Should a patient with Urinary Tract Infection (UTI) symptoms be treated with minimal leukocyte esterase on urinalysis?

From the Guidelines

Patients with symptoms of UTI, regardless of minimal leukocyte esterase on urinalysis, should be treated with antibiotics if they exhibit significant symptoms such as dysuria, frequency, urgency, or suprapubic pain, as recommended by the most recent guidelines 1. When evaluating a patient with UTI symptoms, it is crucial to consider the severity of symptoms and clinical judgment, rather than relying solely on urinalysis results. The presence of minimal leukocyte esterase does not rule out a UTI, as urinalysis has limitations in sensitivity, and clinical symptoms may precede significant pyuria. Some key symptoms that warrant antibiotic treatment, as outlined in the guidelines 1, include:

• Urine changes such as change in color, odor, or cloudy appearance
• Urogenital symptoms like nocturia, decreased urinary output, dysuria, suprapubic pain, or urinary retention
• Mental status changes, such as agitation or aggression
• Gastrointestinal symptoms like decreased fluid intake, nausea, or vomiting
• Other symptoms, including malaise, fatigue, weakness, dizziness, or decreased functional status Empiric antibiotic therapy may be warranted while awaiting urine culture results, with first-line options including nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin 1. It is essential to note that unnecessary antibiotic use contributes to resistance, so clinical judgment balancing symptom severity against the risk of overtreatment is crucial. Follow-up should be arranged if symptoms worsen or persist beyond 48-72 hours of treatment. In complicated UTIs, such as those with obstruction, pregnancy, or immunosuppression, appropriate management of the underlying condition and optimal antimicrobial therapy are necessary, as outlined in the European Association of Urology guidelines 1.

From the Research

Treatment of UTI with Minimal Leukocyte Esterase on Urinalysis

• The decision to treat a patient with Urinary Tract Infection (UTI) symptoms and minimal leukocyte esterase on urinalysis should be based on the patient's symptoms, medical history, and the results of diagnostic tests 2, 3.
• A positive nitrite test or a negative nitrite test with a positive leukocyte esterase (LE) test can confirm UTI, whereas a negative nitrite test with a negative LE test does not rule out infection 2.
• The presence of leukocyte esterase on urinalysis indicates the presence of white blood cells in the urine, which can be a sign of infection, but it is not a definitive diagnostic test 3.
• The Infectious Disease Society of America (IDSA) recommends that the choice of antibiotic for treating UTI should be based on the severity of the infection, the patient's medical history, and the local antimicrobial resistance patterns 4, 3.
• First-line treatments for UTI include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole (when resistance levels are <20%) 5, 3.
• In cases where the probability of UTI is moderate or unclear, urine culture should be performed to guide antibiotic treatment 3.

Antibiotic Resistance and Treatment Options

• Antibiotic resistance is a growing concern in the treatment of UTIs, and the choice of antibiotic should be guided by local resistance patterns 5, 4.
• Nitrofurantoin is a commonly recommended antibiotic for treating UTI, and it has been shown to have a favorable resistance profile 5, 4, 3.
• Other antibiotics, such as fluoroquinolones and trimethoprim-sulfamethoxazole, may have higher resistance rates and should be used judiciously 5, 4, 3.
• The use of antibiotics should be tailored to the individual patient's needs and the local antimicrobial resistance patterns to minimize the risk of resistance development 5, 4, 3.