Treatment of Enterococcus faecalis UTI in Pregnancy

First-Line Treatment Options

The American College of Obstetricians and Gynecologists recommends amoxicillin 500 mg orally every 8 hours for 7 days, or ampicillin 500 mg orally every 8 hours for 7 days as first-line therapy for Enterococcus faecalis UTI in pregnancy, with amoxicillin achieving high clinical (88.1%) and microbiological (86%) eradication rates 1
For hospitalized patients requiring IV therapy, high-dose ampicillin 18-30 g IV daily in divided doses or amoxicillin 500 mg IV every 8 hours is recommended 1

Nitrofurantoin 100 mg orally every 6 hours for 7 days is the preferred alternative for patients with penicillin allergy, with good in vitro activity against E. faecalis and resistance rates below 6% 1

Fosfomycin 3 g orally as a single dose is FDA-approved specifically for UTI caused by E. faecalis and can be used for uncomplicated infections 1
For beta-lactamase producing strains, replacing amoxicillin with amoxicillin-clavulanate for 7 days is recommended 1

The Infectious Diseases Society of America recommends that all pregnant women should be screened for and treated for asymptomatic bacteriuria to prevent progression to pyelonephritis, which occurs in 20-35% of untreated cases 2
Screening with urine culture should be collected at one of the initial visits early in pregnancy, and treatment of asymptomatic bacteriuria in pregnancy reduces pyelonephritis risk and may reduce preterm birth (from 53 per 1000 to 14 per 1000) and very low birth weight (from 137 per 1000 to 88 per 1000) 2
The American College of Obstetricians and Gynecologists recommends 4-7 days of antimicrobial treatment rather than shorter duration for pregnant women with asymptomatic bacteriuria 2

The Centers for Disease Control and Prevention recommends always obtaining susceptibility testing before initiating therapy, even for strains described as "pansensitive," as resistance patterns vary significantly 1
Differentiating colonization from true infection before prescribing anti-enterococcal agents is crucial, as asymptomatic bacteriuria with E. faecalis does not routinely require treatment unless the patient is pregnant 1
The American College of Obstetricians and Gynecologists recommends avoiding fluoroquinolones due to high resistance rates (46-47%) and teratogenic concerns in pregnancy 1
High urinary concentrations of ampicillin can overcome high ampicillin MICs even in ampicillin-resistant VRE strains 1