Nitrofurantoin prophylaxis for bacteriuria and urinary tract infection in children with neurogenic bladder on intermittent catheterization

Objective: To determine the effect of nitrofurantoin prophylaxis on rates of bacteriuria and symptomatic urinary tract infection in children with chronic neurogenic bladder receiving clean intermittent catheterization. Design: Double-blind, placebo-controlled, crossover trial of 15 children receiving nitrofurantoin or placebo for 11 months (5 months receiving one drug, then 1 month of washout followed by 5 months of the alternate drug). Weekly home visits were made. During each visit a sample of bladder urine was obtained by, intermittent catheterization, signs and symptoms of urinary tract infection were recorded, and all medications were recorded as well as a capsule count of the study drug. Results: During nitrofurantoin the frequency of bacteriuria remained high. Cultures of 74% (203 of 274) of the 274 samples on placebo ii ere positive for a pathogen (greater than or equal to 10(4) colony-forming units per milliliter) compared with 65% (165 of 252) of the 252 samples on nitrofurantoin. The bacterial species responsible for bacteriuria, however, were altered; Escherichia coli, the most common pathogen isolated during placebo, was replaced by resistant Klebsiella spp. and Pseudomonas spp. during nitrofurantoin. The carriage of these resistant organisms tripled during nitrofurantoin. Symptomatic infection dropped in half on nitrofurantoin, but this decline was due solely to infections caused by E. coli. Despite an increased frequency of resistant organisms on nitrofurantoin prophylaxis, an increase in urinary tract infections caused by these resistant organisms did not occur. Conclusion: Routine use of nitrofurantoin prophylaxis in an attempt to eradicate bacteriuria in patients with chronic neurogenic bladder is not effective.