What is the next step for a 67-year-old female with a urinary tract infection (UTI) experiencing worsening symptoms, including pain and increased anxiety, on day 4 of Macrobid (Nitrofurantoin) therapy?

From the Guidelines

The patient should be evaluated in person promptly due to worsening UTI symptoms despite 4 days of Macrobid (nitrofurantoin). The patient's worsening symptoms, including increased pain and anxiety, on day 4 of macrobid therapy may indicate treatment failure or complications, such as the development of pyelonephritis or bacterial resistance to nitrofurantoin 1.

Key Considerations

• The patient should be seen today, either by their primary care provider or at an urgent care facility, to assess for potential complications and adjust the treatment plan as needed.
• A urine culture should be obtained to check for antibiotic resistance and guide further treatment decisions.
• Alternative antibiotics, such as trimethoprim-sulfamethoxazole (160/800 mg twice-daily for 3 days) or ciprofloxacin, may be considered if the local resistance rates do not exceed 20% or if the infecting strain is known to be susceptible 1.
• In the meantime, the patient should increase fluid intake, take over-the-counter phenazopyridine (AZO) for urinary pain if not contraindicated, and use acetaminophen or ibuprofen for discomfort.

Potential Complications

• Worsening symptoms while on antibiotics can indicate bacterial resistance to nitrofurantoin, development of pyelonephritis (kidney infection), or other complications that require prompt medical attention.
• Older adults are at higher risk for serious complications, including confusion, sepsis, or kidney damage, if UTIs are not properly treated.

Next Steps

• The patient's primary care provider or urgent care facility should be contacted to arrange for a prompt evaluation and adjustment of the treatment plan as needed.
• The patient should be advised to seek immediate medical attention if symptoms worsen or if they experience any signs of severe complications, such as severe abdominal pain, vomiting, or difficulty breathing.

From the FDA Drug Label

ADVERSE REACTIONS: ...Neurologic: ...Asthenia, vertigo, nystagmus, dizziness, headache, and drowsiness also have been reported with the use of nitrofurantoin. ...Allergic: ...anaphylaxis; arthralgia; myalgia; drug fever; chills; and vasculitis (sometimes associated with pulmonary reactions) have been reported. The patient's worsening symptoms, pain, and increased anxiety on day 4 of Macrobid (nitrofurantoin) may be related to an adverse reaction to the medication, such as a hypersensitivity reaction or a neurologic effect.

• Key considerations:
  • The patient's symptoms could be indicative of a severe reaction, and the medication should be stopped immediately.
  • Further evaluation is necessary to determine the cause of the patient's worsening symptoms. 2

From the Research

Patient Symptoms and Treatment

• The patient is a 67-year-old female with a urinary tract infection (UTI) who has been taking Macrobid for 4 days and is experiencing worsening symptoms, including pain and increased anxiety 3, 4, 5.
• The patient's symptoms may be related to the progression of the UTI or a potential complication, such as pyelonephritis 3.
• The use of nitrofurantoin, the active ingredient in Macrobid, has been shown to be effective in treating uncomplicated UTIs, with clinical cure rates ranging from 51 to 94% 5.

Potential Causes of Worsening Symptoms

• The worsening symptoms may be due to the UTI not responding to the antibiotic treatment, or the development of a resistant strain of bacteria 4, 5.
• Other potential causes of worsening symptoms include the progression of the UTI to pyelonephritis, or the development of a complication such as sepsis 3.
• The patient's anxiety may be contributing to their worsening symptoms, and addressing this anxiety may be an important part of their treatment plan 6.

Next Steps in Treatment

• The patient's treatment plan should be re-evaluated in light of their worsening symptoms, and potential adjustments to their antibiotic regimen or the addition of other treatments should be considered 3, 4, 5.
• The patient's vital signs and symptoms should be closely monitored, and they should be educated on the importance of seeking medical attention if their symptoms worsen or if they experience any signs of complications such as sepsis 7.
• The patient's anxiety should be addressed through counseling or other supportive measures, as this may be contributing to their worsening symptoms 6.