From the Guidelines
Vancomycin is the most appropriate choice for covering Enterococcus faecalis, while ciprofloxacin and flagyl (metronidazole) are not recommended due to variable activity and intrinsic resistance, respectively. The treatment of Enterococcus faecalis infections requires careful consideration of antibiotic susceptibility patterns. According to the 2015 ESC guidelines for the management of infective endocarditis 1, vancomycin is a recommended treatment option for E. faecalis infections, particularly in cases of high-level aminoglycoside resistance. The guidelines suggest using vancomycin at a dose of 30 mg/kg/day IV in 2 doses, in combination with gentamicin, for a duration of 6 weeks. Some key points to consider when treating E. faecalis infections include:
- E. faecalis is intrinsically resistant to metronidazole, making flagyl completely ineffective 1.
- Ciprofloxacin has limited and unpredictable activity against enterococci, with resistance rates often exceeding 50%, so it's not recommended as monotherapy 1.
- Vancomycin is often used for serious E. faecalis infections, but susceptibility testing is crucial due to increasing resistance patterns, particularly vancomycin-resistant enterococci (VRE) 1.
- Combination therapy with vancomycin plus an aminoglycoside (like gentamicin) may be necessary for synergistic killing in serious infections like endocarditis or meningitis 1. It's essential to note that the management of patients with enterococcal infections should always involve infectious disease consultation as the standard of care 1.
From the FDA Drug Label
Ciprofloxacin has been shown to be active against most strains of the following microorganisms, both in vitro and in clinical infections... Aerobic gram-positive microorganisms Enterococcus faecalis (Many strains are only moderately susceptible.)
- Ciprofloxacin: may be active against Enterococcus faecalis, but many strains are only moderately susceptible.
- Vancomycin and Flagyl (Metronidazole): the label does not provide information about the effectiveness of these drugs against Enterococcus faecalis. The FDA drug label for ciprofloxacin does provide some information about its effectiveness against Enterococcus faecalis, but it does not provide information about vancomycin or Flagyl. Based on the information provided for ciprofloxacin, it can be used to cover Enterococcus faecalis, but the effectiveness may vary due to moderate susceptibility 2.
From the Research
Antibiotic Coverage for Enterococcus faecalis
- Ciprofloxacin, vancomycin, and flagyl are commonly used antibiotics, but their effectiveness against Enterococcus faecalis varies.
- Vancomycin is often used to treat Enterococcus faecalis infections, especially in cases of resistance to other antibiotics 3, 4, 5.
- However, vancomycin-resistant Enterococcus faecalis (VRE) is a growing concern, and alternative treatments are needed 3, 6, 7.
- Daptomycin has shown clinical efficacy against VRE and is a useful option for treating Gram-positive infections, including those caused by Enterococcus faecalis 3, 4, 5.
- Flagyl (metronidazole) is not typically used to treat Enterococcus faecalis infections, as it is more effective against anaerobic bacteria 3.
- Ciprofloxacin may not be effective against Enterococcus faecalis, as it is often resistant to fluoroquinolones 3.
Treatment Options for Enterococcus faecalis Infections
- Aminopenicillins, such as amoxicillin, are preferred for treating Enterococcus faecalis infections when the bacteria are susceptible 3.
- Daptomycin, linezolid, and tedizolid are alternative treatment options for VRE infections 3, 4, 5.
- Combination therapy, such as using vancomycin and daptomycin together, may be effective against biofilm-forming Enterococcus faecalis strains 4.
- Fosfomycin has shown in vitro activity against Enterococcus faecalis, including linezolid-resistant strains, and may be a potential treatment option 4.