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Microbiology - Urine sample (mid-stream)

Indications

Symptoms of a urinary tract infection, which are:

Fever

Acute change in mental status

New dysuria, frequency, urgency, incontinence or suprapubic pain

Flank or costovertebral tenderness

Gross haematuria

and patient either

Ambulatory and able to obtain their own specimen (patient-collected sample), or

Non-ambulatory but able void on request and follow instruction (clinician-collected sample)

Contraindications (absolute in bold)

Non-pregnant women with a first episode of acute uncomplicated cystitis (treat empirically)

Alternatives

Treat empirically without urine collection

Sample collection by temporary bladder catheterisation

Informed consent

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Failure (contamination of sample)

Fall

Paraphimosis (from unreduced foreskin)

Procedural hygiene

Standard precautions

Aseptic non-touch technique

PPE: non-sterile gloves, plastic apron, eye protection (if clinician-collected)

Area

Patient toilet or bed space with privacy screening

Staff

Procedural clinician (providing instruction and handling sample)

Equipment

Gauze cloth moistened with normal saline (clinician-collected only)

Bedpan or urinal (clinician-collected only)

Sterile specimen jar (labelled with patient sticker)

Biohazard specimen bag

Clinical waste bin

Sequence (instructions for patient-collected sample)

Wash your hands pre-procedure

Cleans urethral meatus from front to back with gauze soaked with 0.9% sodium chloride

Pass a small amount of urine into the toilet, bedpan, bottle

Collect midstream specimen in sterile container

Finish passing urine into the toilet, bedpan, bottle

Replace and tighten lid

Wash hands then return sample to clinician

Sequence (clinician-collected sample)

Explain procedure to patient

Ensure patient privacy

Sit patient on bedpan or position urinal

Separate labia or retract foreskin if present

Clean urethral meatus from front to back with gauze soaked with 0.9% sodium chloride

Ask patient to pass first part of urine stream into the toilet/bedpan/bottle

Catch midstream specimen in sterile specimen container or sterile kidney dish

Allow patient to void remainder of urine

Ensure that the foreskin is reduced over glans

Replace and tighten lid

Post-procedure care

Process sample (point-of-care urine dipstick and send for culture)

Document time and reason for collection

Tips

In-out catheter sampling is required if the patient is incontinent or unable to assist midstream urine collection

Asymptomatic bacteriuria is common in aged care facility residents (routine screening is not recommended)

Discussion

The ideal voided urine sample for evaluation of UTI is one that accurately represents the bladder bacterial count with minimised contamination by bacteria colonising the distal urethra and genital mucosa.

Good technique includes minimising contact with the mucosa by spreading the labia in females or pulling back the foreskin in uncircumcised males as well as discarding the initial stream which flushes urethral contaminants. Clinical studies do not demonstrate that cleaning the meatus is associated with lower rates of contamination and we remove this step for simplicity of when urine is self-collected by the patient.

Patient instruction on these specific steps is important every time we request a self-collected midstream urine as patient technique is often poor.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

NSW Agency for Clinical Innovation. Collection of urine midstream guidelines. Sydney: ACI; 2008 (updated 2012). 7pp. Available from: http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/165920/Collection-of-Urine-Midstream-Toolikit.pdf

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

eTG complete. Melbourne: Therapeutic Guidelines; 2019 Apr. Acute cystitis in adults. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=acute-cystitis-adults

eTG complete. Melbourne: Therapeutic Guidelines; 2019 Apr. Urinary tract infection in aged care facilities. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=urinary-tract-infection-aged-care

Meyrier A. Sampling and evaluation of voided urine in the diagnosis of urinary tract infection in adults. In: UpToDate. Waltham (MA): UpToDate. 2019 July 1. Available from: https://www.uptodate.com/contents/sampling-and-evaluation-of-voided-urine-in-the-diagnosis-of-urinary-tract-infection-in-adults

Frazee BW, Frausto K, Cisse B, White DE, Alter H. Urine collection in the emergency department: what really happens in there?. West J Emerg Med. 2012;13(5):401-405. doi:10.581/westjem.2012.1.6855

© Agency for Clinical Innovation 2021