From the Guidelines
No, asymptomatic patients with positive leukocyte esterase on urinalysis generally do not require treatment. This finding alone indicates the presence of white blood cells in the urine, which may suggest inflammation, but without symptoms such as pain, burning with urination, frequency, or fever, it is considered asymptomatic bacteriuria. Current medical guidelines, as outlined in the European Association of Urology guidelines on urological infections: summary of the 2024 guidelines 1, recommend against treating asymptomatic bacteriuria in most patient populations because treatment does not improve outcomes and unnecessarily exposes patients to antibiotics, which can lead to side effects and antimicrobial resistance.
There are specific exceptions where treatment is recommended despite lack of symptoms:
- Pregnant women
- Patients undergoing urologic procedures where mucosal bleeding is anticipated
- Sometimes in renal transplant recipients. In these special populations, a urine culture should be obtained to identify the organism and its antibiotic sensitivities before starting appropriate antibiotic therapy, as suggested by the clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America 1.
The rationale for this approach is that most asymptomatic bacteriuria represents colonization rather than infection, and the body can often clear these organisms without intervention. This is further supported by the KDIGO 2025 clinical practice guideline for the evaluation, management, and treatment of autosomal dominant polycystic kidney disease (ADPKD): executive summary 1, which agrees that the recommendations for the general population also apply to people with ADPKD, and asymptomatic bacteriuria should not be treated.
Key points to consider:
- Asymptomatic bacteriuria is common and often represents colonization rather than infection
- Treatment of asymptomatic bacteriuria does not improve outcomes and can lead to unnecessary antibiotic use and resistance
- Specific populations, such as pregnant women and those undergoing urologic procedures, may require treatment despite lack of symptoms
- Urine culture should be obtained in these special populations to guide antibiotic therapy.
From the Research
Asymptomatic Patient with Positive Leukocyte Esterase
- The presence of leukocyte esterase in a urinalysis indicates the presence of white blood cells, which can be a sign of a urinary tract infection (UTI) 2.
- However, a positive leukocyte esterase test does not always confirm a UTI, as false-positive results can occur 3, 4.
- In asymptomatic patients, the clinical significance of a positive leukocyte esterase test is unclear, and treatment may not always be necessary 2, 5.
- A study found that a negative urinalysis, including a negative leukocyte esterase test, can rule out catheter-associated UTI in trauma patients in the intensive care unit 6.
Considerations for Treatment
- The decision to treat an asymptomatic patient with a positive leukocyte esterase test should be based on individual patient factors, such as medical history and risk of complications 5.
- In children, the presence of leukocyte esterase and nitrite in a urinalysis can indicate a UTI, but further evaluation and culture may be necessary to confirm the diagnosis 5.
- In some cases, a positive leukocyte esterase test may be a false positive, particularly in prepubertal girls with vulvovaginitis or boys with phimosis 4.
Diagnostic Approach
- A comprehensive urinalysis, including physical, chemical, and microscopic examinations, can help diagnose UTIs and other conditions 2.
- The use of dipstick urinalysis, including leukocyte esterase and nitrite tests, can be convenient but may have limitations in terms of sensitivity and specificity 3, 6.
- Further evaluation, including urine culture and microscopy, may be necessary to confirm the diagnosis of a UTI and guide treatment 2, 5.