What is the recommended treatment for a patient with elevated leukocytes (white blood cells) in their urinalysis, but no clear evidence of a urinary tract infection (UTI)?

Management of Isolated Leukocyturia Without UTI Evidence

Do not treat isolated leukocytes in the urine with antibiotics in the absence of clinical symptoms or significant bacteriuria. Pyuria alone does not indicate infection and is commonly found without infection, particularly in patients with lower urinary tract symptoms such as incontinence 1.

Understanding Isolated Leukocyturia

Pyuria is not diagnostic of UTI and requires clinical correlation. The presence of white blood cells in urine can occur in multiple non-infectious conditions 1. Key considerations include:

• Asymptomatic bacteriuria (ASB) should not be treated in most patient populations, as it causes neither morbidity nor increased mortality 2, 3
• Pyuria is commonly found in the absence of infection, especially in older adults with lower urinary tract symptoms 1
• Positive dipstick testing alone should not trigger antibiotic treatment without considering the patient's pretest probability based on symptoms 1

When to Pursue Further Evaluation

Obtain a urine culture if the clinical picture is unclear or if symptoms develop 2. Specific indications for urine culture include:

• Development of dysuria, frequency, urgency, or systemic symptoms 2
• Suspected acute pyelonephritis 2
• Symptoms that do not resolve or recur within 4 weeks 2
• Atypical presentation 2

Populations Where Screening and Treatment Are NOT Recommended

The following groups should not be screened or treated for asymptomatic bacteriuria 2:

• Women without risk factors 2
• Patients with well-regulated diabetes mellitus 2
• Postmenopausal women (unless symptomatic) 2
• Elderly institutionalized patients 2, 3
• Patients with spinal cord injury 2
• Renal transplant recipients >1 month post-surgery 2

Exceptions: When to Screen and Treat ASB

Only two populations benefit from screening and treatment of asymptomatic bacteriuria 2:

• Pregnant women: Screen and treat with standard short-course treatment or single-dose fosfomycin 2
• Before urological procedures breaching the mucosa: Screen and treat to prevent post-procedural complications 2

Common Pitfalls to Avoid

Treatment of asymptomatic bacteriuria may be harmful 2. Key pitfalls include:

• Treating pyuria without symptoms leads to unnecessary antibiotic exposure and promotes antimicrobial resistance 2
• Overdiagnosis of UTI in patients with contaminated specimens or asymptomatic bacteriuria results in overtreatment 2
• Antimicrobial therapy promotes reinfection with increasingly resistant organisms, potentially compromising treatment of future symptomatic UTI 2

Clinical Decision Algorithm

Follow this approach for isolated leukocyturia 2, 3, 1:

1. Assess for symptoms: Recent-onset dysuria, frequency, urgency, new incontinence, systemic signs, or costovertebral tenderness 3
2. If asymptomatic: Do not treat, regardless of leukocyte count 2
3. If symptomatic: Obtain urine culture before initiating antibiotics 2
4. If pregnant or pre-urological procedure: Screen and treat if bacteriuria confirmed 2