What is the recommended treatment for Enterococcus Faecalis in chronic bacterial prostatitis?

Treatment of Enterococcus Faecalis in Chronic Bacterial Prostatitis

The recommended first-line treatment for Enterococcus faecalis in chronic bacterial prostatitis is fluoroquinolones, particularly ciprofloxacin or levofloxacin, due to their favorable tissue penetration and relatively low resistance rates.

Diagnostic Approach

• Diagnosis should be confirmed using the Meares-Stamey 4-glass test, which collects first-void urine, midstream urine, expressed prostatic secretions, and post-massage urine, with a positive result indicating a 10-fold higher bacterial count in prostatic secretions than midstream urine 1
• Avoid prostatic massage in acute bacterial prostatitis due to risk of bacteremia 1
• Culture specimens should be tested for antimicrobial susceptibility to guide targeted therapy 2

First-Line Treatment Options

• Fluoroquinolones (ciprofloxacin or levofloxacin) are the preferred antibiotics for E. faecalis in chronic bacterial prostatitis due to:
  • Good prostatic tissue penetration 3, 4
  • Relatively low resistance rates (9.7% for ciprofloxacin, 4.8% for levofloxacin) 5
  • Established clinical efficacy in chronic bacterial prostatitis 3, 4

Treatment Duration and Dosing

• Minimum treatment duration should be 2-4 weeks 4
• If clinical improvement occurs, continue treatment for at least another 2-4 weeks (total 4-8 weeks) 4
• Ciprofloxacin 500mg orally twice daily or levofloxacin 500mg orally once daily are standard dosing regimens 3

Alternative Treatment Options

• Ampicillin or amoxicillin/sulbactam can be considered for fluoroquinolone-resistant strains, as E. faecalis shows low resistance rates (0%) to these agents 5
• Nitrofurantoin may be effective for uncomplicated urinary tract infections due to E. faecalis with 0% resistance reported 5
• For vancomycin-resistant E. faecalis (VRE), options include:
  • Linezolid 600mg IV or orally every 12 hours 2
  • High-dose daptomycin (8-12 mg/kg/day) or in combination with β-lactams 2, 6
  • Tigecycline 100mg IV loading dose then 50mg IV every 12 hours for intra-abdominal involvement 2

Treatment Considerations and Pitfalls

• Avoid tetracycline, erythromycin, and trimethoprim/sulfamethoxazole due to high resistance rates (97.5%, 95%, and 31.5% respectively) 5
• Monitor for treatment failure and consider antibiotic switch if no improvement after 2-4 weeks 4
• E. faecalis strains may develop resistance during treatment, necessitating repeat cultures if symptoms persist 3
• Ciprofloxacin has been shown to be less effective against Streptococcus faecalis (now classified as Enterococcus faecalis) compared to its efficacy against gram-negative organisms in prostatitis 7

Special Situations

• For severe infections or fluoroquinolone-resistant strains, consider combination therapy:
  • Ampicillin plus gentamicin (if no high-level aminoglycoside resistance) 2
  • Ampicillin plus ceftriaxone (for aminoglycoside-resistant strains) 2
• In cases of recurrent infection despite appropriate antibiotic therapy, consider longer treatment courses or suppressive therapy 3

Monitoring and Follow-up

• Repeat cultures after completion of therapy to confirm bacterial eradication 3
• Monitor for symptom improvement using validated prostatitis symptom scores 3
• Consider urological evaluation for underlying structural abnormalities in cases of recurrent infection 4