From the Guidelines
For treating enterococcus urinary tract infections (UTIs), fosfomycin 3 g PO as a single dose is recommended as a first-line treatment option, based on recent guidelines 1. This recommendation is supported by the most recent and highest quality study available, which suggests that fosfomycin is an effective option for uncomplicated UTIs due to vancomycin-resistant Enterococci (VRE) 1. Other treatment options for uncomplicated UTIs include nitrofurantoin 100 mg PO every 6 hours, or high dose ampicillin (18-30 g IV daily in divided doses) or amoxicillin 500 mg IV or PO every 8 hours daily, as outlined in the guidelines 1. However, it's essential to note that the quality of evidence for these recommendations is generally low or very low, emphasizing the need for individualized treatment decisions and susceptibility testing whenever possible 1. Key considerations in managing enterococcal UTIs include:
- Completing the full course of antibiotics even if symptoms improve quickly
- Drinking plenty of fluids
- Following up if symptoms persist
- Being aware of the natural resistance of enterococci to certain antibiotics, such as cephalosporins and trimethoprim-sulfamethoxazole, which guides the selection of effective treatment options 1.
From the Research
Antibiotics for Treating Enterococcus UTI
- The treatment of enterococcus UTI can be challenging due to the emergence of multidrug-resistant strains 2, 3, 4.
- For uncomplicated UTIs, potential oral agents active against multidrug-resistant Enterococcus include:
- Nitrofurantoin
- Fosfomycin
- Fluoroquinolones 4
- For pyelonephritis and complicated UTIs caused by multidrug-resistant Enterococcus, potential parenteral agents include:
- Daptomycin
- Linezolid
- Quinupristin-dalfopristin 4
- Aminoglycosides or rifampin may be considered as adjunctive therapy in serious infections 4.
- Newer agents such as oritavancin and dalbavancin have shown potential activity against certain resistant enterococcal strains 2, 3.
- Tedizolid and oritavancin have good in vitro activity against vancomycin-resistant Enterococcus, but clinical studies against other resistant enterococci are lacking 5.
Resistance to Antibiotics
- Resistance to multiple antibiotics, including vancomycin, has become common in Enterococcus faecium infections 2, 3, 4.
- Quinupristin-dalfopristin, daptomycin, linezolid, and tigecycline have shown activity against vancomycin-resistant Enterococcus, but resistance to these agents has also been reported 3, 6.
- Tigecycline generally showed the greatest activity against vancomycin-resistant Enterococcus, but some strains exhibited resistance to this agent as well 6.