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Sterile pyuria

• Sterile pyuria

• Definitions

• Pyuria: the presence of 10 or more white cells per cubic millimeter in a urine specimen, 3 or more white cells per high-power field of unspun urine, a positive result on Gram’s stain of an unspun urine specimen, or a urinary dipstick test that is positive for leukocyte esterase
• Sterile pyuria: the persistent finding of white cells in the urine in the absence of bacteria, as determined by means of aerobic laboratory techniques (on a 5% sheep-blood agar plate and MacConkey agar plate)
• Bacteriuria: bacterial colony counts of more than 1000 colony-forming units (CFU) per milliliter in urine

• Causes

• Infectious etiologies

• Gynecologic infection
• Urethritis due to chlamydia, Neisseria gonorrhoeae, mycoplasma, or ureaplasma
• Prostatitis
• Balanitis
• Appendicitis
• Viral infection of the lower genitourinary tract
• Genitourinary tuberculosis
• Fungal infection
• Parasitic disease such as trichomoniasis or schistosomiasis

• Non-infectious etiologies

• Current use of antibiotics
• Recently treated urinary tract infection (within past 2 weeks)
• Presence or recent use of a urinary catheter
• Recent cystoscopy or urologic endoscopy
• Urinary tract stones
• Foreign body such as surgical mesh in the urethra or a retained stent
• Urinary tract neoplasm
• Pelvic irradiation
• Urinary fistula
• Polycystic kidney
• Rejection of a renal transplant
• Renal-vein thrombosis
• Interstitial nephritis or analgesic nephropathy
• Papillary necrosis
• Interstitial cystitis
• Inflammatory disease such as systemic lupus erythematosus or Kawasaki’s disease

• Pathogen-directed antimicrobial therapy

• Tuberculosis

• Preferred regimen: Isoniazid AND Rifampin AND Ethambutol AND Pyrazinamide for 3–6 months

• Gonorrhea

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose, then (Azithromycin 1 g PO in a single dose OR Doxycycline 100 mg PO bid for 7 days)

• Chlamydia

• Preferred regimen: Azithromycin 1 g PO in single dose OR Doxycycline 100 mg PO bid for 7 days
• Alternative regimen: Erythromycin base 500 mg PO qid for 7 days

• Mycoplasma and ureaplasma

• Preferred regimen: Azithromycin OR Levofloxacin OR Moxifloxacin

• Genital herpes

• Preferred regimen: Acyclovir 400 mg PO tid for 7–10 days or Acyclovir 200 mg PO five times a day for 7–10 days OR Famciclovir 250 mg PO tid for 7–10 days OR Valacyclovir 1 g PO bid for 7 days

• Trichomoniasis

• Preferred regimen: Metronidazole 2 g PO in a single dose) OR Tinidazole 2 g PO in a single dose

Note: Treat patient’s sex partner if trichomoniasis is diagnosed in patient.

• Fungal infections

• Preferred regimen: Fluconazole OR Posaconazole OR Echinocandins OR Amphotericin B

• Schistosomiasis

• Preferred regimen: Praziquantel 20 mg/kg PO bid for 1–2 days