Should a male patient with leukocytosis (leukocytes), pyuria (White Blood Cells (WBC)) and no bacteriuria be treated for a Urinary Tract Infection (UTI)?

From the Guidelines

Treatment for a urinary tract infection (UTI) is likely warranted in this patient, despite the absence of bacteria in the urinalysis, due to the presence of 75 leukocytes and 12 WBCs, which suggests inflammation in the urinary tract. The recent study by 1 published in 2024 in the European Urology journal, provides guidance on urinary infection management, emphasizing the importance of considering symptoms and urinalysis results together. According to this study, the presence of symptoms such as dysuria, suprapubic pain, or changes in urine color or odor, regardless of urinalysis results, should prompt consideration of antibiotic treatment.

In this case, although the patient's specific symptoms are not mentioned, the presence of leukocytes and WBCs in the urine is a strong indicator of inflammation, which is typically treated with antibiotics to prevent progression of infection. I recommend empiric antibiotic therapy with nitrofurantoin (Macrobid) 100mg twice daily for 5 days, or trimethoprim-sulfamethoxazole (Bactrim DS) one tablet twice daily for 3 days if the patient has no allergies or contraindications. It is essential to note that the absence of bacteria in the urinalysis could be due to various factors, including prior antibiotic use, dilute urine, or certain fastidious organisms that don't grow well in standard culture conditions, as mentioned in the study by 1 published in 2005 in the Clinical Infectious Diseases journal.

Key considerations in managing this patient include:

• Ensuring the patient increases fluid intake to help flush out the infection
• Completing the full course of antibiotics as prescribed
• Monitoring for improvement or worsening of symptoms within 48-72 hours
• Reevaluating and adjusting the antibiotic regimen as needed based on culture results or clinical response, as suggested by the study by 1.

From the Research

Urinalysis Results and UTI Diagnosis

• The patient's urinalysis shows 75 leuckocytes and 12 WBC, but no urine bacteria.
• According to the study 2, pyuria (presence of white blood cells in the urine) is commonly found in the absence of infection, particularly in older adults with lower urinary tract symptoms.
• The study 2 also states that bacteriuria (presence of bacteria in the urine) is more specific and sensitive than pyuria for detecting urinary tract infection.

Treatment Considerations

• The absence of urine bacteria in the patient's urinalysis results suggests that a UTI may not be present.
• However, the study 2 notes that in patients with a high probability of urinary tract infection based on symptoms, negative dipstick urinalysis does not rule out urinary tract infection.
• The study 2 recommends that urine culture should be performed in cases where the probability of urinary tract infection is moderate or unclear.
• If the patient is symptomatic, treatment may still be considered, but it should take into account the risk of urinary tract infection based on symptoms, and first-line treatments such as nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole may be appropriate 2.