A VARIETY OF CURES ARE AVAILABLE FOR URINARY TRACT INFECTIONS -- BUT IT TAKES MORE THAN JUICE

RON GASBARRO, R.Ph., M.S.

Urinary tract infection sufferers, the vast majority of them women, need to be reminded that while UTIs are fairly common, they can have critical complications.

Some folklore remedies have a modicum of merit. These days, women with urinary infections may wheel their shopping carts right past the pharmacy and head for the cranberry juice aisle. A March 9 article in the Journal of the American Medical Association substantiated for many women what their grandmothers had told them all along: that cranberry juice is good for UTIs or "anytime when you have to go too often and it hurts."

The JAMA study found that the benefits of cranberry juice are not related to the acidification of urine, as had been believed. Rather, the study revealed that the juice of this bog-growing heath plant inhibits the way bacteria sticks to the urethral mucosa.

God bless Grandma. But she doesn't have the last word on what makes cranberry therapy work. Pharmacists, however, can more accurately inform patients who are on an all-natural Ocean Spray high.

First, one has to drink no less than 300 milliliters of cranberry juice every day. And it has to be that juice, not orange or guava or prune. Second, cranberry juice does not cure a nasty UTI but has a better than even chance of preventing one. Third, this prophylactic quality comes only after drinking the juice continuously for four to eight weeks. You really gotta like the stuff!

"This is a poor farming town and a lot of people swear by folk remedies like cranberry juice," says Rob Pollard, pharmacist at Akins Super-1 Food Center, Moses Lake, Wash. "I suggest that it's OK to use cranberry juice to get them through the weekend if they can't reach the doctor, but to get to his office as soon as they can."

"I'm sure people around here use cranberry juice as a preventive, but if they rely on it for an infection, they are eventually going to end up in the doctor's office anyway," adds Scott Hendren, pharmacist at Consumer's IGA, Stillwater, Okla.

It's simpler to take an antibiotic and be done with it. Physicians sometimes become overzealous in their prescribing of antibiotics for uncomplicated UTIs, handing out scripts for 10 days of pricey ciprofloxacin. In truth, most uncomplicated UTIs in nonpregnant women -- that is, those with first- or second-time infections, those with symptoms of less than three days and those with no underlying medical conditions such as diabetes, immunosuppression or urological abnormalities -- can be treated with single dose or three-day therapy of dirt-cheap TMP/SMZ or amoxicillin. Easy, quick and does the trick.

"Since this is a small town, our rapport with the doctor is good and they are pretty conscientious about starting off with Bactrim," observes Pollard of Akins Super-1.

"Here the doctors will only use Cipro and the more expensive antibiotics if the infection is stubborn or if they have done their homework by reading the test results and seeing that a drug other than Bactrim is more appropriate," says Hendren.

Patients will typically get, in addition to a prescription for antibiotic, an order for phenazopyridine that stops the burning of a UTI. Once home, the patient usually will notice that the urinary analgesic works quickly, and when faced with a recurrent UTI, may often eschew the refill for the antibiotic -- particularly if it is for something high-priced -- and ask for more Pyridium. Some phenazo products are over-the-counter, so pharmacists should watch the movement of these closely for women desperately trying to eradicate a severe UTI.

Urinary analgesics can take away the sting. But only antibiotics truly eradicate the infection. "We sell a moderate amount of OTC phenazopyridine, so there are people out there using it," notes Hendren. "As far as Pyridium goes, we usually only give out a two-day supply. Whether consumers are adding to their prescription with the OTC product is hard to tell."

Here's where the alert pharmacist can intervene. A woman who is getting multiple refills of phenazopyridine may move from uncomplicated to recurrent and even complicated UTI status. For her, antibiotics can prevent acute pyelonephritis and other kidney infections that may require hospital stay and intravenous antibiotics. The pharmacists should encourage her to break the UTI cycle by taking Septra, Bactrim or amoxicillin in addition to the Pyridium. Pyridium should not be used for more than a couple of days.

In patients with frequent, recurrent infections, pharmacists should encourage them to use the antibiotic and not just the analgesic. Pharmacists should either check the patient's profile for a refill that can be issued at the time of recurrence or allow the patient to keep on hand an antibiotic supply for the time symptoms recur. However, if the time between infections is too long, say, nine months, the dwelling pathogen may have changed and a urinalysis and different antibiotic may be needed.

A relapsed UTI, conversely, implies that the same organism is still in the urinary tract. Treatment has failed because the antibiotic did not clear out the infection the first time. The symptoms from the first infection have subsided but the vaginal reservoir may still harbor pathogens that can cause symptoms, typically within the first two months after initial therapy. A longer course of antibiotics is needed at this juncture.

What are the symptoms of a UTI? Dysuria, or burning sensation upon urination. The discomfort is described as internal rather than external. There is also an acute urgency to void, yet only a few drops of urine are produced.

Such infections are 10 times more common in females than males. The reason is anatomical: a female's urethra is only about 1.5 inches long, compared with 8 or 9 inches in men. The migratory journey of infecting bacteria is much easier in women. A woman's urethral openings are also near anal and vaginal sources of infectious agents, including yeast, whereas a man's urethra is not. Also, a woman lacks the protection of prostate fluid.

Males certainly do develop UTIs. But since the male's urethra is lengthy and completely surrounded by the penis, such infections are immediately classified as complicated because they can rapidly spread upward and involve the prostate (prostatitis) and the bladder (cystitis).

Bladder infection, also called cystitis or honeymoon cystitis, is the most frequent complaint of female patients with more than 20% of all women having one or more at some time in life. The best way to treat cystitis is to prevent it. Women should drink at least two glasses of water prior to intercourse (not during!) and void immediately after it is over (yes, there is time for a kiss goodnight). Drinking water irrigates the urinary tract and minimizes the chances of infection.

A dose of TMP-SMZ shortly after sex (instead of, perhaps, a cigarette) also may reduce the frequency of UTI. (Patients allergic to sulfa drugs should not get TMP-SMZ.)

The drug of choice for most UTIs is TMP-SMZ DS, either two tablets immediately as single-dose therapy or one tablet twice a day for the three-day course. Complicated UTIs using this drug require one tablet twice a day for seven to 10 days at least. Amoxicillin is the next choice, good for sulfa-allergic patients. This can be given as 3 grams in a single dose or 500 milligrams every eight hours for three days. Complicated UTIs need this same dose for at least seven days. Physicians should watch for drug-induced diarrhea.

Nitrofurantoin will work in 90% of uncomplicated UTIs. Physicians can use 200 milligrams as a single dose or 100 milligrams every six hours for three days. This drug is not recommended for complicated UTIs. The one-time dose may precipitate a mild neuropathy. Ciprofloxacin is good for complicated UTIs, such as those caused by enterobacteria. Doctors can prescribe 250 milligrams as a single dose or 250 milligrams twice a day for three days. Complicated episodes need 250 milligrams twice a day for seven days or more. This is the most effective of the "floxacins" and it is rare to find a resistant bug.

Cephalexin can be used during pregnancy, unlike the tetracyclines, sulfonamides, ciprofloxacin or nitrofuratoin, which are contraindicated in the third trimester. It has a narrower spectrum than amoxicillin, TMP-SMZ or nitrofurantoin, but works against proteus, klebsiella and, unlike penicillin, against E. coli. Physicians should use a seven-day regimen only at 500 milligrams every six hours.

As a woman approaches menopause, the vaginal walls become dry because of loss of estrogen. This loss of moisture makes older women prone to UTIs, especially after the friction and trauma to the vagina associated with sex. Estrogen replacement and vaginal estrogen creams can prevent this complication.

Elderly female patients also can have asymptomatic bacteriuria -- that is, bacteria in the urine without symptoms. Most physicians feel that this condition in the elderly is a benign disease and that vigorous treatment and screening programs are not warranted, since most data indicate that such patients are not destined to develop progressive renal damage.

Ron Gasbarro is a registered pharmacist and a frequent contributor to medical publications.