What is the initial treatment for a patient with leukocytes in their urine, indicating a urinary tract infection (UTI)?

Initial Treatment for Leukocytes in Urinalysis

The initial treatment for a patient with leukocytes in their urinalysis suggesting a urinary tract infection (UTI) is antimicrobial therapy with agents effective against common uropathogens according to local sensitivity patterns, which can be administered either orally or parenterally depending on the patient's clinical status. 1

Diagnostic Confirmation Before Treatment

• A positive urinalysis showing leukocytes suggests a UTI, but confirmation with urine culture is necessary before initiating antimicrobial therapy unless the patient appears clinically ill 1
• Obtain a urine specimen by catheterization or suprapubic aspiration for culture if the urinalysis is positive for leukocyte esterase, nitrites, or microscopy shows white blood cells or bacteria 1
• A satisfactory culture is essential to document a true UTI and guide antimicrobial management 1

Treatment Selection Algorithm

For Uncomplicated UTI in Adults:

1. First-line oral options:

   • Nitrofurantoin 5-day course
   • Fosfomycin tromethamine 3g single dose 2

2. Second-line options:

   • Trimethoprim-sulfamethoxazole (if local resistance <20%) 3
   • Oral cephalosporins (cephalexin, cefixime)
   • Amoxicillin-clavulanate 2

3. For complicated UTI in adults:

   • Use a combination of:
     • Amoxicillin plus an aminoglycoside, OR
     • Second-generation cephalosporin plus an aminoglycoside, OR
     • Intravenous third-generation cephalosporin 1

For UTI in Children:

1. Empiric antimicrobial options:

   • Oral options: Amoxicillin-clavulanate, cephalosporins, or trimethoprim-sulfamethoxazole 1
   • Parenteral options: Ceftriaxone (50 mg/kg/day), cefotaxime, gentamicin 1

2. Treatment duration:

   • 7-14 days of therapy is recommended for children 1
   • For adults with complicated UTI: 7-14 days (14 days for men when prostatitis cannot be excluded) 1

Route of Administration

• Both oral and parenteral routes are equally efficacious for initial treatment 1, 4
• Base the choice on practical considerations:
  • Use parenteral route if the patient appears toxic or is unable to retain oral medications 1
  • Otherwise, oral therapy is appropriate and convenient 4

Special Considerations

• For complicated UTIs: Consider underlying factors such as obstruction, foreign bodies, incomplete voiding, or immunosuppression that may affect treatment response 1
• For catheter-associated UTIs: Remove or change the catheter if possible and treat with appropriate antimicrobials 1
• For fluoroquinolones: Only use ciprofloxacin if local resistance is <10% and:
  • The entire treatment can be given orally
  • The patient doesn't require hospitalization
  • The patient has anaphylaxis to β-lactam antimicrobials 1, 5

Monitoring Response

• Follow-up is important to ensure resolution of infection
• A slower or no decrease in leukocyte and bacteria counts during treatment may indicate unsuccessful therapy 6
• Antimicrobial sensitivities of isolated bacteria should be used to adjust antimicrobial choice once culture results are available 1

Common Pitfalls to Avoid

• Don't treat asymptomatic bacteriuria (except in pregnancy), as it may do more harm than good 1
• Don't use fluoroquinolones empirically if local resistance rates are high or if the patient has used them in the last 6 months 1
• Don't miss underlying anatomical abnormalities that may require further evaluation, especially in recurrent UTIs 1
• Don't forget to obtain cultures before starting antibiotics to ensure proper diagnosis and guide therapy 1

Remember that the presence of pyuria (leukocytes in urine) is what distinguishes true UTI from asymptomatic bacteriuria, making it an important diagnostic criterion 1.