What is the treatment for a urinary analysis (UA) showing bacteria and leukocytes?

Treatment of Urinalysis Showing Bacteria and Leukocytes

The presence of bacteria and leukocytes on urinalysis does NOT automatically warrant antibiotic treatment—treatment depends entirely on whether the patient has urinary symptoms. 1

Critical Decision Point: Symptomatic vs. Asymptomatic

If the Patient is ASYMPTOMATIC:

• Do not treat with antibiotics. 1
• This represents asymptomatic bacteriuria (ASB), which should not be treated in most populations 1
• Exceptions requiring treatment: pregnant women and patients scheduled for invasive urinary tract procedures 1
• Populations that do NOT benefit from treating ASB include women with diabetes mellitus and long-term care facility residents 1
• Do not perform surveillance urine testing in asymptomatic patients 1

If the Patient is SYMPTOMATIC:

Proceed with the following algorithm:

Step 1: Confirm Symptomatic UTI

Required symptoms include: 1

• Lower UTI (cystitis): dysuria, frequency, urgency, suprapubic pain, new or worsening incontinence, gross hematuria 1
• Upper UTI (pyelonephritis): fever, costovertebral angle pain/tenderness, rigors, systemic symptoms 1

Non-specific symptoms that should NOT prompt UTI treatment alone: 1

• Confusion, functional decline, fatigue, falls, change in urine odor, cloudy urine (without other symptoms) 1
• These symptoms in elderly patients are poorly predictive of UTI and often lead to inappropriate antibiotic use 1

Step 2: Obtain Urine Culture Before Treatment

• Obtain urine culture and sensitivity testing prior to initiating antibiotics in all symptomatic patients 1
• Culture should be obtained via clean-catch midstream urine or catheterization (not from collection bags, which have high contamination rates) 1
• Diagnosis requires BOTH: positive urinalysis (pyuria and/or bacteriuria) AND ≥50,000 CFU/mL of a uropathogen on culture 1

Step 3: Initiate Empiric Antibiotic Therapy

First-Line Agents for Uncomplicated UTI (Women):

Use one of the following based on local antibiogram: 1, 2, 3

• Nitrofurantoin (5-day course) 1, 4, 5, 6
• Trimethoprim-sulfamethoxazole (TMP-SMX) (3-day course) 1, 2, 3, 4, 5
• Fosfomycin (single 3-g dose) 1, 4, 5, 6

Important considerations: 1, 4, 5, 6

• These first-line agents are less likely to cause "collateral damage" (antimicrobial resistance) compared to fluoroquinolones and beta-lactams 1, 4
• Fluoroquinolones should be restricted due to increasing resistance rates and should not be used as first-line empiric therapy 4, 6, 7
• TMP-SMX should only be used if local resistance rates are <20% 4, 5

Second-Line Agents:

Use when first-line agents are contraindicated or based on resistance patterns: 1, 4, 6

• Fluoroquinolones (ciprofloxacin, levofloxacin) 4, 6
• Beta-lactams (amoxicillin-clavulanate, cephalexin, cefixime) 4, 6

Step 4: Treatment Duration

• Treat for as short a duration as reasonable, generally no longer than 7 days for acute cystitis 1
• Typical durations: 3-5 days for uncomplicated cystitis, 7-14 days for pyelonephritis 1, 4, 8
• Single-dose antibiotics are associated with increased risk of bacteriological persistence and should be avoided (except fosfomycin) 1

Step 5: Adjust Based on Culture Results

• Tailor antibiotic therapy based on culture sensitivities once available 1
• If cultures show resistance to oral antibiotics, consider culture-directed parenteral antibiotics for no longer than 7 days 1
• Lack of correlation between microbiological data and symptoms should prompt consideration of alternative diagnoses 1

Common Pitfalls to Avoid

1. Do not treat based on urinalysis alone without symptoms 1
2. Do not use fluoroquinolones as first-line empiric therapy due to resistance concerns 4, 6, 7
3. Do not treat non-specific symptoms (confusion, fatigue) in elderly as UTI without classic urinary symptoms 1
4. Do not obtain urine cultures in asymptomatic patients 1
5. Do not use prolonged antibiotic courses beyond what is necessary 1