The 2026 Guideline Update on Urinary Tract Infections: Non-Antibiotic Options and Fungal Infections

Urinary tract infections are among the conditions for which antibiotics are most often prescribed. Unnecessary or incorrect use of antibiotics, however, speeds up the development of resistance in bacteria. For this reason, the urological infections guideline of the European Association of Urology (EAU), published in March 2026, puts the principle of “rational antibiotic use” at its centre. In this article we summarise the updates in the guideline and practical information that will be useful in everyday life.

What has changed in the 2026 guideline?

According to the guideline’s own summary of changes, this year’s limited update included the following:

• The recommendations on the diagnosis of cystitis in women were updated.
• The recommendations on the antibiotic treatment of cystitis were updated.
• A new section on fungal urinary tract infections was added.
• The recommendations on preventive antibiotics before prostate biopsy were renewed.
• Antibiotic doses were reviewed.

Why does rational antibiotic use matter?

The guideline points out that 20–50% of the antibiotics prescribed in hospitals are unnecessary or inappropriate. Overuse of antibiotics can lead to the selection of resistant bacteria, side effects such as diarrhoea and greater difficulty with treatment in the future.

One concrete consequence of this principle for patients is that bacteria in the urine without symptoms (asymptomatic bacteriuria) are not treated in most cases. The guideline gives a strong recommendation not to screen for or treat this condition in women without risk factors, postmenopausal women, people with well-controlled diabetes and people with recurrent urinary tract infections. Pregnancy and urological procedures that breach the mucosa are exceptions.

Is a urine culture always needed to diagnose cystitis?

According to the guideline, in women with no other risk factors, cystitis can be diagnosed on the basis of symptoms such as burning when passing urine, frequent urination and a sense of urgency, together with the absence of vaginal discharge. A urine dipstick test is included as a weak recommendation.

A urine culture, on the other hand, is given a strong recommendation in the following situations: suspected infection that has spread to the kidney or the blood, symptoms that do not go away or that return within four weeks after treatment, unusual symptoms, people at high risk of resistant bacteria, and pregnant women. We explain the causes of these symptoms in our article on burning when passing urine.

Can cystitis be treated without antibiotics?

The guideline gives a strong recommendation that women are told about approaches that reduce antibiotic use in the treatment and prevention of cystitis, and that they are informed about the level of evidence for each approach. In patients who are not elderly, non-antibiotic options can be an alternative to antibiotics, with the decision made together with the patient. In the studies reviewed, non-antibiotic approaches reduced antibiotic use by 63%; however, complete recovery rates generally remained lower than with antibiotics, and the risk of a kidney infection increased slightly.

When an antibiotic is needed, the guideline recommends fosfomycin trometamol, pivmecillinam, nitrofurantoin or nitroxoline as the first choice in women, and recommends not using aminopenicillins and fluoroquinolones for cystitis. The doctor decides which medicine is suitable, taking kidney function, pregnancy and local resistance patterns into account; do not start treating yourself with antibiotics left over at home.

What are the non-antibiotic prevention options for recurrent cystitis?

Recurrent cystitis is defined as two or more episodes in the last six months, or three or more in a year. The guideline recommends that the diagnosis is confirmed with a urine culture and that extensive routine investigations are not carried out in women younger than 40 without risk factors. The recommended options and their strength of recommendation are as follows:

Option	Strength of recommendation in the guideline
Vaginal oestrogen in postmenopausal women	Strong
Methenamine hippurate (in women without structural abnormalities of the urinary tract)	Strong
Cranberry products (noting that the evidence is of low quality and contradictory)	Strong
Increasing fluid intake in premenopausal women who drink little fluid	Weak
Probiotics containing strains with proven efficacy	Weak
Herbal combinations containing xyloglucan, hibiscus and propolis, or centaury, lovage root and rosemary	Weak
D-mannose (noting that the evidence is weak and contradictory)	Weak
Vaccine-like immune modulators (only within well-designed clinical trials)	Weak
Hyaluronic acid (± chondroitin sulphate) into the bladder, when simpler methods are not enough	Weak

When these methods are not enough, continuous low-dose or post-intercourse antibiotic prophylaxis is given a strong recommendation. In patients who can follow it reliably, an approach in which the patient starts a short course of antibiotics themselves when symptoms begin can also be used, provided it has been planned with the doctor in advance.

A “strong recommendation” reflects the guideline panel’s confidence in the balance of benefits and harms; it does not mean that the method will work for everyone. For prevention and everyday measures, see our article on urinary tract infections in winter.

What is a fungal urinary tract infection?

According to the new section added to the guideline, only 2–11% of people found to have fungus in their urine (mostly Candida species) have symptoms of a urinary tract infection. This is much more common in people admitted to hospital, especially in intensive care, than in outpatients.

The risk factors listed include older age, female sex, diabetes, kidney failure, conditions that suppress the immune system, a long-term catheter or stent, and recent use of broad-spectrum antibiotics. The guideline’s key messages are:

• If there are no symptoms, finding fungus in the urine usually does not need treatment; the exceptions are patients with a severely reduced number of defence cells in the blood (neutropenic patients), babies with a very low birth weight and the period before a urological procedure that breaches the mucosa.
• If there are symptoms, the fungal species and drug susceptibility should be identified by culture.
• Changing a long-term catheter or stent can help to clear the fungus.
• SGLT2 inhibitors, a group of medicines used for diabetes, can increase the risk of genital fungal infection; fungal cystitis, however, has rarely been reported.

What was presented in this area at the congresses?

At the EAU26 congress in London, two randomised trials were presented showing that in patients who use intermittent self-catheterisation, catheters that can be washed and reused were not worse than single-use catheters in terms of urinary tract infection. The results of the COMPaRE trial from the Netherlands were published in 2026; mild irritation of the urethra was more common with reusable catheters. In the MultICath trial from the UK, antibiotic use was reported to be 35% lower in the mixed-use group.

At the American Urological Association (AUA) meeting held in Washington on 15–18 May 2026, an observational analysis covering more than 57,000 women reported that recurrent urinary tract infections were less common among women following a vegetarian diet. This finding shows an association; it does not prove that diet prevents infection.

When should you see a urologist?

A urological assessment is advisable if you have a fever, shivering, pain in your side or nausea and vomiting, if you are a man, if you are pregnant, if your symptoms continue despite treatment, or if you have two or more infections in six months or three or more in a year. Blood in the urine, or kidney stones together with infections, also need to be assessed. For investigations and treatment options, see the urinary tract infection page. Bringing your previous urine test and culture results with you makes the assessment easier.

Op. Dr. Mücahit Kabar sees patients in Bursa (Nilüfer), Turkey, at Özel Medicabil Nilüfer Hastanesi (weekdays 08:30–12:00, +90 444 8 112) and Özel Jimer Hastanesi (weekdays 13:00–17:00, +90 444 45 67). Appointments are booked through the hospitals’ online booking pages or appointment lines. Consultations are held in English or Turkish; the hospitals’ international patient departments can arrange interpreters for other languages. If you are travelling from abroad, you can send your questions and previous test results by WhatsApp to +90 541 622 54 82 before your visit. See the contact and appointment information for details.

Sources

• EAU Guidelines on Urological Infections 2026 – Full text (PDF)
• EAU Guidelines on Urological Infections 2026 – Summary of changes
• EAU26 Highlights: Day 1 – Uroweb (COMPaRE trial)
• Single-Use vs Reusable Catheters for Intermittent Catheterization in Patients With Urinary Retention: The COMPaRE Randomized Clinical Trial (JAMA Netw Open 2026) – UroToday
• Review of the European Association of Urology (EAU) Congress 2026 – European Medical Journal
• Research Highlights Diet and Hormone Therapy Advances in Preventing Recurrent UTIs in Women – AUA press release