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Antibody-coated bacteria test for localization of urinary tract infections
aerobic and anaerobic bottles within one day. The organism was susceptible to gentamicin, kanamycin, tobramycin, and tetracycline, and resistant to ampicillin, carbenicillin, and cephalothin. A culture of the pleural fluid yielded the same organism, while AFB and fungal cultures were negative. A urine culture yielded no growth. The patient developed increased azotemia, rapid atrial fibrillation, and finally, disseminated intravascular coagulation. Despite treatment with dopamine, steroids, diuretics, digitalis, and the above antimicrobials, the patient expired five days after admission. Two additional blood cultures, taken on the fourth hospital day, grew P. putrefaciens. Autopsy was denied.
P. putrefitciens is a monotrichously flagellated pseudomonad with positive reactions for oxidase, nitrate reduction to nitrite, deoxyribonuclease, gelatinase, and ornithine decarboxylase. Almost all strains also form H~S in Kligler's or TSI agar (differentiation from other H~S-forming gram-negative bacteria is easy because P. putrefaciens will not acidify the butt). The organism has been isolated from soil and water and occasionally from human sources, particularly leg ulcers and the external ear, but only rarely from the respiratory tract. A recent volume on nonfermenting gram-negative rods (I) has reviewed diagnosis and pathogenicity of the organism. One case of septicemia has
been reported previously; it originated from a leg ulcer and was not fatal (2). Our cases (whose sources o f P . ptttrefaciens remained unclear) show that septicemia can be benign or fatal, depending on the status of the host's defenses.
Referellces 1. Gilardi, G. L. 1978. Chapters 2 and 7. In Glucose nonferrnenting gram-negative bacteria in clinical microbiology. CRC Press, West Palm Beach, Florida. 2. Vandepitte, J., and J. Debois. 1978. Pseudomonas putrefiwiens as a cause of bacteremia in humans. J. Clin. Microbiol. 7:70-72.
New Tests
Antibody-coated Bacteria Test for Localization of Urinary Tract Infections Grace Mary Ederer Department of Laboratory Medicine attd Pathology University of Minnesota Minneapolis. Minnesota
In 1974, Thomas et al. (8) developed the antibody-coated bacteria test (ACB), a simple risk-free technique for differentiating kidney infections from bladder infections. They found that bacteria present in the urine sediment of patients with a kidney infection were coated with antibody, whereas bacteria in the urine sediment of patients with a bladder infection were not antibody coated. Jones and his associates (6) evaluated the accuracy of the test with 29 patients on whom a bladder wash-out procedure was performed to establish the site of infection; 28 of the 29 patients with pyeloriephritis were correctly identified by the ACB test in their study. The test is simple to perform. The urine sediment is washed with phosphate-buffered saline and stained with a fluorescein conjugate of antihuman globulin. The positive control for the test is a smear from previously positive urine. The negative control is the patient's infecting organism grown in
4
culture and is included as a check for nonspecific fluorescence. After staining, the test and control slides are examined under a fluorescent microscope. Various authors have reported different criteria for reporting results of the test. Thomas (9) reports a positive ACB test when 25% or more of the bacterial cells fluoresce and a negative test when more than 75% of the bacteria do not fluoresce. Jones (5) states that the ACB test is considered positive if two uniformly fluorescent bacteria are seen in 200 oil immersion fields, and a negative result is reported only after the slide has been scanned for five minutes. Many workers follow Jones' criteria because the validity of that work was substantiated by a direct, localizing technique, the bladder wash-out. It has been shown that false-positive ACB tests occur in patients with funguria (1) and prostatitis (4). When voided urine is used for the test it is important to avoid contamination with fecal organisms (7). Recent studies evaluating the efficacy of the ACB test for determining upper or lower urinary tract infection are not in total agreement. Harding et al. (2) concluded that a positive test indicates upper-tract infection, but a negative result should be interpreted with caution. On the other hand, Hawthorne et al. (3) found that a negative result excluded an upper urinary tract infection with 90% reliability
but that a positive test needed to be interpreted with caution because positive ACB tests may occur with lower urinary tract infections. In reviewing the literature, the need for uniform standards for interpretation of positive and negative ACB tests is very apparent. Jones' criterion in which a test is called "positive" if two or more fluorescing bacteria are found in the entire smear studied, can be more easily standardized among technologists than their individual evaluation of whether 25% or more of the organisms present are fluorescing. Another aspect in favor of Jones" standard is the fact that organisms that have divided will not be coated; unless the specimen is kept at 4°C to prevent multiplication, it would be possible for false-negative tests to occur when the standard of Thomas et al. (9) is applied. In the original description of the procedure, Thomas et al. (8) recommended that a negative control be made using the bacterial isolate causing the infection. Investigators have continued this practice, but a positive reaction with the patient's bacteria and the antihuman globulin conjugate must be rare. We would be interested to know whether any of our readers have seen a positive reaction with the negative control. If no cross reactions occur, this aspect of the procedure could be omitted, thus saving time and money.
Although the ACB test has not been shown to be 100% accurate when compared with the bladder wash-out procedure, it has been helpful in a great number of cases. Additional studies are warranted and should include an evaluation o f 1) the standard to use for declaring positive results and 2) whether a negative control o f the bacterial isolate is necessary.
4. 5. 6.
7. References 1. Everett, E. D., T. C. Eickhoff, and J. M. Ehret. 1975. Immunofluorescence of yeast in urine. J. Clin. Microbiol. 2:142-143. 2. Itarding, G. K. M., T. J. Marrie, A. R. Ronald, S. lloban, and P. Muir. 1978. Urinary tract infection localization in women. J.A.M.A. 240:1147-1150. 3. Hawthorne, N. J., S. B. Kurtz, J. P. Anhalt, and J. W. Segura. 1978. Accuracy of antibody-coated bacteria test in
8.
9.
recurrent urinary tract infections. Mayo Clinic Proc. 53:651-654. Jones, S. R. 1974. Prostatitis as a cause of antibody-coated bacteria in urine. N. Eng. J. Med. 291:365. Jones, S. R. 1976. Antibody-coated bacteria in urine. N. Eng. J. Med. 295:i380. Jones, S. R., J. W. Smith, and J. P. Sanford. 1974. Localization of urinarytract infections by detection of antibodycoated bacteria in urine sediment. N. Eng. J. Med. 209:591-593. Monplaisir, S., C. Courteau, and A. J. Roches. 1977. Antibody-coated bacteria in contaminated urine specimens. N. Eng. J. Med. 296:758-759. Thomas, V., A. Shelokov, and M. Forland. 1974. Antibody-coated bacteria in urine and the site of urinary-tract infection. N. Eng. J. Med. 290:588-590. Thomas, V. L., M. Forland, and A. Shelokov. 1975. Antibody-coated bacteria in urinary tract infection. Kidney Int. 8:S-20-S-22.
Accreditation of JCAH Hospital Laboratories i|
The Federal Register of January 16, 1979 (vol. 44, no. 11) reported a revision o f Medicare regulations pertaining to hospital laboratories. The revision provides that the quality control and proficiency testing requirements of the Joint Commission on Accreditation of Hospitals (JCAH) for accrediting such laboratories are equivalent to those established by the Department of Health, Education, and Welfare. Prior to this revision, JCAH had taken steps to revise and implement upgraded standards. Because o f this action, state health agencies will no longer have to inspect the laboratories of JCAH-accredited hospitals. The effective date of this action was November 24, 1978.
Editorial Should Clinical Microbiology Keep Up W i t h T a x o n o m y ? ~ Y e s J. J. Farmer, III Enteric Section Center for Disease Control Public Health Service U.S. Department of Health, Ethwation and Welfare Atlanta, Georgia 30333 I believe that clinical microbiologists should keep up with taxonomic developments, and I further assert that they always have and always will. If this were not true, we would still see reports such as: "Culture negative for bacilli of the typhoid-paratyphoid-dysentery group and negative for bacilli of meat poisoning. Bacillus colt cttmntttlzis and Bacillus colt cttmmittor present in great numbers; Morgan's Bacillus No. I present in moderate numbers; and Bacillus lactis aerogenes rarely present," which in today's taxonomy translates into: "Negative for Sahnonella and Shigella, heavy growth of E. colt (two different biotypes), moderate growth of Morganella (Proteus) morganii, sparse growth of Enterobacter aerogenes."
One of the best ways to confirm that clinical microbiology has always kept up with taxonomy is to follow the evolution of bacterial names and classifications given in Zinsser's Microbiology from the first edition (1910) to the current or sixteenth edition (1976) (Table 1). The list below contains the names used for some familiar species in the family Emerobacteriaceae. The names of some species have remained the same or changed little, but others have changed constantly during the 16 editions.
I agree that it is usually disastrous to change the species name (specific epithet) of an organism. The literature is cluttered with confusing names for the same species; notorious examples include Salmonella t373hi-S, typhosa; Klebsiella pneumoniae-K. (Enterobacter) aerogenes; and worst of all Acinetobacter calcoaceticus-Herellea vaginicola-Mima polymorphaMor(Lrella lwoffi- Bacterium anitratum. I have fought the proposal to change the well-known and accepted Edwardsiella tarda to E. attguillimortifera because
Table 1 Name Changes for Organisms Over 66 Years of Zinsser's Microbiology First (1910) Edition Bacillus t~phosus Bacillus colt communis Bacilh:s o.Taenea "'Bacilli of meat poisoning" "Paracolon bacilli" "Colon bacillus group" Not described
Eighth (1939) Edition Eberthelht typhosa Escherichhz colt sucrose + Klebsielht ozaenea Various Sahnonella names Several species in the genus Bacterium Morgan's Bacillus No. i
Sixteenth (1976) Edition Salmonella t)phi Escherichia colt Klebsiella ozaenae Many Sabnonella serotypes Many well-described species of Enterobacteriaceae Proteus morganii
P. putrefitciens is a monotrichously flagellated pseudomonad with positive reactions for oxidase, nitrate reduction to nitrite, deoxyribonuclease, gelatinase, and ornithine decarboxylase. Almost all strains also form H~S in Kligler's or TSI agar (differentiation from other H~S-forming gram-negative bacteria is easy because P. putrefaciens will not acidify the butt). The organism has been isolated from soil and water and occasionally from human sources, particularly leg ulcers and the external ear, but only rarely from the respiratory tract. A recent volume on nonfermenting gram-negative rods (I) has reviewed diagnosis and pathogenicity of the organism. One case of septicemia has
been reported previously; it originated from a leg ulcer and was not fatal (2). Our cases (whose sources o f P . ptttrefaciens remained unclear) show that septicemia can be benign or fatal, depending on the status of the host's defenses.
Referellces 1. Gilardi, G. L. 1978. Chapters 2 and 7. In Glucose nonferrnenting gram-negative bacteria in clinical microbiology. CRC Press, West Palm Beach, Florida. 2. Vandepitte, J., and J. Debois. 1978. Pseudomonas putrefiwiens as a cause of bacteremia in humans. J. Clin. Microbiol. 7:70-72.
New Tests
Antibody-coated Bacteria Test for Localization of Urinary Tract Infections Grace Mary Ederer Department of Laboratory Medicine attd Pathology University of Minnesota Minneapolis. Minnesota
In 1974, Thomas et al. (8) developed the antibody-coated bacteria test (ACB), a simple risk-free technique for differentiating kidney infections from bladder infections. They found that bacteria present in the urine sediment of patients with a kidney infection were coated with antibody, whereas bacteria in the urine sediment of patients with a bladder infection were not antibody coated. Jones and his associates (6) evaluated the accuracy of the test with 29 patients on whom a bladder wash-out procedure was performed to establish the site of infection; 28 of the 29 patients with pyeloriephritis were correctly identified by the ACB test in their study. The test is simple to perform. The urine sediment is washed with phosphate-buffered saline and stained with a fluorescein conjugate of antihuman globulin. The positive control for the test is a smear from previously positive urine. The negative control is the patient's infecting organism grown in
4
culture and is included as a check for nonspecific fluorescence. After staining, the test and control slides are examined under a fluorescent microscope. Various authors have reported different criteria for reporting results of the test. Thomas (9) reports a positive ACB test when 25% or more of the bacterial cells fluoresce and a negative test when more than 75% of the bacteria do not fluoresce. Jones (5) states that the ACB test is considered positive if two uniformly fluorescent bacteria are seen in 200 oil immersion fields, and a negative result is reported only after the slide has been scanned for five minutes. Many workers follow Jones' criteria because the validity of that work was substantiated by a direct, localizing technique, the bladder wash-out. It has been shown that false-positive ACB tests occur in patients with funguria (1) and prostatitis (4). When voided urine is used for the test it is important to avoid contamination with fecal organisms (7). Recent studies evaluating the efficacy of the ACB test for determining upper or lower urinary tract infection are not in total agreement. Harding et al. (2) concluded that a positive test indicates upper-tract infection, but a negative result should be interpreted with caution. On the other hand, Hawthorne et al. (3) found that a negative result excluded an upper urinary tract infection with 90% reliability
but that a positive test needed to be interpreted with caution because positive ACB tests may occur with lower urinary tract infections. In reviewing the literature, the need for uniform standards for interpretation of positive and negative ACB tests is very apparent. Jones' criterion in which a test is called "positive" if two or more fluorescing bacteria are found in the entire smear studied, can be more easily standardized among technologists than their individual evaluation of whether 25% or more of the organisms present are fluorescing. Another aspect in favor of Jones" standard is the fact that organisms that have divided will not be coated; unless the specimen is kept at 4°C to prevent multiplication, it would be possible for false-negative tests to occur when the standard of Thomas et al. (9) is applied. In the original description of the procedure, Thomas et al. (8) recommended that a negative control be made using the bacterial isolate causing the infection. Investigators have continued this practice, but a positive reaction with the patient's bacteria and the antihuman globulin conjugate must be rare. We would be interested to know whether any of our readers have seen a positive reaction with the negative control. If no cross reactions occur, this aspect of the procedure could be omitted, thus saving time and money.
Although the ACB test has not been shown to be 100% accurate when compared with the bladder wash-out procedure, it has been helpful in a great number of cases. Additional studies are warranted and should include an evaluation o f 1) the standard to use for declaring positive results and 2) whether a negative control o f the bacterial isolate is necessary.
4. 5. 6.
7. References 1. Everett, E. D., T. C. Eickhoff, and J. M. Ehret. 1975. Immunofluorescence of yeast in urine. J. Clin. Microbiol. 2:142-143. 2. Itarding, G. K. M., T. J. Marrie, A. R. Ronald, S. lloban, and P. Muir. 1978. Urinary tract infection localization in women. J.A.M.A. 240:1147-1150. 3. Hawthorne, N. J., S. B. Kurtz, J. P. Anhalt, and J. W. Segura. 1978. Accuracy of antibody-coated bacteria test in
8.
9.
recurrent urinary tract infections. Mayo Clinic Proc. 53:651-654. Jones, S. R. 1974. Prostatitis as a cause of antibody-coated bacteria in urine. N. Eng. J. Med. 291:365. Jones, S. R. 1976. Antibody-coated bacteria in urine. N. Eng. J. Med. 295:i380. Jones, S. R., J. W. Smith, and J. P. Sanford. 1974. Localization of urinarytract infections by detection of antibodycoated bacteria in urine sediment. N. Eng. J. Med. 209:591-593. Monplaisir, S., C. Courteau, and A. J. Roches. 1977. Antibody-coated bacteria in contaminated urine specimens. N. Eng. J. Med. 296:758-759. Thomas, V., A. Shelokov, and M. Forland. 1974. Antibody-coated bacteria in urine and the site of urinary-tract infection. N. Eng. J. Med. 290:588-590. Thomas, V. L., M. Forland, and A. Shelokov. 1975. Antibody-coated bacteria in urinary tract infection. Kidney Int. 8:S-20-S-22.
Accreditation of JCAH Hospital Laboratories i|
The Federal Register of January 16, 1979 (vol. 44, no. 11) reported a revision o f Medicare regulations pertaining to hospital laboratories. The revision provides that the quality control and proficiency testing requirements of the Joint Commission on Accreditation of Hospitals (JCAH) for accrediting such laboratories are equivalent to those established by the Department of Health, Education, and Welfare. Prior to this revision, JCAH had taken steps to revise and implement upgraded standards. Because o f this action, state health agencies will no longer have to inspect the laboratories of JCAH-accredited hospitals. The effective date of this action was November 24, 1978.
Editorial Should Clinical Microbiology Keep Up W i t h T a x o n o m y ? ~ Y e s J. J. Farmer, III Enteric Section Center for Disease Control Public Health Service U.S. Department of Health, Ethwation and Welfare Atlanta, Georgia 30333 I believe that clinical microbiologists should keep up with taxonomic developments, and I further assert that they always have and always will. If this were not true, we would still see reports such as: "Culture negative for bacilli of the typhoid-paratyphoid-dysentery group and negative for bacilli of meat poisoning. Bacillus colt cttmntttlzis and Bacillus colt cttmmittor present in great numbers; Morgan's Bacillus No. I present in moderate numbers; and Bacillus lactis aerogenes rarely present," which in today's taxonomy translates into: "Negative for Sahnonella and Shigella, heavy growth of E. colt (two different biotypes), moderate growth of Morganella (Proteus) morganii, sparse growth of Enterobacter aerogenes."
One of the best ways to confirm that clinical microbiology has always kept up with taxonomy is to follow the evolution of bacterial names and classifications given in Zinsser's Microbiology from the first edition (1910) to the current or sixteenth edition (1976) (Table 1). The list below contains the names used for some familiar species in the family Emerobacteriaceae. The names of some species have remained the same or changed little, but others have changed constantly during the 16 editions.
I agree that it is usually disastrous to change the species name (specific epithet) of an organism. The literature is cluttered with confusing names for the same species; notorious examples include Salmonella t373hi-S, typhosa; Klebsiella pneumoniae-K. (Enterobacter) aerogenes; and worst of all Acinetobacter calcoaceticus-Herellea vaginicola-Mima polymorphaMor(Lrella lwoffi- Bacterium anitratum. I have fought the proposal to change the well-known and accepted Edwardsiella tarda to E. attguillimortifera because
Table 1 Name Changes for Organisms Over 66 Years of Zinsser's Microbiology First (1910) Edition Bacillus t~phosus Bacillus colt communis Bacilh:s o.Taenea "'Bacilli of meat poisoning" "Paracolon bacilli" "Colon bacillus group" Not described
Eighth (1939) Edition Eberthelht typhosa Escherichhz colt sucrose + Klebsielht ozaenea Various Sahnonella names Several species in the genus Bacterium Morgan's Bacillus No. i
Sixteenth (1976) Edition Salmonella t)phi Escherichia colt Klebsiella ozaenae Many Sabnonella serotypes Many well-described species of Enterobacteriaceae Proteus morganii