Do you treat a male patient with a urinary analysis showing 50-100 thousand Staphylococcus epidermidis and leukocytosis?

Management of Staphylococcus epidermidis in Urine with Leukocytosis

A urinalysis showing 50-100 thousand Staphylococcus epidermidis with a white blood cell count of 14.1 in a male patient should not be treated with antibiotics unless the patient has specific urinary symptoms or risk factors.

Diagnostic Interpretation

• Staphylococcus epidermidis in urine cultures is typically considered a contaminant in previously healthy individuals without urinary tract abnormalities or instrumentation 1
• A WBC count of 14.1 (leukocytosis) has a likelihood ratio of 3.7 for bacterial infection, which is significant but not definitive without accompanying symptoms 2
• The presence of leukocytes alone is not highly predictive of true urinary tract infection and requires clinical correlation with specific urinary symptoms 3
• Asymptomatic bacteriuria is common (15-50% in non-catheterized individuals) and does not require treatment 2

Decision Algorithm for Treatment

Do NOT treat if:

• Patient is asymptomatic (no dysuria, frequency, urgency) 2, 3
• No fever or other systemic symptoms are present 3
• No history of urological abnormalities or recent instrumentation 1
• No immunocompromise or other risk factors 4

Consider treatment if:

• Patient has specific urinary symptoms (dysuria, frequency, urgency) 3
• Fever or other systemic symptoms are present 2
• Patient has underlying urological abnormalities or history of instrumentation 1, 5
• Patient is immunocompromised 4

Evaluation Approach

• Determine if the patient has specific urinary symptoms (dysuria, frequency, urgency, suprapubic pain) 3
• Assess for fever and systemic symptoms that might indicate upper tract involvement 2
• Consider whether contamination is likely (improper collection technique) 3
• Evaluate for risk factors that might make S. epidermidis a true pathogen:
  • History of urological abnormalities 1
  • Recent urinary tract instrumentation 1
  • Immunocompromised status 4

Treatment Considerations

• If treatment is indicated based on symptoms and risk factors, ciprofloxacin can be used if local resistance is <10% 2
• However, ciprofloxacin should not be used if the patient has used fluoroquinolones in the last 6 months 2
• S. epidermidis is included in the FDA-approved indications for ciprofloxacin in urinary tract infections 6
• For complicated UTIs, consider combination therapy with amoxicillin plus an aminoglycoside or a cephalosporin plus an aminoglycoside 2

Important Caveats

• S. epidermidis has increasingly been recognized as a potential pathogen in certain populations, not just a contaminant 7
• Methicillin resistance is common among S. epidermidis isolates (up to 40%), which may affect treatment choices 4
• Treating asymptomatic bacteriuria leads to unnecessary antibiotic use and contributes to antimicrobial resistance 8
• Non-specific symptoms like confusion or functional decline alone should not trigger UTI treatment without specific urinary symptoms 3

Follow-up Recommendations

• If the patient is asymptomatic, no follow-up urinalysis is necessary 8
• If treatment is initiated, consider follow-up culture to ensure eradication if symptoms persist 3
• Consider urological evaluation if S. epidermidis UTI is confirmed in a previously healthy individual, as this may indicate an underlying abnormality 1