Ciprofloxacin (Cipro®) versus Nitrofurantoin (Macrobid®)

Ciprofloxacin advantages over Nitrofurantoin

  • Ciprofloxacin may be used in patients with impaired kidney function. The drug achieves adequate urine concentrations, despite severely impaired renal function.
  • Ciprofloxacin is indicated for more serious urinary tract infections than acute uncomplicated cystitis.
  • Ciprofloxacin provides more convenient three-day therapy.

Nitrofurantoin advantages over Ciprofloxacin

  • Current evidence supports the use of nitrofurantoin as first-line therapy.
  • Unlike ciprofloxacin nitrofurantoin does not produce systemic antibacterial action and as a result does not suppress normal microflora.

Difference between Ciprofloxacin and Nitrofurantoin


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Table 1. Comparison of Ciprofloxacin and Nitrofurantoin

Ciprofloxacin Nitrofurantoin
Brand names
• Cipro®, Cipro XR® • Macrobid® (mixture of the microcrystalline and macrocrystalline forms)
• Furadantin® (microcrystalline form)
• Macrodantin® (macrocrystalline form)
Drug class
Antibiotic, fluoroquinolone Antibiotic, synthetic nitrofuran compound
Dose formulations
• Tablets
• Oral suspension
• Tablets, extended release
• Injection
• Capsules
• Oral suspension
FDA-approved indications
• Urinary tract infections
• Acute uncomplicated cystitis
• Complicated urinary tract infection and pyelonephritis in children
• and many other indications
• Uncomplicated urinary tract infections (treatment and prophylaxis)
Mechanism of action
• Inhibits bacterial DNA synthesis • Nitrofurantoin is converted within bacterial cells to highly reactive intermediates which destroy bacterial ribosomal proteins, damage bacterial DNA, and interfere with cell wall synthesis.
• Nitrofurantoin is rapidly excreted in bile and urine. As a result no systemic antibacterial action is achieved.
Half-life
• 4 hours • 20-60 min
• Half-life of nitrofurantoin is prolonged in patients with renal impairment
Metabolism, Elimination
• Ciprofloxacin is eliminated mainly by renal excretion.
• The drug is also metabolized and partially eliminated in the bile.
• Nitrofurantoin is metabolized and excreted very rapidly. Body tissues metabolize about 60% of nitrofurantoin to inactive metabolites.
• Nitrofurantoin is eliminated mainly in the urine.
Contraindications
• Hypersensitivity to ciprofloxacin
• Concomitant administration with tizanidine
• Allergy to nitrofurantoin
• Impaired renal function (anuria, oliguria, or creatinine clearance <60 mL/min)
• Pregnancy 38-42 weeks of gestation
• History of hepatic dysfunction/cholestatic jaundice with nitrofurantoin
• Infants less than 28 days
Side effects
• Nausea
• Diarrhea
• Liver tests abnormal
• Abdominal pain
• Vomiting
• Rash
• Tendinitis and tendon rupture
• CNS disturbances
• Nausea
• Headache
• Flatulence
• Hepatotoxicity
• Pulmonary toxicity - acute pulmonary hypersensitivity reaction (which occurs in about 1 in 100,000 cases)
• Peripheral neuropathy
Pregnancy category
C B

Ciprofloxacin vs Nitrofurantoin for UTI

Current guidelines1 support the use of nitrofurantoin as first-line therapy for uncomplicated urinary tract infections.

Escherichia coli is responsible for about 80% of UTIs. Most E. coli are sensitive to nitrofurantoin. But this drug is not effective for upper urinary tract infections.

Ciprofloxacin is an alternative antibiotic1 for those who cannot tolerate nitrofurantoin or for bacteria that are resistant to nitrofurantoin. Ciprofloxacin has excellent activity against the clinically important uropathogens.

Reasons why ciprofloxacin is not used as the first line therapy:

  • Ciprofloxacin is no more effective than nitrofurantoin.
  • Ciprofloxacin has wider range of severe adverse effects. Nitrofurantoin is less likely to affect the normal flora of the vagina and gastrointestinal tract2.

Nitrofurantoin (Macrobid®) dosage: 100 mg twice daily for 7 days.

Ciprofloxacin (Cipro®) dosage: 250 mg twice daily for 3 days.

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Head-to-head comparative studies

Results of trial comparing ciprofloxacin with nitrofurantoin for uncomplicated urinary tract infection3. Ciprofloxacin Nitrofurantoin
Dosage regimen 100 mg twice daily for 3 days 100 twice daily for 7 days
Bacteriological eradication 88% 86%
Eradication rates at the 4-6 week follow-up 91% 82%
Clinical resolution 4-10 days after therapy Similar
Side effects Ciprofloxacin caused fewer cases of nausea

Further reading

References

  • 1. Colgan R, Williams M. Diagnosis and Treatment of Acute Uncomplicated Cystitis. Am Fam Physician. 2011;84(7):771-6. 2. Available at American Academy of Family Physicians.
  • 2. Stewardson AJ, Gaia N, Francois P, et al. Collateral damage from oral ciprofloxacin versus nitrofurantoin in outpatients with urinary tract infections. ClinMicrobiol Infect. 2015 Apr;21(4):344.e1-11. PubMed
  • 3. Iravani A, Klimberg I, Briefer C, Munera C, Kowalsky SF, Echols RM. A trial comparing low-dose, short-course ciprofloxacin and standard 7 day therapy with co-trimoxazole or nitrofurantoin in the treatment of uncomplicated urinary tract infection.J AntimicrobChemother. 1999 Mar;43 PubMed

Published: November 15, 2017
Last updated: November 15, 2017

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