Optimizing Prevention of Recurrent Urinary Tract Infections in Older Patients with Frailty

Frailty is associated with impaired immune function, functional decline, and increased vulnerability to both infection and adverse medication effects. Recurrent urinary tract infection (rUTI) is a common and burdensome condition among older persons, particularly those living with frailty. Despite this, frail individuals remain underrepresented in clinical research guiding rUTI prevention. This review outlines current evidence on rUTI prevention strategies in older persons living with frailty. It highlights feasible tools for frailty assessment and explores how frailty contributes to infection risk and impacts the effectiveness and safety of preventive interventions. Nonpharmacological strategies-including continence management, minimization of catheter use, hydration support, and carer education-form the foundation of prevention. Locally applied vaginal estrogen is the best-supported pharmacological option in postmenopausal women. Evidence for cranberry products, D-mannose, and probiotics remains inconsistent in frail populations, while methenamine hippurate offers a promising, well-tolerated alternative to antibiotics. Prophylactic antibiotic use may reduce recurrence in selected patients but carries significant risks, including Clostridioides difficile infection and antimicrobial resistance. Clinical decision-making should be guided by individualized risk assessment, careful consideration of treatment burden, and regular reassessment of both benefits and harms. Further research is urgently needed to inform evidence-based prevention strategies for this vulnerable population.