Urological Survey

1 58
2 59
3 Geriatrics 60
4 61
5 62
6 63
7 Re: Nitrofurantoin vs Other Prophylactic Agents in Reducing Recurrent 64
8 Urinary Tract Infections in Adult Women: A Systematic Review and 65
9 Meta-Analysis 66
10 67
11 J. R. Price, L. A. Guran, W. T. Gregory and M. S. McDonagh 68
12 Division of Urogynecology and Reconstructive Pelvic Surgery, College of Medicine, and Department of Medical Informatics and Clinical
69
13 Epidemiology, Oregon Health and Science University, Portland, Oregon 70
14 Am J Obstet Gynecol 2016; 215: 548e560. doi: 10.1016/j.ajog.2016.07.040 71
15 72
16 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27457111 73
17 74
18 Editorial Comment: Nitrofurantoin is an effective antibiotic widely used in urological practice due 75
19 to its ability to concentrate in urine and its efficacy against many urinary pathogens. Inclusion of 76
20 nitrofurantoin on lists of potentially inappropriate medications in older adults has been controversial, 77
21 particularly among urologists. While nitrofurantoin is included in the Beers Criteria, it is recom- 78
22 mended to be avoided only for long-term prophylaxis due to risk of pulmonary toxicity, which has 79
23 been reported in some cases, and in individuals with severe renal impairment, which could alter 80
24 appropriate metabolism of the medication and impair adequate drug concentration in urine. 81
25 This systematic review and meta-analysis identified 12 randomized controlled clinical trials (1,063 82
26 patients) comparing nitrofurantoin to other antibiotics for long-term prophylaxis against recurrent 83
27 urinary tract infections. Of the 12 trials study quality was rated as poor in 1, good in 1 and fair in 10. 84
28 Overall efficacy was similar between nitrofurantoin and other agents. However, overall adverse 85
29 effects were increased with nitrofurantoin and most were related to the gastrointestinal system. 86
30 Based on these findings, the authors note that risks and benefits should be carefully considered in 87
31 selecting antibiotics for use in adults, particularly regarding nitrofurantoin compared to other agents. 88
32 The lack of any studies rated as very good or excellent indicates limitations of the literature available 89
33 on this topic, and the need for well designed, randomized clinical trials focused in geriatric patients to 90
34 help more definitively answer questions about long-term safety and efficacy in this population. 91
35 92
Tomas L. Griebling, MD, MPH
36 93
Suggested Reading
37 94
38 Brumfitt W, Cooper J and Hamilton-Miller JM: Prevention of recurrent urinary infections in women: a comparative trial between nitrofurantoin and 95
39 methenamine hippurate. J Urol 1981; 126: 71. 96
40 Griebling TL, Dineen MK, DuBeau CE et al: AUA white paper on the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Urol Pract 2016;
97
41 3: 102. 98
42 99
43 Re: Evaluation of the Risk of Nitrofurantoin Lung Injury and Its Efficacy in 100
44 Diminished Kidney Function in Older Adults in a Large Integrated Healthcare 101
45 102
46
System: A Matched Cohort Study 103
47 104
J. M. Santos, M. Batech, M. A. Pelter and R. L. Deamer
48 105
Kaiser Permanente Woodland Hills Medical Center and Kaiser Permanente Southern California, Research and Evaluation, Pasadena, California
49 106
50 J Am Geriatr Soc 2016; 64: 798e805. doi: 10.1111/jgs.14072 107
51 108
52 109
53 0022-5347/17/1974-0001/0 http://dx.doi.org/10.1016/j.juro.2017.01.026 110
54 THE JOURNAL OF UROLOGY® Vol. 197, 1-2, April 2017 111
Ó 2017 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC. Printed in U.S.A.
55 112
56 www.jurology.com j 1 113
57 114

Dochead: Urological Survey LIT 5.4.0 DTD
JURO14311_proof
11 January 2017
9:09 pm
EO:
 2 GERIATRICS

115 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27100576 177

116 178
117 Editorial Comment: Nitrofurantoin is widely used as antibiotic therapy for urinary tract infections 179
118 because of its strong efficacy against a wide spectrum of uropathogens and its relatively low cost. 180
119 181
However, long-term nitrofurantoin use for urinary prophylaxis has been criticized due to potential
120 182
121
respiratory complications such as pulmonary fibrosis, and diminished urinary drug concentration and 183
122 clearance in those with severe renal impairment. This finding has led to the drug being included on 184
123 lists of medications to potentially avoid in geriatric patients. 185
124 This retrospective matched cohort study examined rates of pulmonary toxicity and drug ineffec- 186
125 tiveness in patients treated for acute bacterial cystitis. Data on 13,421 patients older than 65 years 187
126 treated with nitrofurantoin were compared to matched controls provided different antibiotics at a 188
127 ratio of 1 subject to 3 controls. This method helped to increase the statistical power of the analysis. 189
128 Overall, the study found no statistically significant difference between agents regarding pulmonary 190
129 toxicity. However, for patients treated with nitrofurantoin chronic exposure significantly increased 191
130 the risk of pulmonary damage compared to short-term treatment (adjusted RR 1.53, 95% CI 192
131 193
1.04e2.24). Creatinine clearance did not appear to influence rates of treatment failure.
132 194
133
These data support current recommendations to avoid long-term nitrofurantoin due to increased 195
134 risk of pulmonary toxicity but not the suggestion to avoid nitrofurantoin in patients with poor renal 196
135 function due to lack of efficacy. Future prospective randomized trials on this topic would be useful. 197
136 However, risks could outweigh benefits, making the studies difficult to conduct in this potentially 198
137 vulnerable population. 199
138 200
139 Tomas L. Griebling, MD, MPH 201
140 Suggested Reading 202
141 203
142 Rego LL and Zimmern PE: Regular monitoring of older women on long-term nitrofurantoin prophylaxisdwhat does it mean practically? Urol Pract 2016; 3: 7. 204
143 205
144 206
145 207
146 208
147 209
148 210
149 211
150 212
151 213
152 214
153 215
154 216
155 217
156 218
157 219
158 220
159 221
160 222
161 223
162 224
163 225
164 226
165 227
166 228
167 229
168 230
169 231
170 232
171 233
172 234
173 235
174 236
175 237
176 238

Dochead: Urological Survey LIT 5.4.0 DTD
JURO14311_proof
11 January 2017
9:09 pm
EO: