What does it mean to have a significantly elevated white blood cell (WBC) count, numerous bacteria, and elevated leukocytes?

Chronic Urinalysis Findings: Too Numerous to Count WBCs, Many Bacteria, and >500 Leukocytes

These chronic urinalysis findings indicate persistent pyuria and bacteriuria, but in the absence of acute urinary symptoms (dysuria, fever, urgency, frequency, flank pain, new incontinence), this most likely represents asymptomatic bacteriuria that should NOT be treated with antibiotics. 1

What These Laboratory Findings Mean

Your urinalysis shows three abnormal findings that need interpretation in clinical context:

• Too numerous to count (TNTC) white blood cells = severe pyuria, defined as ≥10 WBCs per high-power field, indicating inflammatory response in the urinary tract 1
• Many bacteria = bacteriuria, indicating bacterial colonization or infection of the urinary tract 1
• >500 leukocytes (likely referring to leukocyte esterase on dipstick) = confirms significant WBC presence in urine 1

Critical Clinical Distinction: Colonization vs. Infection

The key question is whether you have symptoms. The presence of bacteria and WBCs in urine alone does NOT equal a urinary tract infection requiring treatment. 1

If You Have NO Urinary Symptoms:

• Do not pursue treatment - asymptomatic bacteriuria affects 15-50% of certain populations (elderly, long-term care residents, those with chronic catheters) and treating it does NOT improve outcomes 1
• Urinalysis and urine cultures should not be performed for asymptomatic individuals - this is a strong recommendation from the Infectious Diseases Society of America 1
• The prevalence of asymptomatic bacteriuria is essentially 100% in individuals with long-term urinary catheters 1

If You HAVE Acute Urinary Symptoms:

Diagnostic evaluation is warranted only if you have acute onset of: 1

• Fever (>100.3°F or 38°C)
• Dysuria (painful urination)
• Gross hematuria (visible blood in urine)
• New or worsening urinary incontinence
• Flank pain (suggesting kidney involvement)
• Suspected bacteremia/sepsis (high fever, shaking chills, hypotension, confusion)

When to Pursue Further Evaluation

Obtain urine culture with antimicrobial susceptibility testing ONLY if: 1

• Pyuria (≥10 WBCs/high-power field) is present on microscopy AND
• You have acute urinary symptoms listed above AND
• Leukocyte esterase or nitrite test is positive on dipstick

Consider blood cultures if signs of systemic infection are present: 2

• Temperature >38°C or <36°C
• Hypotension (systolic BP <90 mmHg)
• Tachycardia, tachypnea, altered mental status
• Suspected urosepsis (high fever, shaking chills, hypotension)

Special Circumstances Requiring Immediate Action

If you have a chronic indwelling urinary catheter and develop suspected urosepsis: 1

• The catheter should be changed prior to specimen collection
• Urine and paired blood cultures should be obtained
• Empiric broad-spectrum antibiotics should be initiated within 1 hour 2

Common Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria with antibiotics - this leads to unnecessary antibiotic exposure, resistance development, and adverse drug effects without clinical benefit 1
• Do not order urine cultures "just to check" without symptoms - the test has poor positive predictive value in asymptomatic individuals and will frequently show bacteria that should not be treated 1
• Do not assume all bacteria in urine require antibiotics - the urinary tract, especially with catheters, is commonly colonized with bacteria that cause no harm 1

What Your Clinician Should Assess

Your healthcare provider should focus on: 1

• Symptom assessment: Specifically asking about dysuria, fever, urgency, frequency, flank pain, new incontinence
• Functional status: Any recent decline in ability to perform daily activities
• Catheter status: If you have a catheter, when was it last changed, any obstruction
• Systemic signs: Fever patterns, blood pressure, heart rate, mental status changes
• Alternative infection sources: Respiratory symptoms, skin infections, gastrointestinal symptoms that might explain any systemic findings

Bottom Line

Chronic pyuria and bacteriuria without symptoms is colonization, not infection, and requires no treatment. 1 If you develop acute urinary symptoms or signs of systemic infection, then—and only then—should antibiotic therapy be considered after appropriate cultures are obtained. 1, 2