Faculty Of Medicine

Alexandria University

Parasitology assignment

“Collection of stool specimen”

Supervised by:
Prof. Dr. Sherine Muslim
Dr. Hala Diab

By: Omar Salah Elabd

ID: 782
Parasitology Department

Introduction:
In the field of diagnostic medical parasitology, proper specimen
collection is critical since the final laboratory results are based on
parasite recovery and identification will depend on the initial quality of
the sample taken. Unless the appropriate specimens are properly
collected, preserved and processed, these infections may not be
detected; therefore, specimen rejection criteria have become much
more important. Laboratory procedures detect organisms within
clinical specimens using morphological criteria, rather than culture or
biochemical tests and/or physical growth characteristics. Final
identification is often based on microscopic examination of stained
preparations. Faecal specimen preparation generally includes one of
several concentration procedures and the preparation of smears for
staining. Examination of clinical material by microscope uses a number
of magnifications, and multiple specimens may be required to find and
confirm the identity of the suspected organism(s). With the
introduction of newer immunoassays, there are now many more
options available to the diagnostic laboratory, and different
laboratories will select different approaches. As methods change,
however, it becomes even more critical for the laboratory to inform
each client of the diagnostic procedure used and ensure that the client
understands the clinical relevance of the test results.
Clinically relevant diagnostic parasitology testing also depends on
receiving appropriate test orders from the physician. Depending on the
patient’s clinical condition and travel history, very specific diagnostic
tests may be recommended. It is extremely important that physician
clients are aware of the test order options available within the
laboratory test menu and the pros and cons of each test when
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considered within the context of the patient’s history and symptoms.

Without the proper test orders, diagnostic test results may be
misleading or actually incorrect. Appropriate and complete
communication regarding test orders between the laboratory and
physicians is mandatory for high-quality patient care.

Safety:
Laboratorians working with stool specimens face potential risks
including ingestion of eggs or cysts, skin penetration by infective larvae,
and infection by nonparasitic agents found in stool and biologic fluids.
These risks can be minimized by adopting universal precautions as well
as standard microbiological laboratory practices (Biosafety Level 2).
These include:

 Wear protective safety glasses, gloves and laboratory coat when

processing specimens.
 Use biological safety cabinets as needed.
 Do not eat, drink, smoke, apply cosmetics or manipulate contact
lenses in work area.
 Decontaminate work surface at least once a day and after any spill
of potentially infectious material.
 If you have cuts or abrasions on the skin of your hands, cover
them with adhesive dressing.
 If you use any sharp instruments, dispose of them in a “sharps”
container for decontamination.
 Remove gloves and wash your hands after completing any task
involving the handling of fecal material.

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Note:
These precautions should be taken even with stool specimens that
have been fixed in preservatives because they may still be infectious.
For example, fixation in formalin takes days or weeks to kill some
parasite cysts or oocysts that are protected by a thick shell. Eggs of
Ascaris lumbricoides may continue to develop and are infectious even
when preserved in formalin.

Precaution before specimen collection:

Procedures for the recovery of intestinal parasites should always be
performed before barium is used for radiological examination. Stool
specimens containing barium are unacceptable for examination, and
intestinal protozoa may be undetectable for 5 to 10 days after barium is
given to the patient. There are also certain substances and medications
that interfere with the detection of intestinal protozoa: mineral oil,
bismuth, antibiotics, antimalarial agents, and nonabsorbable
antidiarrheal preparations. After administration of any of these
compounds, parasitic organisms may not be recovered for a week to
several weeks. The two most commonly used substances are barium
and antibiotics, such as tetracycline, which modify the gastrointestinal
tract flora. Specimen collection should be delayed for
5to10daysoratleast2weeksafterbariumorantibiotics, respectively, are
administered. The use of antibacterial therapy that affects the normal
gastrointestinal tract flora will diminish the numbers of protozoa, since
they feed on intestinal bacteria.

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Specimen Collection:
Fecal specimens should be collected in a:
 Clean
 Wide-mouth containers; oftena0.5-pint(ca.0.24-liter) waxed
cardboard or plastic container
 With a tight-fitting lid.
The fit of the lid is particularly important in order to:
 Prevent accidental spillage.
 Maintain moisture within the specimen.
The specimens should not be contaminated with water or urine,
because water may contain free-living organisms that can be mistaken
for human parasites and urine may destroy motile organisms. Fresh
specimens can also be submitted in collection vials. All fresh specimens
should be carefully handled, since they are potential sources of
infectious organisms, including bacteria, viruses, and parasites.
Every specimen should be identified with the following minimal
information:
 Patient’s name
 Identification number
 Physician’s name
 The date and time the specimen was collected (if the laboratory is
computerized, the date and time may reflect arrival in the
laboratory, not the actual collection time)
 The specimen must also be accompanied by a request form
indicating which laboratory procedures are to be performed

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 It is also be very helpful to have information concerning the

presumptive diagnosis or relevant travel history; however, this
information is rarely available

Under certain circumstances, the physician will have to be contacted

for additional patient history (Example: Fever of unknown origin
[FUO]— possible malaria).

Standard recommendation for the number of specimens to be

collected:
It is recommended that a normal examination for stool parasites
before therapy include three specimens, consisting of two specimens
collected from normal movements and one collected after the use of a
cathartic such as magnesium sulfate or Fleet’s Phospho-Soda. A
cathartic with an oil base should not be used, and a stool softener
(taken either orally or as a suppository) is usually inadequate for
obtaining a purged specimen. The purpose of the laxative is to
stimulate some “flushing” action within the gastrointestinal tract,
possibly allowing one to obtain more organisms for recovery and
identification. Obviously, if the patient already has diarrhea or
dysentery, the use of any laxatives would be contraindicated. Since the
majority of patients are symptomatic prior to submission of stool
specimens for examination, the need for a laxative is relatively
uncommon.
When a patient is suspected of having intestinal amebiasis, six
specimens may be recommended. The examination of six specimens
ensures detection of approximately 90% of amebic infections. However,

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because of cost-containment measures, the examination of six

specimens is rarely requested.
Three specimens are also recommended for post therapy
examinations, and they should be collected as outlined above.
However, a patient who has received treatment for a protozoan
infection should be checked 3 to 4 weeks after therapy, and those
treated for Taenia infections should be checked 5 to 6 weeks after
therapy. In some cases, the physician will assume a cure for tapeworm
infection unless proglottids reappear in the stool; therefore, no post
therapy specimens are submitted for examination.

Collection Times:
A series of three specimens as indicated above should be submitted
on separate days; if possible, the specimens should be submitted every
other day; otherwise, the series of three specimens should be
submitted within no more than 10 days.
If a series of six specimens is requested, the specimens should also
be collected on separate days or within no more than 14 days.

Many organisms, particularly the intestinal protozoa, do not appear

in the stool in consistent numbers on a daily basis, and the series of
three specimens is considered a minimum for an adequate
examination. It is inappropriate for multiple specimens to be submitted
from the same patient on the same day. One possible exception would
be stool collections from a patient who has severe, watery diarrhea a
such that any organisms present might be missed because of the
tremendous dilution factor related to fluid loss. Even under these
circumstances, acceptance of more than one specimen per patient per
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day should not be routine but should be done only after consultation
with the physician.

Although the recommended number of stool specimens is three,

laboratories have been more willing to accept two specimens, primarily
because of cost savings and the assumption that if the patient is
symptomatic, confirmation of any organisms present is just as likely to
be possible from two specimens as from three specimens. However, it
is important that clients understand the pros and cons of two
compared with three stools. Both collection approaches are being used
by diagnostic laboratories.

Note:
Liquid specimens should be examined within 30 min of passage, not
30 min from the time they reach the laboratory. If this general time
recommendation of 30 min is not possible, the specimen should be
placed in one of the available fixatives. Soft (semi formed) specimens
may contain a mixture of protozoan trophozoites and cysts and should
be examined within 1 h of passage; again, if this time frame is not
possible, preservatives should be used. Immediate examination of
formed specimens is not as critical; in fact, if the specimen is examined
at any time within 24h after passage, the protozoan cysts should still be
intact.

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In review, remember that trophozoites only are usually found in

liquid specimens, both protozoan trophozoites and cysts can be
recovered in soft specimens, and generally cysts only are recovered in
formed specimens. The time limits mentioned above are merely
guidelines; however, if fresh specimens remain unpreserved for longer
times before examination, many if not all organisms may disintegrate
or become distorted. Fecal specimens should never be incubated or
frozen prior to examination using routine microscopy. When the
acceptance criteria for specimen collection are not met, the laboratory
should reject the specimen and request additional specimens. Because
there is often a time lag from the time of specimen passage until
receipt in the laboratory, many clinicians, clinics, and inpatient wards
use a specimen collection system that includes stool preservatives. A
number of commercial systems are available with many preservative
choices; the use of such systems has become routine for many
institutions, and some request a custom collection kit that may contain
several types of preservatives for stool specimens, depending on the
tests normally ordered by the clinicians that they service.

References:
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1. Diagnostic medical parasitology 6th edition, Lynne Shore Garcia.

1988.
2. Centers for disease control and prevention, Parasite A-Z index.

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