PREPARED BY Niels Frimodt-Møller, Professor, Senior Hospital Physician, MD

FLEXICULT® URINARY KIT Flexicult® URINARY KIT is a culture kit for diagnosing urinary tract Concurrently with the culturing of bacteria (bacteria quantitation), the resistance of the pathogenic bacteria to trimethoprim, sulfamethizole, ampicillin, nitrofurantoin, and mecillinam will be determined. Flexicult® URINARY KIT is designed as an agar plate that has elevated sides, divided into compartments separated by partitions and is topped by a lid. There is one large counting compartment for semiquantitative determination and five minor compartments, each containing a specific antibiotic. The compartments...

Urinary tract infections (UTI) One of the most frequent infections in the general practice (3400,000/year in Denmark) Occurs 6 times more frequently in women 20% of the women with UTI experience relapses Account for 1/5 of the antibiotic consumption in the general practice Account for 1/2 of E. coli bacteremias Usually caused by E. coli that account for 80% of incidences DEFINITIONS Classification • Asymptomatic / symptomatic Inferior / superior Uncomplicated / complicated Acute / recurrent / chronic Acute uncomplicated • Cystitis: Women 14-60 years of age with symptoms of UTI (painful urination,...

In most patients with complicated UTI with involvement of the upper urinary tract (pyelonephritis), at least 105 bacteria/mL of urine will be found. In patients without any symptoms of UTI, there is asymptomatic bacteriuria when ≥105 bacteria/mL of the same bacterium are identified in two urine samples taken at least 24 hours apart. Pregnant women UTI in pregnant women may be symptomatic or asymptomatic. UTI should in any case be treated in order to reduce the risk of complicated UTI when delivery time is approaching. Pregnant women should be screened for bacteriuria a couple of times during...

DIAGNOSIS Culture procedure 1. Collect a urine sample from a patient with suspected urinary tract infection (UTI). 2. Write the patient's name and the date on the accompanying label. 3. Add 2 drops of urine in each antibiotic compartment and 6 drops in the counting compartment. 4. Put the plate on the table for up to 10 minutes before incubation. OR 1. Pour the urine sample briefly (5-10 sec) over the agar in Flexicult™. If the urine sample does not cover all the agar compartments, tilt the plate so that all the compartments come into contact with the urine sample. 2. Pour excess urine over the...

Bakteria/Fungus E. coli Klebsiella sp. Enterobacter sp. Proteus sp. Proteus vulgaris Pseudomonas aeruginosa Colony color Agar color Red Dark blue/purple Dark blue/purple Light brown Brown Greenish brown Brown Greyish Greenish white/greenish Enterococcus faecalis Small Green/greenish blue Enterococcus faecium Small Greenish/grey Staphylococcus sp. Small White/reddish Candida sp. Large/minor White How to read the number of bacteria/mL of urine The number of colonies should be assessed in relation to the photos below. If there is growth of several species of bacteria, assess the quantity of each...

Bacteria/ Bacteria species Fungus/mL urine < 103 102 - 104 > 103 Irrespective of species Normal flora Pure culture, urinary tract pathogen Predominant urinary tract pathogen in mixture with normal flora Several urinary tract pathogens Candida sp. Patient with symptoms No UTI Patient without symptoms e.g. pregnant - New sample for asympt. bacteriuria New sample for asympt. bacteriuria Possible UTI New sample recommended No UTI Reading Symptomatic UTI: >103-4 bacteria/mL of urine of urinary tract pathogenic bacteria (Enterobacteriaceae, S. saprophyticus, enterococci, etc.) Asymptomatic UTI: >105...

Resistent = R Trime- Sulfame- Ampicillin Nitrofu Mecillithoprim thizole rantoin nam • • • • • E. coli Klebsiella sp. • • R • • Enterobacter sp. • • R • • Proteus sp. • • • R • Proteus vulgaris • • R R • Pseudomonas aeruginosa R R R R R Enterococcus faecalis R R • • R Enterococcus faecium R R • • R Staphylococcus saprophyticus • • • • • Candida sp. R R R R R R can in vitro look sensitive, but clinically there is no effect and the result should be R. Normal flora (skin flora) Even if the sampling procedure has been carried out very meticulously, urine samples will often contain normal flora that...

Stick examination Principles for stick examination of nitrite. For a nitrite reaction to happen, the urine must have been stored in the bladder for at least 2 hours so that the bacteria have had the time to convert nitrate into nitrite. Grampositive cocci (enterococci and staphylococci) do not reduce nitrate. The nitrite reaction has been adjusted to a concentration of >105 bacteria/mL of urine. Interpretation of stick examination results Nitrite Leukocyte Interpretation + + In all probability, the patient has UTI The patient has most likely not UTI. NOTE: up to 10 - 40% false negative* + The...

E. COLI E. coli bacteria are large, gram-negative, often mobile rods. E. coli are the most common bacteria isolated from clinical samples. Approx. 70-80% of all urinary tract infections are caused by E. coli.

KLEBSIELLA SP. Klebsiella are large non-mobile gram-negative rods.. The bacteria grow into large, fat, dark blue/purple colonies. Klebsiella is always resistent to ampicillin Approx. 3-5% of all urinary tract infections are caused by Klebsiella sp. or Enterobacter sp.

ENTEROBACTER SP. Enterobacter are large store mobile gram-negative rods. Enterobacter is always resistant to ampicillin. Approx. 3-5% of all urinary tract infections are caused by Enterobacter sp. or Klebsiella sp.

PROTEUS SP. Proteus are large, mobile, gram-negative rods. The bacteria grow into large, light brown/brown colonies. The agar will be brown round the bacteria. Proteus sp. contributes to the formation of stones as the bacterium splits urea under the formation of ammonia, causing the urine to become alkaline which again causes the precipitation of salts such as calcium phosphate. Approx. 2 - 4% of all urinary tract infections are caused by Proteus sp. most commonly P. mirabillis. 105 cfu/mL