Pediatr Nephrol (2009) 24:15391543

DOI 10.1007/s00467-009-1217-7

ORIGINAL ARTICLE

Bedside diagnosis of outpatient childhood urinary tract

infection using three-media dipslide culture test
Francisco E. Anacleto & Lourdes P. Resontoc &
Grace H. Padilla

Received: 16 March 2009 / Revised: 23 April 2009 / Accepted: 24 April 2009 / Published online: 3 June 2009
# IPNA 2009

Abstract To determine the accuracy of a three-media

dipslide test, the Uricult Trio, for the diagnosis of childhood
urinary tract infections (UTIs), we collected urine specimens from children at the outpatient department. Two
hundred consecutive patients presenting with symptoms of
UTI were examined. Randomly voided, midstream, cleancatch and catheterized samples were used. Each was tested
by routine laboratory culture and the dipslide test. The
subjects ages ranged from 4 months to 7 years, with a
median age of 5 years. There were 112 (56%) boys and 86
(43%) girls. Of the subjects, 98 (49%) showed urine culture
results indicating significant bacteriuria. There was complete agreement in 70 cases (35%). The sensitivity and
specificity of the dipslide were 68% and 82%, respectively.
The positive and negative predictive values were 81% and
71%, respectively. The likelihood ratio for a positive test
was 3.7, while for a negative test it was 0.39. The
specificity, using Escherichia coli special agar, increased
to 85% and the negative predictive value to 93%. The
Uricult Trio dipslide method was technically simple and
could be applied in the outpatient setting. Further studies
F. E. Anacleto (*) : L. P. Resontoc
Section of Pediatric Nephrology, Department of Pediatrics,
Philippine General HospitalCollege of Medicine,
University of the Philippines Manila,
Manila, Philippines
e-mail: anacletomd@gmail.com
F. E. Anacleto
Institute of Child Health and Human Development,
National Institutes of Health,
University of the Philippines Manila,
Manila, Philippines
G. H. Padilla
Department of Pediatrics, Philippine General Hospital,
Manila, Philippines

are required, however, before it can be recommended as a

routine diagnostic tool.
Keywords Urinary tract infection . Dipslide . Uricult Trio .
Plate count . Children

Introduction
Urinary tract infections (UTI) are one of the most common
childhood illnesses caused by bacteria. They have a
reported incidence of 6.6% and are commonly seen among
children under 7 years old, with a peak occurrence in
infants from 012 months [1, 2]. They usually carry a very
good prognosis; however, undiagnosed UTI will often lead
to acute morbidity and may result in long-term medical
complications, including hypertension and reduced renal
function, specifically among children with congenital renal
scars.
The identification of bacteria on urine cultures remains
the gold standard in the diagnosis of UTI in children with
Escherichia coli infection, being detected in 8090% of
isolates [3, 4]. However, conventional plate count methods
in urine culture prove to be costly, time-consuming, and
may even be inaccurate due to improper handling of
specimens. They usually require transport of samples from
point-of-origin to a laboratory facility for inoculation. Urine
specimens are left to stand for long periods of time before
they are processed, which may often cause erroneous
results, as bacteria may multiply if handled improperly.
The three-media dipslide culture test (Uricult Trio, Orion
Diagnostica, Finland) is cheap, rapid, and can be done at the
bedside. The procedure is relatively simple and eliminates the
problem of transporting samples to laboratories. The inoculation and isolation of E. coli can actually be processed in the

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Pediatr Nephrol (2009) 24:15391543

clinic and the result released within 24 h. In identifying E.

coli in vitro, the dipslide agar gave a sensitivity of 95.5
100% and a specificity of 97.299% [5, 6].
In most studies on childhood UTIs the patients are
examined in the emergency room setting, which may affect
the severity and etiology of the disease. To our knowledge,
ours was the first attempt to determine prospectively the
accuracy of Uricult Trio in the diagnosis of UTI in
comparison with that of the standard plate count method
among children at the outpatient department.

Materials and methods

Infants and children from 0 to 7 years of age with any of
the following symptoms listed in Table 1 and with a
positive finding from either a leukocyte esterase test or a
nitrite test by urine dipstick were included in the study.
Subjects with prior intake of antibiotics, obstructive
uropathy, congenital anomalies of the kidneys and urinary
tracts, midline defects, failure to thrive, concomitant
infections, recurrent UTI, asymptomatic bacteriuria, and
other co-morbid conditions were excluded.
Patients were recruited consecutively from the outpatient
department of the Department of Pediatrics of the Philippine
General Hospital, Manila, Philippines. The study was
approved by the local society ethics review board. Informed
consent was obtained from the parents.
Samples were obtained from clean-voided midstream
urine, supervised by a trained physician. In subjects from
whom clean catch was difficult to be obtained, urethral
catheterization was performed. Upon collection, the samples were immediately divided into two sterile urine
containers. The samples were held at 4C until they were
processed.
One sample was dispatched to an accredited microbiology laboratory, where the specimens were processed
according to standard inoculation protocols for plate counts.
This was the reference standard. A loop calibrated to
deliver ~0.01 ml was used to inoculate plates containing
sheep blood agar and McConkey agar. All plates were
incubated at 35 to 37C and examined after 24 h to 48 h
Table 1 Clinical presentation of infants and children with UTIs (GI
gastrointestinal)
Children 2 years old

Children > 2 years old

Crying on urination
Frequency
Hematuria
GI symptoms
Fever without a focus

Dysuria
Urgency
Flank pain
New-onset enuresis
Chills

for colony count and bacterial identification. A colony

count of 104 colony forming units (CFU)/ml of a single
organism was interpreted as a positive result. The routine
plates were read independently by one bacteriologist. The
other specimen was cultured onto the Uricult Trio
dipslide, in accordance with the product inserts guidelines.
The dipslide was unscrewed from the tube without being
allowed to touch the agar surfaces. Holding the Uricult
Trio by the cap, the operator dipped the slide into the
urine sample so that the agar surfaces were totally
immersed. If the volume of urine was too small for this,
the agar surfaces were wetted with urine, and the container
was tilted to ensure complete wetting. Excess urine was
allowed to drain from the slide. The last drops were blotted
on absorbent paper. The slide was screwed tightly back into
the tube. The tube was then placed upright in an incubator
(362C) for 24 h.
After incubation, all the slides were read by one
pediatrician. Because a colony is the result of the multiplication of a single bacterium, the number of colonies indicates
the concentration of colony-forming units (CFUs/ml) in the
urine sample. The colony count was determined from the
originally green cystinelactoseelectrolyte-deficient
(CLED) medium by our matching the colony density with
the model chart it most closely resembled (see Fig. 1).
A colony count of 104 CFU/ml of a single organism is
interpreted as positive result for UTI with the Uricult Trio.
Colonies that grew on the Uricult Trio dipslide were
further sub-cultured, with the standard plate count being
used to assess the validity of the former. There was
complete agreement between the numbers of organisms
that grew on the dipslide and the numbers of colonies
cultured using the reference standard.
Children who were found to have abnormal results were
seen by either a general pediatrician or a pediatric
nephrologist for additional imaging investigation and
subsequent antibiotic treatment for UTI.

Results
Two hundred infants and children who met the study
eligibility criteria were enrolled. Ages ranged from 4 months
to 7 years, with a median age of 5 years. There were 112
(56%) uncircumcised boys and 86 (43%) girls.
The incidence of positive urine culture by reference
standards was 49%. There was complete agreement in 70
cases (35%); the Uricult Trio gave 27 falsely negative
findings of no significant growth (32%) and 23 falsely
positive cultures (18%). The false-negative cultures grew
species of Acinetobacter, Alkaligenes, Enterococcus, Enterobacter, Escherichia coli, Klebsiella, Proteus and Pseudomonas, on standard plates.

Pediatr Nephrol (2009) 24:15391543

1541

Fig. 1 Model chart for colony

density using Uricult Trio
CLED medium

As mentioned earlier, the validity of the dipslide has appeared

to be very accurate in previous studies. However, accuracy is
usually assessed under optimal laboratory conditions rather
than daily office settings. Therefore, results from the former
may not be valid for general practice. Our research largely
confirmed previous work that had found that the dipslide
culture gave results comparable to those of routine cultures
under non-optimal environments [7, 8].
The study showed that, under usual practice settings, the
sensitivity of the dipslide test in particular, but also the
specificity, was lower than in vitro conditions. This can be
for several reasons.
An explanation may be that the reading of a dipslide is
more difficult than expected. It is assumed that the end-

users of bedside dipslide culture tests need not be

experienced bacteriologists but anyone who can actually
read and interpret the results. It is so simple that readers
may act and judge rashly. A possible pitfall with the Uricult
Trio is confluent growth of colonies. A growth of
107 CFU/ml may totally cover the agar surface, which
can be misinterpreted as a negative finding. Fast-growing
Escherichia coli, Enterobacter spp., and Klebsiella spp. can
cover the agar surface completely, in fewer than 24 hours.
The growth of some organisms may be read as negative,
due to their inherent growth characteristics. Pseudomonas
spp. present as clear, colorless, colonies, while Enterococcus spp. appear as pinpoint growths, which may, therefore,
be interpreted as a negative finding.
Another possible reason for the lower sensitivity is that
some bacteria that can cause UTI do not grow on CLED or
McConkey agar, and those are the ones used in the Uricult
Trio. Species of Proteus and Pseudomonas cannot be
cultivated in CLED. Most of these bacteria are identified by
a laboratory using blood agar or other rich culture media.
The influence of the incubation time may also affect the
sensitivity of the results. To date, there has been no
evidence suggesting an optimal incubation period. The
recommendations and instructions provided by the manufacturer give no clear preference for either 24 hours or 48
hours. Our study opted to use the former. This decision may
exclude the slow-growing bacteria such as Alkaligenes and
Acinetobacter species and, therefore, the results may be
read as negative growth.

Table 2 Comparison of Uricult Trio dipslide colony counts and

growth on standard plates

Table 3 Comparison of Uricult Trio dipslide colony counts with

leukocyte esterase and nitrite tests

The results in Table 2 show that the sensitivity of the

Uricult Trio was 68% and the specificity was 82%. The
positive predictive value was 81%, and the negative
predictive value was computed to be 71%. The likelihood
ratio for a positive finding was also calculated as 3.7, while,
for a negative finding, it was 0.39.
Table 3 shows that the sensitivity and specificity of the
dipslide compared with that of the leukocyte esterase and
nitrite test was 43% and 45%, respectively. The positive
predictive value was at 53% and the negative predictive
value was computed to be 36%.

Discussion

Dipslide

Positive
Negative
Total

Culture 104

Dipslide

Positive

Negative

Total

70
33
103

17
80
97

87
113
200

Positive
Negative
Total

Leukocyte esterase nitrite test

Positive

Negative

Total

51
67
118

45
37
82

96
104
200

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All test characteristics are presented only for the standards set by the guidelines of the European Confederation of
Laboratory MedicineEuropean Urinalysis Group (ECLMEUG) and the American Society of Microbiology; thus, for
a symptomatic patient, a cut-off level of 104 CFU/ml is
considered to be a positive finding for a urine culture. It is
important to remember that the interpretation of culture
findings depends on the method of urine collection and on
the clinical presentation. For mid-stream voided specimens,
the current traditional and international standard of
105 CFU/ml is roughly valid, with reference values lacking.
However, in patients with accompanying symptoms such as
dysuria, abdominal pain, or fever, together with a positive
result from a leukocyte esterase test or pyuria, one urine
sample with growth of 103 CFU/ml can be considered as
adequate for a diagnosis of UTI. At a cutoff level of
1,000 CFU/ml, sensitivity of the Uricult Trio dipslide
improves to 90%, but specificity is lower, at 57%. For a
cutoff set at 105, the sensitivity and specificity are 47% and
87%, respectively.
The accuracy of the Uricult Trio is dismally low when
compared with chemical dipstick urinalysis. This reinforces
previous findings that the usefulness of the dipstick test
alone to rule in infection remains doubtful, even with high
pre-test probabilities [9].
A unique feature of the Uricult Trio is the addition of a
special agar of 8-hydroxyquinoline--glucuronide that
selectively enhances the visualization of Escherichia coli.
When this agar is used as the predominant medium for
Uricult Trio, the specificity increases to 85% while
sensitivity is low at 54%. The positive predictive value
when the E. coli special agar is used is 33%, and the
negative predictive value is 93%.
An ideal gold standard should have a high sensitivity
and specificity. For infections, the standard plate count
culture still remains the reference standard, due to its high
specificity, but apparently it has a low sensitivity. Although
the standard method for diagnosis of urinary tract infection
is quantitative urine culture and identification of bacteria, as
many as 70% of urine samples sent to the laboratory are
proven to have negative results [10]. Among women with
simple urinary symptoms, the urine cultures of 42.7% of
them gave negative findings [11]. A negative culture still
does not rule out the disease, especially urinary tract
infections. This may explain the false-positive results and
affect the accuracy of the test. Nonetheless, the Uricult
Trio has sensitivity and specificity rates comparable to
those of the criterion standard test.
A distinctive feature of the Uricult Trio is that it can
identify some organisms like Enterobacter aerogenes,
Citrobacter, Proteus, Pseudomonas, and Serratia by the
characteristic color change seen on the CLED agar.
However, it may be more difficult especially to the

Pediatr Nephrol (2009) 24:15391543

untrained eye. Special training and constant practice to

retain the skill of interpreting culture growth may eliminate
this problem. Moreover, sensitivity may not be assessed at
the bedside, due to the unavailability of antibiotic discs sets.
Dipslides with cultures may be forwarded to the laboratory
for further susceptibility testing.
A high percentage of boys with UTI was seen in this
study. All these children were uncircumcised, which may
contribute to this unusual incidence. Imaging studies should
be done to rule out structural renal disorders. In addition,
the most common organisms isolated from the male
subjects were Proteus spp. and E. coli. In girls, E. coli
and species of Klebsiella and Proteus were the predominant
uropathogens.
Our findings support previous conclusions that Uricult
Trio is not an accurate laboratory test for childhood UTI
[12, 13]. The likelihood ratios cause only small changes in
the odds that a child has UTI. A calculated 30% increase in
post-test probability can only be appreciated.
In conclusion, the Uricult Trio method was convenient
to use and easy to interpret. It provided a semiquantitative
estimate of the bacterial count, which could be useful to
clinicians in examining children with suspected UTI at the
outpatient department. However, false-negative results may
be obtained in which bacterial density in urine is very high
or for which the results are due to uncommon, slowgrowing, urinary pathogens. This can be avoided by
education in the inoculation and interpretation of dipslide
results, but it will require evaluation of performance to find
sources of error. Nonetheless, dipslides keep well and allow
quantification of urinary bacteria at the bedside to some
extent. More importantly, the organisms can be tested in a
laboratory with growth already having begun on the
dipslide. Further studies are required, therefore, before the
product can be recommended as a routine diagnostic tool.
Acknowledgments We thank the Institute of Child Health and
Human Development of the National Institutes of Health, Manila,
Philippines, the Philippine Society of Nephrology, Inc., and Pediatric
Associates, Inc. for their scientific support and materials provided.

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