NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update


Oral fosfomycin trometamol (Monuril®) is indicated in adults for the treatment of uncomplicated lower urinary tract infection (UTI) following microbiological isolation of susceptible organisms. It should be considered as a treatment option for UTI caused by multi-drug resistant organisms and in patients with contraindications to standard therapy. It is given as a single 3g dose on an empty stomach (2-3 hours before or after food), preferably before bedtime and after emptying the bladder. The dose is repeated after three days in men and in all patients with catheter-associated UTI.


It has been added to the Total Formulary restricted to use on the advice of microbiologists or infectious disease physicians when laboratory results indicate sensitivity and according to local primary care or acute care treatment protocols. The Formulary indications are:


  • Treatment of extended-spectrum beta-lactamases (ESBL) lower UTI in non-septic men or non-pregnant women as an oral alternative to IV treatments.
  • Treatment of acute lower uncomplicated UTI, caused by pathogens sensitive to fosfomycin in adult and adolescent females.
  • Prophylactic treatment in diagnostic and surgical transurethral procedures.


Oral fosfomycin trometamol should not be used in complicated UTIs, eg

  • suspected or proven pyelonephritis/upper UTI or peri-nephric abscess
  • escalation of antimicrobial therapy in the absence of positive microbiology
  • patients with sepsis or suspected or proven bacteraemia.


Fosfomycin is an antibiotic with broad-spectrum, bactericidal activity. It is structurally unrelated to other known antibiotics and inhibits bacterial cell wall synthesis by inactivating the enzyme pyruvyl transferase. It is almost completely excreted unchanged in the urine and has good distribution into the kidney, bladder and prostate. A single dose of the trometamol salt produces urinary concentrations effective against most pathogens for at least 36-72 hours.


Fosfomycin is active against both Gram-positive and Gram-negative bacteria including E.coli, Klebsiella and Proteus species and Enterococci (including Vancomycin Resistant Enterococci). It is stable against a range of beta-lactamases and is one of the few oral antibiotic options available to treat lower UTI involving ESBL-producing organisms. This type of infection is being seen more frequently, in both hospitals and the community.




Prepared by                   Dr L Cottom (Clinical Microbiologist) and Dr L Stewart (Antimicrobials Pharmacist) January 2017


Published 09/03/2017