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1
Albert X, Huertas I, Pereiró I, Sanfélix J, Gosalbes V, Perrota C. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database of Systematic Reviews 2004, Issue 3, http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001209/frame.html
Accessed 23.09.14. RATIONALE: Nightly prophylaxis:pooled data from 10 RCTs of poor methodological quality calculated a Relative Risk of having one microbiological recurrence (MR) was 0.21 (95% CI 0.13 to 0.34), favouring antibiotic and the NNT was 1.85. over 6–12 months. But adverse effects do occur and 30% of women did not adhere to treatment. The benefit is lost as soon as prophylaxis stops. Post-coital antibiotics: one study of post-coital ciprofloxacin compared with ciprofloxacin prophylaxis found no significant difference between regimens on the rate of UTIs.

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Stapleton A, Latham RH, Johnson C, Stamm WE. Postcoital antimicrobial prophylaxis for recurrent urinary tract infection. A randomized, double-blind, placebo- controlled trial. JAMA 1990;264(6):702-706. RATIONALE: This small (n = 27) RCT found that the relative risk of symptomatic recurrence was lower with post-coital co-trimoxazole (RR 0.15, 95% CI 0.04 to 0.58). Adverse event rates were low and not significantly different between antibiotic and placebo.

3
Grabe M, Bishop MC, Bjerkland-Johansen TE, Botto H, Cek M, Lobel B, Naber KG, Palou, J, Tenke, P, Wagenlehner F. Guidelines on Urological Infections. European Association of Urology 2009: 1-110. RATIONALE: Standby antibiotics: expert opinion, based on one open prospective trial, is that standby antibiotics may be suitable if the rate of recurrences is not too common. Post-coital antibiotics: expert opinion is that the same antibiotics and same doses as for nightly prophylaxis can be used as a stat dose for post-coital prophylaxis of UTI.

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Cranberry juice has been found to potentially prevent infection by interfering with the attachment of bacteria to urepithelial cells. There are many other compounds found in cranberries that have yet to be explored for their potential adherence activity, but A-type proanthocyanidins (PACs) have been shown to potentially inhibit the adherence of P -fimbriated Escherichia coli to the urogenital mucosa. Without adhesion, E.coli cannot infect the mucosal surface of the urinary tract.

There have been two recent systematic reviews examining the evidence for cranberry products for recurrent UTI. A 2012 Cochrane review of 24 studies (4473 participants) found a small trend towards fewer urinary tract infections in people taking cranberry juice or other products compared to placebo or no treatment but this was not significant (Jepson et al., 2012). Chi-Hung et al (Arch Intern Med 2012) examined 10 trials (1494 subjects, 9 community based) : cranberry-containing products were significantly more effective in women with recurrent UTIs (RR, 0.53; 95% CI, 0.33-0.83) (I 2 = 0%), female populations (RR, 0.49; 95% CI, 0.34-0.73 )but there was substantial heterogeneity across trials

Many people in the Cochrane review studies stopped drinking the juice, suggesting it may be difficult to continue long term. Cranberry capsules may be more convenient than juice and high strength capsules may be most effective.

Thus women should be advised about the relative benefits and risks of daily prophylactic antibiotics, versus post-coital antibiotics, versus stand by antibiotics and cranberry products, so they can make an informed decision. Advise patients taking warfarin to avoid taking cranberry products unless the health benefits are considered to outweigh any risks.

Chi-Hung W, Cheng-Chung F, Nai-Chuan C, Shi-Hung Liu S, Ping-Hsun Y, Tao-Yu W, et al. Cranberry-containing products for prevention of Urinary Tracy Infections in susceptible populations. Arch Intern Med 2012: 172(13): 988-996. This systematic review with meta-analysis of randomised controlled trials included 1494 subjects in the qualitative analysis in 10 review trials, with all but one of the trials following subjects living in the community. Administration of cranberry-containing products differed significantly in form, daily dosage, PAC content, and dosing frequency. Results: cranberry-containing products seemed to be more effective in women with recurrent UTIs (RR, 0.53; 95% CI, 0.33-0.83) (I 2 = 0%), female populations (RR, 0.49; 95% CI, 0.34-0.73) (I 2 = 34%), children (RR, 0.33; 95% CI, 0.16-0.69) (I 2 = 0%), cranberry juice users (RR, 0.47; 95% CI, 0.30-0.72) (I 2 = 2%), and people using cranberry-containing products more than twice daily(RR, 0.58; 95% CI, 0.40-0.84) (I 2 = 18%). The results suggest that cranberry-containing products are associated with protective effect against UTIs. However, this result should be interpreted in the context of substantial heterogeneity across trials.

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Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. The Cochrane Library 2012. Issue 10. http://summaries.cochrane.org/CD001321/cranberries-for-preventing-urinary-tract-infections Accessed 23.09.14. This review identified 24 studies (4473 participants) comparing cranberry products with control or alternative treatments. There was a small trend towards fewer UTIs in people taking cranberry product compared to placebo or no treatment but this was not a significant finding. Many people in the studies stopped drinking the juice, suggesting it may not be an acceptable intervention. In the long term cranberry products (such as tablets or capsules) were also ineffective (although had the same effect as taking antibiotics), possibly due to lack of potency of the 'active ingredient'.

However, four of the five studies in women with recurrent UTI (5 9 4 participants) which included a placebo group provided data that could be com bined in a m eta-analysis (Kontiokari 2 0 0 1 ; Barbosa-Cesnik 2 0 1 1 ; Stothers 2 0 0 2 ; Sengupta 2 0 1 1 ). Results showed a small, non-significant reduction in risk of repeat symptom atic UTI with cranberry treatment compared to placebo or no treatment (RR 0 .7 4 , 9 5 % CI 0 .4 2 to 1 .3 1 ). Two studies in women with recurrent UTI (McMurdo 2 0 0 9 ; N A PRUTI Study 2011) and one study in children (Uberos 2010) compared cranberry product with antibiotic prophylaxis. All three studies used either cranberry capsules or syrup, rather than cranberry juice. Analysis of the two studies in wom en showed that cranberry product compared to antibiotic were equally as effective in reducing the risk of repeat UTI in women (RR 1.31, 95% CI 0.85 to 2.02) The study in children also showed that the cranberry product were equally as effective in reducing the risk of repeat symptomatic UTI compared to antibiotics (RR 0.69, 95% CI 0.32 to 1.51).

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Scottish Antimicrobial Prescribing Group, SAPG 2014. Guidance to improve the management of recurrent lower urinary tract infection in non-pregnant women. http://www.scottishmedicines.org.uk/files/sapg/Management_of_recurrent_lower_UTI_in_non-pregnant_women.pdf Accessed 23.09.14. RATIONALE: This evidence based guidance gives a very good overview of the management of recurrent UTI, suggesting initial simple measures to limit UTI (including better hydration, post coital voiding, cranberry products, and standby antibiotics). Stresses the importance of confirming diagnosis of UTI and investigation of underlying causes and THEN advises low dose antibiotic prophylaxis with review at 6 months.

The POCAST project is funded by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London and by the Imperial College Healthcare Charity (Grant Ref No:7006/P36U).