Cranberry Juice or Cranberry Tablets for Cystitis?

cranberry juice - woman looking for cranberry juice
cranberry juice - glass of cranberry juice

Whilst Cranberry Juice is a healthy drink per se, when you are suffering cystitis or UTIs, in the light of evidence, you may need to seriously rethink whether it is the right thing for you.
If you have ever spoken to us here at Sweet Cures, or your Urology specialist, you will know that it is now frequently suggested to people suffering E. coli related Urinary Tract Infections ( or other gram negative bacteria related infections)  that they should use diet to adjust their urine pH, to be slightly alkaline (about 7.5 on the pH scale). Most bacteria thrive in acidic urine, and it can reach a point when bacterial growth rate is doubled.

Because, of course, urine is naturally acidic, so by doing nothing at all to change that situation, it is easy to see how a minor infection can quickly turn into a full blown attack with a possibility of the outbreak spreading to the kidneys, a very dangerous scenario indeed and a medical emergency.

During the night the urine becomes increasingly acidic which explains why so many of us wake up with a full blown attack already in progress.

E.coli is an Acid Adaptive Bacterium

The overwhelming cause of most urinary tract infections is E.coli (somewhere between 80%-90%). E.coli is an acid adaptive bacterium that is capable of synthesising its nutritional requirements from the surrounding acids in its environment.

Cranberry, along with many other acidifying drinks such as orange and alcohol, creates acidic urine conditions (cranberry juice produces hippuric acid in the urine). “During the 1880s, German physicians reported that urinary excretion of hippuric acid increased after ingestion of cranberries. In 1914, Blatherwick [9] published an article showing that cranberries are rich in benzoic acid, which is then excreted in urine as hippuric acid.” http://cid.oxfordjournals.org/content/38/10/1413.full

When cranberry juice is drunk or cranberry tablets ingested, E.coli is provided with a suitable acidic environment in which to multiply and will multiply at nearly double the normal rate. E.coli multiplies at roughly every 20 minutes in a neutral environment. In an alkaline environment they are slowed to multiplying every 30-40 minutes, and in acid environment they are believed to multiply every 10-20 minutes.

With those numbers in mind, and the knowledge that Cranberry Juice, orange juice, alcohol, and Vitamin C (ascorbic acid) tablets have a potent acidifying effect on the urine, should we really aim to make our urine more acidic during a UTI as popular myth would have us believe?

It would, on the contrary seem that acidic urine makes most bladder infections worse (with the exception of PROTEUS *).

“Other microbes are studied because their acid-resistance systems allow them to survive the low pH in our own stomachs and cause disease. Two such microbes are Escherichia coli, a well-known gastrointestinal pathogen, and Helicobacter pylori, which causes stomach ulcers."

Read More http://serc.carleton.edu/microbelife/extreme/acidic/index.html

This is not a subtle point, nor one that is difficult to grasp. However, it does go directly against years of deeply public information sharing that seems ingrained in the public consciousness.

The trouble is that, in the past, so many people in the NHS and aligned medical organisations have publically come out in favour of the use of cranberry for UTIs that it has taken a long time for new research to become known and to gain credibility and major reports appear to have been buried.

No longer:Ā  http://www.nhs.uk/news/2012/10October/Pages/Cranberry-juice-no-good-in-preventing-bladder-infections.aspx

And, following the application made by Ocean Spray related to their cranberry products, the EFSA Panel concluded in 2009 "the evidence provided is not sufficient to establish a cause and effect relationship between the consumption of O S cranberry products and the reduction of the risk of UTI in women by inhibiting the adhesion of certain bacteria in the urinary tract." The full Summary of Opinion given by EFSA is given on their website:

http://www.efsa.europa.eu/en/efsajournal/pub/943.htm

Clinical Reports on Cranberry Juice

Some clinical trials that have been done suggest results that are no better than a placebo and from a layman’s point of view obfuscate the facts.

Almost every study/report in the cannon, that tries to show cranberry as being useful, uses similarly non-specific references such positive studies by using the terms 'Studies suggest', or 'Modern research indicates', or 'Research has shown'. 
The NICE guideline refers to study of cranberry supplements for the reduction of urinary tract infections in individuals [n=21] with neurogenic bladders secondary to spinal cord injury. http://www.ncbi.nlm.nih.gov/pubmed/15156934

Near the bottom of the report it says: "In terms of results, Linsenmeyer found: “There was no statistically significant treatment (favourable) effect for cranberry supplement beyond placebo when evaluating the 2 treatment groups for bacterial count, WBC count, or WBC and bacterial counts in combination."Right at the end of the report, (the least likely to be read) it says; "In the cranberry group 34.6% of participants failed (i.e., developed a UTI) versus 32.4% in the control group (p = .849)."

That is a statistically significant effect. Statistically, people taking cranberry were more than 2.2% more likely to develop UTIs than people taking placebo (i.e. if they took nothing at all).

In our experience and talking to real people every day, it becomes even clearer that acidifying the urine exasperates most urine infections, not just 2.2% of them!
There is, it is true, a small anti-adhesion effect from cranberry, but for the vast majority of bladder infection agents, the increased bacterial metabolic rate that results from the acidic urine that you get from drinking cranberry more than cancels out any anti-adhesion benefits from taking it.

On the other hand, it seems invariably to be the case that for gram negative bacteria, living in alkali conditions is like living in their own waste - not ideal conditions.
So, in alkaline urine they slow down their metabolic rate and it can take them twice as long to produce a cell division (to double). That's why taking potassium citrate, lemon juice, cider vinegar or any alkalising drink eases the situation. Our grandmothers knew this and drank lemon barley.

Confusion between Vaginal pH and Bladder pH

Since a healthy vagina is colonized by lactobacilli, which are beneficial microorganisms that maintain an acidic (low pH) environment in the vagina, it is often assumed that a similar low pH environment in the urine makes the bladder hostile to bacteria. This is simply not true. The bladder and the vagina are entirely different environments. In the vaginal area, Lactobacilli compete with other bacteria for resources, and as a by-product, and they produce hydrogen peroxide which also creates a hostile environment for bacteria. The tissues of the vagina and the Lactobacilli cells are adapted for exactly this environment, and they are healthy when the pH is low - when the environment is acidic.

Urine, on the other hand is most unlikely to have Lactobacilli living in it, and bacteria that do colonise the bladder are usually pathogenic, and much tougher than Lactobacilli. For the most part though, like Lactobacilli, these pathogens do enjoy an acidic environment, and they don't thrive well in an alkaline environment.

And there's the truth the pH environment that provides a healthy living area for friendly bacteria in the vagina also provides a healthy environment for some distinctly unfriendly bacteria in the bladder.

It is also known that if the E.coli in your body originated from cattle fed on a high grain diet, they can be 1000 times more resistant to acid than other E.coli. These bacteria absolutely thrive in acids. They are tough little bugs that adapt to utilise the environment they are exposed to. They can even get through stomach acids intact.

Acid resistant bacteria populate the human gut when you eat meat or food contaminated with the acid-loving strains, so the very first time you get an E.coli infection, the bacteria can already be acid resistant. (When you get an E.coli infection, the bacteria has invariably been at some point in a human bowel - it could be that person you just shook hands with... and not from you or your partner.) And since Trimethoprim is often used to prevent and treat infections in chicken and cattle, the bacteria are also likely to have genetic Trimethoprim resistance 'built in'.

The cycle: E.coli and Klebsiella (and some other gram negative uropathogens) have 'burst cycle' population explosions that occur under optimum feeding conditions. It goes like this - you drink cranberry or something else that makes the urine acidic - or get dehydrated and there is a build-up uric acid in the bladder. Within a short period of time when the acidic urine gets into your bladder, the E.coli in there burst into a frenzied multiplication cycle, doubling their colony size over the next 20 to 40 minutes. They use up the acids in your urine in the process, and pass alkalis and endotoxins into the urine. As the urine becomes more alkaline, and the bacteria are effectively living in their own waste, they gradually become semi-dormant, slowing down their multiplication rates by as much as 100%. You take another drink of Cranberry or eat some more cranberry tablets, and start the process off again. It's not that they can't metabolise alkalis, but they don't seem to be so efficient at that.

It's a known fact that many people get bacterial cystitis when they are dehydrated and thus build up a high level of urea (uric acid) in the urine. There must be some bacteria present for any bacterial infection, but the cystitis happens because the bacteria have been given the acidic environment in which to multiply out of control. You get a feel for the hardiness of E.coli when you consider that urea is a powerful antiseptic. E.coli says "Hmm, I like that. Please can I have some more urea?"

By avoiding cranberry, Vit C in the form of ascorbic acid, alcohol, Orange Juice, red meat and coffee, and making the urine more alkaline, you take away the acids that are one of the bacteria's primary sources of nutrition, effectively starving them. Better to use a citrate salt like potassium citrate, magnesium citrate, calcium citrate or sodium citrate to make the urine more alkaline. But as always, consult a good nutritionist about any dietary changes (especially about salts if you have high blood pressure).

But Cranberry Always Seems to Help at First!

When you first take cranberry, it kills off any bacteria that cannot survive the acidic environment, and in any colony of bacteria there will be some ‘weaklings’. So cranberry usually provides very temporary relief that is followed by considerable worsening of the symptoms. This is logically because the bacteria that weren't killed off produce, when they multiply, more bacteria that like the acidic environment, and if you didn't already have acid loving bacteria in the first place, because uropathogens are very fast mutators, they are likely to produce mutations that can make better use of the acidic environment than the original cranberry survivors.

This is the similar to the reproductive mechanism that produces antibiotic resistant bacteria.

Until very recently it was believed that the acid in cranberry killed the uropathogens. But that's not what happens. As explained, they adapt quickly to acidic conditions. The adaptation is by survival and multiplication, so you just end up with tougher E.coli.

Now, how mad does this make you? You get a first time urine infection - you get antibiotics. You take cranberry at the same time, and because you are helping the bacteria to grow, and making them tougher, the antibiotic fails. You go for more antibiotics, drink even more cranberry, and here you are now reading this page, still with problems perhaps years later...

Escaping the cycle of reinfection

But the principle of preventing adhesion works. For example, a simple monosaccharide (a rare sugar) called Mannose has up to fifty times the anti-adhesion properties of cranberry, and you also get the advantage of not acidifying your urine. Bacteria attaches to mannose and is simply flushed away.

Note: The above information refers to gram-negative bacteria like E.coli and Klebsiella. This covers the vast majority of bladder infections. However, cranberry may be useful against Proteus type infections. Unlike E.coli, Proteus types generally multiply slower in acid urine, [you can deduce this logically from the fact that P. mirabilis produces urea, which is their 'waste' product. Nothing enjoys living in its own waste...] so basically it's doing the exact opposite of E.coli, which produces alkalis. Summarising, this boils down to the fact that if you have a Proteus infection, cranberry and Vit C might not cause as many problems as it does for people with the more common infections

To reinforce this point, Sweet Cures, who produce Waterfall D-MannoseĀ®, (used for urinary tract infections) have pointed out that very few customers out of hundreds of thousands since 2003 have said cranberry helped and those always turned out to have Proteus mirabilis infections. They are suggesting about 1% of customers

*You are more likely to get Proteus if you have recently been catheterised in hospital, or had a bladder operation. But if you are one of the few for whom Waterfall D Mannose doesn't solve your problem - and you don't have a bladder prolapse or other obvious predisposition to infection, you need to have the bacteria that are affecting you properly checked at a lab. If it is Proteus, also ask which type - the susceptibility of Proteus to particular antibiotics varies with type.

Evidence Base

Cranberry Juice no good in preventing bladder infections NHS.uk

Myth - Cranberry Cure dailymail.co.uk

UTI myths explained health.cleveland

Cranberry juice to stop cystitis? BBC.com

Cranberry juice good for bladder infections? ABC News

Cranberry juice curing urinary tract infections SCMP.com