Comparison of the B-D urine culture kit with a standard culture method and with the MS-2

Effectiveness of Preanalytic Practices on Contamination and Diagnostic Accuracy of Urine Cultures: a Laboratory Medicine Best Practices Systematic Review and Meta-analysis

BACKGROUND

Urinary tract infection (UTI) in the United States is the most common bacterial infection, and urine cultures often make up the largest portion of workload for a hospital-based microbiology laboratory. Appropriately managing the factors affecting the preanalytic phase of urine culture contributes significantly to the generation of meaningful culture results that ultimately affect patient diagnosis and management. Urine culture contamination can be reduced with proper techniques for urine collection, preservation, storage, and transport, the major factors affecting the preanalytic phase of urine culture.

OBJECTIVES

The purposes of this review were to identify and evaluate preanalytic practices associated with urine specimens and to assess their impact on the accuracy of urine culture microbiology. Specific practices included collection methods for men, women, and children; preservation of urine samples in boric acid solutions; and the effect of refrigeration on stored urine. Practice efficacy and effectiveness were measured by two parameters: reduction of urine culture contamination and increased accuracy of patient diagnosis. The CDC Laboratory Medicine Best Practices (LMBP) initiative's systematic review method for assessment of quality improvement (QI) practices was employed. Results were then translated into evidence-based practice guidelines.

SEARCH STRATEGY

A search of three electronic bibliographic databases (PubMed, SCOPUS, and CINAHL), as well as hand searching of bibliographies from relevant information sources, for English-language articles published between 1965 and 2014 was conducted.

SELECTION CRITERIA

The search contained the following medical subject headings and key text words: urinary tract infections, UTI, urine/analysis, urine/microbiology, urinalysis, specimen handling, preservation, biological, preservation, boric acid, boric acid/borate, refrigeration, storage, time factors, transportation, transport time, time delay, time factor, timing, urine specimen collection, catheters, indwelling, urinary reservoirs, continent, urinary catheterization, intermittent urethral catheterization, clean voided, midstream, Foley, suprapubic, bacteriological techniques, and microbiological techniques.

MAIN RESULTS

Both boric acid and refrigeration adequately preserved urine specimens prior to their processing for up to 24 h. Urine held at room temperature for more than 4 h showed overgrowth of both clinically significant and contaminating microorganisms. The overall strength of this body of evidence, however, was rated as low. For urine specimens collected from women, there was no difference in rates of contamination for midstream urine specimens collected with or without cleansing. The overall strength of this evidence was rated as high. The levels of diagnostic accuracy of midstream urine collection with or without cleansing were similar, although the overall strength of this evidence was rated as low. For urine specimens collected from men, there was a reduction in contamination in favor of midstream clean-catch over first-void specimen collection. The strength of this evidence was rated as high. Only one study compared midstream collection with cleansing to midstream collection without cleansing. Results showed no difference in contamination between the two methods of collection. However, imprecision was due largely to the small event size. The diagnostic accuracy of midstream urine collection from men compared to straight catheterization or suprapubic aspiration was high. However, the overall strength of this body of evidence was rated as low. For urine specimens collected from children and infants, the evidence comparing contamination rates for midstream urine collection with cleansing, midstream collection without cleansing, sterile urine bag collection, and diaper collection pointed to larger reductions in the odds of contamination in favor of midstream collection with cleansing over the other methods of collection. This body of evidence was rated as high. The accuracy of diagnosis of urinary tract infection from midstream clean-catch urine specimens, sterile urine bag specimens, or diaper specimens compared to straight catheterization or suprapubic aspiration was varied.

AUTHORS' CONCLUSIONS

No recommendation for or against is made for delayed processing of urine stored at room temperature, refrigerated, or preserved in boric acid. This does not preclude the use of refrigeration or chemical preservatives in clinical practice. It does indicate, however, that more systematic studies evaluating the utility of these measures are needed. If noninvasive collection is being considered for women, midstream collection with cleansing is recommended, but no recommendation for or against is made for midstream collection without cleansing. If noninvasive collection is being considered for men, midstream collection with cleansing is recommended and collection of first-void urine is not recommended. No recommendation for or against is made for collection of midstream urine without cleansing. If noninvasive collection is being considered for children, midstream collection with cleansing is recommended and collection in sterile urine bags, from diapers, or midstream without cleansing is not recommended. Whether midstream collection with cleansing can be routinely used in place of catheterization or suprapubic aspiration is unclear. The data suggest that midstream collection with cleansing is accurate for the diagnosis of urinary tract infections in infants and children and has higher average accuracy than sterile urine bag collection (data for diaper collection were lacking); however, the overall strength of evidence was low, as multivariate modeling could not be performed, and thus no recommendation for or against can be made.

Evaluation of the BD Vacutainer Plus Urine C&S Preservative Tubes compared with nonpreservative urine samples stored at 4°C and room temperature

OBJECTIVES

The stability of urine specimens submitted for culture remains a challenge for many laboratories because of delays in specimen transport. We evaluated the usefulness of BD Vacutainer Plus Urine C&S Preservative Tube in ensuring specimen stability.

METHODS

Clinical urine specimens collected in sterile collection cups (n = 110) were plated onto sheep blood and MacConkey agar following standard laboratory procedures guidelines. Thereafter, specimens were divided into 3 storage conditions: nonpreservative, refrigerated; nonpreservative, room temperature (RT); BD Vacutainer Plus Urine C&S Preservative Tube, RT. For each sample type, additional cultures were set up at 2, 4, 24, and 48 hours.

RESULTS

Initially, 18 specimens had no growth, 32 showed mixed skin flora, and 60 yielded at least 1 uropathogen. Increased colony counts of uropathogens were observed for nonpreserved urine samples stored at RT; these changes were statistically significant. Minor differences between refrigerated urine samples and BD Vacutainer Plus Urine C&S Preservative Tube samples were seen but were not statistically significant.

CONCLUSIONS

The use of preservative-containing collection tubes is desirable to ensure specimen stability when prompt processing or refrigeration is not feasible.

A method for the rapid detection of urinary tract infections

OBJECTIVE

To determine the reliability of a rapid detection method compared with the reference standard streaked agar plate in diagnosing the presence of urinary tract infection (UTI).

METHODS

De-identified clean catch urine specimens from 980 office visit patients were processed during a 30-day period. Classic 1-μL and 10-μL streaked agar plates were used in parallel with the new CultureStat Rapid UTI Detection System (CSRUDS). Urine results were evaluated using the CSRUDS at 30 and 90 minutes after collection. A comparative analysis of the subsequent plate results versus the CSRUDS results was achieved for 973 of these samples.

RESULTS

Positive UTI conditions were accurately identified by both CSRUDS and agar streak plate methods. CSRUDS accurately identified UTI negative conditions with 99.3% reliability at 90 minutes. The negative predictive value of CSRUDS was 99.2% at 30 minutes.

CONCLUSION

Current agar plating for first-round UTI screening has substantial documented problems that can negatively affect an accurate and timely UTI diagnosis. A novel rapid detection system, the CSRUDS provides UTI negative/positive same-day results in ≤ 90 minutes from the start of test. Such rapidly available results will enable more accurate and timely clinical decisions to be made in the urology office, particularly regarding infection status before urologic instrumentation.

The effect of boric acid on bacterial culture of canine and feline urine

OBJECTIVE

To identify the optimal method of submission of canine and feline urine for bacterial culture.

METHODS

Cystocentesis samples from 250 animals (200 dogs, 50 cats) suspected of having urinary tract infections were collected. The reference aliquot, without preservative, was processed on site within 2 hours. Two further aliquots (one without preservative, one with boric acid) were stored at room temperature for up to 7 hours and then posted by guaranteed next day delivery to a commercial laboratory for analysis.

RESULTS

Forty-seven of the samples were positive on culture in the reference test. There was no significant difference between reference test results and those of samples posted without preservative (P=0·39), but samples posted in boric acid were significantly less likely to give a positive result (P=0·01). Samples posted without preservative had a sensitivity of 82% and a specificity of 98%; for boric acid, sensitivity was 73% and specificity 99%.

CLINICAL SIGNIFICANCE

Postal urine samples should be submitted to the laboratory in a plain sterile tube.

Rapid isolation and presumptive diagnosis of uropathogens by using membrane filtration and differential media

Random urine samples from hospitalized patients (n = 550) and seeded sterile filtered urine samples (n = 730) were used to test a membrane filtration technique, Qualture (Future Medical Technologies International, Inc., West Palm Beach, Fla.), for the detection and identification of uropathogens. Results for each sample were compared with those obtained by the calibrated loop (0.01 ml) method to demonstrate the sensitivity of the method as a screening tool and the specificity of the presumptive diagnosis obtained from the pattern of growth on differential media. The medium was supplied as dehydrated nutrient pads (Sartorius AG, Goettingen, Germany) and was activated by rehydration by the addition of the liquid specimen. With a threshold of 10(4) CFU/ml defining a positive culture, the sensitivity of the Qualture was 100%. At lower levels of bacteriuria, the Qualture was more sensitive than the calibrated loop method. Significant infections were presumptively diagnosed at 4 h by filtration rather than at 24 h on agar medium. The specificity of uropathogen identification ranged from 99% for Enterococcus spp. to 83% for Pseudomonas spp. Citrobacter spp. could not be differentiated from Escherichia coli and Providencia spp. could not be differentiated from Proteus spp., which does not create a therapeutic dilemma. Filtration, isolation, quantitation, and presumptive diagnosis are performed in one step, without subculture. Membrane filtration is a sensitive and rapid technique, with the advantage that it can be used as a collection and transport device without the use of growth inhibitors.

Microbial stabilization of antibiotic-containing urine samples by using the FLORA-STAT urine transport system

The FLORA-STAT Urine Transport System (Wadley Biosciences Corp./Lymphokine Partners Ltd., Dallas, Tex.) was evaluated for its efficacy in maintaining organism count and in effectively blocking the bactericidal action of therapeutic antimicrobial agents in urine samples when the urine samples were held at room temperature. Reconstructions with 53 organism-antimicrobial combinations were performed at 0, 4, 8, and 24 h in which the FLORA-STAT system was compared with two boric acid-based systems (Urine C&S Transport Kit [Becton Dickinson VACUTAINER Systems, Rutherford, N.J.]; Sage Urine Collection Kit for Culture [Sage Products, Inc., Cary, Ill.]) and untreated urine. At 24 h, less than 1-log-unit changes in organism counts were found in 100, 92, and 10% of the urine samples without antimicrobial agents and in 97, 65, and 16% of the urine samples with antimicrobial agents for FLORA-STAT-treated, boric acid-treated, and untreated urine samples, respectively. The FLORA-STAT system was further evaluated by sending split samples prepared from laboratory-inoculated patient urine samples (57 without and 50 with antimicrobial agents) to four commercial laboratories by using their respective transport devices and procedures. Samples were also sent to a local reference laboratory which provided prompt processing. Each laboratory received independently labeled transport devices containing untreated, FLORA-STAT-treated, and preservative-treated (if provided by the commercial laboratory) samples prepared from the same urine specimen of a patient. Average estimated transport times ranged from 13 to 24 h for the commercial laboratories; the transport time was less than 4 h for the local reference laboratory.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical evaluation of a urine transport kit with lyophilized preservative for culture, urinalysis, and sediment microscopy

Comparative results of urine culture, specific gravity, chemical urinalysis, and sediment microscopy were assessed when specimens submitted to the clinical laboratory were divided and processed either in a transport kit containing a lyophilized preservative or in a conventional sterile cup without preservative. Overall agreement of results of 853 cultures after a 24-hr holding period (preserved samples at room temperature, unpreserved samples refrigerated) and 277 repeat cultures after a 48-hr holding period also showed excellent agreement (99.1% and 95.7%, respectively). Results of urinalysis and sediment microscopy done on 370 specimens demonstrated greater than 98% agreement after receipt of specimens in the laboratory and greater than 94% agreement after the holding periods. Specific gravity determinations from samples processed in the presence of preservative consistently were 0.006-0.007 units greater than in samples processed without preservative, and a reporting adjustment will be necessary when the transport kit is used.

Effect of the B-D Urine Culture Kit on an automated bacteriuria screen

The effect of urine collected in the B-D Urine Culture Kit (BDT; Becton, Dickinson & Co., Rutherford, N.J.) on the Autobac urine screen (General Diagnostics, Warner-Lambert Co., Morris Plains, N.J.) was investigated. Upon collection, 1,000 clean-voided urine specimens were divided into sterile urine tubes and BDTs. Within 24 h of collection, urine from each tube was cultured by a semiquantitative plate method and screened by the Autobac system. Overall, when screened by the Autobac system, urine collected in the BDT gave fewer false-positive results: 14.4 compared with 22.7% from the sterile urine tubes. However, in comparison with the sterile urine tubes, the BDT false-negative rate was 10.5 versus 4.7%, the detection time was longer, and the cost was increased.

Use of the Becton-Dickinson urine culture tube with the Abbott MS-2 urine screening system

Urine specimens were obtained from 312 obstetric outpatients by sterile midstream technique and aliquots placed in both Becton-Dickinson urine culture tubes and sterile conventional tubes. Quantitative cultures were made from each tube, and each tube was screened for bacteria with the Abbott MS-2 urine screening system. The time required to detect bacteriuria was recorded for both specimens. Isolates from specimens containing greater than or equal to 50,000/ml gram-positive cocci or greater than or equal to 100,000/ml gram-negative bacilli were identified and antimicrobial susceptibility tests performed. Delayed (24 hr) quantitative cultures were done from Becton-Dickinson tubes. By these criteria, 124 urine specimens were positive in both conventional and Becton-Dickinson tubes. Escherichia coli (n = 72), Klebsiella pneumoniae (n = 20), Enterobacter cloacae (n = 8), Proteus mirabilis (n = 4), group B streptococcus (n = 12), and enterococcus (n = 8) were isolated. Time for detection of positive urine samples was similar in both types of tubes. Delayed cultures had significant numbers of false-positive results. Antimicrobial susceptibility results did not appear to be influenced greatly by Becton-Dickinson tube transport. The MS-2 cannot adequately discriminate cultures containing less than 50,000 colony-forming units/ml of urine. The Becton-Dickinson tube appears to be compatible for use with the MS-2 for purposes of screening for bacteriuria.

Evaluation of liquid and lyophilized preservatives for urine culture

Culture results of urine specimens transported conventionally (sterile cup) and in a commercial liquid or an investigational lyophilized preservative were compared in a hospital that experiences substantial delays in specimen transport to the laboratory (greater than 40% of specimens received after a delay of greater than or equal to 2 h). At the time of initial plating in the laboratory, 106 of 111 (95.5%) specimens that were positive (greater than or equal to 10(5) CFU of a single organism per ml in pure culture) after conventional transport were also positive in liquid preservative. After a 24-h holding period (cup refrigerated, preserved urine at room temperature), agreement was 91.4% (96 of 105). At the time of initial plating, agreement between results obtained by the conventional method and those obtained by using lyophilized preservative was 96.9% (63 of 65); after 24 h, agreement was 92.4% (61 of 67). Complete inhibition of growth of three Klebsiella pneumoniae isolates was observed in liquid preservative; however, urine processed in the lyophilized preservative did not show inhibition. The proportion of urine cultures showing no change in quantitative growth between the time of initial plating and repeat plating at 24 h was virtually identical for all three processing methods (83.6 +/- 0.9%). After the 24-h holding period, specimens processed in lyophilized preservative were less likely to show diminished quantitative growth than were specimens processed conventionally or in liquid preservative but were more likely to show an increase in growth of greater than or equal to 1 log. Nonetheless, the apparent lack of toxicity of lyophilized preservative may make it preferable to the currently available liquid preservative.