What is the appropriate treatment for an adult patient with a urinary tract infection, as indicated by 10,000 to 100,000 Colony-Forming Units (CFU) of mixed microbial growth in a urine culture, without specified underlying conditions?

Mixed Microbial Growth (10,000-100,000 CFU/mL) in Urine Culture

Mixed microbial growth at 10,000-100,000 CFU/mL represents contamination, not infection, and should not be treated with antibiotics. 1, 2, 3

Why This Represents Contamination

• Mixed growth is the defining characteristic of contamination. Studies consistently show that specimens with mixed organisms (growth of 2 or more organisms) are contaminated, with rates ranging from 26-68% depending on collection method 1

• The American Academy of Pediatrics establishes that ≥50,000 CFU/mL of a single urinary pathogen is required for significant bacteriuria, and this must be accompanied by pyuria (≥10 leukocytes/mm³) to diagnose UTI 1, 2

• Mixed growth occurs from contamination with perineal, vaginal, or prepucial flora, not from true infection 1

Diagnostic Criteria for True UTI (What You Need)

For a valid UTI diagnosis, you must have ALL of the following 1, 2:

1. Urinalysis showing pyuria (≥10 WBCs/mm³ or positive leukocyte esterase) AND/OR bacteriuria
2. ≥50,000 CFU/mL of a single uropathogen (not mixed growth)
3. Appropriate collection method (catheterization or suprapubic aspiration preferred)
4. Clinical symptoms consistent with UTI

What To Do Next

Do not treat this result. Instead 2, 3:

• If the patient is symptomatic, obtain a properly collected specimen via catheterization or clean-catch with meticulous technique to minimize contamination 1

• If the patient is asymptomatic, this represents asymptomatic bacteriuria with contamination and requires no treatment 1, 3

• Look for specimen quality indicators: Elevated squamous epithelial cells (≥10-20/HPF) confirm contamination 3

Common Pitfalls to Avoid

• Never treat mixed growth as infection. The presence of multiple organisms definitively indicates contamination, regardless of colony count 1, 2, 4

• Do not rely on bag-collected specimens for diagnosis. These have contamination rates of 22-68% and cannot be used to document UTI 1

• Avoid treating based solely on colony count without considering organism type. Specimens with 10,000-49,000 CFU/mL are significantly more likely to yield Gram-positive or mixed organisms (60% vs 6%), suggesting contamination rather than infection 5

When Mixed Growth Might Be Significant (Rare Exceptions)

Mixed infection is genuinely rare but can occur in specific high-risk situations 4:

• Long-term catheterization (most common scenario for true polymicrobial bacteriuria)
• Structural urinary tract abnormalities
• Immunocompromised patients

Even in these cases, you need reproducibility of the same combination of organisms on sequential cultures or recovery of the same organisms from blood cultures in urosepsis to confirm true mixed infection 4

Collection Method Matters

The contamination rate varies dramatically by collection method 1:

• Suprapubic aspiration: 1% contamination rate
• Catheterization: 12% contamination rate
• Clean-catch midstream: 8-26% contamination rate
• Bag collection: 22-68% contamination rate

For definitive diagnosis, use catheterization or suprapubic aspiration 1, 2