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Antibiotic prophylaxis bested cranberry capsules for recurrent UTIs
SAN FRANCISCO — The use of cranberry capsules for the prevention of urinary tract infections was less effective than low-dose antibiotics, according to research presented here at the 52nd Interscience Conference on Antimicrobial Agents and Chemotherapy.
However, when considering prophylaxis options, physicians should also consider the development of resistance among the normal flora, Suzanne Geerlings, MD, PhD, an infectious diseases specialist at the Academic Medical Center in Amsterdam, said at a press conference here.
Suzanne Geerlings
“It was difficult to perform this trial because most of the women wanted to be in the non-antibiotic arm,” Geerlings said. “Women know that if they take antibiotics for long periods of time, they may develop resistance. They also know that once they get an infection, it will be more difficult to treat.”
Geerlings and colleagues conducted a double blind, double dummy, noninferiority trial in which 221 premenopausal women with recurrent UTIs were randomly assigned to prophylaxis with once-daily 480 mg trimethoprim-sulfamethoxazole or twice-daily 500 mg cranberry capsules.
After receiving treatment for 1 year, the proportion of patients experiencing at least one symptomatic UTI was higher among the women who had received the cranberry capsules: four compared with 1.8 (P=.02). Among those who received cranberry capsules, the median time to first symptomatic UTI was 4 months compared with 8 months among those who received the antibiotic.
Among those who received the antibiotic, the researchers found increased resistance rates to trimethoprim, TMP-SMX, amoxicillin and ciprofloxacin to Escherichia coli isolates in the normal flora, 1 month after discontinuing treatment, but the resistance returned to baseline levels after 3 months. There was no resistance observed among women who received the cranberry capsules.
For more information:
Geerlings S. #542. Presented at: 52nd ICAAC; Sept. 9-12, 2012; San Francisco.
Disclosure: Geerlings reports no relevant financial disclosures.
Perspective
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The question of use of non-antimicrobial agents to prevent urinary tract infection in women with frequent recurrences is a significant one. The avoidance of systemic antimicrobial agents is a worthy cause, because of the potential side effects of the drugs and the proven increased risk of developing a more resistant bacterial flora. However, it is important to point out that antimicrobial prophylaxis can be used, with deceased risks, by the approaches of giving single dose prophylaxis with intercourse or by self treating each symptomatic episode as it occurs rather than continuous prolonged administration.
The investigators mention intravaginal estrogens in postmenopausal women. Cochrane evidence based reviews indicate that intravaginal estrogens, but not oral estrogens, do decrease numbers of recurrences in postmenopausal women, but the type of estrogen to use and the duration of therapy have not been standardized.
The studies reported by the current investigators demonstrate that trimethoprim/sulfamethoxazole is superior to oral lactobacilli (L. rhamnosus GR-1 and L. reuteri RC) or oral cranberry capsules. Unfortunately, there was no untreated control group to determine actual effectiveness in treated groups rather than comparative effectiveness.
Cochrane reviews indicate that oral cranberry products are probably effective in reducing recurrences, but the formulation (juice, capsules or tablets) has not been standardized nor has the dose.
The study by Stapleton et al. in Clinical Infectious Diseases 52:1212, 2011, which used intravaginal L. crispatus, had impressive results and the literature contains reports using L. acidophilus and other probiotics with mixed results. Suffice it to say that there is no standardization of strain of bacteria or dose or route of administration.
Despite lack of standardization, all of these approaches are promising and deserve further study. Eventually, practice guidelines on preparation to use and dose for all three approaches and route of administration in the case of probiotics will be helpful.