Collection Of Upper Respiratory Tract Specimens

1. Oropharyngeal (OP) and Nasopharyngeal (NP) swabs

o Optimal timing : spesimen sebaiknya diambil 3 hari setelah gejala
awal muncul dan tidak sampai lewat 7 hari. Idealna sebelum
dibaerikan terapi antibiotik.
o Swab types : menggunakan dacron atau rayon swab yang steril
dengan plastic shaft atau jika ada dengan flocked swabs. Tidak
menggunakan wooden sticks, karna bisa aja mengandung
substansi2 yang menghambat beberapa molecular assays.
o Collecting the OP swabs : masukkan swab ke posterior faring dan
area tonsil. Gosokkan/sapukan swab di ke tonsil dikedua sisi dan
posterior orofaring dan usahakan supaya tidak terkena lidah, gigi,
dan gusi.
o Collecting the NP swabs : masukkan batang kawat yang fleksibel
melalui hidung ke palate (paralel, tidak upwards) sampai mentok.
Lalu sapukan dan putar swabnya lalu tunggu dulu beberapa detik
supaya sekresinya terserap ke cottonnya.
o Specimen handling : letakkan NP dan OP swabs dengan segera ke
vial steril yang tidak mengandung antibiotik. Lalu kasih identitas.
Jika spesimen akan diperiksa dalma waktu 48 jam setelah collection,
maka simpan spesimen di suhu 4 0C lalu kirimkan. Hindari supaya
spesimen tidak membeku dan tidak meleleh juga.
2. Nasopharyngeal wash/aspirate
Biasanya untuk mengumpulkan spesimen pda pasien anak berusia <5
tahun.
o Optimal timing: spesimen sebaiknya diambil 3 hari setelah muncul
gejala dan tidak lebih dari 7 hari. Baiknya sebelum diberi antibiotol.
(=swab)
o Specimen collection : minta pasien duduk dengan dagu agak
diangkat dan sedikit kebelakang. Masukkan 1ml-1.5ml
nonbacteriostatic saline (ph 7) ke salah satu lubang hindung. Flush
a plastic catheter or tubing with 2ml-3ml saline. Masukkan tube nya
ke nostril paralel to palate. Aspirasi sekresi nasofaringeal, dan jika
diperbolehkan, maka lakukan hal yang sama pada nostril yang
satunya.
o Specimen handling: sama dengan handling pada swabs.

Collection of lower respiratory tract specimens

1. Sputum, tracheal aspirate, bronchoalveolar lavage (BAL) fluid, pleural fluid
Selain pengambilan sputum, pengambilan sampel yang lain duilakukan
pada pasien dengan penyakit yang jauh lebih parah, atau pada pasien2
yang dirujuk ke rumah sakit, dan yang fatal.
o Optimal timing: dapat dilakukan kapanpun saat aa indikasi klinis, tp
idealnnya sebelum diberikan terapi antomikroba.
o Specimen types: sputum, tracheal aspirate, BAL fluid, pleural fluid,
ataupun lung biopsy.
o Specimen collection
 BAL fluid, tracheal aspirate, pleural fluid
Kumpulkan spesimen ke kontainer steril. Sentrifugasi
Sputum
Edukasikan pasien tentan perbedan sputum dan sekresi oral.
Minta pasien untuk berkumur dengan air bersih, lalu batuk
untuk mengeluarkan deep sputum secara langsung ke
kontainer steril yang kering.
o Specimen handling: kasih label kontainernya dengan identitas pasien.
Simpan di suhu ruangan jika spesimennya sudah fix. Tp kalo blom fix di suhu
4C di lemari pendingin. Jangan sampai membeku atau meleleh.

Untuk prosedur lebih detailnyaa

1. Nasal Culture

Equipment

o ESwab,
o mini-tip collection kit

Insert the swab into a nares until resistance is met at the level of the turbinate.
Rotate the swab against nasal mucosa. Break swab off into the transport tube
containing 1.0mL of liquid media, send to laboratory.

2. Nasal Smear for Eosinophils

Equipment

One glass slide (available from Micro-Processing in the laboratory)

waxed paper or plastic wrap
ESwab mini-tip collection kit (green capped) or nasal aspirator
Gloves

Obtain mucous sample by one of three methods:

1. Have the child blow his nose into waxed paper or plastic wrap.
2. Insert nasal aspirator into one side of the nose and obtain specimen.
3. Use NPH wire swab: Place the swab near the septum and on the floor of
the nose. Keep the swab in place for 30 seconds and then remove.

Apply a generous smear of mucous by rolling swab or specimen onto a glass

slide. Avoid rubbing swab against the slide because friction increases the
eosinophil count. Allow to dry.

Place the dry slide into a cardboard slide envelope. Tape the envelope shut with
clear tape and send to the Laboratory.
 3. Nasal Wash for Rapid RSV or Rapid Influenza, Adenovirus, or
Parainfluenza virus antigen detection or viral culture.

Equipment

o Sterile normal saline (NS) for irrigation

o luki-trap
o suction catheter
o gloves
o M4 (VIRAL TRANSPORT MEDIA-VTM)medium

Prosedur

1. Have the patient clear any nasal congestion before obtaining the
specimen by blowing his nose or by nasal suctioning.
2. Connect the suction catheter to the luki-trap and then connect the luki-
trap to wall suction.
3. "Wash" for nasal cells by irrigating both nares with 0.5 mL normal saline.
Suction each nares to obtain cells not mucus.
4. Rinse the suction catheter with 1.0-1.5 mL normal saline which helps
move the specimen from the suction catheter into the luki-trap.

Place 0.5mL of saline wash into M4 (VIRAL TRANSPORT MEDIA-VTM)medium and

send both the nasal wash and dilute M4(VIRAL TRANSPORT MEDIA-VTM)
specimens to the laboratory.

If using a bulb syringe,empty contents of the bulb syringe directly into sterile
container. Place 0.5 mL into M4 medium for back-up culture and send both the
nasal wash and the M4 diluted specimen on ice to the laboratory for testing.

NOTE: Do not add M4 viral medium to the specimen. The M4 (VIRAL TRANSPORT
MEDIA-VTM) must be sent on ice. Send directly to Laboratory.

Special Instructions The saline wash specimen is used for the direct antigen
assay. A portion of the specimen must be placed in M4 (VIRAL TRANSPORT
MEDIA-VTM) as it protects the viability of the virus for a back up viral culture
should the direct antigen assay be negative.

4. Nasopharyngeal (NPH)

Equipment

o Rapid RSV, Rapid Influenza, Adenovirus, Parainfluenza virus

o 2 NPH flocked swabs
o M4 (VIRAL TRANSPORT MEDIA-VTM)

NPH culture for N. meningitis or other bacteria ESwab minitip collection

kit(green capped)
NPH for Bordetella pertussis NPH flocked swab or NPH wire swab (green
capped)
Do not place in M4 (VIRAL TRANSPORT MEDIA-VTM))

Specimen Collection (NPH culture and/or B. Pertussis)

1. Hold the child securely. Remove a swab from the culturette. Slide the swab
into the nares to the posterior nasopharynx.
2. Leave swab in place 20-30 seconds or as tolerated. Withdraw the swab.
3. Repeat the process on the other nares with a second swab. Replace the
swab into the culturette. For pertussis PCR, only one swab is used to
culture both nares.

Specimen Collection (Rapid RSV, Rapid Influenza, Adenovirus, and Parainfluenza

virus)

1. Two flocked swabs should be collected.

2. Slide flocked swab into the nares to the posterior nasopharynx (at base of
throat). Rotate the swab and allow 5-10 seconds for liquid to absorb.
3. The first swab can be placed back into the culturette and sent for rapid
testing.
4. Repeat collection with the second flocked swab. The second flocked swab
is broken off into M4 (VIRAL TRANSPORT MEDIA-VTM). This specimen will
be used for the back-up respiratory virus isolation culture if the rapid test
is negative

5. Sputum

Equipment

o sterile cup (clear plastic screw cap)

prosedur

1. Collect specimen resulting from a deep cough into sterile cup. Notify the
physician if unable to obtain specimen.
2. A specimen may be obtained by sterile suction technique using a Luki-trap by
passing a sterile suction catheter along floor of nose to nasopharynx. When
the patient coughs, suction the specimen into trap. Obtain specimen by
suction only with physician order.
3. Twenty-four hour sputum collections are not recommended for culture. If
possible, have the patient rinse mouth and gargle with water prior to sputum
collection. Instruct the patient not to spit saliva or postnasal discharge into
the container. A gram stain smear result on sputum specimens will show
epithelial cells. A sputum specimen containing >25 epithelial cells per low
power field has been contaminated with oropharyngeal secretions during
collection, indicating a poor quality specimen for culture. Laboratory may
indicate the need for specimen recollection. Laboratory evaluates the
 specimen for the predominant pathogenic morphotype if the physician
requests a culture on available specimen.
4. Sputum (acid fast bacilli or mycobacteria) First morning sputum samples of
3.0-5.0 mL is optimal for possible recovery of mycobacterial organisms. Acid
fast stain performed on all sputum specimens.

6. Tracheostomy Culture

Equipment

o Luki trap
o sterile gloves
o sterile suction catheter
o Sterile normal saline
o Luki trap tubes
o disposable clean graduated cup
o Audit trail and label

Prosedur

1. Connect suction catheter to rubber tubing side on aspirating trap and

connect the other side of aspirating trap to the tubing from wall suction.
2. Draw up the appropriate amount of preservative free sterile saline for
irrigation into a syringe. Under 1 year: 0.5mL; 1-3 years: 1 mL; 3 years and
older: 2mL. Pour the remaining normal saline for irrigation into graduated
cup.
3. Suction the patient by putting on sterile gloves, instilling saline from
syringe (without needle), suction patient while keeping the aspirating trap
in a vertical position.
4. If the specimen is in the catheter, suction a small amount of normal saline
for irrigation from graduated cup to move secretions into aspirating trap.
Disconnect aspirating trap from suction tubing and catheter. Connect
tubing on aspirating trap to other side of the trap.

7. Throat (Pharyngeal)

Equipment

o Tongue depressor
o Group A antigen test (rapid) and culture: Rayon dual swab
o Throat culture for GC only: ESwab collection kit
o Routine culture(Haemophilus influenza, Strep pneumoniae): ESwab
collection kit
o NOTE: Do not obtain throat cultures if the epiglottis is inflamed. Sampling
may cause serious respiratory obstruction.

Prosedur
 1. Remove the swab from the collection kit package.
2. Depress tongue gently with tongue depressor.
3. Visualize throat area for obvious purulent areas. Swab between the
tonsillar pillars and behind the uvula. Avoid touching the cheeks, tongue,
uvula or lips.
4. Swab back and fourth across the posterior pharynx, tonsillar area and any
inflamed or ulcerated areas to obtain sample.

Transport
For Group A Strep antigen test and Strep culture: Replace the two swab
specimens in the culturette. When group A Strep antigen (rapid) test and culture
are ordered, the antigen (rapid) test will be performed first. If the result is
positive, the culture will not be processed and the patient will not be charged for
the culture. If the antigen (rapid) test is negative, a culture should be ordered
and completed.
For throat GC culture and routine culture: the swab is broken off into the tube
containing 1.0mL liquid media and sent to the laboratory.