Microbiology Collection Manual
Transcription
Microbiology Collection Manual
South Shore Health Laboratory Services Microbiology Collection Manual-2015 SOUTH SHORE HEALTH LABORATORY SERVICES Microbiology Collection Manual South Shore Regional Laboratory Service 90 Glen Allan Dr. Bridgewater, NS Phone 902-527-5263 • Fax 902-527-5283 1 South Shore Health Laboratory Services Microbiology Collection Manual-2015 Table of Contents 1.0 GENERAL GUIDELINES ............................................................................................................................................................................ 3 1.1 Collection ...............................................................................................................................................................................................................................................3 1.2 Specimen Identification and Information .........................................................................................................................................................................................4 1.3 Specimen Transport..............................................................................................................................................................................................................................5 1.4 Common Transport Container ..............................................................................................................................................................................................................6 2.0 COLLECTION INSTRUCTIONS FOR SPECIFIC SITES ......................................................................................................................... 7 2.1Genital Specimen ......................................................................................................................................................................................................................................7 2.2 Gastrointestinal Tract Specimen ......................................................................................................................................................................................................... 11 2.3 Respiratory Tract Specimen................................................................................................................................................................................................................. 14 2.4 Wound, Tissue, Skin Specimens ......................................................................................................................................................................................................... 20 2.5 Surveillance Testing .............................................................................................................................................................................................................................. 24 2.6 Sterile Body Fluid Specimen ................................................................................................................................................................................................................ 26 2.6.1 Blood Culture Specimen ................................................................................................................................................................................................................ 26 2.6.2 CSF Specimen.................................................................................................................................................................................................................................. 28 2.6.3 Urine Specimen ............................................................................................................................................................................................................................... 29 2.6.4 Sterile Body Fluids: (Excluding CSF, Blood and Urine) ........................................................................................................................................................... 31 3.0 Specimen handling for specific condition or organisms ................................................................................................................................... 32 4.0 Inappropriate Specimen for Bacterial Culture .............................................................................................................................................. 33 5.0 Specimen Rejection ....................................................................................................................................................................................... 37 6.0 Appendix........................................................................................................................................................................................................ 38 6.1 Laboratory Services Fax Request for Patient Information Form------------------------------------------------------ ..................................................................... 38 6.2 Laboratory Service Documentation of Verbal Request from Health Care Providers--------------------------- .......................................................................... 38 6.3 Critical/ None-recollectable Unlabelled/ Mislabelled Specimen Form----------------------------------------------- ..................................................................... 38 2 South Shore Health Laboratory Services Microbiology Collection Manual-2015 1.0 GENERAL GUIDELINES Specimens should be collected before starting antimicrobial agents. Specimens should be collected in an approved container. Specimens in unapproved containers (i.e. mason jars) will not be processed. When Specimens are collected, it is important that the external surface of the specimen container and the requisition are not contaminated. External contamination will usually result in rejection of the specimen by our laboratory. As soon as the specimen is collected and appropriately labeled, the specimen container should be placed in the plastic specimen bag. Fill out the requisition completely and place it in the separate pouch from the specimen container. The requisition must include the following information: Patient’s full name Health Care Number ( or alternate unique identifier) Date of Birth Physician requesting the test 1.1 Collection Use appropriate specimen collection material. Sterile collection material and aseptic technique must be used for collection of specimens using invasive procedures. The specimen should be collected in the standard containers available from Materials Management or from the Lab. For specimens from non-sterile sites, attempt to collect the specimen with as little contamination from the surrounding normal flora as possible If a specimen is to be collected through intact skin, the skin should be disinfected thoroughly, allowing several minutes for the disinfectant to have effect. Examples of skin disinfectants include 70% alcohol, iodine solution, chlorhexidine, etc. If tincture of iodine is used, remove with 70% ethanol after procedure to prevent burning. 3 South Shore Health Laboratory Services Microbiology Collection Manual-2015 1.2 An adequate amount of specimen should be collected. As a general rule, more is better than less. For example, a tube or sterile container with 10 ml of pus is a better specimen than a swab. Small amounts of specimen are subject to drying, becoming aerobic and other forms of deterioration, whereas larger volumes minimize the risk of false negative results. Specimen Identification and Information The specimen container should be labeled with the patient’s full name and Health Care Number (or other unique identifier), Admission label or the Meditech large bar code label. Date and Time of Collection and collector initial should be clearly indicated on the specimen. The specimen source should be clearly indicated on the requisition to ensure that the appropriate processing takes place. For example, a “swab of hip” taken in the OR from a joint would be processed quite differently from a superficial swab of a hip ulcer. When specific diagnoses are being considered, they may have a bearing on the processing of the specimen. This diagnosis should be indicated on the requisition to ensure that the specific questions can be answered. This is particularly important if the suspect organism is unusual or requires special processing. Pertinent historical data (i.e. travel, association with a known outbreak, immunosuppression, or underlying disease) should also be indicated on the requisition. Antibiotic information: Ideally, specimens should be collected before starting antimicrobial agents. If patient is already on antimicrobial treatment, please indicate on the requisition. 4 South Shore Health Laboratory Services Microbiology Collection Manual-2015 1.3 Minimum Turn Around time Culture Urine Culture Stool Culture Throat Culture Miscellaneous Swabs Group B Screen Fluids MRSA Screen Minimum Turn Around Time 1 day 3 days 1 days 2 days 3 days 4 days 1 day 1.4 Specimen Transport Specimens should be transported to the laboratory as quickly as possible. Stool for parasitology should be mixed well with the SAF fixative and can be held at room temperature. Stool for culture should be mixed well with the enteric transport medium. If a syringe is used to collect the sample, remove the needle before transporting to the Lab. If the volume of the specimen is very low, non bacteriostatic sterile saline may be drawn up and used to flush the syringe into a sterile container. The following Chart is a quick guide for common specimens. Specimen type Urine Stool Sputum Swabs in Transport System Body fluids Blood Culture Dermatophytes Culture Store /Transport condition 4 oC 4 oC 4 oC 4 oC Room Temp Room Temp Room Temp 5 Deliver to Lab Within 24 hours Within 24 hours Within 24 hours Within 24 hours Within 1 hour A.S.A.P Within 72 hours South Shore Health Laboratory Services Microbiology Collection Manual-2015 1.5 Common Transport Container Amies Transport Swab: Microorganism collection and transport system for aerobes and anaerobes Dry Sterile Container: Commonly used for Urine, Body Fluids, Aspirate, Sputum , Stool Viral Transport Swab: For Viral Culture: Always check swab expiry date before collection. Collect with expired swab will be rejected 6 South Shore Health Laboratory Services Microbiology Collection Manual-2015 2.0 COLLECTION INSTRUCTIONS FOR SPECIFIC SITES 2.1Genital Specimen Meditech Vaginal Culture VAGC Specimen Source Vaginal Transport Stability Amies swab *if Actinomyces is suspected, please collect anaerobic transport swab, which is available from lab Vaginosis Screen VAGS Vaginal secretion Proper labeled Air Dried Slide Procedure 2-8oC/48 1. Use a speculum without hrs lubricant. 2. Collect secretions from the mucosa high in the vaginal canal with a sterile swab 7 days 1. Use a speculum without lubricant. 2. Collect secretions from the mucosa high in the vaginal canal with a sterile pipette or swab. Vag Group B screen (Prenatal) VAGB Vaginal/rectal Note Only For Patient < 13 Patient with recurrent yeast infection Diagnosis of toxic shock syndrome/ puerperal fever Post-OP No fixative or cyto-spray Yeast is included in the screen Nugent score is only valid for women under 55 Method of choice for yeast infection 3. Prepare a smear in the clinic, allowing it to air dry before sending to the laboratory. 2-8oC/48 1. Collect specimen at 35-37 Please indicate if patient has hrs weeks gestation. penicillin allergy 2. Swab the distal vagina (vaginal introitus), followed by the rectum (insert swab through the anal sphincter) Amies swab 7 South Shore Health Laboratory Services Microbiology Collection Manual-2015 Meditech Specimen Source Genital lesion Transport Stability Procedure Viral Transport swab 2-8oC/48 Clean lesion surface with hrs 0.85%NaCl Collect fluid from vesicle Amies Transport 2-8oC/48 Use a swab for each site and hrs label accordingly Amies swab Sterile container 2-8oC/48 Disinfect scrotal skin hrs Fluid or pus aspirates from abscess Note Genital Ulcer/Lesion VIRC True Swab MISC Testicular abscess MISC Penile Swab MISC Amniotic fluid Vulva BFC Head of penis Amies swab or foreskin Amniotic fluid Sterile Container MISC Vulva Cervical Culture Urethral Culture Please refer to Chlamydia/ Neisseria gonorrhoeae Screening. Common causes of Cervitis are Chlamydia, Neisseria or Herpes, culture do not provide clinical useful information Indicate sites Eye, ear, placenta, vagina..etc Testicular abscess fluid /pus 2-8oC/48 Collect pus from under hrs foreskin A.S.A.P Aspirate fluid by catheter at Csection or at amniocentesis o 2-8 C/48 1. Clean surface with saline hrs 2. Collect exuadate/ pus Amies Transport 8 Viral request: HSV Request for T. palladium should order RPR serology Always check swab expiry date before collection. Collect with expired swab will be rejected Routine screen: Group B strep and Listeria moncytogenes Routine aerobic bacterial culture. If Mycobacterium is suspected. Contact Microbiology Only for wound Collect only if pain, erythema or edema is present H. ducreyi will only be screened upon request South Shore Health Laboratory Services Microbiology Collection Manual-2015 Meditech Chlamydia/ Neisseria gonorrhoeae Specimen Source CHLGCDNA Cervical Transport Stability BD ProbeTec Swab 2-8oC/72 1. Remove excess mucus with cleaning swab and discard. hrs 2. Insert the Female Endocervical Swab into the cervical canal and rotate for 15 to 30 seconds. 3. Place swab in tube 4. Break shaft at score line. 5. Screw cap firmly onto tube. 6. Label tube with patient info and date/time collected. 1. Insert the Male Urethral Swab 2 to 4 cm into the urethra. 2. Rotate for 3 – 5 seconds. 3. Place swab in tube 4. Break shaft at score line. 5. Screw cap firmly onto tube. 6. Label tube with patient info and date/time collected 15-60 mls of first void or 1 hour since last void urine specimen.The patient should collect the first 15-60 ml of voided urine (The first part of the stream-not midstream) If >60 mls urine collected test not processed and specimen recollection indicated ( do not discard portion of sample to obtain 60 ml requirement) Urethral Urine First void urine in sterile container 9 Procedure Note If a swab and urine sample received on same patient urine specimen is not processed. Maximum acceptable transport time (from collection to receipt in YRH Microbiology) - 6 days refrigerated Please do not share Urine Chlamydia specimens with urinalysis and/or urine culture test requests. 2 separate samples are required. Throat swab for Chlamydia screen require different transport swab, please contact Micro for direction South Shore Health Laboratory Services Microbiology Collection Manual-2015 Meditech Abscess MISC Specimen Source Endometrium Transport Stability Amies swab Sterile container 2-8oC/24 1. Insert endometrial suction hr curette or catheter protected Dacron swab through the cervical and transfer beyond the cervical opening into the uterine cavity. 2. Collect sample within the cavity 1. Decontaminate skin 2. Aspirate material from the duct A.S.A.P Obtain aspirates during laparoscopy 21.Collect mid stream urine 8oC/24hr (Pre-massage specimen ) 2.Perform a digital massage through rectum 3. Have patient pass prostatic secretion in the urethra by urination (Post-massage specimen) Batholin cyst Skene’s gland Prostate URNC Fallopian tubes Pre/Post Sterile Container massage urine specimen 10 Procedure Note Routine Screen: enteric bacteria, Group A and Group B strep Anaerobic and Chlamydia Require special transport device, please contact Lab before procedure Clear indicate on requisition for Prostatitis investigation South Shore Health Laboratory Services Microbiology Collection Manual-2015 2.2 Gastrointestinal Tract Specimen Meditech Stool Culture Stool O+P STOC Specimen Transport Source Stool Enteric Transport OPSR- routine Stool screen for Cryptosporidium And Giardia Stool O+P OPCTMicroscopy Only available when criteria is met ( see note) Stool Stability Procedure Note 2-8oC/24 hr 1. Do not allow water or urine to touch the stool. 2. Collect the stool sample on a clean dry surface such as a disposable container or onto plastic wrap placed under the toilet seat. 3. Using the scoop attached to the inside of the lid, add a tablespoon size amount of stool to the vial until the fill line is reached. Use the scoop to thoroughly mix the stool with the material in the vial. 4. Screw the lid on firmly. Do not get any stool on the outside of the container SAF Container 2-8oC /14 DAYS SAF Container 2-8oC /14 DAYS Order by lab only ( send specimen with microbiology Req) 11 Do not obtain sample from the toilet bowl. Pass stool into a clean, dry, wide mouth container or bedpan and transfer into the appropriate lab container Samples from patients in Hosp.>3 days and not admitted with diarrhea are not suitable for testing. Avoid mineral oil, bismuth, barium and kaolin (Kaopectate), or laxatives for 5 days before collecting the sample. This test is only available if any of the following criteria are met: 1. Pediatric ( children <16 years old) 2. Recent Travel/Immigration History (outside North America) 3. Immunocomprimized 4. Special Request Samples from patients in Hosp.>3 days and not admitted with diarrhea are not suitable for testing. South Shore Health Laboratory Services Microbiology Collection Manual-2015 Meditech Stool CDiff CDIF Specimen Transport Source Stool Sterile container Stability Procedure Note 2-8oC /72 hr 1. Do not allow water or urine to touch the stool. 2. Collect the stool sample on a clean dry surface such as a disposable container or onto plastic wrap placed under the toilet seat. 3. Put a sample of stool into the container you were given (at least 1/3 full). 4. Screw the lid on firmly. Do not get any stool on the outside of the container. 1. Pass the tip of a sterile swab approximately 1 inch beyond the anal sphincter. 2. Carefully rotate the swab to sample the anal crypts, and withdraw the swab. 3. Fecal staining must be visible on the swab Routine testing for VRE only. If abscess/wound related, please obtain aspirate specimen for wound culture Stool, Viral VIRC Stool Sterile Container 2-8oC /48hr Anal VREC Anal swab Amies transport 2-8oC /48 hr 12 Must be a diarrhea sample Repeat sample must be 48 hrs apart Children <12 months old will not be processed Indicate suspected virus If its outbreak related, outbreak number must be clearly indicated on requisition South Shore Health Laboratory Services Microbiology Collection Manual-2015 Meditech Specimen Transport Source Anal Vaseline swab Swab Pinworm PINW Aspirate/ biopsy specimen Contact Microbiology before collection Stability Procedure Refrigerated/24hr 1. Used for the detection of enterobius vermicularis ova (pinworms). Use the Vaseline swab provided by the lab. 2. With the patient lying on his/her side, the perianal skin should be exposed and the swab should be rolled over the skin within 1 cm of the anus. 3. The swab should alson be inserted, not more than 5 mm into the anal canal. 4. Replace the Vaseline swab back into the tube and seal tight. 13 Note The ideal time for specimen collection is after the patient has settled for the night or first thing in the morning, before the patient has either washed or passed stool. South Shore Health Laboratory Services Microbiology Collection Manual-2015 2.3 Respiratory Tract Specimen General Consideration: If Corynebacterium diphtheriae, Arcanobacterium haemolyticum, Bordetella pertusis, N.gonorrhoeae, Chlamydia or mycoplasmas are suspected, the physician should contact the microbiology lab prior to specimen collection because special techniques and/or media are required for the isolation of these agents. Meditech Transport Stability Procedure Amies Transport 2-8oC /48 hr Throat Dacron swab 2-8oC /24hr EYEC Conjunctiva/ lid margin Amies Transport 2-8oC /48 hr MISC Dacryocystitis Amies , cellulitis Transport canaliculitis Nose Amies Transport 2-8oC /48 hr Collect superficial wound culture 2-8oC /48 hr 1. Insert a sterile swab into the nose until resistance is met t the level of the turbinates 2. Rotate the swab against the nasal mucosa Throat THRCRoutine culture Throat THSCRapid antigen test Eye Nasal Specimen Source Throat MRSACUL 14 Note Extend sterile swab between the tonsillar pillars and behind the uvula. (Use a tongue depressor to avoid touching the cheeks, tongue, uvula or lips.) Sweep the swab back and forth across the posterior pharynx , tonsillar areas and any inflamed areas to obtain sample. Submitted primarily for the detection of Group A, C and G streptococci. Only for patients <16 years old A throat culture specimen must also be submitted Obtain specimen with a sterile amies swab Roll the swab over the conjunctiva before topical medication is applied. Eye culture for keratatis. viral or endophtalmitiscontact microbiology before collection Nose swab is for MRSA screening only. If it’s for South Shore Health Laboratory Services Microbiology Collection Manual-2015 Meditech Specimen Source Transport Stability Procedure 3. Repeat the process on the other side Ear EARC MISC Otitis enterna Otitis media fluid Otitis media fluid collected by tympanocente sis Amies Transport 2-8oC /48 hr Sterile container A.S.A.P 1. Insert sterile swab into ear canal until resistance is met 2. Rotate swab and allow fluid to collect on swab Clean external canal with mild detergent Use a syringe aspiration technique to obtain fluid from the ear drum Send specimen in sterile container Sinus Aspirates MISC Sinus Sterile Container/ Anaerobic transport A.S.A.P 1. Using a syringe aspiration technique, a specially trained physician or an otolaryngologist will obtain material from maxillary, frontal or other sinuses. 2. Place the contents of the syringe into an anaerobic transport system. Mouth MOUC Oral cavity/ tongue Amies Transport 2-8oC /48 hr 1. Rinse mouth with sterile saline. 2. Wipe the lesion with dry sterile gauze. 3. Swab or scrape areas of exudation or ulceration Expectorated Sputum SPUC Sputum Sterile Container 2-8oC /24 hr 1. If possible, have the patient rinse mouth and gargle with water prior to sputum collection. Clean teeth without toothpaste. 2. Instruct the patient not to expectorate saliva. 3. Collect specimen resulting from a deep cough in a sterile screw-cap container. 15 Note wound/ abscess or sinus , collect aspirate specimen for wound culture Invasive procedure. These specimen are usually submitted to diagnose middle ear infection only if previous therapy has failed Contact Microbiology before collection Please contact Micro lab for TB culture instruction South Shore Health Laboratory Services Microbiology Collection Manual-2015 Meditech Induced Sputum SPUC Specimen Source Sputum Transport Stability Procedure Sterile Container 2-8oC /24 hr 1. Using a wet toothbrush, brush the buccal mucosa, tongue and gums prior to the procedure. 2. Rinse the patient’s mouth thoroughly with water. 3. Using an ultrasonic nebulizer, have the patient inhale approximately 20-30 ml of 3-10% NaCl. 4. Collect the induced sputum in a sterile screwcap container. Tracheostomy and Endotracheal Aspirations SPUC Trachea Sterile container A.S.AP 1. Tracheostomy is followed by colonization within 24 hours of insertion of the tube. Results must be correlated with clinical findings such as fever or infiltrate on chest X-ray. 2. Aspirate the specimen into a sterile sputum trap. Bronchial wash /Bronchoalve olar lavage SPUC FUNS PCPE AFBC Bronchial Sterile Container A.S.A.P 1. Inject sterile 0.85% NaCl (generally 5-20ml aliquots) from a syringe through a biopsy channel of the bronchoscope. 2. Gently suction the saline into a sterile container before administering the next aliquot. (In general, 50-75% of the saline instilled is recovered in the lavage effluent.) 3. Obtain one specimen for each test request 16 Note Bronchial wash and bronchoalveolar lavage specimens are generally obtained before brushing or biopsy specimens to avoid excess blood in the recovered fluid, because blood may alter the concentration of cellular and noncellular components: South Shore Health Laboratory Services Microbiology Collection Manual-2015 Meditech Bronchial Brush Specimens SPUC FUNS PCPE AFBC Specimen Source Bronchial Transport Sterile Container Lower Respiratory tract Biopsies and Aspirate Contact Microbiology before collection Nasopharyngeal aspirates RSV Posterior pharynx Syringe with suction tubing in sterile container Stability Procedure Note A.S.A.P 1. Insert a telescoping double catheter plugged with poly-ethylene glycol at the distal end (to prevent contamination of the bronchial brush) through the biopsy channel of the bronchoscope. 2. Obtain one specimen for each test request For PCP exam, Specimen must be at QE2 within 16 hours and before 1700 . Contact Microbiology before collection A.S.A.P 1. Attach disposable 5cc Luer fitting syringe to the control device of a No.5 French whistle tip suction catheter. 2. Pass the catheter through the nares into the posterior pharynx. DO NOT ALLOW THE TIP TO ENTER THE ORAL CAVITY. The distance to which the catheter is passed must be estimated according to the size of the patient’s head. A cough will be provoked if the catheter tip touches the larynx, at which point the catheter should NOT be advanced further and should be withdrawn somewhat. 3. When the catheter is in position, close the side arm of the control device with the thumb. GENTLY apply suction using the syringe and at the same time slowly withdraw the catheter. 4. When sufficient sample has been collected (0.1 ml for RSV and just visible sample for Pertussis) the catheter may be completely withdrawn. Leave the syringe attached and place the END portion of the catheter into a If both RSV and Pertussis are requested, separate samples must be collected 17 South Shore Health Laboratory Services Microbiology Collection Manual-2015 Meditech Specimen Source Transport Stability Procedure sterile specimen container. 5. Label and place the complete apparatus in a clean zip-lock plastic specimen bag and forward immediately to the Microbiology Lab. Pertussis PCR NPAC Nasopharyngeal aspirates Nasopharyngeal swab Suction tubes in Sterile Container Viral Transport Container A.S.A.P See RSV collection Procedure A.S.A.P See Viral Culture Collection Procedure 18 Note South Shore Health Laboratory Services Microbiology Collection Manual-2015 Meditech Nasopharyngeal swabs` VIRC Specimen Source Posterior pharynx Transport Viral Transport Medium Stability 2-8oC /48 hr Procedure 1. When you collect the specimens, wear gloves and a mask. The mask is to protect you if the patient coughs or sneezes while you are collecting the specimen. Change gloves and wash your hands between each patient. 2. Viruses live in cells. If the patient has a lot of mucus in the nose, this can interfere with the collection of cells. Either ask the patient to use a tissue to gently clean out visible nasal mucus or clean the nostril yourself with a swab. 3. How to estimate the distance to the nasopharynx: Prior to insertion, measure the distance from the corner of the nose to the front of the ear and insert the shaft approximately 2/3 of this length. 4. Seat the patient comfortably. Tilt the patient’s head back slightly to straighten the passage from the front of the nose to the nasopharynx to make insertion of the swab easier. 5. Gently insert the swab along the medial part of the septum, along the floor of the nose, until it reaches the posterior nares – gentle rotation of the swab may be helpful. (If resistance is encountered on one side, try the other nostril, as the patient may have a deviated septum.) 6. Allow the swab to sit in place for 5-10 seconds. 7. Rotate the swab several times to dislodge the columnar epithelial cells. Insertion of the swab usually induces a cough. 8. Withdraw the swab and place it in the collection tube. 9. Refrigerate immediately. 10. Remove gloves. Wash hands. 19 Note Collect specimens as soon after onset of symptoms as possible because the likelihood of obtaining positive results is generally greatest within the first 3 days after onset of symptoms and diminishes rapidly as the course of infection proceeds in otherwise healthy and immunocompeten t individuals. Viruses may be recovered from clinical samples for prolonged periods with disseminated or persistent infections. Collect autopsy specimens as soon after death as possible. South Shore Health Laboratory Services Microbiology Collection Manual-2015 2.4 Wound, Tissue, Skin Specimens Meditech Superficial MISC Wound Deep wounds/ Abscess MISC Specimen Source Wound/specify Wound/Abscess Transport Stability Amies Transport 2-8oC /48 hr Sterile Container A.S.A.P 20 Procedure Note 1. A syringe aspiration is preferable to a swab collection. 2. Disinfect the surface of the wound with 70% alcohol and then with an iodine solution (12% tincture of iodine or a 10% povidoneiodine). Allow the disinfectant to dry prior to collecting the specimen. If tincture of iodine is used, it must be removed with 70% alcohol after the procedure to prevent burns. 3. Using a 3-5ml syringe with a 22-23 gauge needle, a physician will aspirate the deepest portion of the lesion. If a vesicle is present, collect both fluid and cells from the base of the lesion. 4. If the initial aspiration fails to obtain material, inject sterile nonbacteriostatic 0.85% NaCl subcutaneously and repeat the aspiration attempt. 1. Disinfect the surface. with 70% alcohol and then with an iodine solution (1-2% tincture of iodine or a 10% povidone-iodine). Allow the disinfectant to dry prior to collecting the specimen. If tincture of iodine is used, it must be removed with 70% alcohol after the procedure to prevent burns. 2. Aspirate the deepest portion of the lesion, avoiding contamination by the wound surface. Wound swabs are assessed microscopically for quality which determines the workup For open wound: debride and rinse with sterile saline if appropriate prior to collection. South Shore Health Laboratory Services Microbiology Collection Manual-2015 Meditech Ulcers and Nodules MISC Catheter tips MISC Skin/Nail/ Hair Scraping FUCD Specimen Source Wound/ Specify Indwelling Catheter tips Skin/ Nail/ Hair Transport Stability Procedure Note Amies Transport 2-8oC /48 hr 1. Clean the area with 70% alcohol and then with an iodine solution (1-2% tincture of iodine or a 10% povidone-iodine). Allow the disinfectant to dry prior to collecting the specimen. If tincture of iodine is used, it must be removed with 70% alcohol after the procedure to prevent burns. 2. Remove overlying debris. 3. Curette the base of the ulcer or nodule. 4. If exudate is present, collect it with a syringe or sterile swab Decubitus ulcers specimen is not suitable for culture Sterile Container A.S.A.P 1. Clean the skin with 70% alcohol prior to catheter removal. 2. Observing aseptic technique, hold the exposed end of the catheter and carefully remove the catheter from the patient with a sterile instrument, taking care to avoid contact with exposed skin. 3. Holding the distal end over a sterile container, cut the tip with sterile scissors, dropping the last 4-5 cm into the container. 4. Transport to the lab as soon as possible to avoid drying. Order if catheter related sepsis suspected. Wrap scraping in black construction paper and place in an envelope RoomTemp/72 1. Clean the surface 70% alcohol and allow to hours air dry 2. Using a scalpel blade, scrape the periphery of the lesion border. 3. Samples from scalp lesions should include hair that is selectively collected for examination. 21 Blood culture must accompany specimen. South Shore Health Laboratory Services Microbiology Collection Manual-2015 Meditech Specimen Source Transport Stability Bite Wound MISC Pus from wound Sterile Container, Amies Transport A.S.A.P Bone BONC Surgically Removed Bone Sterile container A.S.A.P Punch Skin biopsy TISC Skin Biopsy Sterile container A.S.A.P Soft tissue Aspirate MISC Sinus tract, lesion Sterile Container A.S.A.P Procedure 4. If there is nail involvement, obtain scrapings of debris or material beneath the nail plate. 5. Refold the paper so that the specimen is contained and cannot fall out 6. Place the black paper in the envelope and label accordingly 1. Aspirate pus from the wound, or obtain it at the time of incision, drainage or debridement of the infected wound. 2. Clearly indicate source of the bite 1. Obtain specimen at surgery 2. Submit in sterile container without formalin. 3. The specimen may be kept moist with sterile 0.85% NaCl. 1. Disinfect the surface. with 70% alcohol and then with an iodine solution (1-2% tincture of iodine or a 10% povidone-iodine). Allow the disinfectant to dry prior to collecting the specimen. If tincture of iodine is used, it must be removed with 70% alcohol after the procedure to prevent burns. 2. Collect 3-4mm sample with a dermal punch. 3. Submit in a sterile container without formalin 4. .The specimen may be kept moist with sterile 0.85% NaCl. 1. Disinfect the surface with 70% alcohol and then with an iodine solution (1-2% tincture of iodine or a 10% povidone-iodine). Allow the disinfectant to dry prior to collecting the specimen. If tincture of iodine is used, it 22 Note Do not culture fresh bite wounds, as infectious agents will likely not be recovered South Shore Health Laboratory Services Microbiology Collection Manual-2015 Meditech Specimen Source Transport Stability Procedure must be removed with 70% alcohol after the procedure to prevent burns. 2. Aspirate the deepest portion of the lesion or sinus tract. Be careful to avoid contamination by the wound surface. 23 Note South Shore Health Laboratory Services Microbiology Collection Manual-2015 2.5 Surveillance Testing Meditech Specimen Source Nares Groins MRSA VRE MRSACUL Transport Stability Procedure Amies Transport 2-8oC /48 hr Amies Transport 2-8oC /48 hr 1. moisten tip of swab with sterile saline/water or by inserting the tip of the swab into the culture medium located in the bottom of the culture tube 2. gently insert the swab and rotate 5 times in the anterior nare 3. Using the same swab, repeat the process in the other nare. 1. Moisten tip of swab a with sterile saline/water or by inserting the tip of the swab into the culture medium located in the bottom of the culture tube 2. gently rotate swab 5 times over groin areas 3. using same swab repeat the process in the other groin Moisten tip of swab a with sterile saline/water or by inserting the tip of the swab into the culture medium located in the bottom of the culture tube Rotate swab on the surface Incisions, lesions, exit sites of indwelling catheters Amies Transport 2-8oC /48 hr Stool Sterile Container 2-8oC /48 hr 1. Do not allow water or urine to touch the stool. 2. Collect the stool sample on a clean dry surface such as a disposable container or onto plastic wrap placed under the toilet seat. 3. Put a sample of stool into the container 4. Screw the lid on firmly. 5. Do not get any stool on the outside of the container. Rectal Swab Amies Transport 2-8oC /48 hr 1. Moisten the swab with the medium in the collection tube or sterile saline or water. 2. Gently insert the swab into the rectum or stoma VREC 24 Note Please refer to infection control policy for ordering surveillance testing South Shore Health Laboratory Services Microbiology Collection Manual-2015 Meditech Specimen Source Transport Stability Procedure in order to obtain stool on cotton tip of the swab (visible stool will provide the best specimen) 25 Note South Shore Health Laboratory Services Microbiology Collection Manual-2015 2.6 Sterile Body Fluid Specimen General Considerations: 1. Inform Laboratory before collection 2. Deliver to Laboratory immediately. DO NOT REFRIGERATE. 3. Clearly indicate specimen source and test requested on the requisition or in Meditech 2.6.1 Blood Culture Specimen Adult Population (14 YEARS OLD AND ABOVE) Meditech : BLDC During a single patient encounter, two sets of blood cultures, drawn from two separate sites or same site at least 20 minutes apart should be drawn. Although blood occasionally may need to be obtained from intravenous lines and similar access devices, a culture of blood from such a device should be paired with another culture of blood obtained by venipuncture to assist in interpretation in the event of a positive result. If a 3rd set is required obtain from another patient encounter 20 minutes later or a more appropriate time convenient for patient/lab personnel. The recommended volume is 15-20 ml per venipuncture site The maximum amount of blood cultures per patient per day is 3 sets. Requests for additional blood cultures require consultation with a Laboratory pathologist. Pediatric Population (13 YEARS OLD AND UNDER) Meditech: BLPE During a single patient encounter, blood will be drawn from one site only. The recommended volume for infants and younger children should be no more than 1% of the patient’s total volume. 26 South Shore Health Laboratory Services Microbiology Collection Manual-2015 Patient’s Weight Volume of blood to be drawn Less than 1 Kg 0.5 to 1.0 mL 1 to 2 Kg 1.0 to 1.5 mL 2 to less than10 Kg 1.5 to 3.0 mL 25 to less than 35 3.1 to 10 mL Kg 35 to less than 40 10 to 15 mL Kg BacT/ALERT PF Ref#259794 Pediatric (Yellow top) BacT/ALERT PF Ref#259794 Pediatric (Yellow top) BacT/ALERT PF Ref#259794 Pediatric (Yellow top) BacT/ALERT PF Ref#259794 Pediatric (Yellow top) Greater than 40 Kg BacT/ALERT SA Ref#259789 Aerobic (Royal Blue top) x 2 bottles 20 mL Bottles to use BacT/ALERT SA Ref#259789 Aerobic (Royal Blue top) x 1 bottle Procedure: 1. Remove caps from blood culture bottles 2. Cleanse top of blood culture bottles with 70% v/v isopropyl alcohol swab and allow to air dry Note: For patients less than 34 weeks gestation- use 2% Chlorhexidine Aqueous Solution (alcohol free). Allow to air dry completely before breaking the skin (approx. 3 minutes). 3. Cleanse venipuncture site first with 70% V/V Isopropyl alcohol swab and allow to air dry 4. Cleanse venipuncture site second with 2% w/v Chlorhexidine Gluconate/70% V/V Isopropyl alcohol swab and allow to air dry 5. Do not palpate the venipuncture site after cleansing unless sterile gloves are worn. 6. Collect 5-10 mls(adult) or 0.5-4mls(pediatric) 7. Record the following information on the requisition and specimen labels: a. Time of collection b. Site of collection c. Order of collection eg., 1A, 1B, 2A,2B d. Initials of phlebotomist 27 South Shore Health Laboratory Services Microbiology Collection Manual-2015 2.6.2 CSF Specimen General Considerations: Inform lab service one hour before collection Clearly indicate request for bleed or infection investigation since the specimen will be processed differently An initial CSF sample should be collected prior to antimicrobial therapy for highest diagnostic sensitivity. Meditech : CSFC- Bacterial Culture (Tube2) VIRC-Viral Culture/PCR (Tube 4) Procedure: (Reference only) 1. Lumber puncture: (This procedure is a medical procedure that is performed by a physician guided by appropriate precautions) a. b. c. d. e. f. g. Sequentially collect CSF into 4 calibrated sterile tubes labeled no.1-4 CSF culture will be performed on Tube 2 Minimum specimen for CSF culture is 1 ml. Label specimen accordingly Form# F20.3.064 Record time of collection and signature of collector on LIS requisition and specimen label. Place specimens in plastic specimen transport bag and labels in outside pouch. Deliver immediately to laboratory. 2. Ommaya reservoir fluid or ventricular shunt fluid a. Clean reservoir site with antiseptic solution and alcohol perior to removal of fluid to prevent introduction of infection. b. Remove fluid by aspiration of CSF FROM ommaya reservoir, ventricular drain or shunt. c. Sequentially collect CSF into 4 calibrated sterile tubes labeled no.1-4 d. CSF culture will be performed on Tube 2 e. Minimum specimen for CSF culture is 1 ml. f. Label specimen accordingly Form# F20.3.064 g. Record time of collection and signature of collector on LIS requisition and specimen label. h. Place specimens in plastic specimen transport bag and labels in outside pouch. i. Deliver immediately to laboratory. 28 South Shore Health Laboratory Services Microbiology Collection Manual-2015 2.6.3 Urine Specimen General Considerations Never collect urine from a bedpan or urinal. Thoroughly clean the urethral opening (and vaginal vestibule in females) prior to collection procedures to ensure that the specimen is not contaminated with colonizing microorganisms in this area. Soap, rather than disinfectants is recommended for cleaning the urethral area. If disinfectants are introduced into the urine during collection, they may be inhibitory to the growth of micro-organisms. Transport specimen to the laboratory immediately or refrigerate. (Bacterial counts will remain stable for up to 24 hours at 4°C). Transport urine for viral cultures on wet ice in a sterile container. For mycobacterial cultures, send the first morning voided urine. Three consecutive first morning urine specimens are recommended. Meditech : URNC Procedure Clean Catch Urine Specimen 1. Wash hands with soap. 2. Remove and open the towelettes. 3. Clean genital area with using all of the towelettes. a. Females: separate the folds of urinary opening with thumb and forefinger and clean inside with towelettes, using front to back strokes only. Keep separated during urination (peeing) into container. b. Males: Retract the foreskin, wash penis, ending near the tip. 4. Remove container from package/holder. Do not touch the inside of the container. 5. Begin urinating (peeing) into the toilet. Stop the flow and then begin urinating directly into the container until half full. Stop the flow. Finish urinating in the toilet. 6. Remove cap from package with thumb and forefinger. Do not touch inside of cap. 7. Screw the cap tightly onto the container. 29 South Shore Health Laboratory Services Microbiology Collection Manual-2015 Ileal Conduit urine 1. Remove the external urinary appliance, and discard the urine within the appliance. 2. Gently swab and clean the stomal opening with a 70% alcohol pad and then with 2% tincture of iodine or a 10% povidone-iodine. Allow the disinfectant to dry prior to collecting the specimen. If tincture of iodine is used, it must be removed with 70% alcohol after the procedure to prevent burns. 3. Using sterile technique, insert a double catheter into the stoma. A double catheter helps to minimize contamination of the specimen with skin flora. 4. Catheterize the ileal conduit to a depth beyond the fascial level. 5. Collect the urine drained into a sterile container. Straight (In/Out) Catheter Urine 1. In/out catheter urine specimens are useful when clean-catch urines cannot be obtained or when results from clean-catch urine specimens are equivocal and a diagnosis is critical. 2. Prior to catheterization, the patient should force fluids until the bladder is full. (Forcing fluids may reduce organism number.) 3. Clean the patient’s urethral opening (and in females, the vaginal vestibule) with soap, and carefully rinse the area with water. 4. Using sterile technique, pass a catheter into the bladder. 5. Discard the initial 15-30 ml of urine. 6. Collect a sample in a sterile container. Indwelling Catheter urine 1. 2. 3. 4. Do not collect urine from collection bag. Clean the catheter collection port with a 70% alcohol wipe. Using sterile technique, puncture the collection port with a needle attached to a syringe. Aspirate the urine, and place it in a sterile container. 30 South Shore Health Laboratory Services Microbiology Collection Manual-2015 2.6.4 Sterile Body Fluids: (Excluding CSF, Blood and Urine) Meditech: BFC Procedure Percutaneous Aspirate: 1. Clean the needle puncture sites with alcohol and disinfect it with an iodine solution. If tincture of iodine is used, remove with 70% ethanol after the procedure to avoid burn. 2. Aseptically perform percutaneous aspiration with syringe and needle to obtain fluid 3. Use safety device to protect from needle exposure 4. Immediately place the specimen in a sterile container or a Red-top tube 5. Label specimen accordingly Drainage: 6. 7. 8. 9. Collect a fresh specimen of the fluid draining out from the device in a sterile container Label according Indicate on requisition that this is a drainage specimen The device, tubes or tips are not suitable for culture and will not be processed. 31 South Shore Health Laboratory Services Microbiology Collection Manual-2015 3.0 Specimen handling for specific condition or organisms Please refer to Provincial Public Health Laboratory Network of Nova Scotia Provincial Microbiology Users Manual http://www.cdha.nshealth.ca/pathology-laboratory-medicine Click on above link and Select Provincial Microbiology Users Manual Contact Microbiology Lab at 527-5263 for inquiries 32 South Shore Health Laboratory Services Microbiology Collection Manual-2015 4.0 Inappropriate Specimen for Bacterial Culture Stool Inappropriate Specimen Reason and Explanation Note Alternative Rectal swab for enteric pathogens Insufficient quantity Pathogens may die or insufficient quantity of stool reducing sensitivity Stool specimens taken from inpatients for routine culture/parasites are rarely useful May produce false negative results. The specimen of choice would be Stool Specimen not processed. Studies have shown that after 72 hours of admission, stool specimens taken from inpatients for routine culture/parasites are rarely useful. Specimen will be held for 3 days. Please contact the microbiology department to arrange processing if circumstances warrant. "Please note: Specimen not processed. Clostridium difficile toxin testing is not performed on stool specimens of children <= 12 months of age as up to 65% of healthy infants have asymptomatic carriage of this organism. A specimen for C.difficile toxin was received in preservative. Please resubmit sample in a plain container without any preservative. Formed sample received, only watery stools are acceptable for this procedure. Specimen not processed, please re-submit. Patients with positive tests should not have repeat testing including test of cure, unless they have relapse of their symptoms after completion of therapy. Toxins may be detectable for weeks to months after therapy. Specimens for C.difficle toxin must be at least 48 hours apart. Possible causes of diarrhea for inpatient : Cdiff or viral origin Stool Culture or Ova Parasite testing for patient that have been admitted >72 hours (unless outbreak) Stool, C.difficile Patient <= 12 months old Received in preservative Formed sample received Positive test within 7 days of collection of this spec. C.diff test Request must be 48 hours apart 33 Other causes of diarrhea should be considered." Recollect Recollect watery specimen South Shore Health Laboratory Services Microbiology Collection Manual-2015 Genital Inappropriate Specimen Reason and Explanation Note Alternative Semen/seminal fluid Results may be insensitive or misleading Antibacterial substance may give false negative result. Interpretation difficult as contaminated by normal urethral flora Inaccurate result Contaminated with normal flora Semen samples are not processed because results are not diagnostic and are difficult to interpret. Pre- and post massage urine specimen for prostatitis IUD Cervical / Urethal Swab for C+S Culture Method not available Routine Vaginal Culture Will only be performed on 1. patient <13 years old 2. history of recurrent yeast infection 3. Toxic Shock syndrome/ puerperal fever 4. Post-op Change of Normal Flora in this age group Vaginosis Screen for patient >55 Penis swab (unless lesion, wound or laceration) Lochia Contaminated with normal flora This specimen was collected from a source from which testing may be insensitive, misleading or that seldom yields clinically useful information. Misleading Contaminate with normal flora 34 Intra uterine devices are no longer processed for culture and sensitivity as results are not diagnostic and do not contribute to patient care. Please order Chalmydia GC DNA testing.(CHLGCDNA) If patient is between 13-55 years old without any of the indication, only Bacterial Vaginosis Screen ( Nugent score) will be done. Nugent score will not be performed for patient >55 years old because Nugent score has not been validated for patients over the age of 55. Only WBC and yeast will be reported Treatment, if required is best done on an empirical basis. Cultures of Lochia specimens are not routinely cultured due to contamination from normal vaginal flora. South Shore Health Laboratory Services Microbiology Collection Manual-2015 Respiratory Inappropriate Specimen Reason and Explanation SPUTUM with quality score (Q score) zero Result may be insensitive or misleading Pathogen cannot be distinguished from normal flora Results may be insensitive or misleading Pathogen cannot be distinguish from normal flora Reject if patient is >16 years old NOSE Throat, Rapid screen Note Alternative Send Repeat specimen if clinically indicated Routine cultures of nasal swabs are not performed because results are not predictive of disease. For wound / abscess- Collect aspirate specimen This test is reserved for Children<16 Order Throat Culture Miscellaneous Inappropriate Specimen Reason and Explanation Note Alternative Treatment, if required is best done on an empirical basis. If it’s for wound/ abscess ;collect wound/ abscess aspirate specimen Treatment, if required is best done on an empirical basis. Anal/rectal/perianal/perirectal swab Results may be insensitive or misleading These specimens grow heavy normal flora This specimen was collected from a source from which testing may be insensitive, misleading or that seldom yields clinically useful information. Pilonidal from Coccyx, Cyst OR Sinus Heavy growth of normal flora Results may be insensitive or misleading Fistula( vaginal or enteric) Inaccurate result Heavy growth of normal flora Axilla swabs for MRSA Results may be insensitive or misleading Not suitable for MRSA screening This specimen was collected from a source from which testing may be insensitive, misleading or that seldom yields clinically useful information. This specimen was collected from a source from which testing may be insensitive, misleading or that seldom yields clinically useful information. Axilla swabs are not suitable for routine MRSA screening. Two sets of nare and groin swabs should be collected 35 Treatment, if required is best done on an empirical basis. Nares/ groins for MRSA screening South Shore Health Laboratory Services Microbiology Collection Manual-2015 Inappropriate Specimen Reason and Explanation Foley Catheter tips Inaccurate results Colostomy/ileostomy/stoma drainage Results may be insensitive or misleading Heavy growth of normal flora Gastric washings Only set up if from newborn Ulcers Note Alternative Foley Catheter tips are unacceptable for culture. This specimen was collected from a source from which testing may be insensitive, misleading or that seldom yields clinically useful information. This specimen was collected from a source from which testing may be insensitive, misleading or that seldom yields clinically useful information. Urine Culture Reject if from decubitus, bedsore or buttocks. Set up if from extremities This specimen was collected from a source from which testing may be insensitive, misleading or that seldom yields clinically useful information. Treatment, if required is best done on an empirical basis. Tips Culture tip is not of value if not accompany by blood culture request for clinically suspected septicemia. Order Blood Culture Bag Urine culture specimen Urine from bag is not suitable for culture Most pathogen lose viability on dry swabs Duplicate test within defined time does not improve sensitivity Catheter tips for culture should be submitted with an accompanying peripheral blood culture for correlation purposes. Specimen does not meet storage requirement Dry Swabs Duplicate Tests Only most recent specimen will be processed 36 Treatment, if required is best done on an empirical basis. Treatment, if required is best done on an empirical basis. Collect Catheter or Cystopic specimen if clinically indicated Collect swabs in Amies Transport South Shore Health Laboratory Services Microbiology Collection Manual-2015 5.0 Specimen Rejection Non-critical specimen: Urine, Stool, Sputum, Wound, Vaginal and Miscellaneous swabs collected by non-invasive procedure Critical specimen: Blood Culture, Fluid Culture, OR specimen, Specimen collected by invasive procedures Specimen ID issue Requisition issues Inappropriate Collection and Transport Inappropriate specimen and request Duplicate specimen within 24 hours Specimen with Major Leak Critical Specimen 1.Collection site must signed and submit Form# F20.6.035 2. Specimen will be processed with comment Health care provider should faxed a replacement requisition for the specimen Specimen will be processed Result will be released when amendment requisition received HCP will be informed Specimen will be proceed Comment on final report HCP will be informed. Specimen will be processed with approval from Medical Director Process as usual Specimen will be processed with interpretive caution 37 Non-critical Specimen Reject specimen Health care provider should faxed a replacement requisition for the specimen Specimen will be processed Result will be released when amendment requisition received Reject specimen Reject specimen Process most recent specimen Reject other specimen with “DUP” code Reject specimen South Shore Health Laboratory Services Microbiology Collection Manual-2015 6.0 Appendix 6.1 Laboratory Services Fax Request for Patient Information Form------------------------------------------------------P35 6.2 Laboratory Service Documentation of Verbal Request from Health Care Providers---------------------------P36 6.3 Critical/ None-recollectable Unlabelled/ Mislabelled Specimen Form-----------------------------------------------P37 38 South Shore Health Laboratory Services Microbiology Collection Manual-2015 39 South Shore Health Laboratory Services Microbiology Collection Manual-2015 40 South Shore Health Laboratory Services Microbiology Collection Manual-2015 41