correspondence
Uncomplicated Urinary Tract Infection To the Editor: Hooton (March 15 issue)1 provides a comprehensive review of uncomplicated urinary tract infections. However, I think greater caution is warranted regarding the prescription of nitrofurantoin. The French Health Products Safety Agency (AFSSAPS) has published practice recommendations for the diagnosis of urinary tract infection and for antibiotic therapy in adults with urinary tract infection.2 Owing to the occurrence of severe hepatic and pulmonary side effects that have been reported with nitrofurantoin,3 AFSSAPS has recommended restricting its use to girls (6 years of age or older) and women who have documented cystitis due to susceptible organisms and when no other antibiotic with a better risk–benefit ratio can be used orally. The guidelines recommend that nitrofurantoin not be used as prophylactic treatment (continuous or intermittent) for recurrent urinary tract infection and suggest that repeated treatments with nitrofurantoin be avoided.4 The potential for harm from nitrofurantoin must be recognized.4,5 Hejer Harrabi, M.D. Ibn Al Jazzar Hospital Kairouan, Tunisia
[email protected]
The author replies: I appreciate the concern raised by Harrabi regarding the potential toxicity of nitrofurantoin, which I was not able to address fully in my review article. Nitrofurantoin has been in use in the United States since 1953 and is associated with rare but potentially serious side effects, including acute and chronic pulmonary toxicity, hepatotoxicity, and neuropathy.1,2 Increased concerns about toxicity are likely due in part to a resurgence in the use of nitrofurantoin,2 given its continued activity against most uropathogenic Escherichia coli, along with concomitant increasing resistance to other commonly used antimicrobial agents for urinary tract infection.3 Nitrofurantoin is considered a first-line antimicrobial agent for uncomplicated cystitis, according to recently published international treatment guidelines,3 and it is commonly used for the long-term prevention of recurrent urinary tract infection.4 As with any antimicrobial agent for urinary tract infection, patients should be counseled about potential toxic effects before any use and intermittently during long-term use. Although antimicrobial prevention strategies for recurrent urinary tract infection are recommended only as a last resort, nitrofurantoin continues to have an important role, especially as resistance to other agents has increased.
No potential conflict of interest relevant to this letter was reported.
Thomas M. Hooton, M.D.
1. Hooton TM. Uncomplicated urinary tract infection. N Engl J
University of Miami Miller School of Medicine Miami, FL
[email protected] Since publication of his article, the author reports no further potential conflict of interest.
Med 2012;366:1028-37. 2. AFSSAPS practice recommendations for diagnosis and antibiotic therapy of adult community urinary tract infections. Med Mal Infect 2008;38:Suppl 3:S203-S252. (In French.) 3. AFSSAPS. Letter to health professionals: warning of prescription of nitrofurantoin due to severe hepatic and pulmonary adverse events (http://www.afssaps.fr/Infos-de-securite/ Lettres-aux-professionnels-de-sante/Nitrofurantoine-et-risquede-survenue-d-effets-indesirables-hepatiques-et-pulmonaires-lorsde-traitements-prolonges-Lettre-aux-professionnels-de-sante/ (language)/fre-FR). (In French.) 4. Idem. Letter to health professionals: restriction of prescription of nitrofurantoin due to severe hepatic and pulmonary adverse events (http://www.afssaps.fr/Infos-de-securite/Lettres-auxprofessionnels-de-sante/Nitrofurantoine-Restriction-d-utilisationen-raison-d-un-risque-de-survenue-d-effets-indesirables-graveshepatiques-et-pulmonaires-Lettre-aux-professionnels-de-sante/ (language)/fre-FR). (In French.) 5. Appleyard S, Saraswati R, Gorard DA. Autoimmune hepatitis triggered by nitrofurantoin: a case series. J Med Case Rep 2010;4:311.
1. Guay DR. An update on the role of nitrofurans in the man-
agement of urinary tract infections. Drugs 2001;61:353-64.
2. De Zeeuw J, Schumacher J, Gillissen AG. Nitrofurantoin-
induced pulmonary injury. Waltham, MA: UpToDate, 2012 (http:// www.uptodate.com/contents/nitrofurantoin-induced-pulmonaryinjury). 3. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52(5):e103-e120. 4. Brumfitt W, Hamilton-Miller JMT. Efficacy and safety profile of long-term nitrofurantoin in urinary infections: 18 years’ experience. J Antimicrob Chemother 1998;42:363-71. DOI: 10.1056/NEJMc1205507
n engl j med 367;2 nejm.org july 12, 2012
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