What is the appropriate management for a patient with a possible urinary tract infection (UTI) indicated by urinalysis results showing a few bacteria and elevated squamous epithelial cells?

Management of Urinalysis with Few Bacteria and Elevated Squamous Epithelial Cells

This urinalysis result does not indicate a urinary tract infection requiring antibiotic treatment, as it shows contamination from skin/vaginal cells rather than true infection.

Interpretation of the Current Urinalysis

The urinalysis shows:

• Normal color, appearance, specific gravity, pH
• Negative for glucose, bilirubin, ketones, blood, protein, nitrite, and leukocyte esterase
• No WBCs or RBCs seen
• 10-20 squamous epithelial cells (elevated, normal is ≤5/HPF)
• Few bacteria

Key Diagnostic Considerations

1. Evidence of contamination:

   • High squamous epithelial cell count (10-20/HPF) indicates contamination from skin or vaginal epithelium 1
   • Presence of bacteria with negative leukocyte esterase and absence of pyuria strongly suggests contamination rather than infection 2

2. Absence of infection markers:

   • No leukocyte esterase (sensitivity 83%, specificity 78% for UTI) 2
   • No nitrites (specificity 98% for UTI) 2
   • No pyuria (no WBCs seen) 1

Diagnostic Algorithm

According to the American Academy of Pediatrics and other guidelines, UTI diagnosis requires:

1. Proper specimen collection (clean-catch or catheterization) 2, 1
2. Evidence of inflammation (pyuria and/or positive leukocyte esterase) 2
3. Significant bacteriuria (≥50,000 CFU/mL of a uropathogen) 2

This specimen fails to meet criteria #2 and likely #3, and the high squamous epithelial cell count suggests improper collection.

Recommended Management

1. Do not treat with antibiotics based on this urinalysis 2, 1

   • Treating asymptomatic bacteriuria or contaminated specimens leads to unnecessary antibiotic use and resistance 1

2. If patient has urinary symptoms:

   • Obtain a properly collected specimen (clean-catch midstream after proper cleansing or catheterization) 1
   • For women, consider catheterization to avoid vaginal contamination 1

3. If repeat testing is needed:

   • Process specimen within 1 hour at room temperature or 4 hours if refrigerated 2
   • Consider both urinalysis and urine culture 2, 1

Common Pitfalls to Avoid

1. Misinterpreting contamination as infection:

   • Studies show that abnormal urinalysis results are common in disease-free women regardless of collection technique 3
   • Only nitrite shows high specificity for UTI 3

2. Treating based on bacteria alone:

   • Bacteriuria without pyuria typically represents contamination or asymptomatic bacteriuria 2
   • The American Academy of Pediatrics emphasizes that both bacteriuria AND pyuria are required for UTI diagnosis 2

3. Ignoring specimen quality:

   • High squamous epithelial cell count (>5/HPF) indicates contamination 1
   • Proper collection technique significantly reduces false positives 1

If the patient is symptomatic and UTI remains a concern despite this negative urinalysis, obtain a properly collected specimen for repeat testing before considering antibiotic therapy 1, 4.