Test Id : URNS

When this test is ordered, the reflex tests may be performed and charged. Antimicrobial agents appropriate to the organism and specimen source will be tested according to Mayo Clinic's practice and the laboratory's standard operating procedures.

See Special Instructions to review tables that provide a listing of the antimicrobials routinely tested in the laboratory as well as antimicrobials that may be tested upon request. These tables are organized by isolate groups and are not all inclusive. Call 800-533-1710 and ask to speak to the Bacteriology Antimicrobial Susceptibility Testing Laboratory if the organism or antimicrobial of interest are not listed in these tables.

Specimen must arrive within 24 hours of collection. 

Specimen source is required.

Specimen Type: Urine

Supplies: Urine Tubes, 10 mL (T068)

Collection Container/Tube: Clean, plastic urine collection container

Submission Container/Tube: Plastic, 10-mL urine tube

Specimen Volume: 1 mL

Collection Instructions: Collect a random urine specimen and send refrigerated. Frozen specimens will be canceled.

Specimen Stability Information: Refrigerated 24 hours

• Aerobic Gram-Negative Bacilli Antimicrobials
• Additional Gram-Negative Bacteria Antimicrobials
• Staphylococcus, Enterococcus, Bacillus, and Related Genera Antimicrobials
• Additional Gram-Positive Bacteria Antimicrobials

See Specimen Required

Diagnosis of urinary tract infections

Quantitative culture results may be helpful in discriminating contamination, colonization, and infection

Determining the in vitro antimicrobial susceptibility of potentially pathogenic aerobic bacteria, if appropriate

This test is not intended for medicolegal use.

When this test is ordered, the reflex tests may be performed and charged. Antimicrobial agents appropriate to the organism and specimen source will be tested according to Mayo Clinic's practice and the laboratory's standard operating procedures.

See Special Instructions to review tables that provide a listing of the antimicrobials routinely tested in the laboratory as well as antimicrobials that may be tested upon request. These tables are organized by isolate groups and are not all inclusive. Call 800-533-1710 and ask to speak to the Bacteriology Antimicrobial Susceptibility Testing Laboratory if the organism or antimicrobial of interest are not listed in these tables.

Urinary tract infection (UTI) encompasses a broad range of clinical entities that vary in their clinical presentation, degree of tissue invasion, epidemiologic setting, and antibiotic therapy requirements. There are 4 major types of UTIs: urethritis, cystitis, acute urethral syndrome, and pyelonephritis. UTIs may also be classified as uncomplicated or complicated. Escherichia coli is the leading cause of uncomplicated community-acquired UTI. Risk factors that predispose one to complicated UTIs include: underlying diseases that are associated with kidney infection (eg, diabetes), kidney stones, structural or functional urinary tract abnormalities, and indwelling urinary catheters. Another classification of UTIs is as upper UTI (related to the kidney, renal pelvis, or ureter) or lower UTI (urinary bladder and urethra). The classic symptoms of upper UTI are fever (often with chills) and flank pain. Frequent painful urination, urgency, and dysuria are more often associated with lower UTI.

Antimicrobial susceptibility testing determines the minimum inhibitory concentration (MIC) value of selected antimicrobial agents against isolated potentially pathogenic bacteria. The MIC is the lowest antimicrobial concentration (of a series of increasing concentrations) that inhibits growth of the bacterium. Agar dilution MIC testing is performed by testing for growth of bacteria on agar plates containing varying concentrations of antimicrobial agents.

For each organism-antimicrobial agent combination, the Clinical and Laboratory Standards Institute and/or the European Committee on Antimicrobial Susceptibility Testing provides interpretive criteria for determining whether the MIC should be interpreted as susceptible, susceptible-dose dependent, intermediate, nonsusceptible, resistant, or epidemiological cutoff value

No growth, Organism present <10,000 cfu/mL, or mixed flora.

Identification of probable pathogens with colony count ranges.

Susceptibility results are reported as minimal inhibitory concentration (MIC) in mcg/mL Breakpoints (also known as "clinical breakpoints") are used to categorize an organism as susceptible, susceptible-dose dependent, intermediate, resistant, or nonsusceptible according to breakpoint setting organizations, either the Clinical and Laboratory Standards Institute (CLSI) or the European Committee on Antimicrobial Susceptibility Testing (EUCAST), as applicable.

In some instances, an interpretive category cannot be provided based on available data and the following comment will be included: "There are no established interpretive guidelines for agents reported without interpretations."

Clinical and Laboratory Standards Institute (CLSI) Interpretive Category Definitions:

Susceptible:

A category defined by a breakpoint that implies that isolates with an MIC at or below or a zone diameter at or above the susceptible breakpoint are inhibited by the usually achievable concentrations of antimicrobial agent when the dosage recommended to treat the site of infection is used, resulting in likely clinical efficacy.

Susceptible-Dose Dependent:

A category defined by a breakpoint that implies that susceptibility of an isolate depends on the dosing regimen that is used in the patient. To achieve levels that are likely to be clinically effective against isolates for which the susceptibility testing results (either MICs or zone diameters) are in the susceptible-dose dependent (SDD) category, it is necessary to use a dosing regimen (ie, higher doses, more frequent doses, or both) that results in higher drug exposure than that achieved with the dose that was used to establish the susceptible breakpoint. Consideration should be given to the maximum literature-supported dosage regimens because higher exposure gives the highest probability of adequate coverage of a SDD isolate. The drug label should be consulted for recommended doses and adjustment for organ function.

Intermediate:

A category defined by a breakpoint that includes isolates with MICs or zone diameters within the intermediate range that approach usually attainable blood and tissue levels and/or for which response rates may be lower than for susceptible isolates.

Note: The intermediate category implies clinical efficacy in body sites where the drugs are physiologically concentrated or when a higher-than-normal dosage of a drug can be used. This category also includes a buffer zone, which should prevent small, uncontrolled, technical factors from causing major discrepancies in interpretations, especially for drugs with narrow pharmacotoxicity margins.

Resistant:

A category defined by a breakpoint that implies that isolates with an MIC at or above or a zone diameter at or below the resistant breakpoint are not inhibited by the usually achievable concentrations of the agent with normal dosage schedules and/or that demonstrate MICs or zone diameters that fall in the range in which specific microbial resistance mechanisms are likely, and clinical efficacy of the agent against the isolate has not been reliably shown in treatment studies.

Nonsusceptible:

A category used for isolates for which only a susceptible breakpoint is designated because of the absence or rare occurrence of resistant strains. Isolates for which the antimicrobial agent MICs are above or the zone diameters are below the value indicated for the susceptible breakpoint should be reported as nonsusceptible.

Note: An isolate that is interpreted as nonsusceptible does not necessarily mean that the isolate has a resistance mechanism. It is possible that isolates with MICs above the susceptible breakpoint that lack resistance mechanisms may be encountered within the wild-type distribution after the time the susceptible-only breakpoint was set.

Epidemiological Cutoff Value:

The MIC that separates microbial populations into those with and without phenotypically detectable resistance (non-wild-type or wild-type, respectively). The epidemiological cutoff value (ECV) defines the highest MIC for the wild type population of isolates. ECVs are based on in vitro data only, using MIC distributions. ECVs are not clinical breakpoints, and the clinical relevance of ECVs for a particular patient has not yet been identified or approved by CLSI or any regulatory agency.

When an ECV is reported, an interpretive category is not assigned, and the following comment will be included: "This MIC is consistent with the Epidemiological Cutoff Value (ECV) observed in isolates (WITH / WITHOUT) acquired resistance; however, correlation with treatment outcome is unknown."

-Wild-type (WT) - an interpretive category defined by an ECV that describes the microbial population with no phenotypically detectable mechanisms of resistance or reduced susceptibility for an antimicrobial agent being evaluated.

-Non-wild-type (NWT) - an interpretive category defined by an ECV that describes the microbial population with phenotypically detectable mechanisms of resistance or reduced susceptibility for the antimicrobial agent being evaluated.

Note: MIC values for which ECV's are defined are not to be interpreted or reported as susceptible, intermediate, or resistant but rather as WT or NWT. The ECV's should not be used as clinical breakpoints.(Clinical and Laboratory Standards Institute [CLSI]: Performance Standards for Antimicrobial Susceptibility Testing. 31st ed. CLSI supplement M100. CLSI; 2021:4-6 and 268-269)

European Committee on Antimicrobial Susceptibility Testing (EUCAST) Interpretive Category Definitions:

S -Susceptible, standard dosing regimen: A microorganism is categorized as "Susceptible, standard dosing regimen", when there is a high likelihood of therapeutic success using a standard dosing regimen of the agent

I -Susceptible, increased exposure*: A microorganism is categorized as "Susceptible, Increased exposure*" when there is a high likelihood of therapeutic success because exposure to the agent is increased by adjusting the dosing regimen or by its concentration at the site of infection.

R -Resistant: A microorganism is categorized as "Resistant" when there is a high likelihood of therapeutic failure even when there is increased exposure.*

*Exposure is a function of how the mode of administration, dose, dosing interval, infusion time, as well as distribution and excretion of the antimicrobial agent will influence the infecting organism at the site of infection.

(The European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone diameters. Version 11.0, 2021. Available at www.eucast.org)

In general, the isolation of more than 100,000 colony forming units (cfu)/mL of a urinary pathogen is indicative of urinary tract infection (UTI), however, pediatric patients (< or =2 years of age) may have symptomatic UTI at a lower threshold or more than 50,000 cfu/mL. Isolation of 2 or more organisms with more than 10,000 cfu/mL may suggest specimen contamination. For specimens contaminated with the usual bacterial flora, bacteria that are potentially pathogenic are identified.

A "susceptible" category result and a low minimum inhibitory concentration value indicate in vitro susceptibility of the organism to the antimicrobial tested.

Refer to the Reference Values section for interpretation of various antimicrobial susceptibility interpretive categories (ie, susceptible, susceptible-dose dependent, intermediate, nonsusceptible, resistant, or epidemiological cutoff value.

Although urine is normally sterile, contamination by organisms normally present in the urethra or on periurethral surfaces can allow a proliferation of these organisms yielding misleading urine culture results.

Urine held at ambient temperature for more than 30 minutes supports the growth of both pathogens and contaminants, leading to potentially inaccurate colony counts.

Urine obtained from catheter bags at the bedside and Foley catheter tips are unacceptable for culture.

When antimicrobial susceptibilities are performed, in vitro susceptibility does not guarantee clinical response. Therefore, the decision to treat with a particular agent should not be based solely on the antimicrobial susceptibility testing result.

1. Forbes BA, Sahm DF, Weissfeld AS: Infections of the urinary tract. In: Bailey and Scott's Diagnostic Microbiology. 12th ed. Mosby; 2007:842-855

2. Miller JM, Binnicker JM, Campbell S, et al: A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology. Clin Infect Dis. 2018 Aug 31;67(6):e1-e94. doi: 10.1093/cid/ciy381

3. Procop GW, Church DL, Hall GS, et al: Introduction to Microbiology Part II: Guidelines for the collection, transport, processing, analysis, and reporting of cultures from specific specimen sources. In: Koneman's Color Atlas and Textbook of Diagnostic Microbiology. 7th ed. Wolters Kluwer Health; 2017:66-110

4. Clinical and Laboratory Standards Institute (CLSI): Performance Standards for Antimicrobial Susceptibility Testing. 30th ed. CLSI supplement M100. CLSI; 2020;3-5:254

• Aerobic Gram-Negative Bacilli Antimicrobials
• Additional Gram-Negative Bacteria Antimicrobials
• Staphylococcus, Enterococcus, Bacillus, and Related Genera Antimicrobials
• Additional Gram-Positive Bacteria Antimicrobials

The urine specimen is inoculated onto sheep blood agar and eosin methylene blue agar using a calibrated loop. Following 18 to 24 hours of incubation, semiquantitative colony counts are determined and pathogens or possible pathogens are identified using one or a combination of the following techniques: commercial identification strips or panels, matrix-assisted laser desorption/ionization-time of flight mass spectrometry, conventional biochemical tests, carbon source utilization, real-time polymerase chain reaction, and nucleic acid sequencing of the 16S ribosomal RNA gene. Cultures with fewer than 10,000 colony-forming unit (cfu)/mL of a single species are reported as "Organism present <10,000 cfu/mL." The presence of commensal flora of the urethra (contaminants) and mixed cultures of organisms present in colony counts below 10,000 cfu/mL are reported as "mixed flora."(Chan WW: Urine cultures. In: Leber AL, ed. Clinical Microbiology Procedures Handbook. Vol 1. 4th ed. ASM Press; 2016:section 3.12)

When antimicrobial susceptibility testing is performed, an agar dilution method is used for routine testing. The agar dilution method employs the use of antimicrobial agents incorporated in agar plates. The antimicrobial is added to agar in various concentrations depending upon levels attainable in serum, urine, or both. A standardized suspension of the organism is applied to the agar plates, which are incubated for a minimum of 16 to 18 hours at 35 degrees C. Complete inhibition of all but one colony or a very fine residual haze represents the endpoint.(Clinical and Laboratory Standards Institute [CLSI]: Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria That Grow Aerobically. 11th ed. CLSI standard M07. CLSI; 2018)

Daptomycin and tigecycline are tested by agar gradient diffusion.(Clinical and Laboratory Standards Institute [CLSI]: Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria That Grow Aerobically. 11th ed. CLSI standard M07. CLSI; 2018; package insert: Etest Biomerieux;15203E-EN-2016/07. Available at: www.biomerieux.com/techlib)

Colistin is tested by the CLSI-approved Colistin agar test for Enterobacterales and Pseudomonas aeruginosa.(Clinical and Laboratory Standards Institute [CLSI]: Performance Standards for Antimicrobial Susceptibility Testing. 31st ed. CLSI supplement M100. CLSI; 2021:142-147)

Cefiderocol is tested by disk diffusion.(Clinical and Laboratory Standards Institute [CLSI]: Performance Standards for Antimicrobial Disk Susceptibility Tests. 13th ed. CLSI standard M02. CLSI; 2018)

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This test has been cleared, approved, or is exempt by the US Food and Drug Administration and is used per manufacturer's instructions. Performance characteristics were verified by Mayo Clinic in a manner consistent with CLIA requirements.

87086-Bacterial Culture, Aerobic, Urine

87077-Identification commercial kit (if appropriate)

87077-Ident by MALDI-TOF mass spec (if appropriate)

87077-Bacteria Identification (if appropriate)

87077-Additional Identification procedure (if appropriate)

87077-Identification Staphylococcus (if appropriate)

87077-Identification Streptococcus (if appropriate)

87147 x 1-3-Serologic agglut method 1 ident (if appropriate)

87147-Serologic agglut method 2 ident (if appropriate)

87147 x 4-Serologic agglut method 3 ident (if appropriate)

87147 x 2-6-Serologic Agglut Method 4 Ident (if appropriate)

87153-Aerobe ident by sequencing (if appropriate)

87150-Identification by PCR (if appropriate)

87185-Beta lactamase (if appropriate)

87186-Antimicrobial Susceptibility, Aerobic Bacteria, MIC-per organism for routine battery (if appropriate)

87181-Susceptibility per drug and per organism for drugs not in routine battery (if appropriate)

87150-mec A PCR (if appropriate)

Sample Reports

Normal and Abnormal sample reports are provided as references for report appearance.

Normal Reports | Abnormal Reports

SI Sample Reports

International System (SI) of Unit reports are provided for a limited number of tests. These reports are intended for international account use and are only available through MayoLINK accounts that have been defined to receive them.

SI Normal Reports | SI Abnormal Reports