Should Macrobid (nitrofurantoin) be discontinued in a patient with foul-smelling urine and right flank pain, who has hyperglycemia and trace ketonuria, but a negative urine culture?

From the Guidelines

You should discontinue the Macrobid since your urine culture is negative, as this indicates no bacterial infection is present 1. Your symptoms of foul-smelling urine, flank pain, glucose in urine, and trace ketones suggest other possible causes that should be investigated. The glucose in your urine particularly warrants attention as it could indicate diabetes or other metabolic issues, and the presence of ketones may require monitoring and management to prevent diabetic ketoacidosis or nonketotic hyperosmolar state 1. The flank pain could be related to kidney stones, pyelonephritis, or other kidney conditions. Continuing antibiotics when no infection is present is unnecessary and can lead to side effects, antibiotic resistance, and disruption of normal gut flora.

Some key points to consider in your case include:

• The presence of glucose and ketones in your urine, which may indicate a metabolic issue such as diabetes and requires further evaluation 1.
• The need for further investigation into the cause of your symptoms, which may include blood tests to check blood sugar levels, imaging studies to evaluate your kidneys, or further urinalysis to identify other abnormalities.
• The importance of discontinuing unnecessary antibiotics to prevent side effects and promote antibiotic stewardship 1.
• The potential for ketone testing to guide management and prevent complications in individuals prone to ketosis 1.

Given the information provided and the current guidelines, it is essential to prioritize the investigation of the underlying cause of your symptoms over continuing unnecessary antibiotic treatment.

From the FDA Drug Label

WARNINGS: ... If hepatitis occurs, the drug should be withdrawn immediately and appropriate measures should be taken. ... Hemolysis is an indication for discontinuing nitrofurantoin (macrocrystals); hemolysis ceases when the drug is withdrawn ... If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued.

The patient has a negative urine culture, which indicates that the antibiotic therapy with Macrobid (nitrofurantoin) may not be necessary. Given the potential risks associated with long-term use of nitrofurantoin, such as hepatotoxicity, neuropathy, and Clostridium difficile-associated diarrhea, it is reasonable to consider discontinuing the Macrobid.

• The presence of 3+ glucose and trace ketones in the urinalysis suggests that the patient may have an underlying condition, such as diabetes mellitus, that could increase the risk of adverse effects from nitrofurantoin.
• The patient's symptoms, such as foul-smelling urine and right flank pain, could be indicative of a urinary tract infection, but the negative urine culture suggests that the infection may have been resolved or that the symptoms are due to another cause.
• In the absence of a confirmed bacterial infection, the benefits of continuing antibiotic therapy with Macrobid do not outweigh the potential risks, and the medication should be discontinued 2.

From the Research

Urinary Tract Infection Diagnosis and Treatment

• The patient's symptoms of foul-smelling urine and right flank pain, along with urinalysis results showing 3+ glucose and trace ketones, suggest a possible urinary tract infection (UTI) 3.
• The presence of glucose in the urine may indicate an underlying condition such as diabetes, which can increase the risk of UTIs 3.
• The patient was prophylactically started on Macrobid (nitrofurantoin), a common antibiotic used to treat UTIs 4, 5.

Urine Culture Results and Antibiotic Treatment

• The negative urine culture results suggest that the patient may not have a bacterial UTI, or the infection may be caused by a resistant pathogen 6.
• Despite the negative culture results, the patient's symptoms and urinalysis results may still indicate a UTI, and the antibiotic treatment may be justified 6, 4.
• However, the use of antibiotics should be prudent, and the treatment should be re-evaluated based on the patient's response and the risk of antibiotic resistance 6, 7.

Discontinuation of Macrobid

• Given the negative urine culture results, it may be reasonable to discontinue the Macrobid treatment, especially if the patient's symptoms have resolved 6, 7.
• However, the decision to discontinue antibiotic treatment should be made on a case-by-case basis, taking into account the patient's individual circumstances and the risk of recurrent UTIs 3, 5.