92 COUDRON ET AL.
January 1986
on certain areas of the slide. Other investigators have not
mentioned artifacts or mucus as potential problems in
reading direct smears. It has been our experience that even
with strict compliance to proper specimen collection
technics, a certain number of slides inevitably will have
artifacts or mucus making interpretation difficult.
As already mentioned, a X1,000 magnification was used
to read the direct smears. Syva recommends that slides
be scanned at X400 and that elementary bodies be con-
firmed at X 1,000 magnification. In our opinion X 1,000
(oil) is frequently necessary for confirmation. For prac-
ticality, therefore, the scanning lens should be used with
oil. For laboratories performing a small number of chla-
mydial tests, the $500-1,500 or more necessary to pur-
chase an oil scanning objective may represent an unreal-
isticfinancialburden. Slides were read for 10-15 minutes,
as opposed to ca. 2-5 minutes required to view slides with
the recommended scanning objectives.5,9 Relative to other
published reports, our data indicate there is no loss in
sensitivity or specificity using this procedure.
In summary, we have evaluated the MicroTrak Direct
Specimen Test for the detection of C. trachomatis in 460
male and female genital specimens. Slides were read at
X 1,000 magnification. Our results indicate that this pro-
cedure is as sensitive and specific as other more expensive
and lengthy procedures for chlamydial identification.
Identification of Coagulase-Negative Staphylococci Isolated
from Urinary Tract Infections
PETER M. LEIGHTON, PH.D. AND JEAN A. LITTLE, ART
Coagulase-negative Staphylococci isolated from urinary tract in-
fections were identified using the API Staph-Ident System®. Or-
ganisms were excluded if there was no sign of pyuria or if normal
urethral flora was present in significant amounts. While Staph-
ylococcus saprophytics and Staphylococcus epidermidis ac-
counted for 81% of the isolates from females, 87% of isolates
from males were S. epidermidis, Staphylococcus warneri, or
Staphylococcus haemolyticus. The females fell into two main
age groups, those with infections due to S. saprophyticus (mean
age 25 years) and those due to other Staphylococci (mean age
40-49 years). All males were in a single age group (mean age
70-74 years) irrespective of the infecting agent. In males, S.
Received January 22, 1985; received revised manuscript and accepted
for publication April 2, 1985.
Address reprint requests to Dr. Leighton: Section of Microbiology,
Dr. Everett Chalmers Hospital, Priestman Street, Fredericton, N.B.,
Canada E3B 5N5.
A.J.C.P. .
References
Bradley BS, Fisher LM, Dalton HP: Recovery of Chlamydia tra-
chomatis from patients of a southeastern venereal disease clinic.
Am J Clin Pathol 1980; 73:774-781
Clyde WA, Kenny GE, Schachter J: Cumitech 19, Laboratory di-
agnosis of chlamydial and mycoplasmal infections. WL Drew
(Coordinating ed). American Society for Microbiology, Wash-
ington, D.C., 1984
Mardh PA, Zeeberg B: Toxic effect of sampling swabs and trans-
portation test tubes on the formation of intracytoplasmic inclu-
sions of Chlamydia trachomatis in McCoy cell cultures. Br J
VenerDis 1981;57:268-272
Mardh PA, Westrom L, Colleen S, Wolner-Hanssen P: Sampling,
specimen handling, and isolation techniques in the diagnosis of
Downloaded from https://academic.oup.com/ajcp/article-abstract/85/1/92/1909131 by guest on 08 September 2018
chlamydial and other genital infections. Sex Transm Dis 1981;
8:280-285
Stamm WE, Harrison HR, Alexander ER, Cles LD, Spence MR.
Quinn TC: Diagnosis of Chlamydia trachomatis infections by
direct immunofluorescence staining of genital secretions. A mul-
ticenter trial. Ann Intern Med 1984; 101:638-641
Stamm WE, Holmes KK: Chlamydia trachomatis infections of the
adult, sexually transmitted diseases. Edited by KK Holmes, PA
Mardh, PF Sparling, PJ Wiesner. New York, McGraw-Hill, 1984
Tarn MR, Stamm WE, Handsfield HH, et al: Culture-independent
diagnosis of Chlamydia trachomatis using monoclonal antibodies.
N Engl J Med 1984; 310:1146-1150
Thomas BJ, Evans RT, Hawkins DA, Taylor-Robinson D: Sensitivity
of detecting Chlamydia trachomatis elementary bodies in smears
by use of afluoresceinlabelled monoclonal antibody: Comparison
with conventional chlamydial isolation. J Clin Pathol 1984; 37:
812-816
Uyeda CT, Welborn P, Ellison-Birang N, Shunk K, Tsaouse B: Rapid
diagnosis of chlamydial infections with the MicroTrak Direct
Test. J Clin Microbiol 1984; 20:948-950
Section of Microbiology, Dr. Everett Chalmers Hospital,
Fredericton, N.B., Canada
warneri was associated with cellular changes in the bladder. No
similar association was apparent with the other organisms. The
results suggest that, apart from S. saprophyticus, three species
of Staphylococcus (S. epidermidis, S. haemolyticus, S. warneri)
account for most urinary tract infections, irrespective of the sex
of the patient. (Key words: Staphylococci; Urinary tract infec-
tions; Staphylococcus epidermidis; Coagulase-negative Staphy-
lococci) Am J Clin Pathol 1986; 85: 92-95
DISMISSED until recently as nonpathogenic skin flora,
coagulase-negative Staphylococci are now accepted as
having potential clinical significance. This initial lack of
concern about the coagulase-negative Staphylococci re-
Vol. 85 • No. I BRIEF SCIENTIFIC REPORTS 93
suited in their being grouped together under the one name Table 1. Coagulase-Negative Staphylococci Isolated
Staphylococcus epidennidis. When the organisms of Mi- from Urinary Tract Infections
crococcus biotype III were transferred to the genus Staph-
Male (51) Female (153) Total (204)
ylococcus (Staphylococcus saprophyticus) and became the
first coagulase-negative Staphylococcus with recognized Num- Num- Num-
clinical significance, interest was aroused in the other spe- ber % ber % ber %
cies of this group. It is now recognized that these organisms S. saprophvlicus 4 100 104
(8) (65) (51)
may be involved in infections,23 and it has been S. epidennidis 26 (51) 24 (16) 50 (25)
demonstrated 7- ' 0,22 that the group "Staphylococcus epi- S. haemolvticus 11 (22) 11 (7) 22 (11)
dermidis" consists, in fact, of several species each with a S. wanieri 7 (14) 8 (5) 15 (7)
S. simulans 2 (4) 3 (2) 5 (2)
different pathogenic potential.

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S. hominis 1 (2) 3 (2) 4 (2)
Coagulase-negative Staphylococci often are isolated S. xvlosus — — 2 (1) 2 (1)
S. sciuri — — 1 (1) 1 «D
from urine specimens, frequently in amounts usually S. capitis 1 1
— — (1) «D
considered significant. Nevertheless, in most cases they
are dismissed as contaminants. It was decided to inves-
tigate whether certain species were isolated more fre- Results
quently from urinary tract infections, since this subse- Table 1 shows the number of strains isolated for each
quently could assist in assigning probable significance to species of Staphylococcus, subdivided according to the
isolates from urine specimens. There have been several sex of the patient. As has been reported previ-
previous studies of coagulase-negative Staphylococci iso- ously'-s^13-15-16-20-21-25 S. saprophyticus is the most frequent
lated from the urine 2 - 45 ' 7 "' 9 ' 24 ; they have, however, tended Staphylococcal species causing urinary tract infections in
to involve either a restricted population or the inclusion females, followed by S. epidennidis. Between them they
of isolates present in quantities less than 5 X 107— 1 X 108 accounted for 81% of the infections in females in this
organisms/L. Although Staphylococci may be significant study. In contrast, S. saprophyticus was involved in only
at urinary concentrations less than 108 organisms/L, 41213 four infections in males. S. epidennidis accounted for half
at these lower levels it is difficult to differentiate them of the male infections, with Staphylococcus haemolvticus
from skin contamination. For this reason, it was decided and Staphylococcus warneri accounting for 22% and 14%,
to use the more stringent criterion of >10 8 organisms/L respectively. Together, these three organisms were in-
to try to restrict the study as clearly as possible to true volved in 87% of male infections. The other species iso-
urinary tract infections, and these were then compared lated were Staphylococcus simulans (five strains), Staph-
with respect to the sex and age of the patient. ylococcus hominis (four strains), Staphylococcus xylosus
(two strains), Staphylococcus sciuri (one strain), and
Methods Staphylococcus capitis (one strain). With both males and
females, the four most commonly isolated species ac-
Two hundred four strains of coagulase-negative Staph- counted for 93-95% of the infections.
ylococci isolated from urine specimens received in the The ages of the patients with Staphylococcal urinary
microbiology laboratory of the Dr. Everett Chalmers tract infections are listed in Table 2. Whereas females
Hospital in Fredericton were examined. Specimens were showed a mean age of 25 years for S. saprophyticus and
received from inpatients, the emergency room and hos- 40-49 years for the other three organisms, males showed
pital clinics, physicians' offices, and outlying hospitals and a mean age of 70-74 years for S. epidennidis and S. war-
medical clinics in the Region served by this laboratory. neri and 56 years for S. haemolvticus.
Isolates were not included in the study if there was no
indication of pyuria in the Gram's stained smear; signif- Table 2. Ages of the Patients with Urinary Tract
icant growth (>10 7 organisms/L) of organisms generally Infections due to Coagulase-Negative
associated with skin contamination; less than 5 X 107 Staphylococci
organisms/L of Staphylococci in the specimen; the pres-
Male Female
ence of another potential pathogen in significant amounts;
or duplicate isolations of a previously selected strain. Mean Mean
Staphylococci were identified by means of the API (yrs) (Range, yrs) (yrs) (Range, yrs)
Staph-Ident System® using their Analytical Profile Index® S. sapropliyliais 25 (10-62)
(API Laboratory Products, Ltd, St. Laurent, P.Q., Can- S. epidennidis 70 (24-90) 40 (7-87)
ada). Where the index was not able to give a clear iden- S. haeniolyliciis 56* (2-81) 43 (22-78)
S. warneri 74 (61-89) 49 (1 day-76)
tification, the tables of Kloos and Wolfshohl" were used,
supplemented by conventional tests where necessary. * Median age = 64 years.
94 LEIGHTON A N D LITTLE A.J.C.P. -January 1986

Table 3. Reported Rates of Isolation from the Urine of lates were 5. hominis, which is one of the predominant
Coagulase-Negative Staphylococci species on all areas of the skin.8
An examination of the age distribution (Table 2) dem-
Present
Study Nord18 John 5 Gill3 Nicolle" Ellner2 onstrates a difference between the two sexes. These results
are similar to previously reported findings,1318 which
S. saprophvticus 51* 44 5 11 17 9 showed a mean age of 22-23 years for females with in-
S. epidermidis 25 23 53 63 70 53
S. haemolvticus 11 14 10 9 5 4 fections due to S. saprophyticus and of 60-71 years for
S. warneri 7 3 0 0 0 1 male and female patients with urinary tract infections due
S. sinmlans 2 2 5 6 2 12 to other species of Staphylococcus. The difference in the
S. hominis 2 7 12 0 3 8
mean age of males with infections due to S. haemolylicus
• Percentage of isolates. (56 years) and those due to S. epidermidis and 5". warneri

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Discussion
Table 3 compares the results obtained in this study with
other reports of urinary tract isolates of coagulase-negative
Staphylococci. The present results correspond to those
obtained by Nord and colleagues,19 who also reported re-
sults from a general hospital, with a similar 30:70 ratio
for the distribution of specimens from inpatients and out-
patients. John and associates5 examined urinary tract iso-
lates (> 107 organisms/L) from primarily male patients in
a Veterans Administration Hospital and obtained results
similar to those for the male patients in this study (Table
1). The 12% isolation rate for S. hominis, a predominant
component of the skin flora, suggests, however, that their
low threshold allowed the inclusion of some urethral con-
taminants. In their study, of Staphylococcal isolates from
high colony count urines (>10 8 organisms/L), Gill and
co-workers3 reported a predominance of S. epidermidis.
No indication was given, however, as to the distribution
of the sex of the patients or the inpatient/outpatient ratio.
The discrepancy between their results and those in this
study and the fact that they are similar to those of John
and colleagues5 suggests that their population consisted
primarily of inpatients (male) with a small proportion of
outpatient specimens (female). Nicolle and associates18
examined urine specimens from both inpatients and out-
patients, but their criterion of 107 organisms/L would
again have allowed urethral isolates to enter the study.
Ellner and Myrick2 gave no indication of any selection of
strains, suggesting that many of them also may have arisen
from urethral contamination. Eight percent of their iso-
Table 4. The Most Common Staphylococcal Isolates
from Urinary Tract Infections not due
to S. saprophyticus
Male (47)
Number (%)
S. epidermidis 26 (55)
S. haemolylicus 11 (23)
S. warneri 7 (15)
(70-74 years) is probably an aberration due to the isolation
of 5. haemolylicus from two children. The median for
the ages was 64 years, which approaches the age found
with the other two species.
S. saprophyticus is unique among the Staphylococci in
that it is largely restricted to young women who are out-
patients. If these infections are omitted and the remaining
infections are considered, the results for male and female
patients become similar. For female urinary tract infec-
tions not due to 5. saprophyticus (Table 4), 45% were due
to S. epidermidis, 21% due to S. haemolylicus, and 15%
due to S. warneri. The corresponding values for males
are 52%, 23%, and 15%, respectively. It would appear,
therefore, that the pathogenic potential of these organisms
is unaffected by the sex of the patient and that 5. epider-
midis is associated with half such infections with S. hae-
molylicus and S. warneri involved in most of the rest.
Although 5. warneri has been said to be nonpatho-
genic,2,7 we found it associated with eight male and eight
female cases of urinary tract infections. Of the six male
patients from whom diagnoses were available, three had
malignant tumors of the urinary tract and the other three
had abnormalities of the urinary tract system (benign tu-
mor with bladder obstruction, urethral stricture with
bladder irritation, hydronephrosis with ureteral fistula).
Of the eight cases in males due to S. haemolylicus and 12
cases due to S. epidermidis from whom diagnoses were
available, only one of each was associated with malignancy
in the urinary tract. This suggests that, rather than being
nonpathogenic, S. warneri is an organism of low patho-
genic potential but is a common cause of infections in
the compromised host. S. epidermidis and S. haemolylicus
were involved in infections more frequently, usually in
elderly patients and often with some disorder of the uri-
nary tract. Other species of Staphylococci were detected,
but clearly their pathogenicity is low, and their isolation
from these infections reflects only the occasional infections
Female (53)
associated with most bacteria. These results agree with
those of a previous study,18 which also found that infec-
Number (%) tions due to species other than S. saprophyticus were often
24 (45)
associated with underlying urologic abnormalities.
11 (21) While it is often difficult to differentiate colonization
8 (15) and contamination from a urinary tract infection, the cri-
Vol. 85 • No. I BRIEF SCIENTIFIC REPORTS
teria used in this study was designed to exclude as many
as possible of these "false positives." The results show
that, apart from 5. saprophyticus, there are three species
of Staphylococci (S. epidermidis, S. haemolyticus, S. war-
neri) involved in most urinary tract infections in both
males and females. These organisms are of relatively low
pathogenicity and require an elderly or compromised host
in order to establish an infection. The isolation of any of
these three organjsms from a well-collected specimen,
however, should be regarded as suggestive of a urinary
tract infection.
In the past, speciation of Staphylococci was a time-
consuming procedure avoided by most clinical labora-
tories. The availability of commercial systems has re-
moved this impediment, and the question now has arisen
as to the value of such a complete identification. There
has been discussion in the literature concerning the cost-
effectiveness of speciating coagulase-negative Staphylo-
cocci. 23 ' 823 ' 24 Because there is little variation in the an-
timicrobial susceptibility of the various species and be-
cause there is no apparent variation in the symptoms of
infections caused by them, it was felt that routine specia-
tion would not be helpful. There are special instances,
however, when speciation would assist our understanding
of this group of organisms. A complete identification of
the organism would be useful in severely compromised
patients, cardiac surgery patients, blood cultures, and for
epidemiologic investigations.318 The results of this study
suggest that speciation may also be of use in the assessment
of urinary tract infections due to low numbers of bacteria.
In these cases, it is necessary to differentiate normal ure-
thral flora from significant pathogens. While all Staphy-
lococci can fall into both categories, it will be possible
using this information, together with other clinical infor-
mation such as the presence of leukocytes,1214 to assign
a probable significance to an isolate. By thus restricting
speciation to special situations, the resources of the clinical
laboratory can be concentrated where they will provide
the most benefit, rather than becoming diffused. Even-
tually, as our understanding of coagulase-negative Staph-
ylococci improves and we become more aware of the dif-
ferences between the species, the list of situations requiring
complete bacterial identification will be modified and
possibly expanded.
Acknowledgments. The authors thank Dr. E. V. Haldane and Dr. M.
Dalton for their helpful advice: Dr. K. Aterman for his support: and
Margaret Fredericks for the preparation of this manuscript.
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