Do men with asymptomatic abnormal urinalysis (uA) with white blood cells (WBC) receive antibiotic treatment?

Management of Asymptomatic Bacteriuria in Men

No, men with asymptomatic abnormal urinalysis showing white blood cells (pyuria) should NOT be treated with antibiotics. 1, 2

Key Principle

Pyuria accompanying asymptomatic bacteriuria is NOT an indication for antimicrobial treatment. 1 This is a critical point because the presence of white blood cells in urine often prompts unnecessary antibiotic prescriptions, but pyuria alone—even with bacteriuria—does not warrant treatment in asymptomatic men. 1

Diagnostic Criteria for Asymptomatic Bacteriuria in Men

Before considering any treatment, confirm the diagnosis:

• A single clean-catch voided urine specimen with ≥10⁵ CFU/mL of one bacterial species defines asymptomatic bacteriuria in men 1, 3
• A single catheterized specimen with ≥10² CFU/mL also confirms bacteriuria 1
• The patient must have no urinary symptoms (no dysuria, frequency, urgency, suprapubic pain, fever, or flank pain) 1

When NOT to Treat (The Vast Majority of Cases)

The Infectious Diseases Society of America provides strong evidence against screening or treating asymptomatic bacteriuria in the following groups of men:

• Men without planned urologic procedures (Grade A-I recommendation against treatment) 1, 2, 3
• Diabetic men (Grade A-I recommendation against treatment) 1
• Elderly men living in the community (Grade A-II recommendation against treatment) 1
• Elderly institutionalized men (Grade A-I recommendation against treatment) 1
• Men with spinal cord injury (Grade A-II recommendation against treatment) 1, 2
• Men with short-term or long-term indwelling catheters while the catheter remains in place (Grade A-I recommendation against treatment) 1, 2

The Only Exceptions: When to Treat

Treatment is indicated in only two specific scenarios:

1. Before Urologic Procedures with Mucosal Trauma

• Screen and treat before transurethral resection of the prostate (TURP) (Grade A-I) 1, 2
• Screen and treat before other urologic procedures where mucosal bleeding is anticipated (Grade A-III) 1, 2, 3
• Protocol: Obtain urine culture before the procedure, initiate antibiotics 30-60 minutes before the procedure, use 1-2 doses rather than prolonged therapy, and discontinue immediately after the procedure unless an indwelling catheter remains 2

2. Post-Catheter Removal (Controversial)

• May consider treatment if bacteriuria persists 48 hours after catheter removal in women (Grade B-I), though this recommendation is less clear for men 1

Why Not Treating is the Right Approach

The evidence strongly supports withholding antibiotics because:

• Treatment increases risk of symptomatic infections through selection of resistant organisms 2, 4
• Adverse drug effects occur without clinical benefit 1, 4
• Reinfection with more resistant organisms is common after treatment 2, 4
• No evidence of benefit for preventing progression to symptomatic UTI, renal damage, or other adverse outcomes in asymptomatic men 1, 4

Common Pitfalls to Avoid

• Do not treat based on pyuria alone—white blood cells in urine are common with asymptomatic bacteriuria and do not indicate need for treatment 1
• Do not treat based on cloudy or malodorous urine—these are not sufficient indicators of infection in asymptomatic patients 1
• Do not order routine urine cultures in asymptomatic men—screening is not indicated outside of pre-procedural evaluation 1
• Avoid fluoroquinolones for empiric therapy even when treatment is indicated, due to resistance patterns and adverse effects 5