Better UTI resolution with 5-day nitrofurantoin over single-dose fosfomycin

Originally Published By 2 Minute Medicine®. Reused on Infectious Disease Advisor with permission.
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1. In this randomized controlled trial, women with uncomplicated urinary tract infections receiving 5-days of nitrofurantoin experienced increased clinical and microbiologic resolution at 28 days compared to single-dose fosfomycin.

2. Adverse events were rare, mostly gastrointestinal, and not significantly different between groups.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Use of nitrofurantoin and fosfomycin has increased tremendously for uncomplicated urinary tract infections (UTIs). However, data on their comparative efficacy in high-quality studies is lacking. This randomized controlled trial compared 5 days of nitrofurantoin to single-dose fosfomycin for uncomplicated UTI. The women who received nitrofurantoin had a significantly higher clinical and microbiologic resolution of symptoms with no difference in adverse events.

Though this study suggests a longer course of nitrofurantoin is superior to single-dose fosfamycin, some limitations should be acknowledged. This study was an open-label design, and so women were aware of the antibiotics they were taking which could confound the subjective clinical endpoint of whether symptoms had resolved. Additionally, different laboratories handled the urine cultures, and this lack of centralization could introduce differences in how microbiology was performed.

Click to read the study, published in JAMA

Relevant Reading: Antimicrobial agents for treating uncomplicated urinary tract infection in women

In-Depth [randomized controlled trial]: This study recruited 513 non-pregnant women with lower UTI symptoms, a positive urinary dipstick, and no known colonization or previous infection with an organism resistant to the study antibiotics. Recruitment was multinational and in an open-label fashion, they were randomized to oral nitrofurantoin three times a day for 5 days of a single dose of oral fosfomycin. At 28 days of follow-up, clinical resolution occurred in 70% in the nitrofurantoin group vs. 58% in the fosfomycin group (difference 12%; CI95 4-21%). At the same time point, microbiologic resolution occurred in 74% with nitrofurantoin vs. 63% with fosfomycin (difference 11%; CI95 1-20%). Adverse events were uncommon, mostly nausea and diarrhea, but not significantly different between groups.

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