Nitrofurantoin

Modifiable contributing factors to COVID-19: A comprehensive review

The devastating complications of coronavirus disease 2019 (COVID-19) result from an individual's dysfunctional immune response following the initial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Multiple toxic stressors and behaviors contribute to underlying immune system dysfunction. SARS-CoV-2 exploits the dysfunctional immune system to trigger a chain of events ultimately leading to COVID-19. The current study identifies eighty immune system dysfunction-enabling toxic stressors and behaviors (hereafter called modifiable contributing factors (CFs)) that also link directly to COVID-19. Each CF is assigned to one of the five categories in the CF taxonomy shown in Section 3.3.: Lifestyle (e.g., diet, substance abuse); Iatrogenic (e.g., drugs, surgery); Biotoxins (e.g., micro-organisms, mycotoxins); Occupational/Environmental (e.g., heavy metals, pesticides); Psychosocial/Socioeconomic (e.g., chronic stress, lower education). The current study shows how each modifiable factor contributes to decreased immune system capability, increased inflammation and coagulation, and increased neural damage and neurodegeneration. It is unclear how real progress can be made in combatting COVID-19 and other similar diseases caused by viral variants without addressing and eliminating these modifiable CFs.

Does Protocatechuic Acid Affect the Activity of Commonly Used Antibiotics and Antifungals?

The aim of this study is to evaluate the efficiency of protocatechuic acid (PCA) in enhancing the commonly used drugs used to fight against nosocomial infection. These drugs are represented by routinely used antibiotics, synthetic chemotherapeutic agents with an antimicrobial spectrum, and antifungals. Three concentrations of PCA were added to 12 types of commercial disks used for antibiotic and antifungal susceptibility and tested against bacterial and yeast strains represented by Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, and Candida albicans. The results proved that PCA increased up to 50% of the antibacterial activity, especially that of levofloxacin against Staphylococcus aureus and Escherichia coli. These formulations will lead to new drug design ideas containing a smaller amount of antibiotics with the same effectiveness.

The Bucherer-Bergs Multicomponent Synthesis of Hydantoins-Excellence in Simplicity

Hydantoins and their hybrids with other molecules represent a very important group of heterocycles because they exhibit diverse biological and pharmacological activities in medicinal and agrochemical applications. They also serve as key precursors in the chemical or enzymatic synthesis of significant nonnatural α-amino acids and their conjugates with medical potential. This review provides a comprehensive treatment of the synthesis of hydantoins via the Bucherer-Bergs reaction including the Hoyer modification but limited to free carbonyl compounds or carbonyl compounds protected as acetals (ketals) and cyanohydrins used as starting reaction components. In this respect, the Bucherer-Bergs reaction provides an efficient and simple method in the synthesis of important natural products as well as for the preparation of new organic compounds applicable as potential therapeutics. The scope and limitations, as well as a comparison with some other methods for preparing hydantoins, are also discussed.

Nanostructured perovskite type gadolinium orthoferrite decorated RGO nanocomposite for the detection of nitrofurantoin in human urine and river water samples

Nitrofurantoin (NFT) is mainly used in humans for the treatment of urinary tract infections. NFT is used as feed additives in animals, due to its broad antimicrobial activity. However, it shows more side effects on human health and the environment. Therefore low-cost, portable, and rapid sensors are necessary for the detection of NFT in real samples. Herein, we successfully developed an electrochemical sensor using a glassy carbon electrode (GCE) modified with gadolinium orthoferrite (GdFeO₃) decorated on reduced graphene oxide (RGO) nanocomposite for the detection of NFT. The facile hydrothermal method was used to synthesis a novel GdFeO₃/RGO nanocomposite, the morphological and structural characterization was confirmed by the FESEM, HRTEM, EDX, XRD, Raman, and XPS techniques. The formation mechanism of GdFeO₃/RGO nanocomposite had been discussed. The effective intercalation of the nanostructured GdFeO₃ to the RGO sheets leads to the significant enhancement in physicochemical properties such as electrical conductivity, electro-active surface area, structural stability, and electrochemical activity, which was observed from the EIS and CV experimental results. The electrochemical studies established that the developed GdFeO₃/RGO sensor was highly sensitive and selective to NFT. Moreover, the GdFeO₃/RGO sensor exhibits good sensitivity of 4.1985 μA μM^-1 cm^-2, a low detection limit (LOD) of 0.0153 µM and a linear range from 0.001 to 249 µM for NFT detection under optimized experimental conditions. In addition, the investigation of storage time on the CV response of the GdFeO₃/RGO sensor indicates superior stability. Owing to these extraordinary analytical advantages, the as-fabricated sensor was applied to detect the NFT levels in human urine and river water samples with satisfactory results.

Antimicrobial pharmacokinetics and preclinical in vitro models to support optimized treatment approaches for uncomplicated lower urinary tract infections

INTRODUCTION

Urinary tract infections (UTIs) are extremely common. Millions of people, particularly healthy women, are affected worldwide every year. One-in-two women will have a recurrence within 12-months of an initial UTI. Inadequate treatment risks worsening infection leading to acute pyelonephritis, bacteremia and sepsis. In an era of increasing antimicrobial resistance, it is critical to provide optimized antimicrobial treatment.

AREAS COVERED

Literature was searched using PubMed and Google Scholar (up to 06/2020), examining the etiology, diagnosis and oral antimicrobial therapy for uncomplicated UTIs, with emphasis on urinary antimicrobial pharmacokinetics (PK) and the application of dynamic in vitro models for the pharmacodynamic (PD) profiling of pathogen response.

EXPERT OPINION

The majority of antimicrobial agents included in international guidelines were developed decades ago without well-described dose-response relationships. Microbiology laboratories still apply standard diagnostic methodology that has essentially remained unchanged for decades. Furthermore, it is uncertain how relevant standard in vitro susceptibility is for predicting antimicrobial efficacy in urine. In order to optimize UTI treatments, clinicians must exploit the urine-specific PK of antimicrobial agents. Dynamic in vitro models are valuable tools to examine the PK/PD and urodynamic variables associated with UTIs, while informing uropathogen susceptibility reporting, optimized dosing schedules, clinical trials and treatment guidelines.

Interstitial Lung Disease Secondary to Long-Term Nitrofurantoin Use

Patient: Male, 88-year-old

Final Diagnosis: Interstitial lung disease

Symptoms: Chronic dyspnea

Medication: Nitrofurantoin

Clinical Procedure: None

Specialty: Pulmonology

Neurological and Psychiatric Adverse Effects of Antimicrobials

Antimicrobials are a widely used class of medications, but several of them are associated with neurological and psychiatric side effects. The exact incidence of neurotoxicity with anti-infectives is unknown, although it is estimated to be < 1%. Neurotoxicity occurs with all classes of antimicrobials, such as antibiotics, antimycobacterials, antivirals, antifungals and antiretrovirals, with side effects ranging from headaches, anxiety and depression to confusion, delirium, psychosis, mania and seizures, among others. It is important to consider these possible side effects to prevent misdiagnosis or delayed treatment as drug withdrawal can be associated with reversibility in most cases. This article highlights the different neurotoxic effects of a range of antimicrobials, discusses proposed mechanisms of onset and offers general management recommendations. The effects of antibiotics on the gut microbiome and how they may ultimately affect cognition is also briefly examined.

Nitrofurantoin: friend or foe?

Nitrofurantoin remains the gold standard treatment of uncomplicated cystitis as well as prophylactic treatment of recurrent urinary tract infections. Drug-induced hepatotoxicity presents in acute (3 in 1 000 000) and chronic (1 in 1500) forms. We present a patient with acute liver failure after 5 days of treatment. A 69-year-old man admitted for chronic obstructive pulmonary disease exacerbation 5 days into treatment for cystitis with nitrofurantoin. On admission he was noted to be jaundiced with elevated liver enzymes and normal international normalised ratio. Investigation for infectious, autoimmune and cholestatic causes of hepatotoxicity was negative. The patient improved after discontinuation of the drug and 10 days of methylprednisolone. There are scant data on acute liver failure in the setting of short-term nitrofurantoin administration. The mechanism of toxicity remains unclear, but is hypothesised to be an autoimmune process in which steroids may play a role in treatment. Diagnosis is one of exclusion as the only definitive method of diagnosis is rechallenge.

Complications associated with antibiotic administration: neurological adverse events and interference with antiepileptic drugs

Antibiotic use is associated with toxic effects involving the peripheral and central nervous systems and it may interfere with antiepileptic drugs, causing significant variations in their serum levels and activity. Prompt identification of neurological complications during antibiotic therapy is important in order to make appropriate modifications to medication. Characteristics of the drug and the patient, including age and underlying diseases, may favour these complications. The main aim of this study was to review the neurological adverse events that may follow antibiotic administration, the mechanisms that cause them, and the possibility of prevention and treatment. Moreover, the interference of antibiotics with serum levels and the activity of antiepileptic drugs are discussed. The results demonstrate that antibiotic-associated adverse events involving the nervous system are relatively uncommon and are only rarely severe and irreversible, although neurotoxicity has been reported for several antibiotics. Moreover, for patients receiving antiepileptic drugs, monitoring of drug serum levels to avoid the risk of toxicity or inadequate therapy is mandatory during antibiotic treatment. Areas for future research include the effects of combined antibiotic therapies as well as multiple antiepileptic drugs in study populations with an adequate sample size, including neonates and infants, patients with pharmacoresistant epilepsy and elderly patients.

How Common Are Pulmonary and Hepatic Adverse Effects in Older Adults Prescribed Nitrofurantoin?

OBJECTIVES

To determine the frequency of serious pulmonary and hepatic adverse events (AEs) in persons aged 65 and older prescribed nitrofurantoin.

DESIGN

Retrospective electronic health record (EHR) audit of nitrofurantoin prescriptions and associated AEs.

SETTING

Urban academic medical center.

PARTICIPANTS

All inpatients and outpatients aged 65 and older prescribed nitrofurantoin from January 1, 2010, to December 31, 2014.

MEASUREMENTS

The number of nitrofurantoin prescriptions and pulmonary and hepatic AEs associated with nitrofurantoin use was acquired by data extraction from EHRs.

RESULTS

Of 3,400 individuals aged 65 and older prescribed nitrofurantoin during the study period, 641 were identified as possibly having one of five targeted symptoms or disease complications (pulmonary and hepatic) associated with nitrofurantoin. After a detailed chart audit, 89% were deemed to have no adverse reaction, 7% had a minor side effect or allergy, and 3.9% met criteria for suspicion of a nitrofurantoin-induced AE, five of whom were rated as being highly suspicious for nitrofurantoin toxicity; four of the five were identified with pulmonary toxicity and one with hepatotoxicity. Four of five of these individuals used nitrofurantoin chronically.

CONCLUSION

Nitrofurantoin was prescribed for 3,400 individuals aged 65 and older during the 5-year study period. Serious side effects appeared to be uncommon, but chronic use appeared to be at greater risk.

Unrecognized Interstitial Lung Disease as a Result of Chronic Nitrofurantoin Use

Drug-induced interstitial lung disease is a rare condition attributed to several medications, including antimicrobial agents such as amphotericin B, anti-inflammatory agents such as methotrexate, biologic agents such as bevacizumab, and cardiovascular agents and chemotherapeutic agents. We describe the case of a 73-year-old female who developed interstitial lung disease following chronic use of nitrofurantoin for a urinary tract infection (UTI). The patient was taking nitrofurantoin 100 mg capsules twice daily for approximately 3 years. She presented to the hospital with complaints of a persistent dry cough that started 2 years previously. Her chest radiograph revealed bilateral reticular opacities and some atelectasis. Computed tomography of the chest demonstrated development of subpleural reticular opacities with minimal honeycombing. The patient had a severe restrictive defect on her pulmonary function tests, with a significant reduction in her carbon monoxide diffusion capacity. Multiple infectious disease and autoimmune tests were negative. Utilizing the algorithm of Naranjo (score of 9), it was determined that chronic use of nitrofurantoin was the definite cause of the patient’s interstitial lung disease. Nitrofurantoin was discontinued and she was treated with oxygen and started on an oral steroid, both of which were continued permanently once discharged. Upon discharge, the patient was maintained on 5 L of oxygen at rest and 10 L of oxygen when ambulating. Unfortunately, her lung disease ultimately resulted in her demise several months after her diagnosis. This case report illustrates the importance of rapid recognition of drug-induced lung injuries and discontinuation of the offending agent.

Nitrofurantoin's efficacy and safety as prophylaxis for urinary tract infections: a systematic review of the literature and meta-analysis of controlled trials

OBJECTIVES

Nitrofurantoin has been used for the prevention of urinary tract infection (UTI) for over 60 years. We conducted a systematic review and meta-analysis to assess its efficacy and safety in the prophylaxis of UTI.

METHODS

We performed a systematic review of all controlled trials in humans assessing nitrofurantoin for UTI prophylaxis published from 1946 to 2015. We further reviewed population-level cohort studies evaluating nitrofurantoin's toxicity. Meta-analyses assessing efficacy and adverse events were conducted on controlled trials.

RESULTS

Twenty-six controlled trials including 3052 patients fulfilled entry criteria for the systematic review and meta-analysis on efficacy and toxicity, and 16 population-level cohort studies were identified for review of toxicity. Overall quality was poor, with all studies at increased risk for various biases. When compared with no prophylaxis, nitrofurantoin is effective in the prevention of UTI (risk ratio 0.38 in favour of nitrofurantoin, 95% CI 0.30-0.48). Its prophylactic efficacy is superior to that of methenamine hippurate and comparable to that of other antibacterials. Compared with patients receiving other antibacterials, those receiving nitrofurantoin had an increased risk of 2.24 (95% CI 1.77-2.83) for a non-severe adverse effect. In all controlled trials, only one patient experienced a severe adverse effect (interstitial pneumonia). Cohort studies reported severe adverse effect frequencies of 0.02-1.5 per 1000 nitrofurantoin users.

CONCLUSIONS

Nitrofurantoin is effective in the prevention of UTI. Its use may be associated with increased non-severe adverse effects; severe adverse effects occur infrequently. The risk of severe toxicity seems to increase with the duration of nitrofurantoin prophylaxis.

Nitrofurantoin-induced interstitial pneumonitis: albeit rare, should not be missed

Interstitial lung disease (ILD) is a rare adverse effect of nitrofurantoin and can range from benign infiltrates to a fatal condition. Nitrofurantoin acts via inhibiting the protein synthesis in bacteria by helping reactive intermediates and is known to produce primary lung parenchymal injury through an oxidant mechanism. Stopping the drug leads to complete recovery of symptoms. In this report, we present a case of nitrofurantoin-induced ILD with the recovery of symptoms and disease process after stopping the drug.

Nitrofurantoin revisited: a systematic review and meta-analysis of controlled trials

OBJECTIVES

Nitrofurantoin's use has increased exponentially since recent guidelines repositioned it as first-line therapy for uncomplicated lower urinary tract infection (UTI). We conducted a systematic review and meta-analysis to assess nitrofurantoin's efficacy and toxicity in the treatment of lower UTI.

METHODS

We performed a systematic review of all human controlled clinical trials published from 1946 to 2014 and assessing short-term (≤14 days) nitrofurantoin for lower UTI. Meta-analyses assessing efficacy and adverse events were conducted on randomized trials.

RESULTS

Twenty-seven controlled trials including 4807 patients fulfilled entry criteria; most were conducted between the 1970s and 1990s and were at increased risk for various biases. Nitrofurantoin appears to have good clinical and microbiological efficacy for UTI caused by common uropathogens, with clinical cure rates varying between 79% and 92%. The most methodologically robust studies surveyed indicate overall equivalence between nitrofurantoin when given for 5 or 7 days and trimethoprim/sulfamethoxazole, ciprofloxacin and amoxicillin. Meta-analyses of randomized controlled trials confirmed equivalence in clinical cure, but indicated a slight advantage to comparator drugs in microbiological efficacy (risk ratio 0.93, 95% CI 0.89-0.97). If given for only 3 days, nitrofurantoin's clinical efficacy was diminished (61%-70%). Toxicity was infrequent (5%-16% in the 17 reporting studies), mild, reversible and predominantly gastrointestinal; meta-analyses confirmed no difference between nitrofurantoin and comparators. Hypersensitivity reactions such as pulmonary fibrosis and hepatotoxicity were not observed. Acquisition of resistance to nitrofurantoin is still relatively rare.

CONCLUSIONS

When given short term for lower UTI, nitrofurantoin has good clinical and microbiological efficacy; toxicity is mild and predominantly gastrointestinal.

Antibiotic induced liver injury: what about children?

Antimicrobial agents are important causes of drug-induced liver injury. They are responsible for about 45% of cases of drug hepatotoxicity. Hepatic damage mechanisms are intrinsic or idiosyncratic. Usually, antibiotics are responsible for idiosyncratic toxicity. This review summarizes the rate of incidence and clinical features of hepatotoxicity due to antibiotics and chemotherapics, with particular attention to data regarding paediatric population. Liver injury features have been systematically evaluated for the most commonly administered antibiotics and chemotherapics in adults, even though there is little information about other widely used compounds, as cephalosporine or clarithromycin, and about antibiotics active against multi-resistant bacteria, as carbapenems, vancomycin, clindamycin, and linezolid. By contrast, there is an abundance of case reports in paediatrics, but very few structured studies have been carried out in children. Children are an important class of antibiotic users, with specific metabolic characteristics, so more studies on them should be carried out.

Role of Old Antibiotics in the Era of Antibiotic Resistance. Highlighted Nitrofurantoin for the Treatment of Lower Urinary Tract Infections

Bacterial infections caused by antibiotic-resistant isolates have become a major health problem in recent years, since they are very difficult to treat, leading to an increase in morbidity and mortality. Nitrofurantoin is a broad-spectrum bactericidal antibiotic that, through a complex mode of action which is not completely understood, affects both Gram-negative and Gram-positive bacteria. Nitrofurantoin has been used successfully for a long time for the prophylaxis and treatment of acute lower urinary tract infections in adults, children and pregnant women, but the increased emergence of antibiotic resistance has made nitrofurantoin a suitable candidate for the treatment of infections caused by multidrug-resistant pathogens. Here, we review the mechanism of action, antimicrobial spectrum, pharmacology and safety profile of nitrofurantoin. We also investigate the therapeutic use of nitrofurantoin, including recent data which highlight its role in the management of community urinary tract infection, especially in cases of multidrug-resistant isolates, in which oral active antimicrobials are limited resources nowadays.

Lipid peroxidation, detoxification capacity, and genome damage in mice after transplacental exposure to pharmaceutical drugs

Data on genome damage, lipid peroxidation, and levels of glutathione peroxidase (GPX) in newborns after transplacental exposure to xenobiotics are rare and insufficient for risk assessment. The aim of the current study was to analyze, in an animal model, transplacental genotoxicity, lipid peroxidation, and detoxification disturbances caused by the following drugs commonly prescribed to pregnant women: paracetamol, fluconazole, 5-nitrofurantoin, and sodium valproate. Genome damage in dams and their newborn pups transplacentally exposed to these drugs was investigated using the in vivo micronucleus (MN) assay. The drugs were administered to dams intraperitoneally in three consecutive daily doses between days 12 and 14 of pregnancy. The results were correlated, with detoxification capacity of the newborn pups measured by the levels of GPX in blood and lipid peroxidation in liver measured by malondialdehyde (HPLC-MDA) levels. Sodium valproate and 5-nitrofurantoin significantly increased MN frequency in pregnant dams. A significant increase in the MN frequency of newborn pups was detected for all drugs tested. This paper also provides reference levels of MDA in newborn pups, according to which all drugs tested significantly lowered MDA levels of newborn pups, while blood GPX activity dropped significantly only after exposure to paracetamol. The GPX reduction reflected systemic oxidative stress, which is known to occur with paracetamol treatment. The reduction of MDA in the liver is suggested to be an unspecific metabolic reaction to the drugs that express cytotoxic, in particular hepatotoxic, effects associated with oxidative stress and lipid peroxidation.

Microsomal oxidative stress induced by NADPH is inhibited by nitrofurantoin redox biotranformation

Nitrofurantoin is used in the antibacterial therapy of the urinary tract. This therapy is associated with various adverse effects whose mechanisms remain unclear. Diverse studies show that the nitro reductive metabolism of nitrofurantoin leads to ROS generation. This reaction can be catalyzed by several reductases, including the cytochrome P450 (CYP450) reductase. Oxidative stress arising from this nitro reductive metabolism has been proposed as the mechanism underlying the adverse effects associated with nitrofurantoin. There is, however, an apparent paradox between these findings and the ability of nitrofurantoin to inhibit lipid peroxidation provoked by NADPH in rat liver microsomes. This work was aimed to show the potential contribution of different enzymatic systems to the metabolism of this drug in rat liver microsomes. Our results show that microsomal lipid peroxidation promoted by NADPH is inhibited by nitrofurantoin in a concentration-dependent manner. This suggests that the consumption of NADPH in microsomes can be competitively promoted by lipid peroxidation and nitrofurantoin metabolism. The incubation of microsomes with NADPH and nitrofurantoin generated 1-aminohidantoin. In addition, the biotransformation of a classical substrate of CYP450 oxidative system was competitively inhibited by nitrofurantoin. These results suggest that nitrofurantoin is metabolized through CYP450 system. Data are discussed in terms of the in vitro redox metabolism of nitrofurantoin.

Reversible interstitial lung disease with prolonged use of nitrofurantoin: Do the benefits outweigh the risks?

We describe the case summary of a 70-year-old man diagnosed with interstitial lung disease due to prolonged nitrofurantoin therapy. Despite honeycombing confirmed by computed tomography of the thorax, symptoms and radiographic findings disappeared within 1 month after withdrawal of nitrofurantoin. The case highlights the fact that nitrofurantoin-induced lung disease may run a benign course and respond favorably despite radiographic evidence of established lung fibrosis (honey combing).

Neurotoxic effects associated with antibiotic use: management considerations

The clinical manifestations of antibiotic-induced neurotoxic effects, the underlying mechanisms and management strategies have been reviewed. PubMed and OVID searches (January 1960-June 2010) were conducted using search terms such as antibiotics, side effects, neurotoxicity and encephalopathy which yielded approximately 300 articles. All relevant case reports, case series, letters and retrospective reviews describing neurotoxic effects and those discussing mechanisms of neurotoxicity were included. Antibiotic-induced neurotoxic side effects can have a myriad of neurologic presentations. Patients with prior central nervous system (CNS) disease, renal insufficiency and advanced age may be particularly vulnerable. Treatment consists of discontinuation of the offending agent, use of antiepileptic drugs in the case of seizures or status epilepticus and haemodialysis in certain cases. The risk of CNS toxicity may be reduced via dosage adjustments in high risk populations. Awareness of the potential neurotoxic clinical manifestations of various antibiotics and high degree of vigilance in critically ill patients is essential in identifying a potentially serious, though reversible complications of antibiotic therapy particularly with the advent of newer antimicrobial agents.

Autoimmune hepatitis triggered by nitrofurantoin: a case series

INTRODUCTION

Drugs can occasionally trigger the onset of autoimmune liver disease.

CASE PRESENTATION

Three Caucasian women (aged 65, 42 and 74 years old) who were receiving long-term nitrofurantoin as prophylaxis against recurrent urinary tract infections developed hepatitic liver disease. Serological auto-antibody profiles and liver histology appearances were consistent with autoimmune hepatitis. Two of the patients presented with jaundice, and one required a prolonged hospital admission for liver failure. In all three patients nitrofurantoin was withdrawn, and long-term immunosuppressive therapy with prednisolone and azathioprine or mycophenolate was given. The patients responded well, with liver biochemistry returning to normal within a few months.

CONCLUSIONS

Although nitrofurantoin rarely causes autoimmune hepatitis, this antimicrobial is increasingly used as long-term prophylaxis against recurrent urinary tract infection. General practitioners and urologists who prescribe long-term nitrofurantoin therapy should be aware of this adverse effect.

Hepatotoxicity of antibacterials: Pathomechanisms and clinical

Drug-induced hepatotoxicity is a frequent cause of liver disease and acute liver failure, particularly in patients treated with multiple drugs. Several antibacterial drugs have the potential to cause severe liver injury and failure. This article aims to increase the awareness and understanding of drug induced liver injury (DILI) due to antibacterial drugs. It reviews the pattern of antibacterial DILI and provides details on molecular mechanisms and toxicogenomics, as well as clinical data based on epidemiology studies. Certain antibacterial drugs are more frequently linked to hepatotoxicity than others. Therefore, the hepatotoxic potential of tetracyclines,sulfonamides, tuberculostatic agents, macrolides, quinolones,and beta-lactams are discussed in more detail. Efforts to improve the early detection of DILI and the acquisition of high-quality epidemiological data are pivotal for increased patient safety.

Antibiotic prophylaxis in the management of vesicoureteral reflux

Antibiotic prophylaxis has been, since 1960s, one of the management options in treating vesicoureteral reflux. The purpose of this review article is to provide a concise overview of the rational for antiobiotic prophylaxis and to discuss the various agents used. Some of the current controversies regarding use of antibiotics for reflux will also be presented.

Nitrofurantoin neuropathy: a forgotten adverse effect

BACKGROUND

Nitrofurantoin is a widely prescribed antibiotic used to treat uncomplicated lower urinary tract infections. Unknown in the obstetric and gynecologic literature is the complication of peripheral neuropathy as an adverse effect.

CASE

We describe a patient who developed a severe sensory neuropathy after taking nitrofurantoin intermittently and then continuously over a 7-year period. She recovered almost completely after its discontinuation.

CONCLUSION

Peripheral neuropathy is a rare and potentially reversible adverse effect, unreported in the obstetric and gynecologic literature, and commonly unrecognized by physicians who prescribe it.

[Nitrofurantoin-induced lung disease: about two cases]

INTRODUCTION

Nitrofurantoin is commonly used in the treatment of urinary tract infection and may cause a potential severe complication: interstitial lung diseases.

CASE REPORT

A 78-year-old and an 87-year-old woman treated with nitrofurantoin since respectively 10 months and 6 years developed cough and dyspnea. Antibiotics were ineffective and interstitial lung disease was found. Nitrofurantoin's stopping allowed a clinical and radiological improvement.

CONCLUSION

A good medical supervision is important when nitrofurantoin is prescribed for a long time. The treatment has to be stopped when respiratory symptoms appear to allow an improvement of the symptoms.

ADVERSE REACTIONS OF NITROFURANTOIN, TRIMETHOPRIM AND SULFAMETHOXAZOLE IN CHILDREN

PURPOSE

Many children with urological disease require long-term treatment with antibiotics. In many cases the choice of medical instead of surgical management hinges on the implied safety of certain drugs. Recently some groups have advocated subureteral injection procedures to avoid long-term antibiotics for low grade reflux. We present a concise and relevant review on the use and adverse reactions of nitrofurantoin, trimethoprim and sulfamethoxazole in children.

MATERIALS AND METHODS

We reviewed the literature regarding the safety and toxicity of these drugs. Information regarding absorption, excretion and dosing was also gathered to explain better the mechanisms of toxicity.

RESULTS

Adverse reactions in children reported in the literature related to nitrofurantoin are gastrointestinal disturbance (4.4/100 person-years at risk), cutaneous reactions (2% to 3%), pulmonary toxicity (9 patients), hepatoxicity (12 patients and 3 deaths), hematological toxicity (12 patients), neurotoxicity and an increased rate of sister chromatid exchanges. Adverse reactions in children related to trimethoprim/sulfamethoxazole are almost exclusively due to the sulfamethoxazole component, including cutaneous reactions (1.4 to 7.4 events per 100 person-years at risk), hematological toxicity (0% to 72% of patients) and hepatotoxicity (5 patients). The majority of adverse reactions were found in children on full dose therapy and not prophylaxis.

CONCLUSIONS

The use of nitrofurantoin, trimethoprim and sulfamethoxazole is safe in children for long-term prophylactic therapy. The antibiotic safety issue should not be misconstrued as an argument for surgical therapy, whether minimally invasive or not. Adverse reactions exist to these medicines but they are less common than seen in adults, presumably because of the lower dose used for therapy, and the lack of significant comorbidities and drug interactions in children. Serious side effects are extremely rare and most are reversible by discontinuing therapy. The extremely low potential for significant adverse reactions should be discussed with parents.

Hepatotoxicity of antibiotics and antifungals

Hepatotoxicity associated with any antibiotic is rare. With the wide-spread use of antimicrobial agents, however, hepatic injury is not an infrequent occurrence. Penicillins remain a widely used class of antimicrobials with a well defined record of low hepatotoxicity. The combination of clavulanate with amoxicillin may be associated with the greatest risk for liver injury from any antimicrobial agent. Significant hepatotoxicity also may occur with sulfamethoxazole/ trimethoprim and combination regimens used to treat tuberculosis. An autoimmune-like hepatitis may result from minocycline or nitrofurantoin exposure and most often resolves with cessation of therapy. Treatment with high doses of tetracycline and oxacillin may be associated with severe hepatotoxicity. Early suspicion of hepatocellular injury in the setting of antimicrobial exposure should prompt cessation of therapy and avoidance of rechallenge.

An update on the role of nitrofurans in the management of urinary tract infections

There have been few recent reviews of the nitrofurans in the literature, and none include recently available data on the use of nitrofurazone (nitrofural) in the prevention of catheter-associated urinary tract infection (CAUTI). Nitrofurazone and nitrofurantoin are the only nitrofurans that have become established in clinical use in the 20th century. These 2 nitrofurans have remained clinically useful against a wide spectrum of gram-positive and gram-negative bacteria, including many strains of common urinary tract pathogens. Today, the primary use of nitrofurantoin is as an oral antibacterial treatment for genitourinary infections. Nitrofurazone is primarily used as a topical antibacterial agent in burns and skin grafts and recently was approved for the prophylaxis of CAUTI. The recent development of a nitrofurazone-impregnated catheter as a novel modality in the prevention of CAUTI reflects a renewed interest in the effectiveness of nitrofurans. In an era when concern about bacterial resistance to many anti-infective agents is growing, the nitrofurans have continued to be active against organisms that have developed resistance to antibacterials. The presence of multiple mechanisms of action for the nitrofurans might be expected to reduce the ability of bacteria to develop resistance. Considering that an emergence of resistance to the nitrofurans has not appreciably occurred after several decades of clinical use, the nitrofurans may be unique among common antibacterial agents in this regard.

Nitrofurantoin-induced immune-mediated lung and liver disease

A 60-year-old woman with multiple sclerosis and recurrent urinary tract infections (UTI) was evaluated for the recent onset of a dry cough, dyspnea on exertion, and jaundice. Investigation demonstrated interstitial lung disease with bilateral infiltrates and unilateral effusion, as well as a severe chronic active hepatitis with marked fibrosis. Other notable features were positive antinuclear antibodies and anti-smooth-muscle antibodies and the absence of any possible cause except for nitrofurantoin treatment (Macrodantin, 100 mg/day), which the patient had been taking for the previous 3 years as a prophylactic measure against UTI. The patient died of pneumococcal septicemia less than 30 days after presentation. Pulmonary or hepatic injury caused by nitrofurantoin treatment is rare; their combined occurrence is hardly ever described. Combined drug-induced pulmonary and hepatic toxicity is reviewed and should be considered early in the differential diagnosis to allow reversibility and avoid serious outcomes.

Nitrofurantoin-induced hepatotoxicity mediated by CD8+ T cells

Nitrofurantoin is a synthetic nitrofuran commonly used for the treatment and prophylaxis of urinary tract infections. We describe the case of a 75-yr-old woman who was taking nitrofurantoin as prophylaxis against recurrent urinary tract infections, and who subsequently developed pulmonary and hepatic toxicity. We postulate that a breakdown product of the drug or the drug itself complexed to an endogenous peptide is presented by the class I HLA antigen on the hepatocyte cell membrane, inducing cytotoxic T cell activation and subsequently, hepatocyte death.

Nitrofurantoin rechallenge and recurrent toxicity

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Antibacterial-induced hepatotoxicity. Incidence, prevention and management

Hepatotoxic reactions to antibacterials are rare, occurring with an estimated frequency of between 1 and 10 per 100,000 drug prescriptions for most antibacterials. Although many antibacterial-induced hepatotoxic reactions have a characteristic clinical and biochemical pattern e.g. cholestatic hepatitis (flucloxacillin) or fatty liver (tetracycline), many can also present with a variety of clinicopathological patterns e.g. nitrofurantoin is associated with the development of acute hepatitis, granulomatous hepatitis and chronic active hepatitis. Almost all reactions are idiosyncratic, with no diagnostic laboratory tests to aid the diagnosis. Early diagnosis is essential and requires a vigilant physician to elicit a detailed drug history. Although the outcome is usually good when the offending antibacterial is withdrawn, morbidity may persist for years and fatalities have occurred, particularly when there is a delay in recognising the hepatotoxic antibacterial. There is no specific treatment for antibacterial-induced hepatotoxicity other than withdrawing the implicated drug. For severe disease, however, liver transplantation should be considered.

The use of human lung slices in toxicology

1. Successful use of agar-filled precision-cut rat lung slices in dynamic organ culture prompted the use of this technology with human lung. 2. The larger tissue mass of a human lung required that the trachea be cannulated with a balloon catheter and subsequently inflated with 4 liters of warm agar/medium mixture and then cooled before being precision-cut into 500 microns thick slices. 3. To characterize the human lung slices, viability and the effects of acrolein and nitrofurantoin were assessed over a period of 24 h using protein synthesis and nonprotein sulfhydryl content. 4. Control human lung slices synthesized protein at a linear rate and maintained a stable nonprotein sulfhydryl content for 24 h. 5. Slices incubated with acrolein exhibited no significant decrease in protein synthesis or nonprotein sulfhydryl levels until 24 h. 6. Incubation with nitrofurantoin exhibited a definite time- and dose-dependent inhibition of protein synthesis, and depletion of the cellular thiol pool. 7. These results indicate that this human lung tissue slice system may be used as an in vitro model to identify and screen pneumotoxicants.

Hepatitis due to nitrofurantoin

OBJECTIVE

To report three cases of hepatitis related to the use of nitrofurantoin.

CLINICAL FEATURES

Two patients who had been taking nitrofurantoin for several years, presented with severe liver failure. In both, the drug had been continued despite evidence of liver injury. A third patient presented with acute hepatitis after six weeks of nitrofurantoin therapy.

INTERVENTION AND OUTCOME

One of the patients with liver failure died and the other underwent a successful liver transplantation. The third patient recovered after withdrawal of the drug.

CONCLUSION

These cases emphasise the potential for serious hepatic reactions with nitrofurantoin, the danger of continuing the drug once liver damage has occurred and the need for careful monitoring of liver function during long-term therapy.