Drug induced fatal hepatic toxicity after 1 week nitrofurantoin
Laurenssen, N.C.W., Kramer, M., Aydinli, R., Gisolf, J., Verhave, J.
Voorzitter(s): mw. prof.dr. M.M.E. Schneider, Utrecht & dr. W.G. Meijer, Hoorn
Locatie(s): Zaal 0.11
Categorie(ën):
Introduction: Nitrofurantoin is commonly used in urinary tract infections(UTI). Hepatotoxicity associated with nitrofurantoin is rare. We report the case of a 64 year old male, presenting with fatigue and jaundice beginning 1 week after treatment with nitrofurantoin for a UTI. Severe hepatotoxicity secondary to nitrofurantoin was diagnosed. This made us question the indication of nitrofurantoin for UTI in elderly men.
Case: A 64 year old man with a history of type 2 diabetes and gastric ulcer, was treated with nitrofurantoin for a UTI. After 1 week he suffered from fatigue, nausea and jaundice. Laboratory tests showed elevated cholestatic liver enzymes and decreased liver functions . The diagnosis nitrofurantoin associated cholestatic hepatotoxicity was made by exclusion of other causes of liver disease. During admission the patients clinical condition deteriorated rapidly and he developed multi-organ failure. He died 2 months after hospital admission of severe sepsis.
Discussion: In this case nitrofurantoin was prescribed by the general practitioner who followed the Guideline for Urinary Tract Infections of the DutchCollege of General Practitioners (NHG-guideline). This guideline advises a 7 day treatment with nitrofurantoin in men with UTI without systemic symptoms. The NHG state in case of no signs of tissue invasion, pyelonephritis or prostatitis, there is no reason to use different antibiotics in men compared to women. The SWAB suggests that only in young men below 40, a UTI may be considered as uncomplicated. UTI in young men is rare and data from trials are lacking. An epidemiological study from Norway, reported 6 to 8 uncomplicated UTIs per year in 10 000 men in the age range 21-50 years.There are several arguments to consider UTI in men as complicated. In men with a UTI there is often a concurrent prostatitis. Prostate involvement occurres in more than 90% of men with febrile UTI, even without clinical signs of acute pyelonephritis. Prostatitis is not easy to diagnose since patients don’t always have a fever or pain during rectal examination. Also most UTI’s occurring in men are associated with urological abnormalities, bladder outlet obstruction or instrumentation. Finally men with UTIs are more at risk to develop a bacteremia.
Conclusion: In our patient nitrofurantoin had a severe adverse effect and led to fatal cholestatic hepatotoxicity. We argue that nitrofurantoin is not the first choice for treating a UTI in elderly men. There is often a concurrent prostatitis or urological abnormality and nitrofurantoin has insufficient tissue penetration.