What is the treatment for leukocytes in stool?

Treatment for Leukocytes in Stool

The presence of leukocytes in stool alone is not a condition requiring specific treatment, but rather a diagnostic finding that should prompt further evaluation to identify and treat the underlying cause.

Diagnostic Significance of Fecal Leukocytes

Fecal leukocytes are white blood cells found in stool samples that indicate intestinal inflammation. According to the Infectious Diseases Society of America (IDSA) guidelines:

• Fecal leukocyte examination should not be used to establish the cause of acute infectious diarrhea (strong, moderate recommendation) 1
• Fecal leukocytes have limited diagnostic utility with sensitivity of only 28% for C. difficile and 36% for invasive bacterial pathogens 2, 1
• More specific markers like fecal lactoferrin and calprotectin have largely replaced direct leukocyte examination in clinical practice 3

Diagnostic Algorithm

1. Initial Evaluation:

   • Obtain stool culture and C. difficile testing to exclude infectious etiologies 3
   • Consider testing for fecal inflammatory markers (lactoferrin or calprotectin) which have higher sensitivity (83% for lactoferrin) 3, 4

2. Identify Potential Causes:

   • Infectious: bacterial pathogens (Salmonella, Shigella, Campylobacter, C. difficile)
   • Inflammatory: inflammatory bowel disease (IBD)
   • Medication-induced: immune checkpoint inhibitors, NSAIDs
   • Other: ischemic colitis, radiation colitis

3. Further Testing Based on Clinical Presentation:

   • For persistent symptoms (>14 days): Consider IBD and IBS as underlying etiologies 1
   • For acute diarrhea with fever or bloody stools: Obtain stool cultures 1
   • For healthcare-associated diarrhea: Test for C. difficile 1
   • For moderate-to-severe symptoms: Consider endoscopy with biopsy 3

Treatment Approach

Treatment should target the underlying cause rather than the presence of leukocytes themselves:

For Infectious Causes:

• Bacterial Gastroenteritis:
  • Most cases are self-limiting and require only supportive care
  • Antimicrobial therapy only for specific pathogens or severe disease
  • For C. difficile: discontinue offending antibiotics and treat with appropriate antimicrobials 1

For Inflammatory Bowel Disease:

• Initiate appropriate anti-inflammatory treatment based on disease type and severity 3
• Monitor fecal inflammatory markers every 3-6 months to assess treatment response 3

For Medication-Induced Colitis:

• For immune checkpoint inhibitor-induced colitis: systemic immunosuppression after ruling out infectious etiology 1
• For NSAID-induced inflammation: discontinue NSAIDs 1

Supportive Care:

• Fluid and electrolyte replacement for all patients with significant diarrhea 1
• Oral rehydration therapy is first-line for mild-moderate dehydration 1
• Intravenous fluids for severe dehydration or inability to tolerate oral intake 1

Monitoring and Follow-up

• Follow-up testing is not recommended in most people following resolution of symptoms (strong, moderate recommendation) 1
• For persistent symptoms, clinical and laboratory reevaluation may be indicated 1
• Rising inflammatory marker levels may predict clinical flares in patients with established IBD 3

Important Caveats

• The combination of fecal leukocytes and fecal blood has better predictive value (sensitivity 81%, specificity 74%) for bacterial pathogens than either test alone 5
• Leukocytosis (elevated white blood cells in blood) can be a harbinger of C. difficile infection, often preceding diarrheal symptoms 6
• Fecal leukocytes remain stable at 4°C for at least 3 days, allowing for delayed examination if needed 2
• False positives can occur with NSAID use, colorectal cancer, and recent colonoscopy 3

Remember that fecal leukocytes are a non-specific finding that requires identification and treatment of the underlying cause rather than direct treatment of the leukocytes themselves.