Interpreting culture (case based)

Dr Benedict Sim
Infectious disease physician
Outline for Interpreting culture:

• Sterile vs. non-sterile sites/cultures

• Cultures NOT to ignore
• Cultures that can be ignored
• Tips on how to assess value of cultures
• How and when to collect sputum, urine, skin/soft tissue/bone
infection samples for culture
• Value of gram stains
 Sterile vs non sterile sites
• Sterile sites - Blood, CSF, pleural/pericardial/peritoneal fluid,
synovial fluid
• Semi-sterile sites – deep tissue cultures, clean catch urine, BAL
• Non-sterile sites – skin and wound swabs, sputum, tracheal
aspirates, non clean catch urine

Less positive
predictive value
 Case 1
• 63 year old lady – old stroke, bed ridden, long term CBD
• Hx of being hospitalized 6 weeks ago
• Increasingly lethargic for the last 2 weeks and not tolerating
orally
• No obvious focal source of infection except superficial wound
on her right heel and “milky” urine in CBD
• Upon admission, febrile and BP 76/48
• Blood C&S, urine C&S from CBD and swab C&S taken from
superficial wound on her right heel
Blood cultures
Swab culture
• Patient was started on IV Meropenem upon arrival
• 72 hours later – BP stabilizing, fever settling
• Blood C&S – methicillin sensitive staph aureus
• Urine C&S – ESBL E coli, UFEME – pus cells
• Swab C&S – Coagulase negative staph sensitive to Vanco and
Linezolid
 What antibiotics should we continue for her?
1. IV Vancomycin & Meropenem
2. IV Meropenem
3. IV Cloxacillin
4. IV Vancomycin
5. Others
 CBD, bacteriuria and CAUTI
• Patients on long term CBD uniformly have bacteriuria
• If intending to culture, change CBD & clean genitalia before
inserting & collecting urine from new CBD
• Pus (and bad odour) does not necessarily mean UTI in long
term CBD patients
• Even if cultures positive but no localizing sign of infection (eg
renal angle tenderness), CAUTI to be considered only in the
absence of other sources of infection
• Do not treat asymptomatic bacteriuria
 CONS
• Always insignificant from non sterile skin sites
• Likely insignificant even from non sterile sites
• Unless repeated grown from peripheral vein in a patient with
central lines or suspected IE
 Pathogens in blood cultures
Always pathogenic Unlikely pathogenic
• Group A strep • P acnes
• Pneumococci • Corynebacterium sp
• Gram negative rods • Bacillus sp
• Candida • CONS
• S aureus • Mixed growth of bacteria

Probably pathogenic
• Strep viridans
• Enterococci
 Case 2
• 68 year old man
• Intubated day 7 for COAD exacerbation.
• Has been treated with Ceftriaxone, bronchodilators and
steroids
• Has a new consolidation in the lungs and new onset fever
• Tracheal aspirate taken
• Culture grew candida albicans. Gram stain – yeasts seen
 What antibiotic would you change him to?
1. Pip-tazo
2. Fluconazole
3. Caspofungin
4. Tamiflu
5. All of the above
 Cultures that are to be ignored
• Non significant sputum cultures - Candida sp, CONS,
enterococci, Gm +ve bacilli (except Nocardia, H
parainfluenzae), strep viridans
 Collecting samples
Sputum
• rinse with water to remove excess oral flora;
• Encourage pt to cough deeply
• collect and transport in a sterile container

Urine
• Clean genitalia
• Separate skin folds
• Mid stream urine
 Wound swabs
• Generally unhelpful
• Clean surface of wound or abscess with 70% alcohol and allow to
dry; aspirate pus or fluid if possible; request gram stain for initial guidance
• Swabs discouraged - usually insufficient material for gram stain and culture; if
swabs must be used, be sure quantity is adequate for both culture and gram
stain
• Do not culture chronic superficial wounds or sinus drainage since superficial
cultures correlate poorly with deep cultures - try an obtain a deep culture or
biopsy for culture whenever possible
Insignificant organism
Irritating mixed growth
Gram stains can inform
Sometimes jackpot!
When culturing wounds / SSI / SSTI / ortho
infections
Ideally
• adequate material
• deep tissue / aspirate pus
• OT / sterile procedure
• Clean the top most layer

Read the op notes

Deep tissue cultures after removing
superficial wound covering
Tissue cultures from OT
Copyrights apply
Copyrights apply
Copyrights apply
 Summary 1
• Sterile vs non sterile sites
– Sterile: Blood, CSF, pleural / peritoneal / pericardial fluid, synovial fluid,
deep seated pus
– Not so sterile: BAL, urine, CVC line blood culture, deep tissue cultures
– Non sterile: wound swab, throat swab; sputum; tracheal asp; genital swab
• Less significant if
– cultures take long time to grow
– Cultures have mixed growth
– gram stain negative
– unusual organism / organism with low pathogenicity is grown
– patient not demonstrating signs / symptoms of that infection
– If culture taken from pre-existing tube / sinus (contaminated orifice)
 Summary 2
• Definitely significant +ve blood cultures – Staph aureus,
Candida, gram –ve rods, strep pneumo, strep pyogenes,
H influenzae, Pseudomonas aeruginosa
• Probably significant – strep viridans, Enterococci
• Unlikely significant – CONS; bacillus species, diphteroids,
growing beyond 72 hours (but………..)
• Bacteriuria does not automatically mean UTI. Especially
in long term CBD patients. Change CBD before collecting
culture
 Summary 3
• Non significant sputum cultures - Candida sp, CONS, enterococci,
Gm +ve bacilli (except Nocardia, H parainfluenzae), strep viridans
• When to take sputum cultures – suspecting pneumonia. Don’t
take for ac. Bronchitis; asthma / COAD exacerbation
• How microscopy can help – from sterile site, gram stain always
helpful; quantification and description of gram stain helpful; quality
of specimen from non sterile sites
• How to take samples from a non sterile site
– Wound infection
– Urine cultures, sputum cultures
Thank you