What are alternative treatments for female urinary tract infections (UTIs) when Macrobid (nitrofurantoin) is not available?

From the Guidelines

For female urinary tract infections (UTIs) when Macrobid (nitrofurantoin) is unavailable, the most recommended alternative antibiotic is Fosfomycin trometamol, which can be given as a single 3-gram dose, as suggested by the European Association of Urology guidelines 1. This recommendation is based on the latest guidelines, which prioritize the use of Fosfomycin trometamol due to its minimal resistance and propensity for collateral damage. Some key points to consider when choosing an alternative antibiotic include:

• Patient allergies and tolerance to the medication
• Local resistance patterns and the prevalence of antibiotic-resistant uropathogens
• Pregnancy status and kidney function, as some antibiotics may be contraindicated in these cases
• The severity of the UTI and the presence of any complicating factors, such as pyelonephritis or urological abnormalities. Other alternative antibiotics that may be considered include:
• Trimethoprim-sulfamethoxazole, which is typically prescribed as one double-strength tablet (160mg/800mg) twice daily for 3 days, but its use should be guided by local resistance patterns and patient factors 1
• Cephalexin, which can be used at 500mg four times daily for 5-7 days, but its efficacy and safety profile may vary depending on the specific patient population and local resistance patterns.

From the FDA Drug Label

Fosfomycin tromethamine granules for oral solution is indicated only for the treatment of uncomplicated urinary tract infections (acute cystitis) in women due to susceptible strains of Escherichia coli and Enterococcus faecalis. For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris

Alternative treatments for female UTI where Macrobid is not available include:

• Fosfomycin (PO) 2, for uncomplicated urinary tract infections (acute cystitis) in women due to susceptible strains of Escherichia coli and Enterococcus faecalis
• Trimethoprim-sulfamethoxazole (PO) 3, for the treatment of urinary tract infections due to susceptible strains of Escherichia coli and other organisms.

From the Research

Alternative Treatments for Female UTI

When Macrobid is not available, there are several alternative treatments for female urinary tract infections (UTIs). These include:

• Nitrofurantoin 4, 5, 6, 7
• Fosfomycin tromethamine 4, 5, 6, 7
• Trimethoprim-sulfamethoxazole 5, 6, 7
• Fluoroquinolones 4, 5, 6, 7
• Oral cephalosporins such as cephalexin or cefixime 4
• β-lactams such as amoxicillin-clavulanate 4, 6
• Pivmecillinam 4, 6

Treatment Options for Specific Types of UTIs

For UTIs caused by specific types of bacteria, the following treatments may be effective:

• For ESBL-E coli: nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin 4
• For ESBL-Klebsiella pneumoniae: pivmecillinam, fosfomycin, finafloxacin, and sitafloxacin 4
• For carbapenem-resistant Enterobacteriales: ceftazidime-avibactam, meropenem/vaborbactam, imipenem/cilastatin-relebactam, colistin, fosfomycin, aztreonam, and cefiderocol 4
• For multidrug-resistant Pseudomonas spp.: fluoroquinolones, ceftazidime, cefepime, piperacillin-tazobactam, carbapenems, ceftolozane-tazobactam, ceftazidime-avibactam, aminoglycosides, and colistin 4

Considerations for Treatment

When choosing a treatment for a female UTI, considerations should include:

• Local susceptibility patterns 4
• Patient factors such as age and comorbidities 6, 7
• Potential for adverse effects 5, 6
• Duration of therapy 5, 6