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Nitrofurantoin: friend or foe?
  1. Nicole Kapral,
  2. Rovin Saxena,
  3. Anupam Ashutosh Sule,
  4. Brian Markle
  1. Internal Medicine, St Joseph Mercy Oakland, Pontiac, Michigan, USA
  1. Correspondence to Anupam Ashutosh Sule, Internal Medicine, St Joseph Mercy Oakland, Pontiac, Michigan, USA; anupamsule{at}

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In conjunction with BMJ Case Reports, DTB will feature occasional drug-related cases that are likely to be of interest to readers. These will include cases that involve recently marketed drugs for which there is limited knowledge of adverse effects and cases that highlight unusual reactions to drugs that have been marketed for several years.


Nitrofurantoin remains the gold standard treatmentof uncomplicated cystitis as well as prophylactic treatment of recurrent urinary tract infections. Drug-induced hepatotoxicity presents in acute (3 in 1 000 000) and chronic (1 in 1500) forms. We present apatient with acute liver failure after 5 days of treatment. A 69-year-old man admitted for chronic obstructive pulmonary disease exacerbation 5 days into treatment for cystitis with nitrofurantoin. On admission he was noted to be jaundiced with elevated liver enzymes and normal international normalised ratio. Investigation for infectious, autoimmune and cholestatic causes of hepatotoxicity was negative. The patient improved after discontinuation of the drug and 10 days of methylprednisolone. There are scant data on acuteliver failure in the setting of short-term nitrofurantoin administration. The mechanism of toxicity remains unclear, but is hypothesised to be an autoimmuneprocess in which steroids may play a role in treatment. Diagnosis is one of exclusion as the only definitive method of diagnosis is rechallenge.


More than 5 million prescriptions for nitrofurantoin are filled each year1 as it is the treatment of choice for uncomplicated cystitis as well as prophylactic treatment of recurrent urinary tract infections.2 The incidence of hepatotoxicity has been estimated at 0.0003% to near 0.00075% in combination with other hepatotoxic agents.3 Acute hepatotoxicity (3 in 1 000 …

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  • Republished from Kapral N, et al. Nitrofurantoin: friend or foe? BMJ Case Rep 2018. doi:10.1136/bcr-2018-225629

  • Contributors All authors planned the case report, drafted the manuscript collaboratively and approved the final version, and agree to be accountable for all aspects of the manuscript. NK and RS gathered the data. AAS and BM assisted in analysis and interpretation.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.