Treatment of Enterococcus Faecalis Chronic Prostatitis
Rifampin should not be used in combination with linezolid or levofloxacin for E. faecalis chronic prostatitis due to antagonistic effects and lack of supporting evidence for this specific infection. 1, 2
First-Line Treatment Options
- Linezolid 600 mg orally every 12 hours is recommended as the backbone of therapy for E. faecalis prostatitis due to its proven efficacy against enterococcal infections, including resistant strains 3
- For susceptible strains, linezolid 600 mg orally every 12 hours for 2-3 weeks is recommended as first choice 3
- Daptomycin (8-12 mg/kg/day) can be considered for patients unable to tolerate linezolid, though it may have less prostatic penetration 3
Evidence Against Rifampin Combinations
- The addition of rifampin has been shown to antagonize the activity of daptomycin against both E. faecalis and vancomycin-resistant enterococci in biofilm models 2
- In vitro studies demonstrate that rifampin significantly delayed the bactericidal activity of daptomycin against E. faecalis biofilms 2
- The antagonistic effect of rifampin and linezolid likely occurs because they target different aspects of bacterial protein synthesis, with rifampin inhibiting RNA polymerase and linezolid inhibiting ribosomal protein synthesis 1
Fluoroquinolone Considerations
- Fluoroquinolones like levofloxacin have shown relatively low resistance rates (4.8% for levofloxacin) in E. faecalis strains causing chronic bacterial prostatitis 4
- However, ciprofloxacin monotherapy is not recommended against enterococci due to rapid emergence of resistance and high treatment failure rates 3
- Historical data suggests that ciprofloxacin treatment was insufficient in patients with Streptococcus faecalis (now E. faecalis) prostatitis 5
Alternative Treatment Options
- For resistant strains, high-dose daptomycin (8-12 mg/kg/day) is recommended 3
- The Infectious Diseases Society of America recommends daptomycin at high doses (10-12 mg/kg/day) as a first-line option for treating E. faecalis biofilms 1
- For vancomycin-resistant E. faecalis infections, linezolid 600 mg IV or orally every 12 hours as monotherapy is recommended 1
Important Monitoring Considerations
- Linezolid therapy requires monitoring for adverse effects, including myelosuppression and peripheral neuropathy 3
- Prolonged linezolid therapy without breaks should be avoided due to risk of myelosuppression; use pulse therapy instead 3
- If rifampin must be used in other enterococcal infections, it should always be combined with a second agent to reduce the likelihood of emergence of resistance 3
Pitfalls to Avoid
- Avoid using rifampin with linezolid or daptomycin against E. faecalis as in vitro studies show antagonistic effects 2, 6
- E. faecalis can rapidly develop resistance to rifampin when biofilms are subjected to this antibiotic alone or in combination with ampicillin 6
- Tigecycline should not be used for prostatitis as it achieves low serum levels despite good activity against enterococci 3