycoside resistance is increasing (46.3% for gentamicin), limiting combination therapy options 5, 3
• For gentamicin-containing regimens in patients with normal renal function, administer in multiple divided doses (total ~3 mg/kg/day) rather than once daily 5
• Adjust gentamicin dosing to achieve 1-hour serum concentration of ~3 μg/mL and trough <1 μg/mL 5
• Avoid aminoglycosides in patients with creatinine clearance <50 mL/min due to nephrotoxicity risk 5

Treatment of Resistant Strains

• For vancomycin-resistant E. faecalis, consider combination therapy with rifampin and nitrofurantoin 6
• Infectious disease consultation is strongly recommended for management of resistant strains 5
• Newer agents like daptomycin may be considered for multi-drug resistant strains, though data is limited 5