How would you manage MRSA and Enterococcus faecalis bacteriuria in a patient presenting in severe heart failure without urinary symptoms, fever, or chills, two negative blood cultures, and whose transthoracic echocardiogram shows no new valvular abnormalities?

The core question here is: are you dealing with asymptomatic bacteriuria or a true infection? In the absence of urinary symptoms and in following the IDSA UTI guidelines, asymptomatic bacteria should not be treated except in specific clinical scenarios - pregnancy, urologic instrumentation, renal tr...

In this case, unless the patient has had very recent genitourinary surgery (or pregnant in the case of a female patient), the Enterococcus fecalis is a distractor. The treatment focus should be on the MRSA. It was smart to check blood cultures because this is generally not an ascending pathogen, but...

A small number of people (as high as ~4% by some estimates: Mason et al., PMID 36644414) with asymptomatic bacteriuria are colonized with MRSA in the GU tract. While a small number of these may have underlying Staph aureus bacteremia, the blood culture prior to antibiotics makes this unlikely. The s...