The following Q&A was part of a special online presentation by Dr. Sutherland: “Evaluation and Management of Acute and Recurrent UTIs”, brought to you by ellura. For the full presentation by Dr. Sutherland, please visit https://ellurahcp.com/sutherland-sept20/
Evaluation and Management of Acute and Recurrent UTIs
The following Q&A was part of a special online presentation by Dr. Sutherland
- Q: How does ellura compare to slightly cheaper products, like TheraCran One or Utiva?
“…There are two that are relatively more commonly used…TheraCran and Utiva– my understanding with both of those is that they’re not predominantly made from the juice of the cranberry… and it’s the juice where you get the bioavailable PAC. The PAC that’s found in the stems, the seeds the skin, maybe the presscake form, which is predominantly everything but the juice, is non-bioavailable PAC. So, there’s PAC that’s in there. You can do your testing and you can measure PAC, but it’s not bioavailable, so it’s not helpful to the patient. Therein lies the biggest difference.”
- Q: What do you tell your patients who ask why they can't just drink cranberry juice?
“…Cranberry juice often isn’t made from just the juice. There [are] other compounds that are in there and, so, we don’t know how much bioavailable PAC is in a glass of cranberry juice. Of course, it’s probably going to depend on the different brands, how much PAC might be in there. There’s probably a lot of cranberry juice that one has to drink in order to get the same amount of bioavailable PAC in one pill of ellura. So, number one, there’s no consistency. There’s no regulation to be able to say how much bioavailable PAC is in any glass of a certain brand of cranberry juice, so there’s no recommendation that can be made there.
Number two, it’s a lot of cranberry juice you would inevitably need to drink. Number three, there’s a lot of cost associated with that. Cranberry juice isn’t inexpensive, especially when you get the whole cranberry kind that’s non-sweetened at Trader Joe’s or something. It’s pretty expensive. And then, number four, most of them have a lot of sugar in them. So, many patients maybe can’t or shouldn’t be drinking so much sugar during the day. So, there are a number of reasons why just drinking cranberry juice isn’t going to solve the problem and that the concentrated form in a pill is going to be much more effective.”
- Q: Do you avoid cranberry in patients on anticoagulants, or is it safe for patients on anticoagulants?
“I often get this question when I try to recommend a cranberry supplement from people who are on Warfarin. They say, ‘Well, I can’t have cranberry juice, I can’t have grapefruit juice, I can’t have those kinds of compounds, so I can’t take this cranberry supplement.’ But that is really not the case. The thing that they can’t have that’s in cranberry juice, grapefruit juice, and these other kinds of products is the vitamin K. It’s the vitamin K in those substances that interferes with the anticoagulant effect of Coumadin, as an example. But in the cranberry supplements, and ellura specifically, as it goes through its processing, that vitamin K is no longer in that ellura pill. There’s a very, very small, miniscule amount of vitamin K that’s left in any one tablet. That is really clinically insignificant, and so it is– I think on their labelling, they have to mention it, because there is a little bit of vitamin K, and this has been something that has been of concern. The blanket recommendation is, when you start somebody on ellura, then perhaps check their coagulatory parameters to make sure nothing changes while they’re on their Coumadin. But when you look at it from a theoretical standpoint, there’s no reason that their anticoagulatory parameters should change.”
*For more information about ellura’s ingredients, visit https://ellura.com/pages/ingredients.
- Q: Do you recommend D-mannose?
“I don’t generally recommend D-mannose. I do see plenty of patients who come to me who are already on it, and they’ve been on it for years, and lo and behold they tell me how many UTIs they have every year. So, clearly something’s not working well. But really the reason, ¬ you know, it’s been so widely used over the years and previously widely recommended– But we recently had our academic societies, SUFU/AUA, the Canadian Urology Association came together and made some recommendations about what we do for recurring UTIs, and they looked extensively at all the current literature that’s available and really came to the conclusion that we do not have good concrete data in our literature to support the use of D-mannose. They didn’t even go out and say to recommend using it.
They actually did say there is a lot of data to support the use of cranberry supplements, as long as they are concentrated cranberry supplements with at least 36 milligrams in a dose and with a certain amount of bioavailable PAC active compound, which is what ellura does. I don’t recommend D-mannose. There are other reasons too. The D-mannose, as the word implies, is a sugar. There are many times patients who really shouldn’t be taking a sugar pill because they are diabetic, or there might be other reasons. So I don’t recommend the D-mannose.”
- Q: How safe is vaginal estrogen for breast cancer patients?
“I use vaginal estrogen quite a bit for prescribing it for my patients. I see a lot of women who are postmenopausal, and the benefits of a small local dose of vaginal estrogen, I think, are tremendous or can be tremendous. The question really was, “How safe is it to use in patients that have had a history of breast cancer?” Well, ACOG, the American College of Obstetrics and Gynecology, came out with a position statement noting that local low-dose vaginal estrogen does not seem to increase the risk of breast cancer recurrence or couldn’t show any other type of issue that would develop with low-dose vaginal estrogen.
So, that’s what I really talk to patients about. We sort of generally clinically think of a patient as a two-year survivor. It should be safe to use. We make sure that we’re using a local dose –a very small dose in the vaginal area,– that they’re not overusing it, using it too much and too often, such that it is getting systemic. If they start to have maybe some breast tenderness or other symptoms, then we tell them to decrease the dose a little bit to make sure they’re just getting a local dose.
Even [with] patients who are breast cancer survivors, we still use local vaginal estrogen. If patients are very, very nervous about it, and sometimes patients can be, then I recommend that they talk to their oncologist, and we send a note to the oncologist and have a three-way discussion, if need be. And by and large, at least in the community where I am, the oncologists almost always say it’s absolutely fine. Of course, it can depend on a number of variables with the patient, that might be individual to the patient, so we want to look at some of those individual variables. But as an overall statement, by and large, it’s safe.
If patients are concerned about the dosing, with the estrogen cream, oftentimes, we just tell our patients to put some on their finger and put it on the vaginal area, about one gram. But if you really want to be controlled about the dosing, the smallest dose available is in Vagifem or Yuvafem, which is a little vaginal suppository, and just using that as 10 micrograms of estradiol. Another thing that’s nice is the Estring, which emits a very small dose of estrogen every day. It’s a little ring worn in the vagina over the course of three months. It’s depleted after three months so you take it out and put a new one in, but that’s a very, very low local dose as well.
The reason to use those sometimes is if you have maybe a little bit of an older patient, you’re not so sure about their compliance, you’re not so sure about – you know, they’re really wondering, “Well, how much is a finger fill and how much is–?” If they’re going to use it appropriately, and you’re worried about that, then this kind of minimizes some of the mistakes, I guess, that can be made, if they’re just using an Estring over three months.”
- Q: Would you recommend antibiotics for symptomatic UTIs if a culture shows less than 10 thousand organisms?
“There’s this window between 50 thousand and 100 thousand organisms. If the patient is clearly classically symptomatic, and usually the patient knows, it sounds like, it smells like, it looks like, the urine is cloudy, so on and so forth, then yes, I would go ahead and treat that. If you see them in the office, the question would be, “Should I treatment them empirically versus wait for the urine culture?” It just depends on how miserable the patient is at the time. If they’re not too miserable, I always like to wait for that urine culture.
It comes back and now it shows 50 to 100 thousand. The key here though is 50 to 100 thousand, Right? If it says “50 to 100 thousand mixed normal genital urinary flora,” then the answer is that’s still not a urinary tract infection. An infection is an overgrowth of an isolated organism, so if it says 50 to 100 thousand of an isolated organism, okay, “Uncle.” And they have the right symptoms? I say go ahead, treat it, and hopefully they see prompt resolution of their symptoms.
You’re treating it with the right antibiotics, since you have the urinary culture, so you should see what antibiotic is appropriate for it. If they respond within the first 24 to 48 hours and [are] feeling better, and then [it] is resolved a few days later, then you know that that was correct. If it doesn’t resolve and you’re giving them the antibiotic that is appropriate per that urine culture, then it wasn’t really a UTI. In other words, the classic guidelines SUFU/AUA, greater than 100 thousand of an isolated organism with symptoms is a urinary tract infection worthy of antibiotics. Fifty to a hundred thousand of an isolated organism with symptoms is worthy of treatment. Less than that or not an isolated organism is not a UTI.
Now that also brings us into the category of “What if it’s greater than 100 thousand but they don’t have any symptoms and the urine is even cloudy?” If they don’t have symptoms, it’s not a true urinary tract infection, and that’s where we get into this colonization issue. The patients are just colonized with that organism, but it’s not causing any untoward problems, so it’s not a true infection, and treating it with antibiotics will not solve anything. It will clear up the urine for a little period, but it will come right back, so we don’t treat that either.
A UTI, by definition, has to have symptoms, and symptoms related to the bladder. There’s another question that I get often. Patients who are elderly don’t always get classic UTI-like symptoms: urgency, frequency, dysuria. Sometimes they get change in mental status where they just get extreme fatigue. That is in and of itself not a urinary tract infection, especially if they don’t have a urine culture to support that there’s an isolated organism with substantial quantities that is a urinary tract infection. We get this all the time.
The patients get admitted, they have a little bit of a fever, they have a change in mental status, they check a urine, and they send a culture, and it shows 50 thousand mixed organisms blah, blah, blah and they say, “Oh, you have a urinary tract infection, urosepsis, and they put them on IV antibiotics, and then they send them home. It is not a urinary tract infection. They had a fever and mental status change because they had their fever, but they had it for a different reason, and so, just a change in cognition alone without any lower tract urinary symptoms is not a urinary tract infection. Because “Mom has really been super tired lately,” and that’s it, does not mean she has a urinary tract infection. Those symptoms can go along with a UTI, but they also would have some type of lower urinary tract symptoms as well.”
- Q: Is it safe to wait for culture results before starting a patient on antibiotics?
“It’s absolutely safe to wait for a culture to come back before starting a patient on antibiotics. There are certain cases where you might have somebody who’s a little bit older who doesn’t always have absolutely classic symptoms. When you talk to them, you can get the idea that they’ve got some urinary tract symptoms, or somebody who has situations where they go from, ‘Oh my gosh, I’m feeling it,’ some symptoms, to, ‘I see blood in the urine and I have a high fever,’ boom, and already there, septic. They just don’t get a lot of warning. In those cases, then I think it’s okay to go ahead and start empiric treatment with a big-gun broad spectrum antibiotic, but send the urine for culture first. Send it before you give them the antibiotic, and then tailor your treatment depending on what the urine culture comes back as.
Don’t keep them on the big-gun broad spectrum antibiotic for a full seven days or ten days if that’s not what’s needed. But most of the time, unless a patient is really miserable and you want to help them because of that, you can usually wait a few days. You can wait for the urine culture to come. Just have them drink fluids, maybe use a little bit of Pyridium to feel better. Here’s where you can encourage them to take some extra ellura or take some cranberry juice or something like that. Staying flushed is really the thing that’s going to be the most safe, so just whatever fluids that they’re drinking, just stay well hydrated and stay flushed, so that you’re voiding every couple of hours or so, and it’s absolutely safe.”
- Q: If a patient’s urinalysis is showing blood but they do not have symptoms of a UTI, do you retest post-antibiotic treatment?
“If they don’t have symptoms of a urinary tract infection after you test them, there’s no rationale for doing a test of the cure. A little bit of microscopic blood in the urine alone does not mean they still have a urinary tract infection. A UA that’s infected has blood, has white cells, has nitrites, and the urine is cloudy. Not just blood alone. A little bit of trace blood doesn’t mean anything. If you think about it, if you’ve ever looked inside a bladder, you can imagine what an infection– If you have an infection on your hand and you’re taking an antibiotic, because you had an open sore, let’s say, and you’re taking an antibiotic, the infection is gone, the antibiotic course was only for maybe five days, seven days, but your hand doesn’t look back to normal. Right? It still has to heal, but the infection is gone.
The same thing can be said about what’s potentially happening in the bladder. So, we know you can see sometimes blood in the urine even with the naked eye, you get enough blood that you see the blood in the urine, so imagine what the lining of the bladder looks like if it was bleeding. So, you get rid of the infection, but it doesn’t mean that all of the healing in the bladder has completely taken place. So, to see a little bit of blood in the urine, not with the naked eye, but microscopically, to see a little bit of blood on your test is not so surprising. So, when I see people who do a UA dip in the office like a week later after they put them on five days of antibiotics, and they have them come in on day seven, eight, nine, ten, and they see there’s a little bit of blood, ‘We’re giving you another course of antibiotics,’ there’s no rationale for that, no. Also, the SUFU/AUA guidelines do not recommend a test-of-cure if the patient is without symptoms. They’ve responded to the antibiotics. They’ve responded. If they haven’t, and the antibiotics weren’t sufficient or something is going on, they’re going to have their symptoms come back.”
- Q: What do you do for those patients who are in the office every other week with culture-proven UTIs with symptoms?
“That implies they have a urinary tract infection, a urine culture that shows greater than 100 thousand of an isolated organism, you provided them with the correct antibiotic as you had that urine culture sensitivities, they hopefully feel better, but then they come back because they have another one. That’s the scenario that I talked about a little bit earlier to say, ‘There’s something going on behind the scenes that is not being identified.’
Meaning, it’s not just simple cystitis. They either have a big bladder stone in the bladder, maybe they have a big stone in the kidney, maybe they have a urethral diverticulum, maybe they have a large diverticulum in the bladder that’s housing urine and causing it to get infected, maybe they have a fistula. There’s something else that’s going on behind the scenes that’s not yet recognized. They need a full urological evaluation to include upper-tract imaging as well as a cystoscopy of the bladder.”