Voided midstream urine culture and acute cystitis in premenopausal women

Abstract

Background: The cause of acute uncomplicated cystitis is determined on the basis of cultures of voided midstream urine, but few data guide the interpretation of such results, especially when gram-positive bacteria grow.

Methods: Women from 18 to 49 years of age with symptoms of cystitis provided specimens of midstream urine, after which we collected urine by means of a urethral catheter for culture (catheter urine). We compared microbial species and colony counts in the paired specimens. The primary outcome was a comparison of positive predictive values and negative predictive values of organisms grown in midstream urine, with the presence or absence of the organism in catheter urine used as the reference.

Results: The analysis of 236 episodes of cystitis in 226 women yielded 202 paired specimens of midstream urine and catheter urine that could be evaluated. Cultures were positive for uropathogens in 142 catheter specimens (70%), 4 of which had more than one uropathogen, and in 157 midstream specimens (78%). The presence of Escherichia coli in midstream urine was highly predictive of bladder bacteriuria even at very low counts, with a positive predictive value of 10(2) colony-forming units (CFU) per milliliter of 93% (Spearman's r=0.944). In contrast, in midstream urine, enterococci (in 10% of cultures) and group B streptococci (in 12% of cultures) were not predictive of bladder bacteriuria at any colony count (Spearman's r=0.322 for enterococci and 0.272 for group B streptococci). Among 41 episodes in which enterococcus, group B streptococci, or both were found in midstream urine, E. coli grew from catheter urine cultures in 61%.

Conclusions: Cultures of voided midstream urine in healthy premenopausal women with acute uncomplicated cystitis accurately showed evidence of bladder E. coli but not of enterococci or group B streptococci, which are often isolated with E. coli but appear to rarely cause cystitis by themselves. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases.).

Figure 1. Enrollment and Outcomes

The 236 symptomatic episodes occurred in 226 women; 8 women had 2 episodes each, and 1 woman had 3 episodes.

Figure 2. Correlation between Counts of Colony-Forming Units (CFUs) in Catheter Urine Cultures and in Midstream Urine Cultures

Shown are plots indicating the correlation between bacterial counts in cultures of urine collected by means of a urethral catheter and those in cultures of voided midstream urine in women with symptoms of acute uncomplicated cystitis. Spearman’s correlation coefficients, which are shown in the upper left corners of the panels, are based on all observations. The left-hand column of plots (Panels A, C, and E) show gram-negative organisms, and the right-hand column (Panels B, D, and F) show gram-positive organisms.