Beyond Empirical Antibiotics: Toward Precision-Based Urinary Tract Infection Management and Korea-Specific Guidelines
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Abstract
Urinary tract infection (UTI) remains one of the most common bacterial infections, yet rising antimicrobial resistance and changing healthcare environments have challenged the traditional empiric approach to antibiotic therapy. Recent international guidelines from the European Association of Urology (EAU), Infectious Diseases Society of America (IDSA), and American Urological Association (AUA) collectively demonstrate a paradigm shift toward precision diagnostics, evidencebased antibiotic selection, standardized nonantibiotic prevention strategies, and simplified disease classification systems. The EAU has emphasized culture-based diagnosis, expanded nonantibiotic prophylaxis, and introduced a new framework distinguishing localized from systemic UTI. The IDSA has strengthened restrictions on treating asymptomatic bacteriuria, provided guidance for managing antimicrobial-resistant organisms, and simplified UTI categories. The AUA similarly highlights culture-directed diagnosis and the minimization of prophylactic antibiotics in women with recurrent UTI while formalizing nonantibiotic preventive measures. In Korea, unique resistance patterns, high extended-spectrum beta-lactamase and fluoroquinolone resistance rates, and frequent movement of patients between long-term care facilities and hospitals underscore the need for Korea-specific UTI guidelines. Although national surveillance systems such as KARMS (Korean Antimicrobial Resistance Monitoring System) and KorGLASS (Global Antimicrobial Resistance Surveillance System in Korea) provide valuable data, the evidence base remains insufficient to match the robustness of international guideline development. Establishing updated, Korean-contextualized UTI guidelines is essential for improving patient safety, optimizing antimicrobial stewardship, and effectively responding to the growing threat of resistance. The field is at a pivotal turning point, requiring proactive leadership and coordinated action within Korea’s urological and infectious disease communities.
HIGHLIGHTS
Urinary tract infection (UTI) guidelines are moving from empirical antibiotic use toward precision, stewardship-based care. Recent European Association of Urology, Infectious Diseases Society of America, and American Urological Association updates emphasize simplified classification, culture-based diagnosis, and broader use of nonantibiotic prevention. These converging changes suggest a new global direction for UTI management.
CHANGING PARADIGMS IN URINARY TRACT INFECTION MANAGEMENT
Urinary tract infection (UTI) is one of the most common infectious diseases encountered by clinicians, and a substantial number of patients suffer from its consequences. The most crucial aspect of UTI management is the appropriate use of antibiotics [1]. The discovery of antibiotics a century ago dramatically reduced mortality from infectious diseases and ushered in the “golden age of antibiotics.” However, we now live in an era characterized by increasing antimicrobial resistance and growing concerns about the sustainability of effective antibiotics [2].
As antimicrobial resistance continues to rise worldwide, the traditional empirical approach to antibiotic selection is becoming increasingly insufficient. In particular, the growing population of older adults and frequent movement of patients among hospitals, communities, and long-term care facilities have altered infection patterns and pathogen spectra, pushing the conventional UTI classification system to its limits. Consequently, recent international infectious disease guidelines are converging toward a paradigm that emphasizes precision diagnostics, evidence-based decision-making, and antibiotic stewardship.
Herein, we summarize the recent shifts in UTI management guidelines issued by the European Association of Urology (EAU), Infectious Diseases Society of America (IDSA), and American Urological Association (AUA), and discuss the need to develop a Korea-specific UTI guideline that reflects the realities of the Korean healthcare environment.
RECENT CHANGES IN INTERNATIONAL GUIDELINES: CONVERGING DIRECTIONS IN THE EAU, IDSA, AND AUA
The 2022 revised EAU guideline places particular emphasis on culture-based diagnostic approaches for recurrent UTI (rUTI). It formally incorporates nonantibiotic therapies for the prevention of rUTI, including adequate hydration, immunoactive prophylaxis, probiotics, cranberry products, D-mannose, and vaginal estrogen therapy for postmenopausal women. This marks an important shift, as preventive strategies beyond antibiotics were, for the first time, incorporated at the level of guideline recommendations.
In the 2023 revision, the guideline issued a strong recommendation for the use of methenamine in the prevention of rUTI [3]. In 2024, the guideline updated its recommendations on asymptomatic bacteriuria (ASB), clearly defining the clinical situations in which screening or treatment is warranted [4]. In 2025, a major revision was introduced. One significant change was the adoption of a new UTI classification system, moving away from the traditional “anatomical classification + complicated” model and redefining UTI as “localized vs. systemic” [5]. This is expected to ensure diagnostic consistency and simplify treatment decisions. Another important change was the formal introduction of nonantibiotic treatment options for acute uncomplicated cystitis.
The IDSA guidelines are organized in a topic-specific format. In 2019, the guideline provided clear criteria prohibiting the treatment of ASB except in pregnancy or prior to urologic procedures [6]. In 2024, recommendations were issued regarding antibiotic selection in the context of antimicrobial resistance [7], providing guidance on treatment options for infections caused by extended-spectrum beta-lactamase (ESBL)-producing organisms, based on susceptibility results from urine cultures. In 2025, a new UTI classification system was introduced, simplifying the previous categories—“complicated UTI, uncomplicated UTI, and acute pyelonephritis”— into a binary framework of “complicated versus uncomplicated UTI” [8]. This is in line with the EAU’s “localized/systemic UTI” concept and demonstrates the global trend of simplifying diagnostic systems.
The AUA guidelines focus on a practical approach to rUTI in women. The 2019 guideline emphasized culture-based diagnosis of rUTI and clarified the indications for treating ASB. In 2022, the guideline highlighted nonantibiotic prophylaxis, including methenamine. By 2025, it has further advance this direction by minimizing the use of prophylactic antibiotics for rUTI and standardizing nonantibiotic prevention strategies [9].
These guidelines are evolving from "reducing antibiotic use" to "preventing infections without antibiotics."
NEED FOR KOREA-SPECIFIC UTI GUIDELINES
The Korean Association of Urogenital Infections and Inflammation (KAUTII) has continuously worked on revising its urological infection guidelines. Guidelines on antibiotic use were published in 2022, and those on UTI in 2018. However, with subsequent changes in international guidelines, the Korean guidelines also need to be revised. In particular, regional and age-specific differences in antibiotic susceptibility, rising resistance rates to fluoroquinolones and ESBL-producing organisms, and Korea's unique infection pattern of frequent movement between nursing homes and hospitals indicate the need for Korean-style guidelines that are different from those of other countries [10]. Antibiotic resistance centered around long-term care hospitals has progressed and reached a level of serious concern, making the management of antimicrobial resistance all the more urgent. Although datasets such as KARMS (Korean Antimicrobial Resistance Monitoring System) and KorGLASS (Global Antimicrobial Resistance Surveillance System in Korea) are being accumulated to serve as foundational evidence for guideline development, the current evidence base is still insufficient to match the robustness of international guidelines.
CONCLUSION: FROM THE ERA OF EMPIRICAL PRESCRIBING TO THE ERA OF PRECISION MANAGEMENT
The recent changes in the EAU, IDSA, and AUA guidelines all point in the same direction: less antibiotics, smarter diagnosis, personalized infection management, standardization of nonantibiotic preventive strategies, and the adoption of consistent and simplified disease classification systems.
These developments are not merely trends within international societies—they represent a structural response by the global medical community to the pressing threat of rising antimicrobial resistance. Korea must now follow suit by developing a Korea-specific UTI guideline that reflects Korean patients, Korean resistance patterns, and the realities of the Korean healthcare system. Such efforts will directly translate into improved patient safety and meaningful progress in curbing antibiotic resistance.
The field of UTI stands at a pivotal turning point. It is time for KAUTII to take an active role and prepare for the future.
Notes
Funding/Support
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of Interest
The authors have nothing to disclose. However, he played no role whatsoever in the editorial evaluation of this article or the decision to publish it. The other author has nothing to disclose.
Author Contribution
Conceptualization: SRB; Data curation: HJY; Formal analysis: HJY; Methodology: HJY; Project administration: SRB; Visualization: HJY; Writing - original draft: all authors; Writing - review & editing: all authors.