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ORIGINAL INVESTIGATION

Outpatient Urine Culture
Does Collection Technique Matter?
Edward Lifshitz, MD; Liane Kramer, RNC, BSN

Background: Dysuria is one of the most common pre- neal cleansing and spreading of the labia. In an attempt
senting complaints of young women, and urinalysis is one to decrease contamination from the vagina, the third group
of the most common laboratory tests performed. De- (n=81) was given the same instructions as group 2, with
spite the fact that the midstream clean-catch technique the addition of using a vaginal tampon. Contamination
is commonly used for urine collection, contaminated urine rates were calculated for all 3 groups.
cultures occur with distressing regularity. The mid-
stream clean-catch technique is time-consuming to ex- Results: Contamination rates for the 3 groups were nearly
plain, frequently not performed correctly by patients, identical (29%, 32%, and 31%, respectively). Compar-
costly for supplies, often embarrassing for patients and ing the no-cleansing group with the combined cleans-
staff, and of unproven benefit. Therefore, we designed a ing, midstream groups also showed no difference in con-
study to compare various methods of obtaining speci- tamination rates (28.6% and 31.5%, respectively, with
mens for culture from acutely dysuric young women. P=.65).

Methods: A total of 242 consecutive female patients who Conclusions: In young, outpatient women with symp-
presented with symptoms suggestive of a urinary tract toms suggestive of a urinary tract infection, the mid-
infection were randomized into 3 groups. The first group stream clean-catch technique does not decrease contami-
(n=77) was instructed to urinate into a clean container. nation rates.
No cleansing was done, and the specimen was not ob-
tained midstream. The second group (n = 84) was in-
structed to collect a midstream urine sample with peri- Arch Intern Med. 2000;160:2537-2540

D
YSURIA IS one of the most remained the de facto standard for outpa-
common complaints for tient urine collection.
which young women The MSCC technique in women in-
seek medical care, and volves cleansing the perineum with either
cystitis is one of the most saline or a bactericidal wash, spreading the
common diagnoses. In fact, in 1992, there labia, discarding the first urine sample, and
were an estimated 7 million episodes of collecting a midstream sample in a sterile
acute cystitis in the United States,1 with container. Yet the value of this involved and
the cost of treatment exceeding $1 bil- difficult-to-teach technique has not been
lion.2 Among sexually active young women proved. At least 3 studies in asymptom-
at a university setting, the incidence of uri- atic women found that cleansing did not
nary tract infections was found to be 0.7 decrease the number of contaminated speci-
per person-years.3 mens.7-9 Another study involving asymp-
To minimize contamination from the tomatic females found no difference be-
colon, skin, or vaginal areas, urethral cath- tween catheterized specimens and speci-
eterization was routinely used prior to mens collected in a nonsterile container
From Rutgers University Health 1958 to collect urine specimens for cul- without any precautions,10 and the only
Services (Dr Lifshitz and ture. In that year, 2 articles arguing against study we could find that involved symp-
Ms Kramer) and the
catheterization and for the midstream tomatic women found no difference in
Department of Medicine,
University of Medicine and clean-catch (MSCC) technique were pub- contamination rates between the MSCC
Dentistry of New Jersey–Robert lished.4,5 Other studies have confirmed that method and urine collection without any
Wood Johnson Medical School the MSCC technique is equivalent to cath- precautions or instructions.11
(Dr Lifshitz), eterization in symptomatic women,6 and Further evidence that the method of
New Brunswick, NJ. for the past 40 years, this technique has urine collection may not be as important

(REPRINTED) ARCH INTERN MED/ VOL 160, SEP 11, 2000 WWW.ARCHINTERNMED.COM
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20 years. 17-50 years) who was done.104/mL) of organisms commonly found on the skin and The only exclusion criterion was antibiotic usage or external and internal genitalia were considered to be con- urethral instrumentation in the previous 7 days. 17-41 years) (“mid. while Stamm et al20 showed that ap- Seventy-seven patients (mean age. who ranged vasively obtain urine specimens for comparison.14 and teria. Guilford. were in. and since without manipulation ricidal wipe of witch hazel.3% correlation between The added costs of sterile containers and bactericidal wipes catheterized specimens and those collected in dispos. gone urethral instrumentation. tients how to provide a MSCC specimen backfired when The opposite argument can also be made. Microbiologists at the laboratory were blinded as essary. all mixed cultures as contaminated. patients. This group included S viridans (2 speci- sis (including tests to detect the presence of nitrites. physical examination.3 years. board. structed to insert a vaginal tampon prior to collection. occasionally clostridia and other an- consuming to teach. Final culture reports were classified as no presented to our university clinic and had symptoms sug.13 normal vaginal flora may include Staphylococcus There is some literature to support performing at aureus.12 Attempts to decrease contamination rates to improve contamination rates. Candida albicans. growth. or pure. low-temperature–tolerant neisseriae. and urinary dipstick results. substantial benefit from abandoning the practice. 21. benzalkonium chloride. group B strepto- though in each of 3 studies it was a different component cocci. then there would be a via an educational campaign aimed at teaching male pa. 21. enterococci. For example. and in most cases. Franklin Lanes. Escherichia coli is the causative agent in the overwhelming stream”) were told to cleanse the perineum with a bacte.2 incubated for another 24 hours. midstream collection). and age range. The third group (“everything”) was nal disease or nephrolithiasis. to discard the first urine population was exclusively outpatient. and protein). taminated specimen.0 years). 102 colony-forming units per milliliter or more were con- jected into a receptacle containing boric acid and sodium sidered significant. Staphylococcus epidermidis. acinetobacters. The specimens were plated within 24 hours tory.4 years. members of the family midstream catch in men15). they were automatically relegated to the mid. Because our front to rear. the patients were treated based organisms commonly found on the skin were also deemed on their symptoms and on the results of a “dipstick” analy. streaked on both blood and MacCon- key agar. 21.ARCHINTERNMED. ized patients that showed a 92. all specimens were in. SEP 11. are significant. nonsterile ration were mixed. suggest that mixed cultures in hospitalized patients may While the majority of our subjects were undergraduates.com on May 4. According to the Enterococcus and S epidermis (a total of 6 specimens). possible to know with absolute certainty. the prevailing view among clinicians is that since (n=84. age proximately 13% of cultures obtained from symptomatic range. patients at the health One major decision concerned what constituted a“con- centers are representative of the general university pop. other (REPRINTED) ARCH INTERN MED/ VOL 160. ganisms. and had no history of re- nonsterile container. Mixed was defined as at least 2 or- gestive of cystitis were randomized into 1 of 3 groups. There were only a few patients who needed mentioned characteristics of our population. nerella vaginalis. chlamydiae. al. While specific socioeconomic data units per milliliter using a standard technique. Clinipad Corp. mens) and S aureus (1 specimen). Becton Dickin. often involves embarrassment for both patient and staff.16-19 there is a paucity of data on out- significant minority were graduate students. given the above- stream group. At this time. rent literature on dysuric women. some actinomycetes. Those that were pure were fur- and all full-time students are eligible to be seen at the health ther categorized according to species and colony-forming centers without charge. The second group of patients In general. we classified in age from 17 to 37 years (mean age.archinternmed. and because we did not in- identical to the second. The contamination rates actually increased. 2010 ©2000 American Medical Association. economically diverse group. Other current standard of care. to be contaminants. Conn) by wiping from population likely indicates contamination. were not collected for our subjects. median age. low levels to be reassigned this way. Enterobacteriaceae. In keeping with the cur- kocyte esterase. This study was presented to the institutional review son & Co. Gard- The MSCC technique is difficult and time. no of mixed cultures obtained by the MSSC technique (64%). Rut. leu. NJ) and transported to the labo. Streptococcus viri- least some components of the MSCC technique. corynebac- (spreading of the labia. While there are several studies that ulation: a highly educated. 2000 WWW. when a final reading years. . This group included all our cultures that yielded urologic abnormality or nephrolithiasis. If A decision needed to be made as to what other re- the patients in this group were unable or unwilling to use sults should be considered contaminated. which concluded that informed consent was not nec- ratory. mean age. and to collect the midstream specimen in a clean. All rights reserved. formate (Vacutainer Urine Transport Kit. dans. peptostreptococci. except that the patients. hemoglobin. and methyl p-hydroxybenzoate creases. SUBJECTS AND METHODS using a 1-µm loop. a mixed culture in an uncomplicated outpatient (Rantex. While it is not a tampon. Explaining the concept to patients aerobic rods. majority of cystitis cases.20 coliform organisms of Within 5 minutes of collection. mixed.COM 2538 Downloaded from www. they also found an unusually high rate container without any preparation (no cleansing. (. a not be contaminated. or anatomical defect the chance of a second infection de- solubilized lanolin. age range. as treatment was determined by standard clinical his- to grouping. or known taminants. 21. If the MSCC technique were shown not able diapers. and incubated for 24 hours at 37°C.8 cleansing of the perineum. organisms was not made. mycoplasmata. a preliminary reading was done and the specimen was re- A total of 242 consecutive female patients (mean age. to spread the labia. had not under- output. 17-50 years) randomized to the first of our groups female outpatients by catheterization or suprapubic aspi- (“nothing”) were told to urinate into a clean. specific identification of those gers University is the largest state university in New Jersey. as is usually thought was found in a study of hospital.

All rights reserved. nation rates of 29%. As ex. Klebsiella. (%) of Total Nothing (n = 77) Midstream (n = 84) Everything (n = 81) Total (N = 242). . *See “Subjects and Methods” section for definitions of groups.8) The contamination rates in each of our 3 groups (29%. we were able to combine them into 1 larger group. midstream. No.8% of those obtained with cleansing. †These organisms were labeled contaminants. Culture Results for 2 Groups* is reasonable to postulate that adding a vaginal tampon to the MSCC technique would decrease urine sample con. 32%. yeasts. if we state that in 79.4) 113 (68. money. at least in our study population. outpatient women. our study comprised symp- Table 3. Uncontaminated 55 (71. tions. Total 34 (77. 32%. No. non. (%) Escherichia coli 37 (48) 41 (49) 41 (51) 119 (49) Staphylococcus saprophyticus 1 (1) 0 (0) 3 (4) 4 (2) Enterobacter 3 (4) 0 (0) 1 (1) 4 (2) Klebsiella 1 (1) 0 (0) 1 (1) 2 (1) Proteus 2 (3) 1 (1) 0 (0) 3 (1) Enterococcus † 1 (1) 2 (2) 1 (1) 4 (2) Streptococcus viridans † 0 (0) 1 (1) 1 (1) 2 (1) Staphylococcus aureus† 0 (0) 0 (0) 1 (1) 1 (0) Staphylococcus epidermidis † 1 (1) 1 (1) 0 (0) 2 (1) No growth 11 (14) 15 (18) 10 (12) 36 (15) Mixed 20 (26) 23 (27) 22 (27) 65 (27) Total contaminated† 22 (29) 27 (32) 25 (31) 74 (31) *See “Subjects and Methods” section for definitions of groups. and no precautions (no-wipe.5) 168 (69. SEP 11. it Table 2.3) 71 (79. (%) RESULTS No Cleansing Bactericidal Wipe Table 1 contains a summary of our results. Colony Counts Greater Than 105 Colony-Forming tomatic. cance (P=. accounting for saprophyticus Enterobacter 3 (100) 1 (100) 90% of documented infections. All specimens were collected in clean. respectively) were essentially iden- tical. respectively (Table which allowed us to simplify our results (Table 2). Also. Total contaminated = Mixed + ( Enterococcus + S viridans + S aureus + S epidermis). and Enterobacter. 2010 ©2000 American Medical Association.archinternmed. And since groups 2 and 3 used both mid- stream collection techniques with cleansing. collecting a speci- group than among our midstream plus everything group men in a nonsterile container.ARCHINTERNMED. Culture Results for Each Group* No. with no special instruc- (28. a population for which Units per Milliliter for Uncontaminated Specimens urine cultures are frequently ordered in clinical practice. Unlike most previous studies. Total 77 (100) 165 (100) 242 (100) tion of a vaginal tampon. Proteus.COM 2539 Downloaded from www. and 31%. 1). More than finding suggests that. as a x2 analysis of the last 3 rows of the pure specimens obtained without cleansing and of Table 1 revealed a P value of . and Trichomonas vaginalis.65). and since Our 3 groups—no precautions. no-growth urine cultures are not contaminated. premenopausal women.6) midstream collection with bactericidal wipe and the inser. midstream we could see that these groups were nearly identical (Table plus vaginal tampon—had essentially identical contami- 1). may save time.5) 74 (30. We also found virtually identical colony counts in- Finally. at least for symptomatic young (REPRINTED) ARCH INTERN MED/ VOL 160.6% vs 31. we found that the use of a bactericidal wipe dependent of the use of bactericidal wipes (Table 3). but this trend did not reach signifi. Escherichia coli 27 (73) 64 (78) pected in young. These data suggest that the method of urine collec- As the data in Table 2 show. then we can further categorize results as either contaminated or COMMENT uncontaminated.3% could not be rejected. Staphylococcus 1 (100) 3 (100) whelmingly the most common pathogen.5%).6) 52 (31. nonmidstream). thus. The null hypothesis of equality between our 3 groups 105 colony-forming units per milliliter were seen in 77.com on May 4. Since vaginal secre- tions may potentially contaminate a urine specimen. there was actually a tion does not affect the results of the urine culture and slightly lower contamination rate among our nothing that. Contaminated 22 (28. Table 1. Nothing Midstream + Everything Total We devised a study to compare 3 methods of collec.4) tion: standard midstream collection with bactericidal wipe. 2000 WWW. and embarrassment.7-11 which involved asymptomatic women. E coli was over. The other 10% were al- Klebsiella 1 (100) 1 (100) most evenly divided among Staphylococcus saprophyti. sterile containers. Proteus 2 (100) 2 (100) cus.82. (%) tamination rates. No. This did not decrease colony counts (Table 3). and 31%.

Md: National Center for Health Statistics. with symptoms of lower urinary tract infection 18.76:257-262. Advance Data From Vital and Health elevated. Kebede M. 1987. toms suggestive of upper or complicated urinary tract in- ber of mixed cultures. fect Dis Clin North Am. 2010 ©2000 American Medical Association. the control group had 41%. nantly composed of symptomatic women. Siegman-Igra Y. Hooton TM. Stamm WE.48: from our subjects. 21. crobial growth in urine: contamination or true infection. Donowitz LG. Urine sampling in ambulatory women: midstream clean- catch versus catheterization. 22. rolithiasis or renal disease. Boswell BR. Reprints not available from the authors. thus allowing contaminat. Fihn S. Schwartz D. Turck M. Kim-Foley S. Plorde JJ. This simulated 5. 1981. Masterton RG. Belmin J.4:xiia]. Am J Med. that reported in other studies. 1988. None of these 20 bacterial contamination of samples from women students. Morris RW. Baerheim A. . mostly 25:58-91. Does a clean-catch urine sample reduce posely touched the inside of the cup with our fingers to bacterial contamination? N Engl J Med. Curr Clin Top Infect Dis. Johnson JR. Diagnosis and treatment of acute urinary tract infec- it may have obscured small differences between our tions [published correction appears in Infect Dis Clin North Am. obtained in male patients. 4. Konforti N. Durand I. some fections. thereby re- instruction. ”: an evaluation of a patient educa- an exact percentage was not attainable. “contaminate” the container (simulating the effect of a 8. 1993. our contamination rate was actually lower than specimens in ambulatory women.8. Walter FG. Our study population included women. Stamm WE. We believe that further studies should gain their benefits.3:246-250. patients with more compli- neal region to grow in culture.women. which were collected using a sterile container and 12. . 13.21:655-660. Inui TS. Lipsky BA. Knopp RK. vagina. Flower M.157:514-517.COM 2540 Downloaded from www. 1992. Evaluation of urine sampling technique: patient inadvertently doing the same). the argument may be made that the number of con. Hooton TM. Finally.335: cup. Flournoy DJ. but not sterile. Hughes JP.2:158-159. Inui TS. If the contamination rate was elevated enough. from disposable diapers in elderly incontinent women. our results suggest that it may not be nec- pathogenic colony counts is not warranted. 1996. Avellano E. but as the symp. Barden G. 1990. Perineal cleansing and midstream urine Also. J Clin Microbiol. et al. in the control group having mixed cultures. None had a history of neph. Perineal cleansing before midstream urine: a necessary ritual? Lancet. Gross PA.20 We also compared our 10. The myth of the clean catch urine culture results with those of 446 urine cultures per. 1993. 1983. Ronald AR. We did have a lower percentage of no-growth samples 1984. An approach to urinary tract infections in ambulatory sizable percentage of all persons with urinary tract in. 1993. and from there into a clean test tube. Is the clean-catch midstream void pro- tained 54. Immergut MA. Leisure MK. Diagnosis results on renal ultrasonography and/or intravenous py. US Dept of Health and taminated specimens in all 3 of our groups may have been Human Services publication PHS 94-1250. 42:241-243.24:1-6. we pur. N Engl J Med. Ann Intern Med. 2000. 16. we were careful not 1040-1046. A descriptive analysis of urine cultures: pure versus mixed iso- (14. Br J Gen Pract. (REPRINTED) ARCH INTERN MED/ VOL 160. despite all precautions. Treiber N. Sanford JP. our transport container to be cultured. center. 9. Statistics.17:339-340. and somewhat complicated procedures correctly.328:289-290. Schappert SM. Abandoning the use of the MSSC tech- rates? Several possibilities come to mind.com on May 4. 7.7. formed in the same laboratory but from a different health 11. 1976. we poured sterile saline into a clean symptomatic urinary tract infection in young women. patients may not have been able to perform the sulting in considerable savings in money. They were all premenopausal and without other 19. 1982. with 26.82:319-322. Diagnosis and treatment of uncomplicated urinary tract gests that cultures need not always be obtained.11:551-580. and patients with signs and symp- and midstream collections would not decrease the num. Ann Emerg Med. ing bacteria to reach our clean container. Oudart O.ARCHINTERNMED. 1984. and thus not embarrassment. Gilbert EC. Hy- used. Dudley SM. (cystitis). Goble M. 1979. 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