The 2025 European Association of Urology (EAU) discusses the prophylactic efficacy of various nutraceuticals for preventing recurrent cystitis has been the focus of several research studies. Investigations into probiotics, particularly Lactobacillus spp. administered vaginally and in combination with oral probiotics, show effectiveness in preventing symptomatic cystitis recurrence. However, a systematic review finds lactobacilli alone do not demonstrate superiority over placebo or cranberry monotherapy, highlighting the need for better quality evidence to guide recommendations on administration routes or dosages. Cranberry prophylaxis, particularly with standardized cranberry extract, has been shown to significantly reduce cystitis recurrence in diabetic postmenopausal women and in adult women with recurrent cystitis. Yet, optimal dosing remains unclear, though increased fluid intake with cranberry juice may help reduce cystitis rates. [1]
Preliminary evidence has found some support for use of nutraceuticals that may present antibiotic-sparing options, but again, more research is needed to clarify optimal formulations, dosages, and treatment durations. Topical estrogen therapy, administered either as a cream or pessary, has shown a trend towards preventing recurrent cystitis according to four meta-analyses. These studies consistently found that while topical estrogen is more effective than placebo, it is less effective than antibiotics in preventing recurrences. Antibiotic prophylaxis emerges as the most effective strategy to prevent recurrent cystitis, overshadowing placebo or no treatment, as highlighted by several meta-analyses and systematic reviews. This treatment can be administered either as continuous low-dose prophylaxis over extended periods or as post-coital prophylaxis, with no significant difference in the efficacy between the two methods. However, the optimal duration for continuous antimicrobial prophylaxis remains undetermined, with treatment durations ranging from three to twelve months reported. [1]
Recurrence of cystitis is common upon discontinuation, particularly in individuals experiencing three or more infections per year. It is essential to offer both continuous and post-coital prophylaxis after counselling, especially when behavioral modifications and non-antimicrobial measures fail. Variances in the outcomes between different antibiotics were not statistically significant, indicating that the choice of antibiotic should be informed by local resistance patterns. The recommended regimens include nitrofurantoin (50 mg or 100 mg once daily), fosfomycin trometamol (3 g once a week), trimethoprim (100 mg once daily), and during pregnancy, cephalexin or cefaclor at specified doses. For pregnant women with a history of frequent cystitis before pregnancy, post-coital prophylaxis is advised to mitigate the risk of cystitis. [1]
A 2025 guideline issued by the American Urological Association (AUA), Canadian Urological Association (CUA), and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) presents updated recommendations on managing recurrent uncomplicated urinary tract infections (rUTIs) in women. Guidelines suggest that clinicians, after discussing the risks, benefits, and alternatives, may prescribe antibiotic prophylaxis to reduce the risk of future urinary tract infections (UTIs) in women of all ages who have been previously diagnosed with UTIs. Nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), and fosfomycin are highlighted as preferred first-line therapies for symptomatic episodes, contingent on local antibiogram data. Short treatment durations, generally not exceeding seven days, are recommended to reduce collateral damage associated with prolonged antibiotic use. For non-antibiotic options, clinicians are advised to offer cranberry as a prophylactic measure for women with recurrent UTIs (rUTIs). However, clinicians should inform patients that using D-mannose alone may not be effective in preventing UTIs. The guideline supports the use of cranberry products and methenamine hippurate as non-antibiotic prophylactic measures and stresses the importance of vaginal estrogen therapy for postmenopausal women with recurrent infections. Additionally, for women with rUTIs who consume less than 1.5 liters (50 oz) of water per day, increasing water intake can be suggested as a prophylactic measure (grade C evidence). The document underscores the necessity of balancing the benefits of these approaches with potential risks, advocating for shared decision-making between clinicians and patients to optimize outcomes. [2]
The 2023 Clinical Consensus by the American College of Obstetricians and Gynecologists (ACOG) Committee on Clinical Consensus-Obstetrics explored the management of UTIs in pregnant individuals. When prophylaxis is initiated during pregnancy, two prevalent strategies are typically considered: postcoital or continuous prophylaxis. With the postcoital method, patients take antibiotics either before or after engaging in vaginal intercourse. This approach is associated with fewer adverse events related to antibiotic use. Conversely, continuous prophylaxis involves taking antimicrobials once daily. Although the ideal dose for prophylactic antibiotics is yet to be determined, it is advisable to use a lower single daily dose of an antibiotic to which the isolated bacterium is susceptible, as this could help mitigate antibiotic resistance. Common suppressive regimens for continuous prophylaxis include nitrofurantoin 100 mg orally daily or cephalexin 250–500 mg orally daily. [3]
A 2025 clinical report from the American Academy of Pediatrics provides guidance on the management of perinatal urinary tract dilation (UTD). In the United States, amoxicillin is predominantly used for UTI prophylaxis in newborns, as it is effective against certain gram-negative rods and Enterococcus species. As infants surpass the age of 2 months, the preferred prophylactic antibiotic transitions to trimethoprim-sulfamethoxazole. This change is due to its ability to achieve high urinary concentrations, thereby enhancing its effectiveness in preventing infections. Prior to two months of corrected gestational age, trimethoprim-sulfamethoxazole poses a risk of bilirubin displacement, potentially leading to kernicterus. Nitrofurantoin stands as an effective prophylactic alternative with its primary excretion in urine and minimal tissue penetration, reducing its impact on the gut microbiome. If opting for a cephalosporin, a first-generation option is recommended due to low bacterial resistance. It is crucial to consider local resistance patterns utilizing resources like the hospital antibiogram or community antibiotic sensitivity information. A shared decision-making model that thoroughly evaluates the benefits and risks of continuous antibiotic prophylaxis (CAP) should occur with the patient's family before initiating therapy. Generally, a higher suspicion of obstructive urinary tract disease (UTD) implies that the benefits of CAP may outweigh the risk of developing an infection with a multidrug-resistant organism. [4]