Cystitis Symptoms Without WBC in Urine
Direct Recommendation
When cystitis symptoms persist without white blood cells in the urine, obtain a urine culture to guide treatment, and if symptoms are typical for uncomplicated cystitis, consider empirical antibiotic therapy with first-line agents while awaiting culture results. 1
Diagnostic Approach
The absence of WBCs (leukocyte esterase negative) on urinalysis has excellent negative predictive value but does not completely rule out bacterial cystitis in symptomatic patients. 1
When to Obtain Urine Culture
A urine culture is specifically recommended in the following situations: 1
- Women who present with atypical symptoms (such as absence of pyuria despite typical cystitis symptoms)
- Symptoms that do not resolve or recur within 4 weeks after completion of treatment
- Suspected acute pyelonephritis
- Pregnant women
Clinical Diagnosis Considerations
Diagnosis of uncomplicated cystitis can be made with high probability based on focused history alone (dysuria, frequency, urgency) and absence of vaginal discharge, even when urinalysis shows minimal abnormalities. 1 In patients presenting with typical symptoms of uncomplicated cystitis, urine analysis leads to only minimal increase in diagnostic accuracy. 1
Treatment Strategy
First-Line Empirical Therapy
For women with typical cystitis symptoms despite absent WBCs, first-line empirical treatment options include: 1
- Fosfomycin trometamol 3g single dose (recommended only in women with uncomplicated cystitis) 1
- Nitrofurantoin 100mg twice daily for 5 days 1
- Pivmecillinam 400mg three times daily for 3-5 days (where available) 1
Alternative Agents
If first-line agents cannot be used: 1
- Trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days - only if local E. coli resistance rates do not exceed 20% 1
- Cephalosporins (e.g., cefadroxil 500mg twice daily for 3 days) - if local E. coli resistance is <20% 1
Agents to Reserve
Fluoroquinolones should be reserved for important uses other than acute cystitis due to propensity for collateral damage and ecological effects, despite their high efficacy. 1
Symptomatic Management Alternative
For females with mild to moderate symptoms, symptomatic therapy (e.g., ibuprofen) may be considered as an alternative to antimicrobial treatment in consultation with individual patients. 1 This approach can reduce antibiotic exposure while managing symptoms.
Follow-Up Management
If Symptoms Persist
For women whose symptoms do not resolve by the end of treatment, perform urine culture and antimicrobial susceptibility testing. 1 Assume the infecting organism is not susceptible to the agent originally used, and retreatment with a 7-day regimen using another agent should be considered. 1
Post-Treatment Monitoring
Routine post-treatment urinalysis or urine cultures are NOT indicated for asymptomatic patients after successful treatment. 1
Critical Pitfalls to Avoid
- Do not dismiss symptoms solely based on negative urinalysis findings - bacterial cystitis can occur with minimal or absent pyuria 1
- Avoid amoxicillin or ampicillin for empirical treatment given poor efficacy and high worldwide resistance rates 1
- Do not use beta-lactams as first-line therapy - they have inferior efficacy and more adverse effects compared to other UTI antimicrobials 1
- Consider alternative diagnoses if symptoms persist despite appropriate antibiotic therapy, including interstitial cystitis, urethritis, or vaginitis 1