Should a urinary tract infection (UTI) be treated in the presence of gross hematuria, positive nitrite, and trace leukocyte esterase in the urine?

From the Guidelines

Yes, you should treat this UTI, as the presence of gross hematuria, positive nitrite, and trace leukocyte esterase in the urine suggests a bacterial infection that requires prompt treatment. The symptoms and urinalysis results described are consistent with a complicated urinary tract infection (UTI), which may require a different treatment approach than an uncomplicated UTI. According to the European Association of Urology guidelines on urological infections, published in 2024 1, the typical first-line treatment for a complicated UTI is a 7- to 14-day course of antibiotics, depending on the severity of the illness and local resistance patterns.

The following factors should be considered when selecting an antibiotic:

• The presence of gross hematuria, which may indicate a more severe infection
• The presence of positive nitrite and leukocyte esterase, which indicate a bacterial infection
• The patient's medical history, including any underlying conditions or allergies
• Local resistance patterns and the results of urine culture and susceptibility testing

Some possible treatment options for a complicated UTI include:

• Fluoroquinolones, such as ciprofloxacin or levofloxacin
• Cephalosporins, such as ceftriaxone or cefepime
• Aminoglycosides, such as gentamicin or tobramycin
• Carbapenems, such as meropenem or imipenem

It is essential to consult a doctor for personalized treatment, as the choice of antibiotic and duration of treatment will depend on the individual patient's needs and circumstances. While taking antibiotics, it is recommended to:

• Drink plenty of water
• Urinate frequently
• Take the full course of antibiotics as prescribed
• Monitor for signs of improvement or worsening symptoms, and seek medical attention if necessary.

The presence of gross hematuria and positive nitrite and leukocyte esterase in the urine suggests a bacterial infection that requires prompt treatment to prevent the infection from spreading to the kidneys and becoming more serious. According to the European Association of Urology guidelines, published in 2024 1, and the American College of Radiology Appropriateness Criteria for hematuria, published in 2020 1, prompt treatment is essential to prevent complications and improve outcomes.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim oral suspension and other antibacterial drugs, sulfamethoxazole and trimethoprim oral suspension should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria Urinary Tract Infections For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris It is recommended that initial episodes of uncomplicated urinary tract infections be treated with a single effective antibacterial agent rather than the combination

Treatment Decision:

• The presence of gross hematuria, positive nitrite, and trace leukocyte esterase in the urine suggests a urinary tract infection (UTI) that may be caused by a susceptible organism.
• The drug label indicates that trimethoprim/sulfamethoxazole is effective against certain strains of bacteria that can cause UTIs, such as Escherichia coli.
• Given the presence of symptoms and laboratory findings consistent with a UTI, treatment with an antibacterial agent such as trimethoprim/sulfamethoxazole is warranted. 2

From the Research

Urinary Tract Infection (UTI) Treatment

In the presence of gross hematuria, positive nitrite, and trace leukocyte esterase in the urine, the decision to treat a urinary tract infection (UTI) should be based on the results of diagnostic tests and recent antimicrobial susceptibility of uropathogens 3.

Diagnostic Tests

• The positive predictive value (PPV) and specificity of the nitrite test are high, indicating a strong likelihood of UTI when the test is positive 3.
• A negative nitrite test with a positive leukocyte esterase test also shows a high PPV and sensitivity, suggesting that UTI is still possible even with a negative nitrite test 3.
• The presence of leukocyte esterase and/or blood in the urine increases the sensitivity of the dipstick assay in predicting UTI 4.

Antibiotic Treatment

• For empirical treatment, general practitioners should take into account the changing aetiology with increasing age and the antimicrobial susceptibility of the uropathogen 3.
• The use of nitrofurantoin or cephalexin for the treatment of cystitis is optimum, and in the presence of negative leukoesterase, nitrofurantoin is preferable to cephalexin 5.
• Enhanced preoperative antibiotic treatment based on positive urine dipstick infection tests may not reduce the incidence of positive stone culture but increases the risk of systemic inflammatory response syndrome (SIRS) after percutaneous nephrolithotomy (PCNL) in patients with negative urine cultures 6.

Urinalysis and UTI

• Pyuria is the best determinant of bacteriuria requiring therapy, and values significant for infection differ depending on the method of analysis 7.
• A positive value for nitrites and leukocyte esterase by urine dipstick can be treated without the need for a urine culture in cases of uncomplicated symptomatic UTI 7.
• Urinary nitrite results are not helpful in choosing an initial antibiotic to treat a UTI, and leukocytosis in the blood or urine or the presence of a fever cannot be used to predict bacterial resistance 5.