# Novel Insights on Plant Extracts to Prevent and Treat Recurrent Urinary Tract Infections
## 5 Management of Recurrent UTI by Non-Antibiotic Plant-Based Prevention and Treatments  
Prophylactic antibiotics therapy is the current standard of care to prevent recurrent UTI in many worldwide guidelines [30]. However, recent UK, European, and US guidelines advise prudent antibiotic prescribing to reduce antimicrobial resistance [31]. The reason is that many studies have confirmed the emergence of antibiotic-resistant UTI pathogens after a few weeks of prophylactic therapy, including multiple drug resistance (MDR). It has been reported that most _E. coli_ urinary isolates have resistance to amoxicillin, while colistin and carbapenem resistance are emerging in _Enterobacteriaceae_[1]. Moreover, the prophylactic antibiotic treatment remains of doubtful usefulness, and some of the MDR uropathogenic strains will soon be untreatable with the current antibiotics on which UTI-prone patients rely [1,2]. The problem of antimicrobial resistance is recognized as a global public health concern that provokes high financial costs to healthcare systems and is fueled by the overuse of antibiotics. Since 2014 World Health Organization has highlighted that antibiotic resistance in uropathogens is a key pressure point in the global antimicrobial resistance crisis. Therefore, there is an urgent need to understand UTI pathophysiology better and develop innovative products that use non-antibiotic strategies to prevent and treat UTI. A different non-antibiotic approach might provide the optimal treatment to reduce rUTI. A recently published comprehensive article discusses the future of non-antibiotic prevention and management of recurrent urinary tract infections [1]. Phytotherapy, alternative medicine based on plant extracts [32], is an essential non-antibiotic strategy that has been used for centuries to prevent or treat different diseases, including UTI [33]. Medicinal plants have long been an excellent place to search for innovative ways to treat human health issues. The biologically active substances present in medicinal plants have evolved to protect the plant from pathogens and, therefore, could prevent/treat human infections [34]. Complementary and alternative plant medicine has been an effective practical approach for treating rUTI, especially as a prophylactic therapy of antibiotics, as both have a synergistic effect. Plant medicines are a realistic option for the long-term prevention of rUTI. They are cost-effective, readily available, safe to use, with fewer reported side effects, and do not induce bacterial resistance. The innovation in prophylactic plant-based treatments, especially for UTI-prone patients with high recurrence rates, should target the bottleneck points of UTI pathogenesis. The bioactive plant molecules used in rUTI treatment must prevent uropathogen adherence to urothelial cells, internalization or biofilm formation, and the production of inhibitory molecules against defensive immune response and modulate the natural microbial community, restoring the microbiome dysbiosis. Moreover, phytotherapy is critical in providing a way to reduce rUTI symptoms without using antibiotics. However, aggressive acute UTI treatment requires antibiotic therapy associated with plant-based therapies that increase the antibiotic effect and the host's immune response. However, the mechanism of plant medicines used for the treatment of rUTI is still poorly understood. Further studies are required to disclose the potential of all active compounds responsible for pharmaceutical activities and their potential adverse effects, including mutagenic and carcinogenic activities. The antimicrobial effects of plant extracts are attributed to multiple mechanisms: directly killing microbes, interfering with microbial adhesion to epithelial cells and biofilm formation, stopping the multiplication of pathogens, restoring dysbiosis, improving the host protection acting on natural barriers, serving as immunomodulators, or boosting body oxidant status [35].