I have noticed while authorising sputum culture reports, that some people have high thresholds for working up suspect colonies from plate cultures, only proceeding when the potential pathogen is dominant amongst the upper respiratory tract flora that is also inevitably present.
Other people have very low thresholds for working up suspect colonies, painstakingly trying to pick out potential pathogens even when there only a few of the same colony type present in the milieu.
Depending on what your threshold is, it clearly has the potential to produce a different result for the clinician.
But who is right and who is wrong? Is it that sometimes we just try a bit too hard?
My gut instinct is that a few colonies of a respiratory pathogen (e.g. Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) nestling amongst a mass of mixed upper respiratory tract flora is unlikely to be significant, but I am not aware of any literature that supports such an assertion.
I tend not to get too excited by sputum cultures as a rule… Clinicians don’t hang around waiting for the patient to firstly produce a sputum sample, and then wait another 2 or 3 days whilst the microbiology laboratory processes it. They treat the patient empirically, according to guidelines that are hopefully formulated by laboratory data outlining the expected pathogens and antibiograms in the local area.
Only on rare occasions does a sputum culture result actually change patient management.
If “sputum culture” were a new immunoassay, and therefore subject to FDA approval before being released to the market, it wouldn’t have a prayer of being accepted. The sub-optimal sensitivity and specificity (even with prior filtering of samples using macroscopic appearance and Gram stain) would simply not cut it from a regulatory point of view.
So we will continue to grapple with the vagaries of sputum culture, but I suspect it will be around for many years yet.
But we should not lose any sleep over it, whatever your threshold is…