Semiquantitation of bacteria in sputum gram stains

In many clinical laboratories, bacteria seen in Gram-stained sputum smears are reported semiquantitatively, using a three- or four-category scale consisting of ratings such as numerous, moderate, rare, and none seen. The consistency with which these categories are assigned was evaluated by repeatedly presenting coded smears to seven experienced microbiology technologists. Technologists rated the same smear twice, pairs of smears prepared from the same specimen, and smears prepared after specimen refrigeration. Agreement was assessed with the weighted kappa test. Semiquantitation of gram-negative rods, gram-positive diplococci, and gram-positive cocci in clusters all showed poor reproducibility (kappa = 0.32, 0.34, and 0.17, respectively). Twenty-four percent of paired ratings differed by two or more categories. Lack of reproducibility was due mainly to the inability of the technologists to render a consistent rating when viewing the same slide on separate occasions (P less than 0.001). Variation in the rating styles of different technologists, differences between smears prepared from the same specimen, and specimen refrigeration tended to further decrease the consistency of ratings, but the reductions were not statistically significant. The quantity of potentially pathogenic bacteria in sputum smears is not estimated consistently with standard microscopy procedures and should not be reported.