What is the best management for asymptomatic recurrent Enterococcus (bacteria) urine culture?

From the Guidelines

Asymptomatic recurrent enterococcus in urine cultures should not be treated with antibiotics, as it represents colonization rather than infection. The management of asymptomatic bacteriuria, including cases caused by Enterococcus, is focused on avoiding unnecessary antibiotic use, which can lead to antimicrobial resistance and does not improve outcomes in asymptomatic patients 1. Key points to consider in the management include:

• Asymptomatic bacteriuria is common and often represents harmless colonization, especially in non-pregnant, non-catheterized individuals.
• The presence of bacteria in the urine without symptoms does not necessitate treatment, as it does not reduce the risk of developing symptomatic urinary tract infections (UTIs) or improve morbidity and mortality 1.
• Treatment of asymptomatic bacteriuria may actually increase the risk of subsequent symptomatic UTIs, as suggested by some studies where antimicrobial treatment of ASB was associated with an increased risk of developing symptomatic UTI 1.
• Specific populations, such as pregnant women or patients undergoing urologic procedures, may benefit from screening and treatment of asymptomatic bacteriuria, but this does not apply to the general population with recurrent enterococcus in urine cultures.
• For prevention of recurrence in those with a history of UTIs, non-antibiotic measures such as adequate hydration, proper hygiene practices, and avoiding irritating products are recommended.
• If symptoms develop, treatment options can include ampicillin, amoxicillin, or nitrofurantoin, but the choice of antibiotic and duration of treatment should be guided by local resistance patterns and clinical guidelines 1. The rationale behind avoiding antibiotic treatment for asymptomatic bacteriuria is to prevent antimicrobial resistance, avoid unnecessary side effects, and recognize that asymptomatic bacteriuria often does not benefit from treatment, as supported by guidelines from the American Urological Association and the Infectious Diseases Society of America 1.

From the FDA Drug Label

The cure rates for the ITT population with documented vancomycin-resistant enterococcal infection at baseline are presented in Table 15 by source of infection. Urinary tract12/19 (63)12/20 (60)

The best management of asymptomatic recurrent enterococcus urine culture is not explicitly stated in the provided drug label. However, based on the cure rates presented in Table 15, linezolid may be considered as a treatment option for urinary tract infections caused by vancomycin-resistant enterococci, with a cure rate of 63% 2. Asymptomatic cases are not specifically addressed in the label, and therefore, no conclusion can be drawn regarding the best management of asymptomatic recurrent enterococcus urine culture.

From the Research

Management of Asymptomatic Recurrent Enterococcus Urine Culture

• The management of asymptomatic recurrent enterococcus urine culture is a complex issue, and the approach may vary depending on the specific circumstances 3, 4.
• Routine therapy for asymptomatic bacteriuria with multidrug-resistant Enterococcus is not recommended 4.
• Removal of indwelling urinary catheters should be considered in patients with asymptomatic recurrent enterococcus urine culture 4.
• Antibiotic therapy should be guided by urine culture and susceptibility results, and the selection of antibiotics should be based on the susceptibility patterns of the Enterococcus isolates 3, 4.

Antibiotic Options

• Nitrofurantoin, fosfomycin, and doxycycline have intrinsic activity against enterococci, including vancomycin-resistant Enterococcus, and may be considered as oral options for the treatment of asymptomatic recurrent enterococcus urine culture 3, 4.
• Linezolid and daptomycin should be reserved for confirmed or suspected upper and/or bacteremic vancomycin-resistant Enterococcus urine culture among ampicillin-resistant strains 3.
• Ampicillin may be considered for the treatment of asymptomatic recurrent enterococcus urine culture caused by vancomycin-resistant Enterococcus faecalis, Enterococcus casseliflavus, and Enterococcus gallinarum 5, 6.

Considerations

• The presence of underlying comorbidities, such as diabetes and chronic kidney disease, may not be associated with an increased risk of treatment failure 5.
• Immunocompromised patients may achieve lower cure rates, and the presence of an underlying urinary tract abnormality may be associated with a lower cure rate 5.
• The susceptibility profiles of vancomycin-resistant Enterococcus isolates in urine culture should be considered when selecting oral antimicrobials 6.