No Antibiotic Treatment Recommended for Asymptomatic Leukocyturia and Hematuria
Do not prescribe antibiotics for patients with leukocytes and blood on urinalysis who lack UTI symptoms. This represents asymptomatic bacteriuria (ASB), which should not be treated in most patient populations 1.
Core Principle: Symptoms Are Required for UTI Diagnosis
- UTI diagnosis requires both laboratory findings AND acute-onset urinary symptoms (dysuria, urgency, frequency, suprapubic pain) 1
- Urinalysis and urine cultures should not be performed for asymptomatic patients in the first place 1
- The presence of pyuria (leukocytes) has relatively low predictive value for actual infection and is commonly found without infection, particularly in older adults 1, 2
- Asymptomatic bacteriuria persists for 1-2 years in long-term care residents without evidence of increased morbidity or mortality 1
Why No Treatment Is Appropriate
Antibiotic stewardship and patient safety take priority:
- Treating ASB increases antimicrobial resistance without clinical benefit 1
- Unnecessary antibiotics expose patients to adverse effects including Clostridioides difficile infection 1
- Studies demonstrate that untreated ASB does not increase mortality or morbidity in most populations 1
Clinical Algorithm for Decision-Making
Step 1: Assess for acute-onset UTI symptoms 1
- Dysuria (most specific symptom, >90% accuracy when present) 1
- New or worsening urgency/frequency
- Suprapubic pain
- Gross hematuria with symptoms
- New or worsening incontinence
Step 2: If NO symptoms are present 1
- Do not treat with antibiotics
- Do not order urine culture
- Reassure the patient
- Consider alternative causes for the abnormal urinalysis (contamination, chronic conditions)
Step 3: If systemic signs suggest urosepsis 1
- High fever (>38°C)
- Shaking chills
- Hypotension
- Altered mental status
- Then obtain urine AND blood cultures and treat empirically 1
Special Populations Where ASB Should NOT Be Treated
The following groups should not receive antibiotics for asymptomatic bacteriuria 1:
- Diabetic patients (strong recommendation, moderate-quality evidence) 1
- Older adults with functional/cognitive impairment presenting with delirium or falls without fever or genitourinary symptoms 1
- Patients with indwelling catheters <30 days (bacteriuria and pyuria are virtually universal in catheterized patients and rarely symptomatic) 1, 3
- Spinal cord injury patients 1
- Solid organ transplant recipients >1 month post-transplant 1
Common Pitfalls to Avoid
- Do not reflexively treat positive urinalysis findings without symptoms 1
- Do not assume confusion or delirium in elderly patients is due to UTI - assess for other causes first 1
- Do not use "cloudy urine" or "foul-smelling urine" as indications for treatment - these are not reliable indicators of infection 1
- Recognize that leukocyturia without bacteriuria requires further diagnostic evaluation for non-infectious causes (interstitial nephritis, stones, malignancy), not empiric antibiotics 4
When Urinalysis Results Can Exclude UTI
- Negative leukocyte esterase AND negative nitrite effectively exclude bacteriuria and UTI 1
- Absence of pyuria has excellent negative predictive value for UTI 5, 2
- In diabetic women, leukocyte count <5 cells/hpf predicted absence of UTI in 96% of cases 6
Bottom Line
The finding of leukocytes and blood on urinalysis without symptoms represents asymptomatic bacteriuria or non-infectious causes. Withhold antibiotics, avoid unnecessary urine cultures, and only treat if acute UTI symptoms develop 1. This approach prevents antimicrobial resistance, reduces adverse drug events, and aligns with high-quality evidence showing no benefit from treating asymptomatic findings.