Gram Stain Evaluation With Sputum Culture Reflex

CPT: 87205
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Test Details

Use

Evaluate the acceptability of a sputum specimen for aerobic bacterial culture and to determine the extent of culture work-up

Limitations

An adequate sputum specimen should contain many neutrophils (the exception being in the immunocompromised patient) and few to no squamous epithelial cells. A sputum specimen showing ≥25 squamous epithelial cells/lpf, regardless of the number of white blood cells, is indicative that the specimen is contaminated with saliva and is of poor quality, and culture results therefore cannot be properly interpreted. An additional sputum specimen should be collected and submitted to the laboratory, if clinically indicated, if the sputum is found to be of poor quality.

Results obtained by culture without evaluation for contamination may be noncontributory or misleading.1 A Gram stain from a carefully collected specimen, with neutrophils and lancet-shaped diplococci staining gram-positive, which are intracellular or encapsulated, can provide strong support to the clinical diagnosis of pneumococcal pneumonia; however, culture of expectorated sputum in subjects with bacteremia and pneumococcal pneumonia does not always identify the pathogen.2

Methodology

Microscopy and culture

Additional Information

The client will be notified of an unacceptable specimen. If the specimen is of good quality, a culture is performed for the isolation, identification, and, if necessary, antimicrobial susceptibility testing, of aerobic bacteria considered pathogenic in the lower respiratory tract.

Potential pathogens recovered by usual sputum culture methods include Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus parainfluenzae, Pseudomonas aeruginosa, Escherichia coli, Proteus sp, Moraxella catarrhalis, and rarely many other organisms. Haemophilus sp and Neisseria sp may not be routinely isolated and identified. Thus, if their presence is clinically suspected, they should be specifically requested.

Agents such as Bordetella pertussis, Chlamydia pneumoniae Corynebacterium diphtheriae, Legionella pneumophila, Mycoplasma pneumoniae, and Mycobacterium tuberculosis require special laboratory measures for isolation. Clinical suspicion of involvement by these agents should be communicated to the laboratory.

Specimen Requirements

Specimen

Expectorated sputum

Volume

5 to 10 mL sputum

Minimum Volume

1 to 2 mL sputum

Container

Sterile screw-cap container

Patient Preparation

The patient should be instructed to remove dentures, rinse mouth, and gargle with water. The patient should then be instructed to cough deeply and expectorate sputum into proper container. Be sure the patient understands the difference between sputum and saliva.

Collection

The patient should brush his/her teeth and/or rinse mouth well with water before attempting to collect the specimen to reduce the possibility of contaminating the specimen with food particles, oropharyngeal secretions, etc. The patient should be instructed that only a specimen brought forth by deep cough should be expectorated into the container. After the specimen has been collected, the specimen should be examined to make sure it contains a sufficient quantity (at least 1 mL) of thick mucus (not saliva). Only the screw-cap container should be submitted to the laboratory.

Storage Instructions

Refrigerate at 2°C to 8°C

Causes for Rejection

Unlabeled specimen or name discrepancy between specimen and request label; inappropriate specimen transport device; leaking specimen; specimen received after prolonged delay (usually more than 72 hours); poor quality sputum (contains many squamous epithelial cells due to contamination with saliva)

Clinical Information

Special Instructions

It is strongly recommended that a Gram-stained smear be performed on all expectorated sputa to determine the acceptability of a specimen for bacterial culture.

Footnotes

1. Barrett-Connor E. The nonvalue of sputum culture in the diagnosis of pneumococcal pneumonia. Am Rev Respir Dis. 1971 Jun; 103(6):845-848. 4397407
2. Boerner DF, Zwadyk P. The value of the sputum Gram's stain in community-acquired pneumonia. JAMA. 1982 Feb 5; 247(5):642-645. 6172607

References

Carroll KC. Laboratory diagnosis of lower respiratory tract infections: Controversy and conundrums. J Clin Microbiol. 2002 Sep; 40(9):3115-3120. 12202540
Gleckman R, DeVita J, Hibert D, Pelletier C, Martin R. Sputum Gram stain assessment in community-acquired bacteremic pneumonia. J Clin Microbiol. 1988 May; 26(5):846-849. 2454937
Plorde JJ. The diagnosis of infectious diseases. Harrison's Principles of Internal Medicine. 12th ed, chap 80, New York, NY: McGraw-Hill Inc;1991:454-459.
Stratton CW. Bacterial pneumonias—An overview with emphasis on pathogenesis, diagnosis, and treatment. Heart Lung. 1986 May; 15(3):226-244. 3516931
Wijnands GJ. Diagnosis and interventions in lower respiratory tract infections. Am J Med. 1992 Apr 6; 92(4A):91S-97S. 1580272

LOINC® Map

Order Code Order Code Name Order Loinc Result Code Result Code Name UofM Result LOINC
182352 Gram Stain w/Sputum Cult Rflx 182356 White Blood Cells 14328-9
182352 Gram Stain w/Sputum Cult Rflx 182357 Epithelial Cells 14327-1
182352 Gram Stain w/Sputum Cult Rflx 182358 Result 1 648-6
182352 Gram Stain w/Sputum Cult Rflx 182359 Result 2 648-6
182352 Gram Stain w/Sputum Cult Rflx 182361 Result 3 648-6
182352 Gram Stain w/Sputum Cult Rflx 182362 Result 4 648-6
182352 Gram Stain w/Sputum Cult Rflx 182353 Gram Stain Evaluation 648-6
Reflex Table for Gram Stain Evaluation
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 182354 Sputum Culture 180810 Lower Respiratory Culture 6460-0
Reflex 2 000000 080180 000000 6460-0
Reflex Table for Gram Stain Evaluation
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 182354 Sputum Culture 180810 Lower Respiratory Culture 6460-0
Reflex 2 000000 080181 000000 6460-0
Reflex Table for Gram Stain Evaluation
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 182354 Sputum Culture 180810 Lower Respiratory Culture 6460-0
Reflex 2 000000 080182 000000 6460-0
Reflex Table for Gram Stain Evaluation
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 182354 Sputum Culture 180810 Lower Respiratory Culture 6460-0
Reflex 2 000000 080183 000000 6460-0
Reflex Table for Gram Stain Evaluation
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 182354 Sputum Culture 180810 Lower Respiratory Culture 6460-0
Reflex 2 000000 080185 000000 23658-8
Reflex Table for Gram Stain Evaluation
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 182354 Sputum Culture 080180 Result 1 6460-0
Reflex Table for Gram Stain Evaluation
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 182354 Sputum Culture 080181 Result 2 6460-0
Reflex Table for Gram Stain Evaluation
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 182354 Sputum Culture 080182 Result 3 6460-0
Reflex Table for Gram Stain Evaluation
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 182354 Sputum Culture 080183 Result 4 6460-0
Reflex Table for Gram Stain Evaluation
Order Code Order Name Result Code Result Name UofM Result LOINC
Reflex 1 182354 Sputum Culture 080185 Antimicrobial Susceptibility 23658-8

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