<h2>Practice points</h2><ul><li>Cranberry may decrease the risk of urinary tract infections although data is conflicting. Standardised extracts that report proanthocyanidin (PAC) content may be more reliable</li><li>Probiotics may decrease the risk of urinary tract infections although data is conflicting. They can be administered orally, intravaginally or as yogurt/other cultured milk products</li></ul><h2>Description</h2><ul><li>Urinary tract infections (UTIs) are a group of infections of the urinary tract1 <ul><li>Most common UTI is cystitis; an infection of the bladder1</li><li>Symptoms have rapid onset and may include increased urinary frequency or urgency, dysuria, and cloudy, dark or bloody urine. In the elderly it can cause confusion1,2</li></ul> </li><li>Between 80–90% of UTIs caused by the Gram-negative bacteria Escherichia coli (E. coli)2 </li><li>Between 50–80% of women in the general population will experience a UTI3<ul><li>30–44% will have recurrent episodes3</li></ul> </li><li>UTIs are common in children (2% of boys; 8% of girls by 7y) and recur in 10–30% of cases4</li><li>Incidence of UTI increases with age in women, particularly from middle age5</li></ul>

<h2>Management guidelines</h2>If acute infection suspected:1,2,3 <ul><li>Urinary alkalinisers may help improve stinging</li><li>Seek appropriate medical advice if symptoms do not improve</li><li>A urine sample is necessary to test for infection</li><li>Antibiotics are used to treat bacterial infection</li><li>Drink plenty of water to flush the urinary tract, kidneys and bladder</li><li>Counsel on appropriate preventative strategies including complementary medicine and lifestyle changes</li></ul>

Management

<h2>Primary recommendations</h2><h2>CRANBERRY (Vaccinium macrocarpon)</h2>Mechanism of action<ul><li>May prevent adherence of adhesion proteins (type 1 and p-fimbriae strains), particularly from E. coli, to urinary tract epithelial cells. Without adhesion, the bacteria cannot infect the mucosal surface6</li><li>It is thought that one of the main constituents responsible are proanthocyanidins (PAC)6</li></ul>ResearchThere is conflicting data on use of cranberry products in prevention of UTIs:<ul><li>Some trials have indicated that cranberry juice, extracts and capsules may reduce the risk of recurrent UTI in women with recurrent UTI.7 Additionally, cranberry products may be effective at reducing the risk of UTIs in women in general7</li><li>A 2012 Cochrane review (24 studies; n=473)8 found that cranberry did not reduce occurrence of symptomatic UTI in adults and children, although it had the same effect as antibiotics. Lack of efficacy could potentially be due to a lack of potency: <ul><li>Only 5 of the included studies described using cranberry standardised to PAC, and only one used capsules standardised to PAC. That study found significant reduction in urinary E coli and symptomatic relief in patients with UTI9</li></ul> </li><li>Another 2012 meta-analysis (13 RCTs; n=1616)10 concluded that cranberry-containing products (juice, extracts and capsules) may reduce the risk of recurrent UTI in women with recurrent UTI, although there was considerable heterogeneity across trials: <ul><li>The meta-analysis found that cranberry may be effective at reducing risk of UTIs in women with recurrent UTI, children, and in those using cranberry products &gt;twice/d10</li></ul> </li></ul>Dosage<ul><li> Typically found in tablet/capsule form</li><li>Standardised to contain PACs/d: 72 mg10,13</li><li>Dosage range:11 <ul><li>Adults: 120-400 mL/d or 400-500 mg capsule 1-3/d, although much higher doses have been used (10,000 mg/d)</li><li>Children: 15 mL/kg to 300 mL/d</li></ul> Adverse effects <ul><li>Very large doses (&gt;3 L/d juice) may cause GI upset, diarrhoea, nausea, and vomiting11</li></ul> Key interactions <ul><li>Anti-coagulant and antiplatelet agents: may increase blood levels of the drug. Clinical trials suggest no evidence of increasing drug effect with cranberry juice. Case reports exist. In vitro studies suggest cranberry affects warfarin metabolism (CYP3A4 metaboliser). Unlikely likelihood. Use with caution under supervision of a healthcare professional (HCP)12</li><li>CYP3A substrates: may increase or decrease blood levels of drug via inhibition of this enzyme activity. Possible likelihood. Use with caution under supervision of a HCP12</li><li>Tacrolimus: may decrease drug effect. Possible likelihood. Avoid concomitant use12</li></ul> </li></ul>

Primary

<h2>Seconday recommendations</h2><h2>PROBIOTICS</h2>Mechanism of action<ul><li>May compete with and protect against colonisation and infection by disease-causing organisms14</li><li>May reduce pathogen adherence, growth and colonisation, and modulate host defences14</li><li><ul><li>Research</li><li><ul><li>A 2015 Cochrane review (9 studies; n=735),14 concluded that probiotics (delivered both orally and intravaginally): <ul><li>Showed no significant reduction in risk of recurrent symptomatic UTI</li><li>Showed insufficient evidence to determine therapeutic value in susceptible populations (previous history of UTI, women, school-aged girls, men with enlarged prostates, the elderly)</li><li>However, a benefit could not be ruled out as the data were few and derived from small studies with poor methodological reporting</li></ul> </li><li>A 2015 literature review15 of 3 clinical studies found low-to-moderate evidence suggesting that Lactobacillus strains may be effective in preventing UTI in women <ul><li>One small randomised controlled trial of 100 women showed that recurrent UTI occurred in 15% of women using Lactobacillus-embedded pessaries compared with 27% using placebo16</li></ul> </li></ul></li><li>Dosage information</li><li><ul><li>Typically found in tablet/capsule or powder form</li><li>Quantified by number of colony forming units (CFUs)/g11</li><li>Dosage range is strain-specifi c: between 107 (10 million) -109 (1 billion) CFUs/d. Ensure the supplement contains ≥109 unless research has demonstrated efficacy with smaller amounts11</li></ul></li><li>Adverse effects</li><li><ul><li>May cause diarrhoea, nausea, vomiting, constipation, abdominal discomfort, and vaginal symptoms (discharge, itching)14,16</li></ul></li><li>Key interactions</li><li><ul><li>Antibiotics: nutrient effect on drug, may restore gut flora and reduce diarrhoea secondary to antibiotic therapy. Interaction is likely to occur in most patients. No significant adverse effects expected. Supplementation may be beneficial12</li></ul></li></ul></li></ul>

Secondary

<h2>Diet and lifestyle</h2><ul><li>Wipe from front to back after going to the toilet1</li><li>Urinate immediately following sex to remove pathogens from the urethra1,3</li><li>Avoid condoms and diaphragms that contain spermicide3</li><li>Wear cotton rather than nylon underwear1</li><li>Don’t use perfumed soaps, talcum powder or deodorant around the genital area1</li></ul>

Diet & lifestyle

<h2>References</h2>1. Queensland Health. Urinary tract infection. Queensland Government; 2010 2. Jarvis T, Chan L, Gottlieb T. Assessment and management of lower urinary tract infection in adults. Aust Prescr 2014; 37:7-9. 3. Gupta K, Trautner BW. Diagnosis and management of recurrent urinary tract infections in non-pregnant women. BMJ 2013; 346:f3140. 4. Williams G, Craig JC. Prevention of recurrent urinary tract infection in children. Curr Opin Infect Dis 2009; 22(1):72-6. 5. Raz R. Urinary tract infection in postmenopausal women. Korean J Urol 2011; 52(12):801-8.6. Hisano M, Bruschini H, Nicodemo AC, et al. Cranberries and lower urinary tract infection prevention. Clinics (Sao Paulo) 2012; 67(6):661-8. 7. Natural Medicine 2016. Cranberry Professional Monograph 8. Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 2012; (10):CD001321. 9. Sengupta K, Alluri K, Golakoti T et al. A randomized, double blind, controlled, dose dependent clinical trial to evaluate the efficacy of a proanthocyanidin standardized whole cranberry (Vaccinium macrocarpon) powder on infections of the urinary tract. Current Bioactive Compounds 2011;7(1): 39–46. 10. Wang CH, Fang CC, Chen NC, et al. Cranberry-containing products for prevention of urinary tract infections in susceptible populations: a systematic review and meta-analysis of randomized controlled trials. Arch Intern. Med 2012; 172(13):988-96. 11. Braun L, Cohen M. Herbs &amp; Natural Supplements. 3rd ed. Chatswood: Elsevier; 2010. 12. Blackmores Institute Complementary Medicines Interaction Guide; 2016 13. Howell AB, Botto H, Combescure C, et al. Dosage effect on uropathogenic Escherichia coli anti-adhesion activity in urine following consumption of cranberry powder standardized for proanthocyanidin content: a multicentric randomized double blind study. BMC Infect Dis 2010; 10:94. 14. Schwenger EM, Tejani AM, Loewen PS. Probiotics for preventing urinary tract infections in adults and children. Cochrane Database Syst Rev. 2015; 12:CD008772. 15. Chisholm AH. Probiotics in preventing recurrent urinary tract infections in women: a literature review. Urol Nurs 2015; 35(1):18-21.16. Stapleton AE, Au-Yeung M, Hooton TM, et al. Randomized, placebo-controlled phase 2 trial of a Lactobacillus crispatus probiotic given intravaginally for prevention of recurrent urinary tract infection. Clin Infect Dis 2011; 52(10):1212-7.

Urinary tract infection

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