Type: B

Test 238

SuperUser Account — Tue, 16 Sep 2008 21:42:46 GMT

Test: Bilirubin, Total
Number: 001099
CPT: 82247
Synonyms: TBili
Specimen: Serum
Volume: 1 mL
Minimum Volume: 0.5 mL
Container: Red-top tube or gel-barrier tube
Collection: Separate serum from cells within 45 minutes of collection.
Storage Instructions: Refrigerate
Causes for Rejection: Gross hemolysis; improper labeling; gross lipemia
Reference Interval: 0.1-1.2 mg/dL
Use:

Causes of high bilirubin: Liver disease: hepatitis, cholangitis, cirrhosis, other types of liver disease (including primary or secondary neoplasia); alcoholism (usually with high AST (SGOT), GGT, MCV, or some combination of these findings); biliary obstruction (intrahepatic or extrahepatic); infectious mononucleosis (look also for increased LD (LDH), lymphocytosis); Dubin-Johnson syndrome; Gilbert disease¹ (familial hyperbilirubinemia) is encountered as a moderate elevation with otherwise unremarkable chemistries.

Anorexia or prolonged fasting: 36 hours or more may cause moderate rise.

Pernicious anemia, hemolytic anemias, erythroblastosis fetalis, other neonatal jaundice, hematoma, and following a blood transfusion, especially if several units are given in a short time.

Pulmonary embolism and/or infarct, congestive heart failure.

Drugs: A large number of drugs can cause jaundice by in vivo action or by chemistry methodology. Drugs causing cholestasis and/or hepatocellular damage include diphenylhydantoin, azathioprine, phenothiazines, erythromycin, penicillin, sulfonamides, oral contraceptives, anabolic-androgenic steroids, halothane, aminosalicylic acid, isoniazid, methyldopa, indomethacin, pyrazinamide, and others.

Methodology: Colorimetric
Additional Information: Interpretation of increased bilirubin is greatly enhanced by other chemistry results. In acute viral hepatitis with jaundice, for instance, the transaminases ALT (SGPT) and AST (SGOT) are consistently increased, while an isolated elevation of bilirubin is seen in Gilbert disease.¹ Obstruction causes increases in bilirubin and alkaline phosphatase greater than and out of proportion to the transaminases.² Amylase and lipase are useful in differential diagnosis of obstructive jaundice. In intrahepatic cholestasis, the transaminases are not as increased, relative to bilirubin, as they are in hepatitis.³ Work-up of jaundice has been outlined.^4,5

Nicotinic acid increases the formation of bilirubin in the spleen, leading to a rise in unconjugated bilirubin. This can be used as a test for Gilbert disease¹ in which there is a decreased hepatic clearance of unconjugated bilirubin. Although the indirect bilirubin level is increased in normal controls when nicotinic acid is given, the increase is much greater in patients with Gilbert disease. In the Crigler-Najjar syndrome type I, the unconjugated bilirubin is >20 μg/dL. In type II, the level is <20 μg/dL.

Footnotes:

Ohkubo H and Okuda K, “The Nicotinic Acid Test in Constitutional Conjugated Hyperbilirubinemia and Effects of Steroids,” Hepatology, 1984, 4(6):1206-8.
Scharschmidt BF, Goldberg HI, and Schmid R, “Current Concepts in Diagnosis. Approach to the Patient With Cholestatic Jaundice,” N Engl J Med, 1983, 308(25):1515-9.
Goldberg DM, Spooner RJ, Ellis G, et al, “Biochemical Features of Intrahepatic Cholestasis,” Am J Clin Pathol, 1979, 71(5):557-63.
Ostrow JD, “Jaundice in Older Children and Adults,” Using the Clinical Laboratory in Medical Decision Making, Lundberg GD, ed, Chicago, IL: American Society of Clinical Pathologists, 1983, 41-8.
Fischer MG, Gelb AM, and Weingarten LA, “Cholestatic Jaundice in Adults,” Using the Clinical Laboratory in Medical Decision Making, Lundberg GD, ed, Chicago, IL: American Society of Clinical Pathologists, 1983, 49-54

Test 265

SuperUser Account — Tue, 16 Sep 2008 21:43:02 GMT

Test: Bilirubin, Total and Direct, Serum
Number: 001214
CPT: 82247; 82248
Synonyms: Bili D ; Bilirubin, Total, Conjugated, and Unconjugated
Test Includes: Bilirubin, conjugated (direct); bilirubin, indirect; bilirubin, total
Specimen: Serum
Volume: 3 mL
Minimum Volume: 1 mL
Container: Red-top tube or gel-barrier tube
Collection: Separate serum from cells within 45 minutes of collection.
Storage Instructions: Refrigerate
Causes for Rejection: Severe hemolysis; improper labeling; severe lipemia
Use: Liver and biliary tests are useful in the differential diagnosis of jaundice from bilirubin overproduction (hemolysis), decreased uptake (Gilbert disease), decreased conjugation (hepatocellular disease, familial, drug-induced, pregnancy; obstructive bile duct disease).
Methodology: Colorimetric

Test 268

SuperUser Account — Tue, 16 Sep 2008 21:43:04 GMT

Test: Bilirubin, Direct
Number: 001222
CPT: 82248
Synonyms: Bilirubin, Conjugated
Specimen: Serum
Volume: 1 mL
Minimum Volume: 0.5 mL
Container: Red-top tube or gel-barrier tube
Collection: Separate serum from cells within 45 minutes of collection.
Storage Instructions: Refrigerate
Causes for Rejection: Gross hemolysis; prolonged exposure to light; improper labeling; gross lipemia
Reference Interval: 0.00-0.40 mg/dL
Use: Evaluate liver and biliary disease. Increased direct bilirubin occurs with biliary diseases, including both intrahepatic and extrahepatic lesions. Hepatocellular causes of elevation include hepatitis, cirrhosis, and advanced neoplastic states. Increased with cholestatic drug reactions, Dubin-Johnson syndrome, and Rotor syndrome. In the latter two syndromes, the level is usually <5 mg/dL.
Methodology: Colorimetric
Contraindications: Measurement of direct bilirubin is usually not necessary when the total bilirubin is <1.2 mg/dL.
Additional Information: Theoretically, direct bilirubin should not be increased in hemolytic anemias, in which bilirubin increase should be in the indirect bilirubin fraction in the absence of complications. In practice, some increase in the direct fraction may be encountered in patients with hemolytic anemia in whom complications have not been proven. Some methods have shown the direct bilirubin to be spuriously high. This may be due to different concentrations of sodium nitrite, which may convert some of the unconjugated bilirubin to conjugated bilirubin.^1,2 Direct bilirubin is the water soluble fraction. When increased in serum, bilirubin should become positive in the urine. Physiologic jaundice, occurring 2-4 days after birth, is due to lack of liver glucuronyl transferase.
Footnotes:

Chan KM, Scott MG, Wu TW, et al, “Inaccurate Values for Direct Bilirubin With Some Commonly Used Direct Bilirubin Procedures,” Clin Chem, 1985, 31(9):1560-3.
Mair B and Klempner LB, “Abnormally High Values for Direct Bilirubin in the Serum of Newborns as Measured With the DuPont aca®,” Am J Clin Pathol, 1987, 87(5):642-4

Test 485

SuperUser Account — Tue, 16 Sep 2008 21:46:52 GMT

Test: Bilirubin, Amniotic Fluid Scan
Number: 002196
CPT: 82143
Synonyms: Amniotic Fluid Bilirubin ; Delta OD, Amniotic Scan ; Liley Scan ; OD 450
Test Includes: Delta OD value at 450 nm
Special Instructions: The request form must include weeks of gestation.
Specimen: Amniotic fluid, protected from light
Volume: 5 mL
Minimum Volume: 2 mL
Container: Amber plastic transport tube with amber stopper. (If amber tubes are unavailable, cover standard transport tube completely, top and bottom, with aluminum foil. Identify specimen with patient name directly on the container and on the outside of the aluminum foil. Secure with tape.) For amber plastic transport tube and amber stopper, order LabCorp N^o 23598.
Collection: Protect specimen from light. Amniocentesis is performed by physician. To avoid delays in turnaround time when requesting multiple tests on frozen samples, please submit separate frozen specimens for each test requested.
Storage Instructions: Protect specimen from exposure to light since bilirubin is unstable in light. Although sterile specimens kept in the dark are reported to be stable for 9 months refrigerated and at least 30 days at room temperature, it is probably wiser to keep the sample frozen until it can be analyzed since it cannot be easily replaced if instability is suspected to have affected the result.
Causes for Rejection: Excessive exposure to light; grossly bloody specimen; specimen contaminated with meconium (A single passage into the amniotic fluid will require about 3 weeks to clear.)
Reference Interval: Varies with gestational age
Use: Evaluate cases of suspected maternal-fetal blood incompatibility, hemolytic disease of the newborn
Limitations: No correction for meconium contamination possible
Methodology: Spectrophotometry

Test 545

SuperUser Account — Tue, 16 Sep 2008 21:48:11 GMT

Test: Bile, Qualitative, Urine
Number: 003228
CPT: 81005
Synonyms: Bilirubin, Urine ; Ictotest®
Specimen: Urine (random)
Volume: 3 mL
Minimum Volume: 0.5 mL
Container: Routine urinalysis tube, any clean urinalysis container, plastic urine container, BD urine transport tube, or sterile urine cup
Collection: Random urine collection. Protect from light.
Storage Instructions: Refrigerate
Causes for Rejection: Improper labeling; quantity not sufficient for analysis; unpreserved urine more than 48 hours old or more than 72 hours old in BD transport tube
Reference Interval: Negative
Use: Detect the presence of bilirubin in urine; evaluate the presence of biliary and liver disease
Methodology: Reagent strip

Test 951

SuperUser Account — Tue, 16 Sep 2008 22:00:22 GMT

Test: Bacterial Antigens, Serum, Urine, Cerebrospinal Fluid
Number: 006890
CPT: 87802; 87899 (x3)
Synonyms: Bacterial Antigens for Meningitis, CSF ; Cerebrospinal Fluid Agglutination Test for Bacterial Antigens (CSF, Serum, Urine)
Test Includes: Qualitative determination of the presence of antigens of H. influenzae, S. pneumoniae, N. meningitidis, a limited number to serogroups, and group B Streptococcus
Special Instructions: Submit only one specimen per request form. State source.
Specimen: Serum, urine (random), cerebrospinal fluid
Volume: 2 mL serum, 10 mL urine, or 1 mL CSF
Container: Red-top tube or gel-barrier tube, plastic urine container, or sterile plastic (CSF) tube
Storage Instructions: Refrigerate
Patient Preparation: Usual aseptic aspiration
Causes for Rejection: Inadequate quantity; inappropriate transport device; hemolysis; lipemia; gross bacterial contamination; improper labeling; specimen received after prolonged delay (usually more than 72 hours)
Reference Interval: Negative
Use: Detect bacterial antigens in CSF, urine, and serum
Limitations: May be negative in early meningitis. Does not replace Gram stain and culture. The sensitivity of the tests vary from 50% to 100% depending on the specificity of the antibody and the concentration of antigen in the specimen. This test was most useful for the detection of serious H. influenzae infection. Because of the availability of vaccine, this test is of extremely limited value.
Methodology: Latex agglutination (LA)

Test 975

SuperUser Account — Tue, 16 Sep 2008 22:01:12 GMT

Test: Barbiturates, Serum
Number: 007088
CPT: 82205
Test Includes: Quantitation of barbiturates present in blood when specific barbiturate is not known. Includes amobarbital, butabarbital, butalbital, pentobarbital, phenobarbital, secobarbital.
Specimen: Serum or plasma
Volume: 2 mL
Minimum Volume: 0.6 mL
Container: Red-top tube, lavender-top (EDTA) tube, or green-top (heparin) tube
Collection: Transfer separated serum or plasma to a plastic transport tube. Do not use a gel-barrier tube. The use of gel-barrier tubes is not recommended due to slow absorption of the drug by the gel. Depending on the specimen volume and storage time, the decrease in drug level due to absorption may be clinically significant.
Storage Instructions: Refrigerate
Causes for Rejection: Gel-barrier tube
Use: Evaluate barbiturate toxicity, drug abuse, therapeutic levels; if barbiturates are suspected in a drug overdose, determination of long-, medium-, or short-acting may influence treatment.¹
Methodology: Gas chromatography (GC)
Additional Information: To monitor therapeutic phenobarbital level see Phenobarbital (Luminal®), Serum [007823] . Barbiturates are sedative hypnotics and frequent drugs of abuse, alone and in combination with alcohol. If an overdose occurs, coma and death may result. The implication of any concentration is more serious for short-acting barbiturates than for phenobarbital. The toxic or lethal blood level varies with many factors and cannot be stated with certainty. Lethal blood levels determined at autopsy may be as low as 60 μg/mL for long-acting (phenobarbital) and 10 μg/mL for intermediate- and short-acting barbiturates (amobarbital, butabarbital, butalbital, pentobarbital, secobarbital). In presence of alcohol or other depressant drugs the lethal concentrations may be lower. Addicts, however, may tolerate with no ill effect levels, which would be acutely toxic to a nonaddicted individual. The long-acting drugs are metabolized slowly and depend primarily on the kidney for elimination, the short- and intermediate-acting drugs are metabolized primarily by the liver and are much less dependent on the kidney for excretion. Except for barbital, all barbiturates are primarily transformed by the liver. Only barbital is dependent mainly on renal excretion for termination of its pharmacological action.
Footnotes:

Blanke RB, “Analysis of Toxic Substance,” Clinical Chemistry, Tietz NW, ed, New York, NY: WB Saunders Co, 1986, 1670-744

Test 1070

SuperUser Account — Tue, 16 Sep 2008 22:05:03 GMT

Test: Benzene Metabolite Profile, Urine
Number: 007732
CPT: 82570; 84600
Test Includes: Creatinine, urine; phenol, urine; phenol:creatinine ratio
Specimen: Urine (random)
Volume: 15 mL
Minimum Volume: 5.2 mL
Container: Plastic urine container, no preservative
Collection: Sampling time is end of shift for industrial exposure monitoring. Metabolites with timing “end of shift” (meaning the last 2 hours of exposure) are eliminated rapidly with a half-life less than 5 hours. Such metabolites do not accumulate in the body and, therefore, their timing is critical only in relation to the exposure period.
Storage Instructions: Maintain specimen at room temperature.
Reference Interval:

Environmental exposure: <10.0 mg/L
Occupational exposure: <30 mg/L (chronic exposure to 0.5-4.0 ppm of benzene)¹

Use: Monitor exposure to benzene; for emergency situations (ie, solvent spills), use test Benzene Standard Profile [324095] .
Methodology: Gas chromatography (GC)
Additional Information: Phenol is the primary metabolite of benzene. Phenol comprises approximately 51% to 87% of an absorbed dose of benzene. The hematopoietic system is the chief target for benzene´s toxic effects, which are manifested by alterations in the levels of formed elements in the peripheral blood. These effects have occurred at concentrations of benzene that may not cause irritation of mucous membranes, or any unpleasant sensory effects.² Refer to footnote 2 for specific hematological guidelines.
Footnotes:

Baselt RC and Cravey RH, Disposition of Toxic Drugs and Chemicals in Man, 4th ed, Chemical Toxicology Institute, 1995.
U.S. Department of Labor, Occupational Safety & Health Administration Regulations (Standards-26 CFR), “Medical Surveillance Guidelines for Benzene” - 1910.1028 App.C

Test 1135

SuperUser Account — Tue, 16 Sep 2008 22:07:58 GMT

Test: Beta-Hemolytic Streptococcus Culture, Group A Only
Number: 008169
CPT: 87081
Synonyms: Culture, Throat, Group A Beta-Hemolytic Streptococci Only ; Strep Groups A Culture ; Strep Throat Only
Test Includes: Culture for isolation of group A Streptococcus only. CPT coding for microbiology and virology procedures often cannot be determined before the culture is performed. Routine susceptibility testing is not performed on group A streptococci because penicillin continues to be the drug of choice. There has been no resistance reported and surveillance for resistance is not recommended. If the patient is penicillin allergic, susceptibility test may be requested in the clinical information field. It will be performed at an additional charge. Requests with only a written order and no test number indicated will be processed according to Default Test Order for Ambiguous Orders .
Specimen: Material from posterior pharynx, tonsils, or other inflamed area
Volume: One or two swabs
Container: Bacterial swab transport containing Amies gel (preferred) or double dry Dacron swab
Collection: Both tonsillar pillars and the oropharynx should be swabbed. Do not allow the swab to touch the tongue.
Storage Instructions: Maintain specimen at room temperature.
Causes for Rejection: Unlabeled specimen or name discrepancy between specimen and request label; inappropriate specimen transport device; leaking specimen; specimen received after prolonged delay (usually more than 72 hours); expired transport
Use: Isolate and identify group A beta-hemolytic streptococci; establish the diagnosis of strep throat
Methodology: Culture
Additional Information: Rheumatic fever remains a concern in the United States and serious complications including sepsis, soft tissue invasion, and toxic shock-like syndrome have been reported to be increasing in frequency;¹ therefore, timely diagnosis and early institution of appropriate therapy remains important. Timely therapy may reduce the acute symptoms and overall duration of streptococcal pharyngitis. The sequelae of poststreptococcal glomerulonephritis and rheumatic fever are diminished by early therapy.

As group A streptococci are uniformly susceptible to penicillin, there is no indication for monitoring susceptibility to penicillin and the emergence of resistance. Susceptibility testing is not routinely performed.

Footnotes:

Givner LB, Abramson JS, and Wasilauskas B, “Apparent Increase in the Incidence of Invasive Group A Beta-Hemolytic Streptococcal Disease in Children,” J Pediatr, 1991, 118(3):341-6

References:

Facklam RR, “Specificity Study of Kits for Detection of Group A Streptococci Directly From Throat Swabs,” J Clin Microbiol, 1987, 25(3):504-8.

Kaplan EL, “The Rapid Identification of Group A Beta-Hemolytic Streptococci in the Upper Respiratory Tract. Current Status,” Pediatr Clin North Am, 1988, 35(3):535-42.

Nadler HL, “Group A Strep Detection,” Diagn Clin Test, 1989, 27(3):35-41 (review of rapid methods).

“Rapid Diagnostic Tests for Group A Streptococcal Pharyngitis,” Med Lett Drugs Ther, 1991, 33(843):40-1.

Veasy LG, Wiedmeier SE, Orsmond GS, et al, “Resurgence of Acute Rheumatic Fever in the Intermountain Area of the United States,” N Engl J Med, 1987, 316(8):421-7.

Test 1158

SuperUser Account — Tue, 16 Sep 2008 22:08:56 GMT

Test: Blood Culture, Routine
Number: 008300
CPT: 87040
Synonyms: Culture, Blood, Routine
Test Includes: Culture; isolation, identification, and susceptibility testing (additional charges/CPT code[s] may apply). CPT coding for microbiology and virology procedures often cannot be determined before the culture is performed. Requests with only a written order and no test number indicated will be processed according to Default Test Order for Ambiguous Orders .
Special Instructions: The request form must state clinical diagnosis and time of collection. List current antibiotic therapy, clinical diagnosis, and any special organisms suspected or to rule out. Must indicate if culture is for Brucella or Francisella. Do not use expired blood culture media.
Specimen: Whole blood
Volume: Adults: 16-20 mL total; 8-10 mL per aerobic and anaerobic bottle. Pediatrics: up to 4 mL in one pediatric bottle; as age increases so should the volume of blood collected. Do not add more than 10 mL of blood to either the aerobic or anaerobic bottles, or more than 4 mL of blood to a pediatric bottle. The aerobic bottle has no minimum volume requirement.
Container: One aerobic and one anaerobic blood culture bottle for adults or one pediatric bottle. Do not vent.
Collection: Use adult or pediatric blood culture collection kits provided by LabCorp. See the Procedural Chart for Blood Culture Collection provided in each collection kit for detailed information regarding bottle preparation, venipuncture, and bottle inoculation. Additional information can also be found in the Microbiology Appendix. Blood cultures should be drawn prior to initiation of antimicrobial therapy. The time of collection must be indicated. Strict aseptic technique is essential. If more than one culture is ordered, the specimens should be drawn separately at no less than 30 minutes apart to rule out the possibility of transient bacteremia due to self-manipulation by the patient of mucous membranes in the mouth caused by brushing teeth, etc, or by local irritations caused by scratching of the skin.

Suspected sepsis, meningitis, osteomyelitis, arthritis, or acute untreated bacterial pneumonia: Obtain two blood cultures from two different sites, such as the left and right arms.
Fever of unknown origin such as that caused by an occult abscess: Obtain two blood cultures initially. If those are negative, obtain two more 24-36 hours later. The yield beyond three or four cultures is virtually nil in this condition.
Suspected early typhoid fever and brucellosis: Obtain four blood cultures over 24-36 hours due to low-grade bacteremia involved in these rarely seen diseases.
Endocarditis (acute infective endocarditis): Obtain three blood cultures from three separate venipuncture sites during the first 1-2 hours and begin therapy.
Subacute infective endocarditis: Obtain three blood cultures within the first 24 hours, ideally within no less than hourly intervals. If all are negative at 24 hours, obtain two more. The yield beyond five blood cultures in subacute and endocarditis is virtually nil.

Storage Instructions: Maintain specimen at room temperature. Do not refrigerate.
Patient Preparation: The major difficulty in interpretation of blood cultures is potential contamination by skin flora. This difficulty can be markedly reduced by careful attention to the details of skin preparation and antisepsis prior to collection of the specimen.

Skin preparation: First cleanse the venipuncture site with isopropanol. Then use a ChloraPrep® swabstick to disinfect the site, using progressively larger concentric circles. This prepping agent should remain in contact with the skin for 30 seconds and be allowed to dry to ensure adequate disinfection. The venipuncture site must not be palpated after preparation. Blood is then safely drawn.

Causes for Rejection: Unlabeled specimen or name discrepancy between specimen and request label; bottles received broken; blood culture bottles received after a prolonged delay (usually more than 72 hours); blood not received in blood culture bottles; expired blood culture bottle
Use: Isolate and identify potentially pathogenic organisms causing bacteremia; establish the diagnosis of endocarditis
Limitations: Three negative sets of blood cultures in the absence of antimicrobial therapy are usually sufficient to exclude the presence of bacteremia. One set is seldom ever sufficient.¹ Prior antibiotic therapy may cause negative blood cultures or delayed growth. Blood cultures from patients suspected of having Brucella or Leptospira must be requested as special cultures. Consultation with the laboratory for special culture procedures for the recovery of these organisms prior to collecting the specimen is recommended. Yeast often are isolated from routine blood cultures. However, if yeast or other fungi are specifically suspected, a separate fungal blood culture should be drawn along with each of the routine blood culture specimens. See separate listing for proper collection of Fungus (Mycology) Culture [008482] . Mycobacterium avium complex (MAC) is frequently recovered from blood of immunocompromised patients, particularly those with acquired immunodeficiency syndrome, AIDS. Special procedures are required for the recovery of these organisms; use test Acid-Fast (Mycobacteria) Broth-Based Culture and Smear [182402] .
Methodology: Culture
Additional Information: Sequential blood cultures in nonendocarditis patients using a 20 mL sample resulted in an 80% positive yield after the first set, a 90% yield after the second set, and a 99% yield after the third set. Volume of blood cultured seems to be more important than the specific culture technique being employed by the laboratory. The isolation of coagulase-negative Staphylococcus poses a critical and difficult clinical dilemma. Although coagulase-negative Staphylococcus is the most commonly isolated organism from blood cultures, only a few (6.3%) of the isolates represent “true” clinically significant bacteremia.² Conversely, coagulase-negative Staphylococcus is well recognized as a cause of infections involving prosthetic devices, cardiac valves, CSF shunts, dialysis catheters, and indwelling vascular catheters.³ Ultimately, the physician is responsible for determining whether an organism is a contaminant or a pathogen. The decision is based on both laboratory and clinical data. Frequently this determination includes patient data (ie, patient history), physical examination, body temperatures, clinical course, and laboratory data (ie, culture results, white blood cell count, and differential). The number of positive cultures as defined by a venipuncture is the most relevant criteria to use in determining whether an isolate is a contaminant. Clinical experience and judgment may play a significant role in resolving this clinical dilemma.⁴

In patients who have received antimicrobial drugs, four to six blood cultures may be necessary. Any organism isolated from the blood is usually tested for susceptibility. It is not recommended to culture blood while antimicrobials are present unless verification of an agent´s efficacy is needed. This is confirmed with a single culture.

The diagnosis of bacterial meningitis is accomplished by blood culture as well as culture and examination of the cerebrospinal fluid.⁵ Most children with bacterial meningitis are initially bacteremic.⁶ See tables.

Blood Culture Collection

Clinical Disease Suspected	Culture Recommendation	Rational
Sepsis, meningitis osteomyelitis, septic arthritis, bacterial pneumonia	Two sets of cultures - one from each of two prepared sites, the second drawn after a brief time interval, then begin therapy.	Assure sufficient sampling in cases of intermittent or low level bacteremia. Minimize the confusion caused by a positive culture resulting from transient bacteremia or skin contamination.
Fever of unknown origin (eg, occult abscess, empyema, typhoid fever, etc)	Two sets of cultures - one from each of two prepared sites, the second drawn after a brief time interval (30 minutes). If cultures are negative after 24-48 hours obtain two more sets, preferably prior to an anticipated temperature rise.	The yield after four sets of cultures is minimal. A maximum of three sets per patient per day for 3 consecutive days is recommended.
Endocarditis
Acute	Obtain three blood culture sets within 2 hours, then begin therapy.	95% to 99% of acute endocarditis patients (untreated) will yield a positive in one of the first three cultures.
Subacute	Obtain three blood culture sets on day 1, repeat if negative after 24 hours. If still negative or if the patient had prior antibiotic therapy, repeat again.	Adequate sample volume despite low level bacteremia or previous therapy should result in a positive yield.
Immunocompromised host (eg, AIDS)
Septicemia, fungemia mycobacteremia	Obtain two sets of cultures from each of two prepared sites; consider lysis concentration technique to enhance recovery for fungi and broth systems for recovery of mycobacteria.	Low levels of fungemia and mycobacteremia frequently encountered.
Previous antimicrobial therapy
Septicemia, bacteremia; monitor effect of antimicrobial therapy	Obtain two sets of cultures from each of two prepared sites; increased volume >10 mL/set.	Recovery of organisms is enhanced by dilution and increased sample volume.

Interpretation of Positive Blood Cultures

Virtually any organism, including normal flora, can cause bacteremia.

A negative culture result does not necessarily rule out bacteremia; false-negative results occur when pathogens fail to grow.

A positive culture result does not necessarily indicate bacteremia; false-positive results occur when contaminants grow.

Gram-negative bacilli, anaerobes, and fungi should be considered pathogens until proven otherwise.

The most difficult interpretation problem is to determine whether an organism that is usually considered normal skin flora is a true pathogen.

Adapted from Flournoy DJ and Adkins L, “Understanding the Blood Culture Report,” Am J Infect Control, 1986,14:41-6.

Footnotes:

Aronson MD and Bor DH, “Blood Cultures,” Ann Intern Med, 1987, 106(2):246-53.
Archer GL, “Coagulase-Negative Staphylococci in Blood Cultures: The Clinician´s Dilemma,” Infect Control, 1985, 6(12):477-8 (editorial).
Sheagren JN, “Significance of Blood Culture Isolates of Staphylococcus epidermidis,” Arch Intern Med, 1987, 147(4):635.
Flournoy DJ and Adkins L, “Understanding the Blood Culture Report,” Am J Infect Control, 1986, 14(1):41-6.
Francke E, “The Many Causes of Meningitis,” Postgrad Med, 1987, 82(2):175-88.
Feigin RD, McCracken GH Jr, and Klein JO, “Diagnosis and Management of Meningitis,” Pediatr Infect Dis J, 1992, 11(9):785-814

References:

MacLowry JD, “Clinical Microbiology of Bacteremia: An Overview,” Am J Med, 1983, 75(1B):2-6.

Reller BL, Murray PR, and MacLowry JD, “Blood Cultures II,” Cumitech 1A, Washington, DC: ASM Press, 1982 (review).

Salfinger M, Stool EW, Piot D, et al, “Comparison of Three Methods for Recovery of Mycobacterium avium Complex From Blood Specimens,” J Clin Microbiol, 1988, 26(6):1225-6.

Test 1257

SuperUser Account — Tue, 16 Sep 2008 22:13:46 GMT

Test: Bronchial Washings Cytology
Number: 009035
CPT: 88112
Test Includes: Bronchial washings; bronchoalveolar lavage specimens
Special Instructions: Include type of specimen and pertinent clinical information (ie, patient´s name, age, Social Security number, clinical impression, past diagnoses, radiographic findings, and history of radiation or chemotherapy) on the request form.
Specimen: Bronchial washings or bronchoalveolar lavage specimens obtained by physician
Volume: Not less than 1-2 mL for washings
Container: 50 mL disposable centrifuge tube
Collection: Washings or aspirates collected during the endoscopic examination should be collected and mixed with an equal volume of 50% ethyl alcohol or Saccomanno fixative. Specimens should be properly labeled and delivered immediately to the laboratory. Submit specimens in their original collection containers. (Note: Specimens prepared with fixatives that contain 50% ethyl alcohol, eg, Saccomanno fixative, are not acceptable for microbiology testing.)
Storage Instructions: Refrigerate
Causes for Rejection: Improper labeling; improper fixative; specimen was submitted in a vial that expired according to the manufacturer´s label
Use: Establish the presence of primary or metastatic neoplasms; aid in the diagnosis of respiratory infections with herpesvirus, cytomegalovirus, Aspergillus, Coccidioides, Candida, Actinomyces, Cryptococcus, Histoplasma, Blastomyces, Phycomycetes, Pneumocystis carinii, and Strongyloides; aid in the diagnosis of asbestosis
Limitations: Allowing fluid to stand for a prolonged period before processing may cause deterioration and artifact.
Methodology: The fluid will be centrifuged, supernatant poured off, and diagnostic cells aspirated from the remaining material. Filters, monolayers, and/or cytospins will be made along with a cell block, if applicable. Microscopic examination is performed.

Test 1287

SuperUser Account — Tue, 16 Sep 2008 22:15:05 GMT

Test: Breast Discharge Cytology
Number: 009134
CPT: 88161
Synonyms: Breast Smear ; Nipple Discharge
Special Instructions: Include patient´s name, date of birth, sex, Social Security number, previous malignancy, drug therapy, radiation therapy, mammogram, and all other pertinent clinical information on the request form.
Specimen: Nipple discharge
Volume: Pea-size drop
Container: Cardboard or plastic slide holder(s); Coplin jar(s)
Collection: Gently grip subareolar area and nipple with thumb and forefinger. When secretion occurs, allow pea-sized drop to accumulate on apex of nipple. Touch a clean slide to the nipple and withdraw quickly. Immediately spray slide with fixative or place slides in 95% ethyl alcohol. Repeat procedure until all secretions from nipple are collected on two or more slides.
Storage Instructions: Maintain specimen at room temperature.
Causes for Rejection: Improper labeling; improper fixative; air-drying artifact
Use: Diagnose primary or metastatic malignant neoplasms; differential diagnosis of benign versus malignant processes; aid in the diagnosis of infectious and inflammatory disease
Limitations: Drying of smear(s) before fixation will render specimen unsatisfactory for evaluation.
Methodology: Pap stained: microscopic examination

Test 1309

SuperUser Account — Tue, 16 Sep 2008 22:16:01 GMT

Test: Bronchial Brushings
Number: 009332
CPT: 88104
Synonyms: Brushings Cytology
Special Instructions: Specify the site brushed and include type of specimen and pertinent clinical data (ie, patient´s name, age, patient´s Social Security number, clinical impression, past diagnoses, bronchoscopic and radiographic findings, admitting diagnosis, history of carcinoma, and history of radiation or chemotherapy) on the request form.
Specimen: Brush from lesion area
Volume: Minimum of two slides
Container: Glass slides or centrifuge tubes containing brushes
Collection: Roll brush over glass slide to cover the area of a dime and fix immediately with spray fixative or fix in 95% ethyl alcohol. Label bottle with exact body site, patient´s name, hospital number, room number and date. Using a graphite pencil, label frosted slide with patient´s name. If more than one slide is used, separate them with a paper clip. Disposable bronchial brushes should be submitted in saline with sheath removed and sent to the laboratory immediately.
Storage Instructions: Smears and brushes should be placed in 95% ethyl alcohol; slides may be spray fixed.
Causes for Rejection: Improper labeling; improper fixation; air-drying artifact; specimen was submitted in a vial that expired according to the manufacturer´s label
Use: Establish the presence of primary or metastatic neoplasms; aid in the diagnosis of certain infections with herpesvirus, cytomegalovirus, Aspergillus, Coccidioides, Candida, Actinomyces, Cryptococcus, Histoplasma, Blastomyces, Phycomycetes, Pneumocystis carinii, and Strongyloides; aid in the diagnosis of asbestosis
Limitations: Allowing smears and brushes to air dry before they are fixed will render them unsatisfactory for cytologic evaluation.
Methodology: The fluid will be centrifuged, supernatant poured off, and diagnostic cells aspirated from the remaining material. Filters, monolayers, and/or cytospins will be made along with a cell block, if applicable. Microscopic examination is performed.

Test 1334

SuperUser Account — Tue, 16 Sep 2008 22:17:13 GMT

Test: Beta -2 Microglobulin, Urine
Number: 010173
CPT: 82232
Specimen: Urine (random)
Volume: 10 mL
Minimum Volume: 1 mL
Container: Plastic urine container (do not acidify)
Collection: Patient should empty the bladder, then drink a large glass of water and collect a urine sample within 1 hour. Significant loss of β-₂-microglobulin activity may occur in acidic urine (pH ≤6). Urine should always be collected at high diuresis and the pH adjusted to between 6 and 8 with 1 mol/L sodium hydroxide.
Storage Instructions: Refrigerate
Reference Interval: 0-300 μg/L
Use: Evaluate renal disease; monitor certain types of malignancies and AIDS
Methodology: Immunochemiluminometric assay (ICMA)

Test 1335

SuperUser Account — Tue, 16 Sep 2008 22:17:16 GMT

Test: Beta -2 Microglobulin, Serum
Number: 010181
CPT: 82232
Synonyms: Beta-2 Microglobulin, Serum
Special Instructions: Values obtained with different assay methods should not be used interchangeably in serial testing. It is recommended that only one assay method be used consistently to monitor each patient´s course of therapy. This procedure does not provide serial monitoring; it is intended for one-time use only. If serial monitoring is required, please use the serial monitoring number 480020 (see test below) to order.
Specimen: Serum
Volume: 0.5 mL
Minimum Volume: 0.3 mL (Note: This volume does not allow for repeat testing.)
Container: Red-top tube or gel-barrier tube
Collection: If a red-top tube is used, transfer separated serum to a plastic transport tube.
Storage Instructions: Refrigerate
Reference Interval: See table.¹

Age	Male (mg/L)	Female (mg/L)
0-1 mo	1.6-4.8	1.7-4.5
1-6 mo	1.4-3.3	1.0-3.8
7-11 mo	0.9-3.1	1.0-2.3
1-3 y	0.8-2.2	0.7-2.4
4-6 y	0.6-2.3	0.5-2.2
7-9 y	0.8-1.7	0.7-1.8
10-12 y	0.7-1.8	0.7-2.0
13-15 y	0.7-2.0	0.8-1.9
16-18 y	0.7-1.9	0.6-1.9
>18 y	0.6-2.4	0.6-2.4

Use: Evaluate renal disease; tumor marker for certain types of malignancies
Limitations: Increased synthesis of β-₂-microglobulin may occur in Crohn disease, hepatitis, sarcoidosis, and vasculitis.
Methodology: Immunochemiluminometric assay (ICMA)
Additional Information: β-₂-microglobulin is a cell membrane associated 100 amino acid peptide, a component of the lymphocyte HLA complex. It is increased nonspecifically in inflammatory reactions and in active chronic lymphocytic leukemia in which there is increased lymphocyte turnover. It may be a useful differentiator of glomerular and tubular dysfunction: in glomerular disease β-₂-microglobulin is increased in serum and decreased in urine, while in tubular disorders the opposite changes occur. Urinary β-₂-microglobulin becomes abnormal before serum creatinine in aminoglycoside nephrotoxicity. β-₂-microglobulin is increased in AIDS patients with progressive disease, particularly those with opportunistic infection. The serum β-₂-microglobulin level has been a useful marker for in vivo antiretroviral drug activity. It decreases in response to therapy with AZT. Its use has been combined with CD4 lymphocyte counts to calculate the probability of an HIV-infected person developing AIDS within the next 3 years. Although some studies point to elevated β₂-microglobulin level in the CSF of patients with neurologic involvement by HIV, this is unlikely to provide significant information to guide therapy.
Footnotes:

Soldin SJ, Hicks JM, Bailey J, et al, “Pediatric Reference Ranges for B2-microglobulin and Ceruloplasmin,” Clin Chem, 1997, 43:S199

References:

Anderson RE, Lang W, Shiboski S, et al, “Use of β-₂-Microglobulin Level and CD4 Lymphocyte Count to Predict Development of Acquired Immunodeficiency Syndrome in Persons With Human Immunodeficiency Virus Infection,” Arch Intern Med, 1990, 150(1):73-7.

Calabrese LH, “Autoimmune Manifestations of Human Immunodeficiency Virus (HIV) Infection,” Clin Lab Med, 1988, 8(2):269-79 (review).

Jacobson MA, Abrams DI, Volberding PA, et al, “Serum β-₂-Microglobulin Decreases in Patients With AIDS or ARC Treated With Azidothymidine,” J Infect Dis, 1989, 159(6):1029-36.

Lucey PR, McGuire SA, Clerici M, et al, “Comparison of Spinal Fluid β-₂-Microglobulin Levels With CD4+ T-Cell Count, in vitro Helper T-Cell Function, and Spinal Fluid IgG Parameters in 163 Neurologically Normal Adults Infected With the Human Immunodeficiency Virus,” J Infect Dis, 1991, 163(5):971-5.

Tolkoff-Rubin NE, Rubin RH, and Bonventre JV, “Noninvasive Renal Diagnostic Studies,” Clin Lab Med, 1988, 8(3):507-26 (review).

Test 1356

SuperUser Account — Tue, 16 Sep 2008 22:18:18 GMT

Test: Bile Acids
Number: 010330
CPT: 82239
Synonyms: Glyco and Taurochenodeoxycholic Acid ; Glyco and Taurocholic Acid
Specimen: Serum, frozen
Volume: 1 mL
Minimum Volume: 0.2 mL
Container: Red-top tube or gel-barrier tube
Collection: Transfer serum to a plastic transport tube before freezing. To avoid delays in turnaround time when requesting multiple tests on frozen samples, please submit separate frozen specimens for each test requested.
Storage Instructions: Freeze
Note: Bile acids are unstable when subjected to freezing, thawing, and re-freezing, therefore, avoid freeze/thaw cycles.
Patient Preparation: Patient should be fasting; however, a 2-hour postprandial level has been used by various physicians in order to evaluate hepatic function after the gallbladder has been completely emptied (ie, challenge the liver with a high level of bile acids in the portal circulation).
Causes for Rejection: Specimen not frozen; use of anticoagulants; re-frozen specimen
Reference Interval: 4.5-24.6 μmol/L
Use: Evaluate the enterohepatic cycle consisting of the biliary system, intestine, portal circulation, and hepatocytes
Methodology: Enzymatic
Additional Information: The concentration of bile acids in serum is elevated in patients with many structural liver diseases, due to the inability of the liver to extract bile acids efficiently from portal blood. Metabolic liver diseases such as Gilbert disease, Crigler-Najjar syndrome, or Dubin-Johnson syndrome do not appear to cause elevated bile acid concentrations. Bile acid levels may be altered even when other liver function tests are normal and may serve as a sensitive and specific indicator of liver disease.
References:

Block E, et al, “Efficacy of Postprandial Bile Acid Levels as Diagnostic Tool for Hepatobiliary Disease,” Clin Chem, 1979, 25:1081.

Korman MG, Hofmann AF, Summerskill WH, et al, “Assessment of Activity in Chronic Liver Disease: Serum Bile Acids Compared With Conventional Tests and Histology,” N Engl J Med, 1974, 290(25):1399-402.

Mashige F, Tanaka N, Maki A, et al, “Direct Spectrophotometry of Total Bile Acids in Serum,” Clin Chem, 1981, 27(8):1352-6.

Skrede E, Solberg HE, Blomhoff JP, et al, “Bile Acids Measured in Serum During Fasting as a Test for Liver Disease,” Clin Chem, 1978, 24(7):1095-9.

Test 1555

SuperUser Account — Tue, 16 Sep 2008 22:28:39 GMT

Test: Beta Strep (Group B) Antigen
Number: 018804
CPT: 87802
Special Instructions: Send only one specimen per request form.
Specimen: Serum, urine, or cerebrospinal fluid
Volume: 1 mL serum, 5 mL urine, or 0.5 mL CSF
Container: Gel-barrier tube, plastic urine container, or plastic (CSF) tube
Collection: Indicate source of specimen.
Storage Instructions: Refrigerate
Reference Interval: Negative
Use: Aid in documentation of active beta streptococcal infection
Methodology: Latex agglutination (LA)
Additional Information: Group B Streptococcus is currently one of the most significant human pathogens in the neonatal period. The most common mode of acquisition by the neonate is exposure to the maternal genital flora in utero through ruptured membranes or by contamination during passage through the birth canal. Rapid identification of group B Streptococcus carriers is important in management of premature rupture of the membranes because the effectiveness of intrapartum prophylactic ampicillin may be compromised by awaiting the results of conventional cultures. Infection is manifested in two major forms, early onset septicemic infection manifest in the first few days of life and late onset meningitis which occurs during the first few months of life.

Increased isolation of strains of group B Streptococcus resistant to erythromycin (9%) or intermediate susceptible clindamycin (9.5%) and cefoxitin (15.3%) have been reported. Nineteen percent exhibited a multiple antibiotic resistance pattern. Penicillinase production and resistance to ampicillin were not encountered in the particular series. Susceptibility testing may be useful in selecting alternate antibiotic regimens.

Test 1562

SuperUser Account — Tue, 16 Sep 2008 22:28:58 GMT

Test: Blood Pressure Monitoring
Number: 019372
CPT: 93788
Synonyms: Ambulatory Monitoring, Blood Pressure
Special Instructions: Analysis is available for accounts with ambulatory blood pressure units in their office; supplies and equipment are not included. Contact Ambulatory Monitoring Services (AMS) for additional information, 800-289-4358.

Test 1564

SuperUser Account — Tue, 16 Sep 2008 22:29:01 GMT

Test: Blood Pressure Unit, One-Time Use and Analysis
Number: 019380
CPT: 93788
Special Instructions: Contact Ambulatory Monitoring Services (AMS) for additional information, 800-289-4358.
Use: Analysis and one-time use of ambulatory blood pressure unit

Test 1737

SuperUser Account — Tue, 16 Sep 2008 22:37:19 GMT

Test: Bumblebee
Number: 060011
CPT: 86003
Specimen: Serum
Volume: 0.2 mL
Container: Red-stopper tube or gel-barrier tube
Methodology: Quantitative allergen-specific IgE test

Test 1757

SuperUser Account — Tue, 16 Sep 2008 22:38:08 GMT

Test: Bran, Wheat
Number: 060051
CPT: 86003
Specimen: Serum
Volume: 0.2 mL
Container: 10 mL red-top tube or 10 mL gel-barrier tube
Storage Instructions: Refrigerate
Methodology: Quantitative allergen-specific IgE test

Test 1763

SuperUser Account — Tue, 16 Sep 2008 22:38:23 GMT

Test: Black Bass
Number: 060061
CPT: 86003
Specimen: Serum
Volume: 0.2 mL
Container: Red-stopper tube or gel-barrier tube
Storage Instructions: Refrigerate
Methodology: Quantitative allergen-specific IgE test

Test 1772

SuperUser Account — Tue, 16 Sep 2008 22:38:45 GMT

Test: Bayleaf (Laurel)
Number: 060079
CPT: 86003
Specimen: Serum
Volume: 0.2 mL
Container: Red-stopper tube or gel-barrier tube
Storage Instructions: Refrigerate
Methodology: Quantitative allergen-specific IgE test

Test 1775

SuperUser Account — Tue, 16 Sep 2008 22:38:52 GMT

Test: Bromelin
Number: 060084
CPT: 86003
Specimen: Serum
Volume: 0.2 mL
Container: 10 mL red-top tube or 10 mL gel-barrier tube
Storage Instructions: Refrigerate
Methodology: Quantitative allergen-specific IgE test

Test 1804

SuperUser Account — Tue, 16 Sep 2008 22:40:04 GMT

Test: Bean, Kidney, (Red Bean)
Number: 060277
CPT: 86003
Specimen: Serum
Volume: 0.2 mL
Container: Red-stopper tube or gel-barrier tube
Storage Instructions: Refrigerate
Methodology: Quantitative allergen-specific IgE test