How to manage asymptomatic leukocytes in urine?

Management of Asymptomatic Leukocytes in Urine

For a 49-year-old woman with asymptomatic leukocyturia (125 leukocytes on UA), no screening or treatment is recommended as this likely represents asymptomatic bacteriuria which should not be treated in women without risk factors.

Understanding Asymptomatic Bacteriuria (ASB)

Asymptomatic bacteriuria is defined as the presence of significant bacteria in the urine without urinary symptoms. According to the European Association of Urology (EAU) 2024 guidelines and the Infectious Diseases Society of America (IDSA) 2019 guidelines:

• ASB is common and represents commensal colonization rather than infection 1
• Leukocyturia without symptoms may indicate ASB
• ASB should only be treated in specific circumstances 2

Diagnostic Considerations

When evaluating leukocyturia:

• True urinary tract infection requires:
  • Urinary symptoms (dysuria, frequency, urgency)
  • Evidence of pyuria
  • Significant bacteriuria 2
• Asymptomatic leukocyturia alone does not warrant treatment
• Pyuria is defined as ≥10 WBCs/high-power field or a positive leukocyte esterase test 1

Management Algorithm

1. Assess for symptoms

   • If no symptoms (as in this case): Do not treat
   • If symptoms present: Consider UTI diagnosis and treatment

2. Evaluate risk factors requiring treatment despite being asymptomatic

   • Pregnancy
   • Planned urological procedures breaching the mucosa
   • Neither applies in this case

3. For asymptomatic patients without special circumstances

   • Do not perform additional urine cultures 1
   • Do not initiate antimicrobial therapy 1
   • Monitor for development of symptoms

Rationale for Non-Treatment

The EAU 2024 guidelines strongly recommend against treating ASB in women without risk factors 1. The IDSA 2019 guidelines similarly recommend against screening for or treating ASB in women without risk factors 1. Treatment of ASB has several potential harms:

• Increased antimicrobial resistance
• Elimination of potentially protective bacterial strains
• Risk of C. difficile infection
• Adverse drug effects 2

Special Considerations

• If the patient develops symptoms (dysuria, frequency, urgency), reassess for UTI
• If the patient is pregnant, screening and treatment would be recommended 1
• If the patient is scheduled for urological procedures breaching the mucosa, screening and treatment would be recommended 1

Common Pitfalls to Avoid

1. Overtreatment: Studies show that ASB is frequently overtreated despite guidelines. One study found that 38% of hospitalized patients with ASB received antibiotics unnecessarily 3.

2. Misinterpreting urinalysis: The presence of leukocytes alone does not indicate infection requiring treatment. Factors such as elevated urine white cell count, presence of leukocyte esterase, and nitrites are often incorrectly used to justify treatment in asymptomatic patients 3.

3. Assuming all bacteriuria requires treatment: Clinical studies have shown that ASB may actually protect against superinfecting symptomatic UTI 1.

4. Attributing non-specific symptoms to UTI: In older patients particularly, changes in mental status or falls are often incorrectly attributed to UTI when bacteriuria is detected 1.

By following these evidence-based guidelines, unnecessary antibiotic use can be avoided while maintaining patient safety and quality of care.