What is the appropriate management for a 27-year-old patient with elevated leucocytes and significant presence of epithelial cells in the urine, despite no significant bacterial growth on culture?

Management of Elevated Leukocytes with High Epithelial Cells and Negative Culture

This specimen is contaminated and should not be used to diagnose or treat a urinary tract infection—obtain a properly collected specimen only if the patient has specific urinary symptoms. 1

Interpretation of Current Results

The combination of elevated epithelial cells (108 x 10^6/L) with mildly elevated leucocytes (44 x 10^6/L, just above reference range) and negative culture definitively indicates specimen contamination, not infection. 2, 1

• High epithelial cell counts are the hallmark of contamination from periurethral flora during collection, rendering the urinalysis uninterpretable for UTI diagnosis. 2, 1
• A urine sample with more than 10 WBCs and a significant number of epithelial cells must be considered contaminated. 2
• The negative culture essentially rules out significant bacterial UTI with >95% specificity, even in the presence of pyuria. 1
• Contaminated cultures with mixed normal flora at any concentration lack diagnostic validity for urinary tract infection. 1

Clinical Decision Algorithm

Step 1: Assess for Specific Urinary Symptoms

Do NOT proceed with further testing or treatment if the patient lacks specific urinary symptoms. 1, 3

Look specifically for:

• Dysuria (>90% accuracy for UTI when present) 1
• Urinary frequency or urgency 1
• Fever >37.8°C 1
• Gross hematuria 1
• Suprapubic pain 1

Critical pitfall to avoid: Non-specific symptoms like confusion, functional decline, or malaise alone should NOT trigger UTI evaluation or treatment in any age group. 1, 3

Step 2: If Symptomatic—Obtain Proper Specimen

If specific urinary symptoms are present, collect a new specimen using appropriate technique: 1

• For women: In-and-out catheterization is often necessary to avoid contamination, especially if initial clean-catch was inadequate. 2, 1
• For men: Midstream clean-catch with proper technique or freshly applied clean condom catheter with frequent monitoring. 1
• Process specimen within 1 hour at room temperature or 4 hours if refrigerated. 1

Step 3: If Asymptomatic—Stop Here

If the patient has no specific urinary symptoms, do NOT order repeat urinalysis or culture. 1, 3

• Asymptomatic bacteriuria with pyuria is common (10-50% prevalence in certain populations) and provides no clinical benefit when treated. 1, 3
• Treatment leads to unnecessary antibiotic exposure, resistance development, and adverse effects without improving outcomes. 1, 3

Special Considerations for This 27-Year-Old Patient

At age 27, this patient is in a low-risk demographic for asymptomatic bacteriuria compared to elderly populations. 1

• The mildly elevated leucocytes (44 vs reference <40) combined with high epithelial cells strongly suggests contamination rather than true pyuria. 2, 1
• If symptomatic with dysuria and frequency, the combination of positive leukocyte esterase with nitrite testing achieves 93% sensitivity and 96% specificity for UTI. 1
• A properly collected specimen showing pyuria (≥10 WBCs/high-power field) with positive leukocyte esterase or nitrite warrants urine culture before starting antibiotics. 1

What NOT to Do

• Do not treat based on this contaminated specimen. Continuing antibiotics for contaminated cultures provides no clinical benefit and increases adverse outcomes. 1
• Do not repeat urinalysis if asymptomatic. Screening asymptomatic individuals is explicitly not recommended. 1, 3
• Do not interpret cloudy or smelly urine as infection in the absence of specific urinary symptoms. 1
• Do not assume pyuria alone indicates infection—it often indicates genitourinary inflammation from many noninfectious causes. 1

Quality of Life and Antimicrobial Stewardship Impact

Unnecessary antibiotic treatment causes measurable harm: 1

• Increases antimicrobial resistance
• Exposes patients to adverse drug effects (including Clostridioides difficile infection)
• Increases healthcare costs without clinical benefit
• Educational interventions on proper diagnostic protocols provide 33% absolute risk reduction in inappropriate antimicrobial initiation. 1