Clinically Relevant Microbiology Starts at the Source

Mike Costello, PhD, MT(ASCP) ACL Laboratories 847.349.7403 mike. ostello!a"#o atehealth. om Mar$ Dikema%, MT (ASCP) A&&i%it$ 'ealth S$stem 9(0.738.()38 m"ikema%!a&&i%it$health.or*

Program Objectives

Emphasize that obtaining sensitive and specific microbiology results begins with the patient and not at the door of the microbiology laboratory. Accentuate the importance of proper collection and transport of specimens in both local and referral environments Stress the importance of timely communication between the Microbiology laboratory and those collecting specimens Describe common pitfalls in specimen collection and transport Discuss What rules or principles must be followed in order to collect microbiology specimens which will accurately reflect the pathogenesis of the microbiological agent. ( hurch
D. !he Seven "rinciples of Accurate Microbiology Specimen ollection. . #aboratory Services Microbiology $ewsletter. %olume &' ())*+ algary

Introduction
!he practice of sensitive' specific and cost effective clinical microbiology is intimately tied to the submission and proper handling of optimal specimens for analysis. ,nfortunately' these aspects of clinical microbiology are not as critically controlled as our laboratory assays. -t is our responsibility to educate and notify our healthcare colleagues when specimens arrive at the laboratory that will yield inferior results. .uality assurance of specimen collection and transport is a never ending battle and re/uires long term commitment of your time and resources' but the end results are better patient care and a more rewarding e0perience for those of us who wor1 in the microbiology laboratory.

collected "ith a minimum o# contamination as close to site o# in#ection as possible

Specimen Urine Culture Source of Contamination All non surgical samples become contaminated with urogenital flora during collection. Contaminating bacteria will replicate if specimen is not quickly transferred to a preservative tube or stored (4C . -mproper cleaning of skin or catheter prior to drawing specimen. !ransfer from .". tube to blood culture vial. Collection from catheter. Storage and Transport !ransfer urine to a Urine "reservative tube within #$ minutes of collection (good for 4% hrs. at ambient temp. &ess optimal' store(transport urines at 4 C for up to )4 hrs. Ambient. /ust be incubated in automated system within #) hours. Solution/Monitor "atients must be instructed to properly cleanse the peri*urethral genital skin area prior to collection of the mid* stream portion of the urine stream in order to get an accurate urine culture result. Use of urine preservative tubes. 0ngoing education program. /onitoring contamination rates. &imit use .". tubes. 1o not draw from catheter unless specifically requested (protocol2 discard 34 cath. volume 2 then one culture set from catheter and one from peripheral. Education "rompt feedback to individuals or sites who collected urine for culture. Urine preservative tubes should be used when appropriate. !imely feedback to individuals who collected specimen.

+lood Culture, bacterial, mycobacterial, fungal

$rine Culture Contamination Rates

+ri%e C,lt,re o%tami%atio% rates (-( ba teria at -)00,000 C.+) sho,l" be /(00

A" .2"robe study (%alenstein " Meier 3. ,rine culture contamination4 a ollege of American "athologists .2 "robes study of contaminated urine cultures in 5)& institutions. Arch "athol #ab Med. 655786((46(926(5+..

&9) participants collected information of 6**')9: urine culture specimens8 ().6; were considered contaminated (<( organisms at <6)* 3,+ The to1 )00 o& i%stit,tio%s re1orte" a rate o& 2.30. 4ottom )00 o& i%stit,tio%s re1orte" a o%tami%atio% rate o& 33.80 Males ha#e a lo5er o%tami%atio% rate tha% &emales ()).(0 6s. ((.80) E= departments had a contamination rate of 6:.7;' sites ad>acent to lab had rates of 65.*;' and other sites had rates of ((.6;

%lood Culture

!wo sets of blood cultures should be drawn. $umber of sets positive correlates with true sepsis (e0cept for coagulase negative Staph?+ ( lin Microbiol. =ev 654:7727)(' ())&+ atheter drawn blood cultures

atheter drawn blood cultures are e/ually li1ely to be truly positive (associated with sepsis+' but more li1ely to be colonized (@ lin Microbiol 9749959' ())6.+

Study of positive coagulase negative Staphylococcus cultures and sepsis (

954999' ())C.+

Ane drawn through catheter and other though vein ""% )f 5&; Both drawn from catheter ""%(positif predi1tif value+ )f 200 Both drawn through vein ""% of 57;
lin -nfect Dis.

What is an DAcceptableE Blood

ulture

ontamination =ate for Four #ab??

%lood Culture Contamination Rate %y Service &ra"ing Culture

+lood Cultures Collected +y -ndicated .taff !ype (5 Dedicated phlebotomy staff $*)3 );*:3 :;*#$$ Medical technologists or technicians $ #*#$ ##*#$$ "onlaboratory staff $ #*3$ 3#*8$ 8#*#$$ 6o. of &abs 84 #): #)$ #;3 ##9 ;$ 9; )39 9; #: /ean +lood Culture Contamination 7ate (5 9.): 9.$)

2.84
9.)3 ).83

2. !
).#: 9.$$ 9.4$

4.2#

+erkeris &<, =A !oworek, /> ?alsh, "6 @alenstein. !rends in +lood Culture Contamination. Arch "athol &ab /ed #)8'#)))*#)84, )$$3

What is an DAcceptableE Blood ulture ontamination for Four #ab?? Blood Culture Contamination in =ate Pediatric

Patients Young Children and Young Doctors

%ariable E0perienced physician2older child E0perienced physician2younger child -ne0perienced physician2older child -ne0perienced physician2young child !otal !rue "ositive 8( )32 3alse "ositive 74 )2) "redicative %alue of a "ositive =esult 0.23 0.2(

9( (() 230

)28 382 738

0.37 0.37

Foung hildren G 629* months Alder hildren G <9& months -ne0perienced "hysicians G -nterns and residents in 6 st half of training E0perience "hysicians G =esidents in (nd half of training and senior physicians
"ed -nfect Dis. ())&' (*4&662&6C.

'hat is an (acceptable) blood culture contamination rate*+

Contamination 7ate "opulation 6o. of &abs )3 "ercentile 3$th "ercentile (/edian :3th "ercentile Adults 9); ).)9 ).8) 9.% 6eonates )34 $.:3 ).$% 4.): All "atients 93; ).#3 ).%8 9.;: A +lood culture is considered contaminated if # or more of the following organisms were identified in only one of a series of blood culture specimens2 coagulase negative .taphylococcus, Propionibacterium acnes, /icrococcus spp., @iridans group .treptococcus, Corynebacterium spp., or +acillus spp. (not B. anthracis
th

CA" B*!racks (#888*)$$9 /edian contamination rate of ).8)5 ?hat should your blood culture contamination rate beC #. .tatic model. .et a contamination rate (D95. 7ange ).)95*9.%5 Adults2 $.:35*4.):5 6eonates . 1efine an Eacceptable rateF and institute correct measures when rate drifts above critical value ). Continuous Buality -mprovement /odel. .et a rate that at which )(9 can achieve, D).35 . 0nce 835 of units achieve this rate lower it to ).$5. .trive to be in the top #$ percentile

Ber1eris #H' @A !owore1' MI Walsh' "$ %alenstein. !rends in Blood Arch "athol #ab Med 6(546(((26(5C' ())*

ulture

ontamination.

Principle #1 !he specimen must be collected "ith a minimum o# contamination as close to site o# in#ection as possible ,cont-.
Specimen 7espiratory Culture Source of Contamination -mproper mouth care prior to collection of specimen. &ack of deep cough to obtain lower respiratory material. Storage and Transport Ambient for % hours. 7efrigerated )4 hours. .ome organisms, such as Haemophilus influenzae are susceptible to drying or low temperature. -n transport container. Ambient for no longer that )4 hours. /aHimiIe transport time. Solution/Monitor /onitor 5 reGected sputum. 5 with oral contamination (epithelial cells2 multiple .trep species, usually in clumps on gram stain and culture results . .putum culture @s. blood culture resultsC Education All sputum samples are contaminated to varying degrees with oropharyngeal flora. 7insemouth with sterile saline(water immediately before eHpectoration reduces number of contaminating bacteria. !imely feedback to individuals who collected specimen. .putum samples of D) m& should not be processed unless obviously purulent. .uperficial' cleanse with :$5 alcohol2 aspirate or swab fluid 1eep' cleanse with :$5 alcohol, use syringe, surgical procedure,J. !issue' aspirate or 3*#$ mm piece of tissue.

?ound Culture

-mproper cleaning of wound site prior or collection.

/ycobacteria Culture

.putum' -mproper mouth care prior to collection of specimen.

Ambient for % hours. 7efrigerated )4 hours.

6umber of squamous epithelial cells @s. "/6s seen on <ram stain. "resence of squamous epithelial cells associated with a superficial specimen. !he representative specimen is taken from the advancing margin of the wound (A.C" !eleconference. %#9$, )$$: Contamination rate2 track 5 6A0K required for decontamination. Culture redigests.

!imely feedback to individuals who collected specimen.

Respiratory Cultures

ommunity Ac/uired "neumonia J Sputum re>ection rate and culture correlation with gram stain

%entilator associated pneumonia (%A"+ J appropriate specimen

*C; of all samples were >udged to be of good /uality. "resence of a (predominant morphology+ "M on Hram stain was predictive of whether the sputum culture could demonstrate a pathologic organism. -n the presence of a positive "M' 7&; of cultures yielded a pathologic organism' while a positive culture was obtained in 65.*; of Hram stains without a predominant organism. S. pneumoniae was the most common infection' growing in **.:; of positive sputum cultures. !he sensitivity and specificity of finding Hram2positive diplococci for a positive culture of S. pneumoniae were &); and 5:.&;' respectively (Arch Intern Med. ())C86&C46:(*26:(:' 67):26766+ Blood cultures highly specific but not sensitive (positive in K6); of %A"+ .uantitative cultures of lower respiratory tract specimens show a closer clinical correlation than sputum subcultures ( linical Microbiol. =ev. 654&9:2&*:' ())&.+

/iral Respiratory Cultures Collect Sample 0rom Site o# In#ection

Comparison of nasal swab, nasopharyngeal swab, and nasopharyngeal wash specimens with an expanded gold standard in the Quidel QuickVue influenza test
No. of positive samples no. of samples !"# $pecimen %ype Nasal $wab Nasopharyngeal Swab Nasopharyngeal 0ash $ensitivity '( )* !+,# 50/59 (85%) '- )* !(*# $pecificity '( ', !*(# 50/51 (98 '- '. !*,# &ositive &redictive Value (- +' !,.# 62/71 (87) (. ,/ !+,# Negative &redicative Value -/+ -.. !,,# 112/122 (92) -/1 -.. !,'#

2 Clin 3icrobiol. .//(4 ''5.(1,6.('-

!hroat swabs are even worseM

Low do you 1now that an ade/uate Specimen was submitted for rapid E-A assays???

Samples #or &iagnosis o# /iral Respiratory In#ections

1LA (M-A 0-A Culture

2tility

Sample
"C7
$ung biopsy %ronchial al&eolar la&age/'ash/brush

-iral Titer .(/.

Cost(effort of collection 'ar"

.ource of infection
Site of infection

"asopharygeal secretion LRTC* present Sputum "asopharygeal 'ash (nduced sputum "asopharygeal s'ab "asal 'ash

,eagent Cost 1LA N Culture NN M-A NN(NNN 0-A NNNN 7!*"C7 NNNNN

LRTC cells absent

Throat s'ab )adeno&irus only* Sali&a %lood+

#=! G lower respiratory tract cells (columnar epithelial cells' alveolar macrophages+

-iral Titer $01

7as$

,emote sampling

Submit Specimens 3"ot S'abs

"ancy Cornish MD '''.cap.org

S1in and So#t !issue ,'ound. Cultures

ollect with steel (needle aspirate or scalpel+ Discourage the use of swabs -f infection $A! suspected' DA$N! culture Het infected tissue or body fluid O discourage swabsM P 2use something sharp ( syringe' scalpel' etc + 2close doesnNt count 8DonNt culture the surface Q get deep infected sample8 =emove needles Q send capped syringe with aspirate Share specimen4 Microbiology2Surgical "ath2 ytology 88 #abel specimen and site accurately 88 Hive appropriate history

(Mat1os1i . Sharp SE' Iis1a D#. Evaluation of the . Score and .(9C Systems for cost2effective and clinically relevant interpretation of wound cultures. @ lin Microbiol ())&8CC467&5267:( +

order to recover the pathogen,s. o# interest

Specimen Urine +lood Culture 0ptimal Time Lirst morning specimen preferred. Collect prior to administration of antibiotics. Collect )*9 sets of blood cultures from different sites. -f suspect bacterial endocarditis and initial cultures are negative at 4% hours then collect )*9 additional cultures from different sites. .uspected bacteremia or fungemia with persistently negative blood cultures Comments 0r not have urinated in several hours -nterpretation of one positive culture problematic, especially if isolate is coagulase negative .taphylococcus. Consider laternative blood culture methods dsigned to enhance recovery of mycobacteria, fungi, and other rare and fastidious microorganisms .putum not saliva 6ot midstream urine. "lace sample in transport tube per manufacturerOs instructions &ingering 16A may still be present.

AL+ Culture <C(Chlamydia, urine

!hree consecutive specimens collected %*)4 hours apart, with at least one being an early A/ specimen Lirst voided urine of day. Lirst stream of urine optimal. &ess sensitive' "atient should not have urinated for at least # hour. 1o not use 6A! methods as Eproof of cureF.

Principle #2 3 specimen must be collected at the optimal time,s. in order to recover the pathogen,s. o# interest ,cont.
Specimen 0va and "arasites .tool Cultures 0ptimal Time ?ait #$ days if barium or oil present. Lor multiple samples, collect every other day. 7ecommend ) samples on consecutive days. "rior to 9 days post admission. Comments "lace stool in preservative (#$5 formalin, "@A, .AL, McofiH within one hour of collection. -nstruct patient. "lace in enteric preservative (Cary* +lair immediately. .tool specimens that are obtained 9 days after admission are not usually helpful for the diagnosis of hospital acquired diarrhea .ubmit finger stick !hick P !hin slides or peripheral blood in an M1!A tube within )4 hours. .tore at ambient temperature. !he first 9 days is best.

+lood "arasites

Collect during a febrile episode or every ; hours for a )4 hour period. Collect as soon after onset of symptoms as possible.

@iral Culture

Principle #4 3 su##icient 5uantity o# the specimen must be obtained to per#orm the re5uested tests
Culture 7lood Culture !n!"u" #e$u!re"ents -/ ml of aerobic5 -/ ml for anaerobic bottle : separate swab!s# for each culture . m8 from tube .,1, or ' $ee chart $ee %able Co""ent $ensitivity of a blood culture is directly related to the volume of blood submitted. %wo blood culture sets !-/ m8 in both aerobic and anerobic bottles# before administration of antibiotics is *," sensitive !2. Clin. 3icrobiol. -**, 1(4 ()+6((-#. ;nough material must be submitted for gram stain, if re<uired. $ubmit most turbid tube. :t least /.) m8 of C$= is re<uired for cytospin gram stain. Cooperation with other departments !laboratory and non laboratory# is key.

9ne swab for multiple cultures C$= Culture $urgical and $hared $pecimens :naerobic Cultures

%lood Cultures

6ol,me o& bloo" "ra5% is the si%*le most im1orta%t &a tor i%&l,e% i%* se%siti#it$. A single set for an adult blood culture consists of one aerobic and one anaerobic bottle. Aptimally )0 mL o& bloo" sho,l" be i%o ,late" i%to ea h bottle. %olume of blood for a pediatric culture can be related to the infants weight Solitary blood cultures should be less than *;
(Arch "athol #ab Med. ())6 6(*46(5)26(5C+

-f only enough blood can be drawn for one bottle' inoculate the aerobic bottle.

&CC positive blood cultures' *5.7; from both bottles' (5.7; from aerobic bottle only and 6).C; from anaerobic bottle only (@ -nfect hemother 54((:' ())9+.

Pediatric %lood Cultures 6 /olume

Recommended Pediatric Blood Culture Volumes By Patient Weight Weight Weight Minimum One Two Adult (KG) of (LB) of Volume Pediatric Bottles Patient Patient (mL) Bottle (aerobic and anaerobic) <1.0 Kg 2.2 Lb. 1.0 mL Yes No 1.5-3.9 Kg 2.3-8.6 Lb. 1.5 mL Yes No 4.0-13.9 Kg 8.7-30.6 Lb 3.0 mL Yes No 14.0-24.9 30.7-54.9 10.0 mL No Yes (5 mL in Kg Lb each) >25.0 Kg >55 Lb. 20.0 Ml No Yes (10 mL in each)

Surgical Specimens ,Other Shared Specimens.

C0$$ECT(0" 7"D .7"D$("/ 04 08E,7T("/ ,00M S8EC(ME"S 40, M(C,0%(0$0/9 M(C,0%(0$0/9

T(SS2E
.pecimen siIe of pea or larger .pecimen smaller than a pea (i.e. 6eedle biopsy
"ut entire specimen into Anaerobic transport tube 0n piece oftelfa backed gauIe

4$2(D
"leural "eritoneal Abscess C.L, etc. 4 drops Q ) m& #*)$ m& Anaerobic .terile .pecimen tube !ransport or cup Container !ube

Di&ide

Anaerobic transport tube Kold upright5 uncap, insert specimen and recap Anaerobic Culture

>eep moist by adding #* #*) m& sterile saline Aerobic culture and <ram stain Aerobic culture Lungus culture and stain AL+ Culture and stain @irus Culture

Aerobic culture and <ram stain Aerobic culture Lungus culture and stain AL+ Culture And stain @iral Culture

Aerobic culture Lungus culture and stain Anaerobic Culture AL+ Culture and stain @irus Culture -n @iral !ransport /edium

2,("E
-ndicate source 0n requisition (Cath., cysto, bladder, 7 ureter, &. ureter Ma6imum) hr transport to lab

3cceptable Specimens 0or 3naerobic Culture

Site Abdomen 7cceptable Specimens Peritoneal fluid obtained by needle and syringe Abscess aspirate obtained by needle and syringe Bile Biopsy material surgically obtained Anaerobic swab surgically obtained Ascitic fluid, bile, blood, bone marrow, CSF, pericardial, pleural, seminal, synovial fluid, throacentesis, transudates Aspirate obtained by needle and syringe Biopsy material surgically obtained Anaerobic swap surgically obtained Abscess aspirate obtained by needle and syringe Biopsy material surgically obtained Anaerobic swab surgically obtained Culdoscopy specimens Endometrial aspirate obtained by suction or protected collector Abscess aspirate obtained by needle and syringe Biopsy material surgically obtained Anaerobic swabs surgically obtained IUD for Actinomyces species 2nacceptable Specimens Aerobic swabs

Body Fluids Bone and joint

Superficial material collected with swabs

Central nervous system Female genital tract

Aerobic swabs

Vaginal or cervical swabs

3cceptable Specimens 0or 3naerobic Culture

Site Head and neck 7cceptable Specimens Abscess aspirate obtained by needle and syringe after surface decontamination Biopsy material surgically obtained Anaerobic swab surgically obtained when aspiration is not feasible Transtracheal aspirate Material from percutaneous lung puncture Biopsy material surgically obtained Bronchoscopic specimen obtained by protected brush Thoracatomy specimen Anaerobic swab surgically obtained Aspirate obtained by needle and syringe Biopsy material surgically obtained Aspirate from sinus tract obtained by needle and small plastic catheter Deep aspirate of open-wound obtained through decontaminated skin Deep aspirate of surface ulcer obtained through decontaminated skin Suprapubic aspirate 2nacceptable Specimens Throat or nasopharyngeal swabs Gingival swabs Superficial material collected with swabs

&ungs

Expectorated sputum Induced sputum Endotracheal aspirate Bronchoscopic specimens not specially collected

Soft tissue

Superficial material collected from skin surfaces or edges of wound

Urinary tract

Voided urine Catheterized urine

Principle #7 3ppropriate collection devices and specimen containers must be used to ensure recovery o# all organisms
Culture/S!tuat!on :naerobic Culture Co""ents :naerobic cultures are best collected with metal !needle aspiration or with a scalpel#. :spirates of pus or fluids could be left in syringe if not a long distance transport. : large piece of tissue )6-/ mm will protect anaerobes in center. $pecimen received in aerobic transport media. $tuart>s and :mies media will allow for isolation of facultative anaerobes !:mies giving slightly better yields#. ?se of true anaerobic transport media will result in the best yields of all anaerobes. Consider re@ection of swabs not in anaerobic transport. $pecimen received in N:% transport tube can not be cultured. Collect Chlamydia in 36', ?%3. Collect AC culture in :mies B charcoal and or transport immediately. to lab at ambient temperature for immediate plating. 7acterial culture ordered on tissue placed in formalin. Culture is not an option. Ce<uest another specimen. 7acterial cultures sent in Viral %ransport 3edia. Ce<uest another specimen, most V%3 contain antibiotics $wab not placed in transport media. $pecimen not viable, re<uest another specimen.

Chlamydia or AC Culture

%issue sent in preservative 7acterial Culture sent in viral transport media Dry $wab

Low Does !ransport Affect Fields? %acteria Recovery o# !ime 3naerobic

Placed in in 3erobic83naerobic !ransport Media

%" G opan %i2"a1 Amies Agar Hel collection and transport swabs SSS G Starple0 StarSwab --' "A G BB# "ort2A2 ult

Low Does !ransport Affect Fields? Recovery o#!ime 3naerobic

%acteria Placed in in 3erobic83naerobic !ransport Media ,Cont.

Low Does !ransport Affect Fields? Recovery o#!ime 3naerobic

%acteria Placed in in 3erobic83naerobic !ransport Media ,Cont.

lin Microbiol. ())6495 9::297)

devices and specimen containers must be used to ensure recovery o# all organisms
Culture/S!tuat!on Viral culture sent in bacterial transport media Catheter %ip Cultures Aastric 8avage =luid $pecimens for 3ycobacteria 3ycoplasma ?reaplasma culture sent in bacterial transport media Duodenal Aastric aspirates Co""ents Viral culture sent in 7acterial transport media. Ce<uest another specimen. &robably 9E for adenoviruses and enteroviruses if cultured within .' hours. $ubmit .6' cm of the distal tip or entire catheter if small catheter. %ransport :$:& to lab at ambient temperature. =asting early morning preferred. Aastric fluid re<uires the addition of -.) m8 of +.)" sodium bicarbonate !or -// mg of powder# within ' hours of collection for neutralization $ample should come in a multipurpose transport media !36', ?%3#. :cceptable samples include urine, urethral or cervical swab, semen, biopsy tissue, body fluid, C$=, tracheal, or nasopharyngeal aspirate. ?rine can be transported at 'FC if transport time does not exceed .' hours. &lace aspirate in 9G& fixative !&V:, $:=# within 1/ minutes of collection. %ransport at ambient temperature

devices and specimen containers must be used to ensure recovery o# all organisms ,Cont.
Culture/S!tuat!on &neumocystis @aroveci !carinii# $kin parasites 3ycoplasma pneumoniae Culture 7lood culture from Heparin or ;D%: tubes Co""ents 7ronchoscopy or induced sputum preferred. &lace sample in a sterile, tightly capped container and store transport refrigerated within .' hours &lace skin scraping in a clean dry container, cap tightly and transport to lab within .' hours at ambient temperature Cespiratory sample or C$= in sterile cup. %ransfer specimen into 36' or ?%3. $tore transport at 'FC. %ransport time should not exceed .' hours. Consider amplified nucleic acid assay Heparin is toxic to many organisms. Increased risk of contamination during transfer.

Suggested !ransport Media 9eneral Comments

Medium .tuartOs /edium Amies /edium Amies with Charcoal Cary*+lair 2tility /ost aerobic and some facultative anaerobes. /ost anaerobic and facultative anaerobes <C <eneral purpose medium for transport of stool pathogens (.almonella, .higella, @ibro, Campylobacter, Rersinia, (C. difficile toHin A(+ Q some assays . /any !ypes. Comments <ood general purpose media. 1ual swabs most convenient <ood general purpose media. Rield for facultative anaerobes may be higher than from .tuartOs. +est media for <C All stool specimens that can not be setup within # hour should be placed in Cary*+lair media Cary* +lair media especially useful for Campylobacter. 7ecommend media with oHygen indicator. <eneral transport media are not good for strict anaerobes. 1o not refrigerate. /edia that do not contain mercury or formalin are more environmentally friendly. /ost contain antibiotics which renders then unusable for bacterial culture.

Anaerobic !ransport /edia

0va and "arasite media ("@A, .AL, #$5 formalin, Alcohol based Q McofiH @iral !ransport /edia

"rotoIoa quickly lost in unpreserved stool

/any types

Principle #: Collect all microbiology test samples prior to the institution o# antibiotics

Specimen +lood Culture Kair, skin and nails Lungal Culture Urine Culture

Comments Collect two sets at same time from different sets. 10 60! collect both sets from the same site (assessment for contamination Collect before antifungal therapy or discontinue treatment for at least 3 days. Antibiotics may cause a transient decrease in bacterial concentration resulting in a false negative report

Principle #; !he specimen container must be properly labeled and sealed prior to transport

S!tuat!on :ny unlabeled or improperly labeled specimen sent to the lab :ny leaking container ;ach sample must have at least two uni<ue identifiers $lides transferredJ recommend two identifiers Identify what is in the container

Co""ents 3ay decide to have the individual who collected the specimen to label specimen. 8abel only on bag not allowed. Ce@ect. ?ni<ue identifies may be name, medical record number, age, patient ID number, etc. ?pholds patient safety initiatives. Name and specimen number. $wab from whereK 7ody fluid or urineK

Principle #< Minimi=e transport time or ma>imi=e transport media- !here is al"ays some loss o# viability during transport

Specimen All .pecimens .tool Culture <C Cultures

Ma6imum Transport Time not in Transport Media "rocess within one hour ) hours -mmediately place swab in :mies with

Ma6imum Transport time in Transport media "lace in transport media. .tore and transport as recommended Cary*+lair 4% hours

charcoal or other AC approved transport medium.

7espiratory @iral Cultures Clostridium difficile !oHin Assay Urine for C/@ 6asopharyngeal secretions or aspirates, +A&2 )4 hours at 4C ) hours at ambient temperature :) hours at 4C2 # week, froIen )4 hours. .tore at 4C

Not more than .' hours in :mies with charcoal. $tore transport at ambient temperature.
6ot more than 4% hours if specimen transferred to @iral !ransport /edia Cary*+lair one week (check with manufacturer 6ot recommended

/inimiIe transport time and maHimiIe use of transport media as much as possible

?nvironmentally 0ragile Organisms

%rgan!s" Shigella spp. N. gonorrhoeae N. meningitidis H. influenzae ost &!'ely Spe(!"en $tool Aenital C$= C$=, eye, ear, throat Co""ent Immediate processing recommended $ensitive to cold. Need )6-/" C9.. Immediate processing recommended $ensitive to cold. Immediate processing recommended $ensitive to cold. Immediate processing recommended

.A monitor??

Principle #@ Special handling8Collection instruction must be #ollo"ed

Specimen +lood Culture <astric ?ashing for AL+ +one /arrow Mye .tool specimens for AL+ .putum ?ound .pecimen Special (nstructions +eware of decentraliIed phlebotomy .ince /ycobacteria may die in gastric washings if processing is delayed more than 4 hours. 6eutraliIe acid with #.3 ml of 4$5 disodium phosphate for every 93*3$ ml of gastric washing !he specimen is collected in a ) ml yellow*stoppered .". vacutainer tube (or heparin and sent to the /icrobiology &aboratory immediately. Collection in heparin is also acceptable. 1irect inoculation by physician is recommended for optimal yields "rocess only samples from immunosuppressed patients (bone marrow transplant or A-1. patients Lood should not have been ingested ) hrs. prior to collection. /outh should be rinsed with saline or water. "atient should breathe and cough deeply. Collect eHpectorate in a sterile container and immediately transport to the lab. .urface lesions are unsuitable for anaerobic culture.

Principle #@ Special handling8Collection instruction must be #ollo"ed ,Cont-.

3irst' communicate with those that are doing collections. ollection instructions are written and available. Het involved with nursing orientationQeducation days and as1 to have the instructions given out8 poster board learning8 /uiz or competencies. !al1 to providers when there are problems with specimen collection8 they sometimes do not 1now they could do it better.

Principle #A

Improper specimen Collected #or Ordered !est

7cceptable Specimen Lungal +lood Culture Comments 7outine blood cultures will detect maGority of patients with candidemia. 6eed tissue to make a diagnosis of fungal pneumonia. 1iagnosis of thrush usually only requires gram stain. "olymicrobial

Specimen Lungal +lood Culture

"ot acceptable Specimen

Lungal 7espiratory .pecimens

7outine blood cultures for detection of Kistoplasma capsulatum, Blastomyces dermatitidis, Coccidioides immitis, or Malassezia furfur .putum swabs for AL+ or fungus AL+' .putum Lungus' .putum, Cryptococcus only. !hrushCC Autopsy material, respiratory, decubitus, environmental, stool, urine (not aspirate , vaginal secretions, superficial wounds <ram stain for diagnosis of <C on females .tool received in preservative for @iral Culture Clot tube received for C/@ Culture .ee Anaerobic specimen table <ram stain for diagnosis of <C on males .tool culture in Cary*+lair /edia M1!A tube

Anaerobic Culture .lide for gram stain .tool Culture C/@ Culture

-ntracellular non gonococcal 6eisseria may be detected in female specimens. /ost viral transport media contain antibiotics. Rields for C/@ are higher in unclotted samples.

Criteria 0or Rejection o# Microbiological Specimens

riteria for re>ection must be readily available and laboratory specific ,nlabeled or improperly labeled specimen "rolonged storage or transport -mproper or damaged container Specimen received in fi0ative Aropharyngeal contaminated sputum Duplicate specimens stools' sputum+ within a (C hour period. E0ceptions cleared by the laboratory Specimens unsuitable for culture re/uest (anaerobic culture from not acceptable source' urine from 3oley catheter+ Dry Swab (C2hr collection of urine or sputum for A3B or fungal culture Ather criteria specific to your laboratory

Cultures !hat Should Include a 9ram Stain

S3 or sterile body fluid (cytospin+ Eye "urulent discharge Sputum or transtracheal aspirate All surgical specimens !issue ,rethral e0udates (male only' intracellular gonococcus++ %aginal specimens Wounds

Summary

"ublish specific rules for specimen collection

!here will be e0ceptionsM

Ma1e physician or healthcare provider aware of implications of culturing suboptimal specimens

ommunicate' communicate' communicateM

=eal time feedbac1 ontact the health care wor1er who collected the suboptimal specimen

References

linical Microbiology "rocedures Landboo1. (nd Edition. . LD -senberg ed. ASM. umitechs. ASM "ress. Wash. D . Manual of linical Microbiology' 5th Edition. ASM "ress. Wash. D . ()):.Miller M@. A Huide !o Specimen Management in linical Microbiology. ASM "ress. Wash. D . 6555.