From the Guidelines
The presence of bacteria 2+ on a urinary analysis (UA) should prompt immediate treatment in symptomatic patients, while asymptomatic patients should generally wait for urine culture (UC) results before initiating antibiotic therapy. This approach is supported by the European Association of Urology guidelines, which emphasize the importance of distinguishing between symptomatic and asymptomatic bacteriuria 1. For symptomatic patients, empiric antibiotic therapy can be initiated with first-line options such as nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin. In contrast, asymptomatic patients with bacteria 2+ on UA should not be treated immediately, as asymptomatic bacteriuria often does not require antibiotics except in specific cases, such as pregnant women or before urologic procedures 1.
Key considerations in deciding whether to treat a UA showing bacteria 2+ include:
- Patient symptoms, such as dysuria, frequency, urgency, and suprapubic pain
- Presence of other UA findings, such as positive leukocyte esterase, nitrites, and pyuria (>5-10 WBCs/hpf)
- Patient population, including pregnant women and those with underlying urological abnormalities or comorbidities
- Risk of antimicrobial resistance and adverse effects associated with unnecessary antibiotic use
According to the European Association of Urology guidelines, asymptomatic bacteriuria is common and corresponds to commensal colonization, and treatment should only be considered in cases of proven benefit for the patient 1. The guidelines also recommend that urine culture and antimicrobial susceptibility testing should be performed in all cases of pyelonephritis, and that prompt differentiation between uncomplicated and potentially obstructive pyelonephritis is crucial 1.
In terms of specific treatment options, fluoroquinolones and cephalosporins are recommended for oral empiric treatment of uncomplicated pyelonephritis, while other agents such as nitrofurantoin, oral fosfomycin, and pivmecillinam should be avoided due to insufficient data regarding their efficacy 1.
From the Research
Treatment of Urinary Analysis (UA) with Bacteria 2+
- The decision to treat a UA showing bacteria 2+ immediately or wait for the urine culture (UC) results depends on various factors, including the patient's symptoms, medical history, and the presence of other underlying conditions 2, 3.
- According to the study published in 2020, the recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females is a 5-day course of nitrofurantoin, a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam 2.
- Another study published in 2014 suggests that immediate antimicrobial therapy is recommended rather than delayed treatment or symptom management with ibuprofen alone for acute cystitis in adult women 3.
- A 2023 narrative review on nitrofurantoin suggests that it can be considered as the most effective drug in the treatment of acute urinary infection, but due to the long-term side effects of this drug, especially in elderly patients, it is essential to introduce some criteria for prescribing nitrofurantoin in cases of chronic UTI 4.
Urine Culture (UC) Results
- A 2022 study found that the presence of urinary nitrite is not a reliable predictor of bacterial resistance to antimicrobial therapy in patients with uncomplicated urinary tract infections, and urine bacteriology should be ordered to guide antibiotic therapy 5.
- A 2021 systematic review of randomized control trials found that nitrofurantoin is at least comparable with other uUTI treatments in terms of efficacy, and patients taking nitrofurantoin reported fewer side effects than other drugs 6.
Treatment Approach
- Based on the available evidence, it is recommended to start empiric antibiotic therapy immediately for patients with symptoms of acute cystitis, rather than waiting for the UC results 2, 3.
- The choice of antibiotic should be guided by the patient's medical history, the presence of other underlying conditions, and the local susceptibility patterns of uropathogens 2.
- Nitrofurantoin can be considered as a first-line treatment option for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females, due to its efficacy and relatively low rate of side effects 2, 4, 6.