E. faecalis

Emery Haley, PhD, Scientific Writer

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Clinical Summary

C. koseri is recognized as a classical gram-negative, urease-variable, biofilm-forming uropathogen. 
C. koseri is associated with complicated UTI in older adult and pediatric populations. 
In symptomatic UTI patients, C. koseri: 
- Is not a contaminant (is found in catheter-collected urine specimens). 
- Is viable (can grow out on culture). 
- Is pathogenic (associated with elevated urine biomarkers of infection). 
Reported severe complications of C. koseri UTI include pyelonephritis, polymicrobial bacteremia, and urosepsis. 
Multidrug-resistant C. koseri (especially among hospital-acquired UTIs) is a significant global health threat.

Bacterial Characteristics

Gram-stain

Gram-negative

Morphology

Bacillus

Growth Requirements

Non-fastidious (grows well in standard urine culture conditions)
Facultative anaerobe

Nitrate Reduction

Yes

Urease

Variable

Biofilm Formation

Yes

Pathogenicity

Colonizer or Pathobiont

Clinical Relevance in UTI

C. koseri is a urease-variable microorganism [1] capable of forming biofilms. C. koseri is typically considered to be among the common classical uropathogens in older adults,[2]  but is also being increasingly recognized as common in pediatric UTIs.[3]

In a study of older adult males and females with clinically suspected complicated UTI, C. koseri was detected in both midstream voided and in-and-out-catheter collected specimens indicating that it was truly present in the bladder, not simply a contaminant picked up during voiding.[4]  Furthermore, elevated markers of immune system activation in the urinary tract have been measured from the same clinical urine specimens in which C. koseri was detected, indicating that the presence of C. koseri was associated with an immune response to urinary tract infection.[5–7]   Hospital-acquired C. koseri UTIs pose a particularly serious threat, as these infections increasingly display multidrug- or pandrug-resistance.[8]  Severe complications of C. koseri UTI, including pyelonephritis, polymicrobial bacteremia, and urosepsis, have been reported.[9–11]

Hospital-acquired C. koseri UTIs pose a particularly serious threat, as these infections increasingly display multidrug- or pandrug-resistance.[8]  Although not considered one of the six highest priority “ESKAPE” pathogens, The World Health Organization (WHO) has included this organism in the 2024 Bacterial Priority Pathogens List (BPPL).[111] Severe complications of C. koseri UTI, including pyelonephritis, polymicrobial bacteremia, and urosepsis, have been reported.[9–11] 

Together, these findings indicate that C. koseri should be seriously considered as a uropathogen and demonstrate the value of detecting this organism, particularly in individuals with recurrent UTI and/or risk factors for persistent or complicated UTI.

Treatment

Evidence of Efficacy (Checkmarks): Amoxicillin/Clavulanate, Ampicillin/Sulbactam, Cefaclor, Cefazolin, Cefepime, Cephalexin, Ceftazidime, Ceftriaxone, Ciprofloxacin, Gentamicin, Levofloxacin, Meropenem, Nitrofurantoin, Piperacillin/Tazobactam, Sulfamethoxazole/Trimethoprim, and Trimethoprim.

References

1. BacDive | The Bacterial Diversity Metadatabase Available online: https://bacdive.dsmz.de/ (accessed on 11 February 2025).
2. BioCyc Pathway/Genome Database Collection Available online: https://biocyc.org/ (accessed on 11 February 2025).
3. Hochstedler, B.R.; Burnett, L.; Price, T.K.; Jung, C.; Wolfe, A.J.; Brubaker, L. Urinary Microbiota of Women with Recurrent Urinary Tract Infection: Collection and Culture Methods. Int Urogynecol J 2021, 1–8, doi:10.1007/s00192-021-04780-4.
4. Festa, R.A.; Luke, N.; Mathur, M.; Parnell, L.; Wang, D.; Zhao, X.; Magallon, J.; Remedios-Chan, M.; Nguyen, J.; Cho, T.; et al. A Test Combining Multiplex-PCR with Pooled Antibiotic Susceptibility Testing Has      High Correlation with Expanded Urine Culture for Detection of Live Bacteria in      Urine Samples of Suspected UTI Patients. Diagn Microbiol Infect Dis 2023, 107, 116015, doi:10.1016/j.diagmicrobio.2023.116015.
5. Gaston, J.R.; Johnson, A.O.; Bair, K.L.; White, A.N.; Armbruster, C.E. Polymicrobial Interactions in the Urinary Tract: Is the Enemy of My Enemy My Friend? Infect Immun 2021, 89, doi:10.1128/iai.00652-20.
6. Yoo, J.-J.; Shin, H.B.; Song, J.S.; Kim, M.; Yun, J.; Kim, Z.; Lee, Y.M.; Lee, S.W.; Lee, K.W.; Kim, W.B.; et al. Urinary Microbiome Characteristics in Female Patients with Acute Uncomplicated Cystitis and Recurrent Cystitis. J. Clin. Med. 2021, 10, 1097, doi:10.3390/jcm10051097.
7. Turjeman, A.; Babich, T.; Pujol, M.; Carratalà, J.; Shaw, E.; Gomila-Grange, A.; Vuong, C.; Addy, I.; Wiegand, I.; Grier, S.; et al. Risk Factors for Enterococcal Urinary Tract Infections: A Multinational, Retrospective Cohort Study. Eur. J. Clin. Microbiol. Infect. Dis. 2021, 40, 2005–2010, doi:10.1007/s10096-021-04207-4.
8. Salm, J.; Salm, F.; Arendarski, P.; Kramer, T.S. High Frequency of Enterococcus Faecalis Detected in Urinary Tract Infections in Male Outpatients – a Retrospective, Multicenter Analysis, Germany 2015 to 2020. BMC Infect. Dis. 2023, 23, 812, doi:10.1186/s12879-023-08824-6.
9. Tanaka, Y.; Oishi, T.; Ono, S.; Kono, M.; Kato, A.; Miyata, I.; Ohno, N.; Ouchi, K. Epidemiology of Urinary Tract Infections in Children: Causative Bacteria and Antimicrobial Therapy. Pediatr. Int. 2021, 63, 1198–1204, doi:10.1111/ped.14639.
10. Tien, B.Y.Q.; Goh, H.M.S.; Chong, K.K.L.; Bhaduri-Tagore, S.; Holec, S.; Dress, R.; Ginhoux, F.; Ingersoll, M.A.; Williams, R.B.H.; Kline, K.A. Enterococcus Faecalis Promotes Innate Immune Suppression and Polymicrobial Catheter-Associated Urinary Tract Infection. Infect. Immun. 2017, 85, doi:10.1128/iai.00378-17.
11. Johnson, A.O.; Shipman, B.M.; Hunt, B.C.; Learman, B.S.; Brauer, A.L.; Zhou, S.P.; Blair, R.H.; Nisco, N.J.D.; Armbruster, C.E. Function and Contribution of Two Putative Enterococcus Faecalis Glycosaminoglycan Degrading Enzymes to Bacteremia and Catheter-Associated Urinary Tract Infection. Infect. Immun. 2024, 92, e00199-24, doi:10.1128/iai.00199-24.
12. Parente, G.; Gargano, T.; Pavia, S.; Cordola, C.; Vastano, M.; Baccelli, F.; Gallotta, G.; Bruni, L.; Corvaglia, A.; Lima, M. Pyelonephritis in Pediatric Uropathic Patients: Differences from Community-Acquired Ones and Therapeutic Protocol Considerations. A 10-Year Single-Center Retrospective Study. Children 2021, 8, 436, doi:10.3390/children8060436.
13. Horsley, H.; Malone-Lee, J.; Holland, D.; Tuz, M.; Hibbert, A.; Kelsey, M.; Kupelian, A.; Rohn, J.L. Enterococcus Faecalis Subverts and Invades the Host Urothelium in Patients with Chronic Urinary Tract Infection. PLoS ONE 2013, 8, e83637, doi:10.1371/journal.pone.0083637.
14. Sansone, S.; Ramos, Y.; Segal, S.; Asfaw, T.S.; Morales, D.K. Uncovering Surface Penetration by Enterococci From Urinary Tract Infection Patients. Urogynecology 2024, 30, 320–329, doi:10.1097/spv.0000000000001476.
15. Chieng, C.C.Y.; Kong, Q.; Liou, N.S.Y.; Khasriya, R.; Horsley, H. The Clinical Implications of Bacterial Pathogenesis and Mucosal Immunity in Chronic Urinary Tract Infection. Mucosal Immunol. 2023, 16, 61–71, doi:10.1016/j.mucimm.2022.12.003.
16. Xu, W.; Fang, Y.; Zhu, K. Enterococci Facilitate Polymicrobial Infections. Trends Microbiol. 2024, 32, 162–177, doi:10.1016/j.tim.2023.07.010.
17. Kao, P.H.-N.; Ch’ng, J.-H.; Chong, K.K.L.; Stocks, C.J.; Wong, S.L.; Kline, K.A. Enterococcus Faecalis Suppresses Staphylococcus Aureus-Induced NETosis and Promotes Bacterial Survival in Polymicrobial Infections. FEMS Microbes 2023, 4, xtad019, doi:10.1093/femsmc/xtad019.
18. Abell-King, C.; Pokhrel, A.; Rice, S.A.; Duggin, I.G.; Söderström, B. Multispecies Bacterial Invasion of Human Host Cells. Pathog. Dis. 2024, 82, ftae012, doi:10.1093/femspd/ftae012.
19. Wang, D.; Haley, E.; Luke, N.; Mathur, M.; Festa, R.; Zhao, X.; Anderson, L.A.; Allison, J.L.; Stebbins, K.L.; Diaz, M.J.; et al. Emerging and Fastidious Uropathogens Were Detected by M-PCR with Similar Prevalence and Cell Density in Catheter and Midstream Voided Urine Indicating the Importance of These Microbes in Causing UTIs. Infect. Drug Resist. 2023, Volume 16, 7775–7795, doi:10.2147/idr.s429990.
20. Haley, E.; Luke, N.; Mathur, M.; Festa, R.A.; Wang, J.; Jiang, Y.; Anderson, L.A.; Baunoch, D. The Prevalence and Association of Different Uropathogens Detected by M-PCR with Infection-Associated Urine Biomarkers in Urinary Tract Infections. Res. Rep. Urol. 2024, 16, 19–29, doi:10.2147/rru.s443361.
21. Akhlaghpour, M.; Haley, E.; Parnell, L.; Luke, N.; Mathur, M.; Festa, R.A.; Percaccio, M.; Magallon, J.; Remedios-Chan, M.; Rosas, A.; et al. Urine Biomarkers Individually and as a Consensus Model Show High Sensitivity and      Specificity for Detecting UTIs. BMC Infect Dis 2024, 24, 153, doi:10.1186/s12879-024-09044-2.
22. Parnell, L.K.D.; Luke, N.; Mathur, M.; Festa, R.A.; Haley, E.; Wang, J.; Jiang, Y.; Anderson, L.; Baunoch, D. Elevated UTI Biomarkers in Symptomatic Patients with Urine Microbial Densities of 10,000 CFU/ML Indicate a Lower Threshold for Diagnosing UTIs. MDPI 2023, 13, 1–15, doi:10.3390/diagnostics13162688.
23. Wu, Y.; Li, P.; Huang, Z.; Liu, J.; Yang, B.; Zhou, W.; Duan, F.; Wang, G.; Li, J. Four-Year Variation in Pathogen Distribution and Antimicrobial Susceptibility of Urosepsis: A Single-Center Retrospective Analysis. Ther. Adv. Infect. Dis. 2024, 11, 20499361241248056, doi:10.1177/20499361241248058.
24. Tellapragada, C.; Östlund, H.; Giske, C.; Rasmussen, M.; Berge, A. Recurrent Bacteremia with Enterococcus Faecalis, the Clinical Findings Predicting Endocarditis, and Genomic Characterization of the Isolates: A Retrospective Cohort Study. Eur. J. Clin. Microbiol. Infect. Dis. 2023, 42, 1001–1009, doi:10.1007/s10096-023-04636-3.

About the Author

Dr. Emery Haley is a scientific writing specialist with over ten years of experience in translational cell and molecular biology. As both a former laboratory scientist and an experienced science communicator, Dr. Haley is passionate about making complex research clear, approachable, and relevant. Their work has been published in over 10 papers and focuses on bridging the gap between the lab and real-world patient care to help drive better health outcomes.

Urologists

Primary Care Physicians

Gastroenterologists

Gynecologists

Medical Directors

Post-Acute Care

Healthcare at Home

Urology Clinic

Immediate Care/Urgent Care

Telemedicine

E. faecalis

CHECK BACK SOON FOR OUR FULL BLOG ON THE IMPORTANCE OF ENTEROCOCCUS FAECALIS

Clinical Summary

Bacterial Characteristics

Gram-stain

Morphology

Growth Requirements

Nitrate Reduction

Urease

Biofilm Formation

Pathogenicity

Clinical Relevance in UTI

Treatment

References

About the Author

Urologists

Primary Care Physicians

Gastroenterologists

Gynecologists

Medical Directors

Post-Acute Care

Healthcare at Home

Urology Clinic

Immediate Care/Urgent Care

Telemedicine

CHECK BACK SOON FOR OUR FULL BLOG ON THE IMPORTANCE OF ENTEROCOCCUS FAECALIS

Clinical Summary

Bacterial Characteristics

Gram-stain

Morphology

Growth Requirements

Nitrate Reduction

Urease

Biofilm Formation

Pathogenicity

Clinical Relevance in UTI

Treatment

References

About the Author

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