Management of Asymptomatic Pyuria
Definition and Diagnosis
- Pyuria is defined as the presence of increased numbers of polymorphonuclear leukocytes in the urine and indicates an inflammatory response in the urinary tract 3
- Asymptomatic pyuria refers to pyuria without symptoms or signs referable to urinary infection 4
- Pyuria is typically defined as ≥10 white blood cells per mm³ in an "enhanced urinalysis" or ≥5 white blood cells per high-power field on a centrifuged urine specimen 4
Evidence-Based Recommendations
- The Infectious Diseases Society of America recommends that pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment (strong recommendation, moderate-quality evidence) 1, 2, 5
- The presence of pyuria without symptoms does not distinguish between asymptomatic bacteriuria and symptomatic urinary tract infection 4
- Screening for or treatment of asymptomatic bacteriuria with pyuria is not recommended for premenopausal, nonpregnant women (strong recommendation, high-quality evidence) 1, 2
- Screening for or treatment of asymptomatic bacteriuria with pyuria is not recommended for diabetic women (strong recommendation, high-quality evidence) 1, 2
- Screening for or treatment of asymptomatic bacteriuria with pyuria is not recommended for older persons living in the community (strong recommendation, moderate-quality evidence) 1, 2
- Screening for or treatment of asymptomatic bacteriuria with pyuria is not recommended for elderly, institutionalized subjects (strong recommendation, high-quality evidence) 1, 2
- Screening for or treatment of asymptomatic bacteriuria with pyuria is not recommended for persons with spinal cord injury (strong recommendation, moderate-quality evidence) 1, 2
- Screening for or treatment of asymptomatic bacteriuria with pyuria is not recommended for catheterized patients while the catheter remains in place (strong recommendation, high-quality evidence) 1, 2
- Screening for or treatment of asymptomatic bacteriuria with pyuria is not recommended for infants and children (strong recommendation, low-quality evidence) 6
Exceptions Where Treatment May Be Indicated
- Pregnant women should be screened for bacteriuria (not just pyuria) and treated if results are positive, regardless of the presence of pyuria 1, 2
- Patients undergoing urologic procedures where mucosal bleeding is anticipated should be screened and treated for bacteriuria 1, 2, 7
- Before transurethral resection of the prostate, screening for and treatment of bacteriuria is recommended 1, 2
Clinical Significance of Pyuria
- Pyuria is a hallmark of true urinary tract infection but has limited specificity when used alone 4
- Pyuria without bacteriuria may indicate non-infectious inflammation, tuberculosis, or other conditions 4
Potential Harms of Treatment
- Treatment may increase antimicrobial resistance 4