Sputum Gram Research Articles

Validation of sputum gram stain and culture for diagnosis of pneumonia in critically iii patient: a retrospective observational study

Validation of culture results based on direct gram stain plays a vital role in differentiating pathogens' cause of infection or colonization in pneumonia cases. Our study aims to evaluate the validation of diagnostic microbiology based on gram stain and culture compared to chest radiography in critically ill patients with suspected pneumonia. This was a single-center retrospective data analysis in the Intensive Care Unit at Secondary Care Hospital in Central Java. The quality of sputum was determined by using a Modification Criteria of Bartlett and a Semi-Quantitative Score. The results of sputum culture with neutrophils count > 10 and bacterial count > 2 per field in Gram stain were considered the presumptive pathogen. Seventy sputum specimens were collected; however, only 58 were selected for further analysis in this study. In sputum specimens with Bartlett score +2 and Semi-Quantitave score 3 or 4, the chest x-ray results of all patients had positive infiltrates (100%). Diagnostics accuracy of the results of clinical microbiologist examination with chest X-ray had a sensitivity of 90%, specificity of 60.71 %, accuracy of 65.5%, a positive predictive value of 61.36%, a negative predictive value of 78.6%. It was concluded that validation of diagnostic microbiology based on gram stain and culture had susceptible and adequately specific results to differentiate between presumptive pathogens from colonization in pneumonia cases.

Gram Stain and Culture of Sputum Samples Detect Only Few Pathogens in Community-Acquired Lower Respiratory Tract Infections: Secondary Analysis of a Randomized Controlled Trial.

Identification of the bacterial etiology of lower respiratory tract infections (LRTI) is crucial to ensure a narrow-spectrum, targeted antibiotic treatment. However, Gram stain and culture results are often difficult to interpret as they depend strongly on sputum sample quality. We aimed to investigate the diagnostic yield of Gram stain and culture from respiratory samples collected by tracheal suction and expiratory technique from adults admitted with suspected community-acquired LRTI (CA-LRTI). In this secondary analysis of a randomized controlled trial, 177 (62%) samples were collected by tracheal suction, and 108 (38%) by expiratory technique. We detected few pathogenic microorganisms, and regardless of sputum quality, there were no significant differences between the sample types. Common pathogens of CA-LRTI were identified by culture in 19 (7%) samples, with a significant difference between patients with or without prior antibiotic treatment (p = 0.007). The clinical value of sputum Gram stain and culture in CA-LRTI is therefore questionable, especially in patients treated with antibiotics.

Co-Infection with Cryptosporidium meleagridis and Enterocytozoon bieneusi in an HIV+ Colombian Patient

A 44-year-old human immunodeficiency virus-infected (HIV+) female with severe immunodeficiency Category 3 (C3) diagnosed in 2010 was admitted to hospital with acute diarrhoea. She was non-adherent to antiretroviral therapy (ART) and had a previous suspicion of respiratory symptoms with a cough that had been persisting for 15 days. Clinical examination revealed severe immune deterioration (viral load: 109,655 copies/mL; CD4+ count: 14 cells/mm3), respiratory symptoms (negative sputum Gram stain and tuberculosis culture), and neurological deterioration (serological assays negative for Cryptococcus spp. and Toxoplasma gondii). A coproculture was negative for Campylobacter spp., Salmonella spp., and Shigella spp. Ziehl–Neelsen staining of faecal smears revealed the presence of Cryptosporidium spp. oocysts. PCR testing and sequencing confirmed a concomitant infection with C. meleagridis and Enterocytozoon bieneusi. The patient was treated with metronidazole (500 mg every 8 h for 5 days) and nitazoxanide (500 mg every 12 h for 14 days). After requesting voluntary discharge and abandoning ART and parasiticidal treatments, she experienced a dramatic deterioration of her state of health and contact with her was lost. Our results have demonstrated that molecular-based testing improves the detection of opportunistic pathogens that are difficult to detect by routine microscopy, allows for transmission dynamics investigations, and assists in choosing the best chemotherapeutical option.

Value of sputum Gram stain, sputum culture, and bronchoalveolar lavage fluid Gram stain in predicting single bacterial pathogen among children with community-acquired pneumonia

BackgroundCurrently, the microbial etiology of community-acquired pneumonia in children remains challenging. While Gram stain and sputum culture are commonly used to detect bacterial pathogens, it is unclear whether these approaches can predict single pathogen from bronchoalveolar lavage fluid (BALF) culture.MethodsA retrospective study involving 287 children hospitalized for pneumonia was conducted. Sputum specimens were collected on admission; and BALF specimens were collected within 24 h after admission. Taking BALF culture as the reference standard, the sensitivity and specificity of Sputum Gram stain (SGS), sputum culture, and BALF Gram stain (BGS) were calculated. The agreement between these approaches and BALF culture was compared using kappa statistics.ResultsFor SGS, the specificity was 23%. The overall sensitivity was 70%, including 87% for Gram-positive (G+) cocci, 56% for Gram-negative (G-) cocci, and 50% for G-bacilli. For sputum culture, the specificity was 70%. The overall sensitivity was 64%, including 71% for Streptococcus pneumoniae, 71% for Moraxella catarrhalis, and 64% for Haemophilus influenzae. For BGS, the specificity was 71%. The overall sensitivity was 60%, including 77% for G+cocci, 38% for G-cocci, and 44% for G-bacilli. While SGS had poor agreement with BALF culture, both sputum culture and BGS had moderate agreement with BALF culture.ConclusionsBoth sputum culture and BGS are helpful in predicting single bacterial pathogen from BALF culture among children with community-acquired pneumonia. Sputum cultures and BGS can provide early clues for BALF pathogen when BALF culture results are pending or bronchoscopy is not performed.

Analysis Of Sputum Culture And Gram Staining In Subjects With Lower Respiratory Tract Infection: A Microbiological Assessment

Background: To diagnose the LRTIs (lower respiratory tract infections) in the microbiological laboratory, the most frequentlyemployed method is the microscopic examination of expectorated sputum samples. These sputum samples are generallycontaminated with the normal flora that is resident of the oropharynx. To manage and diagnose lower respiratory tract infections,sputum collection, culture, and microscopy are vital.Aim: The present study was conducted to analyse the sputum culture and gram staining in subjects with lower respiratory tractinfections.Materials & Methods: The study included 140 sputum samples where culture and gram-staining were done. Microscopic examinationof the gram-stained sputum smears was done to assess the presence of epithelial cells, pus cells, or organisms. Bartlett’s gradingsystem was used to assess the quality of the expectorated sputum samples. Bacterial isolates were identified using standard protocols.On Mueller Hinton agar, the Kirby Bauer disc diffusion method was used for testing antibiotic susceptibility.Results: In 140 processed sputum samples, it was seen that there were 55% (n=77) acceptable samples and 45% (n=63) nonacceptable samples. Total potential pathogens obtained from the study samples were 62.85% (n=88) samples were from acceptablesamples, in 76.13% (n=67) potential pathogens were isolated, whereas, from non-acceptable samples, potential pathogens wereisolated from 23.86% (n=21) samples. On assessing the organisms isolated from the study subjects, it was seen that the most commonisolated organism was Klebsiella pneumoniae isolated from 28.40% (n=25) samples followed by Pseudomonas aeruginosa in 14.77%(n=13) samples, Staphylococcus aureus in 13.63% (n=12) study samples, Escherichia coli in 12.5% (n=11) samples, Streptococcuspyogenes in 7.95% (n=7) samples, Klebsiella oxytoca in 6.81% (n=6) study samples, Streptococcus pneumoniae in 5.68% (n=5)study samples, Acinetobacter baumannii, Citrobacter koseri, and Enterobacter aerogenes in 3.40% (n=3) study samplesConclusion: The present study concludes that in subjects with Lower respiratory tract infections, good quality sputum must beobtained, and initial screening of the sputum should be done to obtain.

S2917 Acute Alcoholic Hepatitis With Portal Hypertension Complicated by Tuberculous Peritonitis and Ascites

Introduction: Peritonitis related to tuberculosis (TB) infection is rare in the US and normally associated with immunocompromised states. We present a patient found to have TB peritonitis during evaluation of alcoholic hepatitis without evident lung disease. Case Description/Methods: The patient is a 39 yo male born in Mexico with no medical history who presented with three days of abdominal distention, jaundice, and fevers in the setting of alcohol use disorder. He had no other historic risk factors for TB or cough. Exam was remarkable for a distended abdomen. Laboratory results showed leukocytosis, total bilirubin 3.5 (mg/dL), alkaline phosphatase 295 (U/L), AST 147 (U/L), ALT 62 (U/L), and positive quantiferon gold. Chest x-ray had no pulmonary lesions. Ascites fluid studies were significant for high white count (2214 k/uL) with lymphocytic predominance (91%). The serum ascites albumin gradient was consistent with portal hypertension, and ascites total protein was elevated (3.6 g/dL). Fluid ADA was positive. Cross sectional imaging of the abdomen showed omental caking, peritoneal lining nodularity, and hepatosplenomegaly. Fine needle aspiration of the peritoneum showed necrotizing and non-necrotizing granulomas. Sputum gram stain was negative for acid fast bacilli although sputum and ascites cultures ultimately grew TB (Figure). The patient was started on rifampin, isoniazid, pyrazinamide and ethambutol for TB and abstained from further alcohol use. Three months after discharge, jaundice and ascites had resolved and his liver tests had significantly improved. Discussion: TB peritonitis makes up 4-10% of extrapulmonary TB infections. Though rare in the US, it has a high mortality rate (50-60%). Diagnosis can be complicated by difficulty isolating the organism and culture results can take weeks. TB peritonitis can be supported by ascites fluid studies with elevated lymphocyte count, total protein, and positive ADA; although for more definitive diagnosis peritoneal biopsy should be considered. This patient represents a unique confluence of portal hypertension related ascites, induced by acute alcoholic hepatitis, along with TB peritonitis. It is possible that transient immunosuppression from alcoholic hepatitis served as a risk factor in reactivation and dissemination of latent TB. An index of suspicion for TB infection, based on his foreign birth, along with his abnormal ascites fluid studies, led to the peritoneal biopsy and ultimate culture diagnosis of his infection that might otherwise have been overlooked.Figure 1.: Nodularity of the peritoneal lining.

July 2021 Critical Care Case of the Month: When a Chronic Disease Becomes Acute

No abstract available. Article truncated after 150 words. History of Present Illness A 32-year-old woman with no known past medical history presented with progressive shortness of breath for 2 weeks. She denied having a cough, fever, or chills, but she did have a one-month history of fatigue, weakness, and painful rashes on her hands. PMH, SH, and FH • No known past medical history • Former tobacco user (quit 2 years prior to admission) • No drug use • Worked as an office assistant • Has two pet dogs and four pet macaws • No family history of lung disease • Not taking any prescription medications Physical Exam • BP: 116/65, Pulse: 105, T: 37°C, RR: 28, SpO2: 89% on HHFNC (60L; 100%) • Pulmonary: Tachypneic, in respiratory distress, crackles throughout • Cardiovascular: Tachycardic but regular, no murmurs • Extremities: No edema • Skin: Palms with purplish discoloration and erythematous papules Which of the following should be done next? 1. CT Chest 2. COVID-19 testing 3. Sputum gram stain and …

Study of quality of sputum being submitted for smear examination

Background: One of the key factors influencing the results of sputum smear microscopy is the quality of sputum being submitted. Methods: This is a prospective study of quality of sputum specimens being submitted for smear examination under Revised National Tuberculosis Control Programme and its impact on diagnostic yield of sputum smear microscopy. Based on sputum Gram's staining results, the submitted specimen was classified as 'sputum' and 'saliva'. Results: During the period 21 April to 20 June 2012, 238 sputum specimens submitted for evaluation were studied. Of these, 196 (82%) specimens were submitted for diagnosis and 42 (18%) specimens were obtained during follow-up evaluation. Overall, 42/238 (17.6%) specimens were in fact 'saliva' and not sputum. Among specimens submitted for diagnosis (n = 196), 28/167 (16.8%) specimens reported as 'sputum acid-fast bacilli (AFB) negative' were in fact saliva. Among the specimens submitted on follow-up examination (n = 42), 14 of the 38 (36.8%) specimens reported as 'sputum AFB negative' were actually saliva. A significantly higher proportion of sputum smears submitted on follow-up examination were actually 'saliva' as compared to specimens submitted for diagnosis (14/42 [33.3%] vs. 28/196 [14.3%], χ2 = 6.738; P = 0.014). None of the saliva samples were reported to be 'sputum positive'. Conclusions: The fact that a significant proportion of specimens that are reported smear negative are in fact saliva and not sputum highlights the importance of sputum quality in smear microscopy results. Follow-up specimens are more likely to be saliva possibly because directly observed therapy (DOTS) treatment would have resulted in clinical improvements and patients may not be producing significant sputum anymore.

1498. Etiology of Community-acquired Pneumonia in Adults: A Systematic Review

Background Background: Recent guidelines recommend immediate empiric antibiotic treatment for patients (pts) with community-acquired pneumonia (CAP). Concerns about treatment recommendations and antibiotic stewardship motivated a systematic literature review of the etiology of CAP.MethodsWe reviewed English-language literature using PRISMA guidelines. Data were stratified into diagnostic categories according to the microbiologic studies that were done (Table1).Fig.1. Flowchart of systematic literature review and study selection Table 1. Characteristics of studies reporting the etiology of community-acquired pneumonia Results146 articles with 82,674 CAP pts met criteria for inclusion; 63,938 (77.3%) were inpatients, 16,532 (20.0%) were in- or outpatients, and 2,204 (2.7%) were outpatients. Pneumococcus was the most common cause of CAP without regard to which microbiological techniques were used (33-50% of all cases). The proportion due to this organism declined with time, much more strikingly in the US than in Europe. Haemophilus influenzae was the second most common cause (7-16% of cases), followed by Staphylococcus aureus and Enterobacteriaceae each in 4–10%. Pseudomonas (0.8-4.5%) and Moraxella (1.2-3.5%) were less common; all other bacteria were isolated far less frequently. Mycoplasma caused 4-11% of CAP, Legionella 3-8%, Chlamydophila 2-7%, and Coxiella < 2%; some studies showed a much higher frequency of Mycoplasma. With routine use of viral PCR, a virus was identified in 30-40% of pts; bacterial/viral coinfection was found in 25-35% of these cases. In a separate study of CAP pts in whom viral PCR was positive, 40% had bacterial coinfection. Influenza viruses were identified in 6.2-13.7% of cases and rhinoviruses in 4.1-11.5%. RSV and human metapneumovirus were less common (0.4-4.7%), followed more distantly by other viruses. Even with the use of the most sophisticated diagnostic techniques, no etiologic agent for CAP was identified in > 50% of cases.Trends of identification of S. pneumoniae and H. influenzae as the etiology of CAP (above); and the proportion of S. pneumoniae as the causes of CAP in different geographic regions (below). ConclusionOur results justify current guidelines for initial empiric antibiotic treatment of all pts with CAP. With pneumococcus and Haemophilus continuing to predominate, efforts at antibiotic stewardship might be enhanced by greater attention to routine use of sputum Gram stain and culture. Because viral/bacterial coinfection is relatively common, the identification of a virus by PCR does not, by itself, permit the non-use of an antibiotic.Disclosures All Authors: No reported disclosures

Sputum bacterial profile and antibiotics sensitivity pattern in acute exacerbation of chronic obstructive pulmonary disease

ABSTRACT Background: Constant microbiologic screening of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is vital to control the possible alteration of pathogens, as well as their antibiotic resistance. Objective: to identify sputum bacterial profile and antibiotics sensitivity in patients with AECOPD aiming to adjust antibiotics use and reduce antibiotics resistance. Methodology: This cross-sectional study was conducted on 100 patients with AECOPD. The total and differential leucocytic count, spirometric-indices, sputum gram stain, sputum semi-quantitative culture using colony forming unit (CFU) were done for all patients. Additionally, assessments of the sensitivity of the isolated pathogenic bacterial species were done for 25 antibiotics by disk diffusion method. Results: by sputum semi-quantitative culture 28% of the studied patients have non-pathogenic bacterial growth (i.e., growth of normal flora) and 72% have pathogenic bacterial growth. Amongthose with pathogenic bacterial growth the isolated bacterial species in descending order were klebsiella (40.3%), staphylococcus aureus (19.4%), pseudomonas (12.5%), streptococcal pneumoniae, E. coli (8.3% each), acinetobacter (6.9%), citrobacter (2.8%) and enterobacter (1.4%). The most predictive factors for bacterial etiology in AECOPD in descending orders were decreased blood eosinophils % (B = - 0.16), increased blood neutrophils % (B = 0.04), increased blood lymphocytes (B = 0.02), and lower FEV1% (B = - 0.01). Levofloxacin was the most sensitive antibiotics (91.7%), followed by amikacin (88.9%), ciprofloxacin (87.5%) and gentamycin (87.5%) then imipenem (81.7%) and ofloxacin (76.4%). On the other hand, linezolid and vancomycin were the most resistant antibiotics (95.8% each), followed by clindamycin and cefotaxime (91.7% each) then colistin sulphate and tetracycline (90.3% each). Conclusion: Gram-negative bacterial species especially klebsiella was the most prevalent organism’s in AECOPD. The isolated bacterial species were sensitive mainly to quinolones, gentamycin, amikacin, and imipenem, while it was mainly resistant to clindamycin, cefotaxime, colistin sulphate, tetracycline.

Clinical characteristics of community-acquired pneumonia due to Moraxella catarrhalis in adults: a retrospective single-centre study

BackgroundAlthough Moraxella catarrhalis (M. catarrhalis) is a common cause of community-acquired pneumonia (CAP), studies investigating clinical manifestations of CAP due to M. catarrhalis (MC-CAP) in adults are limited. Since S. pneumoniae is the leading cause of CAP globally, it is important to distinguish between MC-CAP and CAP due to S. pneumoniae (SP-CAP) in clinical practice. However, no past study compared clinical characteristics of MC-CAP and SP-CAP by statistical analysis. We aimed to clarify the clinical characteristics of MC-CAP by comparing those of SP-CAP, as well as the utility of sputum Gram staining.MethodsThis retrospective study screened CAP patients aged over 20 years visiting or admitted to Okinawa Miyako Hospital between May 2013 and April 2018. Among these, we included patients whom either M. catarrhalis alone or S. pneumoniae alone was isolated from their sputum by bacterial cultures.ResultsWe identified 134 MC-CAP and 130 SP-CAP patients. Although seasonality was not observed in SP-CAP, almost half of MC-CAP patients were admitted in the winter. Compared to those with SP-CAP, MC-CAP patients were older (p < 0.01) and more likely to have underlying pulmonary diseases such as asthma and bronchiectasis (p < 0.01). Approximately half of asthmatic MC-CAP and SP-CAP patients had asthma attacks. Although winter is an influenza season in Japan, co-infection with influenza virus was less common in MC-CAP compared to SP-CAP patients (3% vs. 15%, p < 0.01). Bronchopneumonia patterns on X-ray, as well as bronchial wall thickening, bilateral distribution, and segmental pattern on CT were more common in MC-CAP patients than in SP-CAP patients (p < 0.01). Sputum Gram stain was highly useful method for the diagnosis in both MC-CAP and SP-CAP (78.4% vs. 89.2%), and penicillins were most frequently chosen as an initial treatment for both pneumonias.ConclusionsThis is the first study to show that MC-CAP occurred in older people compared to SP-CAP, influenza virus co-infection was less common in MC-CAP than SP-CAP, and that MC-CAP frequently caused asthma attacks. Gram stain contributed for the appropriate treatment, resulting in conserving broad-spectrum antibiotics such as cephalosporins and fluoroquinolones in both MC-CAP and SP-CAP patients.

IMMOBILE TRAVELLER SYNDROME: A CASE REPORT

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Apart from Economic class syndrome which is a well established entity in air travel, Pulmonary embolism can also occur due to other modes of long travel (1). We present a case of pulmonary embolism resulted from continuous car travel. CASE PRESENTATION: A 45-year-old male came with minimal productive cough ,breathlessness of modified medical research council (MMRC) grade 2 and mild fever for five days. He was a normotensive and non diabetic. On examination he had fine crackles over right infra scapular region. Laboratory investigations showed mild leucocytosis with polymorph predominance. Metabolic panel was normal. His chest x ray showed right lower zone ill defined airspace opacity. HRCT Chest revealed right lower lobe sub pleural consolidation with reverse halo sign. Sputum gram stain and modified Ziehl Neelsen stain were not contributory. Based on the clinical scenario ,lab parameters and radiological findings, community acquired pneumonia of right lower lobe was diagnosed and Patient was started on oral antibiotics. After three days patient returned with history of an episode of minimal hemoptysis. He was admitted for further evaluation. On detailed history evaluation he accepted he himself drove his car to a city for five hours without break and after finishing his work he drove back continuously for five more hours to his hometown two days before the illness. Pulmonary thromboembolism was suspected and d-dimer was found to be elevated(690 ng/ml). Echocardiogram was normal. CT Pulmonary angiogram(CTPA) confirmed multiple emboli (polo mint sign) in branches of right inferior pulmonary artery with infarction and pleural effusion. Patient was successfully treated with low molecular weight heparin for five days and discharged with warfarin. The etiological work up found out that he was having homocyteinemia and anti platelet drug with vitamin supplements were given. After nine months patient himself discontinued dabigatran for two weeks and came with right sided pleurisy and right thigh swelling. Venous Doppler study confirmed deep vein thrombosis(DVT) of right femoral vein and CTPA confirmed recurrent thromboembolism in right inferior pulmonary artery. Patient was subjected to IVC filter and treated again with low molecular weight heparin. Now he is on warfarin. DISCUSSION: Travel history is essential when suspecting pulmonary embolism.Immobilisation during long travel is a definite risk factor for deep vein thrombosis and pulmonary thromboembolism.Like Economic class syndrome of air travel ,Pulmonary embolism due to other modes of long travel can be called as ‘Immobile Traveller’s Syndrome’(2). When sub pleural consolidation with reverse halo sign is noted in CT chest, Pulmonary infarction must be considered in differential diagnosis. CONCLUSIONS: High index of suspicion is the key for diagnosis pulmonary embolism in peripheral branches because it may mimic pneumonia or pleural effusion. Reference #1: 1.Paolo Feltracco;Stefania Barbieri;Francesca Bertamini;Elisa Michieletto;Carlo Ori; Economy class syndrome: still a recurrent complication of long journeys.European Journal of Emergency Medicine. 14(2):100-103, APR 2007 Reference #2: 2. Gispert P1, Drobnic ME, Vidal R. Economy-class syndrome or Immobile Traveler's syndrome? Arch Bronconeumol. 2006 Jul;42(7):373-5. DISCLOSURES: No relevant relationships by Nagarajan Appusamy, source=Web Response No relevant relationships by Mathanraj Sinnassamy, source=Web Response No relevant relationships by Sivaraja Subramaniam, source=Admin input

NOT ALL CAVITARY LESIONS WITH AIR FLUID LEVELS ARE LUNG ABSCESSES

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Primary Pulmonary Hodgkin lymphoma is very rare, less than 100 cases have been reported (1,2) as they comprise less than 0.5 % of lung neoplasias (3,4) and of out of those only 2% are PPHL (5). Diagnosis of this neoplasm is very challenging because it usually presents with nonspecific symptoms and radiological images that can be attributed to other etiologies such as infection. CASE PRESENTATION: 26-year-old male presented to his PCP with dry cough, fevers, chills, night sweats, 20-pound unintentional weight loss, and dyspnea for a month. Outpatient treatment with azithromycin for a presumed pneumonia failed and he was admitted to the hospital. He was found to be febrile (39c) and tachycardic (123 beats/min). Laboratory work up was notable for a WBC 25.9. Chest x-ray showed left upper lobe (LUL) lung abscess and left side effusion. He was started on broad spectrum antibiotics. Sputum gram stain was positive for MRSA. CT of the chest showed extensive cavitary necrotic airspace consolidation of the LUL and lingula with moderate left sided pleural effusion(Fig 1). Pleural fluid analysis was found to be exudative in nature. AFB samples were negative. BAL showed gram positive cocci in clusters, however, culture results were negative. Despite antibiotics, the fever persisted, and the patient underwent a second thoracentesis and CT scan that showed progression of the left sided cavitary lesion(2). Repeat bronchoscopy with transbronchial needle biopsy was negative for malignancy. The patient’s symptoms improved, and he was discharged home on antibiotics. One month later the patient was readmitted due to persistent progressive SOB and weight loss. Broad spectrum antibiotics were initiated and repeat BAL was unrevealing. Ultimately, the patient underwent FNA and multiple biopsies around the rim of the LUL “abscess” revealed classical Nodular Sclerosing Hodgkin lymphoma. The patient underwent one cycle of chemotherapy and his symptoms improved significantly, and he was discharged with outpatient follow up. Unfortunately a few months later he presented with the same symptoms and similar CT findings.(Fig 3) DISCUSSION: Cavitary lesions in the lung have a broad differential (6), it is important to consider different etiologies in a patient with recurrent symptoms and non-resolving radiographic abnormalities. Due to the nonspecific signs, symptoms, laboratorial and radiological findings of primary pulmonary lymphomas the diagnosis is very challenging and usually delayed (7, 8) Such as in our case the patient received multiple empirical broad-spectrum antibiotics for suspected abscess without complete resolution of symptoms and progression of radiographic findings. CONCLUSIONS: Our case highlights the importance of considering other differentials for cavitary lung lesions in the treatment plan especially when confronted with a non-resolving symptoms. Reference #1: Rodriguez J, Tirabosco R, Pizzolitto S, et al. Hodgkin lymphoma presenting with exclusive or preponderant pulmonary involvement: a clinicopathologic study of 5 new cases. Ann Diagnos Path 2006;10:83–8 Reference #2: Primary pulmonary Hodgkin's lymphoma and a review of the literature since 2006 Reference #3: Primary Pulmonary Involvement in Mucosa-associated Lymphoid Tissue Lymphoma DISCLOSURES: No relevant relationships by Karim Anis, source=Web Response No relevant relationships by Victor Zavala, source=Web Response

Value Addition on Trend of Pneumonia Disease in India- The Current Update

Pneumonia continues to be the leading infectious cause of death among children under the age of five worldwide. Diagnosis of this disease is primarily dependent on physical examination, clinical history, and radiographic studies. Microbiological studies of the lower respiratory tract secretions have proven to be futile, however, sputum gram staining and culturing methods often aid in the diagnosis and management of these infections. Aspiration pneumonia often occurs in a community setting and primarily involves anaerobes like Staphylococcus aureus or gram-negative rods such as Klebsiella pneumonia, and other Enterobacteriaceae and Pseudomonas species. The total number of cases taken in the study of acute pneumonia was 22 (15 male subjects and 7 female subjects). Biochemical tests were conducted for identifying different organisms present in the samples collected from patients suffering from acute pneumonia. Distribution of bacteria in the case of acute pneumonia was as follows: Staphylococcus aureus was recorded to be the highest (36.36%) followed by Streptococcus pneumonia (18.18%) and Klebsiella pneumonia (18.18%), Pseudomonas pneumonia (13.63%), Haemophilus influenza (9.09%) and lastly Chlamydia pneumonia (4.45%). A maximum number of laboratories proven acute pneumonia cases (36.36%) belonged to 61-70 years. The distribution of cases was marginally more in urban areas (63.63%). By occupation largest group (36.36%) was of others in case of acute pneumonia were as farmers, housewives and others were the largest groups (22.73%) each. The microbial etiology derived from the present study found that Klebsiella pneumonia was an independent risk factor for mortality in severe community-acquired pneumonia. Moreover, two important findings were drawn from this study. K. pneumonia was identified as the causative pathogen in 22% of cases, second to S. pneumonia.

Staphylococcus aureus Pneumonia in the Community.

Staphylococcus aureus is an emergent etiology of community-acquired pneumonia (CAP) over the past 2 decades, with severe community-acquired pneumonia (SCAP) caused by methicillin-resistant S. aureus (MRSA) leading to critical illness and death. S. aureus colonization is associated with a high incidence of pneumonia. Panton-Valentine leukocidin (PVL) is one of the most important virulence factors of S. aureus associated with serious complications. In recent years, community-associated MRSA (CA-MRSA) clones that caused infections in young adults and healthy individuals with no exposure to health care settings and no classical risk factors have emerged. Clinical features at admission including concurrent influenza infection, hemoptysis, multilobar infiltrates, and neutropenia should suggest S. aureus CAP. Sputum Gram stains, cultures (or tracheobronchial aspirates or bronchoalveolar lavage in mechanically ventilated patients), polymerase chain reaction (nasopharyngeal or oropharyngeal or lower respiratory tract specimens), and two sets of blood cultures should be obtained from patients presenting with severe S. aureus CAP. For CAP due to methicillin-susceptible S. aureus, first-line therapy is usually cefazolin, oxacillin, or ceftaroline. For CA-MRSA pneumonia, linezolid is recommended. If vancomycin or teicoplanin are used, combination with clindamycin or rifampicin should be considered in cases of PVL-positive MRSA CAP.

Diagnostic performance of the Sputum Gram Stain in predicting sputum culture results for critically ill pediatric patients with pneumonia

The sputum Gram stain is an inexpensive, rapid, and convenient laboratory method that predicts the bacterial pathogens in patients with pneumonia. This study aimed to evaluate the diagnostic performance of this method in predicting sputum culture results for critically ill pediatric patients. From June 2008 to June 2018, patients with pneumonia with an endotracheal or a tracheostomy tube in place in the Pediatric Intensive Care Unit at Changhua Christian Hospital were enrolled retrospectively. Sputum was collected from each patient via the artificial airway for Gram stain and culture evaluations of bacterial pathogens. Mixed culture results were excluded. A successful prediction was defined as a match of the sputum Gram stain and culture results. A total of 622 records were reviewed, of which 542 were analyzed. Haemophilus influenzae, Pseudomonas aeruginosa, and Streptococcus pneumoniae were the three most common pathogens found. The overall prediction success rate of the sputum Gram stain was 59.23%. The sensitivity of the method in predicting gram-negative bacilli (GNB), gram-negative cocci (GNC), and gram-positive cocci (GPC) was 0.45, 0.67, and 0.61, respectively. Its specificity in predicting GNB, GNC, and GPC was 0.87, 0.98, and 0.87, respectively. Its positive likelihood ratio in predicting GNB, GNC, and GPC was 3.46, 33.50, and 4.69, respectively. The highest prediction success rate among all pathogens was for GNC. The sputum Gram stain had high specificity and relatively low sensitivity in predicting the bacterial pathogens in critically ill pediatric patients. Its high specificity in predicting sputum culture results means that clinicians can confidently use sputum Gram stain results to guide their antibiotic choice for treatment.

Clinical Analysis of Sputum Gram Stains and Cultures to Improve the Quality of Sputum Cultures

Clinical Analysis of Sputum Gram Stains and Cultures to Improve the Quality of Sputum Cultures

Sputum bacterial identification in patients with bronchial asthma exacerbation

Background The role of bacterial pathogens in exacerbations of bronchial asthma is unclear as that of viral infections. Aim To identify sputum bacteria and antibiotic sensitivity in patients with bronchial asthma exacerbation. Patients and methods A descriptive cross-sectional study was conducted on 50 patients with acute bronchial asthma exacerbation. Spirometeric pulmonary function tests, total and differential leukocyte count, sputum Gram stain, culture, and sensitivities were done for all patients. Results Of the studied patients, 50% have growth of normal flora, 12% have fungal growth, and 38% have bacterial growth (63.6 and 36.4% of them have Gram-negative and Gram-positive bacteria, respectively). The most predominant bacteria were Klebsiella pneumoniae (31.8%) and Streptococcal pneumoniae (18.2%), while Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii complex, and Enterobacter aerogenes are equally distributed (9.1%). There was a significant decrease of vital capacity %, forced vital capacity %, and forced expiratory volume in the 1 s % in bronchial asthma with Gram-negative bacteria compared with those with Gram-positive bacteria. The total and differential leukocytic counts nonsignificantly differed between both subgroups. Among the studied patients with bacterial growth, Amikacin, Quinupristin/Dalfopristin, Linezolid, Vancomycin, and Tigecycline were the most common sensitive antibiotics (100%), followed by Tobramycin, Ciprofloxacin, Levofloxacin, and Gentamicin (95.5%). On the other hand, Benzylpenicillin and Oxacillin were the most common resistant antibiotics (100%), followed by Ampicillin (92.3%). Conclusion Bacterial organisms were responsible for only about one-third of bronchial asthma exacerbation, with predominance of Gram-negative organisms. Amikacin, Quinupristin/Dalfopristin, Linezolid, Vancomycin, and Tigecycline, Tobramycin, Ciprofloxacin, Levofloxacin, and Gentamicin were the most common sensitive antibiotics. Benzylpenicillin, Oxacillin and Ampicillin were the most common resistant antibiotics.

Eosinophilic Airway Inflammation in Patients with Stable Biomass Smoke- versus Tobacco Smoke-Associated Chronic Obstructive Pulmonary Disease.

Background.Chronic obstructive pulmonary disease (COPD) is an inflammatory disease with predominant involvement of neutrophils, macrophages and CD8+ lymphocytes. Eosinophilic airway inflammations are reported in stable state and during acute exacerbations of tobacco smoke-associated COPD (TS-COPD). Women exposed to biomass fuel smoke are known to have eosinophils in sputum. However, little is known about the sputum cellular inflammatory profile in biomass fuel smoke-associated COPD (BMS-COPD). We therefore aimed to compare the sputum cellular inflammatory profile in tobacco smoke- and biomass smoke-associated COPD.Methods.The study was conducted in a tertiary care hospital in Goa, India. A total of 113 patients with stable COPD reporting to the outpatient pulmonary clinic were recruited. All participants were ≥ 40 years of age. Sputum induction studies were performed by the method of Pizzichini et al. after baseline subject characterization. Significant eosinophilia was defined as induced sputum eosinophils ≥ 3%.Results.There were 85 TS-COPD and 28 BMS-COPD patients. The mean age [standard deviation (SD)] was 64.7 (7.8) and 63.0 years (8.3), p = 0.32 in TS and BMS-COPD, respectively. Eighteen subjects (21.1%) were female smokers. The smoking pack-year median [interquartile range (IQR)] was 36 (20, 58) and hour-years of biomass smoke exposure mean (SD) was 192.4 (61). The TS-COPD and BMS-COPD cases showed a post-bronchodilator forced expiratory volume in one second (FEV1%) mean (SD) of 57.9 (17.1), and 62.6 (19.4), p= 0.22, respectively. Both groups had similar symptoms and severity of disease. Induced sputum total cell count per gram of sputum × 106 mean (SD) was 3.05 (1.53) for TS-COPD, and 2.55(1.37) for BMS-COPD p=0.12. The neutrophils % mean (SD) was 86.4 (16.5) and 87.9 (10.2), p = 0.64; eosinophils % median (IQR) was 2.5 (1, 10) and 8 (2, 12.8), p = 0.07; lymphocytes % median (IQR) was 0 (0, 0.75) and 0 (0, 1) p = 0.13; macrophages % median (IQR) was 2.5 (0.75, 5.7) and 1 (0, 4.7) p = 0.13; and significant eosinophilia (eosinophils ≥3%) was 42 (49.4%) and 20 (71%), p=0.04, for TS-COPD and BMS-COPD, respectively.Conclusions.For similar severity of disease and clinical symptoms, significant eosinophilic inflammation was observed in stable BMS-COPD, while both groups had similar neutrophilic inflammation.Participant Consent.Obtained.Ethics Approval.The study was approved by the Institutional Ethics Committee of the Goa Medical College, Goa, India.Competing Interests.The authors declare no competing financial interests.

Can sputum gram stain be used to predict lower respiratory tract infection and guide empiric antimicrobial treatment: Experience from a tertiary care hospital

BackgroundThe mortality associated with lower respiratory tract infection is high. Indiscriminate use of antimicrobials leads to alteration of respiratory tract flora and development of multi-drug resistance. Rapid diagnostic tests to confirm infection can guide the clinicians about antimicrobial treatment. So the present study was planned to evaluate the role of direct gram stain examination as a rapid and simple test to help clinicians for appropriate patient management. MethodsThe present study was conducted on 1000 respiratory specimens which were processed using conventional microbiological techniques. Gram stain smear and culture results were compared statistically to assess the sensitivity, specificity, positive and negative predictive value. The agreement between gram stain smear examination and culture was calculated using kappa statistics. ResultsPotential pathogens were obtained from 28 of 209 deeply coughed out sputum samples (13.3%) and from 19 of 315 saliva mixed sputum samples (6%). Out of 473 tracheal aspirates, 115 (24.3%) had potential pathogens. The sensitivity for predicting infection was higher for good quality sputum samples (54%) as compared to poor quality sputum samples (37%). The gram stain and culture of tracheal samples had a good agreement for predicting infection whereas there was only moderate agreement for sputum sample. ConclusionGram stain smear examination from respiratory samples can be used to guide empiric antibiotic therapy pending final culture sensitivity results if the attending physicians ensure appropriate sample collection and transport. In absence of these supportive measures smear examination should not be relied upon for empiric treatment.