What is the appropriate treatment for a patient with a urinary tract infection characterized by the presence of leukocytes in the urine?

From the Guidelines

The patient with a urinary tract infection characterized by the presence of leukocytes in the urine should be treated with first-line therapy, such as nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or fosfomycin, dependent on the local antibiogram, as recommended by the AUA/CUA/SUFU guideline 1. The choice of antibiotic should be based on the local antibiogram and the patient's allergy history, side effects, and cost considerations.

• First-line therapy usually consists of:
  • Nitrofurantoin (Macrobid) 100 mg twice daily for 5 days
  • Trimethoprim-sulfamethoxazole (Bactrim) 160/800 mg twice daily for 3 days
  • Fosfomycin 3 g single dose
• Patients should also increase fluid intake to help flush bacteria from the urinary tract and may take phenazopyridine (Pyridium) 100-200 mg three times daily for 1-2 days to relieve painful urination symptoms. The presence of leukocytes (white blood cells) in urine, known as pyuria, indicates an inflammatory response to infection. Antibiotics work by either killing the bacteria (bactericidal) or preventing their growth (bacteriostatic), allowing the body's immune system to clear the infection. Patients should complete the full course of antibiotics even if symptoms improve before finishing treatment to prevent recurrence and antibiotic resistance, as recommended by the AUA/CUA/SUFU guideline 1. It is also important to note that the treatment duration should be as short as reasonable, generally no longer than seven days, as recommended by the AUA/CUA/SUFU guideline 1. In addition, the IDSA guidelines introduced the concepts of resistance prevalence and collateral damage as key considerations in choosing UTI treatments, which is also supported by the AUA/CUA/SUFU guideline 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of sulfamethoxazole and trimethoprim tablets and other antibacterial drugs, sulfamethoxazole and trimethoprim tablets 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

The presence of leukocytes in the urine suggests a urinary tract infection. Given the information provided, trimethoprim-sulfamethoxazole can be considered for treatment, as it is indicated for urinary tract infections due to susceptible strains of certain organisms, such as Escherichia coli and Klebsiella species. However, the choice of treatment should be based on culture and susceptibility information when available, or local epidemiology and susceptibility patterns. The patient's urine analysis showing leukocytes 500 and nitrates negative supports the diagnosis of a urinary tract infection, but further testing may be necessary to confirm the causative organism and guide treatment. 2

From the Research

Urinary Tract Infection Treatment

The presence of leukocytes in the urine indicates a urinary tract infection (UTI). The appropriate treatment for a patient with a UTI characterized by the presence of leukocytes in the urine is as follows:

• First-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females includes:
  • A 5-day course of nitrofurantoin 3, 4, 5
  • A 3-g single dose of fosfomycin tromethamine 3, 6, 4, 5
  • A 5-day course of pivmecillinam 3, 5
• Second-line options include:
  • Oral cephalosporins such as cephalexin or cefixime 3
  • Fluoroquinolones and β-lactams, such as amoxicillin-clavulanate 3, 6, 4
• It is essential to consider local susceptibility patterns and the patient's clinical data when selecting an antibiotic therapy 3, 6, 4, 5
• The treatment duration is typically 3-5 days for uncomplicated UTIs 5
• In cases of antibiotic resistance, alternative treatment options may be necessary, such as parenteral treatment with piperacillin-tazobactam, carbapenems, or aminoglycosides 3

Considerations

• The increasing prevalence of antibiotic resistance among community uropathogens complicates the treatment of UTIs 3, 6, 4, 5
• The risk of an uncomplicated UTI leading to pyelonephritis is low (1-2%) 5
• Understanding the usual benign course of uncomplicated UTIs can help reduce antibiotic treatment in many cases 5