From the Research
No, a patient with dysuria, normal urinalysis, and a urine culture showing Lactobacillus at 10,000-25,000 CFU/mL does not require antibiotic treatment. Lactobacillus is typically considered a normal vaginal flora and urogenital commensal organism, not a true urinary pathogen. The colony count of 10,000-25,000 CFU/mL is below the traditional threshold for diagnosing a urinary tract infection (which is typically >100,000 CFU/mL for most organisms) 1. The normal urinalysis further supports that this is not a true infection requiring treatment. Instead of antibiotics, the patient should be evaluated for other causes of dysuria such as:
- Vaginitis
- Vulvodynia
- Interstitial cystitis
- Sexually transmitted infections Symptomatic management with increased hydration and urinary analgesics like phenazopyridine (AZO) 100-200 mg three times daily for 2-3 days may help relieve symptoms while investigating the true cause. Unnecessary antibiotic treatment could disrupt the normal microbiome and potentially lead to antibiotic resistance without addressing the actual source of symptoms 2. It's also important to consider the potential harms of overtreatment, as highlighted in a study that suggests most people who are treated for a "UTI" would probably be better off without treatment 2. A study on the diagnostic accuracy of symptoms and signs in women presenting with suspected UTI found that individual symptoms and signs have a modest ability to raise the pretest-risk of UTI, but diagnostic accuracy improves considerably when combined with dipstick tests particularly tests for nitrites 3. However, in this case, the presence of Lactobacillus at a low colony count and normal urinalysis suggests that antibiotic treatment is not necessary. The most recent and highest quality study on the topic of urinary tract infections, published in 2018, supports the idea that asymptomatic bacteriuria should not be treated with antibiotics, and that treatment should be based on symptoms and risk factors 1. Therefore, antibiotic treatment is not recommended for this patient.