Urinary Tract Infestions are one of the most common infections in women.  Current treatment trends for UTI include antibiotic therapy without urine culture and sensitivity testing, short-course therapy, patient-administered (self-start) therapy and outpatient therapy for uncomplicated pyelonephritis (J Urol 2002 Dec;168(6):2351-8).  A high frequency of infections might merit a urological work-up.  Ciprofloxacin 250 mg twice a day for three days costs 60 cents wholesale (14 days if spinal cord injury).  It's probably the best first choice.  Generic Bactrim-DS (trimethoprim/sulfamethoxazole) twice a day for three days (93 cents wholesale) is just as good, but with somewhat more side-effects.  Cefaclor 250 mg three times a day for five days was also successful $7.50 (wholesale) as is cephalexin (Keflex) 250 mg capsules four times a day (54 cents a day).  

Ceftriaxone (Rocephin) is wastefully expensive as are many others.  Amoxicillin and ampicillin are probably somewhat less effective.  Levaquin (levofloxacin) is a wasteful patented antibiotic costing $12 per day.  It did no better than ciprofloxacin in a 388-patient study of chronic bacterial prostatitis (J Urol 2005 Jul;174(1):161-4).  Ofloxacin was no better than the much cheaper ciprofloxacin for UTI (Eur J Clin Microbiol Inf Dis 2000 May;19(5):327-31).  Levofloxacin did no better than ciprofloxacin for acute pyelonephritis (Urol 1998 Jul;52(1):51-5).  They were also very equal in a large study of skin infections (Int J Clin Prac 1998 Mar;52(2):69-74).

A single dose of antibiotic after intercourse may prevent infections in women prone to such infections.  Keeping ciprofloxacin or generic Bactrim on hand is a great idea so that treatment can be started as soon as possible.  Even a single dose of ciprofloxacin 500 mg or generic Bactrim-DS at the first sign of infection has a good cure rate.  I would combine it with cranberry tablets.  Ciprofloxacin, ofloxacin, and generic Bactrim all did equally well with cure rates in the mid 90%s after 3 days for UTI (Am J Med 1999 Mar;106(3):292-9).

Since one recent study found that antibiotics may increase the risk of breast cancer, finding ways to minimize antibiotic usage while protecting the kidneys and stopping infections might be important.  Fortunately, the use of yogurt and, especially cranberry juice or tablets on a regular basis can markedly reduce the risk of infection for most patients.  

Carbonated soft drinks more than doubles the risk of UTIs (Epidemiol 1995 Mar;6(2):162-8).  Pantyhose and panty liners also increase the rate of infection as do multiple sex partners and the man's use of condoms.  Now Foods Cranberry concentrate capsules sell for about $10 for a one month's supply (1.4 grams (2 capsules) twice a day) on www.iherb.com (Feb. 2006).  Eating raw cranberries would be cheaper (5-6 berries twice a day) but much more of a hassle.  Drinking one cup of juice three times a day costs more and is also less convenient.  I recommend yogurt as well, but avoid the standard yogurt with large amounts of added sugar and use the "light" artificially sweetened yogurt or plain yogurt.

Ciprofloxacin 250 mg Twice a Day for Three Days: In a DB PC study of 527 women with acute UTIs with positive cultures, ciprofloxacin 250 mg twice a day did just as well as the much more expensive Cipro XR 500 mg daily for three days each (90% cure rate vs. 93%) ($0.60 vs. $30 wholesale cost). Nausea and diarrhea were very uncommon in both groups but higher with the immediate release. Fourcroy JL, et al. Uniformed Services University of the Health Sciences, Bethesda, Maryland. Antimicrob Agents Chemo 2005 Oct;49(10):4137-43. Urinary infections after removal of short-term catheters have a high 16% rate of resistance to ciprofloxacin. 

Condoms: Condoms Dramatically Increase Urinary Tract Infections: In a case-control study of sexually active college women ages 18-39 years, cases (N = 144) were women with first urinary tract infection (confirmed by culture); controls (N = 286) were similar women without a history of urinary tract infection. After adjusting for frequency of intercourse, using unlubricated condoms compared with using no birth control method dramatically increased the risk of first urinary tract infection (odds ratio = 29.1). Using a lubricated condom (with or without spermicide in the lubricant) or a spermicidal cream or gel with an unlubricated condom was associated with two- to eightfold risk of first urinary tract infection. Condom use and first-time urinary tract infection. Foxman B, Marsh J, Gillespie B, Rubin N, Koopman JS, Spear S. University of Michigan. Epidemiology. 1997 Nov;8(6):637-41 

Cranberry Tablets Just as Good and Cheaper than Juice: In an excellent 1-year DB PC study of 150 sexually active women ages 21-72 years, cranberry ablets twice daily did just as well as juice 250 ml three times daily with a greater than 50% decrease in symptomatic UTI's per year (symptoms + >or= 100 000 single organisms/ml) (20% vs. 18% vs. 32% for placebo). The annual cost of prophylaxis was $624 and $1400 for cranberry tablets and juice respectively. Cost savings were greatest when patients experienced >2 symptomatic UTI's per year (assuming 3 days antibiotic coverage) and had >2 days of missed work or required protective undergarments for urgency incontinence. Total antibiotic consumption was less annually in both treatment groups compared with placebo. A randomized trial to evaluate effectiveness and cost effectiveness of naturopathic cranberry products as prophylaxis against urinary tract infection in women.  Stothers L. University of British Columbia. Can J Urol 2002 Jun;9(3):1558-62.

Cranberry Juice Helped But Urinary Tract Infections Not Prevented by Lactobacillus GG Drink: In a randomized trial of 150 women recovered from an E. Coli UTI, at six months the cranberry group and 16% recurrences vs. 39% LGG drink five times per week and 36% for controls. Randomised trial of cranberry-lingonberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women. Kontiokari T, et al. BMJ. 2001 Jun 30;322(7302):1571; However, Cranberry juice in a geriatric department, where the mean stay was 4 weeks, did not influence the incidence of urinary tract infections. Ugeskr Laeger 2001 May 14;163(20):2782-6. Red, but not white cranberries help.  One study suggested that dried cranberries also help.  The main effect is not due to the lowered pH level of the urine, but to impairing the ability of bacteria to adhere to the bladder surface. In another study with the elderly, cranberry juice 300 ml/day did reduce UTIs, especially from E. Coli. Age Ageing 2005 May;34(3):256-61.

Cranberry Protective, Soft Drinks Bad: Vaginal intercourse increased the risk of UTI; this risk was further increased with condom use. After adjusting for vaginal intercourse with other birth control methods and recentness of current sexual partnership, a single sex act with a condom in the past 2 weeks increased UTI risk by 43%. Having a sex partner for less than 1 year vs. 1 year or more, after adjustment for frequency of vaginal intercourse and birth control method, was associated with about twice the risk of UTI [odds ratio (OR) = 1.97; 95% confidence interval (CI) = 1.04-3.74]. After adjusting for frequency of vaginal intercourse, regular drinking of cranberry juice was protective against UTI (OR = 0.48; 95% CI = 0.19-1.02), whereas drinking carbonated soft drinks appeared to be associated with increased risk (OR = 2.37; 95% CI = 0.75-7.81). Using deodorant sanitary napkins or tampons was associated with a slight increase in risk of UTI (OR = 1.51; 95% CI = 0.74-3.06). Blacks had five times greater risk of UTI than whites after adjusting for frequency of vaginal intercourse (OR = 5.2; 95% CI = 1.89-24.63). Study was with 280 college females. Epidemiology 1995 Mar;6(2):162-8

Cranberry Juice Just as Good Against Anti-Biotic Resistant: property of the cranberry is the key to its urinary tract health benefit. Scientists believe that the proanthocyanidins, or condensed tannins, in cranberries prevent certain E. coli bacteria from sticking to the urinary tract. Benefit starts 2 hr after consumption and lasts 10 hr, therefore, consume at least AM and HS. 6/24/02 JAMA. Rutgers. Ed: Cranberry juice did change nasal pharyx or colonic bacteria in children J Clin Nutr 2005 Dec;24(6):1065-72. Cranberry juice consumption did not alter blood or cellular antioxidant status or several biomarkers of lipid status pertinent to heart disease. Eur J Nutr July 2005. Cranberry juice 250 mL twice a day did slightly suppress H. pylori infections. Helicobact 2005 Apr;10(2):139-45. Cranberry extract 2 g/d did help in a small study of spinal cord patients. J Spinal Cord Med 2004;27(1):35-40. In a 9-month study of 65 women with recurrent female yeast infections, the use of pantyliners or pantyhose, consumption of cranberry juice or acidophil-containing products, a history of bacterial vaginosis, and age <40 years were positively associated with a symptomatic vulvovaginal candidiasis episode. 

Cranberry Juice Capsules Don't Help: In a 6-month DB PC study of 48 patients with recurrent UTIs, 2 grams of concentrated cranberry juice in capsules was of no benefit. Effect of cranberry extract on bacteriuria and pyuria in persons with neurogenic bladder secondary to spinal cord injury. Waites KB, Canupp KC, Armstrong S, DeVivo MJ. University of Alabama. J Spinal Cord Med. 2004;27(1):35-40

Yogurt: Juice, Cheese Reduce Recurrences: women who drank at least one daily glass of fresh juice--either freshly squeezed or from concentrate, with no additional sweeteners--were 34% less likely to have experienced a recent UTI. Juices made from berries was best. Women who reported eating milk products that contain helpful microbes known as probiotic bacteria--such as yogurt and cheese--at least three times each week were almost 80% less likely to have recently developed a UTI than women who ate similar foods less than once per week. 139 women who had developed a UTI within two weeks prior, vs 185 women who had not experienced UTIs within the past five years. Study participants' average age was 30. Kontiokari, Finland, American Journal of Clinical Nutrition 2003;77:600-604.

Yogurt: Urinary Tract Infections Prevented by Intravaginal Lactobacilli: In a study of 41 women treated with an antibiotic for a urinary tract infection, post-therapy vaginal administration of lactobacillus suppositories resulted in a recurrence rate of UTI of only 21%, while in patients given sterilized skim-milk suppositories the recurrence rate was 47%. Univ. W. Ontario. Reid G, Bruce AW, Taylor M. Influence of three-day antimicrobial therapy and lactobacillus vaginal suppositories on recurrence of urinary tract infections. Clin Ther 1992; 14: 11-16. Ed: I recommend everyone to eat yogurt daily.  The benefits are even higher for women than men.

Urinary Incontinence Helped by Muscle Cell Injections: Ryan J. Pruchnic, of the departments of urology and orthopedic surgery, University of Pittsburgh has taken skeletal muscle, cloned it and injected it into urethra in mice as successful Rx. Amer Urol Assoc 5/28/02

Treat Kidney Infections 10 Days: Of 1084 women with acute ambulatory kidney infections in Manitoba, 653 (60.2%) were treated with trimethoprim-sulfamethoxazole and 431 (39.8%) treated with a fluoroquinolone. At age 20, treatment with a fluoroquinolone resulted in a reduced probability of treatment failure compared with trimethoprim-sulfamethoxazole (odds ratio, 0.56). At age 60, there was no difference in the probability of treatment failure (odds ratio, 1.61). No other subject characteristics impacted comparative effectiveness; however, several characteristics increased the odds of treatment failure irrespective of the initial antibiotic. These included: recent urinary tract infection (odds ratio, 2.07), recent antibiotic use (odds ratio, 1.40), and a treatment duration of less than 10 days (odds ratio, 2.18). Univ Alberta. Use of administrative healthcare claims to examine the effectiveness of trimethoprim-sulfamethoxazole versus fluoroquinolones in the treatment of community-acquired acute pyelonephritis in women. Carrie AG, Metge CJ, Collins DM, Harding GK, Zhanel GG. J Antimicrob Chemother. 2004 Jan 28

Antibiotic 3 Days as Good as 7 for Uncomplicated UTI in Elderly Women: In a 183-patients random assignment study of women over 64 using Cipro, the percentage of negative cultures was as high after 3 days (98%) as after 7 (93). Optimal duration of antibiotic therapy for uncomplicated urinary tract infection in older women: a double-blind randomized controlled trial. Vogel T, Verreault R, Gourdeau M, Morin M, Grenier-Gosselin L, Rochette L. CMAJ. 2004 Feb 17;170(4):469-73

Recurrent UTI: Treat on the basis of dipstick findings (positive results for nitrite or leucocytes) and reserve urine culture for when symptoms are not resolving. A urine culture is probably indicated if she is in a high risk group (pregnant women or women with an anatomically or functionally abnormal renal tract). Options to manage recurrent UTIs: a short course of antibiotic treatment at the onset of symptoms of UTI or prophylactic antibiotic treatment (single 200 mg dose of trimethoprim) after sexual intercourse if previous infections have been related to sexual intercourse or she could take a longer course of daily or thrice weekly prophylactic treatment. Cranberry juice treats urinary tract infection and prevents its recurrence. BMJ  11/2003;327:1204 

Thomas E. Radecki, M.D., J.D.

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