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Microbiology / Infectious Disease Specimens

Specimen Containers
Preparation & Shipping of Infectious Agents
Labeling
Test Request Forms
Transport
Result Reporting
Reportable Diseases
Basic Concepts for Collection
Specific Guidelines for Specimen Collection
Abscess
Blood
Body Fluids, Sterile (except urine and cerebrospinal fluid)
Bone Marrow
 
Bronchial Brush/ Washing/ Lavage
Bullae, Vesicles
Cellulitis
Catheters
Cerebrospinal Fluid
Cervix (Endocervix) for Culture
Cervix (Endocervix) for HPV Testing
Chlamydia/Gonorrhea
Cutaneous (fungus only)
Ear
Endometrium
Eye
Nares: MRSA Screen
Nasopharyngeal Washings (RSV, Influenza A & B or Virus Culture)
Nasopharyngeal Swab
Nose
Prostate
Skin
Sputum
Stool, Feces
Throat
Tissues
Urethra
Urine
Vaginal
Wounds
Viral Transport Media (M4)
 

SPECIMENS -- GENERAL REQUIREMENTS

Specimen Containers

Shipping containers, a sterile specimen container, transport media, swabs, and test-specific collection and transport kits are available from Deaconess Regional Lab. Refer to the Infectious Diseases Collection and Transport Media chart at the end of this section for guidelines. Specimens are acceptable for processing only when collected and submitted in the appropriate container. Specimen containers must be securely tightened to eliminate any leakage. Use of collection and transport containers that are past the expiration date is unacceptable.

Preparation and Shipping of Infectious Agents

Microorganisms submitted for additional testing (confirmatory, identification, susceptibility) must be actively growing in pure culture. Submit on appropriate agar slants or in transport media. Use screw-capped tubes, which seal well.

Labeling

Microbiology / Infectious disease specimens are unacceptable unless each specimen is appropriately labeled. The specimen must be identified by the patient’s full name, the source of the specimen and the date/time collected.

Test Request Forms

Microbiology / Infectious disease specimens must be accompanied by a completed test request form or electronic order. The source of the specimen is required. Information regarding the patient, collection time and date, clinical history, symptoms and diagnosis, antimicrobial therapy, and any suspected organism(s) is essential for the optimal and appropriate processing of the specimen. If an organism is sent for identification, the suspected organism must also be indicated.

Transport

It is critical that all specimens are transported as quickly as possible. Prompt processing minimizes loss in viability of potential pathogens and ensures a more accurate appraisal of the quantity of different flora present.

Result Reporting

Preliminary results are issued as soon as accurate data is available. Final results are generated at the completion of the culture. Preliminary results will be called to the physician or unit on positive, significant stain or culture (e.g., blood, CSF, sterile body fluid) results. Significant final results will be phoned.

Reportable Diseases

“Reportable Disease” as designated by the Indiana State Board of Health denotes laboratory findings demonstrating evidence of infections, or reportable communicable diseases on the patient report.

Deaconess Hospital Laboratory forwards patient report of “Reportable Disease” to the Indiana State Board of Health weekly.

It is the responsibility of the physician to follow applicable local and state requirements for reporting.

SPECIMENS - SPECIFIC COLLECTION GUIDELINE

The proper collection of a specimen for culture is the most important step in the recovery of pathogenic organisms responsible for infectious disease. A poorly collected specimen may lead to failure in isolating the causative organism(s) and result in the recovery and subsequent treatment of contaminating organisms.

Basic Concepts for Collection

  • Collect the specimen from the actual site of infection, avoiding contamination from adjacent tissues or secretions.
  • Collect the specimen at optimal times (for example, early morning sputum for AFB culture).
  • Collect a sufficient quantity of material.
  • Use appropriate collection devices: sterile, leak-proof specimen containers. Use appropriate transport media (Amies or Stuart’s for bacterial culture, Cary-Blair for stool culture, M4 for viral and Chlamydia cultures).
  • Whenever possible, collect specimens prior to administration of antibiotics or antivirals.
  • Properly label the specimen and complete the test request form. The source of specimen is required.
  • Minimize transport time. Maintain an appropriate environment between collection of specimens and delivery to the laboratory.
  • If appropriate, decontaminate the skin surface. Use 70-95% alcohol (ALC) and 1-2% tincture of iodine (TIO) or ChloraPrep to prepare the site. Allow a contact time of two minutes (TIO) or 30 seconds (ChloraPrep) to maximize the antiseptic effect. CAUTION: Do not use ChloraPrep on infants less than 2 months.

Specific Guidelines for Specimen Collection

Specimens collected at Deaconess Hospital should be transported at ambient temperature within 1 hour of collection. CSF, body fluids, and bone marrow should be transported immediately.

For specimens collected outside Deaconess Hospital, follow transport and stability guidelines for the specific test.

Abscess

  • Decontaminate the surface with 70-95% ALC and 1-2% TIO or ChloraPrep.
  • Collect purulent material aseptically from an undrained abscess using a sterile needle and syringe. Open miliary abscesses with a sterile scalpel and collect the expressed material with a sterile needle and syringe.
  • Expel air from the syringe, remove the needle and cap the syringe. Alternatively, transfer 5-10 mL of the aspirated material to sterile specimen container. Transport immediately.
  • Swabs are of limited value due to the small amount of material, possible inadequacy of the sample, and their tendency to dry easily. Swabs are not recommended for mycobacterial or fungal culture

Blood

  • Culture bottles:
    • Aerobic/Anaerobic: Green and Orange capped blood culture bottles.
    • Fungus: Green capped blood culture bottle.
    • Mycobacteria (AFB): Black capped blood culture bottle (obtain from Microbiology).
  • Clean hands before drawing blood cultures. Use alcohol hand gel or antiseptic containing soap.
  • Identify the patient.
  • Position patient.
  • Pop tops off bottle(s) and wipe the rubber septum with 70% alcohol pad.
  • Apply tourniquet; ensure the patient’s hand is closed and select the vein.
  • Put on gloves.
  • Cleanse the venipuncture site.
    • Use 70% alcohol pad to clean in a circular area over the venipuncture site. Using strokes from inside to outside for a diameter of 2 to 3 inches.
    • Crush the capsule of ChloraPrep. Clean with ChloraPrep using a back and forth scrubbing motion. Scrub 30 seconds. Friction is required to dislodge the five layers of epithelial cells with harbor skin contaminants.
    • Allow ChloraPrep to dry 30 seconds.
  • Perform the venipuncture using a sterile needle and syringe; once the blood begins to flow, request patient to open hand.
  • Place gauze pad over the puncture site.
  • Remove needle, activating any safety feature according to manufacturer’s instructions.
  • Apply pressure to the venipuncture site making sure bleeding has stopped and then bandage the site.
  • Inoculate blood into bottles. The volume of blood collected is critical. Inoculate the bottles without changing needles.
    • Aerobic (green cap): Inoculate 8-10 mL of blood.
    • Anaerobic (orange cap): Inoculate 8-10 mL of blood.
      Minimum is 5 mL of blood for each bottle.
    • Pediatric (green cap): Inoculate 0.5-4 mL of blood.
    • Fungal (green cap): Inoculate 8-10 mL of blood.
    • Mycobacteria (AFB) (black cap): Inoculate 3-5 mL of blood.
  • Wipe the tops of bottles with clean alcohol pads if blood remains on the rubber septum after inoculation.
  • Label the blood culture bottles with patient identification (top to bottom of bottle) with patient’s name covering the 5 mLs marks on the bottle.
  • Document on the label the following information:
    • Total volume drawn
    • Initials and identification (employee number) of person drawing.
    • How the culture was drawn.
      1. Venous
      2. Arterial
  • Transport within one hour. Hold at room temperature or incubate at 35º C if transport must be delayed.

Body Fluids, Sterile (except urine and cerebrospinal fluid)

  • Prepare the skin as for blood cultures.
  • Collect the fluid using a sterile needle and syringe.
  • Submit fluid or EDTA tube for analysis as follows:
    1. For aerobic and anaerobic organisms, collect 10 mls or greater in sterile container.
    2. For viral isolation, send 3 mL or less fluid in viral transport medium or a sterile container.
    3. If tuberculosis or fungal infections are suspected, larger volumes, (50-100 mL) may be required.  Collect in sterile container.
  • Immediately transport all specimens at ambient temperature.

    Bone Marrow

    • Physicians should wear gowns, masks, and gloves during specimen collection.
    • Prepare skin as for blood cultures.
    • Drape the surrounding skin with sterile linen.
    • Aspirate the marrow percutaneously using a sterile needle and syringe.

    Transfer 3-5 mL to a sterile tube containing sodium heparin (green top) for cultures or molecular tests.

    Bronchial Brush/Washing/Lavage

    • Descriptions of the methodology are readily available in the literature.
    • Transport in a sterile container at 2-8º C for cultures, or frozen for molecular tests.

    Bullae, Vesicles

    • Cleanse the skin as for blood cultures.
    • Aspirate the fluid/purulent material using a sterile needle and syringe.
    • If an aspirate is obtained, place in appropriate viral or bacterial transport.
    • If no material is obtained, unroof vesicle or bullous lesion and use a swab to collect cells from the base of the lesion. Place in appropriate viral or bacterial transport media.

    Cellulitis

    Swabs and leading edge aspirates fail to yield etiologic agents in the majority of cases. If an unusual organism is suspected, a leading-edge (advancing margin) punch biopsy is the recommended specimen of choice.

    Catheters

    • For short catheters (2-3 inches)
      • Decontaminate the skin at the catheter site.
      • Aseptically remove the catheter. Cut the catheter at the skin interface point using sterile technique. Place the catheter segment in a sterile, wide-mouth container.
      • Transport immediately at ambient temperature.
    • For long catheters (8-24 inches):
      • Decontaminate the skin at the catheter site.
      • Aseptically remove the catheter. Submit two segments for analysis. Cut a 2-inch segment of the catheter that was within the blood vessel, using sterile technique. Place the segment in a second sterile, wide-mouth container. Cut a second 2-inch segment of the catheter from the skin interface. Place the segment in a second sterile, wide-mouth container. Label the containers appropriately.
      • Transport immediately at ambient temperature.

    Cerebrospinal Fluid

    • Physicians should wear gowns, masks, and gloves to collect the specimen. Because an open tube is held to collect the fluid, other personnel should stand away or wear masks in order to avoid respiratory contamination.
    • Decontaminate the skin with 1-2% TIO or ChloricPrep, followed by 70-90% ALC using an increasingly outward circular movement.
    • Drape sterile linen over the skin surrounding the puncture site.
    • Insert the needle. Collect the fluid into three sterile leak-proof tubes. Collect an adequate volume of fluid as recommended.
      Culture Type Amount Recommended
      Bacterial > 1mL
      Fungal 8-10 mL
      Molecular >1 mL
      Mycobacterial 8-10 mL
      Viral >2 mL
    • Cap the tubes tightly. Submit the third tube for culture to reduce the possibility of contamination due to skin flora. Transport immediately.
      • For molecular (PCR) analysis transport specimens immediately.
      • For viral culture, if volume is greater than 3 mL, refrigerate and transport at once. If volume is less than 3 mL, add fluid to M4 viral transport media and transport at 2-8ºC.
      • Transport other cultures at ambient temperature.

    Cervix (Endocervix) for Culture

    • For sexually transmitted disease testing, refer to Chlamydia/Gonorrhea.
    • Place the patient in the lithotomic position.
    • Prepare the speculum, avoiding the use of a lubricant other than warm water.
    • Insert the speculum and visualize the cervical os.
    • Remove excess mucus with a cotton ball.
    • Insert a Dacron swab into the cervical os, rotate gently, and allow to remain for 10 to 30 seconds.
    • Remove swab and place in transport medium.
    • Transport at ambient temperature or 2-8º C for viral cultures.
    • Vaginal cultures, in general, do not produce meaningful results and are not recommended, except for group B streptococcal screen.

    Cervix (Endocervix) for HPV Testing

    Liquid-based specimens may be collected and transported (ThinPrep vial).  See Pap smear collection instructions.

    Chlamydia/Gonorrhea

    • Chlamydia/gonorrhea testing is available by several methods.  A DNA amplification method, which detects Chlamydia trachomatis/Neisseria gonorrhoeae nucleic acid in urogenital specimens, is the preferred diagnostic method.
      Culture for Chlamydia trachomatis or Neisseria gonorrhoeae is the method of choice in cases of treatment failure, suspected sexual abuse and for non-genital sources.
    • Specimens for all of the above can be collected following the procedures below.  Test-specific collection and transport kits are required for DNA amplification tests.
      Urine may be collected for Chlamydia/ gonorrhea testing.  See instructions under Urine.
      1. Females (endocervical
        1. Place patient in the lithotomy position.
        2. Insert speculum and visualize the cervical os.
        3. Remove excess mucus from cervical os and surrounding mucosa using the large swab provided in the kit.  Discard this swab.
        4. Insert second swab from kit, 1 to 1.5 cm into endocervical canal.
        5. Rotate swab for 30 seconds in endocervical canal to ensure adequate sampling.
        6. Withdraw swab carefully, avoiding any contact with vaginal mucosa.
        7. Place swab into the test-specific transport tube.
        8. Break swab shaft to fit tube, if required.
        9. Cap tube tightly.
        10. Transport at 2-8°C.
        11. For culture, inoculate sample as specified below.
      1. Males (urethral)
        1. Do not allow patient to urinate for at least one hour prior to collection.
        2. If purulent discharge is present, collect discharge directly on swab.
        3. If no discharge is present, insert smaller swab 2-4 cm into urethra.  Rotate gently to ensure contact with all urethral surfaces.  Leave inserted for two to three seconds.  Rotate gently while withdrawing swab.
        4. Place swab into the test-specific transport tube.
        5. Break swab shaft to fit tube, if required.
        6. Cap tube tightly.
        7. Transport at 2-8°C.
        8. For culture, inoculate sample as specified below.
        9. For culture of N. gonorrhoeae, use calcium alginate or Dacron swabs for specimen collection.  Cotton fibers contain fatty acids that are inhibitory to the gonococcus.  Avoid swabs with wooden sticks.
        10. Transport swab at ambient temperature within 24 hours.
        11. For male patients, also submit a slide of urethral material for Gram stain. 
        12. Rectal culture:
          1. Moisten a swab with sterile water and insert the swab into the anal canal just beyond the anal sphincter.
          2. Allow 10-30 seconds for absorption of the organisms onto the swab.
          3. Withdraw swab gently and inoculate plate as described above.
          4. Stool is not an acceptable specimen for gonorrheal culture.
  • Cutaneous (fungus only)

    • Hair
      • Scrape the scalp with a blunt scalpel or sterile brush.
      • Place specimen in a dry sterile container.
      • Transport at ambient temperature.
      • The following specimens are also acceptable:
        1. Hair stubs.
        2. Contents of plugged follicles
        3. Skin scales
        4. Hair plucked from the scalp with forceps
        Note: Cut hair is NOT an acceptable specimen.
    • Nails
      • Cleanse the nail with 70-95% ALC.
      • Remove the outermost layer by scraping with a scalpel or sterile brush. Scrap from distal to proximal end.
      • Collect material from 10-15 scrapings of the nail.
      • Place specimen in a dry, sterile container.
      • Transport at ambient temperature.
      • The following specimens are also acceptable:
        1. Clippings from any discolored or brittle parts of nail.
        2. Deeper scrapings and debris under the edges of the nail.
    • Skin
      • Cleanse the skin with 70-95% ALC.
      • Collect epidermal scales with a scalpel or sterile brush, at the active border of the lesion.
      • Place specimen in a dry sterile container.
      • Transport at ambient temperature.

    Ear

    • External ear cultures are processed as superficial wounds.
    • Middle ear fluid will be processed as a sterile body fluid. If the diagnosis is otitis media, the specimen of choice is middle ear fluid collected by tympanocentesis.

    Endometrium

    • Place the patient in the lithotomy position.
    • Insert speculum and visualize the cervical os.
    • Place a narrow-lumen catheter within the cervical os.
    • Insert the tip of a culture swab through the catheter and collect the endometrial specimen. This method prevents touching the cervical mucosa and reduces the chance for contamination.
    • Place the culture swab into bacterial transport media and transport at ambient temperature or at 2-8º C for viral cultures.

    Eye

    • Cleanse the skin around the eye with a mild antiseptic.
    • Purulent conjunctivitis:
      • Collect purulent material with a swab.
      • Place the swab into transport media and transport at ambient temperature or 2-8º C for viral cultures.
    • Corneal infections:
      • Swab the conjunctiva as described above.
      • Collect multiple corneal scrapings and inoculate directly onto bacterial agar media (chocolate agar, potato dextrose agar and sheep blood agar) or into viral transport media.
      • Scotch tape plates on opposite sides to keep securely closed during transport.
      • Transport agar plates at ambient temperature or 2-8º C for viral cultures.
    • Intraocular fluid:
      • Collect fluid by surgical needle aspiration.
      • Transport bacterial cultures at ambient temperature, and viral cultures at 2-8º C.

    Nares:  MRSA Screen

    • Wear gloves.
    • Open Culture Swab Plus (red cap).
    • Remove cap from tube.  Insert both swabs into transport system to moisten the swabs.
    • Instruct patient to tilt head slightly back or lie in a prone position.
    • Carefully insert both swabs into the patient’s nostril.  (Children < 10, remove 1 of the swabs from red cap).  The swab tip must be inserted until the fibers are no longer seen or up to one (1) inch.
    • Gently closer nostril and roll swab 5 times.  Release nostril.  Remove swabs.
    • Insert swab into other nostril and repeat the process.  Return swabs to transport container.

    Nasopharyngeal Washings (RSV, Influenza A & B or Virus Culture)

    Flocked swabs and Universal Transport Media (UTM) are an alternative to NP washings.

    • Insert sterile suction catheter inside the nares about 2 cm.
    • Aspirate the secretions into 1-3 mLs sterile saline in a sterile collection trap.
    • Transport at 2-8 ° C.

    Nasopharyngeal Swab

    • Seat the patient comfortably and tilt the head back.
    • Insert a nasal speculum.
    • Insert a nasopharyngeal swab (on a malleable wire) through the speculum into the nasopharyngeal area.
    • Rotate the swab gently and allow to remain for 20-30 seconds.
    •  Remove the swab and place in a non-growth promoting transport medium (such as the CultureSwab Plus container from which the original swab has been removed). Place swab in M4 media for viral cultures.
    • Transport at ambient temperature or 2-8°C for viral cultures.


    Nose 

    • Collect anterior nares culture with a regular cotton swab. In small children, use a nasopharyngeal swab to facilitate collection.
    • Transport at ambient temperature.
      Note: This is an inappropriate specimen for anything other than assessment of staphylococcal or streptococcal colonization.


    Prostate

    • Cleanse the glans with soap and water.
    • Obtain prostate fluid by digital massage through the rectum.
    • Collect fluid using a sterile swab.
    • Transport at room temperature.
    • Alternatively, a urine specimen obtained immediately before and after massage may be submitted for culture.

    Skin

    Refer to Abscess; Bullae, Cellulitis, Vesicles; and Wounds.
     

    Sputum

    • Assure patient cooperation to get an adequate specimen. Deaconess Hospital Laboratory evaluates specimens for adequacy. The number of epithelial cells and white cells are used to grade specimen quality. Cultures on specimens of poor quality are terminated following the gram stain.
    • Instruct the patient as follows:
      • Rinse mouth with tap water to remove food particles and debris.
      • Have patient breathe deeply and cough several times to obtain a deep specimen.
      • Patient should expectorate into dry, sterile container.
    • If patient is unable to produce sputum, induce using saline nebulization.
    • Consult respiratory therapy for assistance.
    • Transport immediately at ambient temperature. Refrigerate if a delay of more than one hour is anticipated.


    Stool, Feces

    • Collect specimen in a stool collection container. Do not submit feces contaminated with urine or toilet water.
    • No more than one stool per day for each test is recommended. This allows the laboratory time to either complete testing or have preliminary results before additional stool tests are ordered.
    • Transfer specimen into an appropriate preservative. (Refer to the Fecal Preservation/Transport Media chart at the end of this section.)
    • Transport at ambient temperature or 2-8?C for viral cultures, Clostridium difficile, rotavirus, fat, pH and reducing substances.


    Throat

    • Use a cotton, Dacron, or calcium alginate swab.
    • Use a tongue blade and a strong light source to ensure good visualization.
    • Reach behind the uvula and swab:
      • both tonsillar fauces
      • the posterior pharynx
      • any ulceration, exudate, lesion or area of inflammation
    • Place the swab into the transport media and transport at ambient temperature or 2-8?C for viral cultures.


    Tissues

    • Tissue collection is an invasive procedure and requires surgery by a trained physician.
    • Collect tissue aseptically. Include material from both the center and the edge of the lesion.
    • Place the specimen in a sterile container.
    • Transport immediately at ambient temperature. For virology cultures, transport at 2-8?C in viral transport media (M4).
    • Do not submit tissue in formalin.


    Urethra

    Refer to Chlamydia/Gonorrhea.


    Urine

    • Instructions for female patient to collect midstream urine for bacterial culture:
      • Remove undergarments.
      • Open 2 towelletes and place on clean surface.
      • Wash hands thoroughly with soap and water, rinse, and dry them on a disposable paper towel or shake off excess water.
      • Open sterile cup. Place lid aside. Do not touch the inside of the cup.
      • Spread labia, with one hand, and keep them continuously apart.
      • Wash front to back with a moist towelette.
      • Take the open sterile cup in the other hand without touching the rim or inner surface of the cup.
      • Void 20 to 25 mL into the toilet and catch a portion of the rest of the urine in the container without stopping the stream. Do not touch the legs, vulva, or clothing with the cup.
      • Place the lid on the cup.
    • Instructions for male patients to collect midstream urine for bacterial culture:
      • Wash and dry hands.  Open towellete and place on clean surface.
      • Retract the foreskin completely. Clean urethra area with moist towelette.
      • Void 20 to 25 mL into the toilet and catch a portion of the remaining urine in the cup without stopping the stream. Do not touch the cup with the penis.
      • Place the lid on the cup.
    • Voided urine for nucleic acid amplification tests (Chlamydia/Gonorrhea):
      • Patient must not have urinated during the previous two hours.
      • Collect the first 10 to 20 mL of the urine stream in a clean, empty plastic cup. Patient does not clean prior to specimen collection.
      • Place the lid on the cup. Cup must have plastic lid. Metal lids are unacceptable.
    • Suprapubic aspiration:
      • This is not a routine technique and is best performed by an experienced individual. Descriptions of the method are readily available in the literature.
      • These specimens are acceptable for anaerobic culture.
    • Indwelling catheter urine:
      • Do not collect urine from the drainage bag because growth of bacteria outside the catheter may have occurred at this site.
      • Clean the catheter with an alcohol pad.
      • Use a sterile needle and syringe to puncture the tubing. Aspirate the urine directly from the tubing.
      • Transfer the urine to a sterile specimen container.
      • Urine catheter tips for culture are not acceptable.
    • Specimen handling:
      • Label the container immediately and refrigerate at 2-8?C within 10 minutes of collection if the specimen cannot be delivered to DHRL within 1 hour.


    Vaginal

    Vaginal cultures do not often produce meaningful results. Group B Streptococcus will be ruled out on all vaginal cultures. If gonorrhea is suspected, testing by nucleic acid detection is recommended. Refer to Chlamydia / Gonorrhea. If yeast infection is suspected, a yeast culture should be ordered.


    Wounds

    • For closed wounds, refer to Abscess and Bullae, Cellulitis, Vesicles.
    • For open wounds:
      • Clean the sinus tract opening of the wound surface mechanically, without using a germicidal agent, to remove as much of the superficial flora as possible.
      • Attempt to culture the base or edges of the wound to avoid collecting “normal flora” organisms.
      • The following are preferred specimens for sinus tracts:
        1. Aspiration material obtained by needle or catheterization.
        2. Curettings from the lining of the sinus tract.
    • Swabs of sinus tracts are acceptable only if the above cannot be obtained. Swabs of sinus tracts may not accurately reflect underlying disease process.
    • Do not submit cultures of superficial lesions for anaerobic culture. Biopsy of advancing margin of wound is the preferred specimen for anaerobes, mycobacteria and fungi.


    Viral Transport Media (M4)

    Some samples can be submitted, without utilizing a transport media, with a reasonable expectation of virus viability. Specimens in this category include, sterile fluids such as cerebrospinal fluid, pleural fluid, blood submitted in EDTA, urine, as well as some nonsterile specimens such as nasopharyngeal washings, sputum bronchoalveolar lavage, and feces. Whenever there is a question of stability, the specimen should be placed in a suitable virus transport media such as Microtest M4. Refer to specific test in the alphabetical test list of this User’s Guide for more information.

    • Tissue and biopsy material can be placed directly into the viral transport media. Each sample need not be more than 1-2 cm in diameter.
    • Abscess material, bullae, pustules, vesicles, lesions, and skin scraping can be collected on the swab and placed directly into viral transport media. If the material has been aspirated, place no more than 3 mL (equal to the amount of transport media) in the vial of M4.
    • CSF should be submitted in a sterile container or no more than 3 mL added to the M4 tube.
    • Urine should be submitted in a sterile container or no more than 3 mL added to the M4 tube.
    • Bronchoalveolar washings, nasopharyngeal washings, sputums, and other sterile body fluids can be submitted in sterile containers or no more than 3 mL placed in the M4 tube.
    • Stool should be submitted in a sterile container, or a small aliquot the size of a walnut can be placed in the M4 tube.
    • Blood should be submitted in an EDTA tube.