Urinary tract infections (UTI) are fairly common among reproductive-age women. They have huge economic consequences due to the need of antibiotics, healthcare bills, and time lost due to illness. Several preventive and therapeutic treatments have been studied in order to control urinary tract infections properly and efficiently. One of the strategies investigated is the use of Cranberry (Vaccinium berries) supplements to treat UTIs in nursing home patients. Cranberries include proanthocyanidin (PAC), which has an adhesive property that is important in preventing E. coli infection of uroepithelial cells in host tissue. Using the complete settler model as a guide, the primary objective of the selected reviews is to evaluate the efficacy of cranberry supplements in reducing UTIs amongst senior adults living in nursing homes. The study compares recipients of the remedy and those who do not receive it.
Methods: Secondary literature was conducted on articles available on EMBASE, MEDLINE, PUBMED database and Cochrane meta-analysis. Five articles were selected for the review concerning the study. Randomized controlled trials (RCTs) that compared reduction of urinary tract infections in cranberry product users versus the placebo and non-placebo function were incorporated into comparative evidential studies.
Results: Clinical trials across the population in the nursing home were identified for qualitative analysis. The random effect of the pooled risk (PR) for both cranberry users and non-users was noted. The effectiveness of the use of cranberry-containing products across the subgroup was effective in the reduction of UTI especially in women with recurrent infection against the groups that not placed on cranberry products containing supplements. According to Cochrane meta-analysis, Jepson & Grain (2013) indicates that the user of cranberry juices among women with recurrent UTI also lowers the UTI infections. However, the study didn’t explore the dosage factor in the tablets for the effective prevention of the UTI. Each of the reviewed studies had a different dosage, frequency, and formulation of the cranberry tablet used.
Conclusion: Finding from the reviewed literature indicates that of the cranberry-containing products potentially reduces and prevents urinary tract infections in most individuals without any adverse effects. Women of advanced age are most prone to UTIs. According to Van den Hout, Caljouw & Putter (2014), 40%-50% of the women population is evidenced to have experienced an episode of UTI occurrence in their lifetime. Pregnant women, elderly, and patients with neuropathic bladder are at an increased risk of UTI infections (Van den Hout et al., 2014)
Implications for Nursing: Due to favorable results derived from using supplements, nursing homes consider other factors like the interaction of cranberry with other drugs as well as other health issues. Taking supplements over an extended period should be considered as it may cause health complications for the user. The interventional approach represents favorable tidings for nursing as a whole as it avails an alternative to the perennial UTI recurrence problem.
Introduction
Irrespective of the method used in studying cranberry supplement implications in reducing the UTIs in nursing, the general health and economic benefits are far more critical. According to the reviews of existing literature, cranberry products containing the supplement reduces the recurrence of UTI infections among all the risk groups in three months (Caljouw et al. 2014). The Proanthocyanidins (PACs) compound in cranberry block certain bacteria like E. coli and H. pylori from adhering to Uroepithelial cells in the host tissue (Caljouw et al .2014). Cranberry ingredients are beneficial in preventing the buildup of the mucus thus reducing the risk of gall bladder infections. It also eliminates certain types of oral bacteria that cause dental decay and gum disease.
According to Van den Hout et al. (2014), urinary tract infections result in close to 7 million outpatient and additional 1million ER visits in the US annually. It also results in about 1milion inpatient cases. Further, Van den Hout et al. (2014) estimated that cost of community-acquired UTIs is $1.6 billion every year. The use of cranberry supplements by the nursing homes would bring the cost of managing the infection down significantly, thus making the intervention economically viable.
Cranberry supplements are cost effective as compared to other products. The number of trips patients make seeking medical attention significantly reduces thus saving time and travel cost. The costs incurred by nursing homes in purchasing cranberries would be significantly high as compared to buying supplements (Van den Hout et al., 2014). The use of supplements has a low caloric load as compared to cranberry juice, which would not be useful to older adults in the nursing home due to age and health complications. Alternatively, the cranberry product has no side effects which are synonymous antibiotics use (Caljouw et al., 2014).
Urinary tract infections (UTIs) are estimated to affect at least 60% of the women worldwide. The UTIs are a significant public health concern. The infections are more prevalent in females than males because the female morphology tends to exhibit a relatively shorter urinary tract presenting a smaller distance for bacteria to ascend into the bladder (Van den Hout et al., 2014). The main risk factors that make females more predisposed to recurrent infection other than their morphological make up are use of contraceptives, sexual intercourse, menopause, antimicrobial resistant, genetics and bacterial virulence (Caljouw et al., 2014)
UTIs are caused by bacteria Escherichia coli (E. coli) which is accountable for many problems of the urinary tract. The treatment of UTIs incorporate the use of antibiotics. However, infection recurrence is a significant drawback to treatment efforts. Hence, prevention strategies become a crucial goal of all health institution and government agencies. Preventive approaches are mainly utilized because of the recurrent nature of the bacteria, increase in microbial resistance and medical costs (Jepson & Grain 2013). Repeated doses of antibiotics and long-term antibiotics prophylaxis are some of the current management strategies used address recurrent UTIs. These methods are immensely useful and effective. However, they have side effects such as super fungal infections gastrointestinal infections (Jepson & Grain 2013).
Reducing urinary tract infections has been a real concern especially for elderly adults living in the nursing homes. The recurrent nature of the UTIs has been a challenge to most health caregivers. Most of existing literature from the EMBASE, PUBMED and MEDLINE indicate that use of the cranberry product is efficient in the reducing and preventing the prevalence of infections by a considerable margin. This study intends to assess the use of cranberry supplement in reducing the occurrence of the UTIs among the elderly population in nursing homes. The study incorporates non-cranberry users as a control group in the study in randomized trials.
Cranberry contains 80% water and 10% carbohydrate. Other essential constituents include flavonoids, anthocyanin, catechins, s triterpinoids and organic acids. The use of cranberry in treating of UTI is related to its unique ability to adhere to the uroepithelial cells thus inhibiting the pathogen. According to Caljouw et al. (2014), cranberry consists of two major compounds that impede the adhesion of E.coli. These include fructose which obstructs the mannose sensitive fimbria adhesion, and the other is a high molecular weight compound (proanthocyanidin- PAC) that inhibits the mannose resistant adhesions of E.coli,
Using the Stetler model to achieve an informed decision-making process, the purpose of the research expedition is to access the efficacy of cranberry use in reducing UTIs among persons above the age of 65 in a nursing home as compared to cranberry none users. The focus of the paper is to evaluate the following PICO(T) question in an adult nursing home (P) on cranberry supplement (I) for reducing the UTIs (C) in comparison with the none-cranberry product containing supplement users (O).
Method
Validation
Selection of the Article. A literature search was conducted from the available database on EMBASE, PUBMED, and MEDLINE collections. The key words were cranberry, urinary tract infections, and elderly adults. Reducing UTI infections in nursing homes was used in the advanced search for varied results. The article selection was further based on a limited criterion on the English language, the full text available and strictly published and reviewed within the last five years. The bibliographies listed in all the articles were also searched to check for any new data captured not present in selected materials. For the final selection of the online articles, the titles and abstracts were reviewed only to obtain the most relevant studies regarding the PICO (T) questions indicated in the literature review.
Meta-analysis following preferred reporting items for systematic and meta-analysis (PRISMA) guidelines were used in data search and sources (Van den Hout, Caljouw & Putter 2014). The final five articles selected for the study included three articles from EMBASE and MEDLINE database and two meta-analyses. PRISMA guidelines were used to analyze evidence from each article. The sources were selected based on their relevance to the review as follows; randomized control trials, comparison of cranberry-containing products versus non-users of cranberry control for prevention of UTIs. The outcome was reported as an incidence of UTIs.
After retrieving the data based on a pre-specified criterion, the data providing only the most relevant information was extracted. The data was used to determine if the use of cranberry supplement among the adults' population in a nursing home was effective in reducing the UTIs as compared to the control group that did not use the supplements. A summary of selected literature is indicated in Table 1. The level of evidence along with each study's title, the name of the authors' methods used, findings and conclusions are also included.
Article Critique
The question on whether the use of cranberry supplements in reducing urinary tract infections in elderly adults in nursing as compared to those who didn't use the supplement is efficient is extensively addressed by many researchers on medical publications. The methods and the approaches used by different researchers varied from one another hence giving varying results. A standard strength witnessed across all the searches is that the included data considered for review was all quantitative, experimental, randomized controls, clinical trials, and quasi-experimental design. Each of the studies performed tests to determine the unique characteristic of the baseline population regarding health diagnostic, sex, age, incidence, and morbidity. Also, selected subjects across all the studies were the elderly residents in the nursing home.
The study sites were long-term care facilities. The presentation of the results of each survey was either in the form of graphs, tables or texts. A High level of evidence through two meta-analyses for the experimental studies provided a credible analysis and synthesis of the findings. A precise methodology on the assignment of the patients to trial groups, control group and administration of cranberry supplements and the dosage was indicated though it varied across all the five studies selected. The outcome of every survey was explicitly noted in the results together with their respective conclusions.
Every review had a methodological weakness which attributed to varied results. According to available literature, some of the studies incorporated semi-experimental design. This design lacks the prospect of random treatment assignment or control thus typically permitting researcher control of the task. The studies that administered the PAC containing supplements to younger females and individuals with a history of recurrent UTIs had a higher efficacy than other groups (Jepson and Craig, 2013). Such factors bring varied results depending on the characteristic of the baseline population.
Further, the methods of administering the PAC dosage differed from each study. None of the studies had similar dosage or concentrate. According to Army et al (2011), a PAC dosage of (RR, 0.62; 95% CI, 0.49-0.80) (I2 = 43%) was effective in controlling the UTIs in women with recurrent history contrary to the results of Jepson & Grain (2013), indicating the efficacy of cranberry supplement in UTIs prevention at RR, 0.49; 95% CI, 0.34-0.73) (I2 = 34% of female population. The clinical trial on the dosage that used more 10g per day showed positive results against UTIs. The clinical survey that used less than 10g too had positive results (Army et al., 2011).
Most of the researchers did not indicate the rationale for selecting a given cranberry dose. Hence, there is a need for a more dose-response study to determine the optimal dosage for cranberry containing the product. The dosage frequency also varied across all the reviews. The efficacy of using the cranberry product in reducing the UTIs could be improved by explicitly indicating the dosage, the frequency of administration and duration for every population along with other factors like age, sex, morbidity, and UTIs incidences in obtaining pooled results.
In conclusion, despite all the methodological weakness of all reviewed studies, the outcome in use of cranberry product to treat UTIs is significant in specific populations. The purpose of the supplement is operational in women suffering from recurrent UTIs, females, children than other groups. However, the dosage is not determined; hence it should be used with caution.
Comparative Evaluations
This review seeks to determine if the use of cranberry product containing supplements reduces the occurrence of UTIs among the elderly in nursing homes as compared to those not taking the supplements. The population clinical environment (going surgery, pregnant, on chemotherapy, or catheter, etc.) in existing literature will be studied to evaluate the implications of the findings for implementations. The current theoretical bases at the nursing homes will be reviewed alongside the available resources to create the required institutional change to accommodate a seamless change process for implementation.
Comparisons and Recommendations
Sample: The selected studies for review comprised samples of elderly adults at nursing homes (long-term care facilities). Sample consideration for the study was based on their risk factor to the UTIs (Caljouw A et al. 2014; Jepson &, Craig, 2013; Wang et al. 2012; Van den Hout, Caljouw & Putter 2014; Laplante et al. (2012). The risk factors across the selected studies were based on exposure to longtime catheterization those with diabetes mellitus and patients on chemotherapy treatment. Residents who were on coumarin were excluded from the study.
Environment: All the reviewed research took place in long-term care facilities. Advanced age (over 65-84 years) and UTI risk factor of the residents were some of the baseline criteria that qualified nursing homes as a proposed site for the study as it increased the applicability of the results and program implementation.
Theoretical Base: Urinary tract infections both lower and upper symptomatic remains one of the most common diseases in nursing homes. The prevalence estimation is at 6%-8%. These infections cause the patients to suffer a lot of pain, loss of time in travel to hospitals, and financial implications in the purchase of drugs (Caljouw et al. 2014).
Several prevention strategies for reducing the incidences of UTIs have been suggested for use in nursing homes. Prevention of infection can alleviate the suffering from the patient; reduce use of antibiotics and microbial resistance. Infection control programs and appropriate use of catheters and UTIs prophylaxis have been considered. One of the main UTIs prophylaxis is the use of antibiotics. Use of antibiotics for long can cause severe side effects and microbial resistance (Jepson & Grain 2013) thus rendering it ineffective in reducing the infection recurrence. Prophylaxis with cranberry products is a potential preventive strategy because it has no side effects to the user. Cranberry contains proanthocyanidin (PAC), a compound which has a stable anti-adhesion impact against Escherichia coli (Wang et al. 2012).
Levels of organization: Instituting a new strategy for reducing UTIs infection would require the involvement of many levels of the organization and the residents in the nursing home. The pharmacist would need to obtain a cranberry containing product from the supplier with a permit from the relevant authorities. The resident would require sensitization on the changes from the Prophylaxis and the importance of supporting the new development at the nursing home. Monitoring on the use of new tablets should be performed to by nursing management and infection control board.
Resources: Use of cranberry-containing product as a strategy in reducing UTIs on a large scale can be expensive. On the contrary, the use of antibiotics is often ineffective due to severe side effects and potential resistance. The cost of 300mg-500mg of cranberry product would cost $10-$15 per person in one month. A visit to UTIs unit will cost $90, and the antibiotics cost $10 to $60 or more depending on the brand (Van den Hout et al., 2014). A change from antibiotics Prophylaxis to cranberry supplements has an increase in the cost of procurement and sensitization programs. To implement the changes, nursing staff and the residents need to undergo education on the need to change from Prophylaxis and the importance of giving the new program much-needed support. Education-related cost for nurses will be minimal as it only requires conviction and a change of mindset. There would be no new changes to the value of equipment except education of residents and further procurement of supplements. Notable reduction in the cost of managing of the UTIs will be evident by the end of the program.
Decision Making
Evaluation. In this study, five articles were retrieved and reviewed to determine if the use of cranberry-containing supplement was efficient in reducing the incidences of UTIs in elderly adults in nursing home. The peer-reviewed literature exhibited high levels of reliability as well as validity and were highly recommended for use are influential research articles. The articles addressed different facets of the application of the remedy within the long-term residential medical setting and primarily dwelt on persons above age 65. Based upon the evaluated literature, use of cranberry was effective in reducing the UTIs incidences because of its compound proanthocyanidin (PAC), which has a stable anti-adhesion effect against Escherichia coli (Wang et al. 2012).
Rationale: The reviewed study was conducted in nursing homes. The population for the study are the residents in the nursing home with high UTIs risk factors. The sample presented an ideal research prospect as they were exceedingly predisposed to infection by the disease. Participants were perennial sufferers of the condition, hence, were enthusiastic to take part in a process that could potentially develop long-term intervention. As there were no other unique characteristics among the patients to that of the general population, the findings were crosscutting and could impact any other sufferer as it did the control group. The survey can be generalized to any other population in a long-term care facility. Implementation of change from previous UTIs Prophylaxis to the new ones containing cranberry is attainable upon provision of finances for nurses as well as procurement of the new product. The current treatments are relatively effective but often presets a flurry of drawbacks that make patients particularly apprehensive of exploring them. Their long-term use is known to cause significant health complications which undercut their use in the first place. Therefore, the cranberry alternative not only appears fitting but will alleviate the traditional problems commonly associated with available curative measures.
Change Steps
To implement new changes to the cranberry program, management needs to bring forth a systematic strategy that will enable institutionalization of required changes. To achieve maximum implementation, change process as described by (Kotter international, 2016) should be adopted. The first step towards change is creating a sense of urgency toward the non-use of current UTI Prophylaxis which does not have cranberry concentrate. The staff and residents at the nursing home should embrace the ideal and all work towards winning. Secondly, a team that should be a guiding coalition should be created. This team should be powerful enough to bring the anticipated changes. They should be able to communicate, set change timelines as well as establish a process and duration for the staff and resident education on the intended program.
The transition from commonly used treatments to new experimental alternatives is often difficult to implement. Caregivers, medical practitioners, and the patients themselves are often skeptic as well as unconvinced of the remedy’s ability to work as effective as the former cures. Therefore, it is imperative that the process is well, managed. Critical obstacles like current UTI Prophylaxis at the site are removed. Residents who use coumarin are excluded from the targeted team. Next, a short-term win will be noted based on the adherence measured over a 1-month interval by counting the number of cranberry tablets the participants took in 5 months of interventions in comparison with the prescribed number of tablet put in the drug dispenser. Continued success will be monitored in line with the previous strategy of reducing the UTIs incidence. If a reduction of UTI incidences is noted with the use of cranberry tablets then continued research in the field will be encouraged. Broad-based actions to empower the vision will be communicated to the entire team to make the decision a culture of the institution.
References
Army B.H Henry., Christopher C.C., Anne B, Luis.., Mat S, Peter. ( 2011). Investigating the preventive use of cranberry capsules in long-term care facility (LTCF) residents is cost-effective depending on urinary tract infection (UTI) risk.
Caljouw, M. A., Hout, W. B., Putter, H., Achterberg, W. P., Cools, H. J., & Gussekloo, J. (2014). Effectiveness of Cranberry Capsules to Prevent Urinary Tract Infections in Vulnerable Older Persons: A Double‐Blind Randomized Placebo‐Controlled Trial in Long‐Term Care Facilities. Journal of the American Geriatrics Society, 62(1), 103-110.
Jepson RG, Craig JC. (2013). Cranberries for preventing urinary tract infections. Cochrane Database System Rev; CD001321.
Kotter International. (2016). Kotter’s 8-Step Process for Leading Change [Web page]. Retrieved September 25, 2016.
Laplante KL. Sarkisian SA., Woodmansee S. (2012). The effects of cranberry Extracts on growth and biofilm production of Escherichia coli and Staphylococcus species. Phytother Res; 26:1371–1374.
Van den Hout WB, Caljouw MAA., Putter H (2014). Cost-effectiveness of cranberry capsules to prevent urinary tract infections in long-term care facilities: Economic evaluation alongside a randomized controlled trial. J Am Geriat Soc; 62:111–116.
Wang C.-H., Fang C.C., Chen N.C., Liu S. S.H., Yu P.H., Wu Y., Chen S.C(2012). Use of Cranberry-containing products for prevention of urinary tract infections in susceptible populations. A systematic review and meta-analysis of randomized controlled trials. Archives Internal Medicine, 172(13), 988–996.
Table 1: Summary of Selected Literature with Level of Evidence Rating
Title
Authors
Purpose
Methods
Findings/ Conclusion
Level of Evidence*
Effectiveness of Cranberry Capsules to Prevent Urinary Tract
Infections in Vulnerable Older Persons: A Double-Blind,
Randomized Placebo-Controlled Trial in Long-Term Care
Facilities
Caljouw A. A. Caljouw, Wilbert B. van den Hout, Hein Putter,
Wilco P. Achterberg, Herman J. M. Cools, and Jacobijn Gussekloo 2014,
To determine whether cranberry capsules
prevent urinary tract infection (UTI) in long-term care
Facility (LTCF) residents.
Double blind randomized placebo controlled multicenter trial.
Primary outcome was incidences of UTIs. Cranberry supplements were found to be more beneficial to high risk UTIs group.
Level III: Controlled trial with randomization
Cranberry-containing products for prevention of urinary tract infections in susceptible populations: a systematic review and meta-analysis of randomized controlled trials
Wang CH, Fang CC, Chen NC, Liu SS, Yu PH( 2012)
To find out if that cranberry-containing products are associated with protective effect against UTIs.
MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were systemically searched
randomized controlled trials
meta-analysis in accordance to the PRISMA
comparison of cranberry-containing products vs. placebo or non -placebo control for prevention of UTI;
Findings indicate that cranberry-containing products are associated with protective effect against UTIs. The incidence of UTI reduction being prevalence more in older women with recurrent UTIs.
Level III: Controlled trial with randomization
Cost-effectiveness of cranberry capsules to prevent urinary tract infection in long-term care facilities: economic evaluation with a randomized controlled trial.
van den Hout WB, Caljouw MAA, Putter H, et al, 2014
To investigate whether the preventive use of cranberry capsules in long-term care facility (LTCF) residents is cost-effective depending on urinary tract infection (UTI) risk.
Economic evaluation with a randomized controlled trial And control clusters were six months in duration.
the use of cranberry increased costs without preventing UTIs. Taking cranberry capsules had a 22% probability of being cost-effective compared with placebo In low-UTI-risk participants, use of cranberry capsules was only 3% likely to be cost effective but not in dosage, frequency and setting.
Level IV: Randomized controlled trial with cohorts or clusters.
Dosage effect on uropathogenic Escherichia coli anti-adhesion activity in urine following consumption of cranberry powder standardized for proanthocyanidins content: a metacentric randomized double blind study.
Army B.H Henry B.
Christopher C.C,
Anne B,
Luis G,
Mat S,
Peter T( 2011)
To determine the effectiveness of cranberries adhesion on uropathogenic E.coli in preventing UTIs in adults at risk for UTIs.
randomized, double-blind versus placebo study were conducted between the cranberry products user and non-user with UTIs risk factors
Administration of PAC-standardized cranberry powder at dosages containing 72 mg of PAC per day in women with recurrent UTIs may offer some protection against bacterial adhesion and virulence in the urinary tract
Level I: Multivariate analysis of results obtained to urinary bacterial adhesion to T24 cells expressed as adhesion index. Randomized controlled trial
Cranberries for preventing urinary tract infections in all community population.
Jepson RG, Craig JC(2013)
To determine To the effectiveness of cranberry products in preventing UTIs in susceptible populations
All randomized controlled trials (RCTs) or quasi-RCTs of cranberry products for the prevention of UTIs in all populations in comparison to placebo/control.
Cranberry products greatly reduced the incidence of UTIs at 12 months (RR 0.65, 95% CI 0.46 to 0.90) compared with placebo/control. Cranberry products were more effective reducing the incidence of UTIs in women with recurrent UTIs, than elderly men and women or people requiring catheterization
Level II: Randomized controlled trial
* Rating System for Hierarchy of Evidence provided by Melnyk, B.M. & Fineout-Overholt, E (2015).
