Updates in Clinical Management of Recurrent Urinary Tract Infections

Urinary tract infections (UTIs) are common and burdensome in women. Here, we discuss challenges with our current models of care and how evolving insights into the female urogenital microbiome have advanced the understanding of how we diagnose, treat, and prevent recurrent UTIs in nonpregnant adult women. Traditional care models attribute recurrent UTIs mainly to gastrointestinal sources, resulting in significant emphasis on eradicating pathogens with potential overreliance on antibiotics. Evidence now shows that the bladder harbors a complex microbiome, with interactions between the urinary and vaginal environments and immune mechanisms at the bladder mucosal surface influencing infection susceptibility. Thus, in updated models of care, more emphasis is placed on enhancing the protective microbiome. This may be especially important in postmenopausal women, who experience microbiome shifts that increase vulnerability to recurrent infections, underscoring the role of estrogen therapy and microbiome-supportive interventions. Updated treatment approaches emphasize antimicrobial stewardship, advocating for confirmation of the diagnosis and delayed antibiotic initiation when safe, and judicious use of antibiotics for symptom relief. Prevention strategies highlight the importance of vaginal estrogen, methenamine salts, and other supplements rather than exclusive reliance on prophylactic antibiotics. Ongoing research into emerging therapies such as UTI vaccines and bacteriophage drugs may further decrease our reliance on antibiotics in the future. This clinical update underscores the need for individualized care plans that balance effective infection management while minimizing antibiotic-related harms, emphasizing a holistic, microbiome-centered approach to recurrent UTI prevention and treatment.