Is Cipro (ciprofloxacin) effective for treating Enterococcus faecalis urinary tract infections (UTIs)?

Ciprofloxacin is Not Recommended for Enterococcus faecalis UTIs

Ciprofloxacin should not be used as empiric therapy for Enterococcus faecalis urinary tract infections due to high resistance rates (approximately 47%) and unfavorable risk-benefit ratio. 1

Resistance Patterns and Recommendations

• E. faecalis demonstrates high resistance to fluoroquinolones, with studies showing 46-47% resistance to ciprofloxacin and levofloxacin 1
• In July 2016, the FDA issued an advisory warning against using fluoroquinolones for uncomplicated UTIs due to serious adverse effects resulting in an unfavorable risk-benefit ratio 2
• Since the 2011 Infectious Diseases Society of America (IDSA) guidelines, fluoroquinolones have not been recommended as first-line therapy for uncomplicated UTI, and their use even as second-line agents is now questioned 2

Preferred Treatment Options for E. faecalis UTI

First-line options:

• Ampicillin/sulbactam (low resistance rates for E. faecalis) 1
• Nitrofurantoin (for uncomplicated lower UTIs only) 2
• Fosfomycin (3g single dose) 2, 3

For complicated UTIs or pyelonephritis:

• Ampicillin-based regimens with susceptibility testing 1
• Consider parenteral therapy with appropriate agents based on susceptibility 2

Treatment Algorithm for E. faecalis UTI

1. Always obtain urine culture and susceptibility testing before initiating therapy for suspected E. faecalis UTI 2
2. For uncomplicated lower UTI:
   • Nitrofurantoin 100mg twice daily for 5 days (if susceptible) 2
   • Fosfomycin 3g single dose 2
3. For complicated UTI or pyelonephritis:
   • Ampicillin/sulbactam (if susceptible) 1
   • If fluoroquinolones must be used, only do so after confirming susceptibility 2

Important Considerations and Caveats

• Fluoroquinolones are associated with significant collateral damage, including disruption of fecal microbiota and increased risk of Clostridium difficile infection 2
• Despite the FDA warning, many providers continue to prescribe fluoroquinolones for UTI when they suspect pyelonephritis or consider the UTI "complicated" 2
• Risk factors for ciprofloxacin-resistant E. faecalis include hospital-acquired infection, treatment in a urological department, and transfer from healthcare centers 1
• E. faecalis is intrinsically resistant to many antibiotics, making treatment options more limited than for other uropathogens 1

Antibiotic Stewardship Principles

• Antibiotic resistance among uropathogens has become more prevalent due to overuse, poor selection of antimicrobial agents, and unnecessarily long treatment durations 2
• Short-course therapy with appropriate agents is preferred to limit development of resistance 2
• Fluoroquinolones should be reserved for important uses other than uncomplicated UTIs 2
• Always adjust therapy based on culture and susceptibility results 2

Remember that E. faecalis UTIs often occur in patients with complicated urinary tract conditions, and treatment may need to address underlying anatomical or functional abnormalities to prevent recurrence 1.