What is the recommended treatment for a patient with leukocyturia (positive leukocytes in urine) indicating a urinary tract infection (UTI)?

Management of Positive Leukocytes in Urine

The presence of leukocytes in urine alone does NOT justify antibiotic treatment—you must confirm both pyuria (≥10 WBCs/high-power field or positive leukocyte esterase) AND acute onset of specific urinary symptoms (dysuria, frequency, urgency, fever >38.3°C, or gross hematuria) before initiating therapy. 1

Immediate Diagnostic Algorithm

Step 1: Assess for Specific Urinary Symptoms

• Look for dysuria, urinary frequency, urgency, suprapubic pain, fever, or gross hematuria 2
• In elderly patients, non-specific symptoms like confusion or functional decline alone should NOT trigger UTI evaluation 1
• If NO specific urinary symptoms are present, this is asymptomatic bacteriuria—do NOT treat 2

Step 2: Obtain Proper Urine Specimen

• Collect urine culture and sensitivity BEFORE starting antibiotics 2, 3
• Use midstream clean-catch in cooperative patients or in-and-out catheterization in women who cannot provide clean specimens 1
• Process within 1 hour at room temperature or 4 hours if refrigerated 1

Step 3: Confirm Pyuria Threshold

• Pyuria must be ≥10 WBCs/HPF on microscopy OR positive leukocyte esterase 1
• Findings of 2-5 WBCs/HPF do NOT meet diagnostic threshold for UTI 1
• High epithelial cell counts indicate contamination—repeat specimen collection 1

Treatment Decision Framework

For Symptomatic Uncomplicated Cystitis (Women):

First-line antibiotics (choose based on local resistance patterns) 2:

• Nitrofurantoin 100 mg twice daily for 5 days 2
• Fosfomycin trometamol 3 g single dose 2
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (only if local E. coli resistance <20%) 2, 4

Treatment duration: 3-7 days maximum for uncomplicated cystitis 2

For Men with UTI:

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 7 days 2, 4
• Fluoroquinolones may be used based on local susceptibility 2

Critical Pitfalls to Avoid

Do NOT treat asymptomatic bacteriuria 2, 1:

• Occurs in 15-50% of elderly and long-term care residents 1
• Treatment provides NO clinical benefit and increases antimicrobial resistance 1
• Exceptions: pregnant women and patients undergoing invasive urologic procedures with anticipated mucosal bleeding 2

Do NOT rely on leukocyte esterase alone 1:

• Sensitivity 83% (range 67-94%), specificity only 78% (range 64-92%) 1
• False positives occur with contamination, oxidizing agents, and certain medications 1
• Positive predictive value is exceedingly low without accompanying symptoms 1

Do NOT order surveillance urine testing in asymptomatic patients 2:

• Routine post-treatment urinalysis or cultures are NOT indicated for asymptomatic patients 2
• Testing should only occur with acute onset of specific urinary symptoms 1

Special Population Considerations

Catheterized Patients:

• Asymptomatic bacteriuria with pyuria is nearly universal—do NOT screen or treat 1
• Evaluate only if fever, hypotension, or suspected urosepsis develops 1

Elderly/Long-Term Care Residents:

• Presence of pyuria has particularly low predictive value due to high asymptomatic bacteriuria prevalence 1
• Evaluate ONLY with acute onset of specific UTI-associated symptoms 2, 1

Recurrent UTIs (≥3 UTIs/year or 2 UTIs in 6 months):

• Obtain urine culture with each symptomatic episode before treatment 2
• Consider non-antibiotic prophylaxis: vaginal estrogen (postmenopausal women), immunoactive prophylaxis, or probiotics 2

When Culture Results Return

If culture is negative despite symptoms:

• Consider alternative diagnoses (interstitial cystitis, urethral syndrome, urolithiasis) 1
• Mixed flora suggests contamination—repeat properly collected specimen 1

If symptoms persist after treatment:

• Perform urine culture and susceptibility testing 2
• Assume organism is not susceptible to original agent 2
• Retreat with 7-day regimen using different agent 2