Natural Clearance of Enterococcus faecalis Infections
Enterococcus faecalis infections do not reliably clear naturally and require antimicrobial treatment, particularly in serious infections like endocarditis, bacteremia, and complicated intra-abdominal infections. The available evidence focuses exclusively on treatment strategies rather than spontaneous resolution, reflecting the clinical reality that these infections require active intervention.
Why Treatment is Necessary
E. faecalis is inherently difficult to eradicate due to its partial resistance to many commonly used antimicrobials including penicillin and ampicillin, with low-affinity penicillin-binding proteins that lead to unacceptable therapeutic failures with monotherapy 1.
The organism causes serious invasive infections including endocarditis, bacteremia, urinary tract infections, intra-abdominal infections, and surgical wound infections that are associated with significant morbidity and mortality 2.
Mortality rates are substantial without treatment, particularly in elderly and fragile populations with endocarditis, where outcomes depend on appropriate antimicrobial therapy rather than host immune clearance 1.
Critical Distinction: Colonization vs. Infection
It is essential to differentiate colonization from true infection before initiating anti-enterococcal antimicrobial therapy 3.
Colonization may persist without causing disease and does not necessarily require treatment, but this is fundamentally different from active infection clearance 3.
True infections require definitive antimicrobial therapy - the guidelines universally recommend 4-6 weeks of treatment for endocarditis, 7-14 days for uncomplicated infections, and extended courses for prosthetic valve involvement 4, 3.
Evidence Against Natural Clearance
No documented cases of spontaneous resolution appear in major guidelines from the American Heart Association, World Society of Emergency Surgery, or recent systematic reviews 3, 5.
Bacteremia often has undetermined origin (48.5% in one study), potentially from gastrointestinal translocation, suggesting persistent infection rather than self-limited disease 6.
Mortality is associated with patient status and infection severity, not with spontaneous clearance mechanisms - significant mortality-associated conditions include polymicrobial bacteremia, oncological disease, ICU stay, and mechanical ventilation 6.
Clinical Implications
Always treat documented E. faecalis infections with appropriate antimicrobials based on susceptibility patterns - ampicillin 2g IV every 4-6 hours remains the gold standard for susceptible strains 4.
Serious infections require bactericidal combination therapy - ampicillin plus gentamicin for synergy in endocarditis, with treatment durations of 4-6 weeks for native valves and minimum 6 weeks for prosthetic valves 4, 3.
Obtain infectious disease consultation for all enterococcal endocarditis cases as standard of care 3, 4.