Urinary Tract Infections — Nonantibiotic Prophylaxis With High-Dose Cranberry Proanthocyanidins
Robust science and clinical guidelines support 36 mg cranberry proanthocyanidins as an intervention to prevent recurrent urinary tract infections and drive optimal antibiotic stewardship efforts.
Call it the “silver tsunami” or the “gray wave”—the surge in this country’s aging population will touch every aspect of health care utilization and delivery. The US population of individuals aged 65 and older has topped 50 million for the first time and is projected to grow to more than 70 million in the next 25 years.1 Urinary tract infections (UTIs) are among the most common infections diagnosed in older adults. They’re also the most frequently occurring infection in long term care residents, accounting for more than one-third of all nursing home–associated infections.2 As the population ages, the overall UTI burden will go up too, requiring new approaches and multidisciplinary strategies to improve the diagnosis, treatment, and, most key, prevention strategies to optimize elder care.
By the Numbers
Further compounding the problem, 25% to 50% of noncatheterized patients in long term care exhibit asymptomatic bacteriuria (AB). This is defined as the presence of bacteria in the urine without clinical signs or symptoms of a UTI. AB increases with age. Antibiotic therapy for AB doesn’t confer any long-term benefits in preventing symptomatic UTIs or improving mortality and may actually increase the incidence of adverse events and antibiotic resistance.3-5 Incorrect use of antibiotics in AB patients is potentially dangerous, with long-lasting negative effects. Multiple urological and infectious disease guidelines advise against treating AB with antibiotics, as does the American Geriatrics Society.4
Antibiotics and UTIs: A Slippery Slope
Long-term antibiotic use is associated with adverse events and diminished care, making it increasingly unsustainable. Some antibiotics have side effects that are especially alarming in aging adults with multiple comorbidities. It’s known that azithromycin—albeit rarely—can lead to dangerous heart arrhythmias. Fluoroquinolones, the most commonly prescribed class of antibiotics, have been associated with an increased risk of tendinitis, peripheral neuropathy, and hypoglycemia. This has led the FDA to issue black box warnings on this class of antibiotics.7 Moreover, antibiotics may interact negatively with many of the other drugs older adults take, including such widely used medications as statins, blood thinners, and kidney and heart medications. As one of the most common infections in long term care facilities, UTIs are also among the top reasons for hospital readmissions among residents, further contributing to poor quality care and increased health care costs.8,9
An Opportunity for Nonantibiotic Intervention
In its recently published guidelines for the management of recurrent UTIs, the American Urological Association highlights the use of cranberry prophylaxis, citing the benefits of proanthocyanidins (PAC), the bioactive ingredient contained in the fruit.10 Only the benefits of PAC from cranberry were highlighted as a consideration for nonpharmaceutical UTI prevention.
36 mg PAC and Proven Antiadhesion Activity
Evaluating Cranberry Products Against the Standard: Variability in Products
Importantly, the American Urological Association’s guidelines caution that many products used in studies were formulated specifically for research purposes, and the availability of similar and appropriately manufactured commercial products may be limited. It’s imperative that those in elder care settings review the research and ingredients prior to initiating cranberry prophylaxis in this vulnerable population.
A New Approach
Putting Prevention Into Practice
Safety and Reliability
To ensure a supplement is reliable for clinical use, the maker must have rigorous manufacturing standards, full transparency of ingredients, proof of consistency and efficacy of dosage and, above all else, clinical evidence with high-quality research supporting its use in various patient populations. Health care providers and patients should be able to readily access a product’s portfolio of evidence related to these standards for full confidence in its efficacy, ie, 36 mg of soluble A-type PAC to elicit clinically significant AAA for UTI prophylaxis.
Of note, the Mayo Clinic Proceedings report says “antibiotic-related reflexes” are a factor in overprescribing. It advises that clinicians slow down and practice more mindful medicine, “because mindfulness and reflection increase diagnostic and therapeutic accuracy.” It’s fair to say that clinicians can receive pressure from patients and their families to prescribe antibiotics, especially at first sign of symptoms. Older adults, for example, experiencing symptoms such as change in behavior and urine odor with no confirmed UTI, shouldn’t be prescribed an antibiotic without additional tests, whenever possible. These symptoms could be associated with other medical issues.
Clinicians should take the opportunity instead to have a conversation with patients and caregivers about the inappropriate use of antibiotics and possible urogesic agents that may help with treating UTI-like symptoms when no infection is present.
To promote superior antibiotic stewardship in the treatment of UTIs in long term care facilities and in all aspects of geriatric medicine, a better strategy for UTI prevention is long overdue. Health care providers must commit to prevention and self-care policies that start with actions to prevent and reduce UTIs altogether. A pharmaceutical-grade supplement that contains proven effective 36 mg PAC is a tool that can be simply and safely implemented into routine care to prevent recurrent UTIs, thus improving the quality of life for elderly patients. Experts are unanimous: Clinicians urgently need alternatives and adjuncts to antibiotics due to the lack of new antibiotics and the rapid speed at which bacteria are becoming resistant.
— Sophie A. Fletcher, MD, is a staff urologist for Sutter Medical Group of the Redwoods and the Sutter Health Foundation in Santa Rosa, California, and is an expert in female urology, voiding dysfunction, neurourology, female pelvic medicine, and reconstructive surgery. Fletcher is chair of the ellura Medical Advisory Board for Trophikos and is credited as the first US physician to implement the first commercial 36 mg proanthocyanidins formula in practice.
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