Sputum Gram Stain Research Articles

A Cluster of Fulminant, Fatal Necrotizing Community-Associated Methicillin-Resistant Staphylococcus aureus Pneumonias

Community-associated methicillin-resistant Staphylococcus aureus is a frequent cause of skin and soft-tissue infections and is increasingly identified as a cause of pneumonia in immunocompetent patients. Panton-Valentine leukocidin, one of several leukocytotoxic peptides secreted by these cocci, is associated with increased virulence. A cluster of 3 unrelated patients with fatal pneumonia presumably caused by community-associated methicillin-resistant S aureus positive for Panton-Valentine leukocidin were treated in a 3-week period. Despite aggressive care and appropriate, timely administration of antibiotics, all 3 patients died. This article reviews the clinical and laboratory features suggestive of this lethal isolate, including unique findings on Gram stains of sputum.

Usefulness of gram-stained sputum obtained just after administration of antimicrobial agents as the earliest therapeutic indicator for evaluating the effectiveness of empiric therapy in community-acquired pneumonia caused by pneumococcus or Moraxella catarrhalis

We present here three cases in which morphological changes and/or a decreased number of Streptococcus pneumoniae or Moraxella catarrhalis could be observed in gram-stained sputum obtained just after the first administration of an antimicrobial agent. Case 1 was a 53-year-old man with pneumonia caused by gram-positive diplococcus, identified as S. pneumoniae, who was administered 2g of ampicillin over a period of 1h. Gram-stained sputum showed smaller or gram-negative pneumococci at the completion of administration of the agent, a decreased number of cocci at 1h after administration, and almost no cocci at 12h after the completion of administration. Case 2 was a 72-year-old woman with pneumonia caused by diplococcus, identified as S. pneumoniae, who was administered 2g of ampicillin over a period of 1h. Gram-stained sputum showed weakly stained, small cocci at the completion of administration of the agent and few cocci at 1h after the completion of administration. Case 3 was a 58-year-old woman with pneumonia caused by a gram-negative diplococcus, identified as Moraxella catarrhalis, who was administered 1g of cefotaxime over a period of 30min. Gram-stained sputum showed few extracellular cocci and some intracellular cocci inside neutrophils 1h after administration and no cocci 2h after the completion of administration. These three cases showed that gram-stained sputum obtained just after and/or 1h after administration of the first antimicrobial agent were suitable as the quickest therapeutic indicator of the effectiveness of empiric therapy, with the effectiveness of the agent being shown much earlier than with markers such as the white blood cell count and C-reactive protein level.

Innovative technology of clinical microbiology for respiratory tract infections:present and future

Respiratory tract infection remains a hot clinical topic.Disappointingly, routine microbiology tests do not meet the needs of target antimicrobial therapy.Widespread practice of antibiotic empiricism has lead to dramatic use of broad-spectrum antibiotics and antimicrobial resistance.The application of new clinical microbiology tests to identify the offending pathogen may allow administration of narrow spectrum antibiotic therapy.To do so,the full clinical microbiology armamentarium with newer point-of-care tests and polymerase chain reaction tests must be exploited.The return of the sputum gram stain and introduction of newer molecular tests would provide information for judicious selection of antimicrobials. Key words: Respiratory tract infections; Molecular diagnostic techniques; Microbiology

The usefulness of changing focus during examination using Gram staining as initial diagnostic clue for infective tuberculosis

Gram staining is a useful technique for detecting bacteria but is highly questionable in detecting Mycobacterium tuberculosis. Its detection generally requires special staining, such as Ziehl-Neelsen staining. We experienced three cases in which tuberculosis was first suggested by Gram staining of sputum or pus, confirmed by Ziehl-Neelsen staining, and diagnosed by polymerase chain reaction or culture. To find colorless tubercle bacilli in clinical samples with various organisms, varying the focus to slightly longer and shorter during study of the slides is indispensable. We present criteria for detecting infective pulmonary tuberculosis in Gram staining. First, in the ordinary focus, weakly stained, thin, gram-positive bacilli are found; second, with a slightly longer focus distance, the thin, cord-like, conspicuous gram-positive bacilli can be observed; and third, with a shorter focus distance, the gram-positive bacilli have changed into the brightened, colorless, or ghost ones. Four laboratory technologists each evaluated 20 Gram-stained samples after being lectured on the criteria, with no prior information about the sample. They accurately evaluated the presence of the bacilli in Gram-stained preparations in more than 90% of samples containing 3+ bacilli on Ziehl-Neelsen staining. Gram staining is available as an easy and rapid initial clue to recognize highly infective tuberculosis.

Indicators of bacterial infection in patients with acute exacerbation of chronic bronchitis for application in clinical trials of antibacterial drugs

This study examined the accuracy of: (a) patient symptoms; (b) microscopic examination of sputum purulence (>25 WBCs and <10 epithelial cells) and (c) microscopic examination of morphological bacterial cell types, in identifying bacterial infection in patients with an acute exacerbation of chronic bronchitis (AECB) for entry to clinical trials. Subjects had a worsening of at least two symptoms from: dyspnoea, sputum volume, and sputum purulence (Anthonisen Type 1 or 2 exacerbation). Sputum samples were collected from all subjects. A total of 97 sputum samples were evaluated. Overall, 58 (60%) subjects were culture-positive; 22 of 29 (76%) subjects with Type 2 exacerbation had a bacterial pathogen isolated compared with 36 of 68 (53%) Type 1 subjects. This difference was not statistically significant. Microscopically purulent samples were found to be significantly more likely to be culture-positive than non-purulent samples. However, the sensitivity (60%) and specificity (67%); and the positive predictive value (73%) and negative predictive value (53%) observed, means that this is not an ideal predictive test for clinical trials. A semi-quantitative approach to Gram staining was identified as a potential indicator of bacterial infection. Sputum specimens with one bacterial cell type present at >10 cells per field, or more than one cell type present with at least one type at a concentration of >25 cells per field, had a high proportion (91%) of culture-positive specimens. Symptoms alone are a poor indicator of bacterial infection. A semi-quantitative examination of a Gram-stained sputum preparation was the best indicator of bacterial infection. This finding may have relevance in the design of clinical trials of antibacterial drugs in AECB.

Invasive trichosporonosis due to &lt;i&gt; Trichosporon asahii&lt;/i&gt; in a non-immunocompromised host: A rare case report

A case of invasive Trichosporonosis due to Trichosporon asahii in an otherwise healthy young adult male presenting as meningoencephalitis and pneumonia is reported here. T. asahii was isolated from cerebrospinal fluid and sputum of the patient and morphologic forms of organism was also demonstrated on direct Gram stain of sputum. The isolate was identified as T. asahii. The patient partially responded to fluconazole therapy. Our case suggests that T. asahii can no longer be linked with Trichospronosis in immunocompromised patient alone and any case of meningitis needs thorough mycological workup for its correct etiological identification and appropriate management.

Sputum Culture Is Not Useful for Diagnosing CAP

Some guidelines recommend sputum Gram staining and culture for patients with suspected community-acquired pneumonia (CAP) who require admission. These

Routine Sputum Culture of Questionable Value in Community-Acquired Pneumonia

Recent study findings and professional guidelines have challenged the practice of using sputum Gram stain and culture to make decisions about antibiotic use for community-acquired pneumonia (CAP). To assess the value of sputum collection relative to CAP severity, researchers in Spain studied 1669 consecutive patients with evidence …

Give Gram Stain and Culture Another Chance

Sputum Gram stain and culture were once the gold standard of diagnosis in patients with pneumonia but have been discounted in recent years, with published sensitivity estimates ranging as low as 20% for both techniques. How often are external factors to blame for their poor performance? Researchers …

&lt;I&gt;Corynebacterium propinquum&lt;/I&gt;呼吸器感染症の3症例

Corynebacterium propinquum, which is included in Corynebacterium group ANF-3, exists as a commensal in the oral flora. This organism has not yet been fully recognized as a respiratory pathogen. We previously reported that the first case with respiratory infection caused by C. propinquum. On the other hand, Corynebacterium pseudodiphtheriticum is recognized as a causative organism in respiratory infections. Recently we experienced two cases with C. propinquum respiratory infections in our hospital. Three types of the onset such as a community-acquired infection, a hospital-acquired infection, and a nursing home acquired infections were observed. Our analysis indicated that gram staining of the purulent sputum is an essential tool to evaluate whether C. propinquum is a respiratory pathogen or not, because this organism is a commensal bacteria.

Community-Acquired Pneumonia

We initiated a prospective study with a group of practitioners to assess the etiology, clinical presentation, and outcome of community-acquired pneumonia in patients diagnosed in the outpatient setting. All patients with signs and symptoms suggestive of pneumonia and an infiltrate on chest X-ray underwent an extensive standard workup and were followed over 4 weeks. Over a 4-year period, 184 patients were eligible, of whom 170 (age range, 15-96 yr; median, 43 yr) were included and analyzed. In 78 (46%), no etiologic agent could be demonstrated. In the remaining 92 patients, 107 etiologic agents were implicated: 43 were due to "pyogenic" bacteria (39 Streptococcus pneumoniae, 3 Haemophilus spp., 1 Streptococcus spp.), 39 were due to "atypical" bacteria (24 Mycoplasma pneumoniae, 9 Chlamydia pneumoniae, 4 Coxiella burnetii, 2 Legionella spp.), and 25 were due to viruses (20 influenza viruses and 5 other respiratory viruses). There were only a few statistically significant clinical differences between the different etiologic categories (higher age and comorbidities in viral or in episodes of undetermined etiology, higher neutrophil counts in "pyogenic" episodes, more frequent bilateral and interstitial infiltrates in viral episodes). There were 2 deaths, both in patients with advanced age (83 and 86 years old), and several comorbidities. Only 14 patients (8.2%) required hospitalization. In 6 patients (3.4%), the pneumonia episode uncovered a local neoplasia. This study shows that most cases of community-acquired pneumonia have a favorable outcome and can be successfully managed in an outpatient setting. Moreover, in the absence of rapid and reliable clinical or laboratory tests to establish a definite etiologic diagnosis at presentation, the spectrum of the etiologic agents suggest that initial antibiotic therapy should cover both S. pneumoniae and atypical bacteria, as well as possible influenza viruses during the epidemic season.

Sputum Gram Stains Still Sometimes Worthwhile

Studies differ on the usefulness of the sputum Gram stain in diagnosing community-acquired pneumonia. Results of a large prospective study from Spain

Diagnostic value of Gram stain and culture of sputum and endotracheal aspirates in bacteremic pneumococcal pneumonia

Except for the positive control, none of the 64 samples was positive for HRV-5. This result suggests that HRV5 is not implicated in the pathogenesis of either primary or secondary Sjogren’s syndrome. Recently, a 933-bp retrovirus sequence amplified by reverse transcriptase P C R has been isolated from the saiivary gland of a patient with primary Sjogren’s syndrome [6]. This sequence was a part of a gene containing overlapping open reading frames encoding part of the protease and reverse transcriptase proteins. Phylogenetic analysis showed that this sequence was related to type B and type D retroviruses and came from an exogenous retrovirus designated HRV-5. This preliminary result suggested that HRV-5 may be associated with Sjogren’s syndrome. Our study provides no evidence that HRV-5 is involved in the etiology of primary or secondary Sjogren’s syndrome. Further studies are needed to investigate a pathogenic role for HRV-5, its epidemiology and its role in other human diseases.

Adult Bacteremic Pneumococcal Pneumonia in a Community Teaching Hospital, 1992-1996n

To review the clinical and laboratory findings of 108 adult patients with bacteremic pneumococcal pneumonia admitted to a community hospital and to determine the value of sputum Gram stains and cultures in the diagnosis of pneumococcal pneumonia in this setting. Using the laboratory logbooks to identify adult inpatients with pneumococcal bacteremia from January 1, 1992, to June 30, 1996, were reviewed medical records. We found 108 patients. There was an apparent increase in prevalence from 1995 to 1996 compared with 1992 to 1994. Patients included 44 men and 64 women. Ages ranged from 20 to 95 years (median, 70 years). The fatality rate was 24.1% and increased with advancing age (no patient younger than 45 years died, and 36.8% of patients aged 85-95 years died). Cigarette smoking, cardiovascular disease, chronic obstructive lung disease, malignant disease, and diabetes mellitus were major underlying conditions. Fever, dyspnea, and cough were the most common presenting symptoms. Sputum Gram stain was useful in the diagnosis when moderate to abundant Gram-positive diplococci were seen. Sputum culture was less useful. Factors associated with higher fatality rate were being 65 years of age or older, APACHE II (Acute Physiologic and Chronic Health Evaluation II) score greater than 15, intensive care unit admission, low or normal leukocyte count, thrombocytopenia, renal dysfunction, diffused infiltrates on chest radiography, bilateral pneumonia, and sputum culture positive for Streptococcus pneumoniae. We found a recent increase in the prevalence of bacteremic pneumococcal pneumonia in adults. Gram stain of sputum is useful, but sputum culture is less sensitive in the diagnosis of pneumococcal pneumonia. The fatality rate remains high. More effort should be made at prevention using pneumococcal immunization.

The intensive care management, mortality and prognostic indicators in severe community-acquired pneumococcal pneumonia.

To determine mortality and factors that might predict outcome in severe community-acquired pneumococcal pneumonia treated by a standard protocol. Prospective, non-concurrent study. Respiratory intensive care unit (ICU) in a teaching hospital. 63 patients who were diagnosed by positive blood culture or Gram stain and culture of sputum or tracheal aspirate were included. Clinical features, severity scores including Acute Physiology and Chronic Health Evaluation (APACHE) II, organ failure and lung injury scores, and the clinical course in the ICU were documented; 79% of patients required mechanical ventilation. Bacteraemia was present in 34 patients (54%); there were no distinguishing clinical features between bacteraemic and non-bacteraemic cases. The overall mortality was 21%, with only 5 deaths (15% mortality) in the bacteraemic group. Shock and a very low serum albumin (< 26 g/l) were the only clinical features that differentiated survivors from non-survivors; lung injury, APACHE II and multiple organ failure scores were all predictive of outcome. The positive predictive value and specificity in predicting death in individuals for the modified British Thoracic Society rule 1 were 26 and 64%; APACHE II > 2057 and 88%; > 2 organ failure 64 and 92%; and lung injury > 233 and 73%, respectively. These results suggest that even in bacteraemic cases mortality should be below 25% with intensive care management and that conventional scoring systems, while predictive of group mortality, are unreliable in individuals.

Early recognition of Streptococcus pneumoniae in patients with community-acquired pneumonia.

The objective of this study was to assess the predictive value of signs, symptoms, and rapidly available laboratory parameters for pneumococci in community-acquired pneumonia (CAP). A prospective study on patients with CAP who were admitted to hospital was conducted. Clinical and laboratory data were collected according to a protocol. Two hundred sixty-eight patients aged 18 years or older, not living in a nursing home or not admitted to hospital within one week of this admission, with a new infiltrate on the chest radiograph consistent with pneumonia were included. According to microbiological and serological tests, patients were allocated to one of two aetiological groups, Streptococcus pneumoniae or "other pathogens". Seventy-three variables were examined for a correlation with one of the aetiological categories by means of univariate and multivariate analysis. The resulting discriminant function was considered a clinical test for which posttest probabilities for pneumococcal pneumonia were calculated. Streptococcus pneumoniae was demonstrated in 79 patients and other pathogens in 83; no pathogens were detectable in 106 patients. The variables "cardiovascular disease", "acute onset", "pleuritic pain", "gram-positive bacteria in the sputum Gram stain", and "leucocyte count" correctly predicted the cause of CAP in 80% of all cases in both groups. Depending on the prevalence of Streptococcus pneumoniae, posttest probabilities for pneumococcal pneumonia were up to 90%. It is concluded that data on history, together with the result of the Gram stain of sputum and the leucocyte count, can help to distinguish Streptococcus pneumoniae from other pathogens causing CAP.

Empiric Outpatient Management of HIV-Related Pneumonia: Economical or Unwise?

Editorials15 February 1996Empiric Outpatient Management of HIV-Related Pneumonia: Economical or Unwise?Henry Masur, MD and James Shelhamer, MDHenry Masur, MDNational Institutes of Health, Bethesda, MD 20892.Search for more papers by this author and James Shelhamer, MDNational Institutes of Health, Bethesda, MD 20892.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-124-4-199602150-00011 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail When immunologically normal patients present with pneumonia that is not severe enough to require immediate hospitalization, most health care providers initiate empiric oral therapy with a macrolide or tetracycline after a radiologic and laboratory evaluation that rarely extends further than a chest radiograph, leukocyte count determination, and perhaps a Gram stain of sputum [1]. Empiric therapy is directed against the common, treatable, community-acquired pathogens, such as Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella species.For immunosuppressed patients, health care providers have hesitated to use such an empiric management approach because the range of potential pathogens is so ...

74-Year-Old Woman With Dyspnea, Fever, and Cough

74-Year-Old Woman With Dyspnea, Fever, and Cough

Corynebacterium pseudodiphtheriticum: A Respiratory Tract Pathogen

From January 1986 through February 1993, there were 16 episodes of respiratory infection due to Corynebacterium pseudodiphtheriticum in 13 patients. The ages of patients ranged from 24 to 77 years; the ratio of male to female patients was 3:1. One patient had three episodes of infection, and another patient had two. In one patient, who died of disseminated intravascular coagulation, the level of IgG was low. One patient was receiving prednisolone when the infection occurred. In two cases a mixed infection with Streptococcus pneumoniae was noted. Sputum cultures yielded C. pseudodiphtheriticum (> or = 10(7) cfu/mL). An increased neutrophil response in the sputum of infected patients was observed. Gram staining and electron microscopy of sputum showed phagocytosis of C. pseudodiphtheriticum by the neutrophils. ELISAs also showed an increase in the level of immunoglobulin against C. pseudodiphtheriticum after infection. Tests for determination of MICs of antibiotics revealed that C. pseudodiphtheriticum isolates were susceptible to ampicillin, amoxycillin/clavulanic acid, cefazolin, cefuroxime, ceftazidime, and imipenem. All strains were resistant to nalidixic acid; borderline susceptibility to ofloxacin, norfloxacin, and ciprofloxacin was noted. We suggest the use of beta-lactam antibiotics in the treatment of infection with C. pseudodiphtheriticum.

Diagnosis of Respiratory Tract Infection and the Use of the Laboratory

Lower respiratory tract infections continue to be among the most common illnesses requiring medical attention with considerable morbidity and morality. Clinical features, including underlying conditions, presenting signs and symptoms, basic laboratory investigations and chest roentgenograms, are not sufficiently precise to infer an etiological agent. These investigations do permit an assessment of severity of illness and can assist in stratification of patients into high risk groups. Properly performed and interpreted Gram stain of sputum is still useful in the initial assessment of these patients, but sputum cultures are less helpful. Blood cultures should be drawn in patients ill enough to require hospitalization, but the yield is low, Pneumococcal antigen testing and serological studies do not add to the routine management of patients with pneumonia. In patients with nosocomial pneumonia, the diagnosis will be established by a synthesis of clinical, roentgenographic and simple laboratory results such as sputum analysis and blood culture. Invasive investigations should be reserved for critically ill patients.