Transcript
Page 1: Interpretation of urine cultures

DR.T.V.RAO MD 1

Dr.T.V.Rao MD

INTERPRETATION OF URINE

CULTURESCUMITECH GUIDELINES

INCORPORATED

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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

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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

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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

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• 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

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• 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

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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

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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)

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COMMON UROPATHOGENS

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• Escherichia coli• Other Enterobacteriaceae (Klebsiella, Enterobacter,

Proteus, Citrobacter)• Pseudomonas aeruginosa• Enterococcus• Staphylococcus saprophyticus• Staphylococcus aureus• Streptococcus agalactiae (group B)• Candida

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UNCOMMON UROPATHOGENS

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• Corynebacterium urealyticum• Hemophilus influenzae and

H. parainfluenzae• Blastomyces dermatitidis• Neisseria gonorrhaeae• Mycobacterium tuberculosis

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• 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

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• 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

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• 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

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• 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

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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

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>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…

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• 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

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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.

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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

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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 <10 4, 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

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• 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

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• 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

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• 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

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• 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

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• 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

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• 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

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ASYMPTOMATIC BACTERIURIA

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• 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

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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

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• Created by Dr.T.V.Rao MD for ‘e’Learning” resources for Microbiologists in the

Developing World • Email

[email protected]

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