What is the appropriate treatment for a patient with microscopic hematuria (>50 Red Blood Cells (RBC)), leukocyturia (10 White Blood Cells (WBC)), and rare bacteria in their urine?

Management of Urine Microscopic with >50 RBC, 10 WBC and Rare Bacteria

The appropriate treatment for a patient with microscopic hematuria (>50 RBC), leukocyturia (10 WBC), and rare bacteria in their urine is to treat the urinary tract infection with an appropriate antibiotic and then repeat urinalysis six weeks after treatment to ensure resolution of the hematuria. 1

Initial Assessment and Diagnosis

• The presence of both red blood cells (>50 RBC/HPF) and white blood cells (10 WBC/HPF) with rare bacteria strongly suggests a urinary tract infection that requires antibiotic treatment 1
• Microscopic hematuria is defined as three or more red blood cells per high-power field on microscopic evaluation of urinary sediment from two of three properly collected urinalysis specimens 1
• The combination of leukocytes, bacteria, and hematuria indicates an infectious process rather than isolated hematuria requiring extensive urologic workup 1, 2
• Leukocyte esterase testing serves as a surrogate marker for pyuria, with high sensitivity (83-94%) but lower specificity (78-91%) for detecting UTIs 3

Treatment Approach

Step 1: Antibiotic Therapy

• Initiate appropriate antibiotic therapy based on local resistance patterns 1, 2
• First-line treatments include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole (when local resistance levels are <20%) 2
• Trimethoprim-sulfamethoxazole is indicated for urinary tract infections due to susceptible strains of E. coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis, and Proteus vulgaris 4
• Consider that resistance is increasing to fluoroquinolones, beta-lactams, and trimethoprim-sulfamethoxazole 2

Step 2: Follow-up Evaluation

• Repeat urinalysis six weeks after completing antibiotic treatment 1
• If hematuria resolves with treatment, no additional evaluation is necessary 1
• If hematuria persists after appropriate antibiotic treatment, proceed with a complete urologic evaluation 1

Complete Urologic Evaluation (if hematuria persists)

• Measure serum creatinine to assess renal function 1, 5
• Examine urinary sediment for dysmorphic red blood cells and red cell casts, which would suggest glomerular origin 5
• Consider upper urinary tract imaging (CT urography is preferred) to detect renal cell carcinoma, transitional cell carcinoma, urolithiasis, and renal infection 1
• Perform cystoscopy to evaluate the lower urinary tract for urethral stricture disease, benign prostatic hyperplasia, and bladder masses 6
• Consider voided urinary cytology in patients with risk factors for transitional cell carcinoma (smoking history, occupational exposure to chemicals/dyes, history of gross hematuria, age >40 years) 1

Risk Assessment for Significant Disease

• Higher risk of urologic malignancy exists in men, persons older than 35 years, and those with a history of smoking 6
• Other risk factors include occupational exposure to chemicals or dyes, history of gross hematuria, history of urologic disorders, irritative voiding symptoms, and history of pelvic irradiation 1
• Patients with these risk factors warrant more thorough evaluation if hematuria persists after treatment 1

Important Caveats

• Asymptomatic bacteriuria (bacteria without symptoms) should not be treated in most adult populations except pregnant women and men under 60 years 7
• A catheterized urinary specimen is indicated if a clean-catch specimen cannot be reliably obtained (e.g., due to vaginal contamination or obesity) 1, 8
• In uncircumcised men, the foreskin should be retracted to expose the glans penis; if phimosis is present, a catheterized specimen may be required 1, 8
• Flow cytometry studies show that successful antibiotic treatment typically results in the deepest decrease in urinary leukocyte and bacterial counts during the first 24 hours of therapy 9