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Fig 2. "Fair" sputum specimen —11 to 19 squamous epithelial cells Fig 3. "Good" sputum specimen—0 to 10 squamous epithelial cells
per low power field (Gram stain, original magnification X100). per low power field (Gram stain, original magnification X100).
Positive
Gram Stain Culture* Sensitivity Specificity PPV NPV Likelihood Ratio
Gpc in clusters Staphylococci 37.1 99.5 90.6 91.9 74.2
t
Gpc in clusters Staphylococcus aureus 36.1 91.2 30.3 93.1 4.1
Gpc in chains Streptococci 48.3 97.4 58.4 96.1 18.6
Gpc in pairs* Streptococcus pneumoniae 92.2 54.7 7.1 99.5 2.0
Gndc Moraxella catharralis 93.1 83.8 7.4 99.9 5.7
Statistical comparison of Gram stain and cul- specimen,25 and it can be difficult to macroscop-
ture results is presented in Table 3. As anticipated, ically differentiate acceptable from nonacceptable
several Gram stain report comments or morpho- sputum specimens at the bedside.26 Nevertheless,
types were not predictive of culture results. For after the specimen is procured, Gram stained, and
example, gram-negative diplococci did not pre- cultured, the physician must decide how to use
dict for culture of M catarrhalis (positive predic- the results. Generally I recommend that informa-
tive value 7.4%). Also, the observation of tion generated from poor specimens be consid-
gram-negative bacilli on Gram stain did not pre- ered of less value than information from good or
dict the presence of gram-negative bacilli poten- fair specimens. Ideally, new specimens should be
tial respiratory pathogens in culture, regardless of collected to replace poor specimens. However,
sputum specimen quality (positive predictive sometimes a poor specimen is the only specimen
value 32.4%-54.9%). Positive likelihood ratios that can be obtained, and the clinician must
greater than 10 were considered most significant, decide how to use results from this specimen.
occurring with gram-positive cocci in clusters Poor specimens can yield useful information and
and staphylococci, and gram-positive cocci in should be evaluated carefully when there is no
chains and streptococci, and small or tiny gram- other choice.18
negative bacilli and haemophili. A positive Gram stain followed by a negative
culture can be misleading. In this situation
Discussion organisms seen on Gram stain can prompt the
The first step in obtaining useful Gram stain and initiation of inappropriate or toxic therapy and
culture results is procurement of an acceptable delay making an accurate etiologic diagnosis.
specimen. 4 ' 6 ' 21_23 Collecting an expectorated Data from the study hospital show that poor spu-
sputum specimen usually includes an explana- tum specimens are more likely to produce posi-
tion to the patient, brushing the patient's teeth tive Gram stains and negative cultures, compared
and/or rinsing the mouth, followed by having the with good or fair specimens.
patient eject an early morning bolus (from a deep In this study, statistical analyses indicated that
cough) into a sterile container.24 Obtaining a Gram stain results often were misleading or not
good specimen might not be as easy as the litera-
ture suggests, because some patients (eg, those
with congestive heart failure) are more likely to
yield poor specimens,16 rinsing the mouth before
expectoration does not always yield an acceptable
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on 28 May 6 LABORATORY MEDICINE VOLUME 29. NUMBER 12 DECEMBER 1998
Table 4. Guidelines for Interpreting Sputum Gram Stains
Gram Stain Morphotype Likely Culture Results Based on Statistical Analyses
Gpc in clusters Staphylococci likely in culture
No Gpc in clusters Staphylococci not likely in culture
Gpc in clusters* Unpredictable for Staphylococcus aureus
No Gpc in clusters* S aureus not likely in culture
Gpc in chains Unpredictable for streptococcal potential respiratory pathogens
No Gpc in chains Streptococcal potential respiratory pathogens not likely in culture
t
Gpc in pairs Unpredictable for Streptococcus pneumoniae
predictive of culture results. Perhaps the most mis- With these problems in mind, I devised guide-
leading finding was the presence of gram-negative lines for interpreting sputum Gram stain reports
bacilli on Gram stains that did not predict the (Table 4), based on data from Table 3. However,
presence of gram-negative bacilli potential respira- these suggestions may not apply to some hospi-
tory pathogens on corresponding cultures (ie, pos- tals owing to variables that could affect the
itive predictive value 32.4%-54.9%; see Table 3). report, such as patient population, unique insti-
This discrepancy between Gram stain and culture tutional flora, microbiologic culture techniques,
results is important because clinicians often are media and evaluation policies, and the way physi-
interested in the presence of gram-negative bacilli cians and other health care providers evaluate
potential respiratory pathogens in the lower respi- Gram stain results. Other investigators should
ratory tract. Gram-negative bacilli might be seen repeat this type of study in their own settings to
on Gram stain but not grown on culture when the determine applicability.
organisms are anaerobes or fastidious. Also, the When Fine and colleagues27 compared Gram
laboratorian reading the culture may not recognize stain with culture and serology, their statistics for
or detect gram-negative bacilli potential respira- S pneumoniae and H influenzae, respectively, were
tory pathogens, especially if they are overgrown by sensitivity 86% and 80%, specificity 72% and
common oral flora. Although the presence of 88%, positive predictive value 43% and 73%, and
gram-negative bacilli on Gram stain poorly pre- negative predictive value 95% and 92%. Their
dicted the presence of gram-negative bacilli poten- statistics were similar to mine, except a lower pos-
tial respiratory pathogens in culture, the absence of itive predictive value for S pneumoniae and a
gram-negative bacilli on Gram stain was a fair pre- lower sensitivity for H influenzae were found.
dictor for the absence of gram-negative bacilli in Although it is difficult to determine the exact
culture. nature of the discrepancies, variables between the
two studies might include what constituted a pos-
itive Gram stain for S pneumoniae and H influen-
zae, and definition of positive culture. In the
current study, blood culture and serologic tests
were not included.