From the Guidelines
Nitrofurantoin should not be given to patients with a GFR less than 60 mL/min and a history of chronic kidney disease. This recommendation is based on the fact that nitrofurantoin can produce a toxic metabolite, which can cause peripheral neuritis, as noted in a study published in the International Journal of Oral Science 1. In patients with reduced kidney function, the risk of toxicity is increased due to impaired renal clearance. The study highlights the importance of avoiding nephrotoxic drugs, such as aminoglycoside antibiotics and tetracyclines, in CKD patients, and similarly, nitrofurantoin should be avoided due to its potential to cause adverse effects.
Some key points to consider when treating patients with CKD and GFR <60 mL/min include:
- Avoiding nephrotoxic drugs and those that require renal excretion for efficacy
- Considering alternative antibiotics, such as amoxicillin, cephalexin, or clindamycin, which have more favorable safety profiles in patients with reduced kidney function, as suggested by the American Heart Association (AHA) recommendations 1
- Dose adjustments should be made based on comments from the patient’s nephrologist to decrease the side effects from CKD
- The choice of antibiotics should be made based on infection severity, local resistance patterns, and patient-specific factors.
Overall, the goal is to minimize the risk of adverse effects and ensure effective treatment for patients with CKD and reduced kidney function.
From the Research
Nitrofurantoin Use in Patients with Reduced Renal Function
- The use of nitrofurantoin in patients with a glomerular filtration rate (GFR) less than 60 mL/min and a history of chronic kidney disease is a topic of debate 2, 3, 4.
- A study published in 2013 found that the contraindication of nitrofurantoin in patients with a creatinine clearance below 60 mL/min is not supported by strong evidence 2.
- Another study published in 2017 found that nitrofurantoin was safe and effective in treating acute uncomplicated cystitis in hospitalized adults with renal insufficiency, including those with a GFR less than 60 mL/min 3.
- A population-based study published in 2015 found that nitrofurantoin was not associated with a higher risk of treatment failure in older women with reduced kidney function, including those with a GFR less than 60 mL/min 4.
- A narrative review published in 2023 highlighted the potential of nitrofurantoin as a first-line therapy for uncomplicated lower urinary tract infection, including in patients with reduced renal function 5.
- A study published in 2019 evaluated the safety and efficacy of nitrofurantoin in frail, community-dwelling, older adults with renal impairment and found that it can be a useful treatment option in this population 6.
Considerations for Nitrofurantoin Use
- The American Geriatrics Society recommends nitrofurantoin for short-term use in patients with a creatinine clearance greater than or equal to 30 mL/min 6.
- The use of nitrofurantoin in patients with reduced renal function should be carefully considered, taking into account the potential risks and benefits 2, 3, 4.
- Pharmacists can play a role in encouraging antimicrobial stewardship and promoting the safe and effective use of nitrofurantoin in patients with renal impairment 6.