urine culture - iacld.iriacld.ir/dl/modavan/bacteriology/urineculturedrvalizadeh.pdf · urine...
TRANSCRIPT
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Urine cultures: contaminants, skin flora, or? MLO-May 2010
►The majority of outpatient urinary-tract
infections are caused by a few common
bacteria and are easily identified
►The not-so-simple cultures (e.g.,
inpatients, extended-care facilities, post-
surgical manipulation, patients on long-
term antibiotics, patients with indwelling
catheters, infants and small children, and
patients with underlying disease)
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Urine cultures: contaminants, skin flora, or? MLO-May 2010
►Be careful what you report
►Preliminary reporting may lead to
misinformation and unnecessary antibiotic
therapy
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Urine cultures: contaminants, skin flora, or? MLO-May 2010
►Example: After 18 to 24 hours incubation,
40,000 cfu/mL of big shiny Group B
Streptococcus are reported on a
nonpregnant patient.
►This as a pure culture and acts on it. After
an additional 24 hours’ incubation, the
culture also grows out >100,000 cfu/mL of
mixed skin/ vaginal flora.
► Now you change the report to “mixed
skin/ vaginal contaminants.”
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Responsible reporting in microbiology
►Communication between
clinician and Clinical
microbiologist / Clinical
Laboratory Scientist is the
most effective means of
preventing inappropriate use
of microbiology information.
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Responsible reporting in microbiology
►A 30-month-old infant was U-bagged for a
urine culture.
► No urinalysis was ordered or performed.
►Culture results were reported out as 2,000
cfu/mL of Pseudomonas aeruginosa.
►The clinician admitted the patient to
pediatrics and started her on IV
ceftazidime.
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Responsible reporting in microbiology
►How could communication between Clinical
microbiologist / Clinical Laboratory Scientist
and the clinician have been improved? Perhaps
by adding a comment to the culture results:
►“No urinalysis requested. Unable to determine
significance of this isolate.”
►“U-bag urine samples are unacceptable
specimens for culture due to contamination from
fecal and/or skin flora.”
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Asymptomatic Bacteriuria
►Asymptomatic Bacteriuria >100,000
CFU/ ml
►The largest patient population at risk
for asymptomatic bacteriuria is the
elderly > 65
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Urinary Tract Infections in Children
Cystitis is an inflammatory condition of the urinary bladder.
♦ Dysuria
♦ Frequency
♦ Urgency
♦ Malodorous urine
Asking parents about urine smell is unlikely to be of benefit
♦ Enuresis
♦ Hematuria
♦ Suprapubic pain
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HIV & AIDS
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Urinary Tract Infections in Children
►Escherichia coli is the most frequent
bacteria to cause UTIs in infants and
children
► 85% to 90% of all UTIs in this age group
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Urinary Tract Infections in Children
►Other organisms causing UTIs include
►Klebsiella
►Enterobacter
►Enterococci
►Staphylococcus
►Proteus
►Pseudomonas aeruginosa
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Urinary Tract Infections in Children
►There is an increased risk of UTIs in
uncircumcised boys in the first 6 months of life
►UTI in uncircumcised males less than 6 months
of age was 1 to 4% .
►Uncircumcised males have a 10- fold increase of
developing a UTI than circumcised males
►The incidence in circumcised males was
only 0.1 to 0.2%
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Urine Sampling Techniques
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Urine Sampling Techniques
►A bagged specimen is useful for urinalysis, but unsuitable for urine culture
►As soon as the child has voided the bag should be removed
► If voiding does not occur within 15 minutes after applying the bag, the bag must be removed and reapplied following the same cleaning routine
►The bag must be checked every 15 minutes until the child voids.
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Urine Sampling Techniques
►Bag urine should be discouraged as
artificially elevated leukocyte counts may
be seen as a result of vaginal reflux of
urine
►Negative cultures provide useful
diagnostic information, but significant
growth should be confirmed with SPA
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Urine Sampling Techniques
►In the infant or child aged 2 months to 2
years, the most effective and reliable way
of obtaining a urine specimen is to
perform either a SPA or transurethral
catheterization
►For older children a midstream urine
collection is adequate when obtained
correctly
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Suprapubic Aspiration (SPA)
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Transurethra Catheterization
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Urine Collection Methods in Children
►Urine Collection Methods for the Diagnosis of Urinary Tract Infection in children under five years
►Sterile Urine Bag or Bag Urine >100,000 CFU/mL
►Clean-Catch or Clean voided urine > 100,000 CFU/mL
►Transurethra Catheterization > 50,000 CFU/mL
►Suprapubic Aspiration (SPA) > 100 CFU/ml
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The American Academy of Pediatrics (AAP)-2011
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The American Academy of Pediatrics (AAP)-2011
►Evaluation of febrile infants and young
children (2 months to 2 years of age).
►Infants and young children are of
particular concern because UTI in this age
group (approximately 5%) may cause few
recognizable signs or symptoms other than
fever and has a higher potential for renal
damage than in older children.
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The American Academy of Pediatrics (AAP)-2011
►Valid urine specimens cannot be obtained
without invasive methods (suprapubic
aspiration [SPA], transurethral
catheterization).
►The standard test for the diagnosis of UTI
is a quantitative urine culture.
►No element of the urinalysis or
combination of elements is as sensitive and
specific
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Urine Culture on Pediatric
►Children particularly those
2 years of age and younger
can have a "normal"
urinalysis but a positive
urine culture
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The American Academy of Pediatrics (AAP)-2011
►Organisms such as Lactobacillus
species, coagulase-negative
staphylococci, and
Corynebacterium species are not
considered clinically relevant
urine isolates in the otherwise
healthy 2-month to 2-year-old.
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The American Academy of Pediatrics (AAP)-2011
►Alternative culture methods
such as the dipslide may have a
place in the office setting;
sensitivity is reported in the
range of 87% to 100%, and
specificity, 92% to 98%.
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Dip n Count
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Cystine Lactose Electrolyte Deficient /(C.L.E.D.) Agar
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Dip n Count
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Dip n Count
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Automated Urine Screening Methods
►Bioluminescence systems detect bacterial
adenosine triphosphate
►A number of photometry methods,
including the Vitek system (bioMerieux
Vitek, Hazelwood, Mo.) have been
developed to measure growth
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Automated Urine Screening Methods
►The clinical evaluations of
all these systems are less
than optimal because
sensitivity for a low grade
bacteriuria has not been
assessed
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Automated Urine Screening Methods
►Particle filtration systems, such as Bac-
TScreen 2000 (bioMerieux Vitek,
Hazelwood, Mo.) are used to trap
organisms and WBCs on filters and then
selectively stain the cells.
► These systems are very sensitive even for
low-grade infections, are somewhat
nonspecific, yield many false-positive
results, and are relatively expensive
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Urine Culture Contamination-2008
►A College of American Pathologists (CAP) Q-Probes Study of 127 Laboratories
►Urine specimen was determined to be contaminated if the culture yielded more than 2 isolates in quantities greater than or equal to 10,000 CFU/mL
►Using these criteria the median institution had a contamination rate of 15.0%
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Clean-catch Midstream urine ?!!
►Three papers in the literature, regarding the value of cleansing and the mid-stream urine collection method.
►Two of the papers concluded that the mid-stream urine clean-catch procedure did not decrease contamination rates in women with symptoms and without symptoms suggestive of a urinary tract infection.
►A third paper concluded that the clean-catch midstream void method is unnecessary for obtaining routine voided urine culture specimens from men.
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Acute Uncomplicated Cystitis in Young Women
Pathogens ►Escherichia coli , 80-90%
♦ Antibiotic-susceptible E. coli is responsible for more than 80 % of uncomplicated UTIs
►Staphylococcus saprophyticus 10%
►Klebsiella pneumoniae
► Proteus mirabilis
►Enterococci
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Urinary Tract Infections in Adults
►Significant Bacteriuria >100,000 CFU/ ml
►1 / 3 or more of symptomatic women <
100,000 CFU / ml
►Low-coliform-count infections : bacterial
count of 100 / 1000 CFU/ ml of urine has
a high positive predictive value for cystitis
in symptomatic women
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Acute cystitis in young men
►Occasionally occur in young men
►Urine culture with a bacterial count of >1,000 CFU / mL of urine ,sensitivity and specificity of 97%
►Not circumcised
►Sexual partner is colonized with uropathogens or anal Intercourse
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Complicated urinary tract infection
►A complicated UTI predispose the patient to persistent infection, recurrent infection
►Elderly men, such as enlargement of the prostate
►Indwelling catheter
►Urine culture with a bacterial count of more than 10,000 CFU / mL of urine
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Asymptomatic bacteriuria in pregnancy
►Pregnant women are at increased risk for UTIs.
►Beginning in week 6 and peaking during weeks 22 to 24
►Pregnant women should be screened for bacteriuria by urine culture at 12 to 16 weeks of gestation
►Urine culture with a bacterial count of more than 100,000 CFU/ mL in urine is considered significant
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Urinary Tract Infections During Pregnancy
►Escherichia coli 80-90%
►Staphylococcus saprophyticus are less common causes of UTI
►Less common organisms that may cause UTI include
♦ Enterococci
♦ Gardnerella vaginalis
♦ Ureaplasma ureolyticum
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Urinary Tract Infections Treatment- Pregnancy
7-10 day
►Ampicillin & Amoxicillin ( B )
►Amoxicillin-clavulanic acid
♦ First (D) and second ( B ) & third trimester (
B )
►Cephalosporins ( B )
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Urinary Tract Infections Treatment- Pregnancy
►Nitrofurantoin ( B ) is a good choice ( before
third trimester (D) )
►Co-trimoxazole ( B – C ) can be taken during the
first and second trimesters
♦ During the third trimester (D) , risk that the infant
will develop kernicterus, especially preterm infants
►Fluoroquinolones (D) and Tetracyclines (D) and
Amikacin (D) should not be prescribed during
pregnancy
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Group B Streptococcal Infection
►Approximately 10% to 30% of pregnant
women are colonized with GBS in the
vagina
►Group B streptococcal (GBS) vaginal
colonization is known to be a cause of
neonatal sepsis and is associated with
preterm rupture of membranes, and
preterm labor and delivery
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Group B Streptococcal Infection
►GBS is found to be the causative organism
in UTIs in approximately 5 percent of
patients
►Streptococcus agalactiae should be
reported from women in childbearing
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Group B Streptococcal Infection
►Culture of group B streptococcus at 35–37
weeks’ gestation
►If GBS is not identified after incubation for 18–
24 hours, reincubate and inspect at 48 hours to
identify suspected organisms
►Penicillin G, 5 million units IV initial dose, then
2.5 million units IV every 4 hours until delivery
♦ Alternative Ampicillin, 2 g IV initial dose,
then 1 g IV every 4 hours until delivery
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Catheter-associated urinary tract infection
►Between 10 -20 % of patients who are
hospitalized receive an indwelling Foley catheter
► Once this catheter is in place, the risk of
bacteriuria is approximately 5% per day ,after 30
days 100%
►Catheter-associated urinary tract infections
account for 40% of all nosocomial infections
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Foley & Nelaton & Male Catheter
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Catheter-associated urinary tract infection
►Symptoms and a urine culture with a
bacterial count of more than 100 /
1000 CFU/ mL of urine
►Progression to concentrations >100,000
CFU/mL occurs predictably and rapidly,
usually within 72 hours
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Catheter-associated urinary tract infection
►Symptomatic bacteriuria in a
patient with an indwelling Foley
catheter should be treated with
antibiotics
►Remove catheter if possible
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Indwelling Catheter
►The catheter tubing should be clamped off above the port to allow collection of freshly voided urine.
►The catheter port or wall of the tubing should then be cleaned vigorously with 70% ethanol
►Urine aspirated via a needle and syringe
►Discard the initial 15-30 ml of urine and submit next flow of urine for culture
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Ileal conduit Urine
►Ileal conduit - urostomy urine
Urine is obtained via a catheter
passed aseptically into the stomal
opening after removal of the
external appliance. Results from
this type of specimen may be
difficult to interpret
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SPECIMEN TRANSPORT AND STORAGE
►Refrigeration for up to 24h (48h) will stabilise the number of colony forming units
►Specimens should be transported and processed within 2h (4h) if possible
►Boric acid preservative at a concentration of 1-2% holds the bacterial population steady for 48-96 hours, and other cellular components remain intact ♦ It should be noted that boric acid may be inhibitory to
some organisms and may inhibit tests for leukocyte esterase
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Rejection criteria
►Specimen is >2 h old
►Reject Foley catheter tips as unacceptable
for culture
►Reject urine from the bag of a catheterized
patient
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Urine Culture
►60% to 80% of all urine
specimens received for culture
contain no etiologic agents of
infection or contain only
contamination / No Significant
►95 % of UTI ; single organism
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Standards for Urine Culture Contamination
►Median contmination rate for outpatient
urines was 18% (25 to 30% )
►Contamination rates tended to be higher
when larger numbers of female urines
were processed
►Extremely high contamination rates from
our OB-GYN clinic
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Pyuria
►Pyuria is present in 96% of symptomatic patients with bacteriuria of 100,000 cfu/mL
►>5 WBCs / hpf ( x 40 )
♦ 50 -100 WBCs / mm3
►Pyuria may be absent in symptomless bacteriuria (eg in pregnancy) and neutropenia, and apparently absent in UTI caused by Proteus species as a result of leukocyte lysis at alkaline pH
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Detection of Pyuria
►Refrigeration cannot preserve the number
of leukocytes beyond 2 hours
►Urinary sediment resulting from
centrifugation of 10 mL of a specimen at
2000 rpm on a tabletop centrifuge for 5
minutes
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Detection of Pyuria
►At least five fields should be examined,
and each leukocyte seen per high-power
field (hpf) (40x) represents approximately
5 to 10 cells per cubic millimeter of urine.
►In this way, 5 to 10 leukocytes/hpf in the
sediment is the upper limit of normal,
representing 50 to 100cells/mm3
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Pyuria ►Pyuria without apparent bacteriuria (ie no
growth on routine culture media) may also
be a result of
►Prior treatment with antimicrobial agents
►Extreme frequency
►Infection with fastidious organisms
►Sexually transmitted diseases
►Renal tuberculosis
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Leukocyte Esterase (LE)
►The leukocyte esterase test of the urine can be
used as a screening examination for pyuria,
► A positive leukocyte esterase test has a reported
sensitivity of 75 to 90 percent in detecting pyuria
associated with a UTI
►Leukocyte esterase test is not sensitive enough
for determining pyuria in patients with acute
urethral syndrome
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Microscopy
►Haematuria may be seen in 40-60% of
patients with acute cystitis
►Squamous epithelial cells (SECs) are a
useful indicator of the degree of
contamination
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Gram staining
►Gram stain may reveal unusual organisms
with distinctive morphology (e.g., H.
influenzae, anaerobes)
►Fix with Methanol
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Gram staining
►In this semiquantitative test, one organism
per oil immersion field of uncentrifuged
urine correlates with 100,000 CFU / mL by
culture
►Because the procedure is time-consuming
and has low sensitivity, it is not routinely
performed in most clinical laboratories
unless it is specifically requested
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Nitrite
►Gram-negative bacteria reduce dietary nitrate to nitrites > 10,000 CFU/ml
►Uropathogens don’t reduce nitrates to nitrite / Negative
♦ Enterococci
♦ S. saprophyticus
♦ Acinetobacter species
►False Negative : pH < 6
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Culture Media
►Sheep Blood Agar 5%
♦ Count the number of colonies present on the
sheep blood agar
►EMB or MacConkey agar
►Columbia-colisitin–nalidixic acid (CNA)
♦ For Gram-positive bacteria
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Semiquantitative colony counts
►Calibrated-loop method
►Nonferrous (Nichrome or platinum)
►Disposable plastic Inoculating loops
►Calibrated to contain either 0.01 (10ul), or
0.001 (1ul) ml
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Calibrated-loop method
►Using the disposable or flamed and cooled calibrated loop
►Swirl the specimen to mix the bacterial suspension evenly
►Mix the urine gently to avoid foaming
►Avoid bubbles by not shaking liquid
►Hold the loop vertically
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Calibrated-loop method
►Dip the end of a sterile calibrated loop (
0.01 / 0.001 ml) in the urine, to just below
the surface and remove vertically
►When the wire above the loop is wetted by
deep immersion into the fluid, excess
liquid drains down the wire and enlarges
the volume transferred.
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Calibrated-loop method
►Vertical sampling from a small container
( < 1 cm ) may deliver only 50% of the
prescribed volume
►Horizontal sampling at a 45-degree angle
from a large container may deliver 150%
of volume
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Calibrated-loop method
►Inspect nondisposable calibrated loops
regularly to confirm that they remain
►Round and are free of bends, dents,
corrosion, or incinerated material
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Calibrated-loop method
►In some laboratories, two plates are inoculated, one with the 0.01- and the other with the 0.001 ml loop, serving as a quality control check
►0.001-ml (1µl) loop ,inside diameter of 1.45 ± 0.06 mm
> 1,000 CFU/ml
►0.01-ml (10µl) loop ,inside diameter of 4-5 to detect colony count > 100 CFU/ml
►Accuracy has an error rate of as much as +/- 50%, particularly when using the 0.001 ml loop
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Calibrated Loop
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Disposable Calibrated Loops
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Calibrated-loop method
►105 CFU/ml shows confluent growth in the
initial drop of urine with the 0.01-ml
(10µl) inoculum
►105 CFU/ml shows approximately 50 -100
colonies with the 0.001-ml (1µl) loop
►30- 300 colonies per plate
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Calibrated-loop method
►The maximum readable using the 0.001-
ml loop is 105 CFU/ml
►The maximum readable on the 0.01-m1
loop is 104 CFU/ml
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Calibration of Microbiological Loops
►Liquids in containers with small diameters
(<1 cm) have high surface tension
►Quantitative loops are used when <20%
error is acceptable.
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Calibration of Microbiological Loops
►The quality control of calibrated loops has always been a subject of irritation to many clinical microbiologists
►The calibrated loops is a vital piece of equipment in the quantitation of urine cultures
►Therefore, the laboratorian must check calibrated loops regularly, preferably on a monthly basis
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Calibration of Microbiological Loops
►Evans blue dye solution (EBD)
►Add 0.75 g of EBD to 100 ml of distilled water
♦ 0.2 g of EBD to 100 ml
►Filter solution through no. 40 Whatman filter paper
►Store at room temperature in a dark bottle for 6 months
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Calibration of Microbiological Loops
►Working solutions
►Prepare dilutions of the EBD (0.75 g / 100
ml ) stock solution in distilled water to
equal to 1:500, 1:1,000, 1:2,000, and
1:4,000
♦ OR Prepare dilutions of the EBD(0.2 g / 100
ml ) stock solution in distilled water to equal to
1:100, 1:200, 1:400, 1:800 , 1:1600 and
1:3200
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Calibration of Microbiological Loops
►Store the dilutions for up to 6 months, but
prepare new dilutions if the reading of any one
dilution differs by 3% from previous readings
►Measure and record the absorbance of each dye
dilution
►Wavelength of 600 -620 nm
►Zero spectrophotometer with distilled water
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Calibration of Microbiological Loops
►Using the 0.001-ml (1µl) loop, transfer 10 loopfuls of the EBD stock dye solution to l0 ml of distilled water.
►After thorough mixing, measure and record the absorbance of this solution
►The absorbance should correspond to that of the 1 :1 ,000 dilution on the calibration curve
►If the average reading is more than +/- 20% of the 1:1,000 stock solution dilution, the loop is inaccurate
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Calibration of Microbiological Loops
►To calibrate the 0.01-ml (10µl) loop,
transfer l0 loopfuls of the EBD stock
solution to 100 ml of distilled water using
the 0.01-ml loop
►The final reading should be the same as
that of the 0.001 loop, i.e., +/- 20% of the
1:1,000 stock solution dilution
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Calibration of Microbiological Loops
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Calibration of Microbiological Loops
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Calibration of Microbiological Loops
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Calibration of Microbiological Loops
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Urine Culture
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Culture methods
►Only streak the blood plate for colony count
►Other plates EMB / MacConkey should be
streaked in quadrants for isolation of colonies:
►Minimize delays (save time and cost) in obtaining
isolated colonies and
►Prevent false-negative culture result due to
antimicrobial inhibition
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Culture methods
►If colony count cannot be
performed due to overwhelming
spreading Proteus, an estimate of
the count can be made from the
isolation plate
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CHROMagar TM Orientation ►For rapid detection and differentiation of urinary tract pathogens, including gram negative and gram positive bacteria
►E.coli - red
►Klebsiella - steel blue
► Proteus - brown halo
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Urine Culture Incubation
►For most routine urines, 18 to 24 hours of incubation at 35°C is enough and you can finalize the culture as “No growth at 24 hours”
►If the urinalysis is positive for nitrate ,leukocyte esterase / WBC or Yeasts , then will incubate the no growth urine an extra day
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Examination of culture media/ 48 h
►The specimen was collected by an invasive technique, such as suprapubic bladder aspiration or straight catheter method
►Tiny or scant colonies are present
►Culture results do not correlate with Gram stain findings or clinical conditions (e.g., the patient has sterile pyuria or symptoms without a positive culture
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Examination of culture media/ 48 h
►The patient is immunocompromised,
including patients who have transplanted
organs
►Yeast or fungal culture is requested
►Many yeasts grow well on EMB
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Examination of culture media/ 48 h
►Candida glabrata
►Corynebacterium urealyticum
►Aerococcus urinae
►One way to avoid missing these pathogens is to
hold "no growth" urines from the "Urology"
service or the transplant service for 48 h
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Examination of culture media/ 48 h
►Hold positive culture
plates at room
temperature for at least 2
to 3 days for possible
further workup
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Screening for Salmonella
►Salmonella typhi and Salmonella paratyphi - S.
typhi and S. paratyphi are frequently isolated
from urine in the early stages of typhoid and
paratyphoid fever.
►Screening urines may be received from suspected
cases and/or their contacts for selective
enrichment and culture
►Carefully add an equal volume (5-10mL) of
uncentrifuged urine to 5-10mL of selenite
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Bacteria in microscopic urine but culture is negative
►Presence of nonviable bacteria due to prior
antimicrobial therapy
►Organisms seen microscopically would not grow
on the typical media used in urine culture
♦ Haemophilus influenzae
♦ Neisseria gonorrhoeae
♦ Acid-fast bacilli
♦ Anaerobes
♦ Bacteria which require different culture conditions
for growth
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Proteus mirabilis
►Proteus mirabilis is common in
young boys / Girls and males and
is associated with renal tract
abnormalities, particularly calculi
►Proteus is more common in male
infections following E.coli
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Staphylococcus saprophyticus
►S.saprophyticus is responsible for about 20
percent of urethritis and cystitis ?!<20% in
sexually active, healthy young women.
►S. saprophyticus adheres to uroepithelial
cells significantly better than S. aureus or
other coagulase-negative staphylococci
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Staphylococcus saprophyticus
►Routine antimicrobial testing of urine
isolates of S.saprophyticus is not advised,
infections respond to concentrations
achieved in urine of antimicrobial Agents
commonly used to acute,
►Uncomplicated UTI (e.g.,Nitrofurantoin,
Trimethoprim ± sulfamethoxazole,or
Fluoroquinolone).
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Coagulase-negative staphylococci
►Coagulase-negative staphylococci are
often considered as urinary contaminants
as they are part of the normal perineal
flora.
►However, they may cause complicated
infections in patients of both sexes with
structural or functional abnormalities of
the urinary tract, prostatic calculi or
predisposing underlying disease
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Staphylococcus aureus
►S. aureus can be a colonizer of the perineal area and the lower GU tract of females
► It can certainly be present as a contaminant in urine
►Rarely an etiologic agent of classic urinary tract infection in the non-catheterized patient
►S. aureus rarely causes infection and is associated with renal abnormality or as a secondary infection to bacteraemia, surgery or catheterisation.
►Presence of significant S. aureus bacteriuria can be indicative of systemic infection (bacteremia, endocarditis, toxic-shock syndrome etc)
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Enterococcus spp.
►Enterococcus spp. causing uncomplicated cystitis can be successfully treated with ampicillin because of the achievable drug levels in the urine
►Report as Enterococcus spp.
►Ampicillin is the drug of choice for cystitis in this case
►If the isolate is Vanco resistant, then we fully identify the organism and do and report full susceptibilities.
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Pseudomonas aeruginosa
►Pseudomonas aeruginosa
(associated with structural
abnormality or permanent
urethral catheterisation)
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Yeast cultures
►When yeast cultures are requested ,
►Culture at least 0.01 ml (10µl) per plate
►Hold cultures for 48 to 72 hr. to detect
yeasts in low number
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Candida
►Bladder colonization with Candida species
is associated with indwelling catheters
►May also be present as contamination
from the genital tract.
► Candida albicans is the most frequently
isolated species
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Candida ►Nosocomial candidal UTI have increased
►On agar medium, young colonies of
Candida albicans can resemble colonies of
coagulase-negative staphylococci
►Because Candida spp. often are recovered
from hospitalized patients with indwelling
catheters, incorrect identification results in
a susceptibility report indicating broad
antimicrobial resistance
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ORGANISMS
►Less common causes include
♦ Haemophilus influenzae
♦ C. trachomatis
♦ Mycoplasma hominis
♦ U.urealyticum
♦ Corynebacterium urealyticum
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Streptococcus viridans
►Viridans group streptococci are infrequent
urinary track pathogens but possible pathogens
♦ >100,000 CFU/ml
♦ WBC / leukocyte esterase (LE) positive
♦ No contaminating urogenital flora
►A count of 10-50,000 most likely represent
contamination
►If the LE test is negative and no usual pathogens
were present, recollection is not necessary
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Streptococcus viridans
►S. milleri (anginosus) group are viridans
streps and important etiologies of
abscesses
►If the viridans strep in the urine is S.
milleri group, it would be useful to make
sure that an abscess is not present in the
genital-urinary tracts
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Streptococcus viridans
►For patients who are not penicillin allergic
since the concentration of antibiotic in the
urine reaches concentrations that are
inhibitory to the viridans strep
►One organsim in this group considered as
a possible urinary tract pathogen is
Aerococcus urinae
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Aerococcus urinae
►Aerococcus urinae is a rarely reported pathogen, possibly due to difficulties in the identification
►Gram-positive coccus that grows in pairs and clusters
►Alpha hemolytic and tetrads/clusters in broth
►Negative for catalase and pyrrolidonyl aminopeptidase / PYR
►Most commonly in elderly males with predisposing conditions
►Suscpetible to penicillin ,Vancomycin ,Ciprofloxacin , Tetracycline
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Aerococcus urinae
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Aerococcus urinae
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Aerococcus urinae
►A. urinae a potential pathogen
►Resistant to Trimethoprim-
sulfamethoxazole ,Gentamicin
►Identification : API 20 Strep system (bio-
Merieux)
► >100,000 CFU/ml
►Urinalysis revealed 4 to 6 WBCs /HPF
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Aerococcus urinae vs. Enterococci
►Bile Esculin negative / Variable, and NaCl
positive
►Negative PYR
►Alpha hemolytic and tetrads/clusters in
broth
►Aerococci are sensitive to vancomycin,
which differentiates them from the
Pediococci
►Strongly alpha hemolytic on a blood agar
plate
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Aerococcus urinae vs. Enterococci
►Colonies appear larger than alpha strep,
but somewhat smaller than Enterococci
►Catalase and PYR negative and LAP
positive
►Treatment options include penicillin for
less severe cases, and penicillin or
vancomycin with gentamicin for more
severe cases.
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Aerococcus spp.
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Aerococcus spp.
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Streptococcus pneumoniae Archives of Internal Medicine, September 27, 2010
►Positive pneumococcal urinary antigen
test result in adult patients hospitalized
with community-acquired pneumonia
(CAP)/ Immunochromatographic
►Specificity of the pneumococcal urinary
antigen test was 96% and that its positive
predictive value ranged from 88.8% to
96.5%
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Corynebacterium urealyticum
►Corynebacterium (strongly urease
positive) in the uropathogens
♦ 48 h incubation
♦ Most of the urinary pathogenic
Corynebacterium are penicillin resistant
♦ Quinolone and sulfa-trimethoprim as other
drugs to test
►Corynebactium urealyticum
►Most corynebacteria isolated from urine
specimens are usually skin contaminants
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Corynebacterium urealyticum
►Prior urinary tract abnormalities or recent
urologic procedures are at the highest risk
►Urine is alkaline
► Chronic or recurrent cystitis, bladder
stones and pyelonephritis
►Organism is strongly urea-positive
►Pure culture or is the predominant isolate
►>100,000 CFU/ml
►It should be identified to the species level.
►Gram stain and a rapid urea test
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Corynebacterium urealyticum
►If Corynebacterium
urealyticum, a rare cause of
UTI, is suspected, the media
should be incubated for 48
hours.
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Lactobacilli > 100,000 CFU / ml
►Typically lactobacilli are considered
contaminants in urine cultures irrespective
of colony counts and whether they are
present in pure culture or with other
organisms.
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Other Bacteria
►Isolation of Bacillus spp. can almost
always be considered contamination.
►L. monocytogenes all cause diseases,
predominantly in highly selected patient
populations and almost always in
association with bacteremia
►Mycobacteria infrequently may be seen in
Gram-stained specimens of urine and
appear as weakly gram-positive bacilli
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REPORTING RESULTS
►When antimicrobial inhibition is observed
(i.e., no growth in the primary area of the
plate but growth in the area where the
inoculum is diluted)
►Do not report the count but report
"Colony count unreliable due to
antimicrobial inhibition”
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REPORTING RESULTS
►">100,000 mixed Gram-positive organisms present, probably represents contamination“
►Mixed flora (particularly mixed Gram-positive flora)
►Multiple bacterial morphotypes present; possible contamination ; suggest appropriate recollection, with timely delivery to the laboratory, if clinically indicated
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REPORTING RESULTS
►If no growth is observed on all media :
► 0.01 ml (10µl) was cultured, report "No
growth of >102 CFU/ml at 24 or 48 h”
►0.001 ml (1µl) was cultured, report "No
growth of >103 CFU/ml at 24 or 48 h”
►No Significant Uropathogen Isolated
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Interpretation of Urine Cultures
►Type of urine submitted
♦ Voided
♦ Straight catheterization
►Clinical history of the patient
♦ Age
♦ Sex
♦ Symptoms
♦ Antibiotic therapy
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Interpretation of Urine Cultures
►A pure culture of S. aureus is considered
to be significant regardless of the number
of CFUs, and antimicrobial susceptibility
tests are performed.
► The presence of yeast in any number is
reported to physicians, and pure cultures
of a yeast may be identified to the species
level
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