Specimen Collection Transport AND: John M. Matsen, M.D. and Grace Mary Ederer, M.P.H.-?
Specimen Collection Transport AND: John M. Matsen, M.D. and Grace Mary Ederer, M.P.H.-?
Specimen Collection Transport AND: John M. Matsen, M.D. and Grace Mary Ederer, M.P.H.-?
TRANSPORT
John M. Matsen, M.D.*
and Grace Mary Ederer, M.P.H.-?
Abstract
T h e a p p r o a c h to the collection and transport o f meaningful and accurate
microbiologic specimens d e p e n d s u p o n the n a t u r e o f the suspected infectious
entity and u p o n the location o f the pathogenic process, as well as the possess-
iota o f a p p r o p r i a t e instrumentation and containers. New information and newly
d e v e l o p e d collection-transport materials have i m p r o v e d the potential for the
successfifl collection and isolation o f pathogenic micro-organisms.
*l'rofessor of l'athology and i'ediatrics, Unive,sity of Utah College of Medicine. Director, Clinical
Laboratories, University of Utah ttospltal, Salt Like City, Utah.
l'Associate I~'rofessorof Laboratory ,Medicine and l'athology, University of Minnesota Medical
Center, ,X[imteapolis,Milmesota. 297
HUMAN PATHOLOGY--VOlUME 7, NUMBER 3 Mu) 1976
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HUMAN P A T H O L O G Y - V O L U M E 7, NUMBER 3 May 1976
urine comes the tbllowing sources: and then she is to discard the used
a. f l a i r and "oilier particulate matter sponge.
from tile perineum may fall into tile e. While the vulva is spread, she is to
urine or the collecting vessel. repeat tile front to back wash with
b. Bacteria from beneath the p r e p u c e the r e m a i n i n g three sponges, dis-
in males am)' contaminate the stream. carding each as its use is finished.
c. ha females, bacteria from vaginal f. This step is followed by a t h o r o u g h
secretions or from the vulva o r distal washing with warln sterile water to
u r e t h r a may contanlinate the re- eliminate the possibility o f contam-
ceptacle o r be caught in the urinar)" inating the specimen with soap.
stream. g. T h e patient now voids. After the
d. Bacteria from the 'bands, skin, or first 20 to 25 nil. Ilas been passed, a
clothing may enter the receptacle. specimen is caugllt directly in the
T h e cleansing procedures must sterile container without stopping
therefore remove contanlinating the stream. T h e cup should be held
organisms from the vulva, urethral iq such a wa)' tlmt contact with the
meatus, and related perineal area, so legs, vulva, o r clotlfing is avoided.
that bacteria found in ttrine can be T h e fingers should lie kept away
assunled to have conte only f i o m tile from the rim and inner surface o f
b l a d d e r and urethra. o f the container.
5. In addition to a private cubicle with a 9. Instructions for males:
toilet or commode, there must be a Tile bands are washed as in section 8.
trained assistant who explains the pro- T h e foreskin must be completely re-
cedure to die patient, makes certain that tracted and the glans penis cleansed
the room is e q u i p p e d with the p r o p e r with liquid soap soaked sponges. Sur-
supplies, a n d insures pronqit transport plus soap is removed with warm sterile
to the laboratory o r refrigeration of the water. T h e patient is instructed to pass
collected Sl~2cilnen. Patients urinate the first portion o f urine into the toilet
more co,nfortably if" no other licrson is bowl and then pass a . p o r t i o n o f the
present. Generally speaking, properly renmining urine into tile specimen con~:
instructed patients will cleanse the penis rather.
or vulva and p e r i n e u m at least as well as 10. h n m e d i a t e l y after collecting, the at-
the ntirse o r attendant. Nevertheless, tendant covers the urine, labels it, and
when local circumstances d e m a n d (e.g., refrigerates the container at 4 ~ to 6 ~ C.
the bedfast patient), the described withitl 10 minutes after voiding, unless
technique is modified to allow a trained it is imnlediatel)" taken to the laboratory.
individual to cleanse the patient and T h e patient is not to replace the top o f
collect tile specimen. the receptacle himself.
6. Supplies u e e d e d for each patient should 11. U n d e r no circumstances should the
include tile following: five sterile cotton urine that is to be studied bacterio-
giluze sponges (,I by 'I itlches), r~ per cent logically be a sinnple taken fronl a
solution o f green soap in water (USI'), larger container, sucl! as a urinal o r
w a r m s t e r i l e water, and a wide mouthed, bedpaq, nor should the urine specimen
sterile, covered receptacle for the urine lie b r o u g h t from home. T h e urine is to
specimen. be collected directly i,ato the sterile con-
7. Before tile collection o f urine, the fol- tainer that will be used for bacterio-
lo~:ing instructions ~hould lie given to .logic studies and examined or refriger-
all Ipa.tients, so that they u n d e r s t a n d ated its rapidly as possible.
what is expected o f tllem. Tile instruc-
tions are to lie repea.ted at every visit. R. Wounds
8. Instructions for females: 1. For tile closed wound technique, see
a. T h e patient is to remove her u n d e r - sections A (abscesses) and E (bullae,
garments. celhditis, petechiae and vesicles).
b. T h e hands are to be thorougldy 2. For open wounds:
washed with soap and water, rinsed, a. Clean tile sinus tract o p e n i n g or tile
a n d d r i e d on a disposable p a p e r wound surface mechanically without
towel, o r the excess water shaken ofE using a germicidal agent.
c. With one hand the patient is to b. These areas frequently yield "nor-
"spread herself," i.e., her labia, and mal'~ flora organisms. T h e r e f o r e , it
keep them continuously a p a r t until is important to attempt to cultuye
the urine, is voided into tile cup. the base o r edges o f the wound.
d. T a k i h g ' , a s i n g l e sponge d r i p p f n g c. Swab specimens o f sinus tracts may
witll soap', she is to wash h e r vulva lie acceptable, but aspiration material.
well, passing only from front to back, obtained by needle or catheterization 303
HUMAN I'ATIIOLOGY--VOLUME 7, NUMBER 3 May 1976
growth of Proleu.~ species. 4-6 Transgrow is tightly fitting covers. When gastric con-
commercially available (BBL), packaged tents are to be cuhured t"o1"this agent, the
in a tightly closed, flat bottle with an ap- aspirate should be neutralized with 10 per
propriate atnaosphere of carbon dioxide. cent sodium carbonate to a pH of 7 befi)re
Transgrow should be inoculated ina- processing or shipping. All other speci-
mediately after procuring the specimen. 4 mens to be cultured for 31. tuberculosis
Modified Thayer-Martin medium sltould should be transmitted to the laboratory as
be inoculated in a Z pattern, followed by indicated for sputum cultures.
cross streaking with a sterile bacterio- Some reference laboratories prefer to
logic loop and incubation in an atmos- have fecal specimens for the isolation of
phere of 3 to 5 per cent carbon dioxide at Salmonella and Shigella submitted in the
35 ~ C. for 20 hours before examination or buffered glycerol-saline solution of Sachs. 2s
shipment, s Transgrow bottles, on the other Ill using buffered glycerol-saline, it is
hand, should be inoculated over the entire recommended that 1 gm. of feces be
agar surface (keeping the bottle upright emulsified in 10 nal. of the preservative.
to maintain the carbon dioxide atmos- The specimen should be ship.ped in a
phere) and incubated at 35 ~ C. before leak-proof, heavy glass container and
shipping. packaged according to postal regulations.
When Hosty and his associates 2~ com- Other methods for slfipping fecal speci-
p a r e d " immediately incubated Thayer- mens for enteric pathogens have also been
Martin medium with cultures held on described. Bailey and Bynoe 2'J found that
Transgrow, cystine trypticase agar, Amies, enteric pathogens survived well when
Stuart, and Culturette media for 24 hours feces was spread thinly over tilter paper
before culturing, they found that there was and allowed to dry. These specimens
a 28, 44, a n d 7 9 per cent loss of N. gonor- could be safely packaged in polyethylene
rhoeae for Amies, Sttmrt, and Cuhurette, envelopes. The Cary and Blair medium ~s
respectively. There was only a 7 per cent and its usefidness for submitting fecal
loss of tiffs organism when cystine trypti- cultures have already been described.
case agar was used and 8 per cent loss Body fluids, such as cerebrospinal
with Transgrow. It is important, therefore, fluid and joint fluid, should be submitted
to keep in mind that the commercially to the laboratory in a sterile container and
available transport systems that have cultured promptly. Since N. meningitidis,
swabs incorporated into their design which is sensitive to reduced temperatures,
should not be used for shipping cultures may be the etiologic agent causing the
for N. gonorrhoeae. Nasopharyngeal cul- meningitis, cerebrospinal fhfid should not
tures for N. meningitidis, if procured on a be refrigerated. Fluids fi'om b o d y sites
swab, should be cultured immediately on other than cerebrospinal lluid and joint
Thayer-Martin medium. Because N. menin- lluid may be refrigerated if it is not pos-
gitidis is very sensitive to cold, these swabs sible to cuhure the specimen immediately.
should never be refi'igerated. Urine, tot example, may be kept at 4 ~ C.
Throat cultures for group A strepto- for five days or more without reducing the
cocci that must be mailed to a distant quantity of bacteria present significantl.y,a~
laboratpry may be collected on polyester Under routine orcumstances, urine
swabs c'ontained in a sterile tube with a specimens subnfitted for quantitative cul-
small amount of silica gel. "~ T h e normal ture should be cultured within 30 to 60
flora of the throat dies, but tim group A minutes after collection or stored at 4 ~ C.
streptococci rentain viable for as long as during transportation, or until they can
three days. Throat swabs for group A be cultured; if these refrigerated specimens
streptococci may also be rolled onto a cannot be cultured within 18 to 24 hours,
piece of sterile filter paper and allowed to another specimen should be requested.
air dry for three to four minutes before When anaerobic bacteria are sus-
being folded and packaged in a poly- pected of being the etiologic agents
ethylene envelope for sitipment7-6'zr causing an infection, material for culture
Sputum specimens for Mycobacterium must be introduced at once into sterile col-
tuberculosis culture should be submitted in lection tubes that have been flushed out
clean, sterile; "wide mouthed jars-with ("gassed out") with oxygen-free carbon
305
IIUMAN I'ATHOLOGY-VOLUME 7, N U M B E R 3 May 197.6
dioxide or nitrogen. Material aspirated 3. Isenberg, II. I).. Washington I1,.1. A., Balows, A.,
with a needle and syringe is preferable; and Sonncnwirth, A. C.: Collection, handling
material p r o c u r e d in this way can be sealed and processing of specimens. In i,ennette, E.
H.. Spauhling. E. I1., and Truant, J. I'.. (Edi-
fi'Oln the air for delivery to the laboratory tors): Manual of Clinical Microbiology. Wash-
by r e m o v i n g the needle and replacing the ington, D.C.. American Society for Microbiolo-
needle cap o r b)' i n t r o d u c i n g the material gy. 1974, Ch. 6, p. 59.
t h r o u g h the r u b b e r d i a p h r a g m o f a 4. Center fi~r Disease Control. Atlanta: l'reparation
"gassed out" vial. I f aspirated material of Modified Tha)cr-,XIartin (M'I'M) ,Medium
fill" Plates or Bottles,January 2, 1975.
c a n n o t be obtained and it is f o u n d neces- 5. Martin,J. E.,'Armstrong, J. t1., and Smith, 1'. B.:
sary to obtain the specimen on a swab, it is New system for cuhivation of A'ei~seria gonm-
intportant to p r o c u r e the specimen with a rkoeae. Appl. Microbiol., 27:802. 1974.
swab that has been p r e p a r e d in a "gassed 6. Martin, .]. E., and I.ester, A.: Transgrow, a me-
dium for transport and growth of A'ei,~seria
Otlt" tribe.
gonorrkoeae and A'ei~wria meniugitMis. I ISMIlA
Special containers o f anaerobic speci- Heahh Rep., 86:30, 1971.
mens that meet these r e q u i r e m e n t s are 7. Holstein, Jr., J. L., ! lost)', T. S., and Martin,J. E.:
co,nntel'ciall)" available.* T h e s e containers Evahmtion of the bag-CO2-generating tablet
have Hn indicator so that if anaerobic con- method for isolation of Neisseria gonorlhoeae.
Am. J. Clin. Path.. 62:558, 1974.
ditions are lost, this fact will be recognized. 8. Center for Disease Control, Atlanta: Techniques
Specintens for anaerobic cuhttre shottld be for the l)iagnosis of Gonorrhea, revised March
t r a n s p o r t e d to the laboratory at once; 1975.
every effort shoukl be m a d e to make cer- 9. Barrett-Con.xlor. E.: The nonvalue ofslmtUm cul-
tain that no afore than 10 to 15 minutes ture in the diagnosis of Imeunmcoccal Imeu -
nlOllia..2~,IIL Rev. Respir. Dis., 103:845, 1!171.
elapse between the time o f procuremet~t 10. Murray, 1'. P,., and Washington, J. A., II: .Micro-
and the inoculation o f ntedia. T h e s e scotfic and bacteriologicatml) sis ofexpcctorated
general rules, as well as m o r e specific sputum. Mayo Clin. Proc., 50:339, 1975.
information, are available in manuals for 11. Kalinski, R. W., Parker, R. II.. Brandt, D., and
anaerobic bacteriology 3~-aa and in the Hoeprich, P. 1).: Diagnostic uscfullleSS and
safety of transtracheal aspiration. New Eng. J.
article by RosetdJlatt ill the Mal'ch 1976 Med., 604:276, 1967.
issue o f H)tmat, Palholo,q.'. It should be 12. Hanhn. [t. H., and Beaty. 11. N.: Transtracheal
rementl)ered if" these special p r o c e d u r e s aspiration in the evaluation of patients with
for transmitting anaerobic cultures to the imeumonia. Ann. Intern. Med.. 72:i83. 1970.
13. Bartlett, J. G., Rosenblatt, J. E., and Finegold,
laboratory are not available that u n d e r no S. 31.: l'ercumneous transtracheal aspiration in
circt,ntstances shottld specime,~s fbr anaer- 9the diagnosis of anaerobic puhnonary infec-
obic cttltttre e v e r be refrigerated, sttch as tion. Ant]. Int. Med., 79:535, 1973.
w o u n d cttltttres procttred in a less optimal 14. Ries, K:, Levison, M. E., and Kaye, I).: Trans-
matmel'. tracheal aspiration in puhnonary infection.
Arch. Intern. Med., 133:.t53, 1974.
15. l'ollock, M. R.: Unsaturated fatty acids in CollOll
plugs. Nature, 161:853. 19-t8.
ACKNO~,VLEDGMENTS
16. Forncy, J. E. (Editor): Collection. llandling, and
Shipment of Microbiological Specimens. i'ublic
T h e authors wish to gr,ttefully ac- lleahh Service Publication No. 976. Washing-
knowledge the excellent secretarial as- to,I. I).C.. (;overnuzent l',iuti,lg Office.
sistance o f Debbie Guevara and Glenna Novenlber 1968.
IB)'tendorp. 17. Stuart, R. 1)., Toshach, S. R.. and P:itsula, T. M.:
The prolflem of transport of~specimens for
cuhure of gonococci. Canad..1. I'ub. lleahh,
*Scott l,aboratorics Inc., Fiskville, R. I. 45:73, 195-t.
18. Cary,'S. G., and Blair, E. B.: New transport medi-
um fi)r shil)ment of clinical specimens. J. Bact..
88:tj6, 1964.'
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1968.
l)cl)artluent of l'athology
University of Utah College of Medicine
Salt Lake Cit)'. Utah 8t132 (Dr. Matscn)
307