Running Head: CRANBERRIES AND UTI PREVENTION 1

Cranberries and Urinary Tract Infection Prevention

Emily Hazelton
University of New Hampshire






















CRANBERRIES AND UTI PREVENTION 2
What is the effect of ingested cranberry products in prevention of
recurrent urinary tract infections in women aged 18-64 compared with
no implementation of prevention?

Population: Women aged 18-64
Intervention: Ingestion of cranberry products (juice, capsules, etc.)
Comparison: No prevention strategy implemented
Outcome: Urinary Tract Infection
Time: 2 weeks-12 months
Background
Urinary tract infections (UTIs) are among the most prevalent infections of the female
population within the United States. Almost half of all women will experience at least one urinary
tract infection within their lifetime. The occurrence is more frequent in sexually-active women,
especially those of college-age (Ehrlich, 2012). Prevention and treatment of acute and chronic urinary
tract infections is vital. Although most UTIs are not serious, some can cause other severe problems,
including kidney infections, which can lead to poor kidney function, hypertension, and even
septicemia, which is life-threatening (Urinary Tract Infections in Adults, 2011).
Because Urinary Tract Infections are so common, prevention is a very important tool in
managing this widespread issue. At home, individuals should be sure to drink plenty of fluids, wipe
from front to back after using the bathroom, and empty their bladder after intercourse. The use of
cranberry products in the prevention of urinary tract infections has been a topic of research for many
years. Researchers believe that chemicals in cranberries prevent infection-causing bacteria from
sticking to the walls of the urinary tract, making it difficult for an infection to take hold. Some studies
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show that specific antioxidants in cranberries change the bacteria, keeping it from getting stuck
within the urinary tract. Evidence shows that ingesting cranberries will not treat urinary tract
infections, but there is substantial research that supports a decrease in bacteria and white blood cells
in the urine after consuming cranberry products, possibly preventing the onset of infection (Miller-
Thrasher, 2013). If cranberry products are added to the diets, as tolerated, of female individuals,
prevalence of Urinary Tract Infections may be effected. Education and current data involving UTI
prevention should be understood by nurses so accurate research and options can be presented to
patients.
Search Methods and Studies
Primary sources were attained through several searches of CINAHL, Medscape, and
Google. A range of terms were used to identify sufficient research articles, including the
following: cranberry juice, cranberry products, women, Urinary Tract Infection
prevention, and study. Limits included English only, full text, and the publishing date of the
research (within 10 years). Inclusion criteria included adult women between the ages of 18 and
64. Exclusion criteria included males, anyone under age 18 or over age 64. The limits reduced the
search results from 103 results to 24 results, which were then further reduced using inclusion and
exclusion criteria, or lack of pertinent data. Studies chosen include a randomized double-blind
noninferiority trial, a modified observational study and a randomized placebo-controlled study, all
using women between the ages of 18 and 64 years old.
Critical Appraisal of Evidence
Each study assessed the role of cranberry products in the prevention of recurrent urinary
tract infections in women. Through analysis and comparison of three clinical trials, it was
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concluded that cranberry products are a successful prevention method of urinary tract infections
in some cases, although they may not be as preventative as other measures and in some cases have
no preventative effect. Two of the three cases showed improved prevention after cranberry
consumption. In one case, it was shown that although cranberry products are not as preventative
as antibiotics, they do not contribute to increased antimicrobial resistance rates, which could
improve the general outcomes of urinary tract infections. Each article examined the effect of
consumed cranberry products in preventing urinary tract infections altogether and decreasing the
frequency of chronic infections. The studies showed a range of improvement in prevention of
infection from no improvement seen to a vast decrease in infection rates. The first study enrolled
twenty women, each of whom consumed one serving of cranberry product per day for a duration
of two weeks. The results were compared to women who received no preventative treatment. The
second study used a randomized double-blind study to compare the effects of cranberry capsules
and antibiotics in combating chronic urinary tract infections, using 221 women. The third study
used comparison groups, with one group consuming cranberry capsules and the other consuming
placebo tablets.
Burleigh et al. (2013) used a modified observational study to assess the effect of
consumption of sweetened, dried cranberries and the incidence of urinary tract infections in
people who commonly contracted UTIs. The mean age of participants was 37 years old, with ages
ranging from 18 to 64 years old. Participants were eligible if they had been diagnosed with at
least 3 urinary tract infections within the past year or 2 urinary tract infections within the past 6
months. A two-week antibiotic washout periods of non-prophylactic antibiotics (i.e. being
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treated for a diagnosed UTI) was required before beginning the study, although those taking daily
prophylactic antibiotics were allowed to participate in the study. A total of 20 women were
involved in the study. There were no significant differences in health between the participants.
According to Burleigh (2013), dried cranberries may contain a different spectrum of
polyphenolics ([type of antioxidant]) than juice, [meaning that] consuming [cran]berries may or
may not be more beneficial than juice in decreasing the incidence of UTIs in susceptible women
(p. 2). Each contributor to the study consumed one serving of sweetened, dried cranberries (SDC)
daily for two weeks. Results showed that over one half of the patients involved in the study did
not experience a urinary tract infection within 6 months of regular SDC consumption. Nine of
seventeen patients reported no urinary tract infections within six months since beginning the
study, indicating a beneficial effect of consuming SDC in reducing recurrent urinary tract
infections in susceptible women. The research adds that sweetened, dried cranberries are an
inexpensive, available addition to the diet and may have prophylactic effects against infection.
The fact that three of the participants were taking daily antibiotic prophylaxis may have affected
the outcome of the study; however, when these individuals were eliminated from analysis, the
urinary tract infection rate six months following the SDC regimen remained significantly
decreased. This particular study also explored the impact of SDC on intestinal E. coli, so it was
difficult to separate the information pertinent to only UTIs at times (Burleigh et al., 2013). There
could have been more detail regarding any side effects (GERD, stomach irritation, etc.)
experienced by the participants, if any. Beyond that, the study and its outcome was easily
CRANBERRIES AND UTI PREVENTION 6
understandable and relevant to the topic in question. Any flaws within the study presumably have
little to no effect on the accuracy of the results.
Beerepoot et al. (2011) used a randomized double-blind study with two groups receiving
different preventative urinary tract infection measures. The study compared the prophylactic use
of Trimethoprim-Sulfamethoxazole antibiotics (Bactrim) with the consumption of condensed
cranberry capsules. A total of 221 premenopausal women, over age 18, with recurrent urinary
tract infections were randomized into groups that completed 12-month prophylactic use of either
Bactrim (480 mg once daily) or cranberry capsules (500 mg twice daily). Participants had to have
a medical history of at least 3 symptomatic urinary tract infections in the year before enrollment
in the study. Exclusion criteria included individuals with UTI symptoms at the start of the study.
Participants also could not have any adverse reactions to the antibiotic used or have any cranberry
allergies. Results were gathered through the average number of symptomatic urinary tract
infections experienced by participants over 12 months, as well as the average time until the first
infection was diagnosed after the treatment. The number of participants with at least one
symptomatic UTI, and the development of antibiotic resistance in E. coli was higher in those who
used antibiotics. After 12 months, results showed that symptomatic urinary tract infections were
about 2 times higher in the cranberry group than in the Bactrim group. The average time elapsed
before the first symptomatic UTI was diagnosed after treatment was 4 months for the cranberry
group and 8 months for the group receiving Bactrim. There were increased resistance rates for
trimethoprim, amoxicillin, and ciprofloxacin on the infections in participant who received
Bactrim as a prophylaxis. Antibiotic resistance did not increase in the group receiving
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cranberries. The antibiotic and the cranberries were equally well-tolerated by participants. The
study showed that in premenopausal women above age 18, antibiotics were more effective than
cranberry products in preventing recurrent urinary tract infections, at the expense of further
resistance of antibiotics. It was noted that the cranberry capsules did contribute to increased UTI
prevention, although not as much as antibiotic prophylaxis (Beerepoot et al., 2011). The article
presented information effectively with clear analysis of findings and detailed account of the study.
The participants were randomly selected, aside from age range and UTI history, which removes
risk of bias within the study. Information was easy to follow with clear headings and
subheadings.
Barbosa-Cesnik et al., (2011) used the comparison of a treatment group and placebo group
to investigate the capability of cranberry juice in combating urinary tract infections among
women. Participants were women aged 18 to 40 years old who had presented with at least 3 UTI
symptoms to the University of Michigan Health Service laboratory over the span of two years.
Symptoms included painful/frequent urination, and report of urgency, hematuria or supra-pubic
pressure. Exclusion criteria included antibiotic treatment within the last 48 hours, hospitalization
or catheterization in the last 2 weeks, kidney stones, diabetes, pregnancy, cranberry allergy, or no
evidence of recurrent UTIs. Most participants were part of the college population. Participants
were randomly assigned to drink 8 oz. of low-calorie cranberry juice cocktail twice daily or 8oz
of a placebo juice twice daily for a period of six months. Randomization was done through
assignment of a lot number at the time of enrollment. The trial study groups were similar in socio-
demographics and known urinary tract infection risk factors. The placebo juice was formulated to
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mimic the flavor and color of cranberry juice without any cranberry content. Clean-catch
midstream urine specimens were collected at 3 and 6 month visits. Participants also completed
questionnaires regarding UTI symptoms at 1, 2, 4, and 5 months following the beginning of the
study. A total of 319 women participated in the study. Of the 319, 155 were assigned to cranberry
juice and 164 were assigned to the placebo drink. Results showed that the group using the
cranberry juice had a slightly higher urinary tract infection recurrence rate than the group using
the placebo drink, demonstrating that cranberry has no effect on prevention of recurrent urinary
tract infections (Barbosa-Cesnik et al., 2011). The article gave clear insight into the format of the
study and the results. Some of the charts were difficult to understand, but would likely be easier
to follow with more background knowledge regarding the study. The comparison to a placebo
group allowed for no bias among participants and those proctoring the study, possible allowing
for more precise results. Discrepancies that altered the number of participants was clearly
explained.
Evidence Synthesis
According to the presented studies, there is evidence that supports the idea that cranberry
products are effective in preventing urinary tract infections. There is also evidence that suggests
cranberry product consumption has no effect on preventing urinary tract infections. The outcomes
of the studies could have been influenced by the form of cranberry used (capsules, juice, dried
fruit) or by compliance of the participants in consuming the cranberry products as directed. There
were noteworthy differences between the studies used. The form of cranberry product used in
each study was different. Different forms included capsules, dried fruit, and juice. The usage of
CRANBERRIES AND UTI PREVENTION 9
different kinds of cranberry may have influenced results. The time frame of the studies also
differed, ranging from 2 weeks to 12 months. This also may have had an effect on results.
There are nearly no disadvantages to consuming cranberries, aside from allergic reactions
and the potential for gastric upset. It appears that some individuals benefit from cranberry
products as a preventative measure for UTIs while others do not. According to this research,
antibiotics are the most beneficial prophylactic measure in preventing urinary tract infections,
although frequent antibiotic use can lead to antimicrobial resistance, making treatment of UTIs
more difficult.
Clinical and Research Recommendations
The use of cranberry products may be a good option for some individuals in preventing
recurrent urinary tract infections. Patients who have been on long-term antibiotic therapy may
benefit from the consumption of cranberry products, keeping bacteria from building up in the
urinary tract while avoiding contribution to antimicrobial resistance. Patients may benefit from
adding cranberries to their diet after experiencing urinary tract infections. Nurses and other health
care professionals should be educated and current on UTI prevention strategies, including the
option of experimenting with cranberry products so they can present prevention options to their
patients.





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References Cited
Barbosa-Cesnik, C., Brown, M. B., Buxton, M., Zhang, L., DeBusscher, J., & Foxman, B. (2011).
Cranberry Juice Fails to Prevent Recurrent Urinary Tract Infection: Results From a
Randomized Placebo-Controlled Trial. Clinical Infectious Diseases, 52(1), 23-30.

Beerepoot MJ, ter Riet G, Nys S, Van der Wal W.M., Corianne A.J., de Borgie M,. . . . .
. Geerlings S.E. (2011). Cranberries vs Antibiotics to Prevent Urinary Tract
Infections: A Randomized Double-blind Noninferiority Trial in Premenopausal
Women. Arch Intern Med.;171(14):1270-1278. doi:10.1001/archinternmed.2011.306.

Burleigh, A. E., Benck, S. M., McAchran, S. E., Reed, J. D., Krueger, C. G., & Hopkins, W. J.
(2013). Consumption of sweetened, dried cranberries may reduce urinary tract infection
incidence in susceptible women -- a modified observational study. Nutrition Journal, 12(1),
53-67. doi:10.1186/1475-2891-12-139

Ehrlich, S. D. (2012). Urinary tract infection in women. University of Maryland Medical Center.
Retrieved May 2, 2014, from https://umm.edu/health/medical/altmed/condition/urinary-
tract-infection-in-women

Miller-Thrasher, M. (2013). Cranberries and Preventing Urinary Tract Infections (UTIs).
WebMD. Retrieved May 2, 2014, from http://www.webmd.com/urinary-incontinence-
oab/womens-guide/cranberries-for-uti-protection

Urinary Tract Infections in Adults. (2011). Urinary Tract Infections in Adults. Retrieved May
2, 2014, from http://kidney.niddk.nih.gov/kudiseases/pubs/utiadult/#serious