Highlights
- Molecular diagnostics and novel antibiotics are revolutionizing UTI treatment and management strategies.
- Explore promising non-antibiotic therapies to enhance urinary tract health and tackle resistance.
Summary and Background
Urinary tract infections (UTIs) are common bacterial infections worldwide, mainly caused by gram-negative bacteria like Escherichia coli and Klebsiella species. Rising multidrug-resistant (MDR) pathogens complicate treatment, especially for complicated UTIs (cUTIs). Advances in molecular diagnostics, such as multiplex PCR and next-generation sequencing (NGS), enable faster and more accurate pathogen identification and resistance profiling. New antibiotics like gepotidacin (Blujepa), approved in 2025, provide effective options against resistant strains. Non-antibiotic treatments, including immunotherapy, probiotics, and platelet-rich plasma (PRP) therapy, are being explored to reduce recurrence and antimicrobial resistance.
UTIs affect both sexes, with women having a higher lifetime risk. The bacteriology is dominated by gram-negative bacteria, with increasing MDR strains posing treatment challenges. Traditional diagnostics, including symptom assessment and urine culture, have limitations, prompting updates in clinical guidelines that better classify complicated infections based on systemic signs rather than underlying conditions alone. Tailored antimicrobial strategies considering resistance patterns are essential for effective management.
Advances in Diagnosis
Molecular techniques like multiplex PCR, loop-mediated isothermal amplification (LAMP), and NGS improve upon standard urine cultures by enabling rapid detection of a wider range of pathogens and resistance genes. These methods offer higher sensitivity and faster results, supporting targeted antibiotic therapy. Point-of-care assays integrating pathogen and resistance detection are in development. However, their effectiveness in atypical or low-burden infections requires further validation. Future diagnostics aim to combine genomic technologies, nanobiotechnology, and artificial intelligence to deliver rapid, comprehensive, and cost-effective testing.
Treatment of Uncomplicated and Complicated UTIs
Uncomplicated UTIs, mostly bladder infections in women without urinary tract abnormalities, are traditionally treated empirically with antibiotics. The FDA-approved gepotidacin offers a new oral treatment option with efficacy comparable to nitrofurantoin. Other common antibiotics include nitrofurantoin, fosfomycin, trimethoprim-sulfamethoxazole, and pivmecillinam. Non-antibiotic options like immunotherapy show promise for preventing recurrence. Guidelines recommend short-course treatments, typically five days, with individualization for higher-risk patients.
Complicated UTIs require careful antibiotic selection due to higher resistance risk. Empirical therapy usually involves third- or fourth-generation cephalosporins, piperacillin-tazobactam, or fluoroquinolones; carbapenems are reserved for severe cases with sepsis. Oral step-down therapy is recommended once clinical improvement occurs. Treatment durations have shortened, with 5–7 days for non-bacteremic cUTIs and about 7 days for bacteremic cases. New antibiotics are in development to address resistant pathogens, though evidence varies.
Strategies Against Multidrug-Resistant Uropathogens
MDR uropathogens, including ESBL-producing Enterobacteriaceae, challenge UTI treatment. Novel antibiotics like gepotidacin and β-lactam/β-lactamase inhibitor combinations target resistant strains. Updated guidelines recommend stratified empiric therapy and early oral switch when feasible, with longer courses for specific conditions such as bacterial prostatitis. Non-antibiotic measures include probiotics, cranberry products, d-mannose, estrogens, immunostimulants, and intravesical glycosaminoglycans, which may reduce recurrence without promoting resistance. Emerging therapies like PRP offer additional alternatives, especially for recurrent infections linked to urinary tract dysfunction.
Emerging Non-Antibiotic Treatments and Prevention
Non-antibiotic therapies gaining attention include immunotherapy to boost host defenses, autovaccine therapy tailored to patient-specific bacteria, probiotics to modulate microbiota, herbal remedies, and nanotechnology-based interventions. Vaccine development aims to enhance urinary immunity and reduce bacterial adherence, with some recombinant vaccines inducing mucosal and systemic responses without boosters. Hormonal therapies, particularly vaginal estrogen, are under study to prevent UTIs in postmenopausal women. These approaches collectively aim to lower infection rates and dependence on antibiotics.
Challenges and Future Directions
MDR bacteria and diagnostic limitations complicate UTI management globally, especially in resource-limited regions. Molecular diagnostics promise improved detection and resistance profiling but require cost-effective, accessible implementation. Oral antibiotic options for complicated infections remain limited, and some therapies like colistin need specialist oversight. Innovative treatments such as personalized autovaccines, PRP therapy, and phage therapy are under investigation. Advances in biosensor diagnostics integrating AI could enhance rapid, targeted treatment. Ongoing collaboration among industry, academia, and healthcare is crucial to develop effective therapies and combat antimicrobial resistance in UTIs.
The content is provided by Harper Eastwood, Scopewires
