Patent Description:
The present description relates to a synergistically active composition comprising a cranberry extract and at least one antibiotic for treating a bacterial infection.

As antibiotic resistance in microbial pathogens embodies a global threat to public health, it demands the development of novel strategies for managing microbial infections. The long-term effectiveness of most antibiotic treatments is restricted by both pathogen drug resistance and non-target effects on the host's commensal microbial community. Over the last decade, research on antimicrobials has shifted towards an alternative approach to combat pathogens using anti-infective drugs that selectively interrupt virulence pathways to help prevent or cure bacterial infections. Anti-infective drugs that do not perturb survival or viability of bacterial pathogens should be less likely to promote resistance than conventional antibiotics. Until now, the development of anti-infective synthetic drugs has been limited to the laboratory and preclinical studies. Natural bioactive compounds derived from plant species show promising therapeutic properties to combat the emerging resistance in microbial pathogens, which can be exploited as next generation anti-infective drugs.

The identification of selective anti-virulence therapies that abolish the production of virulence determinants without affecting the viability of pathogenic bacteria would be extremely useful in combating bacterial infections caused by broad-spectrum antibiotic-resistant pathogens.

There is thus a need to be provided with new antibacterial composition.

In accordance with the present disclosure, there is now provided a synergistically active composition according to claim <NUM>.

In an embodiment, the cranberry extract comprises proanthocyanidins, flavanols, anthocyanidins, procyanidins, terpenes, hydroxybenzoic acids, hydroxycinnamic acids, flavonoids, tannins, phenolic acids, other bioactive molecules or combinations thereof.

In another embodiment, the cranberry extract is from at least one of Vaccinium macrocarpon, Vaccinium oxycoccos, Vaccinium microcarpum, and Vaccinium erythrocarpum.

In a further embodiment, the cranberry extract is from Vaccinium macrocarpon.

In another embodiment, at least one antibiotic is an aminoglycoside, a polyketide, a macrolide, a benzenoid, an azolidine, an organic phosphonic acid, or their derivatives and combinations thereof.

In an embodiment, at least one antibiotic is kanamycin tetracycline, azithromycin, trimethoprim, sulfamethoxazole, nitrofurantoin, fosfomycin, or their combinations thereof.

In another embodiment, at least one antibiotic is trimethoprim and sulfamethoxazole.

In a further embodiment, the composition is a quorum sensing (QS) inhibitor.

In another embodiment, the composition permeabilizes cell membranes to the at least one antibiotic.

In a further embodiment, the composition inhibits efflux pumps.

In an embodiment, the composition enhances membrane transport of tetracycline.

In another embodiment, the composition described is an antagonist of LasR or RhIR.

It is also described the use of the composition described herein for treating a bacterial infection.

It is also described the use of the composition described herein in the manufacture of a medicament for treating a bacterial infection.

It is further described the use of the composition encompassed herein for decreasing multidrug resistance.

It is further described the use of the composition encompassed herein for decreasing biofilm formation.

It is also described a method of treating a bacterial infection, comprising administering the composition described herein.

In an embodiment, the subject is an animal or a human.

Reference will now be made to the accompanying drawings.

It is provided a synergistically active composition comprising a cranberry extract and an antibiotic for treating a bacterial infection.

Compounds derived from the American cranberry (V. macrocarpon L. ) have been reported to exhibit anti-oxidant, anti-adhesion, anti-motility and anti-cancer activities. Herein, it is provided the anti-bacterial efficacy of the composition described herein comprising cranberry-derived proanthocyanidins and antibiotic and its potential in treating clinical and multiple drug resistant pathogenic bacterial strains.

Bacteria have evolved multiple strategies for causing infections that include producing virulence factors, undertaking motility, developing biofilms, and invading host cells. N-acylhomoserine lactone (AHL)-mediated quorum sensing (QS) tightly regulates the expression of multiple virulence factors in the opportunistic pathogenic bacterium Pseudomonas aeruginosa. It is demonstrated herein an anti-virulence activity of a cranberry extract rich in proanthocyanidins (cerPAC or cPAC) against P. aeruginosa in the model host Drosophila melanogasterand show this is mediated by QS interference. cerPAC reduced the production of QS-regulated virulence determinants and protected D. melanogaster from fatal infection by P. aeruginosa PA14. Quantification of AHL production using liquid chromatography-mass spectrometry confirmed that cerPAC effectively reduced the level of AHLs produced by the bacteria. Furthermore, monitoring QS signaling gene expression using lacZ fusion reporters revealed that AHL synthases Lasl/Rhll and QS transcriptional regulators LasR/RhIR genes were inhibited and antagonized, respectively, by cerPAC. Molecular docking studies suggest that cranberry-derived proanthocyanidin binds to QS transcriptional regulators, mainly interacting with their ligand binding sites.

The fruit of the American cranberry (Vaccinium macrocarpon L. ) has been anecdotally reported as a natural remedy for urinary tract infections for centuries. Accordingly, a growing number of studies have examined the potential anti-oxidant, anti-adhesion, anti-motility and anti-cancer properties of cranberry-derived compounds. A number of these studies focused on the bioactivity of a specific fraction of cranberry phytochemicals known as proanthocyanidins (cPACs). Research shows that these condensed tannins hinder bacterial attachment to cellular or biomaterial surfaces, impair motility of the pathogens Pseudomonas aeruginosa, Escherichia coli and Proteus mirabilis, and can induce a state of iron limitation in uropathogenic E. While many studies have suggested that consumption of cranberry-derived materials, namely cranberry capsules and cranberry juice, is effective in preventing bacterial infections, few have looked at the effects of these cranberry-derived materials in vitro and in vivo after consumption. Indeed, the effect of bioactive cPACs on bacterial virulence in vivo and mechanisms by which they do so are poorly understood. To date, not much attention has been given to the anti-virulence properties of cPACs.

aeruginosa is an opportunistic and versatile γ-proteobacterium that readily develops antibiotic resistance and is responsible for various infections affecting immunocompromised individuals, such as those suffering from cystic fibrosis. aeruginosa regulates most of its virulence factors in a cell density-dependent manner via cell-to-cell communication, commonly known as quorum sensing (QS). aeruginosa has two major N-acylhomoserine lactone (AHL)-based QS pathways, the Las and Rhl QS systems, and one <NUM>-alkyl-<NUM>-(<NUM>)-quinolone (AQ)-based QS system, which function in a cascade manner. The Las system is positioned at the top of the QS hierarchy and uses N-<NUM>-(oxo-dodecanoyl)-L-homoserine lactone (<NUM>-oxo-C<NUM>-HSL) as its signal molecule, and involves Lasl and LasR as the synthase and regulator, respectively. The Rhl system uses N-butanoyl-L-homoserine lactone (C<NUM>-HSL) as its signal, and involves Rhll and RhlR as the synthase and regulator, respectively. The LasR initiates the QS regulatory systems, partially activates the transcription of RhlR and other regulators of Pseudomonas quinolone signal (PQS) and integrated quorum sensing (IQS) systems. The complex QS regulation network influences, both positively and negatively, the transcription of possibly <NUM>-<NUM>% genes of P. aeruginosa. The QS system is an essential part of the organism's virulence and is required to establish infection in the mammalian host.

It was reported that cranberry proanthocyanidins slightly potentiate the effect of the antibiotic activity of gentamicin (<NPL>). On the contrary, as demonstrated herein, it is disclosed a synergistically active composition comprising a cranberry extract and an antibiotic for treating a bacterial infection.

Four different fractions of cranberry proanthocyanidins were tested, as provided by Ocean Spray Cranberries (see Table <NUM>).

To verify the antibiotic synergy of cranberry proanthocyanidins (cPACs) with targeted types of antibiotics of interest in the context of urinary tract infections, checkerboard assay was performed for Escherichia coli CFT073, Proteus mirabilis H14320, Pseudomonas aeruginosa PAO1, P. aeruginosa PA14 and Enterococcus faecalis ATCC <NUM>. Trimethoprim, sulfamethoxazole, fosfomycin, nitrofurantoin, norfloxacin antibiotics are commonly used for the treatment of urinary tract infections. Antibiotic interaction was analyzed for the combinations of each antibiotic with cPAC sample. <FIG> shows the fractional inhibitory concentration (FIC) index values of each cPAC fraction in the presence of different types of antibiotics for five pathogenic strains. The corresponding FIC index values of the combination of sulfamethoxazole with all four cPAC samples were < <NUM> for five pathogenic bacterial strains, demonstrating a synergistic effect (Table <NUM>).

In order to verify whether antibiotic synergy of cPAC can limit infection in vivo, a fruit fly killing assay was used in which cPAC or kanamycin alone or in combination were administered to Drosophila melanogaster flies infected with P. aeruginosa PA14. As shown in <FIG>, the median survival of D. melanogaster after exposure to P. aeruginosa was <NUM> without cPAC (PA14 only), but <NUM> with cPAC-Kan combination treatment, which is significantly (χ2 = <NUM>, df = <NUM>, P<<NUM>) less virulence based on the comparison of survival curves. The median survival of infected D. melanogaster with cPAC only and Kan alone was <NUM> and <NUM>, respectively. The survival of uninfected D. melanogasterwas identical to the treatment with only cPAC (without PA14).

To further investigate the mechanism of action behind the synergy between tetracycline and cPACs, tetracycline membrane transport assay was performed. As shown in <FIG>, each cPAC sample enhanced the uptake of tetracycline in E. coli CFT073 cells at different levels. cPAC-<NUM> and cPAC-<NUM> enhanced the uptake of tetracycline in P. aeruginosa PAO1 cells in a dose dependent manner, while cPAC-<NUM> fails to enhance the tetracycline uptake and cPAC-<NUM> support at lower level compare to cPAC-<NUM> and cPAC-<NUM> (<FIG>). Results shown in <FIG> show the uptake of tetracycline in P. mirabilis HI4320 and P. aeruginosa PA14 in absence and presence of cPAC samples at different concentrations. The sample cPAC-<NUM> enhances tetracycline uptake in a dose dependent manner compared to cPAC-<NUM>, -<NUM> and -<NUM> for HI4320, while cPAC-<NUM> fails to enhance the tetracycline uptake in PA14 cells compared to cPAC-<NUM>, -<NUM> and -<NUM>. This mechanism of action correlates with the measured synergy of each cPAC sample (see Table <NUM>) with tetracycline for each strain.

Growth curve measurements show that each cranberry proanthocyanidin fraction (without antibiotic) did not reduce the growth rates of E. coli CFT073 and P. aeruginosa PAO1 when compared to untreated cells of each strain (<FIG>). This demonstrates that the observed bioactivity of the cranberry proanthocyanidins extract is not a killing effect but rather a synergism with the antibiotic.

Cranberry proanthocyanidins also significantly reduced biofilm formation formed by E. coli CFT073 at sub-lethal concentrations (see <FIG>). Proanthocyanidins derived from cranberry cause cell membrane permeabilization and efflux pump inhibition of pathogenic bacteria without affecting cell membrane integrity.

To analyze anti-biofilm activity of cPAC for E. coli CFT073, P. mirabilis HI4320 and P. aeruginosa PA14, sub-lethal concentrations of cPAC (<NUM> and <NUM> ug/mL) without and with gentamicin were chosen for biofilm studies. As shown in <FIG> and <FIG>, cPAC in combination with gentamicin (at sub-lethal concentrations) had significant inhibitory effects on biofilm formation (P<<NUM>) for CFT073 and HI4320 in dose dependent manner. In case of PA14, cPAC in combination with gentamicin (at sublethal concentrations) failed to inhibit biofilm formation (<FIG>). This indicates that cPAC fractions in combination with gentamicin at sub-lethal concentration are effective to inhibit biofilm formation of CFT073, PAO1 and HI4320.

The specific mechanism(s) of action for the observed synergistic interactions between proanthocyanidins and antibiotic is disclosed. As mentioned herein above, the proanthocyanidins at sub-inhibitory concentrations permeabilize the cell outer-membrane and inhibit multidrug resistance efflux pumps involved in multidrug resistance in pathogenic bacteria, without affecting cell membrane integrity (see <FIG>). This is interesting, because elimination of persister cells at sub-inhibitory concentrations of cranberry proanthocyadins can reduce the amount of antibiotic required for the treatment of chronic and recurrent infections. The beneficial properties of cranberry proanthocyanidins suggest that the combination of the natural compounds and antibiotics is an effective new anti-bacterial therapy.

Treatment with cerPAC significantly inhibited the staphylolytic (LasA, F<NUM>,<NUM>= <NUM>, p <<NUM>), elastolytic (LasB, F<NUM>,<NUM>= <NUM>, p <<NUM>) and alkaline proteolytic (AprA, F<NUM>,<NUM>= <NUM>, p <<NUM>) activities of P. aeruginosa PA14 (<FIG>). Importantly, this inhibition was achieved without affecting bacterial growth (<FIG>).

To verify whether cerPAC can limit infection in vivo, a fruit fly killing assay was used in which cerPAC was administered to Drosophila melanogaster infected with WT P. aeruginosa PA14. As shown in <FIG>, the median survival of D. melanogaster after exposure to P. aeruginosa was <NUM> without cerPAC, but <NUM> with cerPAC treatment, which is significantly (χ<NUM> = <NUM>, df= <NUM>, P <<NUM>) less virulence based on the comparison of survival curves. The survival of uninfected D. melanogaster was identical to the treatment with only cerPAC.

The difference in the treated or untreated PA14 strains' ability to kill D. melanogaster in this feeding assay may have been due to modified survival of the bacteria on the filter papers used for exposure during incubation. To address this possibility, the survival of PA14 was analyzed on the paper discs without and with <NUM>µg mL-<NUM> cerPAC under the same conditions as the fly feeding assay. There was no significant difference (F<NUM>,<NUM>= <NUM>, P= <NUM>) in culturability of the bacterium on the filter paper discs in the absence and presence of cerPAC during incubation (see <FIG>), indicating that an alteration in survival ability of bacteria could not account for the observed differences in fly killing. Overall, these results indicate that cerPAC protect D. melanogaster from P. aeruginosa infection.

To determine the ability of cerPAC to modulate the production of the two principal AHL molecules by P. aeruginosa PA14, AHL production kinetics were determined in absence or presence of <NUM>µg mL-<NUM> cerPAC. As shown in <FIG>, cerPAC significantly impairs the production of <NUM>-oxo-C<NUM>-HSL (t= <NUM>, df= <NUM>, p <<NUM>) and C<NUM>-HSL (t= <NUM>, df= <NUM>, p <<NUM>), in P. aeruginosa PA14 at exponential and late stationary phase, respectively. This reduction in the production of the QS signals was observed without affecting bacterial growth (<FIG>).

To understand the mechanism for the reduction in AHL levels, β-galactosidase transcriptional fusion reporters of lasl (<NUM>-oxo-C<NUM>-HSL synthase) and rhll (C<NUM>-HSL synthase) were assayed in P. aeruginosa PA14 bioreporter strain with the same <NUM>µg mL-<NUM> cerPAC exposure. These bioassays revealed that expression of both AHL synthase genes (lasI and rhlI) is repressed by cerPAC (<FIG>). Similarly, it was investigated whether presence of cerPAC affects the expression of the two cognate transcriptional regulator genes lasR and rhlR using lacZ transcriptional fusion reporters. Expression of both regulator gene fusions was partially repressed in the presence of cerPAC (<FIG>). Thus, cerPAC inhibits both AHL synthases and partially represses the LuxR-type regulator genes associated with the production of the two AHL signals in P. aeruginosa PA14.

It was further investigated whether cerPAC affects LasR and/or RhlR induction by exogenous AHLs using bioreporter AHL-negative PA14 mutants with IacZfusions. As expected, when <NUM>-oxo-C<NUM>-AHL or C<NUM>-HSL were supplied to their respective bioreporters, they activated the expression of lasl and rhll, respectively (<FIG>). While cerPAC had no effect on the activity of the reporters, there was a significant (p <<NUM>) reduced activation by either AHLs in presence of cerPAC (<FIG>). This indicates that cerPAC partially inhibits the activation of both LasR- and RhlR-directed transcription of lasI and rhlI, respectively, the primary targets of these LuxR-type regulators. Additionally, LasR and RhlR activation titration was performed in absence and presence of three different concentrations of cerPAC, which resulted in lower activation of LasR and RhlR (<FIG>). This indicates that cerPAC can reduce the activation of both regulators by their native AHLs, likely as a potential antagonist.

To assess a possible physical interaction between cerPAC components and either AHL molecule, C<NUM>-HSL and <NUM>-oxo-C<NUM>-HSL were quantified in cell-free growth medium using an ethyl acetate extraction procedure followed by LC-MS analysis. As shown in <FIG>, there was no difference in the concentration of AHLs with or without cerPAC, demonstrating that cerPAC components do not bind to the AHLs and therefore do not inhibit QS by physical interaction.

Inhibition of Las-type QS regulators' activities by cerPAC may be due to structural interactions, important for the functional activity of transcriptional regulatory proteins. To address this possibility, in silico docking analysis was performed using protein structures of LasR (2UV0 (<NPL>)), Lasl (1RO5 (<NPL>)), the monomer and dimer of epicatechin molecules (important components of cPACs). The interaction energy scores (obtained using Moldock tools) of the predicted docking complex and the known crystallographic complex structures of the LasR with ligand <NUM>-oxo-C<NUM>-HSL were compared. The Moldock interaction energy score of -<NUM> kcal mol-<NUM> for the predicted complex of LasR with <NUM>-oxo-C<NUM>-HSL was marginally lower than the Moldock interaction energy score of -<NUM> kcal mol-<NUM> obtained for the crystallographic complex of LasR with ligand <NUM>-oxo-C<NUM>-HSL (<FIG> and Table <NUM>).

The epicatechin and its dimer (proanthocyanidin) molecules were docked separately in the internal cavity of LasR (<FIG>). Ligand binding domain (LBD) of LasR with a volume of <NUM>Å<NUM>, exhibits sufficient space to accommodate the monomer or dimer of epicatechin with a volume of <NUM>Å<NUM> or <NUM>Å<NUM>, respectively. The in silico docking analysis suggests that the complex formation between the epicatechin and LasR, with a Moldock interaction energy score of -<NUM> kcal mol-<NUM>, is more favorable than LasR-proanthocyanidin complex with Moldock score of -<NUM> kcal mol-<NUM> (Table <NUM>). The proanthocyanidin formed six hydrogen bonds at the internal binding cavity of LasR compared to four hydrogen bonds of the LasR-<NUM>-oxo-C<NUM>-HSL or LasR-epicatechin complex (<FIG>). The increase in the Moldock score for the docking complex of LasR with proanthocyanidin compared to LasR-epicatechin complex was observed due to the steric constraints of the proanthocyanidin structure in the internal cavity space of LasR identified by the comparison of their internal energies (Table <NUM>).

Due to the lack of crystallographic structure of Lasl protein bound with its natural substrates or functional analogues, an in silico docking analysis was performed to predict a complex of Lasl with its natural substrate S-adenosyl L methionine (SAM) (<FIG>). This putative complex with Lasl was used as a reference for both docking analyses of epicatechin and proanthocyanidin. The best five structural positions of SAM with higher interaction energies occupied the same binding cavity on the Lasl protein. The docking analysis showed the formation of hydrogen bonds of SAM with residues that surround the putative binding cavity with Moldock interaction energy score of -<NUM> kcal mol-<NUM> (<FIG> and Table <NUM>). The binding cavity known for the second substrate of Lasl, the acyl-acyl carrier protein (acyl-ACP) was not identified as a potential binding site for either of the tested cerPAC components (epicatechin or proanthocyanidin). The Lasl-epicatechin complex showed single hydrogen bond with Moldock interaction energy score of -<NUM> kcal mol-<NUM> (<FIG> and Table <NUM>). The docking complex of the Lasl protein with the proanthocyanidin molecule suggests the more favorable complex formation with five hydrogen bonds and Moldock interaction energy score of -<NUM> kcal mol-<NUM> compared to the Lasl-SAM complex (<FIG>). This in silico docking analysis suggests that both main components of cerPAC have the potential to form complexes with LasR and Lasl proteins to compete with their native ligands <NUM>-oxo-C<NUM>-HSL and SAM, respectively.

As demonstrating herein, cerPAC acts as a general QS inhibitor by interfering with the binding of the AHL ligand to LuxR-type transcriptional regulators. To verify that cerPAC is able to impede QS in other bacterial species, an AHL production kinetics assay was performed to examine the effect of administering cerPAC to wild type strains of Burkholderia ambifaria and Chromobacterium violaceum. The addition of cerPAC to growth medium significantly impairs the production of the two main AHLs (Cs-HSL and C<NUM>-HSL) in B. ambifaria (<FIG>) and C<NUM>-HSL in C. violaceum (<FIG>). Since the primary target of LuxR regulators are luxl homologues, these observations validate the capacity of cerPAC to interfere with AHL-mediated QS in different bacterial species.

It is showed herein that a cranberry extract enriched in PACs restricts virulence of P. aeruginosa in a fruit fly animal model and inhibits QS mechanisms. In addition, the cerPAC does not perturb cell viability of P. aeruginosa, indicating that use of these molecules may provide less selective pressure towards the development of resistance than conventional antibiotics (bactericidal and bacteriostatic, which pose strong selective pressure in any environment). The anti-virulence efficacy of cerPAC is based on: <NUM>) it reduces the production of AHL signaling molecules; <NUM>) it represses the expression of the QS regulators LasR and RhlR and autoinducer synthases Lasl and Rhll; <NUM>) it antagonizes the activation of LasR and RhlR by their cognate autoinducers; and <NUM>) epicatechin and proanthocyanidin, the main components of cerPAC, are modeled in silico to interact with the LBD of LasR and LasI. In addition, cerPAC also inhibit AHL production in strains of the Gram-negative species B. ambifaria and C. Thus, cerPAC could have anti-virulence activity against various pathogens with clinical importance.

For in vivo study, a fly feeding assay was used because it represents a long-term infection model and involves feeding starved flies with bacterial cultures. This method is better adapted to chronic infections compared to the fly nicking model. A dose of cerPAC was supplied at the start of infection and virulence was subsequently reduced, indicating that a cranberry extract enriched in PACs could function as a prophylactic. These results, when considered with other literature, indicate that the use of effective prophylactic molecules with anti-virulence activity, specifically for P. aeruginosa, could be a best practice in the clinical setting. It is noteworthy that the extract used herein contains approximately <NUM>% proanthocyanidins, and thus, it is presumed that the bioactivity observed can be mostly attributed to these molecules.

That a cerPAC alone inhibits QS has not been previously reported in the peer-reviewed scientific literature. Las and Rhl OS systems were targeted because they are at the top of the P. aeruginosa quorum sensing hierarchy. Both AHL molecules induce their own production and activate the corresponding LuxR-type transcriptional regulators LasR and RhlR. In the presence of the cranberry extract, an impairment in AHL production was observed, along with reduced gene expression of AHL synthase (LasI and Rhll) and partial repression of their regulators (LasR and RhIR). Interestingly, it is demonstrated that cerPAC, a potent in vivo inhibitor, is an effective antagonist of both LasR and RhIR, two regulators that act reciprocally on key virulence determinants.

The successful molecular docking of epicatechin or proanthocyanidin with LasR demonstrates that the inactivation of transcriptional regulators may be the primary mechanism of action for the cerPAC as anti-virulence factors in vivo.

The results disclosed herein show that cerPAC protects D. melanogaster from P. aeruginosa likely through an inhibition of QS without negative effect on bacterial growth. Antagonist activity and in silico analysis projected the potential mechanism of action to the inhibition of AHL regulators.

It was also demonstrated that the incorporation of cranberry derived materials (CDM) in silicone increased susceptibility of P. mirabilis biofilms to gentamicin, which results in biofilm disruption (see <FIG>).

To explore the genetic basis for the synergy in antimicrobial activity observed between cPACs and antibiotics, as well as the effect of cPACs on bacterial biofilm forming potential, transcriptional analysis was performed using qRT-PCR to observe the differential expression of genes associated with multidrug resistance, bacterial motility, virulence, adhesion, and biofilm formation for each of the two bacterial strains. Gene expression of E. coli CFT073, P. aeruginosa PAO1 and P. mirabilis HI4320 shown in <FIG>, <FIG> and <FIG> respectively, indicate that cPACs, at sub-lethal concentrations, repressed the expression of genes associated with multiple drug resistance (emrA, acrB, and marC in CFT073; acrA and marC in HI4320; oprM, mexA, and mexX in PAO1), motility (fliC, flhD, motB, fimH, fimA, and papA2 in CFT073; flaA and flhD in HI4320; fliC and fleQ in PAO1), virulence determinants (chuA in CFT073; cysJ in HI4320; plcH, phzS, and pvdA in PAO1), adhesion (fimH, fimA, and papA2 in CFT073; atfB in HI4320; cupA1 and pelA in PAO1), and biofilm formation (uvrY in CFT073; ureD in HI4320; lasB in PAO1). This transcriptional analysis confirms the trends observed with the antibiotic synergy and biofilm assays.

The sulfamethoxazole (SMX) antibiotic is known to synergize with trimethoprim (TMP) and they are commonly used in combination for clinical applications. To investigate the interaction between cPAC fraction and the combination of the two antibiotics, a checkerboard assay was performed with mixture of TMP-SMX at sub-inhibitory concentration ratio with each cPAC to analyze growth inhibition of HI4320 and PA14. The cPAC enhanced the synergy of TMP-SMX combination and reduced MIC up to <NUM>%, which is higher compared to the measured synergy of cPAC with individual antibiotics TMP and SMX for the growth inhibition of PA14(<FIG>).

There is a possibility that catechin (a monomer of cPAC structure) and cPACs from different sources could synergize differently with antibiotics compared to the cPAC fractions tested above. To investigate this possibility, the checkerboard assay was performed using four bacterial strains and analyzed for determination of FIC index values. As shown in <FIG>, catechin synergizes with trimethoprim for the growth inhibition of P. aeruginosa PAO1 and fails to show synergy for the other three strains, while a cPAC sample obtained from Dr. Amy Howell (Rutgers University) (cPAC-AH) synergizes with trimethoprim for the growth inhibition of all four strains based on FIC index ≤<NUM>.

Cranberry powder from dehydrated whole crushed cranberries (Atoka Cranberries, Quebec, Canada) was used as the cranberry derived material (CDM) of interest. CDM was incorporated into LSR30 implant grade silicone. mirabilis biofilms were grown on CDM-modified silicone surface and subsequently treated with gentamicin and ciprofloxacin at sub-MICs. A synergy of CDMs with gentamicin was observed.

Encompassed herein is the combination of the cranberry extract and composition described herein with an antibiotic according to claim <NUM>.

Also encompassed is the combination of the cranberry extract and composition described herein with different materials used in the art for non-limiting application in medical settings such as natural anti-infective, antimicrobial, anti-biofilm or anti-virulence agent in individual or combinatorial therapies thereof.

Further encompassed is the combination of the cranberry extract and composition described herein with materials used for non-limiting applications such as edible or non-edible functional or non-functional food coatings or food packaging
The present disclosure will be more readily understood by referring to the following examples.

Five organisms were used to demonstrate the efficacy of the composition described herein: E. coli strain CFT073 (ATCC <NUM>), P. mirabilis HI4320 (<NPL>), P. aeruginosa PAO1 (ATCC <NUM>), and P. aeruginosa PA14 (UCBPP-PA14, <NPL>), P. aeruginosa PAO1 (ATCC <NUM>) and E. faecalis ATCC <NUM>. Pure stock cultures were maintained at - <NUM> in <NUM>% (v/v) frozen glycerol solution. Starter cultures were prepared by streaking frozen cultures onto LB agar (LB broth: tryptone <NUM>/L, yeast extract <NUM>/L and NaCl <NUM>/L, supplemented with <NUM> w/v % agar (Fisher Scientific, Canada)). After overnight incubation at <NUM>, a single colony was inoculated into <NUM> of LB broth and the culture was incubated at <NUM> on an orbital shaker at <NUM> rpm for time lengths specific to each experiment. LB broth was used for bacterial culture in all experiments unless otherwise specified.

Minimum Inhibitory Concentration (MIC) was determined by preparing two-fold serial dilutions of each cPACs fraction and antibiotic in Mueller Hinton broth adjusted with Ca<NUM>+ and Mg<NUM>+ (MHB-II, Oxoid, Fisher Scientific, Canada). A range of concentration of the antibiotics gentamicin (<NUM>-<NUM>µg/mL), tetracycline (<NUM>-<NUM>µg/mL), kanamycin (<NUM>-<NUM>µg/mL), azithromycin (<NUM>-<NUM>µg/mL), trimethoprim (<NUM>-<NUM>µg/mL), sulfamethoxazole (<NUM>-<NUM>µg/mL), nitrofurantoin (<NUM>-<NUM>µg/mL), fosfomycin (<NUM>-<NUM>µg/mL), norfloxacin (<NUM>-<NUM>µg/mL), ciprofloxacin (<NUM>-<NUM>µg/mL) and ampicillin (<NUM>-<NUM>µg/mL), was used. Dilutions were prepared in flat bottom, <NUM> well microtitre plates (untreated, Falcon, Corning, Fisher Scientific, Canada). Each well of a microtitre plate was then inoculated with the desired bacterial strain (grown in MHB-II and diluted to <NUM><NUM> CFU/mL) and the plate was incubated at <NUM> for <NUM> hours under static conditions. Bacterial growth was assessed by (i) monitoring the optical density of the cell suspension in each well at <NUM> (OD600 nm), and (ii) the resazurin microtitre plate assay. In the resazurin microtitre plate assay, each well of a microtitre plate was supplemented with <NUM> resazurin, incubated in dark for <NUM> at room temperature, followed by fluorescence measurements at ex/em <NUM>/<NUM> using a TECAN Infinite M200 Pro microplate reader (Tecan Group Ltd. , Switzerland). The lowest concentration of a compound able to prevent increase in OD600 nm and resazurin fluorescence intensity was recorded as the MIC for that compound.

The checkerboard microdilution assay was used for evaluation of in vitro antimicrobial synergy between two compounds (i.e., antibiotic and each cPAC fraction). Two-fold serial dilutions were prepared in MHB-II for each of the two compounds under study. The serial dilutions were then loaded into <NUM> well plates to achieve combinations having different concentrations of each of the two compounds. Each well was subsequently inoculated with <NUM><NUM> CFU/mL of the desired bacterial strain and incubated at <NUM> for <NUM> hours under static conditions. The Fractional Inhibitory Concentration Index (FICI) for each combination was calculated by using the following formulae: <MAT>.

The FICls were interpreted as follows: FICI of ≤<NUM> (synergy); <NUM> <FICI ≤ <NUM> (no interaction/indifference); FICI of ><NUM> (antagonism).

Biofilm formation was quantified using the standard microtitre plate model. Briefly, overnight cultures (MHB-II broth, <NUM>, <NUM> rpm) were diluted <NUM>:<NUM> (v/v) into fresh MHB-II broth (with or without each cPAC fraction and their combination with gentamicin), to <NUM><NUM> CFU/mL. Aliquots (<NUM>µL) of these cultures were transferred into the wells of polystyrene, flat bottom, non-treated <NUM> well plates (Falcon, Corning), in triplicate. For all assays, biofilms were allowed to develop for <NUM> hours at <NUM> under static conditions, after which OD600 values were recorded, the spent broth was decanted from the wells and the wells were gently rinsed three times with DI water. The washed biofilm was stained with crystal violet (CV). For CV stain assay, <NUM>µL of <NUM>% (w/v) CV was loaded in each well and the plates were incubated for <NUM> minutes under static condition at room temperature. The wells were subsequently rinsed with DI water to remove excess dye and the CV adsorbed to the biomass in each well was solubilized in <NUM>µL of absolute ethanol for <NUM> minutes. The solubilized CV was then quantified (as OD570) using a microplate reader. Control experiments were performed with cell-free broth to adjust for background signal.

The outer membrane permeabilization activities of each cPAC fraction and antibiotic were determined by the <NUM>-N-phenylnapthylamine (NPN, Sigma-Aldrich Canada) assay with some modifications. Briefly, overnight bacterial cultures were diluted <NUM>:<NUM> in MHB-II medium to a final volume of <NUM>, with or without sub-MIC supplementation of each cPACs fraction or gentamycin (as a positive control), and grown to an OD600 of <NUM>-<NUM> (<NUM>, <NUM> rpm). The cells were harvested, washed with <NUM> HEPES buffer (pH <NUM>), and resuspended in the same volume (<NUM>) of <NUM> HEPES buffer (pH <NUM>) containing <NUM> N-ethylmaleimide (NEM, Sigma-Aldrich Canada). Aliquots (<NUM>) were mixed with NPN to a final concentration of <NUM> (in cell suspension) and fluorescence was measured using the microplate reader (ex/em <NUM>/<NUM>).

The BacLight kit (L-<NUM>, Invitrogen, Life Technologies Inc. , Canada) was used to assess cell membrane damage. Overnight bacterial cultures were diluted <NUM>:<NUM> in fresh MHB-II broth to a final volume of <NUM>, grown to an OD600 of <NUM>-<NUM>, washed with filter-sterilized <NUM> phosphate buffered saline (PBS, pH <NUM>) and resuspended in <NUM>/<NUM> of the original volume. The washed cells were then diluted <NUM>:<NUM> v/v into stock solution of each cPACs fraction at <NUM>/<NUM> MICs or DI water (control). Cultures were incubated at room temperature (<NUM>±<NUM>) on a tube rocker for <NUM> minutes. At the end of the incubation period, an aliquot was taken for CFU counts and the remaining suspension was washed with <NUM> PBS and resuspended to an OD600 of <NUM>. An aliquot (<NUM>µL) of each bacterial suspension was removed and added to a <NUM>-well, black, clear-bottom plate (Corning, Fisher Scientific, ON, Canada) along with an equal volume of the BacLight reagent (<NUM>× stock solution, L13152, Invitrogen, Life Technologies Inc. , Canada) and the plates were incubated for <NUM> minutes at room temperature in the dark. At the end of the incubation period, fluorescence intensity was recorded for both kit components, SYTO-<NUM> (ex/em <NUM>/<NUM>) and propidium iodide (ex/em <NUM>/<NUM>), using the microplate reader. Fluorescence readings from samples were normalized to the values obtained from untreated control to determine the ratio of membrane compromised cells to cells with intact membrane. CTAB (Sigma-Aldrich Canada), a cationic detergent that is known to cause membrane damage, was used at <NUM>/<NUM> MICs as a positive control for membrane disruption.

To assess the effect of each cPAC fraction on the inhibition of the proton motive force driven multidrug efflux pump, an ethidium bromide (EtBr) efflux assay was performed. An overnight grown culture of each strain was diluted <NUM>:<NUM> using MHB-II broth to a final volume of <NUM> and grown to an OD600 of <NUM>-<NUM> (at <NUM>, <NUM> rpm). Cells were loaded in polystyrene microcentrifuge tubes (<NUM>) and mixed with <NUM> EtBr and each cPAC fraction at <NUM>% of their MIC, or <NUM> of the proton conductor, carbonyl cyanide m-chlorophenylhydrazone (CCCP, Sigma-Aldrich Canada), as positive control. Replica tubes that did not receive cPAC or proton conductor served as negative controls. The tubes were incubated for <NUM> hour (<NUM>, <NUM> rpm). The inoculum was then adjusted to <NUM> OD600 with MHB-II broth containing <NUM> EtBr and <NUM> aliquots of this mixture were pelleted (<NUM>×g, <NUM> at <NUM>). The pellets were incubated on ice immediately, resuspended in <NUM> of MHB-II and aliquoted (<NUM>µL) into a polystyrene <NUM> well, black, clear-bottom plate (Corning, Fisher Scientific, Canada). EtBr efflux from the cells was monitored at room temperature using the microplate reader (ex/em <NUM>/<NUM>). Readings were taken at <NUM> minute intervals for <NUM> hour to monitor efflux pump activity. The background fluorescence of the medium was subtracted from all measurements and the assay was repeated independently in triplicate.

The cranberry extract rich in proanthocyanidins (cerPAC) was obtained from Ocean Spray Cranberries Inc. The supplier prepared the sample according to well established methods by enriching from cranberry fruit juice extract. The exact composition contains approximately <NUM>% proanthocyanidins. A dry powder of cerPAC was solubilized in deionized water and sterilized by filtration (<NUM> PVDF membrane filter). Bacteria used in this study were P. aeruginosa strain PA14 (wild type) and isogenic QS mutant strains in lasI, rhlI, lasR and rhlR as well as wild type strains Burkholderia ambifaria HSJ1, Chromobacterium violaceum ATCC <NUM> and Staphylococcus aureus ATCC <NUM>. Plasmids carrying lacZ fusion with genes lasI (pSC11, transcriptional fusion; pME3853, translational fusion), lasR (pPCS1001, transcriptional fusion), rhlI (pMW305, transcriptional fusion; pME3846, translational fusion) and rhlR (pPCS1002, transcriptional fusion) were introduced into appropriate P. aeruginosa PA14 QS mutant strains by electroporation, as described previously. All bacterial strains were preserved in glycerol stock (<NUM>% v/v) culture at -<NUM> and cultured in Tryptone Soy Broth (TSB) medium, with antibiotics if required for plasmid maintenance: tetracycline (<NUM> L-<NUM>), carbenicillin (<NUM> L-<NUM>), gentamicin (<NUM> L-<NUM>), streptomycin (<NUM> L-<NUM>) and spectinomycin (<NUM> L-<NUM>).

To assess LasB elastolytic activity, filter-sterilized culture supernatant samples (<NUM>µL) from late stationary phase cultures of strain PA14 were mixed with <NUM> elastin Congo red reagent (Sigma-Aldrich) and <NUM>µL <NUM> Tris-HCl (pH <NUM>). Release of Congo red from degraded elastin was measured as A<NUM> after <NUM> of incubation at <NUM> with shaking at <NUM> rpm, followed by centrifugation. For assessment of LasA staphylolytic activity, <NUM> mLof S. aureus ATCC <NUM> overnight cultures were boiled for <NUM>, and <NUM>µl were mixed with <NUM>µL of filtered culture supernatants of PA14. The OD<NUM> was measured after <NUM> of incubation at <NUM> and <NUM> rpm. To analyze alkaline protease (AprA) activity, filter-sterilized culture supernatant samples (<NUM>µL) from late stationary phase cultures of PA14 were vortexed with <NUM> of Hide-Remazol Brilliant Blue R powder (Sigma-Aldrich) in <NUM>µL of <NUM> Tris-HCl buffer (pH <NUM>) containing <NUM> CaCl<NUM>. The tube was then incubated at <NUM> at <NUM> rpm for <NUM>. The insoluble hide azure blue was removed by centrifugation at <NUM>,<NUM> × g for <NUM> at <NUM> and the absorption of the supernatant was measured at <NUM>. All experiments were carried out in triplicate.

Fruit flies (D. melanogaster) were infected orally in fly feeding assay as before (<NPL>; <NPL>), with some modifications. Briefly, flies were anesthetized under a gentle stream of carbon dioxide. Male flies (<NUM>- to <NUM>-days-old) were starved of food and water for <NUM>-<NUM> and separated into vials (<NUM> per vial) containing <NUM> of <NUM>% sucrose agar (sterile) without and with <NUM>µg mL-<NUM> cerPAC and <NUM>-cm filter paper disks (sterile) containing freshly grown bacterial culture suspension. To achieve this freshly grown culture, an overnight PA14 culture was inoculated in <NUM> TSB culture and incubated at <NUM> and <NUM> rpm until OD<NUM> = <NUM>. This culture was centrifuged at <NUM>,<NUM> × g for <NUM> and the resulting pellet resuspended in <NUM>µL of sterile <NUM>% sucrose, without and with <NUM>µg mL-<NUM> cerPAC. All filters were soaked appropriately with this culture suspension, along with sucrose agar, in feeding vials prior to transferring flies into the vial. Separate feeding vials soaked with <NUM>µL of <NUM>% sucrose without and with <NUM>µg mL-<NUM> cerPAC were used as negative controls for each experiment. Post-infection mortality of flies was monitored daily for <NUM> days, with each treatment tested twice in triplicate.

Specific estimation of AHL molecules was achieved by LC-MS in the positive electrospray ionization (ESI+) mode, combined with the MRM mode, as described previously (<NPL>).

Samples of PA14 culture exposed to cerPAC were retrieved at different time points and OD<NUM> was measured. An aliquot of methanolic internal standard was mixed with each sample to adjust final concentration <NUM> L-<NUM> of <NUM>,<NUM>,<NUM>,<NUM>-tetradeutero-<NUM>-hydroxy-<NUM>-heptylquinoline (HHQ-d<NUM>) and <NUM> L-<NUM> of <NUM>,<NUM>,<NUM>,<NUM>-tetradeutero-<NUM>,<NUM>-dihydroxy-<NUM>-heptylquinoline (PQS-d<NUM>). All culture samples were vortex-mixed and extracted twice with ethyl acetate (<NUM>:<NUM>, vol:vol), each ethyl acetate extract pooled and evaporated at <NUM> under a gentle stream of nitrogen. The residue was then resuspended in acidified acetonitrile (HPLC grade, containing <NUM>% ACS grade acetic acid) at ten times the initial concentration and <NUM>µl aliquots were injected for LC-MS analysis.

The LC-MS analyses were performed with a Quattro II (Waters) triple quadrupole mass spectrometer (MS) equipped with a Z-spray interface as described previously (<NPL>). Nitrogen was used for drying and argon was used as collision gas in multiple reactions monitoring (MRM) mode. HPLC (<NUM> HP) was equipped with a <NUM>×<NUM> Eclipse XDB C8 column (Agilent) and the MS was connected to the HPLC through a T splitter (Valco). The third output of the splitter was fitted with a tube of internal diameter and length such that only <NUM>% of the initial flow goes to the electrospray probe. Solvent A: ultrapure water containing <NUM>% ACS grade acetic acid. Solvent B: acetonitrile (HPLC grade), containing <NUM>% ACS grade acetic acid. The solvent gradient for the chromatographic runs was as follows: from <NUM> to <NUM> <NUM>% solvent A; from <NUM> to <NUM> <NUM>% solvent B; from <NUM> to <NUM> <NUM>% solvent B; from <NUM> to <NUM> <NUM>% solvent A; from <NUM> to <NUM> <NUM>% solvent A. Flow rate was set at <NUM>µL min-<NUM> split to <NUM>µL min-<NUM> by the T splitter. The MS parameters were: positive mode; needle voltage <NUM> kV; cone <NUM> V; block temperature <NUM> and drying gas <NUM>; nebulising gas <NUM>µL min-<NUM> and drying gas <NUM>µl min-<NUM>. In full scan mode, the scanning range was set to m/z <NUM>-<NUM>.

β-galactosidase activity was measured as described by<NPL>), with slight modifications. Briefly, cells were grown in TSB without and with cerPAC to various cell densities. Samples of cell culture were retrieved at different time points and diluted in Z-buffer (Na<NUM>HPO<NUM> <NUM>; NaH<NUM>PO<NUM> <NUM>; KCl <NUM>; MgSO<NUM>. <NUM><NUM>O <NUM>; β-mercaptoethanol <NUM>; pH <NUM>). Cells in Z-buffer were permeabilized by the addition of one drop of <NUM>% SDS and two drops of chloroform. Then, <NUM>µL of <NUM> mL-<NUM> ONPG was added to each reaction mixture, and enzyme reaction was stopped using <NUM>µL of <NUM> Na<NUM>CO<NUM>. Cell debris were separated by centrifugation at <NUM>,<NUM> × g for <NUM> sec and color development was monitored at <NUM>. β-galactosidase activity was expressed in Miller units (MU), calculated as follows: <NUM>,<NUM>×OD<NUM>/T (min)×V (mL)× OD<NUM>.

To evaluate the activity of cerPAC as antagonists/agonists against the natural AHL ligand of LasR or RhIR, <NUM>-oxo-C<NUM>-HSL (Sigma-Aldrich) and C<NUM>-HSL (Cayman Chemical) were used as inducers in this assay. The AHL-deficient strain that has been engineered to produce β-galactosidase upon activation of LasR by <NUM>-oxo-C<NUM>-HSL [ΔlasI (lasI-lacZ; pME3853)] and RhlR by C<NUM>-HSL [ΔrhlI (rhI-lacZ; pME3846)], were grown overnight in TSB medium. The overnight culture was diluted in fresh TSB and was grown to achieve an OD<NUM> = <NUM>. An appropriate amount of sterilized cerPAC stock solution prepared in MilliQ water was added to sterile culture tube containing TSB. For control condition, either <NUM>-oxo-C<NUM>-HSL or C<NUM>-HSL (stock solution in DMSO as a control) was added to sterile culture tube containing TSB, final DMSO concentration (after addition of cells) did not exceed <NUM> % v/v. Bacterial cells were added to TSB (final OD<NUM> = <NUM>) without and with cerPAC approximately <NUM> prior to the addition of the AHL at a final concentration of <NUM>-<NUM> (for <NUM>-oxo-C<NUM>-HSL) or <NUM>-<NUM> (for C<NUM>-HSL), to achieve final volume of <NUM>. Culture tubes were incubated at <NUM> for <NUM> under shaking at <NUM> rpm, measurement of cell OD<NUM> and β-galactosidase assay were performed at the regular time intervals after <NUM> of incubation. The concentration of cerPAC that reduced or increased the β-galactosidase activity compared to controls containing <NUM>-oxo-C<NUM>-HSL or C<NUM>-HSL (without cerPAC) was considered to determine antagonist or agonist activity.

To understand the interaction between components of the cerPAC with LasR and Lasl protein structures, a virtual docking was performed using the Piecewise Linear Potential and Lennard-Jones algorithms that can identify steric and hydrogen bonding interactions, and the Coulomb potential for electrostatic forces. In silico docking analysis was performed using the Molegro Virtual Docker <NUM> suite without the incorporation of water molecules. To maintain the search robustness, twenty rounds of iteration were used for each docking process. The S-adenosyl L methionine (NCBI Pubchem CID <NUM>) and the <NUM>-oxo-C<NUM>-HSL (NCBI Pubchem CID <NUM>) molecular structures were used as native ligand molecules, for the Lasl (RCSB Protein data base ID 1RO5) and LasR (RCSB Protein data base ID 2UV0) proteins, respectively. The components of cerPAC, epicatechin (NCBI PubChem CID <NUM>) and proanthocyanidin (NCBI PubChem CID <NUM>) molecular structures were used as ligands in virtual docking for both proteins. The MolDock search tool, that combines guided differential evolution and a cavity prediction algorithm was used for docking scores (in kcal mol-<NUM>) based on the interaction energies of each complex. The best five positions with high Moldock interaction energies were sampled and compared in every complex computed. The Computed Atlas of Surface Topography of proteins was used to explore the volumes of the cavities in the target proteins. The molecular graphics and analyses were performed using the UCSF Chimera version <NUM>.

To assess growth kinetics, P. aeruginosa PA14 was grown in the absence or presence of cerPAC at <NUM>, <NUM>, <NUM>, <NUM> and <NUM>µg mL-<NUM>. An overnight culture of PA14, grown at <NUM> with shaking at <NUM> rpm, was diluted <NUM>,<NUM>-fold with TSB medium. This cell suspension containing approximately <NUM><NUM> cells mL-<NUM> was aliquoted into sterile <NUM>-well honeycomb microplates containing different amount of cerPAC and incubated at <NUM> until stationary phase was reached. The OD<NUM> was recorded at <NUM> minutes time intervals using a BioScreen C system (Growth Curves USA, Piscataway, NJ). Each condition was set-up in four replicates. The optimum concentration of cerPAC that did not hinder growth of PA14 in TSB was selected in all subsequent assays, unless otherwise noted. Similarly, another set of experiments was conducted with larger volume (<NUM>) to analyze the effect of cerPAC on growth and AHL production. Samples were collected at different time points for OD<NUM> and LC/MS analyses. Dry weight of the bacterial suspensions at each time point was determined using pre-weighed aluminum cups that were incubated at <NUM> for <NUM> to allow water evaporation. Cups were weighed again to determine total dry weight.

Enumeration of viable bacteria on filter during the infection period was completed using separate test vials inoculated with PA14 and uninoculated control sucrose vials that were sampled on alternative days, up to <NUM> days during infection period. Briefly, filters from the test vials were removed in sterile environment, placed in <NUM> polypropylene tube containing <NUM> of LB broth and vortexed for <NUM> sec. This LB medium containing the sampled bacterial cells was serially diluted in phosphate buffer saline solution (pH <NUM>), and <NUM>µL was plated onto TSB agar and Pseudomonas Isolation agar (Thermo Scientific Remel, Fisher Scientific, Canada). Colonies were enumerated after incubation at <NUM> for <NUM>.

Tetracycline membrane transport was assayed with some modifications (<NPL>; <NPL>) by monitoring the fluorescence enhancement of tetracycline when it enters the cell. Bacterial culture in MHB-II were grown to OD<NUM>=<NUM>, inoculated in fresh media and grown to OD<NUM>=<NUM>. Cells were pelleted at <NUM> rpm for <NUM> minutes and resuspended in <NUM>:<NUM> volume of <NUM> HEPES buffer pH <NUM>. Tetracycline and cPACs samples were pipetted into the black non-transparent microtitre well plate (Falcon, Fisher Scientific, Canada) to adjust assigned concentration in <NUM> HEPES buffer pH <NUM>. Cell suspension was pipetted and the fluorescence read at initial point and after <NUM> minutes at room temperature. Fluorescence at excitation and emission wavelengths of <NUM> and <NUM>, respectively were monitored.

Claim 1:
A synergistically active composition comprising an enriched polyphenolic cranberry extract comprising approximatively <NUM>% proanthocyanidins (cPAC), and
- fosfomycin, tetracycline, trimethoprim, nitrofurantoin or azithromycin for use in treating a P. mirabilis urinary tract infection;
- azithromycin, sulfamethoxazole, nitrofurantoin or fosfomycin for use in treating P. aeruginosa PA01 urinary tract infection;
- kanamycin, tetracycline, azithromycin, nitrofurantoin or sulfamethoxazole for use in treating P. aeruginosa PA14 urinary tract infection; or
- azithromycin, tetracycline, kanamycin or nitrofurantoin for use in treating E. coli urinary tract infection.