{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T10:03:14Z","timestamp":1785146594580,"version":"3.55.0"},"reference-count":67,"publisher":"BMJ","issue":"8","license":[{"start":{"date-parts":[[2026,4,27]],"date-time":"2026-04-27T00:00:00Z","timestamp":1777248000000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["DTB"],"published-print":{"date-parts":[[2026,8]]},"abstract":"<jats:p>Recurrent urinary tract infections (rUTIs) are a burdensome condition affecting approximately 6% or 1.7\u2009million women in the UK. UTIs are also a common reason for antibiotic use, with UK data demonstrating that they are the second most common reason for antibiotic prescribing after respiratory tract infections. UTIs also result in significant healthcare costs, with hospital admissions alone estimated to have cost the National Health Service in England over \u00a3600\u2009million from 2023 to 2024. This review provides an up-to-date overview of the management of rUTIs, focusing on the updated 2024 National Institute for Health and Care Excellence guidance, which recommends a stepwise approach starting with behavioural measures, then progressing to non-antibiotic and finally antibiotic prevention. It also compares the guidance with international recommendations and outlines the current evidence on pathogenesis, diagnostic approaches and treatment options, including behavioural measures, non-antibiotic interventions (eg, vaginal oestrogen and methenamine hippurate) and antibiotic prophylaxis. Key challenges in primary care are discussed, such as diagnostic uncertainty, patient dissatisfaction and antimicrobial resistance (AMR). Emerging research in point-of-care testing, the urinary microbiome and novel therapies is also highlighted. This review aims to support safe prescribing, improve patient satisfaction and mitigate AMR by promoting antimicrobial and diagnostic stewardship in the management of rUTIs.<\/jats:p>","DOI":"10.1136\/dtb.2025.000042","type":"journal-article","created":{"date-parts":[[2026,4,27]],"date-time":"2026-04-27T17:20:18Z","timestamp":1777310418000},"page":"116-125","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Update to the management of recurrent urinary tract infections in women aged 16 years and older"],"prefix":"10.1136","volume":"64","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6762-6986","authenticated-orcid":false,"given":"Leigh","family":"Sanyaolu","sequence":"first","affiliation":[{"name":"Division of Population Medicine and PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haroon","family":"Ahmed","sequence":"additional","affiliation":[{"name":"Division of Population Medicine and PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7264-5260","authenticated-orcid":false,"given":"Miriam","family":"Santer","sequence":"additional","affiliation":[{"name":"Primary Care Research Centre, University of Southampton, Southampton, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sian","family":"Jones","sequence":"additional","affiliation":[{"name":"Person with lived experience, -, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gail","family":"Hayward","sequence":"additional","affiliation":[{"name":"Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,4,27]]},"reference":[{"key":"2026072702101436000_64.8.116.1","doi-asserted-by":"publisher","DOI":"10.1007\/s00345-021-03913-0"},{"key":"2026072702101436000_64.8.116.2","doi-asserted-by":"publisher","DOI":"10.1093\/jac\/dkx504"},{"key":"2026072702101436000_64.8.116.3","unstructured":"UK Health Security Agency (UKHSA) . English surveillance programme for antimicrobial utilisation and resistance (ESPAUR). Available: https:\/\/assets.publishing.service.gov.uk\/media\/6936ac34b612700b2cb73607\/ESPAUR-report-2024-to-2025.pdf [Accessed 7 Jan 2026]."},{"key":"2026072702101436000_64.8.116.4","unstructured":"UK Health Security Agency . Understanding the burden of UTI hospitalisations in England. 2025. Available: https:\/\/www.gov.uk\/government\/publications\/understanding-the-burden-of-uti-hospitalisations-in-england\/understanding-the-burden-of-uti-hospitalisations-in-england [Accessed 11 Oct 2025]."},{"key":"2026072702101436000_64.8.116.5","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0190521","article-title":"Incidence and antibiotic prescribing for clinically diagnosed urinary tract infection in older adults in UK primary care, 2004-2014","volume":"13","author":"Ahmed","year":"2018","journal-title":"PLoS ONE"},{"key":"2026072702101436000_64.8.116.6","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1003336","article-title":"Antibiotic prescribing for lower UTI in elderly patients in primary care and risk of bloodstream infection: A cohort study using electronic health records in England","volume":"17","author":"Shallcross","year":"2020","journal-title":"PLoS Med"},{"key":"2026072702101436000_64.8.116.7","doi-asserted-by":"publisher","DOI":"10.1016\/S1047-2797(00)00072-7"},{"key":"2026072702101436000_64.8.116.8","doi-asserted-by":"publisher","DOI":"10.3399\/bjgp15X686965"},{"key":"2026072702101436000_64.8.116.9","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1016\/j.eclinm.2019.07.012","article-title":"Lower Urinary Tract Infections: Management, Outcomes and Risk Factors for Antibiotic Re-prescription in Primary Care","volume":"14","author":"Pujades-Rodriguez","year":"2019","journal-title":"EClinicalMedicine"},{"key":"2026072702101436000_64.8.116.10","unstructured":"Bonkat G , Kranz J , Cai T , et al . EAU guidelines on urological infections. 2026. Available: https:\/\/d56bochluxqnz.cloudfront.net\/documents\/full-guideline\/EAU-Guidelines-on-Urological-Infections-2026.pdf [Accessed 24 Mar 2026]."},{"key":"2026072702101436000_64.8.116.11","doi-asserted-by":"publisher","DOI":"10.1097\/JU.0000000000000296"},{"key":"2026072702101436000_64.8.116.12","unstructured":"National Institute for Health and Care Excellence (NICE) . Urinary tract infection (recurrent): antimicrobial prescribing. NICE guideline NG112; 2024. Available: https:\/\/www.nice.org.uk\/guidance\/ng112 [Accessed 17 Sep 2025]."},{"key":"2026072702101436000_64.8.116.13","doi-asserted-by":"publisher","DOI":"10.3399\/BJGP.2024.0015"},{"key":"2026072702101436000_64.8.116.14","doi-asserted-by":"publisher","DOI":"10.1093\/infdis\/jiae331"},{"key":"2026072702101436000_64.8.116.15","doi-asserted-by":"crossref","DOI":"10.1093\/jacamr\/dlad156","article-title":"Epidemiology and microbiology of recurrent UTI in women in the community in Oxfordshire, UK","volume":"6","author":"Vazquez-Montes","year":"2024","journal-title":"JAC Antimicrob Resist"},{"key":"2026072702101436000_64.8.116.16","unstructured":"Office for National Statistics (ONS) . Population estimates for the UK, England, Wales, Scotland and Northern Ireland: mid-2023. 2024. 2024. Available: https:\/\/www.ons.gov.uk\/peoplepopulationandcommunity\/populationandmigration\/populationestimates\/bulletins\/annualmidyearpopulationestimates\/latest#cite-this-statistical-bulletin [Accessed 6 Mar 2025]."},{"key":"2026072702101436000_64.8.116.17","doi-asserted-by":"crossref","first-page":"e31","DOI":"10.1093\/cid\/ciae653","article-title":"State-of-the-Art Review: Recurrent Uncomplicated Urinary Tract Infections in Women","volume":"80","author":"Advani","year":"2025","journal-title":"Clin Infect Dis"},{"key":"2026072702101436000_64.8.116.18","doi-asserted-by":"publisher","DOI":"10.1038\/s41579-024-01092-4"},{"key":"2026072702101436000_64.8.116.19","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2015.05.032"},{"key":"2026072702101436000_64.8.116.20","doi-asserted-by":"publisher","DOI":"10.1128\/JCM.05852-11"},{"key":"2026072702101436000_64.8.116.21","doi-asserted-by":"publisher","DOI":"10.1128\/JCM.02876-13"},{"key":"2026072702101436000_64.8.116.22","unstructured":"National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summaries (CKS) . Urinary tract infection (lower) - women: scenario: recurrent UTI (no haematuria, not pregnant or catheterised). 2025. Available: https:\/\/cks.nice.org.uk\/topics\/urinary-tract-infection-lower-women\/management\/recurrent-uti-no-haematuria-not-pregnant-or-catheterized\/ [Accessed 20 Feb 2025]."},{"key":"2026072702101436000_64.8.116.23","unstructured":"UK Health Security Agency . Diagnosis of urinary tract infections: quick reference tools for primary care. 2025. Available: https:\/\/www.gov.uk\/government\/publications\/urinary-tract-infection-diagnosis\/diagnosis-of-urinary-tract-infections-quick-reference-tools-for-primary-care#background [Accessed 11 Oct 2025]."},{"key":"2026072702101436000_64.8.116.24","unstructured":"Scottish Intercollegiate Guidelines Network guideline (SIGN) . SIGN 160 management of suspected bacterial lower urinary tract infection in adult women. 2020. Available: https:\/\/www.sign.ac.uk\/media\/1766\/sign-160-uti-0-1_web-version.pdf [Accessed 24 Oct 2025]."},{"key":"2026072702101436000_64.8.116.25","doi-asserted-by":"crossref","first-page":"2080","DOI":"10.1093\/jac\/dkad212","article-title":"Evidence-based appraisal of two guidelines for the diagnosis of suspected, uncomplicated urinary tract infections in primary care: a diagnostic accuracy validation study","volume":"78","author":"Fanshawe","year":"2023","journal-title":"J Antimicrob Chemother"},{"key":"2026072702101436000_64.8.116.26","unstructured":"UK Health Security Agency . The \u2018how to\u2026?\u2019 series how to undertake a structured clinical review with patients aged 16 and over who experience: recurrent urinary tract infection. 2025. Available: https:\/\/elearning.rcgp.org.uk\/mod\/book\/view.php?id=12649 [Accessed 11 Oct 2025]."},{"key":"2026072702101436000_64.8.116.27","unstructured":"The Scottish Antimicrobial Prescribing Group (SAPG) . Management of recurrent urinary tract infection (UTI) in non-pregnant women. 2021. Available: https:\/\/www.sapg.scot\/guidance-qi-tools\/infection-specific-guidance\/urinary- tract-infections-utis\/ [Accessed 12 Oct 2025]."},{"key":"2026072702101436000_64.8.116.28","unstructured":"National Institute for Health and Care Excellence (NICE) . Suspected cancer: recognition and referral - nice guideline [NG12]. Available: https:\/\/www.nice.org.uk\/guidance\/ng12\/resources\/suspected-cancer-recognition-and-referral-pdf-1837268071621 [Accessed 24 Oct 2025]."},{"key":"2026072702101436000_64.8.116.29","doi-asserted-by":"crossref","first-page":"434","DOI":"10.3390\/antibiotics12030434","article-title":"Patients\u2019 and Healthcare Professionals\u2019 Experiences and Views of Recurrent Urinary Tract Infections in Women: Qualitative Evidence Synthesis and Meta-Ethnography","volume":"12","author":"Sanyaolu","year":"2023","journal-title":"Antibiotics (Basel)"},{"key":"2026072702101436000_64.8.116.30","doi-asserted-by":"crossref","DOI":"10.1186\/1471-2296-15-162","article-title":"How women manage recurrent urinary tract infections: an analysis of postings on a popular web forum","volume":"15","author":"Flower","year":"2014","journal-title":"BMC Fam Pract"},{"key":"2026072702101436000_64.8.116.31","doi-asserted-by":"crossref","DOI":"10.1186\/s12905-022-01757-3","article-title":"The emotional impact of urinary tract infections in women: a qualitative analysis","volume":"22","author":"Grigoryan","year":"2022","journal-title":"BMC Womens Health"},{"key":"2026072702101436000_64.8.116.32","doi-asserted-by":"publisher","DOI":"10.3399\/bjgp10X514747"},{"key":"2026072702101436000_64.8.116.33","doi-asserted-by":"crossref","DOI":"10.1136\/bmj-2021-0068229","article-title":"Alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women: multicentre, open label, randomised, non-inferiority trial","volume":"376","author":"Harding","year":"2022","journal-title":"BMJ"},{"key":"2026072702101436000_64.8.116.34","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-119-6-199309150-00002"},{"key":"2026072702101436000_64.8.116.35","doi-asserted-by":"crossref","DOI":"10.1128\/JCM.00143-19","article-title":"Interaction between Antibiotic Resistance, Resistance Genes, and Treatment Response for Urinary Tract Infections in Primary Care","volume":"57","author":"Ho","year":"2019","journal-title":"J Clin Microbiol"},{"key":"2026072702101436000_64.8.116.36","doi-asserted-by":"publisher","DOI":"10.1186\/s12894-020-00764-6"},{"key":"2026072702101436000_64.8.116.37","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2017.8531"},{"key":"2026072702101436000_64.8.116.38","unstructured":"Confronting antimicrobial resistance 2024 to 2029. 2024. Available: https:\/\/www.gov.uk\/government\/publications\/uk-5-year-action-plan-for-antimicrobial-resistance-2024-to-2029\/confronting-antimicrobial-resistance-2024-to-2029#theme-2---optimising-the-use-of-antimicrobials-1 [Accessed 21 Feb 2025]."},{"key":"2026072702101436000_64.8.116.39","unstructured":"Public Health Wales NHS Trust . Antibacterial resistance in urinary coliforms in Wales 2024. 2025. Available: https:\/\/phw.nhs.wales"},{"key":"2026072702101436000_64.8.116.40","doi-asserted-by":"publisher","DOI":"10.1016\/S1473-099(18)30296-2"},{"key":"2026072702101436000_64.8.116.41","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(24)01867-1\/ATTACHMENT\/4F9FA746-A486-4BC0-BF71-075D4D1D6D56\/MMC3.PDF"},{"key":"2026072702101436000_64.8.116.42","doi-asserted-by":"crossref","first-page":"1509","DOI":"10.1001\/jamainternmed.2018.4204","article-title":"Effect of Increased Daily Water Intake in Premenopausal Women With Recurrent Urinary Tract Infections: A Randomized Clinical Trial","volume":"178","author":"Hooton","year":"2018","journal-title":"JAMA Intern Med"},{"key":"2026072702101436000_64.8.116.43","doi-asserted-by":"crossref","unstructured":"Cooper TE , Teng C , Howell M , et al . D-mannose for preventing and treating urinary tract infections. Cochrane Database Syst Rev 2022;2022. doi:10.1002\/14651858.CD013608.pub2","DOI":"10.1002\/14651858.CD013608.pub2"},{"key":"2026072702101436000_64.8.116.44","doi-asserted-by":"crossref","first-page":"619","DOI":"10.1001\/jamainternmed.2024.0264","article-title":"d-Mannose for Prevention of Recurrent Urinary Tract Infection Among Women: A Randomized Clinical Trial","volume":"184","author":"Hayward","year":"2024","journal-title":"JAMA Intern Med"},{"key":"2026072702101436000_64.8.116.45","doi-asserted-by":"crossref","first-page":"881","DOI":"10.1007\/s11255-025-04747-0","article-title":"Comparison of increased hydration, d-mannose, and antibiotic prophylaxis for recurrent urinary tract infection prevention in premenopausal women: a three-arm randomized-controlled study","volume":"58","author":"Iossa","year":"2025","journal-title":"Int Urol Nephrol"},{"key":"2026072702101436000_64.8.116.46","doi-asserted-by":"crossref","unstructured":"Williams G , Stothart CI , Hahn D , et al . Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 2023;2023. doi:10.1002\/14651858.CD001321.pub7","DOI":"10.1002\/14651858.CD001321.pub7"},{"key":"2026072702101436000_64.8.116.47","doi-asserted-by":"crossref","unstructured":"Perrotta C , Aznar M , Mejia R , et al . Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev 2008.:CD005131. doi:10.1002\/14651858.CD005131.pub2","DOI":"10.1002\/14651858.CD005131.pub2"},{"key":"2026072702101436000_64.8.116.48","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1007\/s00192-020-04397-z","article-title":"Estrogen for the prevention of recurrent urinary tract infections in postmenopausal women: a meta-analysis of randomized controlled trials","volume":"32","author":"Chen","year":"2021","journal-title":"Int Urogynecol J"},{"key":"2026072702101436000_64.8.116.49","doi-asserted-by":"publisher","DOI":"10.3310\/AAFO2475"},{"key":"2026072702101436000_64.8.116.50","doi-asserted-by":"crossref","first-page":"571","DOI":"10.1007\/s00192-021-04849-0","article-title":"Methenamine hippurate compared with trimethoprim for the prevention of recurrent urinary tract infections: a randomized clinical trial","volume":"33","author":"Botros","year":"2022","journal-title":"Int Urogynecol J"},{"key":"2026072702101436000_64.8.116.51","doi-asserted-by":"crossref","first-page":"1873","DOI":"10.1016\/j.cmi.2025.07.006","article-title":"Methenamine hippurate as prophylaxis for recurrent urinary tract infections in older women\u2014a triple-blind, randomised, placebo-controlled, phase IV trial (ImpresU)","volume":"31","author":"Heltveit-Olsen","year":"2025","journal-title":"Clin Microbiol Infect"},{"key":"2026072702101436000_64.8.116.52","article-title":"Antibiotics for preventing recurrent urinary tract infection in non-pregnant women","volume":"2004","author":"Albert","year":"2004","journal-title":"Cochrane Database Syst Rev"},{"key":"2026072702101436000_64.8.116.53","doi-asserted-by":"publisher","DOI":"10.1093\/cid\/ciab116"},{"key":"2026072702101436000_64.8.116.54","doi-asserted-by":"publisher","DOI":"10.1001\/archinternmed.2011.306"},{"key":"2026072702101436000_64.8.116.55","doi-asserted-by":"publisher","DOI":"10.1001\/archinternmed.2012.777"},{"key":"2026072702101436000_64.8.116.56","doi-asserted-by":"crossref","first-page":"e209","DOI":"10.1016\/S3050-5038(25)00178-5","article-title":"Prophylactic antibiotics to prevent recurrent urinary tract infections and risk of antibiotic resistance: target trial emulation with the SAIL Databank","volume":"2","author":"Sanyaolu","year":"2026","journal-title":"The Lancet Obstetrics, Gynaecology, & Women\u2019s Health"},{"key":"2026072702101436000_64.8.116.57","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2024-090012","article-title":"plaTform fOr Urinary tract infection diagnostiC evAluatioN (TOUCAN): a protocol for a prospective diagnostic accuracy study of point-of-care testing in patients suspected of acute uncomplicated urinary tract infection in primary care clinics in England","volume":"15","author":"Turner","year":"2025","journal-title":"BMJ Open"},{"key":"2026072702101436000_64.8.116.58","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1016\/j.cmi.2023.10.005","article-title":"Clinical effectiveness of point of care tests for diagnosing urinary tract infection: a systematic review","volume":"30","author":"Tomlinson","year":"2024","journal-title":"Clin Microbiol Infect"},{"key":"2026072702101436000_64.8.116.59","article-title":"Probiotics for preventing urinary tract infections in adults and children","volume":"2015","author":"Schwenger","year":"2015","journal-title":"Cochrane Database Syst Rev"},{"key":"2026072702101436000_64.8.116.60","doi-asserted-by":"crossref","first-page":"761","DOI":"10.1016\/j.euf.2024.04.002","article-title":"Bacterial Vaccines for the Management of Recurrent Urinary Tract Infections: A Systematic Review and Meta-analysis","volume":"10","author":"Mak","year":"2024","journal-title":"Eur Urol Focus"},{"key":"2026072702101436000_64.8.116.61","doi-asserted-by":"crossref","unstructured":"Larcher R , Dinh A , Monnin B , et al . Phage therapy in patients with urinary tract infections: a systematic review. Expert Rev Anti Infect Ther 2025;1\u201312. doi:10.1080\/14787210.2025.2513459","DOI":"10.1080\/14787210.2025.2513459"},{"key":"2026072702101436000_64.8.116.62","doi-asserted-by":"publisher","DOI":"10.1086\/313596"},{"key":"2026072702101436000_64.8.116.63","doi-asserted-by":"publisher","DOI":"10.1093\/oxfordjournals.aje.a010170"},{"key":"2026072702101436000_64.8.116.64","doi-asserted-by":"publisher","DOI":"10.1086\/315827"},{"key":"2026072702101436000_64.8.116.65","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijid.2015.10.014"},{"key":"2026072702101436000_64.8.116.66","first-page":"3","article-title":"Nitrofurantoin: reminder of the risks of pulmonary and hepatic adverse drug reactions","volume":"16","year":"2023","journal-title":"Drug Safety Update"},{"key":"2026072702101436000_64.8.116.67","unstructured":"National Institute for Health and Care Excellence (NICE) . Pyelonephritis (acute): antimicrobial prescribing. NICE Guideline; 2018."}],"container-title":["Drug and Therapeutics Bulletin"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/dtb.2025.000042","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T09:10:43Z","timestamp":1785143443000},"score":1,"resource":{"primary":{"URL":"https:\/\/dtb.bmj.com\/lookup\/doi\/10.1136\/dtb.2025.000042"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,27]]},"references-count":67,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,7,27]]},"published-print":{"date-parts":[[2026,8]]}},"alternative-id":["10.1136\/dtb.2025.000042"],"URL":"https:\/\/doi.org\/10.1136\/dtb.2025.000042","relation":{},"ISSN":["0012-6543","1755-5248"],"issn-type":[{"value":"0012-6543","type":"print"},{"value":"1755-5248","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,27]]}}}