The use of nitrofurantoin in the treatment of acute cystitis helps preserve the activity of fluoroquinolones

According to the guidelines of the American Society for Infectious Diseases, the standard treatment recommended for uncomplicated acute cystitis in women is a 3-day course of trimethoprim / sulfamethoxazole (cotrimoxazole). The alternative therapy is nitrofurantoin for 7 days. However, there is little evidence of the effectiveness of nitrofurantoin (furadonin) in the treatment of acute uncomplicated cystitis for less than 7 days. The factual use of this drug is becoming increasingly important in relation to the increasing resistance of uropathogens to cotrimoxazole.

To compare the efficacy and tolerability of a 5-day course of nitrofurantoin with a 3-day course of cotrimoxazole in the treatment of uncomplicated acute cystitis, as well as to assess the effectiveness of cotrimoxazole in the treatment of cystitis caused by uropathogens insensitive to this drug, an open comparative randomized study was conducted. The researchers randomized 338 women aged 18 to 45 with symptoms of acute cystitis and a urine culture test with bacteriuria of at least 102 CFU / ml in two groups. In the first group, patients received cotrimoxazole 1 double-dose tablet (960 mg) 2 times a day for 3 days, in the second - nitrofurantoin 100 mg 2 times a day for 5 days. The groups were comparable by age (21 years on average), marital status, race, incidence of urinary tract infections, sexual activity and use of spermicides in the past month.

The exclusion criteria were pregnancy, lactation, diabetes mellitus, lack of constant contraception, anatomical abnormalities of the urinary tract, allergies to the drugs studied and current or recent use of antibiotics.

After excluding women with a negative urine culture who did not visit the clinic for follow-up visits, data were available on 148 of 167 women in the cotrimoxazole group and 160 of 171 women in the nitrofurantoin group.

The main objective of the study was to assess the frequency of clinical recovery 30 days after treatment, the additional clinical and microbiological efficacy of treatment for 5 to 9 days after the end of treatment, and for women treated with cotrimoxazole, the frequency of clinical recovery based on the sensitivity of the isolated microorganisms to this drug.

Clinical ineffectiveness has been viewed as the need to prescribe antibiotics for persistent or new symptoms of UTI or pyelonephritis (pain in the spine).

Microbiological healing was considered to be the presence of less than 105 CFU / ml of uropathogens during urine culture and a decrease in the number of uropathogens corresponding to at least one unit on a logarithmic scale compared to the initial visit (s 'there were no symptoms); with persistent or recurring symptoms of UTI, less than 102 CFU / ml uropathogenic in urine.

Cultures were considered to be contaminated when 3 or more pathogens were detected.

As agents responsible for UTI, E. coli (82%), E. coli in combination with another uropathogenic agent (4%), Staphylococcus saprophyticus (8%), as well as enterococci, Klebsiella spp., Proteus mirabilis, Enterobacter spp. or group B streptococci (1-3% each).

14% of uropathogens (12% E. coli and 23% of other microorganisms) were moderately sensitive or resistant to cotrimoxazole.

The clinical cure rate between the groups did not differ significantly (117 out of 148 [79%] vs 134 out of 160 [84%] for cotrimoxazole and nitrofurantoin, respectively) (mean difference -5% , 95% CI - 13-4%). The clinical and microbiological results of the disease on day 5–9 after treatment also did not differ significantly (90% vs 90% and 91% vs 92% for cotrimoxazole and nitrofurantoin, respectively)

In the group of patients receiving cotrimoxazole, clinical recovery was more often in the presence of sensitive pathogens (110 out of 131 [84%] vs 7 out of 17 [41%] in the group with insensitive uropathogens; p less than 0.001) and the incidence of microbiological healing was also higher in the subgroup of patients infected with cotrimoxazole-sensitive strains (123 of 127 [97%] vs 11 out of 17 [65%]; p less than 0.001).

Of the 3 women with nitrofurantoin resistant pathogens in the nitrofurantoin group, only 1 had clinical and microbiological ineffectiveness.

The incidence of adverse events was comparable in the two groups (31% with cotrimoxazole and 28% with nitrofurantoin), the most common being nausea or diarrhea, headache, slight signs of change in well-being and vaginal itching. Due to the development of adverse events, treatment was discontinued in 1% of patients in the cotrimoxazole group and 2% in the nitrofurantoin group.

A five-day course of nitrofurantoin in clinical and microbiological efficacy is equivalent to a three-day course of cotrimoxazole in acute uncomplicated cystitis, following which nitrofurantoin should be considered an effective antimicrobial drug that helps maintain activity fluoroquinolones for the treatment of this category of patients.