NON-ANTIBIOTIC PREVENTION STRATEGIES FOR RECURRENT URINARY TRACT INFECTIONS IN WOMEN: A SYSTEMATIC REVIEW
DOI:
https://doi.org/10.31435/ijitss.3(51).2026.6695Keywords:
Recurrent Urinary Tract Infection, Non-Antibiotic Prophylaxis, Methenamine Hippurate, Vaginal Estrogen, Cranberry, Antimicrobial StewardshipAbstract
Recurrent urinary tract infections (rUTIs) in women represent a frequent and burdensome clinical problem, often leading to repeated antimicrobial exposure, reduced quality of life, and increased healthcare utilization. Although antibiotic prophylaxis can reduce recurrence, long-term or repeated antibiotic use contributes to adverse effects, disruption of the urogenital microbiota, and antimicrobial resistance. This systematic review summarizes current evidence on non-antibiotic prevention strategies for rUTIs in adult women, with emphasis on methenamine hippurate, vaginal estrogen, cranberry products, D-mannose, probiotics, increased fluid intake, immunoprophylaxis, and intravesical glycosaminoglycan therapies. A structured literature search was performed in PubMed/MEDLINE and PubMed Central for studies and reviews published up to September 2026. Relevant randomized trials, systematic reviews, meta-analyses, clinical reviews, and guideline documents were included. The strongest contemporary evidence supports methenamine hippurate as an antibiotic-sparing alternative in selected women, vaginal estrogen in peri- and postmenopausal women, cranberry products as an option with modest benefit, and increased water intake in women with low baseline fluid intake. Evidence for D-mannose and probiotics is inconsistent, while immunoprophylaxis and intravesical therapies remain promising but require further standardization. Non-antibiotic prevention should be individualized according to menopausal status, recurrence pattern, comorbidities, preferences, and local antimicrobial stewardship priorities.
References
Anger, J., Lee, U., Ackerman, A. L., Chou, R., Chughtai, B., Clemens, J. Q., Hickling, D., Kapoor, A., Kenton, K. S., Kaufman, M. R., Rondanina, M. A., Stapleton, A., Stothers, L., & Chai, T. C. (2019). Recurrent uncomplicated urinary tract infections in women: Aua/cua/sufu guideline. The Journal of Urology, 202(2), 282-289. https://doi.org/10.1097/JU.0000000000000296
Anger, J., et al. (2025). Updates to recurrent uncomplicated urinary tract infections in women: Aua/cua/sufu guideline (2025). the journal of urology. https://pubmed.ncbi.nlm.nih.gov/40905426/
Beerepoot, M. A. J., Geerlings, S. E., van Haarst, E. P., van Charante, N. M., & ter Riet, G. (2013). Nonantibiotic prophylaxis for recurrent urinary tract infections: A systematic review and meta-analysis of randomized controlled trials. The Journal of Urology, 190(6), 1981-1989. https://doi.org/10.1016/j.juro.2013.04.142
Chen, Y. Y., Su, T. H., Lau, H. H., & Wang, K. L. (2020). Estrogen for the prevention of recurrent urinary tract infections in postmenopausal women: A meta-analysis of randomized controlled trials. International Urogynecology Journal, 32, 17-25. https://doi.org/10.1007/s00192-020-04397-z
Goddard, J. C., & Janssen, D. A. W. (2018). Intravesical hyaluronic acid and chondroitin sulfate for recurrent urinary tract infections: Systematic review and meta-analysis. International Urogynecology Journal, 29(7), 933-942. https://doi.org/10.1007/s00192-017-3508-z
Harding, C., Mossop, H., Homer, T., Chadwick, T., King, W., Carnell, S., Lecouturier, J., Abouhajar, A., Vale, L., Watson, G., Forbes, R., Currer, S., Pickard, R., & Thiruchelvam, N. (2022). Alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women: Multicentre, open label, randomised, non-inferiority trial. BMJ, 376, e068229. https://doi.org/10.1136/bmj-2021-0068229
Hayward, G., Mort, S., Hay, A. D., Moore, M. V., Thomas, M., Voysey, M., & Butler, C. C. (2024). D-mannose for prevention of recurrent urinary tract infection among women: A randomized clinical trial. JAMA Internal Medicine, 184(6), 619-628. https://doi.org/10.1001/jamainternmed.2024.0264
Hooton, T. M., Vecchio, M., Iroz, A., Tack, I., Dornic, Q., Seksek, I., & Lotan, Y. (2018). Effect of increased daily water intake in premenopausal women with recurrent urinary tract infections: A randomized clinical trial. JAMA Internal Medicine, 178(11), 1509-1515. https://doi.org/10.1001/jamainternmed.2018.4204
Lee, B. S. B., Bhuta, T., Simpson, J. M., & Craig, J. C. (2012). Methenamine hippurate for preventing urinary tract infections. Cochrane Database of Systematic Reviews, 10, CD003265. https://doi.org/10.1002/14651858.CD003265.pub3
Naber, K. G., Cho, Y. H., Matsumoto, T., & Schaeffer, A. J. (2009). Immunoactive prophylaxis of recurrent urinary tract infections: A meta-analysis. International Journal of Antimicrobial Agents, 33(2), 111-119. https://doi.org/10.1016/j.ijantimicag.2008.08.011
National Institute for Health and Care Excellence. (2024). Urinary tract infection (recurrent): Antimicrobial prescribing. NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK611967/
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hrõbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., ... Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71. https://doi.org/10.1136/bmj.n71
Perrotta, C., Aznar, M., Mejia, R., Albert, X., & Ng, C. W. (2008). Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database of Systematic Reviews, 2, CD005131. https://doi.org/10.1002/14651858.CD005131.pub2
Raz, R., & Stamm, W. E. (1993). A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. The New England Journal of Medicine, 329(11), 753-756. https://doi.org/10.1056/NEJM199309093291102
Schwenger, E. M., Tejani, A. M., & Loewen, P. S. (2015). Probiotics for preventing urinary tract infections in adults and children. Cochrane Database of Systematic Reviews, 12, CD008772. https://doi.org/10.1002/14651858.CD008772.pub2
Wagenlehner, F. M. E., et al. (2025). Non-antibiotic prophylaxis for recurrent urinary tract infection: A narrative review and clinical guide for primary and hospital care. https://pubmed.ncbi.nlm.nih.gov/42411541/
Williams, G., Hahn, D., Stephens, J. H., Craig, J. C., & Hodson, E. M. (2023). Cranberries for preventing urinary tract infections. Cochrane Database of Systematic Reviews, 4, CD001321. https://doi.org/10.1002/14651858.CD001321.pub6
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, 755-763. https://pubmed.ncbi.nlm.nih.gov/35013872/.
Mak, Q., Greig, J., Dasgupta, P., Malde, S., & Raison, N. (2024). Bacterial vaccines for the management of recurrent urinary tract infections: A systematic review and meta-analysis. european urology focus. https://pubmed.ncbi.nlm.nih.gov/38644097/
Kwon, et al. (2026). Intravesical therapy for recurrent urinary tract infection: A systematic review and meta-analysis. BJU international https://doi.org/10.1111/bju.70252
Effectiveness of non-antibiotic therapies in the management of recurrent urinary tract infections in women: A systematic review. (2026). https://pubmed.ncbi.nlm.nih.gov/42133003/
Non-antibiotic interventions to prevent recurrent urinary tract infections in women: Overview of systematic reviews of randomised controlled trials. (2026). https://pubmed.ncbi.nlm.nih.gov/42225392/
Probiotic prophylaxis in adult women with recurrent uncomplicated urinary tract infections: A systematic review of randomized controlled trials. (2026). https://pubmed.ncbi.nlm.nih.gov/42362021/
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Maciej Krzesimir Kuświk, Paweł Zdebski, Dominika Dmowska, Mikołaj Lewandowski, Karolina Rymska, Alicja Serafin, Wiktoria Bajek, Dominik Chrzanowski, Marcelina Kaczmarek, Kinga Żmuda
This work is licensed under a Creative Commons Attribution 4.0 International 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.
