Extensive Microbiological Testing Research Articles

Diffuse Alveolar Hemorrhage in Hematopoietic Cell Transplantation.

Diffuse alveolar hemorrhage (DAH) is a morbid syndrome that occurs after autologous and allogeneic hematopoietic cell transplantation in children and adults. DAH manifests most often in the first few weeks following transplantation. It presents with pneumonia-like symptoms and acute respiratory failure, often requiring high levels of oxygen supplementation or mechanical ventilatory support. Hemoptysis is variably present. Chest radiographs typically feature widespread alveolar filling, sometimes with peripheral sparing and pleural effusions. The diagnosis is suspected when serial bronchoalveolar lavages return increasingly bloody fluid. DAH is differentiated from infectious causes of alveolar hemorrhage when extensive microbiological testing reveals no pulmonary pathogens. The cause is poorly understood, though preclinical and clinical studies implicate pretransplant conditioning regimens, particularly those using high doses of total-body-irradiation, acute graft-versus-host disease (GVHD), medications used to prevent GVHD, and other factors. Treatment consists of supportive care, systemic corticosteroids, platelet transfusions, and sometimes includes antifibrinolytic drugs and topical procoagulant factors. Therapeutic blockade of tumor necrosis factor-α showed promise in observational studies, but its benefit for DAH remains uncertain after small clinical trials. Even with these treatments, mortality from progression and relapse is high. Future investigational therapies could target the vascular endothelial cell biology theorized to contribute to alveolar bleeding and pathways that contribute to susceptibility, inflammation, cellular resilience, and tissue repair. This review will help clinicians navigate through the limited evidence to diagnose and treat DAH, counsel patients and families, and plan for future research.

Nanoapatites Doped and Co-Doped with Noble Metal Ions as Modern Antibiofilm Materials for Biomedical Applications against Drug-Resistant Clinical Strains of Enterococcus faecalis VRE and Staphylococcus aureus MRSA.

The main aim of our research was to investigate antiadhesive and antibiofilm properties of nanocrystalline apatites doped and co-doped with noble metal ions (Ag+, Au+, and Pd2+) against selected drug-resistant strains of Enterococcus faecalis and Staphylococcus aureus. The materials with the structure of apatite (hydroxyapatite, nHAp; hydroxy-chlor-apatites, OH-Cl-Ap) containing 1 mol% and 2 mol% of dopants and co-dopants were successfully obtained by the wet chemistry method. The majority of them contained an additional phase of metallic nanoparticles, in particular, AuNPs and PdNPs, which was confirmed by the XRPD, FTIR, UV–Vis, and SEM–EDS techniques. Extensive microbiological tests of the nanoapatites were carried out determining their MIC, MBC value, and FICI. The antiadhesive and antibiofilm properties of the tested nanoapatites were determined in detail with the use of fluorescence microscopy and computer image analysis. The results showed that almost all tested nanoapatites strongly inhibit adhesion and biofilm production of the tested bacterial strains. Biomaterials have not shown any significant cytotoxic effect on fibroblasts and even increased their survival when co-incubated with bacterial biofilms. Performed analyses confirmed that the nanoapatites doped and co-doped with noble metal ions are safe and excellent antiadhesive and antibiofilm biomaterials with potential use in the future in medical sectors.

Fungal Diagnostic Stewardship in Bronchoscopy Specimens for Immunocompetent Patients in the Intensive Care Unit

ObjectiveTo evaluate the diagnostic yield of fungal smears and cultures from bronchial lavage and wash specimens obtained from immunocompetent patients in the intensive care unit (ICU) because respiratory tract samples from patients in the ICU often undergo extensive microbiological testing. Patients and MethodsIn total, we enrolled 112 immunocompetent adult patients treated in the medical and surgical ICU between July 1, 2016, and June 30, 2017. We evaluated whether the results of fungal smears and cultures of specimens obtained from bronchoscopy and bronchoalveolar lavage changed patient care. ResultsIn total, 131 bronchoscopic specimens and 31 bronchoalveolar lavage specimens were tested for fungi. Cultures were held for an estimated 4680 culture-days. Two results changed patient therapy. In both cases, other routine tests provided the same information as fungal culture before these results were returned. ConclusionIn immunocompetent, critically ill patients, fungal culture of respiratory tract specimens does not add diagnostic value. Routine fungal culture of respiratory tract specimens should be discouraged in this population.

Severe Rhabdomyolysis Associated With RSV.

Severe rhabdomyolysis is associated with morbidity and mortality. We report on a previously well male who developed severe rhabdomyolysis, sepsis, and multi-organ failure. The patient made a complete recovery. Extensive microbiological testing was only positive for RSV, making this the first reported case of adult RSV-related rhabdomyolysis in the literature.

Atypical aetiology in patients hospitalised with community-acquired pneumonia is associated with age, gender and season; a data-analysis on four Dutch cohorts.

BackgroundMicroorganisms causing community-acquired pneumonia (CAP) can be categorised into viral, typical and atypical (Legionella species, Coxiella burnetii, Mycoplasma pneumoniae, and Chlamydia species). Extensive microbiological testing to identify the causative microorganism is not standardly recommended, and empiric treatment does not always cover atypical pathogens. In order to optimize epidemiologic knowledge of CAP and to improve empiric antibiotic choice, we investigated whether atypical microorganisms are associated with a particular season or with the patient characteristics age, gender, or chronic obstructive pulmonary disease (COPD).MethodsA data-analysis was performed on databases from four prospective studies, which all included adult patients hospitalised with CAP in the Netherlands (N = 980). All studies performed extensive microbiological testing.ResultsA main causative agent was identified in 565/980 (57.7 %) patients. Of these, 117 (20.7 %) were atypical microorganisms. This percentage was 40.4 % (57/141) during the non-respiratory season (week 20 to week 39, early May to early October), and 67.2 % (41/61) for patients under the age of 60 during this season. Factors that were associated with atypical causative agents were: CAP acquired in the non-respiratory season (odds ratio (OR) 4.3, 95 % CI 2.68–6.84), age <60 year (OR 2.9, 95 % CI 1.83–4.66), male gender (OR 1.7, 95 % CI 1.06–2.71) and absence of COPD (OR 0.2, 95 % CI 0.12–0.52).ConclusionsAtypical causative agents in CAP are associated with respectively non-respiratory season, age <60 years, male gender and absence of COPD. Therefore, to maximise its yield, extensive microbiological testing should be considered in patients <60 years old who are admitted with CAP from early May to early October.Trial registrationNCT00471640, NCT00170196 (numbers of original studies).Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-1641-9) contains supplementary material, which is available to authorized users.

A 13-Year-Old Girl with Recurrent Inguinal Lymphadenopathy

PEDIATRIC ANNALS 43:4 | APRIL 2014 Editor’s note: Each month, this department features a discussion of an unusual diagnosis in areas including genetics, radiology, or dermatology. A description and images are presented, followed by the diagnosis and an explanation of how the diagnosis was determined. As always, your comments are welcome via email at pedann@Healio.com. For diagnosis, see page 137 A13-year-old girl was referred to our hospital for diagnostic evaluation of recurrent inguinal lymphadenopathy. Eleven months before, she had been admitted to another institution with non-specific right inguinal lymphadenopathy associated with bi-monthly intermittent mild fever and hypochromic microcytic anemia, elevation of C-reactive protein (CRP), and hypergammaglobulinemia at blood screen. After excluding infectious causes by blood exams, diagnostic lymph nodal excisional biopsy was performed to exclude malignant etiologies. Histological examination showed nonspecific lymphoid hyperplasia, and the girl was discharged with the diagnosis of non-specific lymphadenopathy and irondeficiency anemia, with prescription of iron supplements. During the following months, follow-up blood exams showed persistence of anemia. At admission to our institution, the physical examination was unremarkable except for the presence of a mass in the inner upper aspect of the right thigh. An accurate history revealed that the mass had reappeared soon after the biopsy; the lesion was below the biopsy area and had enlarged slowly during the course of 10 months. It did not show any inflammatory signs (calor, dolor, rubor, or loss of function); had a solid, woody consistency; and was not movable. During the hospital stay, initial diagnostic workup confirmed persistence of microcytic anemia — interpreted as anemia of chronic disease — elevation of CRP and erythrocyte sedimentation rate (ESR) and hypergammaglobulinemia (Table 1). Considering the elevated inflammatory markers, antibiotic therapy was started. Nevertheless, all of the extensive microbiological tests performed both on blood and on bone marrow were negative. Indeed, an underlying infectious disease was excluded (Table 1). Auto-inflammatory causes and autoimmune diseases responsible for recurrent lymphadenopathy were also excluded because serum auto-antibodies screening results were negative (Table 1). An inguinal ultrasound scan revealed the presence of a 4 × 3 × 4 cm oval lesion in the internal upper side of the right thigh. The edges of the mass appeared to be well-defined, and it was predominantly Case Challenge

How Risky Are Pinholes in Gloves? A Rational Appeal for the Integrity of Gloves for Isolators

Isolators provide a high degree of protection for the product and/or the environment and operators in pharmaceutical production, as well as for analytical and sterility testing. Gloves allow for performing testing and for easy access to the process. Due to their nature-thin plastic, highly flexible-and their risk of puncture or rupture, they are regarded as one of the main potential sources of contamination. Glove integrity testing is therefore a main issue and has been addressed by many regulations such as those imposed by the USP, U.S. Food and Drug Administration, and Pharmaceutical Inspection Convention. This paper presents a short overview of different glove integrity test procedures and their ability to detect leaking gloves. Additionally, extensive microbiological tests have been performed to give more evidence and cross-correlation to physical testing. Most of the physical tests have limitations either in detecting pinholes and/or they are difficult to implement for routine testing. Microbiological tests are only applicable for evaluation and validation purposes, but not for routine testing, because they are time-consuming and do not allow immediate action. Routine visual verification of gloves by trained personnel turns out to be a very reliable technique. Additional microbiological tests supported by microbiological environmental monitoring helped to develop a new concept presented here on how to handle gloves with pinholes. It is proposed not to automatically consider a pinhole in a glove as a breach in isolator integrity, but to consider any action in view of controlling and monitoring the effective bioload on the outside of the gloves. With the combination of semi-automatic physical testing with independent protocol, visual inspection, and control of bioload through microbiological environmental monitoring potential contamination, risks can be minimized and maximum safety maintained. Isolators are enclosure designs to protect critical handling and process steps in pharmaceutical environments. They provide a high degree of protection for product and/or environment and operators against particles, potentially hazardous active principles, and microbial load. Gloves mounted on windows and doors of the isolator allow for manipulation, performing testing, and access to the process. Due to their nature and their use with risk of puncture or rupture, they are regarded as a potential source for contamination. Glove integrity testing has therefor been addressed by regulations such as those imposed by the USP and the Food and Drug Administration. This paper presents a short overview of various glove integrity test procedures and their ability to detect leaking gloves. Most of the tests have limitations either in detecting pinholes and/or they are difficult to implement for routine testing. Routine visual verification of gloves by trained personnel turns out to be a very reliable technique. Additional microbiological tests led to a new concept presented here on how to handle gloves with pinholes and how to take action. With this approach, risks can be minimized and maximum safety maintained by controlling and monitoring the effective bioload on the outside of the gloves.

Diagnostic Strategies for Healthcare-Associated Pneumonia

The first point of a good diagnostic strategy for healthcare-associated pneumonia (HCAP) is correct classification of patients with specific criteria, as suggested by the last American Thoracic Society/ Infectious Diseases Society of America (ATS/IDSA) guidelines. However, clinical practice and recent literature have suggested new risk factors for multidrug-resistant infection (MRI): the presence of permanent indwelling devices, prior antibiotic use in the last 3 months, chronic and advanced pulmonary diseases (chronic obstructive pulmonary disease, bronchiectasis, etc.), history of alcoholism, and immunosuppression. The clinical presentation in HCAP patients is often unusual (mild respiratory symptoms and frequent extrapulmonary manifestations) due to different factors: advanced age, neurological disorders, and multiple chronic comorbidities. Moreover, HCAP commonly presents a worse clinical course than community-acquired pneumonia, a prolonged length of stay, and a mortality rate close to hospital-acquired pneumonia. Chest radiography and routine laboratory markers (including C-reactive protein) are always needed for clinical evaluation and severity assessment. The clinical use of new biomarkers of infection and sepsis (procalcitonin, etc.) is currently being investigated. Extensive microbiological testing to overcome the high prevalence of MRI in HCAP, including urinary antigens for Legionella and Streptococcus pneumoniae; blood cultures; Gram staining and low respiratory tract secretions (sputum, tracheobronchial aspirate, fibrobronchial aspirate, protected specimen brush, bronchoalveolar lavage); and cultures for aerobic, anaerobic, mycobacterial, and fungal pathogens are recommended, whereas the indication for serology tests for respiratory viruses and atypical pathogens is low. By contrast, the new polymerase chain reaction-based techniques for the rapid identification (2 to 4 hours) of microbial pathogens in respiratory samples (nasopharyngeal swab, bronchoalveolar lavage) seem to be the most innovative future perspective in the diagnostics of HCAP.

A message in a bottle: a case report

In intensive care medicine, correctly identifying the underlying cause of illness in patients presenting to critical care units is often the key to applying a successful therapeutic regimen. We report on a patient in whom, despite anamnestic hints, the correct diagnosis was obscured by misleading laboratory results. A previously healthy male physician aged 36 years presented to the emergency room because of balance disturbances and gait problems. These symptoms began a few hours after ingestion of remarkably bitter tasting mineral water in the office of the research laboratory. Soon after admission, the patient became progressively confused and reported visual hallucinations; his neurological symptoms rapidly worsened. The findings of initial diagnostic tests, including blood tests, microbiological and toxicological screening, cranial computed tomography scanning and magnetic resonance imaging, were unremarkable. Nevertheless, the patient soon had to be sedated and intubated to prevent aspiration. Within the next 24 hours the patient developed multiple organ failure with renal, liver, respiratory and circulatory failure, and signs of disseminated intravascular coagulation and rhabdo-myolysis. Severe sepsis of unknown cause was presumed, and empirical treatment with antibiotics and a course of activated protein C was initiated; clinical management required high amounts of fluids and catecholamines. Extensive microbiological tests, including repeated blood and sputum cultures, serology for leptospira and borrelia, and polymerase chain reaction for herpes simplex virus DNA, were unfruitful. On day 3 after admission repeated toxicological examination of blood samples and the mineral water revealed contamination with acrylamide at high concentrations. Treatment with antibiotics and activated protein C was immediately terminated, and therapy with high doses of N-acetylcysteine was initiated to replenish hepatic glutathione stores. Between days 4 and 8 cardiac function gradually returned to normal, and platelet count, coagulation parameters and renal function also improved. On day 6 the patient was extubated; he exhibited signs of severe peripheral polyneuropathy with initial tetraplegia, bilateral affection of the vagal nerve and resulting laryngoplegia. When he was transferred for further neurological rehabilitation after 21 days of intensive care, the patient was still suffering from occasional confusion and hallucinations and was unable to walk. Acute acrylamide intoxication in humans is a rare event that has been reported only once in the literature [1]. The diagnosis should be considered in individuals with access to acrylamide (for instance, those working in molecular laboratories) who develop symptoms of central nervous system disturbances followed by cardiovascular, respiratory and other organ manifestations [2]. Gas chromatographic tandem mass spectrometry has been proven to be a sensitive method for the detection of acrylamide [3]. The clinical picture of acrylamide intoxication might suggest severe sepsis with acute onset, but this diagnosis should be challenged as long as it remains a working hypothesis.

Diagnosis of a Critical Respiratory Illness Caused by Human Metapneumovirus by Use of a Pan-Virus Microarray

A pan-virus DNA microarray (Virochip) was used to detect a human metapneumovirus (hMPV) strain associated with a critical respiratory tract infection in an elderly adult with chronic lymphocytic leukemia. This infection had previously eluded diagnosis despite extensive microbiological testing for possible etiologic agents. The patient's hMPV strain did not grow in viral culture, and only one of five specific reverse transcription-PCR assays for hMPV was positive.