What is the appropriate management for an asymptomatic patient with a urinalysis showing 2+ leukocyte esterase, WBC (White Blood Cells) 11-20, and moderate epithelial cells?

Management of Asymptomatic Pyuria with Contaminated Specimen

Do not treat this patient with antibiotics—this urinalysis shows a contaminated specimen (moderate epithelial cells) in an asymptomatic patient, which represents neither infection nor an indication for further testing. 1

Immediate Management

• No antibiotics should be prescribed because the patient lacks specific urinary symptoms (dysuria, frequency, urgency, fever >38.3°C, or gross hematuria), which are required to justify treatment even when pyuria is present 1
• No urine culture should be obtained because asymptomatic patients should not have urinalysis or cultures performed routinely, regardless of urinalysis findings 1
• Discontinue any further urinary testing as the presence of moderate epithelial cells indicates contamination, making the leukocyte esterase and WBC results unreliable 1

Why This Patient Should Not Be Treated

The urinalysis findings do not meet criteria for urinary tract infection for three critical reasons:

• Contaminated specimen: Moderate epithelial cells indicate the specimen was contaminated during collection, which is the most common cause of false-positive leukocyte esterase results 1
• Asymptomatic bacteriuria with pyuria is common: This occurs in 15-50% of elderly and long-term care facility residents, and treatment provides no clinical benefit while increasing antimicrobial resistance and exposing patients to drug toxicity 1
• Pyuria alone has exceedingly low positive predictive value: The presence of leukocytes without symptoms often indicates genitourinary inflammation from noninfectious causes rather than bacterial infection 1

Clinical Decision Algorithm

Step 1: Assess for specific urinary symptoms 1

• Dysuria (burning with urination)
• Urinary frequency or urgency
• Fever >38.3°C (101°F)
• Gross hematuria
• Suprapubic pain
• Costovertebral angle tenderness

If NO symptoms present → Stop here. Do not order further testing or treatment 1

If symptoms ARE present → Obtain properly collected specimen (midstream clean-catch or catheterization) and repeat urinalysis before making treatment decisions 1

Evidence Supporting No Treatment

The Infectious Diseases Society of America provides a strong recommendation (Grade A-II) that asymptomatic bacteriuria with pyuria should not be treated, even when accompanied by positive cultures 1. This recommendation is based on evidence showing:

• Treatment of asymptomatic bacteriuria provides no clinical benefit in terms of reducing symptomatic UTI episodes, hospitalization, or mortality 1
• Unnecessary antibiotic treatment causes measurable harm including increased antimicrobial resistance, adverse drug effects, and healthcare costs 1
• Educational interventions on proper diagnostic protocols provide a 33% absolute risk reduction in inappropriate antimicrobial initiation 1

Patient Education and Follow-Up

Educate the patient to return immediately if any of these symptoms develop: 1

• New onset of burning with urination (dysuria)
• Urinary frequency or urgency
• Fever or chills
• Blood in urine
• Suprapubic or flank pain

No routine follow-up urinalysis is needed unless symptoms develop 1

Common Pitfalls to Avoid

• Do not treat based on urinalysis alone: The combination of 2+ leukocyte esterase and WBC 11-20 without symptoms does not justify antibiotic therapy 1
• Do not ignore specimen quality: Moderate epithelial cells invalidate the urinalysis results and indicate the need for proper collection technique if symptoms develop 1
• Do not misinterpret non-specific symptoms: In elderly patients, confusion or functional decline alone should not trigger UTI treatment without specific urinary symptoms 1
• Do not order "just in case" cultures: Asymptomatic patients should not have urine cultures performed, as this leads to overtreatment of colonization 1

Special Considerations

If this patient were in a special population requiring treatment of asymptomatic bacteriuria, the only exceptions are: 1

• Pregnant women (screen in first trimester)
• Patients undergoing endoscopic urologic procedures with anticipated mucosal bleeding

For all other populations, including elderly patients, long-term care residents, and catheterized patients, asymptomatic bacteriuria should never be screened for or treated 1