Does Enterococcus faecalis in urine require antibiotic treatment?

From the Guidelines

Enterococcus faecalis in urine typically requires antibiotic treatment when it causes a symptomatic urinary tract infection (UTI), and the recommended first-line treatment is ampicillin 500 mg IV or PO every 8 h daily or high dose ampicillin (18-30 g IV daily in divided doses) for uncomplicated cases, as suggested by 1 and 1. The choice of antibiotic should be guided by antibiotic susceptibility testing whenever possible, and treatment should be tailored to the individual patient's needs.

• For uncomplicated urinary tract infections due to VRE, alternatives include nitrofurantoin 100 mg PO every 6 h 1 or a single dose of fosfomycin 3 g PO 1.
• Patients with penicillin allergies or complicated infections may require alternative treatments, such as linezolid 600 mg IV or PO every 12 h 1 or high dose daptomycin 8-12 mg/kg/day 1.
• Asymptomatic bacteriuria generally does not require treatment, except in pregnant women or before urologic procedures.
• It is essential to differentiate colonization from true infection prior to empiric prescription of anti-VRE antimicrobial agents, as noted in 1.
• Novel agents, such as eravacycline, have shown in vitro activity against VRE, but more clinical evidence is needed to provide guidance on their role in treating VRE infections, as mentioned in 1.
• The treatment duration should be based on individual clinical conditions, and patients should complete the full course of antibiotics even if symptoms improve, drink plenty of water, and follow up if symptoms persist or worsen after treatment.
• In cases of VRE infections, it is crucial to consider the potential for antibiotic resistance and to consult with specialists in infectious diseases, cardiology, and clinical pharmacy, as recommended in 1.

From the FDA Drug Label

Fosfomycin tromethamine granules for oral solution is indicated only for the treatment of uncomplicated urinary tract infections (acute cystitis) in women due to susceptible strains of Escherichia coli and Enterococcus faecalis. The presence of Enterococcus faecalis in urine may require antibiotic treatment, specifically for uncomplicated urinary tract infections (acute cystitis) in women, as indicated by the use of fosfomycin 2.

• Key points:
  • Enterococcus faecalis is a susceptible strain for treatment with fosfomycin.
  • Treatment is indicated for uncomplicated urinary tract infections (acute cystitis) in women.

From the Research

Enterococcus Faecalis in Urine and Antibiotic Treatment

• Enterococcus faecalis is a type of bacteria that can cause urinary tract infections (UTIs) 3, 4.
• The treatment of UTIs caused by Enterococcus faecalis can be challenging due to the emergence of antibiotic-resistant strains 4.
• Antibiotic treatment options for Enterococcus faecalis in urine include:
  • Ampicillin: may be effective against vancomycin-resistant E. faecalis 3, 5.
  • Nitrofurantoin: may be effective against vancomycin-resistant E. faecalis 3, 4.
  • Linezolid: may be effective against vancomycin-resistant E. faecalis, but its use is limited due to potential side effects 3, 4.
  • Fosfomycin: may be effective against vancomycin-resistant E. faecalis, but its use is limited due to potential side effects 3, 4.
• The choice of antibiotic treatment should be guided by urine culture and susceptibility results 4.
• In some cases, combination therapy with multiple antibiotics may be necessary to effectively treat Enterococcus faecalis UTIs 6, 5.

Biofilm Formation and Antibiotic Resistance

• Enterococcus faecalis can form biofilms in the urinary tract, which can contribute to antibiotic resistance and treatment failure 7.
• The formation of biofilms by Enterococcus faecalis is associated with the presence of certain virulence genes, such as asa1 and esp 7.
• The accumulation of virulence genes and antibiotic resistance genes in Enterococcus faecalis isolates can make treatment more challenging 7.

Treatment Considerations

• The treatment of Enterococcus faecalis UTIs should take into account the potential for antibiotic resistance and biofilm formation 3, 4, 7.
• The choice of antibiotic treatment should be guided by urine culture and susceptibility results, as well as the patient's medical history and underlying health conditions 4.
• In some cases, removal of indwelling urinary catheters may be necessary to effectively treat Enterococcus faecalis UTIs 4.