RECURRENT UTIs IN NON-PREGNANT WOMEN: NON-ANTIBIOTIC PREVENTION AND AN OUTPATIENT STEWARDSHIP ALGORITHM
DOI:
https://doi.org/10.31435/ijitss.4(48).2025.4254Keywords:
Recurrent Urinary Tract Infection, Non-Antibiotic Prophylaxis, Women’s Health, ReviewAbstract
Introduction: Recurrent urinary tract infections (rUTIs) in non-pregnant women represent a major clinical and socioeconomic burden, increasingly complicated by antimicrobial resistance and limited antibiotic options.
Aim of the Study: This narrative review synthesizes current evidence on non-antibiotic prevention strategies and proposes a structured outpatient stewardship algorithm.
Methodology: A comprehensive literature search across PubMed, Scopus, Web of Science, and Cochrane Library (inception–September 2025) identified studies on behavioral, pharmacological, and immunological prophylaxis in adult women with recurrent uncomplicated UTIs.
Results: Evidence supports lifestyle optimization—adequate hydration, postcoital voiding, and intimate hygiene—as safe but variably effective measures. Cranberry-derived proanthocyanidins and D-mannose demonstrate moderate efficacy in reducing recurrences, while vaginal estrogen significantly benefits postmenopausal women by restoring mucosal integrity. Immunostimulants such as OM-89 and methenamine hippurate emerge as promising antibiotic-sparing options, supported by high-quality randomized trials. The proposed outpatient algorithm prioritizes elimination of modifiable risk factors, sequential non-antibiotic prophylaxis, and restricted antibiotic use guided by urine culture results. Non-antibiotic strategies have shown favorable cost-effectiveness and reduced healthcare utilization compared with continuous antibiotic prophylaxis. Future research should standardize outcome definitions, incorporate microbiome and immunological analyses, and evaluate long-term cost–benefit profiles through multicenter pragmatic trials.
Conclusions: Integrating non-antibiotic prevention into structured stewardship frameworks offers a sustainable, patient-centered model for rUTI management, mitigating resistance development while maintaining clinical efficacy.
References
Aydin, A., Ahmed, K., Zaman, I., Khan, M. S., & Dasgupta, P. (2015). Recurrent urinary tract infections in women. International urogynecology journal, 26(6), 795–804. https://doi.org/10.1007/s00192-014-2569-5
Dason, S., Dason, J. T., & Kapoor, A. (2011). Guidelines for the diagnosis and management of recurrent urinary tract infection in women. Canadian Urological Association journal = Journal de l'Association des urologues du Canada, 5(5), 316–322. https://doi.org/10.5489/cuaj.11214
Zeng, Z., Zhan, J., Zhang, K., Chen, H., & Cheng, S. (2022). Global, regional, and national burden of urinary tract infections from 1990 to 2019: an analysis of the global burden of disease study 2019. World journal of urology, 40(3), 755–763. https://doi.org/10.1007/s00345-021-03913-0
Yang, X., Chen, H., Zheng, Y., Qu, S., Wang, H., & Yi, F. (2022). Disease burden and long-term trends of urinary tract infections: A worldwide report. Frontiers in public health, 10, 888205. https://doi.org/10.3389/fpubh.2022.888205
Medina, M., & Castillo-Pino, E. (2019). An introduction to the epidemiology and burden of urinary tract infections. Therapeutic advances in urology, 11, 1756287219832172. https://doi.org/10.1177/1756287219832172
Simmering, J. E., Tang, F., Cavanaugh, J. E., Polgreen, L. A., & Polgreen, P. M. (2017). The Increase in Hospitalizations for Urinary Tract Infections and the Associated Costs in the United States, 1998-2011. Open forum infectious diseases, 4(1), ofw281. https://doi.org/10.1093/ofid/ofw281
Cai T. (2021). Recurrent uncomplicated urinary tract infections: definitions and risk factors. GMS infectious diseases, 9, Doc03. https://doi.org/10.3205/id000072
Foxman B. (2002). Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. The American journal of medicine, 113 Suppl 1A, 5S–13S. https://doi.org/10.1016/s0002-9343(02)01054-9
Naber, K. G., Tirán-Saucedo, J., Wagenlehner, F. M. E., & RECAP group (2022). Psychosocial burden of recurrent uncomplicated urinary tract infections. GMS infectious diseases, 10, Doc01. https://doi.org/10.3205/id000078
Maxwell, K., Roberts, L., Kramer, M., Price, J., Newlands, A., & Finlay, K. A. (2023). Psychosocial burden and healthcare disillusionment in recurrent UTI: a large-scale international survey of patient perspectives. Frontiers in urology, 3, 1264299. https://doi.org/10.3389/fruro.2023.1264299
Lodise, T. P., Nowak, M., & Rodriguez, M. (2022). The 30-Day Economic Burden of Newly Diagnosed Complicated Urinary Tract Infections in Medicare Fee-for-Service Patients Who Resided in the Community. Antibiotics (Basel, Switzerland), 11(5), 578. https://doi.org/10.3390/antibiotics11050578
Corrales-Acosta, E., Zaragoza, E. C., Pérez, M. M., Perdomo, S. B., Corrales-Riveros, J. G., & Corrales, M. (2025). Prevention of recurrent urinary tract infection in Women: An update. Microbiology Research, 16(3), 66. https://doi.org/10.3390/microbiolres16030066
Chen, Y. C., Chang, C. C., Chiu, T. H. T., Lin, M. N., & Lin, C. L. (2020). The risk of urinary tract infection in vegetarians and non-vegetarians: a prospective study. Scientific reports, 10(1), 906. https://doi.org/10.1038/s41598-020-58006-6
Boyko, E. J., Fihn, S. D., Scholes, D., Chen, C. L., Normand, E. H., & Yarbro, P. (2002). Diabetes and the risk of acute urinary tract infection among postmenopausal women. Diabetes care, 25(10), 1778–1783. https://doi.org/10.2337/diacare.25.10.1778
Williams, G., Stothart, C. I., Hahn, D., Stephens, J. H., Craig, J. C., & Hodson, E. M. (2023). Cranberries for preventing urinary tract infections. The Cochrane database of systematic reviews, 11(11), CD001321. https://doi.org/10.1002/14651858.CD001321.pub7
Jepson, R. G., Williams, G., & Craig, J. C. (2012). Cranberries for preventing urinary tract infections. The Cochrane database of systematic reviews, 10(10), CD001321. https://doi.org/10.1002/14651858.CD001321.pub5
Abdullatif, V. A., Sur, R. L., Eshaghian, E., Gaura, K. A., Goldman, B., Panchatsharam, P. K., Williams, N. J., & Abbott, J. E. (2021). Efficacy of Probiotics as Prophylaxis for Urinary Tract Infections in Premenopausal Women: A Systematic Review and Meta-Analysis. Cureus, 13(10), e18843. https://doi.org/10.7759/cureus.18843
Kwok, M., McGeorge, S., Mayer-Coverdale, J., Graves, B., Paterson, D. L., Harris, P. N. A., Esler, R., Dowling, C., Britton, S., & Roberts, M. J. (2022). Guideline of guidelines: management of recurrent urinary tract infections in women. BJU international, 130 Suppl 3(Suppl 3), 11–22. https://doi.org/10.1111/bju.15756
Harding, C., Chadwick, T., Homer, T., Lecouturier, J., Mossop, H., Carnell, S., King, W., Abouhajar, A., Vale, L., Watson, G., Forbes, R., Currer, S., Pickard, R., Eardley, I., Pearce, I., Thiruchelvam, N., Guerrero, K., Walton, K., Hussain, Z., Lazarowicz, H., … Ali, A. (2022). Methenamine hippurate compared with antibiotic prophylaxis to prevent recurrent urinary tract infections in women: the ALTAR non-inferiority RCT. Health technology assessment (Winchester, England), 26(23), 1–172. https://doi.org/10.3310/QOIZ6538
Lazarus, J. E., & Gupta, K. (2024). Recurrent UTI in Women-Risk Factors and Management. Infectious disease clinics of North America, 38(2), 325–341. https://doi.org/10.1016/j.idc.2024.03.010
Aggarwal, N., & Leslie, S. W. (2025). Recurrent Urinary Tract Infections. In StatPearls. StatPearls Publishing.
Ackerman, A. L., Bradley, M., D'Anci, K. E., Hickling, D., Kim, S. K., & Kirkby, E. (2025). Updates to Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2025). The Journal of urology, 101097JU0000000000004723. Advance online publication. https://doi.org/10.1097/JU.0000000000004723
Sen A. (2008). Recurrent cystitis in non-pregnant women. BMJ clinical evidence, 2008, 0801.
Carney, H. C., Ward, C. R., Bailey, S. J., Bruyette, D., Dennis, S., Ferguson, D., Hinc, A., & Rucinsky, A. R. (2016). 2016 AAFP Guidelines for the Management of Feline Hyperthyroidism. Journal of feline medicine and surgery, 18(5), 400–416. https://doi.org/10.1177/1098612X16643252
Betschart, C., Albrich, W. C., Brandner, S., Faltin, D., Kuhn, A., Surbek, D., & Geissbuehler, V. (2020). Guideline of the Swiss Society of Gynaecology and Obstetrics (SSGO) on acute and recurrent urinary tract infections in women, including pregnancy. Swiss medical weekly, 150, w20236. https://doi.org/10.4414/smw.2020.20236
Reid, R., & CLINICAL PRACTICE GYNAECOLOGY COMMITTEE (2010). SOGC clinical practice guideline. No. 252, December 2010. Oral contraceptives and the risk of venous thromboembolism: an update. Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC, 32(12), 1192–1197. https://doi.org/10.1016/S1701-2163(16)34746-6
Kwok, M., McGeorge, S., Mayer-Coverdale, J., Graves, B., Paterson, D. L., Harris, P. N. A., Esler, R., Dowling, C., Britton, S., & Roberts, M. J. (2022). Guideline of guidelines: management of recurrent urinary tract infections in women. BJU international, 130 Suppl 3(Suppl 3), 11–22. https://doi.org/10.1111/bju.15756
Stapleton, A. E., Dziura, J., Hooton, T. M., Cox, M. E., Yarova-Yarovaya, Y., Chen, S., & Gupta, K. (2012). Recurrent urinary tract infection and urinary Escherichia coli in women ingesting cranberry juice daily: a randomized controlled trial. Mayo Clinic proceedings, 87(2), 143–150. https://doi.org/10.1016/j.mayocp.2011.10.006
Beerepoot, M., i Geerlings, S. (2016). Profilaktyka bez antybiotyków w przypadku infekcji dróg moczowych.Patogeny (Bazylea, Szwajcaria), 5(2), 36. https://doi.org/10.3390/pathogens5020036
Albert, X., Huertas, I., Pereiró, I. I., Sanfélix, J., Gosalbes, V., & Perrota, C. (2004). Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. The Cochrane database of systematic reviews, 2004(3), CD001209. https://doi.org/10.1002/14651858.CD001209.pub2
Funaro, J. R., Moehring, R. W., Liu, B., Lee, H. J., Yang, S., Sarubbi, C. B., Anderson, D. J., & Wrenn, R. H. (2021). Impact of Education and Data Feedback on Guideline-Concordant Prescribing for Urinary Tract Infections in the Outpatient Setting. Open forum infectious diseases, 9(3), ofab214. https://doi.org/10.1093/ofid/ofab214
El Hennawy, H. M., Safar, O., El Madawie, M. Z., Gopiechand, J., Tawhari, I., Nazer, W. E., Zaitoun, M. F., & Faifi, A. S. A. (2025). Clinical and financial impacts of nursing education programs on recurrent urinary tract infections after kidney transplant: a cohort study. BMC nephrology, 26(1), 232. https://doi.org/10.1186/s12882-025-04153-9
Ramírez-Sevilla, C., Gómez-Lanza, E., Llopis-Manzanera, J., Cetina-Herrando, A., & Puyol-Pallàs, J. M. (2023). Effectiveness and health cost analysis between immunoprophylaxis with MV140 autovaccine, MV140 vaccine and continuous treatment with antibiotics to prevent recurrent urinary tract infections. Actas urologicas espanolas, 47(1), 27–33. https://doi.org/10.1016/j.acuroe.2022.08.016
Nickel, J. C., & Doiron, R. C. (2023). An Effective Sublingual Vaccine, MV140, Safely Reduces Risk of Recurrent Urinary Tract Infection in Women. Pathogens (Basel, Switzerland), 12(3), 359. https://doi.org/10.3390/pathogens12030359
King, W., Homer, T., Harding, C., Mossop, H., Chadwick, T., Abouhajar, A., & Vale, L. (2024). Cost-effectiveness of methenamine hippurate compared with antibiotic prophylaxis for the management of recurrent urinary tract infections in secondary care: a multicentre, open-label, randomised, non-inferiority trial. BMJ open, 14(4), e074445. https://doi.org/10.1136/bmjopen-2023-074445
Zemdegs, J., Iroz, A., Vecchio, M., Roze, S., & Lotan, Y. (2023). Water intake and recurrent urinary tract infections prevention: economic impact analysis in seven countries. BMC health services research, 23(1), 1197. https://doi.org/10.1186/s12913-023-10234-y
Kim, D. S., & Lee, J. W. (2023). Urinary Tract Infection and Microbiome. Diagnostics (Basel, Switzerland), 13(11), 1921. https://doi.org/10.3390/diagnostics13111921
Kwak, Y., Kim, H. G., Seok, J., Kim, S., Kim, E. M., & Kim, A. (2024). The Critical Role of Intracellular Bacterial Communities in Uncomplicated Recurrent Urinary Cystitis: A Comprehensive Review of Detection Methods and Diagnostic Potential. International neurourology journal, 28(1), 4–10. https://doi.org/10.5213/inj.2448066.033
Harding, C., Chadwick, T., Homer, T., Lecouturier, J., Mossop, H., Carnell, S., King, W., Abouhajar, A., Vale, L., Watson, G., Forbes, R., Currer, S., Pickard, R., Eardley, I., Pearce, I., Thiruchelvam, N., Guerrero, K., Walton, K., Hussain, Z., Lazarowicz, H., … Ali, A. (2022). Methenamine hippurate compared with antibiotic prophylaxis to prevent recurrent urinary tract infections in women: the ALTAR non-inferiority RCT. Health technology assessment (Winchester, England), 26(23), 1–172. https://doi.org/10.3310/QOIZ6538
Grigoryan, L., & Trautner, B. W. (2024). Antibiotic Stewardship Interventions for Urinary Tract Infections in Outpatient Settings: A Narrative Review. Infectious disease clinics of North America, 38(2), 277–294. https://doi.org/10.1016/j.idc.2024.03.006
Beecher, C., Duane, S., Vellinga, A., Murphy, A. W., Cormican, M., Smyth, A., Healy, P., Moore, M., Little, P., Geoghegan, C., & Devane, D. (2022). COSUTI: A Core Outcome Set (COS) for Interventions for the Treatment of Uncomplicated Urinary Tract Infection (UTI) in Adults. Antibiotics (Basel, Switzerland), 11(12), 1846. https://doi.org/10.3390/antibiotics11121846
Shamas, N., Stokle, E., Ashiru-Oredope, D., & Wesangula, E. (2023). Challenges of implementing antimicrobial stewardship tools in Low to Middle Income Countries (LMICs). Infection prevention in practice, 5(4), 100315. https://doi.org/10.1016/j.infpip.2023.100315
Published
Issue
Section
License
All articles are published in open-access and licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0). Hence, authors retain copyright to the content of the articles.
CC BY 4.0 License allows content to be copied, adapted, displayed, distributed, re-published or otherwise re-used for any purpose including for adaptation and commercial use provided the content is attributed.
How to Cite
