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Running head: EFFECTIVENESS OF CRANBERRY PRODUCTS IN PREVENTING
RECURRENT UTIS IN FEMALES

Are Cranberry Products Effective in Preventing Recurrent Urinary Tract Infections in the Female
Population?
Hannah Pettis
5/4/2014
Dr. Fetzer
University of New Hampshire

EFFECTIVENESS OF CRANBERRY PRODUCTS IN PREVENTING
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I. Background and Rationale
A Urinary Tract Infection is an infection that can happen anywhere along the urinary tract
including the urethra, bladder, ureters, and kidney. A lower UTI, or commonly referred to an
uncomplicated UTI involves the urethra and bladder only. Uncomplicated UTIs are more
common in women compared to men, with about 50% of women being treated within their
lifetime (Couling, 2008). Anatomically, women are at a higher risk for contracting a UTI due to
shorter length of the urethra, meaning there is less distance the bacterium has to travel. Recurrent
UTI can be defined as either a relapse where infection is caused by the same strain of organism,
or reinfection where the infection is caused by a different strain or different species of organism
(Couling, 2008). Women who present with recurring UTI should be treated as for any acute
episode of UTI, usually with a three-day course antibiotic. However there are complications
associated with long-term use of antibiotics, such as antibiotic resistance. This suggests the need
for more measures to be taken in order to prevent recurrent UTIs and the chance of antibiotic
resistance.
There are preventative methods women can take in order to avoid these recurrent
infections, and one suggestion includes the use of cranberry products. The exact use of cranberry
in UTI prophylaxis is unknown, however one plausible hypothesis is that two of its
compounds, fructose and an unknown polymeric substance, inhibits the adherence of bacteria,
especially E.coli, to the epithelial cells in the bladder wall to prevent colonization (Wang,
2013). Cranberry has also shown in recent studies to increase the acidity of urine, which is
harmful to the environment of bacterium. Cranberry can come in several forms, including juice
and tablets, usually between 200-500 mg of cranberry extract. Evidence based practice needs to
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confirm that the use of cranberry is recommended in preventing recurrent UTIs, and if so which
source of cranberry product is more beneficial in the prevention of recurrent UTI in women. Not
only will this help avoid the re- use of antibiotics that could lead to the current epidemic of
antibiotic resistance, but ultimately improve the urinary tract health of women and the possible
complications associated with recurrent UTIs.

II. Search Methods
a. CINHAL, Pubmed.gov, Mayo Clinic
b. Google, Ehis.ebscohost.com
c. Key Words: UTI Prevention, Cranberry Product, Female Population, Recurrent UTI
d. Limits Used: English only, women, prevention methods, Hx of recurrent UTI
e. Six
f. Inclusion: randomized studies with cranberry products, females, pre and post menopausal, UTI
prophylaxis
Exclusion: men, SCI, renal surgical patients

III. Critical Appraisal of the Evidence
Study #1
Bailey, 2006 conducted a pilot study determining if a concentrated cranberry extract
could prevent recurrent urinary tract infection in women. Women between the ages of 25-70
years were included in this study with a history of a minimum of 6 UTIs in the proceeding year
as a criteria measure. As an intervention, the women took a cranberry capsule BID for twelve
weeks containing 200 mg of the concentrated extract that was standardized to be 30% phenolics
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(a cranberry metabolite). There was also an initial questionnaire used to determine the patients
medical history, and they were asked at monthly intervals if any of the information had changed.
All of the women included in the study also had a urinalysis conducted within 24 hours before
starting the study preparation, and then once a month for four months following. Subjects in the
study were then followed up two years later. As a result, twelve women completed the 12-week
study and continued to be available for follow-up two years later. During the study, none of the
women had a UTI, and no adverse events were reported. Two years later, 8 of the 12 women
continued to take the cranberry product and continue to be free of UTI. Strengths of this study
include the length of time the study was conducted over to show that lack of UTI was sustained
for a long period of time, making the efficacy of the product more valuable. There was also
effective follow up with the women in that a questionnaire was provided monthly to describe any
changes in their medical history in regards to UTI. Proper diagnostics were also incorporated
into the study, which contribute to the efficacy of results as well. Weaknesses include a non-
randomized intervention group with a means of comparison of a control group. The implications
of strengths of this study can contribute to effective prophylaxis in women due to the uniqueness
of the longer UTI-free period of time with this cranberry extract product. Perhaps a cranberry
product with high phenolic content may completely prevent UTIs in women who are susceptible
to recurrent infections.
Study #2
Stapleton, 2012 conducted a study to compare the time to UTIs and the rates of
asymptomatic bacteriuria and urinary P-fimbriated E.coli during a 6 month period in women
ingesting cranberry juice versus a placebo juice daily. The patients and methods included
premenopausal women with a history of recent UTI in the past 12 months who were enrolled
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from November 2005 through December 2008 at two centers. They were randomized to 1 of 3
groups: 4 oz. of cranberry juice daily, 8 oz. of cranberry juice daily, or a placebo juice. Time to
UTI (symptoms and pyuria) was the main outcome. The factors of asymptomatic bacteriuria,
adherence, and adverse effects were also assessed at monthly visits. Results yield 176
participants were randomized with 120 to cranberry juice and 56 to placebo. They were followed
up for an average of 168 days. The cumulative rate overall for the cranberry group was 0.29 and
0.37 in the placebo group. The adjusted hazard ratio for UTI in the cranberry juice group vs. the
placebo group was 0.68. This essentially means that for every 2 people who had cranberry juice,
approximately 3 people had the placebo juice. The proportion of women with P-mbriated
urinary E coli isolates during the intervention phase was 10 of 23 (43.5%) in the cranberry juice
group and 8 of 10 (80.0%) in the placebo group. Overall, cranberry juice did not significantly
reduce UTI risk compared to the placebo. The strengths of this study show that there was a large
population for a means of comparison as well as three distinct groups. The sample was very
specific and essential to a study for women with recurrent UTI. There was also a very high
adherence rate to the intervention. Weaknesses of the study include the difficulty in determining
the hazard ratio and its implications in the study. The placebo group was also quite small (only a
10 sample size), which made it an illegitimate means of comparison to the intervention group.
However this study has implications to nursing in that it shows a suggestive intervention may not
be helpful in preventing UTIs with daily intake of cranberry juice and this method needs to
continue to be researched in its effectiveness.

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Study #3
Efros, 2010 conducted a study determining the safety, tolerability, maximal tolerated
dose, and efficacy of a concentrated cranberry liquid blend called UTI-STAT with Proantinox
(which is a concentrated form of cranberry) in female patients with a history of recurrent UTI
infections. Women aged 18-75 years were screened and had to have at least two or more UTIs in
the 6 months before study entry and could not have a current UTI. The average age was 46.
Once the sample was determined, the cranberry agent was administered orally at 15, 30, 45, 60,
and 75 mL daily for 12 weeks (each amount was a different sample group). Blood and urine
samples were collected at baseline at weeks 4 and 12. The primary measurements were the
safety, tolerability, and maximal tolerated dose. The secondary measurements were the efcacy
with regard to recurrent UTI and quality-of-life (QOL) symptoms. As a result, the sample size
came to have 23 women with analyzable data. The maximum tolerated dose was 75 mL of the
liquid, and the recommended dose was 60 mL. The secondary measurements showed that only 2
of the 23 women reported a recurrent UTI. At 12 weeks the worry of recurrent UTI was reduced
and the QOL was increased which was measured by a questionnaire at the end of the study. In
conclusion, the cranberry liquid showed good tolerability in women with a history of recurrent
UTIs. The strengths of this study include not only the beneficial effects of this cranberry product
in helping with UTI prophylaxis, but also a positive outcome of the quality of life of participants.
This was a unique measurement that I have yet to see in any other study of recurrent UTI
prophylaxis in women and is one that nurses are constantly trying to pursue in their patient-
centered care plans. Weaknesses of the study include a small sample size and the statement of an
exact amount that was most beneficial in the prevention of UTI. It was not clear if 75 mL was
well tolerated and if it was the key amount to drink on a daily basis. The implications of the
Pettis 7
strengths of this study into nursing practice is very useful in that the beneficial effects of UTI-
STAT may be a key aid in the prevention of recurrent UTI in this population of women. It could
potentially avoid the need for repeat antibiotics and could be narrowed down to be the most
effective product. However more studies should be conducted to compare this to other beneficial
cranberry products.

IV. Evidence Synthesis
After weighing the collected research on the effectiveness of cranberry products in the
prevention of recurrent UTIs in the female population, best evidence practice research shows that
cranberry products are effective in UTI prophylaxis. The two forms of product that prove to be
effective include cranberry tablets and a concentrated cranberry liquid. Cranberry tablets deem to
be effective when 200 mg cranberry 30% phenolics capsules are taken BID, when taken up to 12
weeks or longer as needed. This was able to prevent recurrent UTIs in all of the participants of
the study who had at least six UTIs in the previous year. The concentrated cranberry liquid, UTI-
STAT with Pronantinox deemed to be effective and tolerable when drinking 60-75 mL of the
liquid daily for up to 12 weeks or continued as needed. This was effective for 2/23 both pre and
postmenopausal women who had recurrent UTI with at least two infections six months prior. It
was tolerable, proven to have efficacy in UTI prophylaxis, and increased the quality of life in the
sample of women. Lastly, four or eight ounces of cranberry juice on its own was determined in a
study to not have a significance in recurrent UTI prophylaxis according to the researchers
because it was below a 50% effectiveness rate. In my opinion, a 43.5% prevention rate has
significance in preventing recurrent UTIs to some degree. Collectively, the studies are all
Pettis 8
consistent in that fact that they show that cranberry products are effective in decreasing the risk
of obtaining a recurrent UTI in the female population.

V. Clinical and Research Recommendations
Based on my critical appraisal of evidence involving the prevention of recurrent UTIs in
women, certain cranberry products can be used for prophylaxis under the guidance of evidence-
based practice. Due to the high rate of UTI occurrence in women, prevention methods are
essential to female urinary tract health. Prevention can ultimately reduce discomfort, improve
quality of life, and reduce healthcare costs associated with the treatments and complications. If
women are educated on the evident cranberry products, more UTIs can be avoided along with the
complications associated with them such as pyelonephritis and sepsis, which contribute to
morbidity (Moralejo, 2008). Continuous antibiotic treatment can also be avoided and the
associated risk of antibiotic resistance that is a prevalent epidemic across our healthcare system.
Nurses can improve patient education interactions by incorporating this method of prophylaxis
into their patients plan of care. However, there needs to be more research conducted on the
various cranberry products in comparison with each other to determine which is the most
effective in recurrent UTI prophylaxis. I had trouble finding studies that were directly compared
to each other; therefore it is still inconclusive in which product to suggest for prevention based
on evidence-based practice.

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References
Bailey, D. T., Dalton, C., Daugherty, F. J., & Tempesta, M. S. (2007). Can a concentrated
cranberry extract prevent recurrent urinary tract infections in women? A pilot
study. Phytomedicine, 14(4), 237-241. Retrieved
from http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=2009572903&site=
ehost-live
Couling, R. (2008). Managing lower UTI in adults in the community. Nurse Prescribing, 6(11),
485-489. Retrieved
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Efros, M., Bromberg, W., Cossu, L., Nakeleski, E., & Katz, A. E. (2010). Novel concentrated
cranberry liquid blend, UTI-STAT with proantinox, might help prevent recurrent urinary
tract infections in women.Urology, 76(4), 841-845.
doi:http://dx.doi.org/10.1016/j.urology.2010.01.068
Moralejo, D. (2008). Review: Cranberry products may prevent urinary tract infection in women
with recurrent infections. Evidence Based Nursing, 11(3), 74-74. Retrieved
fromhttp://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=2009982269&site=
ehost-live
Stapleton, A. E., Dziura, J., Hooton, T. M., Cox, M. E., Yarova-Yarovaya, Y., Chen, S., &
Gupta, K. (2012). Recurrent urinary tract infection and urinary escherichia coli in women
ingesting cranberry juice daily: A randomized controlled trial. Mayo Clinic
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Proceedings, 87(2), 143-150. Retrieved
ehost-live
Wang, P. (2013). The effectiveness of cranberry products to reduce urinary tract infections in
females: A literature review. Urologic Nursing, 33(1), 38-45. doi:10.7257/1053-
816X.2013.33.1.38

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Running head: EFFECTIVENESS OF CRANBERRY PRODUCTS IN PREVENTING

RECURRENT UTIS IN FEMALES

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