The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.

Letter to the editor

Editor, -There has been some adverse publicity regarding the long-term use of nitrofurantoin. Some of my patients who require long-term prophylactic antibiotics, usually for urinary tract infection, are asking to come off this medication.

I find nitrofurantoin is a very useful antibiotic which is readily available (30 tablets with one repeat helps to ensure that patients do actually stay on it!). Nitrofurantoin is rapidly absorbed and rapidly excreted with high urinary concentrations and has good activity against Gram negative bacteria. It has a very low incidence of fungal problems especially vaginal candidiasis and a low incidence of gastrointestinal adverse effects.

It would be useful to know how these benefits can be weighed up against the risk of harm.

Tim Skyring
Urological surgeon
Figtree, NSW

Author's comments

Professor J. Turnidge, Infectious disease physician, comments:

Dr Skyring's letter highlights the dilemma faced by many practising clinicians: do I change my practice because of increasing reports of adverse reactions when the drug has a number of advantages?

He points out the significant benefits of nitrofurantoin and is rightly concerned that patients have been put off by recent publicity. For nitrofurantoin, the rates of adverse reactions are low, but some of these reactions are troublesome.

The reaction of most recent concern is peripheral neuropathy, although this problem has been known for many years. It is most likely in the elderly and others with reduced renal function. Of equal concern is immune-mediated hepatotoxicity, which most often resolves after cessation, but which can be fulminant. A third problem is pulmonary toxicity that can mimic pulmonary fibrosis.1

There are other serious reactions to nitrofurantoin, but the question remains as to whether they are more frequent than with other drugs used for prophylaxis against urinary tract infections, such as trimethoprim with or without sulfamethoxazole. Without a clear picture of the comparative toxicities of drugs taken over the longer term, it is not possible to make sensible recommendations about which drugs are favoured. The best way of dealing with the dilemma is to discuss the benefits and harms of all options with the patient. Dr Skyring should note that nitrofurantoin is still recommended in the current version of Therapeutic Guidelines: Antibiotic.