Urinary tract infections (UTIs) are among the most common bacterial infections encountered in clinical practice. In response to the growing threat of antimicrobial resistance, the European Association of Urology (EAU) has released the 2026 update of the Urological Infections Guidelines, introducing major changes to the classification and management of UTIs while reinforcing the principles of antibiotic stewardship.

The updated guidelines synthesize the latest evidence to help clinicians optimize antibiotic selection, dosing, and treatment duration.

The most significant change is a revised classification framework. The traditional distinction between “complicated” and “uncomplicated” UTIs has been replaced by a classification on the basis of clinical presentation. Under the new framework, UTIs are categorized as either localized infections, such as cystitis, or systemic infections, such as pyelonephritis and prostatitis.

New Classification

Localized UTIs are characterized by symptoms such as dysuria, urinary urgency, or suprapubic pain without systemic features and can generally be managed in an outpatient setting. In contrast, systemic infections present with signs such as fever, chills, hypotension, delirium, or costovertebral angle tenderness and require prompt evaluation, laboratory testing, imaging when indicated, hospitalization, and immediate intravenous antibiotic therapy.

The guidelines also emphasize assessing individual patient risk factors that may increase the likelihood of treatment failure, regardless of whether the infection is localized or systemic.

Reducing Unnecessary Antibiotic Use

The updated recommendations place strong emphasis on avoiding unnecessary prescribing of antibiotics.

Speaking with Univadis Spain, part of the Medscape Professional Network, José Medina-Polo, MD, Department of Urology at 12 de Octubre University Hospital in Madrid, Spain, and a member of the panel of the EAU guidelines on urologic infections, said, “The key point is to avoid antibiotic treatment for asymptomatic bacteriuria.” Except in pregnant women and before urologic procedures involving mucosal disruption, this condition does not require antibiotics. In fact, studies show that treating asymptomatic bacteriuria in women with recurrent UTIs increases the risk for recurrence.

He added that delaying antibiotic treatment may also be appropriate for selected patients with mild localized infections.

“With the new classification based on localized and systemic infections, symptoms become the determining factor,” he said. “In patients with localized symptoms, no risk factors, and appropriate counseling, delaying antibiotic therapy may be considered because up to 60% of mild localized infections resolve without antibiotics.”

The guidelines noted that both localized and systemic UTIs may be accompanied by patient-specific risk factors that can compromise treatment success. Clinicians should actively assess and address these factors when managing patients.

Asymptomatic Bacteriuria

The EAU guidelines strongly recommend against screening for or treating asymptomatic bacteriuria in most populations, including healthy women, patients with well-controlled diabetes, postmenopausal women, residents of long-term care facilities, and patients with lower urinary tract dysfunction.

According to the guidelines, treatment provides no clinical benefit and may destroy potentially protective bacterial flora, contributing to antimicrobial resistance.

Routine screening and treatment are recommended only for pregnant women and patients undergoing urologic procedures expected to breach the urinary tract mucosa.

Nonantibiotic Prevention

Although these alternatives are important for reducing antimicrobial resistance, the evidence supporting them is, in some cases, considered only “moderate” or “weak” compared with the well-established efficacy of low-dose antibiotic prophylaxis.

“It is important to recognize that these recommendations are based on published studies, and some of these approaches have not been evaluated over as long a period as antibiotic prophylaxis. For example, topical estrogen is a safe therapy strongly recommended for postmenopausal women. Other strategies, such as immunoprophylaxis, have also shown promising results. However, immunoprophylaxis encompasses several distinct approaches that should not be evaluated as a single group because they differ in their characteristics and supporting evidence. The sublingual formulation, for example, has been evaluated in studies with more than 1 year of follow-up, and a recent systematic review supports its efficacy and safety,” said Medina-Polo.

New Frontiers: Herpes Simplex Virus, Fungal UTIs, and Prostate Biopsy

The 2026 guidelines also introduce several new chapters that reflect evolving clinical practice. Among the most notable are recommendations for the diagnosis and management of genital herpes simplex virus infection, which accounts for up to 60% of genital ulcers, and fungal UTIs, most commonly caused by Candida albicans.

The guidelines also revise the recommendations for antibiotic prophylaxis before urologic procedures. A key update is the recommendation for transperineal prostate biopsy. On the basis of new evidence, antibiotic prophylaxis is no longer recommended for patients without specific risk factors for infectious complications, thereby reducing unnecessary antibiotic use.

Conclusions

The guidelines concluded that they provide healthcare professionals with an evidence-based framework for the diagnosis and management of urologic infections. At the same time, they emphasize that the recommendations serve as a reference and do not replace individualized clinical judgment. Treatment decisions should always take into account each patient’s clinical circumstances, comorbidities, and preferences.

Medina-Polo reported having no relevant conflicts of interest.

This story was translated from Univadis Spain.