Is cefuroxime (a second-generation cephalosporin antibiotic) effective for treating a patient with leukocyturia (high White Blood Cell (WBC) count in urine), indicating a likely bacterial urinary tract infection (UTI)?

Is Cefuroxime Appropriate for Patients with High WBC Count in Urine?

Cefuroxime is an appropriate antibiotic choice for treating confirmed bacterial urinary tract infections (UTIs) caused by susceptible organisms, but the presence of high WBC count (leukocyturia) alone does NOT justify treatment—you must first confirm that the patient has acute urinary symptoms AND obtain a urine culture to guide therapy. 1

Critical Diagnostic Requirements Before Treatment

The presence of leukocytes in urine has exceedingly low positive predictive value for actual infection and often indicates genitourinary inflammation from noninfectious causes. 1 You must confirm BOTH of the following before initiating any antibiotic:

• Pyuria threshold: ≥10 WBCs/high-power field OR positive leukocyte esterase 1
• Acute urinary symptoms: Dysuria, frequency, urgency, fever >38.3°C, or gross hematuria 1

If the patient lacks specific urinary symptoms, this represents asymptomatic bacteriuria with pyuria, which occurs in 15-50% of elderly patients and should NOT be treated regardless of WBC count. 1 Treatment provides no clinical benefit and only increases antimicrobial resistance and drug toxicity. 1, 2

When Cefuroxime Is Indicated

Cefuroxime is FDA-approved for urinary tract infections caused by Escherichia coli and Klebsiella species, which are the most common uropathogens. 3 The drug demonstrates excellent activity against beta-lactamase-producing gram-negative bacilli that commonly cause UTIs. 4

Microbiological Coverage

Cefuroxime provides effective coverage against:

• E. coli (85% of uncomplicated UTIs) 5
• Klebsiella pneumoniae 5
• Beta-lactamase-producing enterobacteriaceae 4
• Proteus mirabilis 6

The drug is more active against enterobacteriaceae than conventional oral cephalosporins and maintains stability against beta-lactamases. 6, 4

Proper Diagnostic Algorithm

Before prescribing cefuroxime, follow this sequence:

1. Assess for acute urinary symptoms (dysuria, frequency, urgency, fever, hematuria) 1
2. If symptomatic: Obtain properly collected urine specimen (midstream clean-catch or catheterization if contamination suspected) 1
3. Perform urinalysis: Check for leukocyte esterase, nitrite, and microscopic WBCs 1
4. Order urine culture with susceptibility testing before starting antibiotics 1
5. If pyuria ≥10 WBCs/HPF AND symptoms present: Initiate empiric therapy while awaiting culture 1

Dosing and Treatment Duration

For uncomplicated UTIs, cefuroxime axetil 250 mg twice daily for 7 days has demonstrated 86-93% bacteriological cure rates. 5, 7 For more severe infections or suspected pyelonephritis, increase to 500 mg twice daily. 6

The European Association of Urology guidelines recommend 10-14 days of treatment for complicated UTIs (14 days for men when prostatitis cannot be excluded). 8

Critical Pitfalls to Avoid

• Never treat based on leukocyturia alone without confirming acute urinary symptoms—this leads to unnecessary antibiotic use and resistance. 1, 9
• Do not assume all positive cultures represent infection—distinguish true UTI from asymptomatic bacteriuria, which has 10-50% prevalence in certain populations. 1
• Avoid empiric treatment without culture in complicated UTIs, as gram-positive and multidrug-resistant organisms may be present. 8
• Do not treat catheter-associated asymptomatic bacteriuria—bacteriuria and pyuria are nearly universal (essentially 100%) in chronic catheterization. 9

Special Considerations

Elderly Patients

In elderly or long-term care residents, pyuria has particularly low predictive value due to high asymptomatic bacteriuria prevalence. 1 Evaluate only with acute onset of specific UTI-associated symptoms—not confusion, falls, or functional decline alone. 1, 9

Complicated UTIs

The microbial spectrum is broader in complicated UTIs, including Proteus spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 8 Cefuroxime lacks activity against Pseudomonas and Enterococcus faecalis. 4 Therefore, obtain culture and susceptibility testing before initiating therapy in patients with obstruction, foreign bodies, recent instrumentation, or healthcare-associated infections. 8

Resistance Patterns

In one study, 42.5% of isolates were resistant to trimethoprim-sulfamethoxazole, while all were susceptible to cefuroxime. 5 However, local resistance patterns should guide empiric selection, and therapy should be tailored once culture results are available. 8, 3

Antimicrobial Stewardship

Discontinue antibiotics immediately if culture returns negative or shows contamination (mixed flora), as continuing provides no benefit and increases resistance. 1 Educational interventions on proper diagnostic protocols provide 33% absolute risk reduction in inappropriate antimicrobial initiation. 1