What is the treatment for a urine culture positive for Lactobacillus?

Treatment of Lactobacillus in Urine Culture

Lactobacillus species in urine cultures are typically considered contaminants or colonizers rather than true pathogens and generally do not require antimicrobial treatment unless the patient is symptomatic. 1

Diagnostic Considerations

• Lactobacillus in urine cultures should be interpreted in the context of clinical symptoms, as asymptomatic bacteriuria (ASB) should not be treated 2, 1
• Distinguish between true infection and contamination/colonization by assessing:
  • Presence of urinary symptoms (dysuria, frequency, urgency) 1
  • Urine quality (clean-catch vs. potentially contaminated specimen) 2
  • Quantitative bacterial count (higher counts may be more significant) 3
• Pyuria alone is not an indication for treatment of asymptomatic bacteriuria 2

Treatment Algorithm

For Asymptomatic Patients:

• Do not treat asymptomatic bacteriuria with Lactobacillus as this promotes antimicrobial resistance and increases risk of recurrent UTIs 2, 1
• Screening for and treatment of asymptomatic bacteriuria is specifically not recommended for:
  • Premenopausal, non-pregnant women 2
  • Diabetic women 2
  • Older persons living in the community 2
  • Institutionalized elderly 2
  • Persons with spinal cord injury 2
  • Catheterized patients while catheter remains in place 2

For Symptomatic Patients:

• For true symptomatic Lactobacillus UTI (rare):
  • First-line: Nitrofurantoin for 5-7 days 1
  • Alternative: Trimethoprim-sulfamethoxazole 40/200 mg twice daily for 5-7 days 1
  • Extend treatment to 10-14 days for patients with delayed symptom resolution 1

Special Populations

• Pregnant women: Screen for and treat bacteriuria at least once in early pregnancy with a 3-7 day course of appropriate antibiotics 2
• Patients undergoing urologic procedures with mucosal trauma: Screen for and treat bacteriuria prior to the procedure 2
  • Short course (1-2 doses) of targeted antimicrobial therapy is suggested 2
  • Initiate therapy 30-60 minutes before the procedure 2

Prevention of Recurrent UTIs

• For women with recurrent UTIs:
  • Consider vaginal estrogen therapy for peri- and post-menopausal women 2
  • Cranberry products may be offered as prophylaxis, though evidence for efficacy is limited 2
  • Lactobacillus probiotics may have potential for prevention of recurrent UTIs, though current evidence is insufficient to make a strong recommendation 2, 4, 5

Common Pitfalls

• Treating asymptomatic Lactobacillus in urine leads to unnecessary antibiotic use, increased resistance, and potentially more recurrent UTIs 2, 3
• Overinterpretation of laboratory data (positive nitrites, pyuria, higher bacterial counts) is associated with overtreatment of asymptomatic bacteriuria 3
• Failing to distinguish between contamination, colonization, and true infection 1
• Not addressing underlying structural or functional abnormalities of the urinary tract that may predispose to recurrent infections 1