Best practice in primary care pathology: review 2
W S Smellie, J O Forth, C A M McNulty, L Hirschowitz, D Lilic, R Gosling, D Bareford, E Logan,
K G Kerr, G P Spickett, J Hoffman, A Galloway, C A Bloxham
............................................................... ............................................................... .
J Clin Pathol 2006;59:113–120. doi: 10.1136/jcp.2005.031526
This second best practice review examines five series of
common primary care questions in laboratory medicine:
(1) laboratory testing for allergy, (2) diagnosis and
monitoring of menopause, (3) the use of urine cytology, (4)
the usefulness of the erythrocyte sedimentation rate, and (5)
the investigation of possible urinary tract infection. The
review is presented in a question–answer format. The
recommendations represent a pre ´cis of guidance found
using a standardised literature search of national and
international guidance notes, consensus statements, health
policy documents, and evidence based medicine reviews,
supplemented by MEDLINE EMBASE searches to identify
relevant primary research documents. They are standards
but form a guide to be set in the clinical context. Most are
consensus rather than evidence based. They will be
updated periodically to take account of new information.
See end of article for
Dr W S A Smellie,
Department of Chemical
Hospital, Cockton Hill
Road, Bishop Auckland,
County Durham DL14
6AD, UK; info@smellie.
Accepted for publication
2 August 2005
methodology for obtaining the questions, search-
ing the literature, and writing the answers has
been described in this journal.1
Each subject is introduced with a brief
summary of the type of information found and
is handled separately.
Although the individual subjects are not
related because they cover the disciplines of
clinical biochemistry, microbiology, immuno-
logy, haematology, and cellular pathology, they
are designed once completed to form a resource
that will be indexed and cover a wide range of
the most common primary care laboratory issues,
to be made available to users.
Where the new General Medical Services
(GMS) contracts in the UK make specific
reference to a laboratory test, the indicator or
target is appended at the end of the answer.
his is the second in a planned series of
reviews to answer several questions that
arise in primary care use of pathology. The
IGE (TOTAL AND ALLERGEN SPECIFIC)
MEASUREMENT (DL AND GPS)
This short question series examines the use of
total and allergen specific IgE, mostly in the
context of the investigation of allergy. The
documents found provide fairly close consensus
and several comment on the need to identify the
appears to be increasingly limited need for the
measurement of total IgE, particularly in the
investigation of allergy.
When should I request total IgE in general
We recommend that there is very limited
need for this test in general practice, except
as an adjunct to the diagnoses listed below.
N IgE concentrations can be increased in non-
allergic states such as parasite infections,
Churg-Strauss vasculitis, certain immune
deficiencies such as the hyper-IgE syndrome,
IgE myeloma, Hodgkin lymphoma, and atopic
dermatitis.2These are all rare conditions,
usually diagnosed in secondary care, and the
measurement of IgE is not crucial to the
N Total IgE alone can neither confirm nor
exclude allergy: increased concentrations
may suggest an atopic state, but normal or
low values do not exclude allergy.3 4Normal or
low IgE concentrations also cannot be used as
a prescreening test for radioallergosorbent
testing (RAST).4 5Therefore, it is inappropri-
ate to request total IgE in isolation from
general practice in this context.
GMS contract indicator: none.
When should I request allergen specific
We recommendallergenspecific IgE
measurement in the presence of the clinical
suspicion of type 1 IgE mediated hypersen-
sitivity/allergy, principally for inhaled anti-
gens. There is no need to request total IgE
when requesting RAST.
N Seasonal rhinoconjunctivitis (hay fever).
N Perennial rhinoconjunctivitis.
N Acute urticaria with angio-oedema.
N Food allergy (with suspected trigger).
N Drug allergy (with suspected trigger).
N Suspected allergy to insect stings.
There is limited consensus guidance on the use
of RAST testing in particular, as distinct from
allergy testing in general, and the guidance
above is drawn principally from review articles
and by extrapolation from clinical studies.
Abbreviations: AUA, American Urological Association;
FSH, follicle stimulating hormone; GMS, General Medical
Services; MH, microscopic haematuria; RAST,
radioallergosorbent testing; UTI, urinary tract infection
RAST refers to one of the first tests used to test allergen
specific IgE, which is no longer in use; a more appropriate
name is allergen specific IgE testing. It is used as a more
accessible or more convenient alternative to skin prick
testing.6It is only useful for assessing type I IgE mediated
reactions (immediate hypersensitivity); RAST tests are there-
fore not useful for assessing pseudo-allergic reactions that are
not mediated by IgE (such as non-allergic food intolerance;
reactions to radiocontrast media, morphine, and aspirin;
physical urticarias, etc.).5 7 8Angio-oedema without urticaria
is usually not an IgE mediated allergic reaction.9RAST testing
and skin prick testing are of little value in chronic urticaria,
which is usually not caused by IgE dependent mechanisms.
RAST tests must be requested for a specified antigen based
on clinical history.5 7–9They are of no benefit as screening
tests without specified antigens.7–9It follows from this that
requests should not be for widespread antigen screening. Test
results must be interpreted in conjunction with clinical
findings.2 5 7–9The specificity and sensitivity of RAST results
vary for the different allergens tested (for example, poor for
fruits and vegetables). Overall, RAST tests have relatively low
sensitivity and can be negative in the presence of allergy.3 6 10–12
In addition, adverse reactions to foods are IgE mediated
allergies in only about a third of patients.5 11 12Therefore,
RAST tests are of limited value in this situation. It follows
from this that RAST testing in food intolerance is unlikely to
be helpful, and we recommend that it is used only in the
initial investigation of severe acute food intolerance reactions
where a specific food is suspected.
The efficacy of unconventional/alternative allergy testing
has not been confirmed, and can neither substitute nor
complement RAST and other classic allergy tests.7 8Therefore,
these tests are not recommended.
GMS contract indicator: none.
INVESTIGATION OF THE MENOPAUSE (RG AND
The documents found are consistent in their recommenda-
tions for laboratory testing in the menopause. The clearest
message from these documents is that hormone measure-
ments have no role in diagnosing menopause in patients of
menopausal age with typical symptoms, or in monitoring
patients on oral hormone replacement. They identify specific
areas for their use. These answers do not specifically address
premature ovarian failure, which will be examined in later
questions on subfertility.
When should I request tests for menopause?
We recommend that hormone assays are of no value
in investigating women over 45 years old with typical
menopausal symptoms. Follicle stimulating hormone
(FSH) assays in suspected premature ovarian failure or
an atypical menopausal presentation are limited to
indicating that ovarian failure may have occurred.
It is agreed that a serum FSH result in excess of 30–40 IU/
litre, depending on author and testing laboratory, is the best
single biochemical indicator for ovarian failure in the
menopause.13–16However, in the climacteric phase identifica-
tion of the menopause in a woman by FSH assay is not
recommended because hormone values fluctuate greatly
during this period. Therefore, the diagnosis of menopause
in patients over 45 years who have menopausal symptoms
should be based solely on clinical criteria.14 17–19
In younger women presenting with possible early meno-
pause (, 45 years) or premature ovarian failure (, 40 years)
FSH assays can be useful. The finding of two separate FSH
results of . 40 IU/litre taken four to eight weeks apart
suggests ovarian failure.18One guideline recommends testing
oestrogen and FSH.13However, premenopausal results cannot
exclude ovarian failure as a diagnosis,18and although fertility
declines greatly in association with FSH values over 25 IU/
litre, they offer no guarantee of infertility, and advice to
discontinue contraception is based on the length of amenor-
rhoea (see below). Population ranges of FSH even 10 years
after clinical onset of menopause are also20extremely wide,
and can depend on assay method.18Hormone tests are also
thought to play no role in deciding on the type of hormone
replacement therapy for symptomatic menopause if being
Two other patient groups who may benefit from FSH
assays are those on the oral contraceptive and those who
have had a hysterectomy. In both cases, the biological marker
of oligomennorhoea as an indicator of ovarian failure is not
applicable. In women coming off oral contraception, alter-
native contraception should be used for one year of
amenorrhoea in those . 50 years old and for two years in
those , 50 years old.13 14 18
There is considerable unnecessary requesting of FSH assays
in women over 45 years with menopausal symptoms. This
could be greatly reduced by the use of requesting guidelines
agreed between the laboratory and requesting clinicians.21
GMS contract indicator: none.
What tests are required to monitor women on
hormone replacement therapy?
We do not recommend that FSH or oestrogen should
be measured to monitor patients on hormone replace-
ment therapy except in the following situations:
N Questionable absorption.
N Before replacement of oestrogen implants.
N Questionable compliance.
Women should be assessed only on clinical response where
treatment is given for symptomatic relief and treatment
altered where appropriate.13 14 22–25The assay of oestrogen may
occasionally be of value to establish its adequate absorption
Measurements have also been recommended in women with
an oestrogen implant before implant replacement to ensure
that no accumulation of oestrogen has occurred to avoid
supraphysiological concentrations and possible tachyphy-
laxis.14 23 24Neither FSH nor oestrogen measurement is
recommended in women receiving oral hormone replace-
ment,14because results are difficult to interpret meaningfully,
and vary depending on oestrogen type. There is a theoretical
case for measuring oestradiol in patients with persisting
symptoms if poor treatment compliance is suspected.
GMS contract indicator: none.
ERYTHROCYTE SEDIMENTATION RATE (EL AND DB)
The erythrocyte sedimentation rate (ESR), often used as a
non-specific screen for illness, causes interpretation difficul-
ties because of various factors that influence values and can
lead to further investigations. This question examines
situations when use of the test is and is not recommended,
based on a range of guidelines and primary studies of test
utility. It does not attempt to compare its usefulness with
that of plasma viscosity, which is used as an alternative test
in many situations.
When should I request an ESR?
We recommend that26ESR should be used:
N To evaluate patients with unexplained symptoms or
a deterioration of health status when:
inflammatory, neoplastic, or infectious disease is
a specific diagnosis is not made effectively by
N To monitor the activity of giant cell arteritis,
polymyalgia rheumatica, and inflammatory arthri-
There is no evidence to support the use of the ESR in
asymptomatic individuals and this test should not be
appended to ‘‘routine’’ investigations.27 28
The ESR is a relatively non-specific test that is frequently
ordered during the diagnosis and monitoring of disease. A
variety of factors influence the sedimentation rate.27 29
Disease related factors that may affect the ESR include
plasma immunoglobulin and fibrinogen concentrations, and
the presence and degree of anaemia. Factors unrelated to
disease processes that may affect ESR values include age, sex,
and drug treatment.
A simple rule for calculating the normal ESR with age is:
(age + 10) 4 2 for women, age 4 2 for men.30
There is no evidence to support the use of the ESR in
asymptomatic individuals.27 29Raised ESR values are found in
a variety of pathological states. If the clinical history and
physical findings are suggestive of specific disease processes,
other investigations are usually more appropriate.28For
instance, although individuals with an ESR greater than
100 mm/hour are probably suffering from serious systemic
disease, the presence of such diseases (malignancy, infection,
cirrhosis, collagen disease, etc.) is generally detectable by
clinical examination and history. However, the ESR may
provide useful information when:
N Used as a diagnostic criterion for temporal arteritis and
polymyalgia rheumatica.28 31 32
N Monitoring response to treatment in temporal arteritis and
polymyalgia rheumatica.31 33A clinical response would be
expected in two to four days but inflammatory markers
normalise over two weeks or longer.34
N Used as a component of some clinical indices of
N Following the course of patients with rheumatoid arthritis
or other connective tissue disorders.36
N Screening for tissue infection in specific situations—for
example, after orthopaedic surgery or suspected pelvic
inflammatory disease37 38—although C reactive protein
may be more useful in diagnosis and monitoring
N Assessing response of Hodgkin disease to treatment.41 42
N Assessing elderly persons with vague complaints in whom
there is a moderate to strong possibility of underlying
disease, but no definite findings after history and physical
For those general practices who are served by a
laboratory that offers plasma viscosity as a test in
preference to ESR.
When should I measure plasma viscosity?
Done under ideal conditions, changes in the ESR and
plasma viscosity roughly parallel one another in many but
not all situations. Both reflect changes in fibrinogen and/or
globulin concentrations. The measurement of viscosity has
several advantages. Unlike the ESR, which may be falsely
raised as a result of the vagaries of ambient room
temperature, age, anaemia, or length of time after specimen
collection, plasma viscosity is very reproducible, and is
thought to reflect more closely the clinical severity and the
efficiency of treatment of a given disease state. In addition, in
contrast to the ESR, the normal range is the same for both
sexes and for all ages above 3 years.45A more detailed
comparison of ESR and plasma viscosity will follow in a later
question answer set.
GMS contract indicator: none.
URINE CYTOLOGY (LH, JH, AND CAB)
In a laboratory setting, most requests for urine cytology are
received from hospital clinics, with primary care specimens
forming a minority. The guidance provided is taken mostly
from studies of test utility rather than consensus guidance,
and relates specifically to the initial primary care investiga-
tion of the situation described.
When should I request urine cytology (particularly in
the context of microscopic haematuria; MH)?
We recommend urine cytology in patients in the
N Patients with symptomatic MH.
N Asymptomatic MH in patients . 40 years old or
younger patients with risk factors for urological
N The follow up of patients who have been treated for
bladder cancer (in conjunction with urinalysis for
MH and other tests if available).
N As a secondary investigation in frank haematuria.
Gross or visible haematuria requires evaluation of the
upper and lower urinary tract.46–48Urine cytology has a
supportive role in the evaluation of these patients49in
conjunction with upper tract imaging, cystoscopy, and
bladder biopsy. However, in one study,49urine cytology did
not lead to the discovery of additional tumours that were not
detected by other investigations. Recent urinary tract
instrumentation should be excluded as a cause of gross
MH (by dipstick analysis) is more controversial. Although
it is generally accepted that symptomatic MH requires
microscopy, this has recently been questioned.50There are
no reliable data on the incidence of underlying bladder
neoplasms in patients with symptomatic MH. Nonetheless,
one small study of women who had incontinence and/or
irritative voiding and MH showed cytology to be of value,51
and the American Urological Association (AUA) best practice
guidance recommends urine cytology in patients with a
history of irritative voiding symptoms.52Urine cytology is not
helpful in the evaluation of men with lower urinary tract
Best practice in primary care pathology: review 2115
symptoms47because asymptomatic MH is a frequent finding
in patients who have benign prostatic hyperplasia,53and
urine cytology is not an investigation of choice to detect
prostatic malignancy. It has not been evaluated in this
Urinary tract infection (UTI) does not require investigation
with urine cytology, but by microbiological testing.54–57
Cytological samples in the setting of UTI may be obscured
by polymorphs, and it is sensible to exclude and treat
infection before submitting samples for cytological evaluation
if indicated in a patient presenting with a UTI.
Asymptomatic MH is common in adult primary care
populations (2.5–4.3%),58and up to 11% of patients with
asymptomatic MH have been reported to have underlying
urothelial malignancy.59–61However, in a review of 17 series,
comprising a total of 5000 patients, urological cancer was
diagnosed in , 3% of cases. A Californian study found
asymptomatic MH in 2.9% of 20 751 patients, 0.5% of whom
had urothelial cancer, yet cancer was also found in 0.5%
without MH. Therefore, the authors concluded that the
presence of asymptomatic MH was not significantly asso-
ciated with urological cancer or other serious urological
disease.62No studies have demonstrated improved outcomes
from screening for asymptomatic MH.63
Screening for asymptomatic MH cannot be recommended
as a means of detecting urological malignancy, but in
patients . 40 years with an incidental finding of MH, the
AUA recommends complete urological evaluation (including
cytology).52The importance of age as a risk factor is
supported by a study in a subspecialised urological setting
where 87% of patients in whose samples malignant cells were
found were . 50 years of age. However, it should be noted
that 72% had a history of gross haematuria. The AUA52also
recommends complete urological evaluation (including cytol-
ogy) in younger patients with a history that is ‘‘suspicious of
underlying urological disease’’. The relative merits of full
urological investigation (including cytology) in younger
patients with asymptomatic MH have not been evaluated
and are therefore debatable.64 65
A combination of MH and proteinuria in younger patients
is a predictor of non-neoplastic primary renal disease.66In
patients with this combination of findings on dipstick
examination, the cytological identification of red blood cell
casts and dysmorphic red blood cells may serve as a further
indicator of renal parenchymal disease.61However, there
appear to be differences in laboratory practice as to whether
this identifier would form part of microbiology macroscopy/
culture examination or whether urine cytology would be
expected, because the conventional role of urine cytology is to
diagnose malignancy. Primary care organisations should
clarify current arrangements in place in their laboratory.
Cytology is advised in patients with risk factors for
transitional cell carcinoma,67
methods66 67probably have higher combinations of sensitivity
and specificity in patients with low grade non-invasive
tumours and those with carcinoma in situ.67 68In patients
with incidental MH, the risk factors listed by the AUA as
indications for urine cytology include: smoking history,
occupational exposure to carcinogenic chemicals or dyes
(benzenes or aromatic amines), analgesic abuse (for example,
phenacetin), cyclophosphamide, and pelvic irradiation.52
Known schistosomiasis bladder infection may reasonably be
included in relevant populations as a predisposing factor for
bladder cancer.69Cytology has been used in the follow up of
patients who have been treated for bladder cancer in
conjunction with testing for MH.
In the laboratory a single cytospin deposit70(as opposed to
the preparation of duplicate slides) is adequate for cytological
although other screening
evaluation, saves resources, and caused minimal loss of
clinically relevant information.
GMS contract indicator: none.
MANAGING URINARY SYMPTOMS (CAMM, AG,
These questions and answers make recommendations about
when and how primary care should investigate urinary
symptoms. This guidance is based on evidence discussed in
detail in Health Protection Agency (www.hpa.org.uk) and
PRODIGY (www.prodigy.nhs.uk) guidelines and in the other
key references quoted.
When should I send a urine specimen in patients
with possible urinary tract infection?
In adults we recommend a urine specimen in:
N Failed antibiotic treatment or persistent symptoms
in all individuals.71
N Recurrent UTI.71
N Suspected pyelonephritis.72
N All men with urinary symptoms consistent with
N Catheterised patients with fever > 38˚C, rigors,
vomiting, new onset confusion, or costovertebral
tenderness (see ‘‘In catheterised patients’’ below).74
N Pregnancy75 76:
– screening for asymptomatic bacteriuria at first
– investigation of urinary symptoms.
N Anatomical abnormalities of the genitourinary
N Renal impairment.73
N Suspected or known immunosuppression—for
N In sexually active men and women with urinary
symptoms consider Chlamydia trachomatis infection
and send appropriate specimens.
Waiting for the results of urine culture in patients with
suspected UTI delays diagnosis and is not cost effective.
Conversely, prescribing antibiotics to all patients with urinary
symptoms will lead to overuse of antibiotics. Empirical
antibiotic treatment in acute, uncomplicated UTI in women77
should be based on the severity and classic nature of the
symptoms and urine dipstick results, with the exception of
the specific situations listed in the recommendations above.
Submission of a urine specimen before starting treatment
may be helpful to identify antibiotic susceptibility, particu-
larly in the event of treatment failure, although it should not
Patients with failed antibiotic treatment or recurrent UTI
are more likely to have an infection caused by a bacterium
that is resistant to antibiotics.71Therefore, urine culture and
susceptibility is used to confirm that antibiotic choice is
Patients with renal impairment or abnormalities of the
genitourinary tract are more likely to have ascending
infection/pyelonephritis and antibiotic resistant bacteria,
and it is therefore most important to confirm antibiotic
susceptibility.73Similarly, bacteraemia is much more com-
mon in patients with pyelonephritis or fever than in
uncomplicated UTI (15–20%) and, therefore, it is important
to confirm antibiotic susceptibility73in these cases.
In children we recommend a urine specimen from:
N Neonates or infants with:
– unexplained fever . 24 hours
– prolonged neonatal jaundice
– failure to thrive.
N Children of any age with:
– unexplained fever
– urinary symptoms
– vomiting, unexplained abdominal pain, loin pain
– haematuria, hypertension
– suspected sexual abuse.
Guidance is based on recommendations of the Royal
College of Physicians for the management of acute UTI in
Greater opportunities for health gain lie in improving
the detection and treatment of acute UTI in children than
in the detection and management of vesico–ureteric reflux.79
Increased submission of urine samples from children
with the above signs or symptoms leads to greater
detection of UTI.80Fever alone can produce pyuria in
children,81highlighting the need for laboratory diagnosis of
In the elderly we recommend a urine specimen if:
N Dysuria (burning or pain passing urine).
N Fever > 38˚C.
N Acute change in continence.
N Fever plus one of, new or worsening:
– suprapubic pain
– urinary incontinence
– gross haematuria.
Do not send urine from elderly patients if:
N Asymptomatic, irrespective of dipstick nitrite/leuco-
N Subacute or chronic non-specific decline in health
status as the only symptom because this is a non-
N Chronic incontinence without other symptoms.
N Catheterised and asymptomatic patients.
Asymptomatic bacteriuria is extremely common82(20%
of . 65 year olds and 50% of . 80 year olds or patients
with dementia) and is not associated with increased
Routine dipstick testing of urine samples for nitrite and
leucocytes, and urine culture results in unnecessary anti-
biotics and treatment of asymptomatic bacteriuria.83 84
In catheterised patients74 85we recommend a urine
N Fever or rigors without identified cause.
N New onset delirium or costovertebral tenderness.
N Pre-urological surgery.
Bacteriuria is present in most patients with longterm
urinary catheters (. 28 days), but the incidence of fever in
longterm catheterised patients is low (approximately one
episode/100 days of catheterisation). In 50% of catheterised
patients with fever, bacteraemia is present and is caused by
ascending urinary infection.85In patients with paraplegia,
other non-specific symptoms, such as vomiting and increased
spasticty, may indicate urinary tract infection.
Antibiotic treatment of asymptomatic bacteriuria in the
presence of a catheter does not improve outcome.
When should I use urine dipsticks?
N Suspected uncomplicated UTI in adults in combina-
tion with assessment of clinical symptoms.
N Suspected UTI in children, to confirm suspicions of
UTI, but a urine specimen should be submitted
irrespective of results.
N Dipsticks are not reliable in young children (under 2
N Dipstick results should always be interpreted in the
context of clinical symptoms.
Testing for leucocytes (leucocyte esterase) and bacteria
(nitrite) in combination appears at present to be the best
means of dipstick testing.
Positive blood or leucocytes alone can be found in UTI but
are also found in the urethral syndrome (urethral inflamma-
tion),86which does not warrant antibiotic treatment. Nitrite
testing alone is not recommended.87
A negative nitrite and leucocyte test can often be used to
rule out UTI, because it has a reported negative predictive
values of up to 95% or above,78although reported meta-
analysis sensitivity figures are lower (80–90%).88 89These
differences probably relate to clinical context. A positive
result does not necessarily indicate infection: reported
specificity is 60–80%.78 88–90
Several guidance sources78 87 91
culture in uncomplicated lower UTI in women is not
necessary, but stress the need for culture in the other
situations listed above. The European Confederation of
Laboratory Medicine guidelines recommend a ‘‘clinical filter’’
after the dipstick test is performed, to put the result in the
clinical context before decision making.87No robust simple
algorithms combining symptom scores and dipstick results
are available,92and there is no clear consensus as to whether
urine testing of any form is necessary in all women with
possible UTI, in view of the usual self limiting course of the
When reading the dipstick test it is important to wait for
the time recommended by the manufacturer. Nitrite is
produced by the action of bacterial nitrate reductase in urine.
Because contact time between bacteria and urine is needed,
morning specimens are most reliable.94It should also be
noted that falsely negative results can be obtained with
bacteria that cannot reduce nitrate, such as enterococci.
Proteinuria occurs in UTI but is also present in other
state that subsequent
Best practice in primary care pathology: review 2 117
conditions and is relatively non-specific. Other diagnoses
should be considered for isolated proteinuria.95
How should I interpret urine dipstick results?91
Figure 1 provides a guideline flowchart of the interpreta-
tion of urine dipstick results.
How should I obtain a urine specimen?
N A midstream specimen should be obtained from
men, women, and older children. In females, clean-
ing with water or antiseptic or holding the labia
apart does not reduce contamination.96–99
N Intoddlers,a potty washedinhotwater withwashing
up liquid is better than a bag urine.100A urine
collection pad in a nappy may be used for infants.101
N Refrigerate specimens to prevent bacterial over-
growth, or use specimen pots containing boric
acid.102 103Because boric acid is antibacterial, speci-
men pots should be filled to the indicated level to
obtain the optimum boric acid concentration.
How should I interpret laboratory results?
N More than 105organisms/ml (or . 108/litre) of pure
growth (single bacterium isolated) obtained from a
midstream specimen of urine has historically been
considered diagnostic of UTI.
N However, lower counts of pure growth (103/ml or
less), or a mixed growth of two organisms only
(. 105/ml) may also indicate UTI in patients with
signs and symptoms of UTI.87
Mixed growth from a midstream urine sample usually
indicates that the urine has been contaminated on collection
by perineal flora; this is often indicated by the presence of
epithelial cells on the microscopy report. However, patients
with longterm indwelling catheters may have infections with
mixed organisms, although is should be emphasised that
mixed growth from a cultured specimen of urine does not
require antimicrobials in the absence of signs/symptoms of
We are most grateful to Mrs S Richardson for typing this manuscript
and to the following people who are kindly reviewing the group’s
work and adding valuable comments in addition to those of the
steering group: Professor IS Young (Association of Clinical
Biochemists); Dr R Gama and Dr R Herriot (Association of Clinical
Pathologists); Dr AJ Mifsud (Association of Medical Microbiologists);
Dr MJ Galloway (British Society for Haematology); Dr R Neal and
Dr P Hannaford (Royal College of General Practitioners); Dr AB
Provan (Royal College of Pathologists); and the other senior officers
of these Associations and Colleges who assisted in recruiting
Typical symptoms of UTI
Perform near patient test with nitrite
UTI very unlikely,
protein, blood all
negative up to
give advice on
Treat with first
line agent on local
laboratory or HPA
UTI or urethral
time of specimen.
Treat if appropriate,
send urine for culture
Guidance on how to interpret urine dipstick results. HPA, Health Protection Agency; NPV, negative predictive value; UTI, urinary tract
This work has been supported (in alphabetical order) by the
Association of Clinical Biochemists, Association of Clinical
Pathologists, Association of Medical Microbiologists, British Society
for Haematology, Royal College of General Practitioners, Royal
College of Pathologists, and the Sowerby Centre for Health
Informatics in Newcastle, representatives of which have contributed
to the reviewing process. The opinions stated are however those of
W S A Smellie, C A Bloxham, J Hoffman, Bishop Auckland General
Hospital, Cockton Hill Road, Bishop Auckland, County Durham DL14
J O Forth, Prodigy, Sowerby Centre for Health Informatics, Bede House,
All Saints Business Ce ´ntre, Newcastle Upon Tyre NEI 2ES, UK
C A M McNulty, Health Protection Agency Primary, Care Unit,
Microbiology Department, Gloucester Royal Hospital, Great Western
Road, Gloucester GL1 3NN, UK
L Hirschowitz, Department of Cellular Pathology, Royal United Hospital,
Combe Park, Bath BA1 3NG, UK
D Lilic, University Hospital of North Durham, North Road, Durham DH1
R Gosling, Darlington Memorial Hospital, Hollyhurst Road, Darlington,
County Durham DL3 6HX, UK
D Bareford, Russells Hall Hospital, Dudley, West Midlands DY1 2HQ,
E Logan, Department of Haematology, Kings Mill Centre, Mansfield
Road, Sutton in Ashfield, Nottingham NG17 4JL, UK
K G Kerr, Department of Microbiology, Harrogate District Hospital,
Lancaster Park Road, Harrogate, North Yorkshire HG2 7SX, UK
G P Spickett, Royal Victoria Infirmary, Queen Victoria Road, Newcastle
upon Tyne NE1 4LP, UK
A Galloway, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP,
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