Laboratory Diagnosis of UTI

Complaining
patient

Obtain the urine sample

Study the presence

of bacteria

Common Pathogens Causing UTI Methods for diagnosis

Bacteria Urine Appearance

Gram Positive
Viruses Direct Microscopic Examination
Staphylococcus saprophyticus
Enterococcus Spp. Adenovirus
CMV Isolation on Culture Media
Gram negative Fungi
Escherichia coli Candida Spp. Identification by:
Klebsiella Spp. Enterobacteriacae  Colonial morphology & culture characteristics
Proteus Spp. Hemorrhagic  Microscopic appearance
 Biochemical tests
Pseudomonas aeruginosa Cystitis
Mycobaterium Tuberculosis Reactivation >>> Secondary Extra-pulmonary TB
Leptospira Spp. Weil's disease
Antimicrobial susceptibility tests
 How is mid-stream urine sample collected?
Diagnosis of UTI
• Patient’s complaint • WASH hands & external genitalia with WATER and DRY the area.
Urgency
Frequency • Do NOT collect the INITIAL STREAM of urine since it may be
Dysuria contaminated with skin and urethral normal flora.

• Samples
• Collect urine MID-WAY through the urination process.
Mid-stream urine sample.
Collected in sterile container.
• Collect urine in a STERILE screw-top container.
Cultures must be done within 1 hour
after collection or stored in a refrigerator
at 4 °C for no more than 18 hours.

1. Appearance of Urine Specimen 2. Urine Dipstick Test

• Simple and rapid preliminary screening test to
exclude normal urine samples.

• Commercially available dipstick tests can be used

to predict bacteriuria based on detection of:
Nitrite (Bacteria reduce nitrate into nitrite)
Leukocytes esterase (Present in PMNLs >>> Pyuria)

Clear Cloudy
3. Microscopic Examination of Specimen Interpretation of Bacterial Growth
It is examined as wet preparation to detect: on Culture Media
• Diagnosis of urinary tract infections requires
Pyuria Crystals
Red Cells demonstration that the number of potential
& Casts pathogens present in freshly voided urine is
greater than those likely to result from
Yeast Parasitic contamination.
 Up to 10 WBCs/ HPF  Few Cells Eggs • This requires counting of bacteria in the urine
 10-40 WBCs/ HPF  Moderate
 More than 40 WBCs/ HPF Significant sample.

How to Count Bacteria in Urine Samples

• It is done using a calibrated loop that holds
0.001 ml of urine to streak the culture media.
• Number of microorganisms in 1 ml of urine is
calculated.
• Presence of ≥105 colonies per ml urine >>>
Significant Bacteriuria.
• If urine sample is collected from bladder by
suprapubic aspiration or from urinary
catheter >>> Presence of even small numbers ≥105 colonies per ml urine
of bacteria is considered significant. >>> Significant Bacteriuria
 Flashcards
In diagnosis of UTIs
Nutrient Agar: Blood Agar: MacConkey’s Agar: Cled Agar
Basic medium Enriched medium Selective and differential

• Culture on Cystine lactose electrolyte-deficient (CLED) agar medium:  Differential medium: contains bromothymol blue indicator (turns
yellow in acidic pH)
 Supports growth of Gram-negative and
Gram-positive organisms.  lactose-fermenting (LF)  lactose-non-fermenting (LNF)
organisms → give yellow organisms→ don’t cause color
 Electrolyte-deficient → inhibits the
color on Cled change (appear blue).
swarming of Proteus → allows the
detection of other pathogens present
in the sample. Non-inoculated CLED
Important tests Oxidase test

Important tests
Catalase test

-ve +ve +ve -ve

Indole test urease test Citrate test

 Staph. saprophyticus

Gram +ve Cocci

Gram +ve cocci in grape Coagulase -ve Catalase +ve

like clustures

Enterococcus Faecalis Gram –ve Bacilli

Gram +ve cocci in pairs Bleaching of litmus milk Catalase -ve

 E. Coli E. Coli

-Ve -Ve

Lactose fermenter complete β hemolysis yellow lactose

on MacConkey’s on blood agar fermenting colonies on Oxidase negative Indole +ve Ferment 3 sugars Urease & Citrate -ve
agar CLED agar on TSI agar with
acid and gas
production

Klebsiella pneumoniae Klebsiella pneumoniae

+Ve +Ve

Lactose fermenter
Oxidase negative
with mucoid colonies Ferment 3 sugars on
indole -ve urease test +ve
on MacConkey’s agar TSI agar with acid and
citrate test +ve
gas production
Proteus Spp. Proteus Spp.

+Ve

Non-lactose
Oxidase negative
fermenter on Ferment glucose only Citrate -ve
P. mirabilis: P. vulgaris: urease +ve
MacConkey’s agar indole -ve indole +ve + acid, gas &H2S

Pseudomonas aeruginosa Pseudomonas aeruginosa

+Ve +Ve

Green Non-lactose
complete β hemolysis oxidase +ve indole -ve Non fermenter on tsi citrate +ve urease +ve
Exopigment on fermenter on
on blood agar
nutrient agar MacConkey’s agar
 Candida albicans

Fungi

Candida albicans

UTIs Stations
Station (1) Station (2)
• A 23 years old woman, recently married, presented with dysuria and • A 60 years old diabetic patient was hospitalized and required the
increased urinary frequency for 3 days. Midstream urine sample was insertion of a urinary catheter. Three days later, he developed fever
collected. Microscopic examination of urine sample revealed many and suprapubic pain. Urine sample was collected for culture.
pus cells.
1. What is your provisional diagnosis?
• Hospital-acquired catheter-associated UTI (CAUTI).
1. What is your provisional diagnosis?
2. What is the most probable causative organism?
• A case of honeymoon cystitis.
• Gram –ve bacilli:
2. What is the most probable causative organism?
a. Escherichia coli.
• Gram –ve bacilli:
b. Klebsiella pneumoniae.
a. Escherichia coli.
c. Proteus species.
• Gram +ve Cocci:
d. Pseudomonas aeruginosa.
a. Staphylococcus saprophyticus.
• Fungi
b. Enterococcus species.
a. Candida