Recurring UTIs? 9 Proven Nonantibiotic Solutions

Medscape

6 days ago

Urinary tract infections (UTIs) are more common in women due to anatomical and behavioral factors. Half of all women experience at least one UTI in their lifetime. Approximately 25% of patients develop recurrent UTIs, defined as three episodes in the past 12 months or two episodes in the past 6 months, with at least one confirmed by urine culture.
At the 25th Annual Congress of the Argentine Society of Infectious Diseases (2025), Sandra Aronson, MD, general practitioner, geriatrician, and infectious disease specialist at Hospital J.A. Fernández and Hospital Italiano in Buenos Aires, Argentina, noted that 5% of recurrent UTIs occur within 2 weeks of the initial episodes. These are usually caused by microorganisms persisting in areas where antibiotics cannot reach or by inappropriate antibiotic use. The remaining 95% were reinfected with new strains.
Recent international guidelines recommend the initiation of nonantibiotic strategies to prevent recurrence, reserving antibiotics as a last resort. 'We have nonantibiotic tools available, some with proven efficacy and others with great promise,' Aronson said.
Patient Education Challenges
Speaking with Medscape Spanish, Aronson acknowledged that promoting behavioral changes or nonantibiotic measures can be more challenging than prescribing medication. 'Patients often value a prescription more than advice to drink more water,' she said.
'It's similar to respiratory infections. It is much easier to give antibiotics to a patient with a cold than to explain why they are not necessary. These conversations take longer. But those of us who genuinely believe antibiotic resistance is or will become a problem aim to reserve these drugs for when they are truly needed.'
Nine Nonantibiotic Strategies
Aronson presented nine nonantibiotic strategies for the initial management of recurrent UTIs. She stated that the supporting evidence is uneven but stronger than in the past, making clinicians more likely to recommend these measures.
Behavioral Changes
Recommendations include drinking at least 1.5 L of water daily, emptying the bladder regularly, maintaining good hygiene, urinating after sexual intercourse, and avoiding spermicides, diaphragms, tampons, tight clothing, and douching.
In a 2017-2018 study of 140 women with recurrent UTIs who drank less than 1.5 L of water daily, those who increased their intake by 1.5 L for 1 year had a 50% reduction in new episodes (1.7 vs 3.2) and in antibiotic use (1.9 vs 3.6).
Estrogens
Vaginal estrogens increase glycogen levels in the vaginal mucosa, which promotes Lactobacillus colonization, lowers pH, and prevents the growth of local uropathogens. A meta-analysis of eight studies involving approximately 5,000 women found that vaginal estrogen significantly reduced recurrent UTIs compared to placebo (risk ratio, 0.42). Adverse effects, including vaginal discomfort, irritation, and itching, were mild. No benefits were observed with the administration of oral estrogen.
A recent US study of 40 primary care physicians reported that 96% prescribed vaginal estrogens for recurrent UTIs, with 58% doing so frequently. Vaginal estrogen is the leading nonantibiotic treatment option in clinical practice.
Cranberries
Cranberries may acidify urine, and their proanthocyanidins can prevent Escherichia coli and other bacteria from adhering to uroepithelial cells, particularly in postmenopausal women. 'Not all cranberry products contain the same amount of this compound,' Aronson noted.
A 2023 Cochrane review found that cranberries reduced the risk of recurrent UTIs by approximately 25% in certain groups, including women. The European Association of Urology recommends cranberries to prevent recurrent cystitis, citing a favorable benefit-harm profile despite limited evidence. The recommended intake is 200-300 mL of juice daily for 6 months.
Probiotics
Probiotics may restore normal vaginal microbiota, create an acidic pH, and prevent bacterial adhesions. Evidence from meta-analyses and systematic reviews is mixed; however, some studies have reported up to a 50% reduction in the number of UTI episodes. 'Not all lactobacilli are the same,' Aronson emphasized. 'Preparations should contain Lactobacillus crispatus and certain other strains.'
D-mannose
D-mannose is a natural sugar that blocks the attachment of type 1 bacterial fimbriae to the uroepithelium. A meta-analysis of 390 patients found that it was effective in preventing recurrent UTIs compared with placebo, with efficacy comparable to that of antibiotics such as nitrofurantoin. Another systematic review reported improved quality of life, fewer recurrences, and longer infection-free periods. 'Evidence is still limited, and more studies are needed, but side effects are few none of which are serious,' Aronson said.
Methenamine
Methenamine hippurate or mandelate hydrolyzes formaldehyde and ammonia, creating an acidic bactericidal environment by denaturing bacterial proteins.
A 2021 meta-analysis suggested a 'trend toward benefit' in preventing recurrent cystitis, although no significant differences were observed compared with other approaches. A subsequent clinical trial involving 240 patients showed that methenamine hippurate administered twice daily for 12 months was noninferior to antibiotic prophylaxis, with similar rates of adverse events.
Oral Vaccines
MV140 is a sublingual vaccine containing inactivated E coli V121, Klebsiella pneumoniae V113, Enterococcus faecalis V125, and Proteus vulgaris V127 strains. It is one of the most studied immunomodulatory options and has shown promising results. Three cohort studies found that MV140 reduced cystitis compared to antibiotic prophylaxis.
Protein extracts from 18 uropathogenic E coli strains have also shown some benefits, but Aronson noted that further studies are needed before they can be recommended with any level of evidence.
Hyaluronic Acid/Chondroitin Sulfate
The evidence is stronger for combining hyaluronic acid and chondroitin sulfate than for using either alone. A systematic review of 13 studies involving 764 women found that a combination of gentamicin (80 mg) was effective in managing recurrent UTIs. Aronson recommended reserving this approach for specific cases.
Phage Therapy
Phage therapy uses bacteriophage viruses that cause rapid bacterial cell death and alter the microbial population. It is used more frequently for treatment than for prevention. 'Anything that helps us avoid antibiotic use is welcome,' Aronson concluded.
Aronson reported no having relevant financial relationships.
This story was translated from Medscape's Spanish edition.