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| Natural Medicines in the Clinical Management of Urinary Tract Infections |
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Antibiotics |
Immunomodulators |
Kidney and Bladder Teas
Miscellaneous |
The Bottom Line |
References
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Urinary tract infections are about 50 times more common in women than in men. This is primarily due to anatomical differences. Women have a shorter urethra. Bacteria have a shorter distance to travel in order to get established in the bladder. A woman's urethra is also closer to the rectum. This makes it easier to transfer pathogenic bacteria from the rectal area to the urethral area.
Urinary tract infections are rare in healthy men. When they do occur in a man, it's most often the result of an underlying condition such as prostate disease, incontinence, or some other condition. Since there is almost always some other condition involved, urinary tract infections in men are almost always considered complicated.
In elderly patients, there is no difference in urinary tract infection rates between men and women. In these patients, urinary tract infections are usually caused by other conditions such as incomplete bladder emptying or incontinence.
| Factors that INCREASE the Risk of Urinary Tract Infections |
- Sexual activity
- Incontinence
- Using a diaphragm or spermicide
- Holding urine for long periods of time
- Taking baths
- Douching
- Recent bacterial infection
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Lower urinary tract infections, or "cystitis," are the most common and are considered uncomplicated. Symptoms usually have rapid onset and typically include increased urinary frequency, urgency, and painful urination.15826
Upper urinary tract infections that reach the kidney, or "pyelonephritis," are considered complicated. It can be difficult to distinguish between complicated and uncomplicated urinary tract infections because symptoms are often similar.15826 But it's important to make the distinction because treatment can be different for the more serious, complicated cases.
In pyelonephritis, patients are more likely to have chills, fever, and flank pain.15826 Some people can also have nausea and vomiting. In some cases, a longer course of oral antibiotics works. But hospitalization and intravenous antibiotics are sometimes necessary in more severe cases.
Patients with malodorous urine or who have symptoms with a slow onset need to be evaluated for other potential conditions, such as a yeast infection or a sexually transmitted disease (e.g., chlamydia, gonorrhea).
Urinary tract infections are usually caused by Escherichia coli (E. coli), Staphylococcus, Enterococcus, Proteus, Klebsiella, or Serratia species. Uncomplicated urinary tract infections are easily treatable. Short courses of antibiotics, primarily trimethoprim/sulfamethoxazole (Septra, Bactrim) or fluoroquinolones (e.g., Cipro) provide quick and effective relief.
Many women turn to natural medicines for urinary tract infections. Most women know when they have one. Many women feel confident self-diagnosing and treating the condition.
Some natural medicines that are tried work similar to antibiotics...by killing bacteria. Others have unique mechanisms like increasing immune function, blocking bacterial adhesion in the urethra, or causing a diuretic or flushing effect to clear out bacteria.
| Commonly Used Conventional and Natural Medicines for Urinary Tract Infections*
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Antibiotics
Conventional Medicines
Ciprofloxacin (Cipro)
Nitrofurantoin (Macrodantin)
Trimethoprim/sulfamethoxazole (Bactrim, Septra)
Natural Medicines
Garlic (Allium sativum)
Goldenseal (Hydrastis canadensis)
Uva ursi (Arctostaphylos uva-ursi)
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Immunomodulators
Natural Medicines
Bifidobacteria
Echinacea (Echinacea angustifolia)
Lactobacillus
Yogurt
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Kidney and Bladder Teas
Asparagus (Asparagus officinalis)
Goldenrod (Solidago virgaurea)
Java tea (Orthosiphon aristatus)
Lovage (Levisticum officinale)
Parsley (Petroselinum crispum)
Stinging nettle (Urtica dioica)
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Miscellaneous
Blueberry (Vaccinium angustifolium)
Cranberry (Vaccinium macrocarpon)
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| *Note: Many natural products are tried for urinary tract infections, but very few have reliable evidence that they work. Inclusion in this list does NOT imply that these products are effective for urinary tract infections.
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| | | | Antibiotics |  | |
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Acute uncomplicated urinary tract infections are usually treated with a quinolone (e.g., ciprofloxacin) or trimethoprim/sulfamethoxazole (TMP/SMX, Bactrim, Septra). Nitrofurantoin (Macrodantin) is considered a second-line choice for acute urinary tract infections. It is also often used for women with recurrent urinary tract infections.
There's some concern about overuse of quinolones for urinary tract infections. Clinicians are hearing about increased resistance to TMP/SMX (Bactrim, Septra) and therefore going straight to a quinolone. But resistance to TMP/SMX is regional. In many areas, E. coli is still susceptible to TMP/SMX. In these areas, TMP/SMX is still the preferred choice for most patients with an uncomplicated urinary tract infection.
When resistance rates are 20% or higher, or for patients who can't take TMP/SMX due to allergies or other reasons, a quinolone or nitrofurantoin is appropriate.
For more information on antibiotic treatment of uncomplicated urinary tract infections, get the Pharmacist's Letter / Prescriber's Letter Detail-Document #220610: Treatment of Uncomplicated Urinary Tract Infections.
Some women turn to natural medicines with antibiotic activity.
Uva ursi (Arctostaphylos uva-ursi), also known as bearberry, is often promoted for urinary tract disorders, including urinary tract infections. It's had long history of use in North America. It was even included in the US National Formulary from 1820 until 1950 as a "urinary antiseptic."
Uva ursi contains arbutin, which has in vitro activity against several bacteria, including E. coli and other urinary tract pathogens. But there's not much evidence in humans. A small, preliminary study suggests that women with recurrent urinary tract infections who take uva ursi have a lower risk of developing another infection.1932
There is also not much known about uva ursi's safety, especially when consumed for long-periods. In fact, Natural Medicines Comprehensive Database rates uva ursi as "POSSIBLY UNSAFE" when used for prolonged periods. That's because the hydroquinone constituent might have mutagenic and carcinogenic effects.
Tell patients to steer clear of uva ursi until we know more about its safety and effectiveness. There isn't any evidence that it works as well as prescription antibiotics for acute urinary tract infections. And the prolonged use necessary for prophylaxis might not be safe.
Goldenseal (Hydrastis canadensis) is another popular "herbal antibiotic." It is often combined with other products that target urinary tract disorders, including uva ursi. Goldenseal contains berberine, which has antibacterial activity.7258,7259 But berberine from goldenseal has very poor bioavailability.2591 Some experts question whether it could reach high enough concentrations to have any benefit. On the other hand, it is thought that berberine concentrates in the bladder when goldenseal is taken orally.2583 Therefore, even though not much berberine is absorbed systemically, it is possible that it might reach higher concentrations in the bladder...where it is needed most.
So far, the only evidence supporting goldenseal is anecdotal. No studies have shown that goldenseal, when used alone or in combination with other products, is effective for urinary tract infections. Tell patients NOT to rely on it.
It might seem strange that people try garlic (Allium sativum) for urinary tract infections. We usually think of garlic for warding off cholesterol and vampires. But it also seems to have antimicrobial effects. Fresh garlic is active against E. coli, Staphylococcus aureus, and Candida albicans.4808
Some people extrapolate this preliminary evidence and suggest that it must therefore be good for urinary tract infections. But, so far, there is no clinical research that suggests garlic helps.
| Practice Pearl |
| Tell patients not to apply garlic topically for urinary tract infections...and especially not intravaginally (yes, some people actually do this). Fresh garlic applied topically can cause severe burns and ulcerations.4832,4833,8017 |
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Question #1 | | A patient wants to use garlic to prevent recurring urinary tract infections. Which of the follow should you tell her? | | | | | | | | |
| | | View brands containing: | | - | Garlic |
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| | Immunomodulators | | |
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Some people use natural products for urinary tract infections because they stimulate the immune system. The thinking is that increasing immune activity might reduce the duration of infection.
Echinacea (Echinacea angustifolia) is one of the most common immune stimulating herbs. It's most popular for treating the common cold and flu. But some people are also using it to treat bacterial infections like urinary tract infections.
There is some evidence that echinacea can increase certain measures of immune function such as lymphocyte activity and phagocytosis.3279,6388,6389 Whether this translates into improved treatment for urinary tract infections is unknown.
There is some evidence that combining echinacea with topical econazole (Spectazole) might lower the recurrence rate of vaginal yeast infections. But so far there is no reliable evidence that echinacea works for urinary tract infections. Don't recommend it.
| Practice Pearl |
| Tell patients who are allergic to ragweed, marigolds, or daisies to avoid echinacea. Echinacea is from the same plant family and is more likely to cause an allergic reaction in people who are sensitive to other plants in the family. |
You've probably heard the term probiotics before. You can think of probiotics as the opposite of antibiotics. Antibiotics are designed to kill off unwanted pathogenic bacteria. Probiotics are meant to replace the bacteria that we normally have in our bodies...the "normal flora."
When people talk about probiotics they are usually referring to a few different varieties. They usually include different strains of lactobacillus and strains of bifidobacteria. These probiotics are available in capsules or in fermented foods like yogurt.
There is a lot of interest in using probiotics for diseases that might be caused by depletion or alteration of the normal flora. The normal flora plays an important role in protecting the body from invasion by pathogenic bacteria. When the normal flora is disrupted, pathogenic bacteria are more likely to colonize and cause disease. That's where probiotics come in. Probiotics are thought to help replenish the normal flora and prevent pathogenic bacteria from colonizing.
Probiotics seem to work against infection in three ways: 1.) competitive inhibition; 2.) bacteriocidal effects; 3.) immune system stimulation.
Probiotics compete with pathogenic bacteria for mucosal binding sites.4369,4378,6086,6089,6091,6092 That is, they competitively inhibit pathogenic bacteria. If the pathogenic bacteria cannot bind to the mucosa, they are not able to colonize and cause disease.
Lactic acid producing probiotics such as lactobacillus and bifidobacteria are bacteriocidal. For example, in the vagina, lactic acid production lowers vaginal pH. This makes it more difficult for pathogenic bacteria to colonize.6089 Lactobacilli can also produce a substance called bacteriocin, which inhibits growth of some bacteria and fungi.6090,6091
Finally, probiotics seem to stimulate immune function. Lactobacillus and other probiotics seem to increase antibody production in response to pathogens, stimulate cytokine production, and stimulate lymphocyte and macrophage activity.4379,6089,7754,8512,8565
Despite all of the promising initial research, there is no consensus regarding the benefits of probiotics for urinary tract infections. A small, preliminary study suggests that women who use a lactobacillus-containing vaginal suppository following antibiotics have a lower recurrence rate.6095 But another small study suggests that a lactobacillus vaginal suppository does not reduce urinary tract infections in women with recurrent infections.4581 Another study using a yogurt drink containing lactobacillus also suggests that it does not reduce the occurrence of urinary tract infections.8253
So far, all of the studies have been small and very preliminary. More evidence is needed to determine if probiotics offer any benefit for women with urinary tract infections. For now, don't recommend them.
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Question #2 | | There is some concern that echinacea might interact with some prescription drugs. Which of the following drugs, in theory, might interact with echinacea? (HINT: Click the above link to go to the echinacea monograph; then scroll down to the Interactions with Drugs section) | | | | | | | | |
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Question #3 | | Which of the following best explains how probiotics might prevent urinary tract infections? | | | | | | | | |
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| | Kidney and Bladder Teas | | |
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You'll see a lot of people trying certain teas for urinary tract infections. A large group of herbs are used to make special teas called "kidney and bladder teas." Many are promoted for loosely defined conditions like urinary tract inflammation. Most of these products are reported to have "aquaretic" effects...meaning they increase urine output.
Some examples of these teas are asparagus root, goldenrod, java tea, lovage, parsley, and stinging nettle. These products are either used as teas or in combination with high fluid intake. The well-known German Commission E approves many of these for preventing urinary tract or kidney disorders. But there is no reliable scientific support for using these products. There's also concern these products might worsen urinary tract inflammation...because some products increase urine flow by irritating urinary tract mucosa. Don't recommend these products until more is known about their safety and effectiveness.
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Question #4 | | Which of the following natural products works most similar to an antibiotic? | | | | | | | | |
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| | Miscellaneous | | |
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Cranberry (Vaccinium macrocarpon) juice is one of the best known natural remedies for urinary tract infections. Cranberry juice is acidic, so people used to think that it worked for urinary tract infections by making the urine acidic and therefore preventing bacterial replication. More recent research shows that this is not true.
The prevailing theory now is that constituents in cranberry prevent bacterial adhesion to the mucosa and therefore prevent pathogenic colonization. For example, proanthocyanidins in cranberry seem to wrap around E. coli and prevents it from binding to epithelial cells.3333,3338,6690
There is some evidence that young and elderly women who regularly drink cranberry juice (e.g., Ocean Spray Cranberry Juice Cocktail) have decreased recurrence of urinary tract infections.6758,7008,8253
Neither cranberry juice nor cranberry extract seem to prevent urinary tract infections related to neurogenic bladder in adults or children.2811,6759,11980
The evidence at this point is not real strong, but drinking cranberry juice is safe. Women with recurring urinary tract infections may want to consider drinking cranberry juice to see if it helps.
Explain to patients that there is no evidence cranberry juice is effective for treating an acute urinary tract infection.8995 In fact, some evidence suggests that cranberry constituents are not able to remove pathogenic bacteria that are already adhering to the mucosa.8252 This suggests that cranberry wouldn't be effective for existing urinary tract infections.
Patients will ask if they should try concentrated cranberry capsules...instead of drinking the juice. So far, it's not clear if the capsules help like the juice. Until we know more, tell patients who want to use cranberry to stick with the juice.
| Practice Pearl |
| Warn diabetes patients that some cranberry juices have added sugar content. Tell them to pick a product that uses an artificial sweetener instead. |
Blueberries (Vaccinium angustifolium) and blueberry extract are also used to help prevent urinary tract infections. Blueberry contains proanthocyanidins similar to cranberry. Therefore, in theory, blueberry might also help prevent bacteria adhesion. However, at this point, there is no clinical evidence that blueberry is effective.15825
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Question #5 | | Which of the following best explains how cranberry juice might prevent urinary tract infections? | | | | | | | | |
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Question #6 | | There has been some debate about whether cranberry juice might interact with warfarin. Which of the following represents the most current thinking on this issue? (HINT: Click link above to go to the cranberry monograph; then scroll down to the Interactions with Drugs section) | | | | | | | | |
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| | The Bottom Line | | |
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There is no reliable substitute for antibiotics for treatment of acute urinary tract infections. Advise patients not to rely on natural medicines for treating an acute urinary tract infection. Postponing treatment could result in a more serious kidney infection.
There is some interesting research on ways to PREVENT recurring urinary tract infections. But so far the evidence is weak.
The product with the best evidence is cranberry. But more evidence is still needed before it can be recommended across the board. If patients want to use cranberry to see if it helps, suggest they use an appropriate amount...about 10 ounces/day.
Tell patients to avoid the commonly used "kidney and bladder teas." There's not enough information about safety and effectiveness.
Suggest that women take the following non-drug-related steps to help decrease their risk of developing a urinary tract infection:
- Wear cotton-crotch underwear.
- Don't hold urine for long periods of time.
- Drink plenty of fluids.
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Question #7 | | Overall, the evidence supporting natural medicines for preventing urinary tract infections is weak. Which of the following has the best evidence for PREVENTING urinary tract infections? | | | | | | | | |
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Question #8 | | Which of the following steps can women take to decrease their risk of developing a urinary tract infection? | | | | | | | | |
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Recommendation Chart for Natural Medicines Used for UTI *
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| | KEY: | | Consider recommending this product.
| | | | | | Don't recommend using this product.
| | | | | | Recommend against using this product.
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* These proposed recommendations are based solely on the Safety and Effectiveness
Ratings contained in Natural Medicines Comprehensive Database. This assumes use
of high-quality, uncontaminated products and the use of typical doses. Keep in
mind that some products are never appropriate for some patients due to
concomitant disease states, potential drug interactions, or other clinical
factors. Use your clinical judgment before recommending any product.
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| References
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| | 1932 | Larsson B, Jonasson A, Fianu S. Prophylactic effect of UVA-E in women with recurrent cystitis: a preliminary report. Curr Ther Res 1993;53:441-3. | | 2583 | Sun D, Abraham SN, Beachey EH. Influence of berberine sulfate on synthesis and expression of Pap fimbrial adhesin in uropathogenic Escherichia coli. Antimicrob Agents Chemother 1988;32:1274-7. | | 2591 | Bhide MB, Chavan SR, Dutta NK. Absorption, distribution, and excretion of berberine. Indian J Med Res 1969;57:2128-31. | | 2811 | Schlager TA, Anderson S, Trudell J, Hendley JO. Effect of cranberry juice on bacteriuria in children with neurogenic bladder receiving intermittent catheterization. J Pediatr 1999;135:698-702. | | 3279 | Chavez ML, Chavez PI. Echinacea. Hosp Pharm 1998;33:180-8. | | 3333 | Harkins K. What's the use of cranberry juice? Age Ageing 2000;29:9-12. | | 3338 | Schmidt DR, Sobota AE. An examination of the anti-adherence activity of cranberry juice on urinary and nonurinary bacterial isolates. Microbios 1988;55:173-81. | | 4369 | deRoos NM, Katan MB. Effects of probiotic bacteria on diarrhea, lipid metabolism, and carcinogenesis: a review of papers published between 1988 and 1998. Am J Clin Nutr 2000;71:405-11. | | 4378 | Hudault S, Lievin V, Bernet-Camard MF, et al. Antagonistic activity exerted in vitro and in vivo by Lactobacillus casei (strain GG) against Salmonella typhimurium C5 infection. Appl Environ Microbiol 1997;63:513-8. | | 4379 | Sutas Y, Hurme M, Isolauri E. Down-regulations of anti-CD3 antibody-induced IL-4 production by bovine caseins hydrolyzed with Lactobacillus GG-derived enzymes. Scand J Immunol 1996;43:687-9. | | 4581 | Baerheim A, Larsen E, Digranes A. Vaginal application of lactobacilli in the prophylaxis of recurrent lower urinary tract infection in women. Scand J Prim Health Care 1994;12:239-43. | | 4808 | Sasaki J, Kita T, Ishita K, et al. Antibacterial activity of garlic powder against Escherichia coli O-157. J Nutr Sci Vitaminol (Tokyo) 1999;45:785-90. | | 4832 | Cronin E. Dermatitis of the hands in caterers. Contact Dermatitis 1987;17:265-9. | | 4833 | Lee TY, Lam TH. Contact dermatitis due to topical treatment with garlic in Hong Kong. Contact Dermatitis 1991;24:193-6. | | 6086 | Darouiche RO, Hull RA. Bacterial interference for prevention of urinary tract infection: an overview. J Spinal Cord Med 2000;23:136-40. | | 6089 | McGroarty JA. Probiotic use of lactobacilli in the human female urogenital tract. FEMS Immunol Med Microbiol 1993;6:251-64. | | 6090 | Velraeds MM, van der Mei HC, Reid G, et al. Inhibition of initial adhesion of uropathogenic Enterococcus faecalis by biosurfactants from Lactobacillus isolates. Appl Environ Microbiol 1996;62:1958-63. | | 6091 | Reid G, Cook RL, Bruce AW. Examination of strains of Lactobacilli for properties that may influence bacterial interference in the urinary tract. J Urol 1987;138:330-5. | | 6092 | Chan RCY, Reid G, Irvin RT, et al. Competitive exclusion of uropathogens from human uroepithelial cells by Lactobacillus whole cells and cell wall fragments. Infect Immun 1985;47:84-9. | | 6095 | 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;14:11-6. | | 6388 | Luettig B, Steinmuller C, Gifford GE, et al. Macrophage activation by the polysaccharide arabinogalactan isolated from plant cell cultures of Echinacea purpurea. J Natl Cancer Inst 1989;81:669-75. | | 6389 | Stimpel M, Proksch A, Wagner H, et al. Macrophage activation and induction of macrophage cytotoxicity by purified polysaccharide fractions from the plant Echinacea purpurea. Infect Immun 1984;46:845-9. | | 6690 | Burger O, Ofek I, Tabak M, et al. A high molecular mass constituent of cranberry juice inhibits helicobacter pylori adhesion to human gastric mucus. FEMS Immunol Med Microbiol 2000;29:295-301. | | 6758 | Haverkorn MJ, Mandigers J. Reduction of bacteriuria and pyuria using cranberry juice. JAMA 1994;272:590. | | 6759 | Foda MMR, Middlebrook PF, Gatfield CT, et al. Efficacy of cranberry in prevention of urinary tract infection in a susceptible pediatric population. Can J Urol 1995;2:98-102. | | 7008 | Avorn J, Manone M, Gurwitz JH, et al. Reduction of bacteriuria and pyuria after ingestion of cranberry juice. JAMA 1994;271:751-4. | | 7258 | Amin AH, Subbaiah TV, Abbasi KM. Berberine sulfate: antimicrobial activity, bioassay, and mode of action. Can J Microbiol 1969;15:1067-76. | | 7259 | Sun D, Courtney HS, Beachey EH. Berberine sulfate blocks adherence of Streptococcus pyogenes to epithelial cells, fibronectin, and hexadecane. Antimicrob Agents Chemother 1988;32:1370-4. | | 7754 | Madsen KL, Doyle JS, Jewell LD, et al. Lactobacillus species prevents colitis in interleukin 10 gene-deficient mice. Gastroenterology 1999;116:1107-14. | | 8017 | Ali M, Thomson M, Afzal M. Garlic and onions: their effect on eicosanoid metabolism and its clinical relevance. Prostaglandins Leukot Essent Fatty Acids 2000;62:55-73. | | 8252 | Lowe FC, Fagelman E. Cranberry juice and urinary tract infections: what is the evidence? Urology 2001;57:407-13. | | 8253 | Kontiokari T, Sundqvist K, Nuutinen M, et al. Randomised trial of cranberry-lingonberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women. BMJ 2001;322:1571. | | 8512 | Isolauri E, Sutas Y, Kankaanpaa P et al. Probiotics: effects on immunity. Am J Clin Nutr 2001;73:444S-450S. | | 8565 | Hatakka K, Savilahti E, Ponka A, et al. Effect of long term consumption of probiotic milk on infections in children attending day care centres: double blind, randomised trial. BMJ 2001;322:1327. | | 8995 | Jepson RG, Mihaljevic L, Craig J. Cranberries for treating urinary tract infections. Cochrane Database Syst Rev 2004;2:CD001322. | | 11980 | Waites KB, Canupp KC, Armstrong S, DeVivo MJ. Effect of cranberry extract on bacteriuria and pyuria in persons with neurogenic bladder secondary to spinal cord injury. J Spinal Cord Med 2004;27:35-40. | | 15825 | Jepson RG, Craig JC. A systematic review of the evidence for cranberries and blueberries in UTI prevention. Mol Nutr Food Res 2007;51:738-45. | | 15826 | Car J. Urinary tract infections in women: diagnosis and management in primary care. BMJ 2006;332:94-7. |
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