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Three Part Question

In a [child diagnosed with UTI] is [trimethoprim better than nitrofurantoin] at [reducing symptoms and time of illness]?

Clinical Scenario

You have just diagnosed a child with a UTI and are about to start them on a course of antibiotics. You wonder which antibiotic is most appropriate, Nitrofurantoin or Trimethoprim, in eradicating symptoms and preventing recurrance.

Search Strategy

MEDLINE, EMBASE and CINAHL, via OVID
The Cochrane library Issue 2 2005.
[Bestbets Paediatric filter] AND [urinary tract infection.mp./ or exp Urinary Tract Infections] AND [trimethoprim.mp./ or exp trimethoprim] AND [nitrofurantoin.mp./ or exp nitrofurantoin]LIMIT to English language and Humans
cochrane:children AND uti AND nitrofurantoin AND trimethoprim

Search Outcome

103 papers found on Medline, 9 of which were relevant, 2 of which were in spanish therefore excluded. All papers considered of relevance found on EMBASE were the same as those found on Medline. 0 papers found answering the 3 part question on CINAHL.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Spencer et al 1994 UK	538 female patients, aged 18 years and over, from 45 different GP centres across the UK, presenting with one or more symptoms of uncomplicated UTI	Prospective randomized controlled trial	Clinical outcome (symptom relief) and bacteriological outcome of trial treatments, and patients experiencing adverse events	% patients cured taking: Nitrofurantoin 87.2%, Co-trimoxazole 84.5%, trimethoprim 86.5%. % patients with bacteriuria cured: Nitrofurantoin 86.1%, Co-trimoxazole 84.6%, trimethoprim 89.0%	Numbers don't add up. Don't show any statistical analysis. Patient group only included women. Randomisation method not clear.
sander et al 1981 UK	159 patients between 15 – 5 years of age with symptoms of UTI and pyuria	PRCT	Bacteriological cure rates after 10 days treatment with Nitrofurantoin or Trimethoprim	2 weeks after treatment:Nitrofurantoin 88%, Trimethoprim 90% 6 weeks after treatment:Nitrofurantoin 81% Trimethoprim 75%	Doesn't compare effects of the two drugs on clinical outcome. Small number of patients in study. Numbers don't add up.
			Number of side-effects after 10 days treatment	Nitrofurantoin 12% Trimethoprim 26%
Iravani et al 1999 USA	713 adult females with a primary diagnosis of uncomplicated lower UTI	PRCT	Bacteriological and clinical response following 3 day Ciprofloxacin or 7 day Co-trimoxazole or Nitrofurantoin	Bacteriological response: Ciprofloxacin 88%, co-trimoxazole 93%, Nitrofurantoin 86%. Clinical response: Ciprofloxacin95%. Co-trimoxazole 95%, nitrofurantoin 93%

Comment(s)

Only two papers were found which actually focused on comparing the clinical efficacy between nitrofurantoin and trimethoprim. The other study compared nitrofurantoin with co-trimoxazole, therefore it would be inappropiate to use this paper in the evaluation of trimethoprim versus nitrofurantoin, as co-trimoxazole is a mixture of trimethoprim with sulphamethoxazole and therefore its clinical efficacy is different to just trimethoprim. Both studies showed that the bacteriological cure rate was similar in both groups of patients treated with either nitrofurantoin or trimethoprim. The paper by RC Spencer et al also showed that clinical outcome (symptom relief) was similar for both nitrofurantoin and trimethoprim, with nitrofuranotin having only a slight 0.7% advantage. The two studies found only use women as the population studied and therefore their conclusions are only applicable to adult female patients and not to children. Much more research needs to be done into comparison between nitrofurantoin and trimethoprim, especially in the paediatric population.

Clinical Bottom Line

There is no evidence to compare the efficacy of trimethoprim and nitrofurantoin with regards to reducing symptoms and time of illness, in children with UTI. However, in studies where comparisons have been made between the two drugs, it has been shown that the bacteriological cure rate is similar for both and therefore neither is advantageous over the other.

References

1. R C Spencer, D J Moseley, M J Green smith. Nitrofurantoin modified release versus trimethoprim or co-trimoxazole in the treatment of uncomplicated urinary tract infection in general practice. Journal of Antimicrobial Chemotherapy May 1994 33 Suppl A:121-9.
2. Sander J. Aandahl E. Fellner H. Kalstad S. The treatment of urinary tract infections in out-patients A double-blind comparison between trimethoprim and nitrofurantoin. Journal of International Medical Research. 9(3):181-5, 1981.
3. Iravani A. Klimberg I. Briefer C. Munera C. Kowalsky SF. Echols RM. A trial comparing low-dose, short-course ciprofloxacin and standard 7 day therapy with co-trimoxazole or nitrofurantoin in the treatment of uncomplicated urinary tract infection. Journal of Antimicrobial Chemotherapy Mar 1999 43 Suppl A:67-75.