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Interpretationofurineculture 111215200736-phpapp02

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Asif Pasha

This document discusses guidelines for interpreting urine cultures. It provides information on: 1. Risk factors for complicated urinary tract infections including indwelling catheters and diabetes. 2. Proper collection and transport of urine specimens to ensure accurate culture results. 3. Common and uncommon urinary pathogens including E. coli, Enterococcus, and Candida. 4. Interpretation of urine culture results based on colony forming unit counts, with over 105 CFUs having a 95% probability of true infection for symptomatic patients.

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Dr.T.V.Rao MD INTERPRETATION OF URINE CULTURES CUMITECH GUIDELINES INCORPORATED 12/15/2011DR.T.V.RAO MD 1
PATHOPHYSIOLOGY OF URINARY TRACT INFECTION • Uncomplicated urinary tract infection: Bacterial or yeast infection in a structurally and neurologically normal urinary tract • Complicated urinary tract infection: Bacterial or yeast infection in a urinary tract with functional or structural abnormalities
RISK FACTORS IN COMPLICATED URINARY TRACT INFECTION • Indwelling catheters • Urinary calculi • Neurogenic bladder • Prostatic enlargement • Uterine prolapse • Urologic instrumentation or surgery • Renal transplantation • Diabetes mellitus
URINARY TRACT SPECIMENS • First-voided morning urine optimal (generally bacteria have been proliferating in bladder urine for several hours) • Midstream urine specimens (initially voided urine contains urethral commensals) • Indwelling catheters (freshly placed, urine aspirated by needle inserted into catheter) (Foley catheter tips not acceptable) • Straight catheter specimens • Suprapubic aspirates (infants or children, recovery of anaerobes) Cystoscopic collection of urine Contamination-free specimen 12/15/2011DR.T.V.RAO MD 4
• Urine collected in sterile specimen container must be processed within 2 hours, or refrigerated and processed within 24 hours • Urine collected in sterile specimen container with borate preservative should be processed within 24 hours (no refrigeration required) COLLECTION OF URINE SPECIMENS 12/15/2011DR.T.V.RAO MD 5
• Transport to lab as soon as possible • Urine should be cultured within 2 hours or be refrigerated for up to 24 hours • Microorganisms grow very rapidly in urine at room temperature • This could give a false positive culture result PROMPT TRANSPIRATION NEEDED 12/15/2011DR.T.V.RAO MD 6
SPECIMEN INOCULATIONS • All cultures processed by Semiquantitative method a loop of standard dimension of approximately known volume is inoculated into selected culture plate • In general a loop of SWG – 28 with a diameter of 3.26 mm internal diameter which can hold a drop of water or urine 0.004 ml. • After inoculation the culture plates are incubated at 370c extending to > 18 hours are read • The colony counts are made, as each colony corropsdes to number of viable bacteria per ml of urine DR.T.V.RAO MD 712/15/2011
INOCULATION OF URINE • Inoculation of urine for quantitative culture (colony forming units→cfu’s) performed with a calibrated 0.001 mL and 0.01 mL plastic or wire loop • Sheep blood agar (SBA) utilized for quantitative urine culture • With 0.001 ml loop, 1 colony on SBA equivalent to 1,000 cfu’s per mL of urine • With 0.01 ml loop, 1 colony on SBA equivalent to 100 cfu’s per mL of urine • MacConkey agar utilized as selective differential agar for gram-negative bacteria, Colistin nalidixic acid agar as selective agar for gram-positive bacteria, and chocolate agar for fastidious gram-negative bacteria (Haemophilus) 12/15/2011DR.T.V.RAO MD 8
COMMON UROPATHOGENS 12/15/2011DR.T.V.RAO MD 9 • Escherichia coli • Other Enterobacteriaceae (Klebsiella, Enterobacter, Proteus, Citrobacter) • Pseudomonas aeruginosa • Enterococcus • Staphylococcus saprophyticus • Staphylococcus aureus • Streptococcus agalactiae (group B) • Candida
UNCOMMON UROPATHOGENS 12/15/2011DR.T.V.RAO MD 10 • Corynebacterium urealyticum • Hemophilus influenzae and H. parainfluenzae • Blastomyces dermatitidis • Neisseria gonorrhaeae • Mycobacterium tuberculosis
• With 0.001 ml loop, 1 colony on SBA equivalent to 1,000 cfu’s per mL of urine • With 0.01 ml loop, 1 colony on SBA equivalent to 100 cfu’s per mL of urine COUNTING THE COLONIES DR.T.V.RAO MD 1112/15/2011
• A single species of Enterobacteriaceae recovered at >105 cfu’s/mL urine: with patients symptomatic for urinary tract infection, 95% probability of true bacteriuria INTERPRETATION OF URINE CULTURES: GENERAL GUIDELINES 12/15/2011DR.T.V.RAO MD 12
• Significant bacteriuria in an asymptomatic patient is 100,000 or more colonies per milliliter of urine from a midstream, clean- catch specimen; yet, a colony count of 200 Escherichia coli per ml may be significant in a midstream male void or catheterized female. About 95% of all positive UTI cultures will produce essentially pure cultures if urine is collected carefully and the media inoculated promptly. WHAT IS SIGNIFICANT BACTERIURIA DR.T.V.RAO MD 1312/15/2011
• A single species of Enterobacteriaceae recovered at 104-105 cfu’s/mL urine: with patients symptomatic for urinary tract infection, 33% probability of true bacteriuria WHAT CAN BE A SIGNIFICANT COUNT DR.T.V.RAO MD 1412/15/2011
URINE CULTURES Organisms/ml --- very important! <10,000 (Rare) • May indicate contamination • Lab usually does not identify the organisms • Generally not treated unless there is a single organism and patient has S&S 12/15/2011DR.T.V.RAO MD 15
>100,000 organisms/ml (Many) • Usually indicates an infection • Patient most likely will have S&S • Most often will be treated with antibiotic appropriate for that organism URINE CULTURES… 12/15/2011DR.T.V.RAO MD 16
• One isolate at >104: Full ID and Susceptibility • One or two gram- negative isolates at >105 and other isolates at least 10X less: Full ID and Susceptibility of gram-negative isolates CUMITECH GUIDELINES FOR INTERPRETATION OF ROUTINE URINE CULTURES DR.T.V.RAO MD 1712/15/2011
CUMITECH GUIDELINES FOR INTERPRETATION OF ROUTINE URINE CULTURES1 • One isolate at >104: Full ID and Susceptibility • One or two gram-negative isolates at >105 and other isolates at least 10X less: Full ID and Susceptibility of gram-negative isolates • Other patterns of isolates at >104: Presumptive ID only • Ignore mixed urethral flora at <104 1Clarridge, Johnson, Pezzlo, and Weissfeld, ASM Cumitech 2B, November 1998. 12/15/2011DR.T.V.RAO MD 18
HOW TO REPORT URINE CULTURES: CUMITECH RECOMMENDATIONS • Negative urines (no growth)0.01 ml inoculum Sterile or < 100 CFU/ml OR • No growth of > 100 CFU/ml • 0.001 ml inoculum Sterile or < 1000 CFU/ml OR • No growth of > 1000 CFU/ml 12/15/2011DR.T.V.RAO MD 19
READING THE CULTURE PLATES • A true infection in the absence of prior antibiotic therapy the number of bacteria is likely to be at least 105 or more. • Contaminated specimens present with colony counts <104, however even less than 103 • On several occasions the colonies are diverse species • Several studies prove counts >104 to be considered as presence of Urinary tract infection with the supporting clinical history • On some occasions more than one pathogen is isolated but should be processed for all practical purposes eg E.coli along with Streptococcus fecalis On few occasions even counts 103 are proved significant DR.T.V.RAO MD 2012/15/2011
• A single species of Enterobacteriaceae recovered at >105 cfu’s/mL urine: with patients symptomatic for urinary tract infection, 95% probability of true bacteriuria • A single species of Enterobacteriaceae recovered at 104-105 cfu’s/mL urine: with patients symptomatic for urinary tract infection, 33% probability of true bacteriuria INTERPRETATION OF ENTEROBACTERIACEAE DR.T.V.RAO MD 2112/15/2011
• A single species of Enterobacteriaceae recovered at >105 cfu’s/mL urine: with patients symptomatic for urinary tract infection, 95% probability of true bacteriuria • A single species of Enterobacteriaceae recovered at 104-105 cfu’s/mL urine: with patients symptomatic for urinary tract infection, 33% probability of true bacteriuria INTERPRETATION OF ENTEROBACTERIACEAE DR.T.V.RAO MD 2212/15/2011
• Gram-positive, fungal, and fastidious uropathogens often present in lower numbers (104-105 cfu’s/mL urine) • Urethral commensals recovered at <104 cfu’s/mL urine GRAM POSITIVES AND FUNGI THE COUNTS MAY BE <105 12/15/2011DR.T.V.RAO MD 23
• Other patterns of isolates at >104: Presumptive ID only • Ignore mixed urethral flora at <104 • 1Clarridge, Johnson, Pezzlo, and Weissfeld, ASM Cumitech 2B, November 1998. CUMITECH GUIDELINES FOR INTERPRETATION OF ROUTINE URINE CULTURES1 DR.T.V.RAO MD 2412/15/2011
• One or two isolates at >102 to 105: Full ID and Susceptibility is essential before confirmed as uncommon isolates • 1Clarridge, Johnson, Pezzlo, and Weissfeld, ASM Cumitech 2B, November 1998. CUMITECH GUIDELINES FOR INTERPRETATION OF SPECIAL OR UNCOMMON URINE CULTURES1 DR.T.V.RAO MD 2512/15/2011
• Negative culture results showing no bacterial growth are available after 24 hours. Positive results require 24-72 hours to complete identification of the number and type of bacteria found REPORTING OF NEGATIVE URINE CULTURES DR.T.V.RAO MD 2612/15/2011
ASYMPTOMATIC BACTERIURIA 12/15/2011DR.T.V.RAO MD 27 • Presence of uropathogens by culture without signs or symptoms of urinary tract infection • Clinically significant (should be treated) with preschool children (? vesicoureteral reflux, congenital urinary tract anomaly), pregnant women, and adults with obstructive uropathy • Without clinical significance (should not be treated) for adults in absence of urinary tract obstruction
WHEN TO DO AN ANTIBIOTIC SENSITIVITY TESTING ON URINE ISOLATE? • Follow laboratory guidelines for susceptibility testing of isolates in which a definitive ID and AST is recommended, according to Cumitech, CMPH, MCM, IDSA, other guidelines. That would include “significant CFU/ml” of :Enterobacteriaceae • P. aeruginosa • Enterococcus sp. • S. aureus • Significant CoNS, except S. saprophyticus • Others, including yeast, upon request or if SOP’s have been set up in accordance with CLSI Guidelines of Best practices 12/15/2011DR.T.V.RAO MD 28
• Created by Dr.T.V.Rao MD for ‘e’Learning” resources for Microbiologists in the Developing World • Email • doctortvrao@gmail.com DR.T.V.RAO MD 2912/15/2011

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Interpretationofurineculture 111215200736-phpapp02

  • 1. Dr.T.V.Rao MD INTERPRETATION OF URINE CULTURES CUMITECH GUIDELINES INCORPORATED 12/15/2011DR.T.V.RAO MD 1
  • 2. PATHOPHYSIOLOGY OF URINARY TRACT INFECTION • Uncomplicated urinary tract infection: Bacterial or yeast infection in a structurally and neurologically normal urinary tract • Complicated urinary tract infection: Bacterial or yeast infection in a urinary tract with functional or structural abnormalities
  • 3. RISK FACTORS IN COMPLICATED URINARY TRACT INFECTION • Indwelling catheters • Urinary calculi • Neurogenic bladder • Prostatic enlargement • Uterine prolapse • Urologic instrumentation or surgery • Renal transplantation • Diabetes mellitus
  • 4. URINARY TRACT SPECIMENS • First-voided morning urine optimal (generally bacteria have been proliferating in bladder urine for several hours) • Midstream urine specimens (initially voided urine contains urethral commensals) • Indwelling catheters (freshly placed, urine aspirated by needle inserted into catheter) (Foley catheter tips not acceptable) • Straight catheter specimens • Suprapubic aspirates (infants or children, recovery of anaerobes) Cystoscopic collection of urine Contamination-free specimen 12/15/2011DR.T.V.RAO MD 4
  • 5. • Urine collected in sterile specimen container must be processed within 2 hours, or refrigerated and processed within 24 hours • Urine collected in sterile specimen container with borate preservative should be processed within 24 hours (no refrigeration required) COLLECTION OF URINE SPECIMENS 12/15/2011DR.T.V.RAO MD 5
  • 6. • Transport to lab as soon as possible • Urine should be cultured within 2 hours or be refrigerated for up to 24 hours • Microorganisms grow very rapidly in urine at room temperature • This could give a false positive culture result PROMPT TRANSPIRATION NEEDED 12/15/2011DR.T.V.RAO MD 6
  • 7. SPECIMEN INOCULATIONS • All cultures processed by Semiquantitative method a loop of standard dimension of approximately known volume is inoculated into selected culture plate • In general a loop of SWG – 28 with a diameter of 3.26 mm internal diameter which can hold a drop of water or urine 0.004 ml. • After inoculation the culture plates are incubated at 370c extending to > 18 hours are read • The colony counts are made, as each colony corropsdes to number of viable bacteria per ml of urine DR.T.V.RAO MD 712/15/2011
  • 8. INOCULATION OF URINE • Inoculation of urine for quantitative culture (colony forming units→cfu’s) performed with a calibrated 0.001 mL and 0.01 mL plastic or wire loop • Sheep blood agar (SBA) utilized for quantitative urine culture • With 0.001 ml loop, 1 colony on SBA equivalent to 1,000 cfu’s per mL of urine • With 0.01 ml loop, 1 colony on SBA equivalent to 100 cfu’s per mL of urine • MacConkey agar utilized as selective differential agar for gram-negative bacteria, Colistin nalidixic acid agar as selective agar for gram-positive bacteria, and chocolate agar for fastidious gram-negative bacteria (Haemophilus) 12/15/2011DR.T.V.RAO MD 8
  • 9. COMMON UROPATHOGENS 12/15/2011DR.T.V.RAO MD 9 • Escherichia coli • Other Enterobacteriaceae (Klebsiella, Enterobacter, Proteus, Citrobacter) • Pseudomonas aeruginosa • Enterococcus • Staphylococcus saprophyticus • Staphylococcus aureus • Streptococcus agalactiae (group B) • Candida
  • 10. UNCOMMON UROPATHOGENS 12/15/2011DR.T.V.RAO MD 10 • Corynebacterium urealyticum • Hemophilus influenzae and H. parainfluenzae • Blastomyces dermatitidis • Neisseria gonorrhaeae • Mycobacterium tuberculosis
  • 11. • With 0.001 ml loop, 1 colony on SBA equivalent to 1,000 cfu’s per mL of urine • With 0.01 ml loop, 1 colony on SBA equivalent to 100 cfu’s per mL of urine COUNTING THE COLONIES DR.T.V.RAO MD 1112/15/2011
  • 12. • A single species of Enterobacteriaceae recovered at >105 cfu’s/mL urine: with patients symptomatic for urinary tract infection, 95% probability of true bacteriuria INTERPRETATION OF URINE CULTURES: GENERAL GUIDELINES 12/15/2011DR.T.V.RAO MD 12
  • 13. • Significant bacteriuria in an asymptomatic patient is 100,000 or more colonies per milliliter of urine from a midstream, clean- catch specimen; yet, a colony count of 200 Escherichia coli per ml may be significant in a midstream male void or catheterized female. About 95% of all positive UTI cultures will produce essentially pure cultures if urine is collected carefully and the media inoculated promptly. WHAT IS SIGNIFICANT BACTERIURIA DR.T.V.RAO MD 1312/15/2011
  • 14. • A single species of Enterobacteriaceae recovered at 104-105 cfu’s/mL urine: with patients symptomatic for urinary tract infection, 33% probability of true bacteriuria WHAT CAN BE A SIGNIFICANT COUNT DR.T.V.RAO MD 1412/15/2011
  • 15. URINE CULTURES Organisms/ml --- very important! <10,000 (Rare) • May indicate contamination • Lab usually does not identify the organisms • Generally not treated unless there is a single organism and patient has S&S 12/15/2011DR.T.V.RAO MD 15
  • 16. >100,000 organisms/ml (Many) • Usually indicates an infection • Patient most likely will have S&S • Most often will be treated with antibiotic appropriate for that organism URINE CULTURES… 12/15/2011DR.T.V.RAO MD 16
  • 17. • One isolate at >104: Full ID and Susceptibility • One or two gram- negative isolates at >105 and other isolates at least 10X less: Full ID and Susceptibility of gram-negative isolates CUMITECH GUIDELINES FOR INTERPRETATION OF ROUTINE URINE CULTURES DR.T.V.RAO MD 1712/15/2011
  • 18. CUMITECH GUIDELINES FOR INTERPRETATION OF ROUTINE URINE CULTURES1 • One isolate at >104: Full ID and Susceptibility • One or two gram-negative isolates at >105 and other isolates at least 10X less: Full ID and Susceptibility of gram-negative isolates • Other patterns of isolates at >104: Presumptive ID only • Ignore mixed urethral flora at <104 1Clarridge, Johnson, Pezzlo, and Weissfeld, ASM Cumitech 2B, November 1998. 12/15/2011DR.T.V.RAO MD 18
  • 19. HOW TO REPORT URINE CULTURES: CUMITECH RECOMMENDATIONS • Negative urines (no growth)0.01 ml inoculum Sterile or < 100 CFU/ml OR • No growth of > 100 CFU/ml • 0.001 ml inoculum Sterile or < 1000 CFU/ml OR • No growth of > 1000 CFU/ml 12/15/2011DR.T.V.RAO MD 19
  • 20. READING THE CULTURE PLATES • A true infection in the absence of prior antibiotic therapy the number of bacteria is likely to be at least 105 or more. • Contaminated specimens present with colony counts <104, however even less than 103 • On several occasions the colonies are diverse species • Several studies prove counts >104 to be considered as presence of Urinary tract infection with the supporting clinical history • On some occasions more than one pathogen is isolated but should be processed for all practical purposes eg E.coli along with Streptococcus fecalis On few occasions even counts 103 are proved significant DR.T.V.RAO MD 2012/15/2011
  • 21. • A single species of Enterobacteriaceae recovered at >105 cfu’s/mL urine: with patients symptomatic for urinary tract infection, 95% probability of true bacteriuria • A single species of Enterobacteriaceae recovered at 104-105 cfu’s/mL urine: with patients symptomatic for urinary tract infection, 33% probability of true bacteriuria INTERPRETATION OF ENTEROBACTERIACEAE DR.T.V.RAO MD 2112/15/2011
  • 22. • A single species of Enterobacteriaceae recovered at >105 cfu’s/mL urine: with patients symptomatic for urinary tract infection, 95% probability of true bacteriuria • A single species of Enterobacteriaceae recovered at 104-105 cfu’s/mL urine: with patients symptomatic for urinary tract infection, 33% probability of true bacteriuria INTERPRETATION OF ENTEROBACTERIACEAE DR.T.V.RAO MD 2212/15/2011
  • 23. • Gram-positive, fungal, and fastidious uropathogens often present in lower numbers (104-105 cfu’s/mL urine) • Urethral commensals recovered at <104 cfu’s/mL urine GRAM POSITIVES AND FUNGI THE COUNTS MAY BE <105 12/15/2011DR.T.V.RAO MD 23
  • 24. • Other patterns of isolates at >104: Presumptive ID only • Ignore mixed urethral flora at <104 • 1Clarridge, Johnson, Pezzlo, and Weissfeld, ASM Cumitech 2B, November 1998. CUMITECH GUIDELINES FOR INTERPRETATION OF ROUTINE URINE CULTURES1 DR.T.V.RAO MD 2412/15/2011
  • 25. • One or two isolates at >102 to 105: Full ID and Susceptibility is essential before confirmed as uncommon isolates • 1Clarridge, Johnson, Pezzlo, and Weissfeld, ASM Cumitech 2B, November 1998. CUMITECH GUIDELINES FOR INTERPRETATION OF SPECIAL OR UNCOMMON URINE CULTURES1 DR.T.V.RAO MD 2512/15/2011
  • 26. • Negative culture results showing no bacterial growth are available after 24 hours. Positive results require 24-72 hours to complete identification of the number and type of bacteria found REPORTING OF NEGATIVE URINE CULTURES DR.T.V.RAO MD 2612/15/2011
  • 27. ASYMPTOMATIC BACTERIURIA 12/15/2011DR.T.V.RAO MD 27 • Presence of uropathogens by culture without signs or symptoms of urinary tract infection • Clinically significant (should be treated) with preschool children (? vesicoureteral reflux, congenital urinary tract anomaly), pregnant women, and adults with obstructive uropathy • Without clinical significance (should not be treated) for adults in absence of urinary tract obstruction
  • 28. WHEN TO DO AN ANTIBIOTIC SENSITIVITY TESTING ON URINE ISOLATE? • Follow laboratory guidelines for susceptibility testing of isolates in which a definitive ID and AST is recommended, according to Cumitech, CMPH, MCM, IDSA, other guidelines. That would include “significant CFU/ml” of :Enterobacteriaceae • P. aeruginosa • Enterococcus sp. • S. aureus • Significant CoNS, except S. saprophyticus • Others, including yeast, upon request or if SOP’s have been set up in accordance with CLSI Guidelines of Best practices 12/15/2011DR.T.V.RAO MD 28
  • 29. • Created by Dr.T.V.Rao MD for ‘e’Learning” resources for Microbiologists in the Developing World • Email • doctortvrao@gmail.com DR.T.V.RAO MD 2912/15/2011