NON-ANTIBIOTIC PREVENTION STRATEGIES FOR RECURRENT URINARY TRACT INFECTIONS IN WOMEN: A SYSTEMATIC REVIEW
TL;DR
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.
Abstract
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.