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Diagnosis of Intestinal Parasites

Test code(s) 8625X, 37213X, 39480X, 10018, 681X, 6653, 6652, 1748, 17297

Question 1. What tests are recommended for diagnosing intestinal parasites?

While the ova and parasite (O&P exam) is ordered most often, it is not recommended as the routine test for diagnosis of intestinal parasites in the United States as many intestinal parasites are not reliably detectable by O&P exam. Test recommendations for specific parasitic pathogens are listed below:

Question 2. What pathogenic organisms are commonly detected in an O&P exam (TC681X)?

Quest Diagnostics offers O&P testing in accordance with guidelines set forth by the Clinical Laboratory Standards Institute (CLSI) and in concert with best practices published in various American Society of Microbiology (ASM) press books for optimizing the collection, testing, and reporting of human parasitic pathogens. O&P exams may detect trophozoites and/or cysts of important human parasitic pathogens including Cryptosporidium sp, Coccidia sp, Entamoeba histolytica, E histolytica/dispar, Giardia sp, Isospora sp, Microsporidia sp, Schistosoma mansoni, and Schistosoma haematobium, as well as non-pathogenic parasites that indicate exposure to unclean environmental sources.

Question 3. Are there recommendations for specific parasite testing in certain patient populations?

Yes, recommended testing can vary depending on symptoms, travel history, and geographic prevalence of disease. Guidance on this topic based upon ASM and IDSA recommendations is provided in the table below2,14:

Question 4. Why are multiple specimens recommended for human stool exams?

Parasites may only be shed intermittently and repeat testing may be necessary for detection. For routine examination for parasites prior to treatment, a minimum of 3 specimens, collected on alternate days, is recommended. For patients without diarrhea, 2 of the specimens should be collected after normal movements, and 1 after a cathartic, such as magnesium sulfate. If the patient has diarrhea, do not use a laxative. Submission of more than 1 specimen collected on the same day usually does not increase the sensitivity of the test.2-5

For Giardia antigen testing, testing of specimens collected on 2 different days is recommended to improve sensitivity.5

Question 5. What transport media does Quest Diagnostics accept for stool exams, and why?

Preferred transport media for stool ova and parasite exams include either a single vial of Total-Fix or paired vials of 10% formalin and PVA. These transport media have met verification and validation criteria for reliability with respect to our specific human parasitic pathogen testing methodologies.6-13

Question 6. What transport media does Quest Diagnostics not accept for stool exams, and why?

We do not accept Ecofix, Protofix, SAF, or any other preservatives outside of those mentioned above. Any transport media besides those listed as “acceptable” above have either not been validated or did not pass validation criteria for use with our specific testing methodologies.6

Question 7. Why are stool studies not recommended for hospital inpatients?

Data suggest that for patients who have been hospitalized for more than 3 days, diarrhea is generally the result of non-parasitic causes.2

Question 8. Which non-stool sources are appropriate for O&P exam?

Urine is acceptable for the detection of Schistosoma haematobium. Urine should be collected around noon and submitted in a sterile, leak-proof container, and transported to the laboratory refrigerated as soon as possible.

Sputum or bronchoaveolar lavage may be submitted in in Total-Fix, 10% formalin or unpreserved for examination when Paragonimus westermani eggs, Strongyloides stercoralis larvae, Ascaris lumbricoides larve, or hookworm larve are suspected. Unpreserved specimens should be refrigerated and transported to the laboratory as soon as possible.

The CDC recommends the additional non-stool sources listed below.12 Note that testing of these specimens may require medical director approval.

  • Duodenal aspirates should be submitted in Total-Fix or 10% formalin for examination when Giardia duodenalis or Strongyloides stercoralis are suspected.
  • Sigmoidoscopy material and abscesses of the liver and lung should be submitted in Total-Fix or PVA when Entamoeba histolytica is suspected. 

References

  1. M-28-A2. CLSI Guideline. Procedure for Recovery and Identification of Parasites from the Intestinal Tract. Approved Guideline, 2005.
  2. Garcia LS, Bruckner DA. Diagnostic Medical Parasitology. 5th ed. Washington, DC: American Society of Microbiology; 2007.
  3. Shimizu RY, Garcia LS. Chapter 133: Specimen Collection, Transport and Processing: Parasitology. In Jorgensen JH, Pfaller MA, Carroll KC, et al, eds. Manual of Clinical Microbiology. 11th ed. Washington, DC: American Society of Microbiology; 2015.
  4. Leber AL., ed. Clinical Microbiology Procedures Handbook. 4th ed. Washington DC: American Society for Microbiology; 2016.
  5. Wheatley WB. A rapid staining procedure for intestinal amoeba and flagellates. Am J Clin Pathol. 1951;21:990-991.
  6. Medical Chemical Corporation, Inc. Total-Fix™ Stool Collection System procedure. 2013.
  7. Tille PM. Bailey & Scott’s Diagnostic Microbiology. 13th ed. St Louis, MO: Elsevier; 2014.
  8. http://www.questdiagnostics.com/testcenter/TestCenterHome.action.
  9. Garcia LS, Shimizu RY. Evaluation of intestinal protozoan morphology in human fecal specimens preserved in EcoFix: comparison of Wheatley’s trichrome stain and EcoStain. J Clin Microbiol. 1998;36:1974-1976.
  10. Fedorko DP, Williams EC, Nelson NA, et al. Performance of three enzyme immunoassays and two direct fluorescence assays for detection of Giardia lamblia in stool specimens preserved in ECOFIX. J Clin Microbiol. 2000;38:2781-2783.
  11. McHardy IH, Wu M, Shimizu-Cohen R, et al. Detection of intestinal protozoa in the clinical laboratory. J Clin Microbiol. 2014;52:712-720.
  12. https://www.cdc.gov/dpdx/diagnosticprocedures/stool/specimencoll.html.
  13. https://catalog.hardydiagnostics.com/cp_prod/Content/pdf/Comments%20on%20TOTAL-FIX-HardyD.pdf.
  14. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis. 2017;65(12):e45-80. 
This FAQ is provided for informational purposes only and is not intended as medical advice. A clinician’s test selection and interpretation, diagnosis, and patient management decisions should be based on his/her education, clinical expertise, and assessment of the patient.
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Effective 11/05/2018 to present