From the Guidelines
An asymptomatic patient with a urinalysis showing positive Leukocyte esterase and negative nitrites does not require antibiotic treatment. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of treating symptoms rather than laboratory findings alone 1. The presence of leukocyte esterase indicates inflammation, which can occur from various non-infectious causes, including contamination during collection, dehydration, exercise, or adjacent inflammation.
Key Considerations
- Asymptomatic bacteriuria or sterile pyuria are common in asymptomatic individuals and typically do not benefit from antibiotics 1.
- Unnecessary antibiotic use contributes to antimicrobial resistance and may cause adverse effects.
- Treatment should be guided by symptoms rather than laboratory findings alone.
- If the patient later develops symptoms such as dysuria, frequency, or urgency, clinical reassessment would be appropriate at that time.
Special Considerations
- Further evaluation with a urine culture may be warranted if the patient has risk factors such as pregnancy, planned urologic procedures, or immunocompromised status 1.
- The classification of complicated UTI should be reserved for those with congenital or acquired structural and/or functional abnormalities of the urinary tract and/or immune suppression or pregnancy.
Recommendations
- Avoid treatment of asymptomatic bacteriuria in women with recurrent UTI, as this has been shown to foster antimicrobial resistance and increase the number of recurrent UTI episodes 1.
- Use nitrofurantoin when possible as a first-line agent for re-treatment since resistance is low and, if present, decays quickly.
From the Research
Asymptomatic Patient with Positive Leukocyte Esterase and Negative Nitrites
- The presence of positive Leukocyte esterase and negative nitrites in an asymptomatic patient's urinalysis may indicate a urinary tract infection (UTI) 2.
- However, the sensitivity and specificity of the leukocyte esterase test alone are 77% and 96%, respectively, which may not be sufficient to detect asymptomatic bacteriuria 2.
- The combination of nitrite and leukocyte esterase tests may provide an acceptable cost-effective alternative to screening all asymptomatic patients with urine cultures, with a sensitivity and specificity of 92% and 95%, respectively 2.
Treatment Considerations
- There is no clear evidence to suggest that asymptomatic patients with positive Leukocyte esterase and negative nitrites require treatment 3, 4, 5.
- The decision to treat should be based on individual patient factors, such as the presence of symptoms, underlying medical conditions, and the risk of developing complications 3.
- 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, 6.
Antibiotic Choice
- The choice of antibiotic should be based on local resistance patterns and patient-specific factors, rather than urinalysis results alone 4, 5.
- Nitrofurantoin or cephalexin may be suitable options for the treatment of cystitis, with nitrofurantoin being preferable in the presence of negative leukoesterase 5.