SPECIMEN COLLECTION AND

TRANSPORT
John M. Matsen, M.D.*
and Grace Mary Ederer, M.P.H.-?

Abstract
T h e a p p r o a c h to the collection and transport o f meaningful and accurate
microbiologic specimens d e p e n d s u p o n the n a t u r e o f the suspected infectious
entity and u p o n the location o f the pathogenic process, as well as the possess-
iota o f a p p r o p r i a t e instrumentation and containers. New information and newly
d e v e l o p e d collection-transport materials have i m p r o v e d the potential for the
successfifl collection and isolation o f pathogenic micro-organisms.

T h e first step in the accurate diag- ence o f these micro-organisms is im-

nosis o f infectious disease is the collection
of a p r o p e r specimen. All too m a n y times,
t h r o u g h ignorance or t h r o u g h negligence,
the specimen sent to the laborator)" has
been obtained either with i m p r o p e r tech-
nique or in an inadequate a m o u n t or from
an i n a p p r o p r i a t e site. Certain specimens
are flu'ther c o m p r o m i s e d t h r o u g h delayed
or i m p r o p e r t r a n s p o r t to the laboratory,
allowing quantitative distortion o f organ-
ism relationships. It is the intent o f this
discussion to review the c u r r e n t state o f the
art with respect to specimen collection and
transport.
SPECIMEN COLLECTION
General Principles
Somlz u n d e r s t a n d i n g o f the prin-
ciples g o v e r n i n g normal flora is important,
not only for the interpretation o f culture
resuhs but for the d e v e l o p m e n t o f a mean-
ingful a p p r o a c h to the collection o f
specimens. T h e skin, u p p e r respiratory
tract, intestinal tract, fenmle genital area,
and open wounds all develop an environ-
merit o f nornml microbial llora. T i m pres-
portant in the commensal relationship that
we have with the microbial world, and
t h o u g h they create problems in specimen
collection and interpretation, their ab-
sence would create an ecological vacuum
into which o t h e r organisms would surel)'
migrate, and possibly precipitate clinical
disease.
T h e presence o f normal flora, even
with o u r c u r r e n t state o f knowledge, cannot
be ignored, but can be handled in one o f
the following ways:
i. Cleansing the area with an appropriate
disinfectant, e.g., 2 per cent iodine for preblood
cuhure skin preparation.
2. Looking specifically tbr organisms
whose presence is known to pose a threat, e.g.,
group A beta hemolytic streptococci in the
throat.
3. Complete bypassing of areas of normal
flora to reach tissue areas or body cavities not
normally colonized with microbial agents, e~g.,
suprapubic aspiration urine specintens.
4. Utilizing qttantitation as a ineans of
determining probable disease association, e.g.,
quantitative clean catch urine specimens.
A d e q u a t e e q u i p m e n t and materials
are a n o t h e r i m p o r t a n t general considera-
tion in the collection and transport process.

*l'rofessor of l'athology and i'ediatrics, Unive,sity of Utah College of Medicine. Director, Clinical
Laboratories, University of Utah ttospltal, Salt Like City, Utah.
l'Associate I~'rofessorof Laboratory ,Medicine and l'athology, University of Minnesota Medical
Center, ,X[imteapolis,Milmesota. 297
 HUMAN PATHOLOGY--VOlUME 7, NUMBER 3 Mu) 1976

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 SI'ECIMEN COI,I.ECTION AND TRANSI)ORT-MA'rs~.~, EDERER

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299
 HUMAN P A T H O L O G Y - V O L U M E 7, NUMBER 3
Newly d e v e l o p e d plastic disposable con-
tainers have both assisted in a n d de-
tracted f r o m the enhancetnet~t o f collec-
tion a n d t r a n s p o r t , d e p e n d i n g O11 their
design. For the protection o f personnel,
p r e s e r v a t i o n o f organisnl viability, and
ease o f lmndling, the design o f these ina-
terials b e c o m e s a m a t t e r for carefttl labor-
atory assessment and inpttt with respect
to decisions relating to the pttrchase o f
equipment.
Every l a b o r a t o r y shottld p r o v i d e a
s p e c i m e n r e q u i r e m e n t protocol for use by
the physician a n d nursitag personnel. T h e
latest in technologic advances are at times
completely offset by an i n a p p r o p r i a t e
s p e c i m e n , a n d tile physician m a y reqttire
l a b o r a t o r y g u i d a n c e in p r o v i d i n g the ap-
p r o p r i a t e specimen. T a b l e 1 offers an
e x a m p l e o f a specintetl r e q u i r e m e n t list
that m i g h t be used by a clinical micro-
biology laboratory.
T h e l a b o r a t o r y will at tintes be able to
r e s p o n d to clinical informatiotl p r o v i d e d
and, by taking extra steps in the laboratory,
give o t h e r than rotttine i n f o r n m t i o n in
retttrn, if the following i n f o r m a t i o n is pro-
vided on each spectmeti reqttest slip:
date, time o f collection, patient's natne a n d
location, s p e c i m e n source, diagnosis,
doctor's n a m e , antibiotic t h e r a p y and
o t h e r relevant infortnation. Space for each
o f these answers shonld be p r o v i d e d on
the reqttest slip.
Specific Specimen Guidelines
I n addition to actual specilnen re-
q n i r e m e n t s , i n f o r m a t i o n should be dis-
s e m i n a t e d f r o m the l a b o r a t o r y relating to
the specific p r o c e d u r a l guidelines to be
followed to obtain the a p p r o p r i a t e speci-
nten. Wlmt follows, titan, is a review o f
suggestions relating to the steps necessary
to secure tim optimal s a m p l e t o t ctdture.
We h a v e elected to pttt this in outline forth
for the sake o f e c o n o m y o f space and ease
o f extraction. T h e abbreviations r e f e r r i n g
to the materials used in skin, lesion, or
area p r e p a r a t i o n are:
A L C = 70 to 95 p e r cent alcohol a n d
T I O = 1 to 2 per cent tincture o f iodine.
A generalization shottld be m a d e also
to avoid repetitiotts r e f e r e n c e to the
m a x i m that the iodine a n d alcohol are
bes~ alIo'wed to r e m a i n at least'two minutes
b e f o r e a s s n m i n g that an a p p r o p r i a t e ef-
300 fect has occurred.
May 1976
A. Abscesses
1. I'repare tile surfime with T I O and ALC,
or iodophor and ALC.
2. Aspirate as nmch purulent material as
possible.
3. Send tile Slmcimen immediately to tile
laboratory ill a glass syringe from which
all the air has been expressed or in all
anaerobic transport vial (preferably 5
to 10 cc.).
4. Swabs are of limited value because of
the small amount of material and pos-
sible'inadequacy of tile sample and be-
cause of their tendency to dr)' easily.
B. Anaerobes
T h e reader is referred to the review by
Rosenblatt in this symposium (p. 177,
March 1976 issue).
C. Blood
1. First cleanse skin with ALC.
2. Follow with TIO. *love in an ever in-
creasing circular pattern, starting at the
point of projected needle insertion. (It
is the authors' opinion that the use of
Ii'II has resuhed in higher contamina-
tion rates.)
3. Use a sterile needle and syringe or
closed system blood collection tubing,
e.g., Blood Taking Unit (Becton-Dickin-
son) or Blood Collecting Unit (Hospital
Service Teclmology Corporation).
4. Apply a tourniquet proximal to the
point of venous entry. I)o not touch the
vein after cleansing and before needle
entry.
5. Use a new needle if the skin must be
re-entered.
6. Cleanse tim iodine from the skin after
tile specimen is collected.
7. Use of a two bottle system is recom-
mended. (For an excellent review of tim
current recomnmndations tor the band-
ling and processing of blood cuhures,
the reader is referred to the excellent
review on blood cuhnres in the Cumitech
series))
D. Body fluids (except urine and cerebrospinal
fluid)
1. The skin is prepared as for blood ct, l-
lures (C above).
2. A sterile needle and syringe are used.
3. All specimens should be handled so as
to insure anaerobic isolation, i.e., col-
lection into a glass syringe or an
anaerobic transport vial.
4. Preferably 5 to 10 cc. is sent to the
laboratory. It is best to trm]sl6ort such
specimens immediately to the labora-
tory, not only to maximize allpropriate
processing, but to insure prompt results
fi'om immediately available'laboratory
procedures.
 SPECIMEN C O L L E C T I O N A N D T R A N S I ' O R T - M a a - s E , ~ , EDERER
E. Bullae, cellulitis, p.etechiae, vesicles
1. T h e skin is cleansed as for bloo d cul-
tures (section C). In the case o f bullae
and vesicles, care is exercised to avoid
lesion rtlpttlre.
2. A sterile needle and syringe are used.
3. As much material as feasible is aspirated.
4. If no aspirate is available, McGaw's
balanced saline may be injected and
aspirated. It is best to a t t e m p t this at
lesion edges.
5. Petechiae pose special problems, and
some p r e f e r excoriation o f the skin with
a needle tip after vigorous cleansing.
In tiffs event, iodine should be removed
with ALC prior to this exercise. A swab
is then used to inoculate chocolate agar
plates immediately at the bedside or to
put material on a slide for" a G r a m stain.
F. Cerebrospinal tluid
1. T h e physician wears gloves, a gown,
and a mask.
2. T h e skin is p r e p a r e d with T I O , fol-
lowed, before needle insertion, with
ALC. Use increasing outward circular
movements.
3. Drape the s u r r o u n d i n g skin with sterile
linen.
4. Needle insertion is followed ideally by
collection o f more than 2 cc. o f c e r e b r o -
spinal fluid into a sterile container for
which a l e a k p r o o f cap is available.
5. Because an open tube is held to collect
the tluid, t h e physician should wear a
mask, and other personnel should stand
away or wear a mask, in o r d e r to avoid
respiratory contamination.
6. T h e specimen is transported immediate-
ly to the laboratory, because the organ-
isms likely to be isolated are fastidious.
7. Separate tubes ideally are used to col-
lect specimens for a cell count and
chemistries.
G. Cervix and e n d o m e t r i t l m
1. T h e patient is placed in the litlrotomy
position.
2. A specuhun is inserted and the cervical
os visualized. Excess mtreus is removed
with a cotton ball.
3. For gonococcal and cervical cultures for
other reasons, the swab is inserted in the
distal portion o f the cervical os, rotated
gently, and allowed to remain for 10 to
30 seconds. Gonococcal cuhures are
plated immediately onto modified
T h a y e r - M a r t i n plates 4"5 o r streaked on
Transgrow meditlm 6 in carbon dioxide
containing bottles. If a plate is to be
inoculated, it should be at room
t e m p e r a t u r e . One plate is used for each
site culttlrdd (see section H). T h e plate
can then be placed into a plastic bag
with a carbon dioxide generating tab-
let. 7
4. If T r a n s g r o w bottles are inoculated, the
bottle should be held upright and the
cap removed only briell)" in o r d e r to
retain the gaseous carbon dioxide
present.
5. Endometrial cultures should be ap-
proached either by needle aspiration o r
by a double l u m e n catheter t h r o u g h
the cervical os. A n u m b e r 16 straight
"all purpose" Foley urethral or French
catheter is inserted carefully througl~
the cervical os. A slight cut has been
previously m a d e in the advancing e n d
to allow egress o f a nmnber 8 infant
feeding tube, which is fed tllrough the
lumen o f the Foley catheter to obviate
normal f o r a contamination.
6. T h e aspirated material is handled as
with anaerobic specimens.
H. G o n o r r h e a s
1. See preceding section on cervix (G).
2. I f purulent nmteria[ is present in the
u r e t h r a o r if o t h e r lesions are present,
these should be cultured as the second
site, in addition to the cervix. Otherwise
a rectal swab is indicated. This specimen
can be obtained withotlt an anoscope, by
inserting a cotton swab approximately
1 inch into the anal canal. Tire swab is
then moved from side to sitle to sample
the crypts anti left for 10 to 30 seconds
to allow absorption o f organisms onto
the swab.
3. For more detailed information, it is sug-
gested that the r e a d e r review refer-
ence 8.
1. Nasoplmrynx
1. Tire patient is comfortably seated,
preferably with tile head tilted back.
2. A nasal speculum is gently inserted.
3. A nasopharyngeal swab, on a malleable
wire with a Teflon coated nontoxic tip,
is inserted t h r o u g h the speculum into
the uasopbaryngeal area.
4. T h e swab is rotated gently and allowed
to re,nain for 20 to 30 seconds. Tile
swab is then removed and placed in
a nongwowth promoting transport
9medium, such as the Culturette con-
tainer, f i o m which the original swab has
been r e m o v e d ? ~
5. It is i m p o r t a n t to stress the use of trans-
port media with these specimens be-
cause the swab tip is small and vulnerable
to d r y i n g and the organisms likely to be
present are rather fastidious.
6. T h e s e spechnens shoukl be transported
p r o m p t l y to the laboratory.
7. Special culture media are necessary if 301
 HUMAN PATIfOI.OGY-VOI.UME 7, NUMBER 3
unnsual organisms such as lhndetella
perius,~is are expected.
J. Nose
Anterior nares cultures are easily taken with
a r e g u l a r cotton swab. In small cllildren this
is best done with a swab snch as described
in section I (nasopharynx).
K. Skin
1. See also sections A (abscesses) and E
(bullae, cellulitis, petechiae, and
vesicles).
2. See section R (wounds).
L. Sl)t,tum
I. S p u t u m is a very SUSl)ect specilnen un-
less patient cooperation is asst, red and
unless special laboratory assessment is
p e r f o r m e d to d e t e r m i n e numbers of
squamous epithelial cells and let, ko-
cytes?
9. Tile patient should be properly in-
structed as to what is desired. A sterile
container is p r o v i d e d for tim expectora-
ted material.
3. I f the patient is unable to produce
sputum, sputunl induction may be
effected by imstural drainage, saline
nebulization, or chest percussion.
,t. Again, since some o f tile organisms are
fastidious, tile specimen should be
traqsported p r o m p t l y to tile laboratory.
5. See also section O (transtradleal aspira-
tion).
M. Stool, feces
1. A sterile container is sufficient if tile
specimen can be t r a n s p o r t e d p r o m p t l y
to the laboratory.
2. If a delay o f over two to three hours is
expected, use 0.033 M phosphate buffer
mixed with equal parts o f glycerol or
Alnies, Cary-Blair, o r Stuart transport
umdium.
3. If a delay of many Ilours is expected or
if tim specimen is to lie sent by mail, use
0.033 M pllosphate buffer with an eqt, al
part o f glycerol.
4. A swab o f rectal mucus or a renal swab
inserted 1 inch into tile anal canal is a
suitablc ahernative for Shigella and for
e u h u r e when a stool specime,~ is not
available. Tile specimen shot,ld be trans-
ported in transport media as in step 2.
N. T h r o a t
I. A cotton, Dacron, o r calciuln algi,mte
swab is used with good visualization (usc
a tongue blade and a good light source).
Swab both tonsillar fat,ces and the pos-
terior pharynx, reaching up behind the
u v u l a and c u h u r i n g any ulceration,
'exudate, lesion, o r area ofinflamination.
302 2. Cuhures for g r o u p A beta hemolytic
May 1976
streptococci need not be subnlitted in
t r a n s p o r t medium.
O. T r a n s t r a c h e a l aspirate
1. This technique is not a routine c u h u r e
teclmique and is best done by an
experienced individual. Descriptions o f
tile methodology and considerations
are readily available in tim literature, v - u
9. Submit a specimen to insure isolation o f
anaerobic organisms.
P. U r e t h r a
1. A c u h u r e is indicated when a Gram
stain o f the uretllral exudate is not posi-
tive, in tests of cure, or as a test for
asymptolnatic urethral infection. Use a
sterile bacteriologic wire 10011 to obtain
tile specimen from tile anterior u r e t h r a
I))' gently scraping tile llltlCOSa. An
alternative to tile loop is a sterile calcium
alginate urethral swab that is easily
inserted into the urethra, s One migllt
also use the nasopharyngeal swab de-
scribed in section I (nasopharynx).
2. T h e s e cultures are then Ilandled as out-
lined in step 3 in section G (cervix).
Q. Urine
T h e li~llowing is extracted from Cunlitech 2
and represents an excellent a p p r o a c h to
these d i m c u h specimens.*
I. It is best to obtain early m o r n i n g
specimens wllenever possible. Because
o f tile opportunity for bacteria to grow
d u r i n g overnight incubation in tile
urinary bladder, bacterial cotlnts are
higllest at tiffs time. Tile tn'ine o f pa-
tients wilo are receiving forced fluids
may be sufficiently diluted to reduce tim
colony Collnt below 10 s p e r nil.
9. T h e ease o f obtaining a clean voided
urine specimen varies greatly d e p e n d i n g
u p o n tile age, sex, and ability o f the
patient to cooperate. In all instances
a r r a n g e m e n t s for the collection must be
tile responsibility o f an adequately
trained individual. T h e following de-
tailed instructions to laboratory stafF,
nursing personnel, aild ,patients are
r e c o m l n e n d e d for collecting specimens
from ambulatory adults. Instructions
for patients should be both verbal and
written.
3. Tile teclmiqne for collecting a clean
voided urine specimen is relatively
simple and can be readily taught to inost
patients. A few words to decrease anxiety
and stimulate tile patient's interest will
go a long way toward establishing rap-
port and enlisting tile patient's co-
operation.
4. Extraneous bacterial contamination o f
*Reproduced with the imblisher's, l)ermission.
 SI'ECIMEN C O L L E C T I O N A N D TRANSPORT--MATSEN, EDERER
urine comes the tbllowing sources:
a. f l a i r and "oilier particulate matter
from tile perineum may fall into tile
urine or the collecting vessel.
b. Bacteria from beneath the p r e p u c e
in males am)' contaminate the stream.
c. ha females, bacteria from vaginal
secretions or from the vulva o r distal
u r e t h r a may contanlinate the re-
ceptacle o r be caught in the urinar)"
stream.
d. Bacteria from the 'bands, skin, or
clothing may enter the receptacle.
T h e cleansing procedures must
therefore remove contanlinating
organisms from the vulva, urethral
meatus, and related perineal area, so
that bacteria found in ttrine can be
assunled to have conte only f i o m tile
b l a d d e r and urethra.
5. In addition to a private cubicle with a
toilet or commode, there must be a
trained assistant who explains the pro-
cedure to die patient, makes certain that
the room is e q u i p p e d with the p r o p e r
supplies, a n d insures pronqit transport
to the laboratory o r refrigeration of the
collected Sl~2cilnen. Patients urinate
more co,nfortably if" no other licrson is
present. Generally speaking, properly
instructed patients will cleanse the penis
or vulva and p e r i n e u m at least as well as
the ntirse o r attendant. Nevertheless,
when local circumstances d e m a n d (e.g.,
the bedfast patient), the described
technique is modified to allow a trained
individual to cleanse the patient and
collect tile specimen.
6. Supplies u e e d e d for each patient should
include tile following: five sterile cotton
giluze sponges (,I by 'I itlches), r~ per cent
solution o f green soap in water (USI'),
w a r m s t e r i l e water, and a wide mouthed,
sterile, covered receptacle for the urine
specimen.
7. Before tile collection o f urine, the fol-
lo~:ing instructions ~hould lie given to
all Ipa.tients, so that they u n d e r s t a n d
what is expected o f tllem. Tile instruc-
tions are to lie repea.ted at every visit.
8. Instructions for females:
a. T h e patient is to remove her u n d e r -
garments.
b. T h e hands are to be thorougldy
washed with soap and water, rinsed,
a n d d r i e d on a disposable p a p e r
towel, o r the excess water shaken ofE
c. With one hand the patient is to
"spread herself," i.e., her labia, and
keep them continuously a p a r t until
the urine, is voided into tile cup.
d. T a k i h g ' , a s i n g l e sponge d r i p p f n g
witll soap', she is to wash h e r vulva
well, passing only from front to back,
and then she is to discard the used
sponge.
e. While the vulva is spread, she is to
repeat tile front to back wash with
the r e m a i n i n g three sponges, dis-
carding each as its use is finished.
f. This step is followed by a t h o r o u g h
washing with warln sterile water to
eliminate the possibility o f contam-
inating the specimen with soap.
g. T h e patient now voids. After the
first 20 to 25 nil. Ilas been passed, a
specimen is caugllt directly in the
sterile container without stopping
the stream. T h e cup should be held
iq such a wa)' tlmt contact with the
legs, vulva, o r clotlfing is avoided.
T h e fingers should lie kept away
from the rim and inner surface o f
o f the container.
9. Instructions for males:
Tile bands are washed as in section 8.
T h e foreskin must be completely re-
tracted and the glans penis cleansed
with liquid soap soaked sponges. Sur-
plus soap is removed with warm sterile
water. T h e patient is instructed to pass
the first portion o f urine into the toilet
bowl and then pass a . p o r t i o n o f the
renmining urine into tile specimen con~:
rather.
10. h n m e d i a t e l y after collecting, the at-
tendant covers the urine, labels it, and
refrigerates the container at 4 ~ to 6 ~ C.
withitl 10 minutes after voiding, unless
it is imnlediatel)" taken to the laboratory.
T h e patient is not to replace the top o f
the receptacle himself.
11. U n d e r no circumstances should the
urine that is to be studied bacterio-
logically be a sinnple taken fronl a
larger container, sucl! as a urinal o r
bedpaq, nor should the urine specimen
lie b r o u g h t from home. T h e urine is to
be collected directly i,ato the sterile con-
tainer that will be used for bacterio-
.logic studies and examined or refriger-
ated its rapidly as possible.
R. Wounds
1. For tile closed wound technique, see
sections A (abscesses) and E (bullae,
celhditis, petechiae and vesicles).
2. For open wounds:
a. Clean tile sinus tract o p e n i n g or tile
wound surface mechanically without
using a germicidal agent.
b. These areas frequently yield "nor-
mal'~ flora organisms. T h e r e f o r e , it
is important to attempt to cultuye
the base o r edges o f the wound.
c. Swab specimens o f sinus tracts may
lie acceptable, but aspiration material.
obtained by needle or catheterization 303
 HUMAN I'ATIIOLOGY--VOLUME 7, NUMBER 3 May 1976
is preferable. Curettings obtained
"from the lining of tile sinus tract also
provide excellent culture material.
d. For ulcerations or open wounds,
curettings or biopsy specimens are
best. These are placed into a sterile
transport container. It is best to put
these into an anaerobic transport
tube, because anaerobic cultures may
be indicated on some wounds. Here
again, swabs are least desirable. Tis-
sue or aspirated material provides
the greatest yield.
SPECIMEN T R A N S P O R T
Tile method chosen for transportation
of specimens to the laboratory shares equal
importance with the proper procurement
of the specimen for nficrobiologic exant-
ination. In order to obtain accurate and
meaningful results of microbiologic cul-
tures, each specimen must be submitted in
a sterile container and delivered to the
laboratory promptly. T h e specimen should
be inoculated on appropriate media as
soon as possible after it arrives in the
laboratory.
Frequently specintens are procured
on wooden or plastic applicator sticks tip-
ped with a variety of fibers, including
cotton, Dacron, rayon, polyester, and
calcium alginate. Pollock a5 reported that
cotton fibers contained fatty acids, wlfich
may be bactericidal for certain organisms,
and thus care should be taken when using
cotton tipped swabs. Calcium alginate
wool has been recommended as one substi-
tute? 6
Since it is not always possible to cul-
ture specimens obtained on fiber tipped
applicator sticks immediately, several
transport ntedia have been devised through
ithe years to maintain the viability of the
pathogen suspected. Stuart, Toshach, and
Patsula x7 recommended a semisolid, non-
nutrient, reductive medium tor tile trans-
port of specimens when gonococci are sus-
pected. Stuart medium contains sodium
tfiioglycollate, sodium glycerophosphate,
calcium chloride, methylene blue, and a
low concentration of agar. With Stuart
transport mediuna the specimen is ob-
tained on buffered swabs impregnated
with charcoal. Cary and Blair TM modified
the Sttmrt medium ', the major cltanges
wer~ the substitution of inorganic phos-
304
pilate for tile glycerol)hosphate and ad-
j u s t m e m of the pH to 8.4. With their
medium, Cary and Blair were able to
maintain the viability of enteric pathogens
at room temperature for as long as 49
days without overgrowth of normal fecal
flora. In 1967 Amies 19 modified the Stuart
medium using a slightly different formtda-
tion from tlmt of Cary and Blair; charcoal
was included as an integral part of the
formula rather titan being incorporated
into tile swabs as had been recommended
by Stuart.
In recent years a number of com-
mercially manutactured, sterile, dispos-
able transport units have appeared on the
market. The transport units produced by
five manufacturers have been studied in
our laboratory.2~ These included Cul-
turette, Trans-Cul, Handiswab, Securline,
and Culture Caddy. There are basic simi-
larities in the systems. Modifications oil
either the Stuart or tile Ainies medium
are used in all these transport systems, and
the applicator sticks are tipped with fibers
other than cotton. The major variation is
in the design of tile package and medium
storage compartment. It appears, however,
that despite these innovative develop-
ments in design of bacteriologic transport
systems, specimens submitted for bacterio-
logic study should be cultured at once, or if
held at room temperature they should be
cultured within four hours. Certain organ-
isms may remain viable, without a signifi-
cant increase or decrease in numbers, if
the specimen is held in a transport system
at 4 ~ C. None of the transport systems
studied was appreciably better than the
other.
Although the Stuart medium was
specifically designed for transporting
specimens for the isolation of Neisseria
gonorrhoeae, a medium dew,eloped by
Thayer and b,lartin 2~ was found to be far
superior. T h e modifications of this en-
riched chocolate medium with antibiotics
include the substitution of ristocetin and
polymyxin B with vancomycin, sodium
colistimethate, and nystatin and tile in-
corporation of a chemically defined sup-
plement.22,23 A modification of the
Thayer-Martin medium called Transgrow
was made, in which the agar and glucose
content of the medium was increased, and
trintethoprin lactate was added to inhibit
 SPECIMEN COLLECTION AND TRANSPORT--MA'rSErq Et)ERvR
growth of Proleu.~ species. 4-6 Transgrow is
commercially available (BBL), packaged
in a tightly closed, flat bottle with an ap-
propriate atnaosphere of carbon dioxide.
Transgrow should be inoculated ina-
mediately after procuring the specimen. 4
Modified Thayer-Martin medium sltould
be inoculated in a Z pattern, followed by
cross streaking with a sterile bacterio-
logic loop and incubation in an atmos-
phere of 3 to 5 per cent carbon dioxide at
35 ~ C. for 20 hours before examination or
shipment, s Transgrow bottles, on the other
hand, should be inoculated over the entire
agar surface (keeping the bottle upright
to maintain the carbon dioxide atmos-
phere) and incubated at 35 ~ C. before
shipping.
When Hosty and his associates 2~ com-
p a r e d " immediately incubated Thayer-
Martin medium with cultures held on
Transgrow, cystine trypticase agar, Amies,
Stuart, and Culturette media for 24 hours
before culturing, they found that there was
a 28, 44, a n d 7 9 per cent loss of N. gonor-
rhoeae for Amies, Sttmrt, and Cuhurette,
respectively. There was only a 7 per cent
loss of tiffs organism when cystine trypti-
case agar was used and 8 per cent loss
with Transgrow. It is important, therefore,
to keep in mind that the commercially
available transport systems that have
swabs incorporated into their design
should not be used for shipping cultures
for N. gonorrhoeae. Nasopharyngeal cul-
tures for N. meningitidis, if procured on a
swab, should be cultured immediately on
Thayer-Martin medium. Because N. menin-
gitidis is very sensitive to cold, these swabs
should never be refi'igerated.
Throat cultures for group A strepto-
cocci that must be mailed to a distant
laboratpry may be collected on polyester
swabs c'ontained in a sterile tube with a
small amount of silica gel. "~ T h e normal
flora of the throat dies, but tim group A
streptococci rentain viable for as long as
three days. Throat swabs for group A
streptococci may also be rolled onto a
piece of sterile filter paper and allowed to
air dry for three to four minutes before
being folded and packaged in a poly-
ethylene envelope for sitipment7-6'zr
Sputum specimens for Mycobacterium
tuberculosis culture should be submitted in
clean, sterile; "wide mouthed jars-with
tightly fitting covers. When gastric con-
tents are to be cuhured t"o1"this agent, the
aspirate should be neutralized with 10 per
cent sodium carbonate to a pH of 7 befi)re
processing or shipping. All other speci-
mens to be cultured for 31. tuberculosis
should be transmitted to the laboratory as
indicated for sputum cultures.
Some reference laboratories prefer to
have fecal specimens for the isolation of
Salmonella and Shigella submitted in the
buffered glycerol-saline solution of Sachs. 2s
Ill using buffered glycerol-saline, it is
recommended that 1 gm. of feces be
emulsified in 10 nal. of the preservative.
The specimen should be ship.ped in a
leak-proof, heavy glass container and
packaged according to postal regulations.
Other methods for slfipping fecal speci-
mens for enteric pathogens have also been
described. Bailey and Bynoe 2'J found that
enteric pathogens survived well when
feces was spread thinly over tilter paper
and allowed to dry. These specimens
could be safely packaged in polyethylene
envelopes. The Cary and Blair medium ~s
and its usefidness for submitting fecal
cultures have already been described.
Body fluids, such as cerebrospinal
fluid and joint fluid, should be submitted
to the laboratory in a sterile container and
cultured promptly. Since N. meningitidis,
which is sensitive to reduced temperatures,
may be the etiologic agent causing the
meningitis, cerebrospinal fhfid should not
be refrigerated. Fluids fi'om b o d y sites
other than cerebrospinal lluid and joint
lluid may be refrigerated if it is not pos-
sible to cuhure the specimen immediately.
Urine, tot example, may be kept at 4 ~ C.
for five days or more without reducing the
quantity of bacteria present significantl.y,a~
Under routine orcumstances, urine
specimens subnfitted for quantitative cul-
ture should be cultured within 30 to 60
minutes after collection or stored at 4 ~ C.
during transportation, or until they can
be cultured; if these refrigerated specimens
cannot be cultured within 18 to 24 hours,
another specimen should be requested.
When anaerobic bacteria are sus-
pected of being the etiologic agents
causing an infection, material for culture
must be introduced at once into sterile col-
lection tubes that have been flushed out
("gassed out") with oxygen-free carbon
305
 IIUMAN I'ATHOLOGY-VOLUME 7, N U M B E R 3
dioxide or nitrogen. Material aspirated
with a needle and syringe is preferable;
material p r o c u r e d in this way can be sealed
fi'Oln the air for delivery to the laboratory
by r e m o v i n g the needle and replacing the
needle cap o r b)' i n t r o d u c i n g the material
t h r o u g h the r u b b e r d i a p h r a g m o f a
"gassed out" vial. I f aspirated material
c a n n o t be obtained and it is f o u n d neces-
sary to obtain the specimen on a swab, it is
intportant to p r o c u r e the specimen with a
swab that has been p r e p a r e d in a "gassed
Otlt" tribe.
Special containers o f anaerobic speci-
mens that meet these r e q u i r e m e n t s are
co,nntel'ciall)" available.* T h e s e containers
have Hn indicator so that if anaerobic con-
ditions are lost, this fact will be recognized.
Specintens for anaerobic cuhttre shottld be
t r a n s p o r t e d to the laboratory at once;
every effort shoukl be m a d e to make cer-
tain that no afore than 10 to 15 minutes
elapse between the time o f procuremet~t
and the inoculation o f ntedia. T h e s e
general rules, as well as m o r e specific
information, are available in manuals for
anaerobic bacteriology 3~-aa and in the
article by RosetdJlatt ill the Mal'ch 1976
issue o f H)tmat, Palholo,q.'. It should be
rementl)ered if" these special p r o c e d u r e s
for transmitting anaerobic cultures to the
laboratory are not available that u n d e r no
circt,ntstances shottld specime,~s fbr anaer-
obic cttltttre e v e r be refrigerated, sttch as
w o u n d cttltttres procttred in a less optimal
matmel'.
ACKNO~,VLEDGMENTS
T h e authors wish to gr,ttefully ac-
knowledge the excellent secretarial as-
sistance o f Debbie Guevara and Glenna
IB)'tendorp.
*Scott l,aboratorics Inc., Fiskville, R. I.
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l)cl)artluent of l'athology
University of Utah College of Medicine
Salt Lake Cit)'. Utah 8t132 (Dr. Matscn)
307