Non-Antibiotic Prophylaxis for Recurrent Urinary Tract Infection: A Narrative Review & Clinical Guide for Primary and Hospital Care.

Abstract

Recurrent urinary tract infection (rUTI) is a common and distressing condition disproportionately affecting females. It also accounts for a substantial proportion of antibiotic prescribing in primary care. Repeated antibiotic exposure contributes to adverse effects, disruption of the urogenital microbiome and the accelerating global threat of antimicrobial resistance. Consequently, contemporary clinical guidelines increasingly emphasise non-antibiotic prophylactic strategies as a core component of rUTI management. This narrative review synthesises contemporary evidence and guideline recommendations from the European Association of Urology (EAU), the National Institute for Health and Care Excellence (NICE), and the American Urological Association (AUA) on non-antibiotic prophylaxis for rUTI. It places particular focus on practical implementation in primary care. Behavioural and risk-factor optimisation, methenamine hippurate, topical estrogen, D-mannose, probiotics, cranberry products, immunoactive prophylaxis and intravesical therapies are reviewed. These are appraised with respect to efficacy, safety, tolerability, accessibility and quality of evidence. This review highlights key differences in guideline positioning and identifies areas of ongoing uncertainty and future research. Additionally, this review explores the central role of general practitioners in confirming diagnosis and initiating first-line non-antibiotic prophylaxis. Moreover, their role in supporting shared decision-making and managing timely specialist referral, where appropriate, is highlighted. Considerations for both men and women with rUTI are discussed. To support the translation of evidence into practice, this article includes pragmatic clinical tools, such as a shared decision-making aid, a stepwise treatment algorithm, and a structured risk-factor checklist. By integrating evidence-based non-antibiotic strategies into routine care, clinicians can reduce antibiotic exposure, improve patient outcomes, and respond proactively to the global challenge of antimicrobial resistance.