Today in Australia, dipsticks are often the first diagnostic tool GPs use to confirm an infection. These tests look for signs of infection, such as white blood cells (leucocytes or pus cells), blood, pH levels and nitrites. Although they are useful in confirming a clearly positive diagnosis, studies in the early 1990s concluded they are highly insensitive and unreliable at excluding infection in most clinical settings4. About a decade later, another team of researchers comprehensively studied the reliability of urinary dipsticks and determined that these first-line screening tests were not up to the job of excluding significant UTI. It found dipsticks identified white blood cells just 55 percent of the time and nitrites (another positive indicator of infection) only 10 percent of the time. A negative result offers no useful information in ruling out a UTI3. Given the proven shortcomings of urinary dipsticks, GPs should be extremely cautious when relying on this test to rule out a UTI.
After your GP listens to your symptoms and dipsticks your sample, they will more than likely send your urine sample to the lab to see what bacteria is causing your UTI. The lab will use a quantitative microbial culture from a mid-stream urine (MSU) sample to grow the bugs. The lab (either a real life technician or an automated machine) will also conduct a urinalysis and look at a small amount of your urine under a microscope to check for other signs of infection, such as white blood cells, red blood cells, epithelial cells and any other signs. These readings will be used alongside the MSU culture results to determine if there is a genuine infection.
MSU cultures are considered the gold standard for diagnosing UTI and have been used since the late 1950s. For over 30 years, researchers have warned of serious deficiencies that lead to these tests missing at least 50 percent of infections1,5. Studies have been repeated and calls for the abandonment of MSU culturing have been echoed, but these warnings have gone ignored and MSU culturing remains the main diagnostic tool for UTI around the world.
“We make our clinical decisions in infectious disease in urology based on technology that’s over 100-years-old. We’re still taking urine samples, plating it on an AGAR, and putting it in 24 hours in an incubator and then making a decision. We now know that we grow less than one percent of potential uropathogens by this technique; we don’t culture biofilm bacteria; and we miss 99.9 precent of possible microorganisms that are in the environment that might be related to infectious disease.” Dr Curtis Nickel, Professor of Urology, Queen’s University, Canada. Click to hear more.
“That’s another myth, the fact that infections are present only when the bacteria are present at 10^5 or greater. And that was never the intent of Kass’ original report. The amount of bacteria in people that have UTI varies. When you get up the urine has been concentrated during the night, sure it can be 10^5. But when you’ve had coffee and urinated it can be 10^2 and that’s also significant. But labs aren’t culturing at 10^2. We miss a lot of true UTIs by setting cut-off limits based on dogma that we think needs to be trashed.” Dr Paul Schreckenberger, Loyola University, Chicago, USA. Click to hear more.
“Many women with the appropriate symptoms are dismissed as not suffering from an infection when they do in fact have one. This controversial view is supported by much published literature. I am sorry to record this, because in doing so I identify a worrying deficiency in our diagnostic protocols, but the evidence is out there for everyone to read.” Professor James Malone-Lee, Emeritus Professor of Nephrology, UCL, and Director of the LUTS Clinic, Whittington Hospital, London, UK.
The following information is for those who like detail. For the rest of you, all you need to remember is researchers have known for over 30 years that MSU cultures miss half of the infections they test for, yet they are still considered the gold standard method for diagnosing UTI around the world. This is not good enough!
The MSU culture was first introduced by Edward Kass 60 years ago. He was looking for a method to determine a dividing line between ‘infection’ and ‘contamination’ in pregnant women with acute pyelonephritis (a kidney infection)—a much more severe and serious form of urinary infection.
Kass applied a quantitative culture method to urine which became widely known as the Kass Criteria. The Kass Criteria requires a pure growth of a known urinary pathogen that reaches a colony count of 10^5, or greater. These methods were soon adopted by labs for diagnosing acute UTI. Kass’ report was never intended or validated for this purpose, but for some reason it has become the gold standard around the world for diagnosing acute UTI6.
To understand why MSU culture misses 50 percent of urinary infections, it will help to break it down further.
Kass held the common belief at the time that the urinary tract was sterile—so any single urinary pathogen that grew from an uncontaminated sample must be the offending pathogen. In light of the recently published discovery that the urinary tract houses its very own microbiome containing many hundreds of different species7, this completely undermines the traditional significance of what ‘grows’ and whether it is a pathogen, a harmless commensal or a contaminant.
Kass also followed a set of principles developed in the late 1880s referred to as Koch’s Postulates. This rule stipulates only a single organism is responsible for an infection (pure growth). The requirement of a pure growth ignores the possibility of polymicrobial infections, which have recently become accepted by researchers as commonplace with UTI6. Polymicrobial infections can either involve more than one bacterial species, a combination of two non-pathogenic bacteria that come together to become pathogenic, or it can be a mix of a bacteria, fungus, virus or mould that give each other the pathogenic edge8. As the science world moves past the limitations of Koch’s Postulates, the understanding of polymicrobial infections is increasing rapidly and the list of known polymicrobial diseases is growing. From 2010 to 2012, publications of polymicrobial infections increased by 300 percent9.
This TED talk by molecular biologist, Bonnie Bassler, gives a fascinating insight into how bacteria in polymicrobial communities cooperate and communicate, both within their own species and between different species.
Despite the rapid understanding of polymicrobial infections, as it stands today in clinical labs, MSU cultures that grow more than one species will most likely be reported as (depending on the lab), ‘no significant growth’, ‘mixed growth of no/doubtful significance’ or ‘contamination’. This could mean countless genuine polymicrobial urinary infections are being routinely discarded and these patients are not receiving treatment for their infections.
To identify the pathogen responsible for a UTI, what grows must be a ‘known urinary pathogen’. Traditionally, known urinary pathogens are: Escherichia coli (80 percent), Staphylococcus saprophyticus (10–15 percent), Klebsiella, Enterobacter, Proteus species and enterococci10.
The criterion of a ‘known uropathogen’ has lost integrity since the discovery of the female urinary microbiome (FUM). The urinary tract contains a community of hundreds upon hundreds of microbes. Some which are pathogenic—others that possibly play a protective role. Some of these microbes culture easily—others will not culture under existing lab methods at all7. Knowledge of the FUM now suggests that because one species grows easily under existing culturing methods (i.e. Escherichia coli), it does not necessarily mean it is the pathogen causing symptoms. Likewise, it is also very possible that the offending pathogen is unculturable and never identified. This creates a complicated dilemma for clinical microbiology that can no longer be ignored.
For diagnostic purposes, a bacteria is only considered a pathogen if it grows to a certain measure during the culturing process. This is known as a colony forming unit (cfu). The adoption of the cfu criterion came from Kass’ 1950s study of 74 women with acute pyelonephritis (a kidney infection) with large levels of bacteria rapidly multiplying and thriving in their urine. He then backed up his findings with another study of pregnant women with severe acute pyelonephritis. From these two studies, he determined a (widely criticised) diagnostic measure for pathogenic bacteria to be held at 10^5 cfu.
Alongside basing this benchmark on those with severe, acute kidney infections, Kass didn’t consider variables associated with low bacterial counts, such as difficulties in growing certain bacteria outside the body, slow growing bacteria, or the concentration of the urine sample. Scientists and researchers have criticised Kass’ threshold as insensitive and questioned its suitability as a diagnostic measure1,3.
White blood cells
White blood cells (leukocytes or pus cells) are also a common UTI indicator used by labs. The threshold was first set by Cuthbert Dukes almost 90 years ago after studying 300 asymptomatic males and females. He concluded a count of 10 or more white blood cells/mm3 as ‘abnormal’. Here are the problems associated with Dukes’ threshold:
The urothelium is a thin tissue which lines the bladder and most of the urinary system. Elevated epithelial cell counts are considered a normal sign of infection when coupled with bacterial growth that reaches the existing criteria.
If a sample shows elevated epithelial cells without positive bacterial growth, it is usually described as distal urethra contamination in men and vaginal contamination in women. However, research from the UK12 and the US13 has demonstrated that epithelial cell exfoliation (also known as sloughing or shedding) is a first line defence mechanism/innate immune response to rid the epithelium of low-grade infection by invading pathogens. The more cells which are shed reflects the severity of infection and possibly the stronger the immune response. It is no longer accepted by science that elevated epithelial cells in samples of those with lower urinary tract symptoms (LUTS) and no bacterial growth, is due to sample contamination.
This is an example of a MSU culture (urine micro/culture) report from someone experiencing fluctuating UTI symptoms for a month. This particular sample tested positive for leucocytes and nitrites at the GP clinic and was sent to the lab for testing. The lab report showed raised leucocytes (pus cells), erythrocytes (blood), epithelial cells and no significant growth. The clinic informed the patient there was no infection and treatment was not required. This person continued to have escalating symptoms and further ‘negative’ tests, before being diagnosed with a Chronic UTI.
This is an example of a typical positive test result where a single known urinary pathogen has satisfied the testing criteria.
For more information about the shortcomings of gold standard UTI testing tools, please check the PDFs below:
Some practitioners have abandoned traditional MSU cultures and have started using DNA-based molecular testing to identify urinary bacteria. This testing is generating interest because of its ability to identify all bacteria in a urine sample. There is no consensus on the value of DNA-based molecular testing in diagnosing UTIs. Some research experts are critical due to the current lack of understanding of the urinary microbiome and the inability to describe the microbes truly responsible for health and disease.
DNA-based molecular testing is best used by experienced practitioners in conjunction with the patient’s history, symptoms and other tests. Since DNA is not greatly affected by time or temperature, urine samples can be sent by courier without needing to be iced. Current or recent antibiotic use will also not impact the test. Testing technologies between labs vary and tests cost anywhere between $244 and $1,200 AU, depending on the test and the lab.
In Australia, anecdotal reports so far highlight difficulties for people finding practitioners who understand the test results and have specialist knowledge in treating chronic UTI.
Although it is still early day, it is hoped that molecular testing will one day allow the identification of a personalised healthy urinary microbiome and inform future treatment options for UTI.
Please Note: This form of testing is not cheap and further testing may be required throughout treatment, so please do your research to find out more about testing and freight costs. Patients have also reported it is important to work with an experienced practitioner who understands how to interpret the results and prescribe treatment accordingly. There are a number of patients who have accessed DNA testing, but their local doctor has not understood how to interpret the results and prescribe a treatment, or they have simply refused the test results. Please speak to a trusted practitioner before choosing this option.
Formerly PathoGenius Laboratory, MicroGen DX provides Next-Gen Sequencing for urine testing and is located in Texas, USA. This lab accepts samples from international self-requests (ie you can order your own test). The website states:
“Recurrent or chronic UTIs are sometimes the result of more than just a single infectious organism. Urine culture is biased towards a single infectious organism based on CFU (colony-forming unit) count, possibly leading to inappropriate therapy. Some problematic organisms are not readily grown in culture which may lead to incorrect treatment or non-treatment. The advantage of NGS is the ability to test and detect multiple organisms simultaneously, including those that may not grow readily in culture. And if the patient is currently on antibiotic therapy or has a recent history of antibiotic therapy, detection of pathogens by NGS is not impacted by the presence of antibiotics.”
RTL Genomics is a sister-lab to MicroGen Dx focused on research services. It is not a clinical laboratory and does not offer diagnostic services. However, through its clinical research programme they will accept self-referral urine samples from internationals who are not working with a US practitioner. You will receive a clinical report for research purposes, but RTLGenomics does not provide this data as clinical diagnostics. Patients have said it is important to work with an experienced practitioner to interpret these tests results.
Aperiomics Inc offers Next Generation Sequencing (NGS) with ‘deep shot-gun metagenomic sequencing’. Their technology uses 100 percent of the DNA, opposed to NGS 16S that uses .001% of the DNA. Their UTI test identifies all known bacteria, viruses, fungi and parasites that have been genetically sequenced. This lab accepts samples from international self-requests.
DNA-based molecular testing is not the straight forward answer we have all been waiting for. DNA-based molecular testing will identify the known microbes in your urine sample (both good and bad) and it will certainly identify microbes where standard cultures are drawing blanks. What we don’t know is if the bacteria identified are causing you to have symptoms. Let us explain why.
We now know our bladders have a resident bacterial community, therefore it’s expected bacteria will show up in a urine sample from healthy control and those with infection. The tests report on the highest bacterial loads, but whether those microbes are responsible for the infection/symptoms is still unknown. If an infection involves intracellular bacteria or bacteria in biofilms, these microbes will only be identified if infected cells have been shed into the urine sample.
At this stage, the testing is on offer to willing customers—but the jury is still out when it comes to the accuracy of interpreting these results and prescribing an appropriate treatment for chronic UTI.