© 2008 THE AUTHORS 1634 JOURNAL COMPILATION © 2 0 0 8 B J U I N T E R N A T I O N A L | 1 0 2 , 1 6 3 4 – 1 6 3 7 | doi:10.1111/j.1464-410X.2008.07809.x 2008 The Authors. Journal compilation 2008 BJU International Original Article NITROFURANTOIN FOR UTI KASHANIAN et al. Nitrofurantoin: the return of an old friend in the wake of growing resistance James Kashanian, Payam Hakimian, Michael Blute Jr, Jean Wong, Himmansh Khanna, Gilbert Wise and Ridwan Shabsigh Division of Urology, Maimonides Medical Center, Brooklyn, NY, USA Accepted for publication 28 March 2008 from 2003 to 2007, taken from a community-based institutional hospital in Brooklyn, NY, USA. RESULTS In all, 10 417 cultures grew Escherichia coli from 2003 to 2007. Overall, from 2003 to 2007, 95.6% of E. coli urine isolates were susceptible to nitrofurantoin, with an average 2.3% resistance rate. By contrast, E. coli uropathogens had a mean 75.6% and 75.9% susceptibility and 24.2% and 24% resistance rate to both ciprofloxacin and levofloxacin, respectively. Co-trimoxazole (trimethoprim/sulfamethoxazole; ‘TMP/ SMX’) had a mean 29% resistance rate to E. coli over the same 5-year period. CONCLUSIONS We consider that nitrofurantoin is a good fluoroquinolone-sparing alternative to co- trimoxazole; this study shows that nitrofurantoin is bactericidal to a mean of 95% of E. coli UTIs. Nitrofurantoin also has a resistance rate of 2.3%, by contrast to the quinolones (ciprofloxacin and levofloxacin), with resistant rates of ≈ 24%, and Co- trimoxazole, with a resistant rate of 29%. Nitrofurantoin is an acceptable treatment for uncomplicated UTIs and should now be considered the first-line treatment. A reconsideration of UTI treatment guidelines might now be appropriate. KEYWORDS urinary tract infection, antibiotics, nitrofurantoin, resistance, Escherichia coli Study Type – Therapy (individual cohort study) Level of Evidence 2a OBJECTIVE To re-evaluate the first- and second-line therapies for treating uncomplicated urinary tract infection (UTI), as although fluoroquinolones are commonly used for this purpose, its level of use is thought to be inappropriately excessive and will eventually have a detrimental impact; thus we hypothesise that nitrofurantoin might be the best choice for this indication, due to its low frequency of use and its high susceptibility rate in common UTI pathogens. MATERIALS AND METHODS We retrospectively analysed antimicrobial susceptibility patterns of urinary isolates INTRODUCTION Arguably the most profound advance in the management of UTIs has been the introduction of antimicrobial agents. Since the discovery of sulfanilamide in the 1930s for treating cystitis, antibiotics have been the mainstay of treatment for cystitis and pyelonephritis [1]. Over the past 70 years, the use of antimicrobials for treating UTI has developed, during which various antibiotics have come in and out of favour. For instance, due to the severity of side-effects associated with sulfanilamide, its medicinal practicality was rightly limited [2]. It was not until 1953 that a truly safe and effective treatment for uncomplicated UTI was introduced, i.e. nitrofurantoin, followed by the use of quinolones in the 1960s, then β -lactams and trimethoprim/ sulfamethoxazole (‘TMP/SMX’, co-trimoxazole) in the 1970s [1]. In the 1970s and 1980s amoxicillin was regarded as empirical treatment for UTI. Unfortunately, the pervasive use of amoxicillin for this indication during that time rendered it useless, due to increasing resistance [1]. In the 1990s the Infectious Disease Society of America affirmed the use of co-trimoxazole as the first-line agent for treating of acute cystitis in women, where the resistance is < 10–20% [3]. Since then, the increased use of co-trimoxazole in the 1990s led to high levels of resistance in many parts of the USA and worldwide [1,4,5]. This more recent wave of widespread resistance to co-trimoxazole and amoxicillin has led to the use of fluoroquinolones for the empirical treatment of UTI. This recent shift in antibiotic treatment has alarmed many physicians. In a survey of physicians nationwide, most felt that the level of fluoroquinolone use in treatment of cystitis is inappropriately excessive and will eventually have a detrimental impact on society [6]. A major concern to physicians is the possibility of rapid cross-resistance between quinolones. In a multi-continent study there was a 25% increase in resistance of UTI pathogens to norfloxacin in the brief period that it was available [5]. Similarly, there was 15% and 18% resistance of Escherichia coli to ciprofloxacin in Europe and in Latin America, respectively [7]. Although resistance to ciprofloxacin is higher in both Europe and Latin America, the resistance rates reported in the USA are alarming. While certain drugs continue to be BJUI BJU INTERNATIONAL