Hello urologists, gynaecologists, primary care doctors and all of you who have to deal with urinary tract infections. Urinary tract infection management and prevention is one of the activities on a routine basis for all caregivers. This Newsletter intends to review the last recommendation for managing and preventing urinary infections. Our focus is reducing the number of infections, avoiding antibiotic use when not indicated to prevent resistance and reviewing the evidence about non-antibiotic measures to prevent infections. Scientific support of the evidence and practice guidelines recommendations will be the key to all the information in the Newsletter.

This issue focuses on the recent updates to the European Association of Urology (EAU) Guidelines on Urological Infections, specifically concerning the management of urinary tract infections (UTIs) using phytotherapeutic agents such as xyloglucan, hibiscus, and propolis (XHP).

The second article reviews the management of UTIs in patients with neurogenic bladder using urine acidification through the use of L-methionine.

The third article addresses the evaluation of complicated urinary tract infections and highlights the importance of strict adherence to established management protocols.

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The 2025 edition of the European Association of Urology (EAU) Guidelines on Urological Infections presents an updated section on the management of cystitis, with a particular focus on non-antibiotic treatment options. New sections on disease management and prevention have also been introduced.

In relation to non-antibiotic treatments for cystitis, several studies have assessed the role of cranberry products, including both cranberry juice and encapsulated cranberry powder. The review concluded that current evidence supporting the use of cranberry products in the management of acute cystitis remains insufficient. It is important to note, however, that the proanthocyanidin content varied considerably across the studies, ranging from 7.5 mg to 224 mg, which may have influenced outcomes. The efficacy of D-mannose, either alone or in combination with cranberry, was also evaluated. Due to significant heterogeneity in the dosages employed across studies, the available evidence remains inadequate to support a formal recommendation. Only one study, which investigated a combination of D-mannose, citric acid, prebiotic fibres, Astragalus, and dandelion (referred to as the DAPAD complex), demonstrated higher rates of clinical and bacteriological resolution.

Phytotherapeutic agents have also been evaluated. A herbal combination containing Centaurii herba, Levistici radix, and Rosmarini folium was shown to be non-inferior to fosfomycin trometamol in treating acute lower cystitis in women aged 18–70 years with typical symptoms. Furthermore, a randomised controlled trial assessed a combination of L-methionine, Hibiscus sabdariffa, and Boswellia serrata in comparison with antibiotics for treating acute episodes in women with recurrent cystitis. Both treatment arms demonstrated improvements in quality of life at one- and three-month follow-up. Additionally, the phytotherapeutic combination was associated with a reduced recurrence rate and a higher proportion of patients presenting with asymptomatic bacteriuria, which may act as a protective factor against symptomatic infection. Thus, combinations incorporating Centaurii herba, Levistici radix, Rosmarini folium, L-methionine, Hibiscus sabdariffa, and Boswellia serrata appear to be promising therapeutic options for women with recurrent cystitis.

The guidelines also evaluated treatment involving xyloglucan, gelose, Hibiscus, and propolis. Multicentre randomised controlled trials have shown that this combination significantly reduced urinary incontinence and urgency of micturition compared to placebo, with resolution of symptoms. 

Additionally, the section on the management of recurrent cystitis reviewed several non-antibiotic prophylactic strategies. Vaginal and/or oral administration of Lactobacillus spp. probiotics has not yet yielded sufficient evidence to support recommendations regarding the route of administration, optimal dosage, or duration of treatment. Similarly, further research is needed to determine the most effective concentration, formulation, and duration of cranberry prophylaxis in managing recurrent cystitis. Although D-mannose is often combined with cranberry, current evidence suggests that daily D-mannose administration does not significantly reduce the proportion of women with recurrent cystitis in primary care who experience subsequent clinically suspected episodes.

Conversely, the combination of xyloglucan, Hibiscus, and propolis may provide a protective barrier that prevents uropathogenic Escherichia coli from adhering to the uroepithelial cell walls. A systematic review and meta-analysis involving 178 patients reported that this combination was effective in preventing recurrent cystitis compared with placebo, demonstrating high patient compliance and a reduction in antibiotic use.

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The basis of this article is the evaluation of urinary acidification as a strategy for the prevention and management of urinary tract infections (UTIs) in patients with neurogenic bladder. It has been demonstrated that Gram-negative microorganisms exhibit restricted growth in an acidic urinary environment. The study was a randomised, double-blind, placebo-controlled, multicentre trial involving 89 patients with neurogenic bladder dysfunction secondary to spinal cord injury. The aim was to assess the efficacy of L-methionine in preventing UTIs. The control group received a placebo.

Of the total cohort, 83.1% were male, and 57 patients required bladder emptying via intermittent catheterisation. In the treatment group, participants received two tablets of L-methionine (500 mg each) three times daily. Prior to study initiation, the mean UTI frequency among participants was 2.6 infections per year, with no statistically significant difference between the two groups. During the observation period, 51.1% of patients in the L-methionine group remained infection-free, compared with 36.4% in the placebo group. The incidence of UTIs was 0.75 infections per patient in the L-methionine group versus 1.48 in the placebo group. The calculated annual risk of developing a UTI was 1.08 infections with L-methionine prophylaxis, compared with 2.19 infections without prophylaxis (placebo). This corresponds to a 50.6% reduction in UTI incidence in favour of the treatment group. L-methionine was generally well tolerated throughout the study period.

Based on the study findings, L-methionine significantly reduces the incidence of urinary tract infections, likely due to its ability to inhibit bacterial growth, reduce bacterial cytoadherence, and influence the virulence profile of Escherichia coli. The study population consisted of patients with neurogenic bladder, a group often considered clinically challenging. In conclusion, L-methionine appears to be an effective prophylactic agent for reducing UTI recurrence in patients with neurogenic bladder dysfunction, with minimal side effects, even when administered over an extended period.

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Complicated urinary tract infection (cUTI) represents a distinct pathological entity that is often associated with the isolation of resistant microorganisms and a more severe clinical course, potentially progressing to sepsis. However, the definition of cUTI remains a subject of debate, particularly due to the limited consideration of clinical symptoms in current classifications. the European Association of Urology (EAU) Guidelines recommend taking into account specific risk factors and propose a classification based on systemic versus localised urinary tract infections.

The present article provides an analysis of adherence to the United States Food and Drug Administration (FDA) guidance on cUTIs, an evaluation of the significance of risk factors in treatment failure, and a Delphi consensus process conducted by a multidisciplinary panel. The findings revealed low adherence to FDA guidance in studies addressing cUTIs, with considerable heterogeneity in the reporting of study parameters, patient characteristics, and microbial pathogens. The risk factor analysis identified the presence of an indwelling urinary catheter or stent as the most impactful patient-related risk factor for treatment failure. This was followed by anatomical abnormalities of the urinary tract causing impaired drainage, and the presence of urinary calculi. The authors emphasised several unresolved issues requiring further discussion and investigation, including the optimal duration of treatment, the timing for evaluating treatment response, parameters for sustainability, and clear definitions of treatment success (e.g., time to defervescence and acceptable colony count thresholds at test-of-cure).