What is the recommended management for an older adult patient with leukocyturia, indicated by a urinalysis showing more than 30 WBCs, who is scheduled for elective hip replacement surgery and has otherwise normal urinalysis results?

Management of Preoperative Leukocyturia Before Hip Replacement

Do not delay or cancel the elective hip replacement surgery based solely on asymptomatic leukocyturia (>30 WBCs) with otherwise normal urinalysis findings. 1, 2

Immediate Assessment Required

Determine if the patient has any urinary symptoms:

• Dysuria, urinary frequency, urgency, fever >38.3°C, gross hematuria, or suprapubic pain 3, 4
• If completely asymptomatic, this represents asymptomatic bacteriuria with pyuria, which should NOT be treated 3, 4

Verify specimen quality:

• High epithelial cell counts indicate contamination and require repeat collection 4
• Use midstream clean-catch or catheterization for proper specimen 3, 4

Clinical Decision Algorithm

If Patient is Asymptomatic:

Proceed with surgery as planned without antibiotic treatment or further urinary workup 1, 2

Evidence supporting this approach:

• A prospective study of 510 patients undergoing hip/knee replacement found 36% had preoperative asymptomatic bacteriuria, yet only 5% developed symptomatic UTI postoperatively, all successfully treated with oral antibiotics with no effect on the joint replacement 1
• The Infectious Diseases Society of America explicitly states urinalysis and urine cultures should not be performed for asymptomatic residents (Grade A-I recommendation) 3
• Asymptomatic bacteriuria prevalence is 15-50% in older adults, and treatment provides no clinical benefit while increasing antimicrobial resistance 3, 4

If Patient Has Urinary Symptoms:

Obtain urine culture before proceeding with surgery 3, 4

Delay surgery and treat the UTI if:

• Pyuria (≥10 WBCs/HPF) PLUS positive culture PLUS acute urinary symptoms are present 3, 4
• Complete 7-10 days of appropriate oral antibiotics based on culture susceptibilities 2
• Reschedule surgery after treatment completion 2, 5

Critical Evidence on Surgical Risk

The data on asymptomatic bacteriuria and surgical complications is conflicting:

• Against routine treatment: The highest quality prospective study (510 patients) found no increased risk of prosthetic joint infection from untreated asymptomatic bacteriuria 1
• Supporting selective treatment: One retrospective study (963 patients) found bacteriuria on urinalysis increased superficial wound infection risk (4.2% vs 0.6%, OR 7.587), though 90.5% of these patients had negative urine cultures 6
• Symptomatic UTI clearly increases risk: Preoperative symptomatic UTI increases overall postoperative complications (OR 1.551) in general surgery patients 5

The Association of Anaesthetists guidelines note that leukocytosis >17 × 10⁹/L may indicate infection (commonly chest or urine), but isolated pyuria without symptoms does not meet this threshold 3

Recommended Perioperative Management

Standard prophylaxis regardless of urinalysis findings:

• Single dose IV cefuroxime 1.5g at induction 1
• Insert urinary catheter immediately preoperatively and remove within 24 hours to minimize catheter-associated UTI risk 2

Do NOT:

• Order urine culture in asymptomatic patients 3, 4
• Treat asymptomatic bacteriuria with antibiotics 3, 1
• Delay surgery for isolated pyuria without symptoms 1, 2

Common Pitfalls to Avoid

Misinterpreting pyuria as infection: The presence of WBCs has low positive predictive value for actual UTI—it often represents genitourinary inflammation from noninfectious causes 4

Overtreating asymptomatic findings: Treatment of asymptomatic bacteriuria increases antimicrobial resistance, exposes patients to drug toxicity, and provides no clinical benefit 3, 4

Ignoring specimen contamination: Repeat collection with proper technique if epithelial cells are elevated 4