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NUTRITION 411
The Use of Cranberry Products for
Urinary Tract Infection Prevention
Jennifer Sallit, PhD, RD; and Nancy Collins, PhD, RD, LD, FAPWCA
Table 1. Tips for preventing urinary tract
infections (UTIs)
costs.1,2 UTIs are the most prevalent source of bacteremia, the
most common cause for hospital transfers, and the most common condition for which antibiotics are prescribed. Although
patients usually respond to antimicrobial treatment, the recurrence rate is high and associated with side effects. It is estimated that more than 50% of elderly patients in LTC will
have a recurrence, usually within 6 months, despite antibiotic
therapy.3,4 The frustration of repeated cycles of antibiotic
agents with diminished effects due to microbial resistance has
a significant impact on the patient’s quality of life (QoL).
Teach patients these tactics to help avoid UTIs:
- Urinate when you need to. Do not hold it in.
- Drink an adequate amount of water each day.
- Don’t use douches or feminine hygiene sprays.
- Wear underpants with a cotton crotch.
- Take showers instead of tub baths, if possible.
- Wipe from front to back to prevent bacteria around
the anus from entering the vagina or urethra.
- Finish all antibiotics as prescribed; do not stop
mid-course even if you feel better.
- Consume cranberry-containing products.
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rinary tract infections (UTIs) are the most prevalent inU
fection in long-term care (LTC), accounting for at least
40% of all infections and more than 8% of total nursing home
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Antibiotic Usage
UTIs alone account for 30% to 56% of all prescriptions
for antibiotics in LTC facilities.5,6 Escherichia coli is the most
common cause of UTIs in older adults. E. coli strain resistance is now approximately 40% to 50% to ampicillin, approximately 20% to trimethoprim-sulfamethoxazole, and in
just the last few years resistance has gone from 1% to 5% to
more than 20% to fluoroquinolone.7 This reduces treatment
options for UTIs and can add significant costs when newer,
more expensive antibiotics are needed. Additionally, every
antibiotic regimen fosters resistant subpopulations of bacteria that can later re-infect that same patient or their caregivers or be passed around to other patients, particularly in
the LTC environment. Side effects of antibiotics also must
be considered and include allergic reactions, nausea, interactions with foods or other drugs, and depletion of beneficial
bacteria in the colon that can lead to diarrhea, stomach or
intestinal upset, changes in mental status, yeast infections,
and Clostridium difficile (C. diff).
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Development of UTIs
Urine is normally sterile, so in order for a UTI to occur, E.
coli from a fecal or vaginal source must migrate upward, enter
the urethra, attach, and begin to multiply. As the bacteria multiply, they ascend up the urethra into the bladder. E. coli have
finger-like projections (fimbriae) on their cell surface that
allow them to attach to receptors on epithelial cell walls using
a Velcro-like effect that can resist the cleansing action of urine
flow. Because E. coli are living, they continue to move after adherence, irritating and destroying the urethral or bladder wall
and causing inflammation. The inflammation causes a painful
burning sensation. In some cases, these pathogens will rupture
underlying blood vessels, resulting in visible blood in the
urine. Inhibiting E. coli from attaching to the urinary tract
wall is one of the most important ways to prevent UTIs.
Older adults are at increased risk for UTIs due to age-related changes. Decreased estrogen as part of menopause leads
to thinning and weakening of the mucosa, reducing its ability
to resist bacteria. A decrease in estrogen also leads to pH
changes in the vagina, favoring E. coli colonization. An aging
immune system decreases antibody response to pathogens.
Changes in microbiota (microflora) include an increase in
harmful bacteria and a decrease in beneficial bacteria. Plus, as
we age, the ability to concentrate urine decreases. To help
counteract these changes, daily consumption of cranberry
products is recommended.
Cranberries
Proanthocyanidins (PACs) — flavonoids found in cranberries — can prevent E. coli from attaching to the urinary
tract wall. PACs from cranberries target E. coli cells in three
Jennifer Sallit, PhD, RD, serves as Scientific Director for Medical Nutrition USA, a division of Nutricia, where she conducts research in gerontological nutrition,
manages the science programs, and aids in the development of medical nutrition products. Her current research focus is on improving the nutritional status of
older adults through specialized medical foods. Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of RD411.com and Wounds411.com.
For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Correspondence may be sent to Dr. Collins at [email protected]. This article was not subject to the Ostomy Wound Management peer-review process.
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liquid contains a proprietary blend of cranberry concentrate,
vitamin C, D-mannose, fructooligosaccharides (FOS), and
bromelain. The ingredients work by counteracting the effects
of E. coli: cranberry concentrate inhibits the ability E. coli to
adhere to the urinary tract wall; bromelain, a proteolytic enzyme from the stem and juice of pineapples, has an anti-inflammatory effect that can be beneficial in reducing
symptoms caused by E. coli; vitamin C helps maintain adequate urine acidity, creating a less tolerable environment for
E.coli; D-mannose reduces adhesion of E.coli to the urinary
tract wall; and FOS stimulate the growth of beneficial bacteria
in the colon, reducing the number of E.coli. Each serving (1
oz, 30 mL) of this product provides as much cranberry PACs
as 16 8-oz glasses of cranberry juice cocktail but without the
sugar and with only 2 calories per serving compared to 150
calories per glass of cranberry juice. This makes the product
appropriate for patients with diabetes as well as patients on
fluid restriction, with renal insufficiency, or older adults who
have trouble consuming large fluid volumes. The higher the
concentration of PACs, the greater their impact on E. coli, suggesting that concentrated products that have not been highly
diluted have the greatest effects.
Cranberries in the literature. Several recent studies
have shown cranberry juice consumption can reduce bacteriuria and prevent symptomatic recurrences of UTIs.8-14
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ways: 1) they alter E.coli cell membranes, 2) they compress
fimbriae, greatly reducing E.coli’s ability to remain in place
long enough to launch an infection, and 3) they change E. coli
shape from rods to spheres, affecting its activity. All of these
effects inhibit the bacteria’s ability to attach to cells lining the
bladder wall, prevent the bacteria from making contact with
cells, and disrupt bacterial communication. The E. coli can be
flushed out in the urine instead of causing an infection.
Provision options. Cranberry tablets/capsules have the
ability deliver concentrated doses of PACs but the amounts
vary considerably from brand to brand. For example, the
source of the cranberry powder in the tablets can be derived
from freeze-dried cranberry juice, cranberry juice concentrate,
whole cranberry, cranberry concentrate, and cranberry extract, all with varying amounts of PACs and recommended
doses ranging from two to six pills per day. Cranberry
tablets/capsules typically contain 300 to 500 mg of cranberry
(concentrate, extract, juice) per tablet (~6 to 10 mg PACs).
Many older adults have difficulty tolerating several tablets per
day and nursing administration can be cumbersome, particularly if a patient is tube fed.
Another example of a concentrated product is UTI-Stat®
with proantinox® (Medical Nutrition USA Inc, Englewood,
NJ), a novel urinary tract cleansing complex clinically proven
to help prevent recurrent UTIs (rUTI). This ready-to-drink
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References
1. Nicolle LE. Asymptomatic bacteriuria in the elderly. Infect Dis Clin North
Am. 1997;11(3):647–662.
2. Richards CL. Urinary tract infections in the frail elderly: issues for diagnosis, treatment and prevention. Int Urol Nephrol. 2004;36(3):457–463.
3. Hooton TM, Stamm WE. Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am. 1997;11(3):551–581.
4. Ikäheimo R, Siitonen A, Heiskanen T, Kärkkäinen U, Kuosmanen P, Lipponen P, Mäkelä PH. Recurrence of urinary tract infection in a primary
care setting: analysis of a 1-year follow-up of 179 women. Clin Infect
Dis. 1996;22(1):91–99.
5. Warren JW, Palumbo FB, Fitterman L, Speedie SM. Incidence and characteristics of antibiotic use in aged nursing home patients. J Am Geriatr
Soc. 1991;39(10):963–972.
6. Mylotte JM. Measuring antibiotic use in a long-term care facility. Am J
Infect Control. 1996;24(3):174–179.
7. Karlowsky JA, Kelly LJ, Thornsberry C, Jones ME, Sahm DF. Trends in
antimicrobial resistance among urinary tract infection isolates of Escherichia coli from female outpatients in the United States. Antimicrob
Agents of Chemother. 2002;46(8):2540–2254.
8. Raz R, Chazan, B, Dan M. Cranberry juice and urinary tract infection.
Clin Infect Dis. 2004;38(10):1413–1419.
9. Kontiokari T, Salo J, Eerola E, Uhari M. Cranberry juice and bacterial
colonization in children—a placebo-controlled randomized trial. Clin
Nutr. 2005;24(6):1065–1072.
10. Guay DR. Cranberry and urinary tract infections. Drugs.
2009;69(7):775–807.
11. Nowack R, Schmitt W. Cranberry juice for prophylaxis of urinary tract
infections — conclusions from clinical experience and research. Phytomedicine. 2008;15(9):653–667.
12. Pérez-López FR, Haya J, Chedraui P. Vaccinium macrocarpon: an interesting option for women with recurrent urinary tract infections and other
health benefits. J Obstet Gynaecol Res. 2009;35(4):630–639.
13. Bailey DT, Dalton C, Joseph Daugherty F, Tempesta MS. Can a concentrated extract prevent recurrent urinary tract infections in women? A
pilot study. Phytomedicine. 2007;14(4):237–241.
14. Kiel R, Nashelsky J, Robbins B, Bondi S. Clinical inquiries: does cranberry juice prevent or treat urinary tract infection? J Fam Pract.
2003;52(2):154–155.
15. Howell AB. Cranberry proanthocyanidins and the maintenance of urinary
tract health. Crit Rev Food Sci Nutr. 2002;42(3 suppl):273–278.
16. Jepson RG, Craig JC. Cranberries for preventing urinary tract infections.
Cochrane Database Syst. Rev. 2008;(1):CD001321.
17. Stothers L. A randomized trial to evaluate effectiveness and cost effectiveness of naturopathic cranberry products against urinary tract infection in women. Can J Urol. 2002;9(3):1558–1562.
18. Efros M, Bromberg W, Cossu L, Nakeleski E, Katz AE. Novel concentrated cranberry liquid blend, UTI-STAT with Proantinox, might help prevent recurrent urinary tract infections in women. Urology.
2010;76(4):41–45.
19. Common Terminology Criteria for Adverse Events Version 3.0 (v3.0).
Cancer
Therapy Evaluation Program. 2003. Available at:
http://ctep.cancer.gov.
20. Groutz A, Blavias JG, Fait G, Sassone AM, Chaikin DC, Gordon D. The
significance of the American Urological Association Symptom Index
score in the evaluation of women with bladder outlet obstruction. J Urol.
2000;163(11):207–211.
21. Ware JE, Kosinski M. Interpreting SF-36 summary health measures: a
response. Qual Life Res. 2001;10(5):405–413; discussion 415–420.
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The anti-adhesion activity of PACs is evident in the urine
within 2 hours and persists for up to 10 hours following ingestion of cranberry juice.15 This suggests that in order to get
protection from cranberry products, they must be consumed
prophylactically on a daily basis. However, some studies with
high dropout rates have indicated that the prolonged consumption of cranberry juice is not feasible for many because
of its cost, highly acidic taste, volume required to consume,
and caloric load.9,10,14,16 In this respect, concentrated cranberry
products high in PACs may be a better alternative to cranberry
juice in terms of patient compliance and tolerability.17
A recent clinical study determined the safety, tolerability,
QoL, and efficacy of UTI-Stat® in female patients with a history of rUTIs.18 Subjects had an average of 2.78 ± 0.73 UTIs
at baseline. The product was administered daily for 12 weeks.
Blood, urinary dipstick testing, and urinalysis were completed
at baseline and at weeks 4 and 12. Safety variables — ie, adverse events and clinical laboratory test results (hematology
and urinalysis) — were assessed. Safety was monitored continuously during the 12-week study period and the study participants were interviewed and examined by a study physician
at the beginning and end of the study. Adverse events were
graded using the National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.019 according to
the severity (mild, moderate, severe, or life-threatening) and
the relationship to the study medication (unlikely related, possibly related, or probably related). QoL was measured using
the American Urologic Association20 (AUA) Symptom Index
and the Medical Outcomes Study Short-Form, 36-item Questionnaire21 (SF-36). Most (91%) subjects remained UTI-free
over 3 months taking doses up to 60 mL/day; 9% reported a
rUTI, results markedly better than historical data (36%). QoL
and AUA were significantly improved (P = 0.0097 and P =
0.045, respectively). The product showed a good safety profile,
tolerability, and demonstrated effectiveness in reducing rUTIs
and increasing QoL in both pre- and post-menopausal females with history of rUTI.
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Coming next month: the bariatric patient
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Practice Points
Table 1 lists tips for educating patients on UTI prevention.
Considering the emerging resistance to antibiotics used to
treat UTIs, the development of new treatment and prevention
strategies has become critical. Administering concentrated
cranberry products to patients and residents in LTC along
with encouraging proper hygienic measures and hydration
may help decrease the occurrence and recurrence of UTIs.
Furthermore, due to the prevalence of UTIs, nonantibiotic
treatment options can play an important role in alleviating
the public health issue of antibiotic resistance. n
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