INTERPRETATION OF URINE CULTURES

CUMITECH GUIDELINES INCORPORATED

Dr.T.V.Rao MD

DR.T.V.RAO MD

12/15/2011

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

DR.T.V.RAO MD

12/15/2011

COLLECTION OF URINE SPECIMENS

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)
DR.T.V.RAO MD 12/15/2011

PROMPT TRANSPIRATION NEEDED

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

DR.T.V.RAO MD

12/15/2011

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

12/15/2011

INOCULATION OF URINE
Inoculation of urine for quantitative culture (colony forming unitscfus) 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 cfus per mL of urine With 0.01 ml loop, 1 colony on SBA equivalent to 100 cfus 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)
DR.T.V.RAO MD 12/15/2011

COMMON UROPATHOGENS
Escherichia coli

Other Enterobacteriaceae (Klebsiella, Enterobacter, Proteus, Citrobacter)

Pseudomonas aeruginosa

Enterococcus
Staphylococcus saprophyticus Staphylococcus aureus

Streptococcus agalactiae (group B)

Candida

DR.T.V.RAO MD

12/15/2011

UNCOMMON UROPATHOGENS
Corynebacterium urealyticum Hemophilus influenzae and H. parainfluenzae Blastomyces dermatitidis Neisseria gonorrhaeae

Mycobacterium tuberculosis
DR.T.V.RAO MD 12/15/2011

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COUNTING THE COLONIES

With 0.001 ml loop, 1 colony on SBA equivalent to 1,000 cfus per mL of urine With 0.01 ml loop, 1 colony on SBA equivalent to 100 cfus per mL of urine
DR.T.V.RAO MD 12/15/2011

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INTERPRETATION OF URINE CULTURES: GENERAL GUIDELINES

A single species of Enterobacteriaceae recovered at >105 cfus/mL urine: with patients symptomatic for urinary tract infection, 95% probability of true bacteriuria

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WHAT IS SIGNIFICANT BACTERIURIA

Significant bacteriuria in an asymptomatic patient is 100,000 or more colonies per milliliter of urine from a midstream, cleancatch 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.

DR.T.V.RAO MD

12/15/2011

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WHAT CAN BE A SIGNIFICANT COUNT

A single species of Enterobacteriaceae recovered at 104-105 cfus/mL urine: with patients symptomatic for urinary tract infection, 33% probability of true bacteriuria
DR.T.V.RAO MD 12/15/2011

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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

DR.T.V.RAO MD

12/15/2011

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URINE CULTURES
>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

DR.T.V.RAO MD

12/15/2011

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CUMITECH GUIDELINES FOR

INTERPRETATION OF ROUTINE URINE CULTURES

One isolate at >104:

Full ID and Susceptibility

One or two gramnegative isolates at >105 and other isolates at least 10X less: Full ID and Susceptibility of gram-negative isolates
DR.T.V.RAO MD 12/15/2011

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CUMITECH GUIDELINES FOR INTERPRETATION OF ROUTINE URINE CULTURES 1

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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DR.T.V.RAO MD

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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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12/15/2011

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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 >10 4 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 10 3 are proved significant

DR.T.V.RAO MD 12/15/2011

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INTERPRETATION OF ENTEROBACTERIACEAE
A single species of

Enterobacteriaceae recovered at >105 cfus/mL urine: with patients symptomatic for urinary tract infection, 95% probability of true bacteriuria A single species of Enterobacteriaceae recovered at 104-105 cfus/mL urine: with patients symptomatic for urinary tract infection, 33% probability of true bacteriuria
DR.T.V.RAO MD 12/15/2011

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INTERPRETATION OF ENTEROBACTERIACEAE
A single species of Enterobacteriaceae recovered at >105 cfus/mL urine: with patients symptomatic for urinary tract infection, 95% probability of true bacteriuria A single species of Enterobacteriaceae recovered at 104-105 cfus/mL urine: with patients symptomatic for urinary tract infection, 33% probability of true bacteriuria
DR.T.V.RAO MD 12/15/2011

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GRAM POSITIVES AND FUNGI THE COUNTS MAY BE <105

Gram-positive, fungal, and fastidious uropathogens often present in lower numbers (104-105 cfus/mL urine) Urethral commensals recovered at <104 cfus/mL urine
DR.T.V.RAO MD 12/15/2011

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CUMITECH GUIDELINES FOR INTERPRETATION OF ROUTINE URINE CULTURES 1

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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DR.T.V.RAO MD

12/15/2011

CUMITECH GUIDELINES
FOR INTERPRETATION OF SPECIAL OR UNCOMMON URINE CULTURES1

One or two isolates at >102 to 105: Full ID and Susceptibility is essential before confirmed as uncommon isolates

1 Clarridge,

Johnson, Pezzlo, and Weissfeld, ASM Cumitech 2B, November 1998.

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12/15/2011

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REPORTING OF NEGATIVE URINE CULTURES 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
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ASYMPTOMATIC BACTERIURIA
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 SOPs have been set up in accordance with CLSI Guidelines of Best practices

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 Created by Dr.T.V.Rao MD for eLearning resources for Microbiologists in the Developing World
Email
doctortvrao@gmail.com

DR.T.V.RAO MD

12/15/2011

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