Urinary Tract Infections In Women Research Articles

A Review for Clinical Practice in the Treatment and Prevention of Recurrent Urinary Tract Infections in Women over Age 65

A Review for Clinical Practice in the Treatment and Prevention of Recurrent Urinary Tract Infections in Women over Age 65

Evaluation of the diagnostic accuracy of lower urinary tract symptoms (LUTS) in uncomplicated UTI in Pakistani women.

To evaluate the diagnostic accuracy of lower urinary tract symptoms in uncomplicated urinary tract infection in women. The cross-sectional study was conducted from September 2020 to December 2021 after approval from the ethics review board of Jinnah Postgraduate Medical Centre, Karachi, and comprised data of women aged at least 16 years from 8 institutions across Pakistan. Data included menstruation status, symptoms, urinalysis and organisms found in urine samples. The association of urinalysis variables with symptoms among culture-positive patients was measured to assess the certainty of positive diagnosis. Data was analysed using SPSS 23. Of the 457 women with mean age 37.87±13.9 years, 182(39.8%) had a positive urine culture. Dysuria was the most significant symptom 120(65.9%), followed by daytime frequency 114(62.6%) amongst culture-positive patients. On urinalysis, 139(76.3%) had white blood cells, and 66(36.2%) had haematuria. Dysuria along with the presence of leucocyte esterase had the highest diagnostic utility (p=0.002). Urgency along with haematuria was strongly predictive of urinary tract infection (p=0.058). The diagnosis of uncomplicated urinary tract infection in women could be reliably made based on a combination of symptoms along with urine analysis without urine culture.

Game-Changing Antibiotic Solutions for Chronic UTIs in Women

Urinary tract infections (UTIs) are prevalent in primary healthcare settings, with persistent recurrences posing significant challenges. These recurrences necessitate extended antibiotic use, adversely affecting patients' quality of life, mental health, and physical activity. The evolving defense mechanisms of bacteria against the host immune system and antibiotics complicate treatment. This article examines the pathomechanisms of recurrent UTIs, focusing on bacterial defense factors. Understanding these mechanisms is essential for developing innovative treatments, particularly non-antibiotic methods, to reduce antibiotic use and its associated side effects, thereby improving patients' overall well-being. The review synthesizes current knowledge on the pathomechanisms, diagnostics, and treatments for recurrent UTIs, emphasizing the impact on patients' mental and physical health. It highlights innovative, non-antibiotic treatment approaches.

Gaps in knowledge and recurrent urinary tract infections in women.

The focus of this review is to present recent literature and gaps in knowledge (GIKs) surrounding the current and future treatment and prevention of uncomplicated recurrent urinary tract infections (rUTIs) in women. Recurrent urinary tract infections are common, significantly reduce quality of life, and create a substantial economic burden to the healthcare system. They are disproportionately affecting the postmenopausal women. Antibiotics, which are used for the treatment and prophylaxis of uncomplicated rUTI, have become problematic, as there is a global rise in allergy and resistance to these agents and their use is associated with further antimicrobial resistance. Thus, in recent decades, several alternative, nonantibiotic approaches have been evaluated. There is a critical need for a concerted and standardized methodology for diagnosing, treating, and monitoring women with rUTIs. Additionally, novel nonantibiotic alternative treatment and preventive measures for UTIs are desperately required to address the global issue of antibiotic recalcitrance in all age groups, and specifically older women. Research efforts have sought to develop alternative and more effective techniques; many of which appear to be promising, but require additional evaluation and validation through clinical trials.

Population pharmacokinetics of oral fosfomycin calcium in healthy women.

Fosfomycin is an antibiotic extensively used to treat uncomplicated urinary tract infections in women, and it is available in different salts and formulations. The European Medicines Agency (EMA) recommends further studies to characterize the pharmacokinetics of fosfomycin calcium for oral administration and to justify its dosage recommendation. A population pharmacokinetic model of fosfomycin calcium was developed after oral administration to healthy women. A clinical trial (a randomized, open-label, bioavailability study of single and multiple doses of 1000 mg capsules, single dose of 500 mg capsule and single dose of 250 mg/5 mL suspension of oral fosfomycin calcium under fasted conditions in healthy women volunteers, Code: PD7522.22, EudraCT: 2020-001664-28) was carried out at the Clinical Trial Unit, Araba University Hospital (Vitoria-Gasteiz, Spain). Twenty-four healthy women were included in the study, and plasma samples were collected at different times over a period of 24 h. The concentration-time data of fosfomycin in plasma were modelled by a population approach using a nonlinear mixed-effects modelling implemented by NONMEM 7.4 (ICON Clinical Research LLC, North Wales, PA, USA). The pharmacokinetics of fosfomycin was best described by a two-compartment model. Creatinine clearance and body weight were identified as covariates for fosfomycin clearance and volume of distribution, respectively. This study provides relevant information on the pharmacokinetic profile of fosfomycin in women after oral administration as calcium salt. This population model may be very useful for establishing dosage recommendations of fosfomycin calcium to treat urinary tract infections in women.

The Role of the Gut, Urine, and Vaginal Microbiomes in the Pathogenesis of Urinary Tract Infection in Women and Consideration of Microbiome Therapeutics.

The gut, urine, and vaginal microbiomes play significant roles in the pathogenesis of recurrent urinary tract infections (rUTIs). Analysis of these microbiota has shown distinct associations with urinary tract infections. Encouraging data indicate that rUTIs may be responsive to microbiome treatments such as fecal microbiota transplantation, expanding potential treatments beyond antibiotics, hydration, and behavioral interventions. If successful, these nonantibiotic therapies have the potential to increase time between rUTI episodes and reduce the prevalence of multidrug-resistant organisms. In this review, we discuss the role of the 3 microbiomes in the pathogenesis of rUTI and utilization of live biotherapeutic products as therapy for rUTI.

Editorial Comment on “Systematic Review of the Global Literature on Uncomplicated Recurrent Urinary Tract Infections in Women: Underscoring Major Heterogeneity”

Editorial Comment on “Systematic Review of the Global Literature on Uncomplicated Recurrent Urinary Tract Infections in Women: Underscoring Major Heterogeneity”

Prevalence of Urinary Tract Infection among Women in Virudhunagar, Tamil Nadu: Treatment Approach and Perspectives

Introduction: Urinary tract infections (UTIs) represent a significant health burden, particularly among women worldwide. Understanding the prevalence and associated risk factors of UTIs is crucial for effective management and treatment. This research focuses on exploring the prevalence of UTIs in women in Virudhunagar, Tamil Nadu, and identifying the microbial agents responsible for these infections. Aim: The primary objective of this study is to determine the prevalence of urinary tract infections among women in Virudhunagar, Tamil Nadu, and to investigate associated risk factors. Additionally, the research aims to evaluate the microbial agents causing UTIs in the region to inform the development of tailored and effective treatment strategies. Study Design: A Prospective Observational Study was conducted over a period of 6 months at the Outpatient and Obstetric and Gynaecological department of a Tertiary Healthcare Teaching hospital. Female patients presenting with symptoms suggestive of UTIs were recruited for participation in the study after providing informed consent. Methodology/Methods: Data collection encompassed various parameters including patient demographics, symptoms, urine culture results, prescribed antibiotics, and concurrent medications. A sample size of 480 participants was determined through an extensive review of literature. Statistical analysis was performed to analyze the collected data. Results: Out of the 480 participants, 117 individuals tested positive for UTIs, indicating a prevalence rate of [24.4%]. The age group 15-24 exhibited the highest incidence of UTIs, with a mean age of 30. Educational and marital status was found to influence infection rates. Common symptoms included increased frequency of urination and painful urination. E.coli was identified as the primary pathogen responsible for UTIs. Cephalosporin antibiotics were the most frequently prescribed treatment modality. Conclusion: Urinary tract infections are prevalent among women in Virudhunagar, Tamil Nadu, as evidenced by the findings of this study. The identification of associated risk factors and microbial agents provides valuable insights for clinical decision-making and the development of tailored treatment approaches. These findings underscore the importance of continued research in UTI management to address the global health burden posed by this infection.

Post-Toilet Wiping Style Is Associated With the Risk of Urinary Tract Infection in Women.

Urinary tract infection (UTI) has a lifetime incidence of ≥50% in women. A wide variety of clinical, physiological, and lifestyle risk factors for UTI have been identified, but the exact relationship between post-toilet anal and perineal hygiene practices, especially the wiping direction with toilet paper, and UTI risks has not been investigated yet. Therefore, this study cross-sectionally investigated the post-toilet wiping habit and lifetime UTI events in the general population. Individuals who visited two hospitals in Japan between April 2020 and March 2023 were initially recruited. Self-reported questionnaires regarding post-toilet wiping habits and past UTI events were collected, and their relationship was investigated in males and females. Subgroup analyses by age were further performed to estimate the impact of age on the relationship. A total of 294 individuals (141 males and 153 females) agreed to participate and answered the question of post-toilet wiping direction. The number of individuals with post-toilet wiping with the arm from the front between the legs was 32 (23%) in males and 68 (44%) in females. The lifetime UTI events were more frequent in females than in males (p<0.0001). The impact of post-toilet wiping with the arm from the front between the legs on UTI events, adjusting for the age and history of diabetes mellitus, was not statistically significant both in males and females (p≥0.10 for both). Meanwhile, when the relationship was evaluated by different age groups, wiping habits from the frontand UTI were significantly associated with each other in middle-aged women aged 40-59, whereas they were not in younger and older age groups. Approximately 40-50% of women performed post-toilet wiping with the arm from the front between the legs. This post-toilet wiping habit was suggested to be a potential risk of UTI in women, especially in middle-aged subgroups, and may be better to be changed to wiping from behind.

IJCM_279A: Evaluation of diabetes mellitus as a risk factor for urinary tract infection in women: A case control study

Background: Diabetes mellitus (DM) disrupts insulin production and function leads to hyperglycaemia and subsequently exacerbating the risk of complications. Studies highlight hyperglycaemia’s impact on neutrophil function, predisposing diabetic patients to severe infections like pneumonia, urinary tract infections (UTIs), and skin issues. Objectives: To quantify DM’s contribution to UTI development, and to assess the risk of contracting UTI conferred by diabetes mellitus in otherwise healthy women and to characterize the UTI in the cases. Methodology: The case control study was conducted among 200 participants (100 cases with UTI and 100 controls without UTI) from 3 hospitals affiliated to Kasturba Medical College, Mangalore. The data were collected using a structured proforma. Chi – square test and students ‘t’ test was used for comparison of the results across the groups. Results: Patients with urinary tract infections (UTI) showed a higher prevalence of diabetes mellitus (DM) (27.66%) compared to controls (7.45%). The UTI patients were 4.75 times more likely to have DM. Diabetic UTI cases exhibited elevated glycated haemoglobin (HbA1C) and random blood sugar levels than controls. Complicated UTIs were more prevalent in diabetic (77%) than non-diabetic (60%) UTI cases, with E. coli being the most common infecting organism. Conclusion: The uncontrolled diabetes mellitus confers an increased risk of developing UTI and the risk of developing UTI caused by organisms which are not known to cause infections in people with normal immunity (like Candida species). Additionally, diabetics show a higher proportion of complicated UTI cases as compared to non-diabetics.

Reducing Recurrent Urinary Tract Infections in Women with MV140 Impacts Personal Burden of Disease: Secondary Analyses of a Randomized Placebo-controlled Efficacy Study

BackgroundRecurrent urinary tract infection (rUTI) remains a major health burden for women. A randomized, double-blind, placebo-controlled trial (RCT; NCT02543827) reported that female patients with rUTI receiving a sublingual vaccine, MV140, had a reduction in rUTI and increase in UTI-free rate compared with placebo. ObjectiveTo determine the impact of MV140 on the personal burden of disease in women with rUTI using secondary endpoint data from the pivotal RCT evaluating MV140. Design, setting, and participantsIn the primary RCT, female patients with rUTI enrolled in Spain and UK (from October 2015 to April 2019) were randomized to placebo (6 mo) or MV140 (3 or 6 mo), and followed for 12 mo. Individuals analyzed in this secondary analysis included those in the placebo and 3-mo (recommended dose) groups. InterventionA polybacterial sublingual vaccine, MV140 (four inactivated whole-cell bacteria—Escherichia coli, Klebsiella pneumoniae, Proteus vulgaris, and Enterococcus faecalis), or placebo. Outcome measurements and statistical analysisSymptom severity scoring, antibiotic use, safety, and multiple aspects of quality of life (QoL; Short-Form Questionnaire [SF-36]) were assessed. Results and limitationsCompared with the placebo group (n = 76), the 3-mo vaccinated group (n = 74) experienced fewer overall UTI symptoms (mean symptom score 102.2 ± 222.9 vs 194.2 ± 178.8; p = 0.0002), fewer days on antibiotics (12.4 ± 17.7 vs 28.7 ± 25.2; p = 0.0001), and improved total, general, and physical SF-36 QoL improvement (differences in means for total SF-36 score 15.7; 95% confidence interval [CI] 8.80, 22.64; p < 0.0001), with only social function QoL showing no impact (4.07; 95% CI –4.93, 13.08; p = 0.3744). ConclusionsThree months of MV140 is associated with a reduction of the personal burden of UTI by reducing overall UTI symptoms and antibiotic use, improving QoL in women with rUTI. Patient summaryThree months of MV140 vaccine, which has previously been shown to reduce the risk of urinary tract infection safely, is associated with a reduction in the personal burden of disease.

Antibiotic Profiling of E. coli Borne UTI Infection in Tertiary Healthcare Settings.

Introduction In general, with frequent recurrence of urinary tract infections (UTIs), long-term antibiotic therapy is stipulated at a low dose. With this type of situation and with easy access to several classes of antibiotics in tertiary health care settings, the use of such drugs results in the development of resistant bacteria in patients.Escherichia coliis a frequent cause of UTI observed. Hence, it was proposed in the present study to assess the antimicrobial resistance status ofE. coliin UTI-infected patients. Methods This study was conducted among female patients diagnosed with UTI.About 80 urine samples were collected in an aseptic condition, Under the process of culture identification 44 samples were found to be positive for UTI infection. The positive samples were plated on blood agar. Out of 44 samples, 18 samples were found to be positive, and 26 samples were negative for E. coli infection. The 18 samples were screened on MALDI-TOF for identification. Further, the samples were assessed for susceptibility to antibiotic medication within the study area. Result The study identified different strains ofE. coli,and the CHB geneE. coli wasfound in eight samples. The sample showed pink oval-round spots in the culture medium and was resistant to nitrofurantoin, cephalosporin, and cephalexin antibiotics. Hence, antimicrobial susceptibility tests arenecessaryfor managing and treating bacterialE. coliinfections. Conclusion E. coliis a common bacterium found in the vaginal region of patients, suggesting a potential infection.E. colican be associated with UTIs in women. The results from this study conclude thatE. coliis rapidly becoming multidrug-resistant, as only higher antibiotics can inhibit its growth. To effectively manage infections caused byE. coliproper diagnosis, laboratory testing, and antibiotic treatment are required.

General practitioners' decision making managing uncomplicated urinary tract infections in women: a qualitative study.

To be effective, interventions aimed at increasing the appropriateness of antibiotic use in primary care should consider the perspectives of prescribing physicians. To explore the decision making of general practitioners (GPs) when managing uncomplicated urinary tract infections (uUTIs) in women. A qualitative study using semi-structured interviews with 22 GPs in Bavaria and Baden-Württemberg (southern Germany). Verbatim transcripts were analysed through inductive qualitative content analysis. We generated the following three main themes: factors facilitating the decision making; factors complicating the decision making; and consultation modalities. According to participants, following evidence-based recommendations makes the prescription decision smoother. GPs' and patients' prior experiences and beliefs guides decisions towards certain antibiotics, even if those experiences and beliefs contradict evidence-based recommendations. Patient expectations and demands also condition antibiotic prescribing, favouring it. Organisational constraints, such as time pressure, the day of the week (for example, before weekends), and a lower cost of antibiotics for patients than alternative treatments favour the decision to prescribe antibiotics. Diagnostic and prognostic uncertainty complicates decision making, as does scepticism towards evidence-based recommendations. Discordance within the patient-doctor relationship contributed to this complexity. Regarding consultation modalities, a more in-depth consultation and shared decision making were seen as helpful in this process. We identified different factors as intervening against or for a straightforward management decision when dealing with women with uUTIs. They reveal the complexity behind the GPs' decision making. Providing GPs with easy-to-apply guidance while removing economic constraints to allocate sufficient consultation time, and supporting shared decision making may help GPs appropriately manage uUTIs in women.

The emotional impact of uncomplicated urinary tract infections in women in China and Japan: a qualitative study

BackgroundUncomplicated urinary tract infections (uUTIs) are one of the most common community-acquired infections, particularly among women. Common symptoms of UTI include dysuria, urinary urgency and increased frequency, and lower abdominal pain. With appropriate treatment, symptoms may resolve in a few days. However, there is a lack of research on the emotional impact of this disease. We conducted a qualitative, interview-based study to gain a greater understanding of the emotional impact of uUTIs in women in China and Japan.MethodsA qualitative, exploratory, in-depth, interview-based study was conducted between 19 November 2020 and 25 February 2021. Women aged ≥ 18 years who experienced ≥ 1 uUTI and received antibiotic treatment in the past year were eligible for inclusion. Participants must have experienced ≥ 1 of the following symptoms during a uUTI episode: urinary urgency, frequency, dysuria, or lower abdominal/suprapubic pain. Participants who reported back pain or fever (indicative of complicated UTI) were excluded. Participants with recurrent or sporadic UTIs were included, with specific screening criteria used to ensure capture of both groups. Following a screening call, a structured, in-depth telephone interview (~ 30 min in duration) was conducted by three female external moderators trained in qualitative interviewing, assisted by an interview guide. Interviews were analysed individually and thematically, with the results presented within the identified themes.ResultsA total of 65 women with uUTI completed the in-depth telephone interview: 40 (62%) from China and 25 (38%) from Japan. Participants reported that the symptoms of uUTI affected multiple aspects of their lives, and described feelings of embarrassment, frustration, guilt, dread, and loneliness associated with symptoms that interfered with relationships, work and daily activities, and sleep. Participants reported seeking healthcare from several different points of contact, from local pharmacies to hospitals.ConclusionsOur analysis highlights the profound emotional impact of uUTIs in women in China and Japan, and the journey these participants take before their initial interaction with a healthcare professional. These insights emphasise the need to better understand the full impact of uUTI, and the role of healthcare professionals in improved patient education and support.

Robotic simple cystectomy as a last resort for antibiotic-recalcitrant recurrent urinary tract infections in women

To report a series of women with antibiotic-recalcitrant recurrent urinary tract infections (rUTI) managed with robotic simple cystectomy and ileal conduit urinary diversion. Following Institutional Review Board approval, all female patients who underwent robotic cystectomy for rUTI between 2011-2021 were identified from a prospectively-maintained internal database at a tertiary care center. Exclusion criteria included interstitial cystitis, neurogenic bladder, urinary tract neoplasm, or congenital abnormality. Electronic medical records were reviewed by an independent researcher. Patients were also administered the Quality of Life Questionnaire-C30 (QLQ-C30). Twenty-four patients met inclusion criteria. Median age was 75 years (range 53-87). Median rUTI duration was 6 (interquartile range (IQR) 2-10) years. Median UTI count in the 12 months preceding cystectomy was 5 (IQR 3-9). Infections with multidrug resistant organisms were found in 21 patients (88%). The 30-day postoperative complication rate was 79% (19/24), of which 11% were Clavien-Dindo grade ≥III. The main late complication was parastomal hernia, with 17% requiring repair or revision. At a median of 36 months (range 12-61) post-operatively, the median QLQ-C30 global health status score was 50 (range 33-83). Cystectomy is a last-resort management option for women with severely symptomatic end-stage bladders in the setting of antibiotic-recalcitrant rUTI. Patients should be counseled thoroughly regarding possible acute and long-term postoperative complications. Select patients, managed in high-volume referral centers, can benefit from robotic simple cystectomy with ileal conduit urinary diversion.

MV140 sublingual vaccine proves promising in fighting recurrent urinary tract infections in women.

MV140 sublingual vaccine proves promising in fighting recurrent urinary tract infections in women.

Intravaginal Delivery of Herbal Pharmaceutical Interventions for Uncomplicated UTIs in Women

Background: Urinary tract infection (UTIs) is the most common infection in women affecting approximately 75% of women worldwide during their pregnancy, and in pre and postmenopausal women. Typical symptoms include urinary frequency, urgency, suprapubic discomfort, and dysuria. Method: An introduction to the epidemiology of UTIs and detailed herbal nanoformulation treatment approach through novel intravaginal route is intended through this narrative review. UTIs are associated with significant morbidity and mortality, and they affect the quality of life of the affected patients. Multidrug-resistant bacteria and recurrent UTIs are becoming more common. Development of resistance, adverse effects of antibiotics, and other associated problems lead to establishing the research framework to find out the alternative approaches in controlling UTIs. Antibiotic- free treatments for uncomplicated urinary tract infections UTIs should be used, saving drugs for severe infections. Herbal medication might be used instead of antibiotics for uncomplicated UTIs, in addition to analgesics for purely symptomatic treatment. Conclusion: This review identifies the pathophysiology of UTI, distinguish the intravaginal route as an alternative to oral delivery route, summarizes the management of urinary tract infections and highlights the anti-uropathogenic and anti-bactericidal effects of herbal approaches to prevent or treat urinary tract infections.

Does regular ingestion of whole cranberries, cranberry juice, or products containing these as whole ingredients prevent recurrent urinary tract infections in women?

Does regular ingestion of whole cranberries, cranberry juice, or products containing these as whole ingredients prevent recurrent urinary tract infections in women?

Relationship between routine urinary catheterization and postoperative urinary symptoms and urinary tract infections in women undergoing elective caesarean section.

The aim of the study was to detect the relationship between routine urinary catheterization and postoperative urinary symptoms and urinary tract infections (UTIs) in women undergoing elective caesarean sections (ECSs). One hundred women undergoing ECSs were included in this observational study and randomized into a catheterized (C) group, including women who underwent ECS after insertion of indwelling Foley's catheter, and a non-catheterized (NC) group, including women who underwent ECS without Foley's catheter. The Foley's catheters were removed from all participants in the C group once they were freely ambulant and had recovered from the effect of the spinal anaesthesia. Participants were asked about any abnormal postoperative urinary symptoms (dysuria, frequency, urgency, and/or urinary retention), and to collect urine samples (mid-stream) once they were freely ambulant for urine cultures. The postoperative dysuria, frequency, and urgency were significantly higher in the C group compared to the NC group [36% (18/50), 40% (20/50), and 34% (17/50) vs. 8% (4/50), 6% (3/50), and 6% (3/50), respectively], (p = 0.006, 0.001 and 0.004, respectively). The urinary tract infections and the postoperative antimicrobials used were significantly higher in the C group compared to the NC group [40% (20/50) and 40% (20/50) vs. 6% (3/50) and 6% (3/50), respectively], (p = 0.001 and 0.001, respectively). The postoperative hospital-stay after the ECSs was significantly higher in the C group compared to the NC group (5.4 ±1.8 days vs. 3.8 ±1.15, respectively), (p = 0.001). Routine urinary catheterizations in women undergoing ECS significantly increase the odds of postoperative dysuria, frequency, urgency, UTIs, and the postoperative antimicrobials used.

Cranberries for preventing urinary tract infections.

Cranberries contain proanthocyanidins (PACs), which inhibit the adherence of p-fimbriated Escherichia coli to the urothelial cells lining the bladder. Cranberry products have been used widely for several decades to prevent urinary tract infections (UTIs). This is the fifth update of a review first published in 1998 and updated in 2003, 2004, 2008, and 2012. To assess the effectiveness of cranberry products in preventing UTIs in susceptible populations. We searched the Cochrane Kidney and Transplant Specialised Register up to 13 March 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. All randomised controlled trials (RCTs) or quasi-RCTs of cranberry products compared with placebo, no specific treatment or other intervention (antibiotics, probiotics) for the prevention of UTIs were included. At least two authors independently assessed and extracted data. Information was collected on methods, participants, interventions and outcomes (incidence of symptomatic UTIs, positive culture results, side effects, adherence to therapy). Risk ratios (RR) with 95% confidence intervals (CI) were calculated where appropriate. Study quality was assessed using the Cochrane risk of bias assessment tool. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. For this update, 26 new studies were added, bringing the total number of included studies to 50 (8857 randomised participants). The risk of bias for sequence generation and allocation concealment was low for 29 and 28 studies, respectively. Thirty-six studies were at low risk of performance bias, and 23 studies were at low risk of detection bias. Twenty-seven, 41, and 17 studies were at low risk of attrition bias, reporting bias and other bias, respectively. Forty-five studies compared cranberry products with placebo, water or no specific treatment in six different groups of participants. Twenty-six of these 45 studies could be meta-analysed for the outcome of symptomatic, culture-verified UTIs. In moderate certainty evidence, cranberry products reduced the risk of UTIs (6211 participants: RR 0.70, 95% CI 0.58 to 0.84; I² = 69%). When studies were divided into groups according to the treatment indication, cranberry products probably reduced the risk of symptomatic, culture-verified UTIs in women with recurrent UTIs (8 studies, 1555 participants: RR 0.74, 95% CI 0.55 to 0.99; I² = 54%), in children (5 studies, 504 participants: RR 0.46, 95% CI 0.32 to 0.68; I² = 21%) and in people with a susceptibility to UTIs due to an intervention (6 studies, 1434 participants: RR 0.47, 95% CI 0.37 to 0.61; I² = 0%). However, there may be little or no benefit in elderly institutionalised men and women (3 studies, 1489 participants: RR 0.93, 95% CI 0.67 to 1.30; I² = 9%; moderate certainty evidence), pregnant women (3 studies, 765 participants: RR 1.06, 95% CI 0.75 to 1.50; I² = 3%; moderate certainty evidence), or adults with neuromuscular bladder dysfunction with incomplete bladder emptying (3 studies, 464 participants: RR 0.97, 95% CI 0.78 to 1.19; I² = 0%; low certainty evidence). Other comparisons were cranberry products with probiotics (three studies) or antibiotics (six studies), cranberry tablets with cranberry liquid (one study), and different doses of PACs (two studies). Compared to antibiotics, cranberry products may make little or no difference to the risk of symptomatic, culture-verified UTIs (2 studies, 385 participants: RR 1.03, 95% CI 0.80 to 1.33; I² = 0%) or the risk of clinical symptoms without culture (2 studies, 336 participants: RR 1.30, 95% CI 0.79 to 2.14; I² = 68%). Compared to probiotics, cranberry products may reduce the risk of symptomatic, culture-verified UTIs (3 studies, 215 participants: RR 0.39, 95% CI 0.27 to 0.56; I = 0%). It is unclear whether efficacy differs between cranberry juice and tablets or between different doses of PACs, as the certainty of the evidence was very low. The number of participants with gastrointestinal side effects probably does not differ between those taking cranberry products and those receiving a placebo or no specific treatment (10 studies, 2166 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%; moderate certainty evidence). There was no clear relationship between compliance with therapy and the risk for repeat UTIs. No difference in the risk for UTIs could be demonstrated between low, moderate and high doses of PACs. This update adds a further 26 studies, taking the total number of studies to 50 with 8857 participants. These data support the use of cranberry products to reduce the risk of symptomatic, culture-verified UTIs in women with recurrent UTIs, in children, and in people susceptible to UTIs following interventions. The evidence currently available does not support its use in the elderly, patients with bladder emptying problems, or pregnant women.