Brooklyn Pruett, PharmD and Lisa C. Hutchison, PharmD, MPH

Nitrofurantoin (Macrobid®) is a broad-spectrum antibiotic with gram-positive and gram-negative activity commonly used for treatment and prevention of urinary tract infections (UTIs).1 Nitrofurantoin is excreted into the urine by the kidneys where it achieves therapeutic concentrations. Once in the urine, nitrofurantoin inhibits bacterial protein synthesis, aerobic energy metabolism, DNA synthesis, RNA synthesis, and cell wall synthesis. Adverse effects of nitrofurantoin include pulmonary toxicity, hepatic dysfunction, peripheral neuropathy, hemolytic anemia, and Clostridium difficile-associated diarrhea.

Previously, nitrofurantoin was on the American Geriatrics Society (AGS) Beers Criteria of medications potentially inappropriate for use in older adults. The guideline recommended to avoid nitrofurantoin in geriatric patients with a creatinine clearance less than 60mL/min due to lack of efficacy.2 The recommendation also stated to avoid use for long-term suppression of UTI because of the potential for pulmonary toxicity, hepatotoxicity, and peripheral neuropathy. However, in the 2015 AGS Beers Criteria the threshold for creatinine clearance concern was decreased to 30mL/min for nitrofurantoin because of questions about the old evidence regarding nitrofurantoin excretion and new, albeit low quality, evidence for effectiveness.3

Two studies support use of nitrofurantoin in older women for treatment of UTI. The most recent study was a retrospective cohort study that compared use of nitrofurantoin and trimethoprim in women with renal impairment and a UTI.4 Inclusion criteria were women greater than 18 years of age who received a prescription for nitrofurantoin or trimethoprim for a treatment of a UTI which was defined as (1) no antibacterial treatment six-months prior to receiving either treatment, (2) at least a one- year medication history prior to the antimicrobial starting date, and (3) a six-month follow up medication history after starting the antimicrobial therapy. Exclusion criteria included patients with antibacterial use less than three days or greater than ten days. The primary outcome was treatment failure defined as starting a second antibiotic for treatment of a UTI within one month. The secondary outcome was hospitalization due to adverse effects.

For nitrofurantoin, the overall incidence for ineffective treatment was 14.4% as compared to 16.6% for trimethoprim. The occurrence of treatment failure increased with decreased renal function, but this was not statistically significant. Adverse events that occurred included pulmonary reactions (painful respiration, pleural effusion), and blood dyscrasias. For nitrofurantoin users the risk of an adverse event was significantly higher in patients with renal impairment, defined as a GFR less than 50 mL/min/1.73m2. These results indicate that nitrofurantoin reaches therapeutic effects in the urine for bactericidal activity at least as effective as trimethoprim. However, results also suggest that adverse events were significant in renal impaired patients.

Based on these findings and reconsideration of the old data, the 2015 AGS Beers Criteria panel of experts changed the recommendation so nitrofurantoin is considered inappropriate for treatment of UTI when the patient has a creatinine clearance less than 30mL/min (instead of 60mL/min). The use of nitrofurantoin for long-term suppression of UTI is still considered potentially inappropriate given the risk for toxicity.

 

References:

1. Macrobid® . North Norwich, NY: Norwich Pharmaceuticals, Inc; 2009.
2. Resnick, Barbara, and James T. Pacala. “2012 Beers Criteria.” Journal of the American Geriatrics Society 60.4 (2012): 612-13. The American Geriatrics Society. Web. 15 Jan. 2016. http://www.americangeriatrics.org/files/documents/beers/2012AGSBeersCriteriaCitations.pdf
3. “American Geriatrics Society 2015 Updated Beers Criteria for Potentially
Inappropriate Medication Use in Older Adults.” Journal of the American Geriatrics Society 63.11 (2015): 2227-246. Accessed 15 Jan. 2015. http://onlinelibrary.wiley.com/store/10.1111/jgs.13702/asset/jgs13702.pdf?v=1&t=ijkhj451&s=034b8ee90406aeba02f3ceb2d969e01d3b9c7e7c
4. Geerts, Arjen F. J., et al. “Ineffectiveness and Adverse Events of Nitrofurantoin in  Women with Urinary Tract Infection and Renal Impairment in Primary Care.” European Journal of Clinical Pharmacology Eur J Clin Pharmacol 69.9 (2013):  1701-707. Web.  http://link.springer.com.libproxy.uams.edu/article/10.1007%2Fs00228-013-1520-x

Deborah J. Persell, PhD, RN, APN,  Arkansas State University

Hope has long been seen as essential for health and well-being. When present, it helps individuals cope, be at peace, and increase the quality of their lives. Unfortunately, hope is often forged in stress, loss, despair and threats to life. As we age, we naturally experience circumstances that can threaten hope: loss of friends and loved ones, financial instability, loneliness, failing health, and loss of independence. Disasters of any type can amplify already difficult circumstances and/or personal strengths. Years of life experience prepare seniors to survive difficult circumstances and be agents of hope.

Many disaster response organizations, particularly faith-based ones, endeavor to promote activities that foster hope. In times of disaster, seniors both contribute as volunteers or receive services of faith-based organizations (FBOs), providing disaster response. In one study of faith-based disaster response, located in New Orleans two years after Hurricane Katrina, just over 32% of the volunteers and 44% of the staff were over the age of 60.1 Through participating in disaster response, these seniors contributed hope to the recipients of the response services needed for survival. Volunteers and staff alike refer to the work of disaster response as giving and receiving love. The ability to do this is an attribute of hope.2 One example of the impact of their work, even by accident, on the hope of a survivor is shared by a staff member of a FBO. “They just roofed the wrong house… no excuse for it. No excuse. But, the homeowner pulled into the driveway and saw that the house was roofed. They were just so discouraged that they were coming home to commit suicide and when they saw the new roof on their house that changed their outlook on  life completely.”{1

Some seniors may say the physical demands of disaster response limit their ability to contribute but as one volunteer shared, the ability to sit and listen is also important and part of the work of offering hope. “When you see someone in so much pain you just want to feel that with them, you don’t want them to be alone in a dark place, you want to be able to come with them, set next to them and cry, and say you’re not alone. I don’t know what you’ve been through and no I can’t ever feel the same way you do because I didn’t ever go through your experience, but I’m going to sit here and I’m going to cry with you.”1

The work of disaster response provides a framework for determining what to do next. Having a sense of direction and having goals are characteristics of hope.2 Whether the goal is for seniors to help themselves or someone impacted by disaster to recover a lost item, clean their yard, clear damaged goods from a home or reconnect with lost neighbors, the goals provide direction and hope can be a result. It could be said that in order to set such goals one has to believe there is a potential for the goal to be met and that the potential for possibilities in difficult circumstances exists. These beliefs are also attributes of hope.2

Having deep inner strength is another element of hope.2 Life experiences have taught seniors how to dig deep and capitalize on the inner strength they have developed over the years. This fortitude, determination, or other descriptions of inner strength, help them carry on in the face of difficult circumstances and embody hope. One resident of New Orleans describes it like this. “I’m a spiritual person and my family and I have always been in church and in a time like this your spiritual hope is really the only thing that you have to rely on. You can’t rely on the government, it’s just knowing that everything’s going to be OK, you just have to have that faith to know that God is there. He’s watching over everything that’s happening, giving us the strength to endure what we have to endure until things get better.”1

Difficult circumstances in disaster can be anticipated. Planning to survive disasters is a goal in and of itself that gives direction to preparations. Successful preparations by seniors puts them in position to contribute to the response and be part of providing hope for others. Key preparation tasks for seniors may be found in Box 1.

Box 1. Disaster Preparation Activities for Seniors
1. Develop a personal disaster plan – write it down (See redcross.org)
          • Family/friend contact information
          • Key medical information
          • Prescription information
          • Include where you will go if you have to leave your home and how you will get there
2. Collect disaster supplies specific to your need
          • Food & water for 96 hours
          • Flashlights, batteries and chargers
          • Medication
          • Assistive devices (glasses, hearing aids, canes, walkers)
          • Nutritional supplements
3. Keep disaster supplies in your car
4. Keep your car gas tank full
5. Keep a supply of cash
6. Share your plans with a friend or family member – have a buddy
7. Plan for your pet’s needs

Seniors wishing to be part of faith-based disaster response should act before a disaster strikes. They may check with their local faith congregations to determine if a particular congregation has a disaster response team or knows where one might be located. Completing any required paper work or training for disaster response prior to the disaster occurring increases the likelihood a senior can quickly be utilized. In addition, senior volunteers must maintain optimal health, be up-to-date with immunizations, and have ready travel/response supplies (including sufficient medication) and a back-up plan to activate for personal obligations. A list of organizations that respond regularly to disasters may be found on the National Volunteer Organizations Active in Disaster web site
(http://www.nvoad.org/voad-network/national-members/).3

In addition to community-based organizations, other non-government organizations, such as the American Red Cross, provide many opportunities for seniors to volunteer during a disaster. Remember, the work of disaster response provides a mechanism of hope to seniors participating in the response and to those whom they help.
References:
1 Persell, D.J. (2016). Vehicle of Hope: Faith-Based Disaster Response. NursingClinics of North America, Dec, 2016. In press.
2 Herth, K. A. & Cutcliffe, J. R. (2002). The concept of hope in nursing 6: Research/education/policy/practice. British Journal of Nursing, 11(21), 1404-1411.
3 National Volunteer Organizations Active in Disaster, Incorporated. (2014). NVOAD National Organization Members. http://www.nvoad.org/voad-                                    network/national- members/