Antibiotic Treatment for UTI with Enterococcus faecalis and E. coli

Initial Assessment and Management

• The Infectious Diseases Society of America recommends obtaining urine culture prior to initiating antimicrobial therapy due to the wide spectrum of potential infecting organisms and increased likelihood of antimicrobial resistance in catheterized patients 2
• The Infectious Diseases Society of America suggests replacing the indwelling catheter if it has been in place for ≥2 weeks, as this improves clinical outcomes and decreases polymicrobial bacteriuria 2
• Collecting a new urine specimen from the freshly placed catheter before starting antibiotics is recommended to ensure accurate culture results 2

Empiric Antibiotic Selection

• The American College of Physicians recommends ampicillin/sulbactam as first-line therapy for coverage of both E. faecalis and E. coli in elderly patients with an indwelling catheter 1, 2
• Consideration of renal function when dosing antibiotics is crucial, as elderly patients often have reduced kidney function 1

Targeted Therapy Based on Culture Results

• For E. faecalis, ampicillin/amoxicillin is the drug of choice if susceptible 1
• Fosfomycin 3g oral powder as a single dose is recommended if oral therapy is appropriate and the infection is limited to the lower urinary tract 1
• Nitrofurantoin 100mg four times daily is recommended for uncomplicated lower UTI, but use with caution in elderly patients with reduced renal function 1

Duration of Treatment

• The Infectious Diseases Society of America recommends 7-14 days of therapy for complicated UTI in elderly patients with an indwelling catheter 1, 2
• Treatment may need to be extended if the patient does not have a prompt clinical response with defervescence by 72 hours 3

Monitoring and Follow-up

• Monitoring for clinical improvement within 72 hours of initiating therapy is recommended 3
• If no improvement occurs, consider catheter replacement (if not already done) and reevaluation for possible complications 2
• Obtaining follow-up urine cultures if symptoms persist despite appropriate therapy is recommended 1

Common Pitfalls to Avoid

• The Infectious Diseases Society of America does not recommend treating asymptomatic bacteriuria in catheterized patients as it leads to antimicrobial resistance without clinical benefit 4, 5
• Routine periodic changing of indwelling catheters to prevent CA-bacteriuria is not evidence-based 4
• Prophylactic antimicrobials should not be administered routinely at the time of catheter placement, removal, or replacement 4