- Email: [email protected]
Question and answer
specimen. Although streptococcal Fc ieceptors have been documented, at least 95% of Staphylococcus aureus strains are known to contain protein A that binds the Fc portion of immunoglobulins by a nonimmune mechanism (4, 5). At 400-500X magnification the resulting apple-green fluorescent particles are indistinguishable from chlamydial elementary bodies. At higher magnification, the staphylococci may be distinguished by their larger size and the tendency to stain, as most bacteria do, at the periphery of the organism, causing a halo effect. In our opinion, if the MicroTrak direct specimen test is not examined by highly experienced technologists, this nonspecific fluorescence may not be consistently and reliably differentiated and couldlead to a high rate of false positive reports. Considering that this phenomenon has been reported earlier for monoclonal antibodies against Legionefla pneumophila (4), it is surprising that this type of artifact has not been reported more frequently with other direct fluorescent antibody procedures because polyclonal antibodies will also bind to Fc receptors ( 1, 2). In order to avoid this obstacle and improve the specificity of the test, some authors have recommended blocking protein A activity by incubating the smears for 30 min with normal serum from a chlamydia seronegative donor, before adding the monoclonal conjugate (3). Before we were aware of this recommendation, we blocked the nonspecific binding of the monoclonal antibody to protein A with a 1: 10 dilution of a seronegative
serum. This procedure was pretested by preparing smears on MicroTrak slides with a protein A containing S. aureus. The smears were then stained with and without the recommended blocking step using chlamydial seronegative sera. The manufacturer of MicroTrak comments on this possible source of error stating that “C. trachomatis elementary bodies can be distinguished from bacteria by characteristic morphology,” and that, “chlamydial elementary bodies are approximately 300 nm in diameter and stain evenly over the entire surface while bacterial cells are generally 2-3 times larger than elementary bodies and tend to stain at the rim, producing a doughnut-like appearance (7).” A difference between these morphological entities is evident but we believe that only highly skilled fluorescent microscopists can make this judgement with any degree of confidence. To remedy this problem we recommend that the manufacturer include the blocking step described above as part of the test procedure and perhaps include chlamydial seronegative sera in the kit. Alternatively, we suggest the removal of the Fc fraction of the monoclonal conjugate immunoglobulin either enzymatically or by blocking with soluble protein A (4).
2.
Gosting, I. H. et al. 1984. Identification of species-specific antigen in Legionella pneumophila by a monoclonal antibody. J. Clin. Microbial. 20: IO3 I 1035.
3.
Krech, T. et al. 198.5. Interference of Staphylococcus aureus in the detection of Chlamvdia trachomatis by monoclonal aniibodies. Lancet i: I 16 I - I 162.
4.
Langone, J. J. 1982. Protein A from Staphylococcus aureus and related immunoglobulin receptors produced by streptococci and pneumococci. Adv. Immunol. 32:157.
5.
Reis, K. J., E. M. Ayoub, and W. D. P. Boyles. 1984. Streptococcal Fc receptors: I. Isolation and partial characterization of the receptor from group C streptococcus. J. Immunol. 132:3091-3097.
Ruijs, G. et al. 1984.
6.
Rapid detection with monoclonal antibodies of Chlamydia trachomatis in urethral smears and urine sediments. Lancet i:960-961.
I.
Syva. Revised
8.
Tam, M. R. et al. 1984.
9.
Uyeda, C. T. et al. 1984. Evaluation of MicroTrakTM direct specimen test for identification of Chlamydia trachomaris in clinical specimens (abst.). Abstracts of the Annual Meeting of the American Society for Microbiology. p. 254.
July 1985. MicroTrak. Chlamydia trachomatis direct specimen test technical information brochure 8H 184-8. Culture indcpendent diagnosis of Chlamydia trachomatis using monoclonal antibodies. N. Engl. J. Med. 310:1146-l 150.
Anthony D’ Auria, M.S. Chief Microbiologist St. Peter’s Medical Center New Brunswick, Nenj Jersey
References
1. Forsgoen,
A., and J. Sjoquist
Protein A from I. Pseudoimmune gamma-globulin. 827.
a
08903
1966.
Staphylococcus aureus. reaction with human J. Immunol. 97:822-
David Alcid, M.D. Chief, Infectious Disease St. Peter’s Medical Center New Brunswick, New Jersey
08903
Question and Answer
Q: Our laboratory routinely receives vaginal smears from ER patients for Gram stain primarily to determine the presence of gram-negative diplococci. What is the current recommendation regarding the value of vaginal Gram stains in light of the fact that other gram-negative organisms can morpho-
82
0196-4399/X6/$0.00
+ 02.20
logically
resemble
Neisseria
gonor-
rhoeae?
Denise DeMattie, MHS, MT (ASCP) SM Manager, Silrler Joliet.
0 1986 Elsevier
A: Gram stains prepared from
\vag-
inal swab specimens are usually not
Microbiolog) Cross Hospital Illinois 60432
Science Publishing Co..
Inc.
very helpful in detecting gonococcal infection, because the vagina does not represent the site of infection in pubertous females. Neisseria gonorrhoeae preferentially adheres to and infects the transitional and columnar
Chnical
Microbiology
Newshmer
8: I I. I986
epithelial cells of the cervix and endocervical canal. The adult female vaginal epithelium, composed primarily of stratified squamous epithelial cells overlying connective tissue, is generally not susceptible to gonococcal attachment and growth. In prepubescent females. however, the vaginal mucosa may become infected with gonococci, and these patients may develop “gonococcal vaginitis,” presenting with itching and a crusting vaginal discharge as the predominant symptoms. While Gram stains of vaginal secretions may be noncontributory or even misleading in the diagnosis of gonorrhea in women due to the presence of morphologically similar organisms (e.g.. Mo~a.re//~ species), a Gram stain of carefully collected endocervica/ material may indeed be very useful in the diagnosis. Specimens should be col-
lected from the endocervical canal under direct visualization with a speculum in place. Vaginal and cervical mucous should first be removed with cotton or gauze. The swab should be inserted into the cervical OSand moved from side to side, allowing time for organisms to become adsorbed to the swab surface. Any obvious mucopurulent cervical discharge should also be collected. Frequently, purulent discharge containing organisms may be expressed from the urethra and periurethral glands, providing excellent specimens for microscopic and cultural examination. Gram-stain smears are prepared by gently rolling the swab on a glass slide, thereby causing minimal disruption of the morphology of cells and organisms in the specimen. Properly collected endocervical Gram-stained smears have a sensitivity
of anywhere from 50 to 70%. An endocervical Gram-stained smear showing gram-negative diplococci within polymorphonuclear cells, particularly from a woman with other signs and symptoms (lower genital tract pain, dysuria, abnormal pelvic examination), is highly predictive of gonococcal infection. In asymptomatic women, however, the predictive value of the Gram stain is much lower. Of course, culture of this material should also be performed in addition to a Gramstained smear. Examination of vaginal specimens is preferred for the diagnosis of Candida and Trichomonas vaginalis vaginitis, and is helpful in the clinical diagnosis of nonspecific vaginosis.
Q: Our lahorrrtor-T bcwuld like to trcyuire reji~rence mcitericil. particularly kodtrchr0nie.s for- general microbiology. rn~cology. nl~c.~~bLI~.tCrioIog~. and pwusitolog!. Are you twwre of N source from \chich rc*emight be cable to obttrin them?
$80.00 and they are available from the Educational Products Division of the American Society of Clinical Pathologists (2100 W. Harrison Street, Chicago, IL 60612). Atlas of Diagnostic Medical Parasitology. This three-volume series of slides encompasses blood and tissue parasites, intestinal protozoa, and intestinal helminths. As with the Arfus of Clinical Mycology, both laboratory and clinical slides are included. This set was published in 1976 so that newly described organisms such as Cryprosporidium are not included. Each volume costs $100.00 and is available from the American Society of Clinical Pathologists at the address listed above. Centers for Disease Control Laboratoy Updates. The Laboratory Update series is produced by the Laboratory Training and Consultation Division at the Centers for Disease Control. The series includes slide/tape sets covering all areas of clinical microbiology. These sets are available on loan from most state public health laboratories. Write to your state laboratory for a list of sets that are currently available. American Society for Microbiology Slide Collection. The ASM has a series of kodachromes available, most
of which deal with clinical microbiology and are sold individually. A catalog can be purchased for $1 .OOfrom the Publication and Sales Department, American Society for Microbiology, 1913 I St., N. W., Washington, DC 20006. Listen, Look, and Learn Series on Clinical Microbiology. This newly published (1985) collection of slides is the end product of a collaborative effort of the American Society for Microbiology and Health Education Resources, a nonprofit educational organization. The slide/tape collection covers all areas of the clinical microbiology laboratory, including bacteriology, parasitology, mycology, and virology. Chlumydiu, mycoplasmas, and rickettsias are also included in the series. The set contains more than 700 slides organized into 24 lectures with a printed text of test questions and answers. Inquiries about this series should be made to Health Education Resources, Inc., 4733 Bethesda Ave., Suite 735, Bethesda, MD 20814.
Sandra Travis. M.S. M.T. (ASCP) Sr. Mtrrj. Mc~lic~trl Ccwret Wtrllo Wtrlltr . Wtr.vlli~~g/o~~ 99362 A: Several sources are available for obtaining slide sets for all areas of clinical microbiology (including virology!). Some of these sets are part of slide/tape presentations for continuing medical laboratory education. Slide bets currently available include: Atltrs of‘C/inictrl Mycology. This hix-volume collection of more than 500 kodachrome slides covers aerobic actinomyceteh. yeasts, systemic mycoses, opportunistic fungi. laboratory contaminants, subcutaneous mycoses, and dermatophytes. In general, the slides are of high quality and include both laboratory and clinical photographs. The set was published in 1979, so that the accompanying slide index is somewhat out-of-date, particularly regarding taxonomy. Each volume is priced at
Climcal
Microbiology
Newleucr
8: I I. 19X6
B 1986 Elsevirr
Science Publishing Co.. Inc.
William M. Janda, Ph.D. Department of Medical Laboratory Sciences University of Illinois at Chicago Chicago, Illinois 60612
William d. Janda, Ph.D. Department of Medical Laboratory Sciences University of Illinois at Chicago Chicago. Illinois 60612
0196-4399/86/$0.00
+ 02.20
83
Invitation to Contributors Case Reports Reports documenting. interesting case presentations are invited for possible publication in the CIinicaf Microbiology Newsletter. Submitted case reports should be written concisely and should contain: a) a brief clinical history summarizing the symptoms and course of the illness; b) a description of how the organism(s) were cultured and differentiated from closely associated organisms; and c) the resultsof susceptibilitytesting for the isolate(s). Referem Authors are responsible for the accuracy of references, which should include complete publication information. References should be listed in alphabetical order by the fit author’s last name, numbered consecutively, and cited in the text by these numbers. Some typical examplesof referencesare listed below. Consult this issuefor additional examplesof Newsletter referenceformat. 1. Edwards, P. R., and W. H. Ewing. 1972. Identification of Enterobacteriaceue. 3rd ed. Burgess Publishing Co., Minneapolis. (Underline only words italicized in the original.) 2. Hoeprich, P. D., M. A. Saubolle, and A. C. Houston. 1977. Susceptibility testing of fungi, pp. 101-106. In A. Bondi, et al. @Is.). The clinical laboratory asan aid in chemotherapyof infectious disease.University Park Press,Baltimore. (List all editors if fewer than three.) 3. Rubin. S. J. et al. 1976. Combined serotyping and biotyping of Serrutiu marcescens. J. Clin. Microbial. 3582-585. (List all authors if fewer than four.) Letters ’ Letters expressing opinions or offering helpful technical hints will be considered for publication (subject to editing) provided they are signed by all authors and do not exceedtwo typewritten (double-spaced)pages. Questiotis and Answers Questions about microbiologic techniques or about general problems in clinical microbiology may be submitted. They will bc answeredby the editorial board or by other individuals in the field. Preparation and Submission of Material All material submitted for publication in the Newsletter should bc typed double-spaced (including references) on standard 8’/2 x 11 paper. The original typescript and four copies should be sent to: J. G. McRelvic Clinical Microbiology
Newsletter
ElsevierSciencePublishing Co., Inc. 52 Vanderbilt Avenue New York, New York 10017
Editors
Subscription Information Clinical Microbiology Ncwslerrer
Marie B. Coyle
is published
52 Vanderbilt Avenue, New York, postage and handling in the United
Paul A. Granato
Co.,
Inc.,
NY 10017. Subscription rate is $70.00 for 24 issues including States. Canada, and Mexico. Add $25.00 for postage (airmail)
twice
monthly
by Elsevier
Science
Publishing
in
Europeand $28.00for the restof the world.
Josephine A. Morello
This newsletter copying articles
R. J. Zabransky
has been registered with the Copyright Clearance Center, Inc. Consent is given for for personal or internal use, or for the personal or internal use of specific clients. This
consent is given on the condition that the copier pay through the Center the per-page fee stated in the code on each page for copying beyond rhat permitted by the U.S. Copyright Law. If no code appears on an article. the author has nof given broad consent fo copy. and permission fo copy must be obtained directly from the author. This consent does not extend lo other kinds of copying, such as for general distribution.
Q 1986ElsevierSciencePublishingCo., Inc. ISSN0196-4399 CMNEEJ8(11)77-84, 1986 Elsevier
Address Elsevier missing foreign Elsevier
resale,
0196-4399/86BO.O0
+ 02.20
and promotional
Postmaster: Co., Inc.,
Send address changes 52 Vanderbilt Avenue,
Editorials necessarily
and letters printed in this newsletter reflect the opinions of the editors.
Clinical Microbiology and Communicable
84
advertising
purposes,
or for creating
new collective
works
orders, changes of address, and claims for missing issues to Journals Fulfillment Department. Science Publishing Co., Inc.. 52 Vanderbilt Avenue, New York, NY 10017. Claims for issues can be honored only up to three months for domestic addresses and six months for addresses. Duplicate copies will nor be sent lo replace ones undelivered due to failure to notify of change of address.
Newsletter Diseases.
10 Chico/ New York,
is abstracted
0 1986 Elsevicr Science Publishing Co.. Inc.
Microbiology NY 10017. are published
in Tropical
Newslerrer.
Elsevier
for the interest
Diseases
Bulletin
Clinical
Science
Publishing
of the readers
and do not
and Absrracrs
on Hygiene
Microbiology
Newslener
8: 1 I, 1986
serum. This procedure was pretested by preparing smears on MicroTrak slides with a protein A containing S. aureus. The smears were then stained with and without the recommended blocking step using chlamydial seronegative sera. The manufacturer of MicroTrak comments on this possible source of error stating that “C. trachomatis elementary bodies can be distinguished from bacteria by characteristic morphology,” and that, “chlamydial elementary bodies are approximately 300 nm in diameter and stain evenly over the entire surface while bacterial cells are generally 2-3 times larger than elementary bodies and tend to stain at the rim, producing a doughnut-like appearance (7).” A difference between these morphological entities is evident but we believe that only highly skilled fluorescent microscopists can make this judgement with any degree of confidence. To remedy this problem we recommend that the manufacturer include the blocking step described above as part of the test procedure and perhaps include chlamydial seronegative sera in the kit. Alternatively, we suggest the removal of the Fc fraction of the monoclonal conjugate immunoglobulin either enzymatically or by blocking with soluble protein A (4).
2.
Gosting, I. H. et al. 1984. Identification of species-specific antigen in Legionella pneumophila by a monoclonal antibody. J. Clin. Microbial. 20: IO3 I 1035.
3.
Krech, T. et al. 198.5. Interference of Staphylococcus aureus in the detection of Chlamvdia trachomatis by monoclonal aniibodies. Lancet i: I 16 I - I 162.
4.
Langone, J. J. 1982. Protein A from Staphylococcus aureus and related immunoglobulin receptors produced by streptococci and pneumococci. Adv. Immunol. 32:157.
5.
Reis, K. J., E. M. Ayoub, and W. D. P. Boyles. 1984. Streptococcal Fc receptors: I. Isolation and partial characterization of the receptor from group C streptococcus. J. Immunol. 132:3091-3097.
Ruijs, G. et al. 1984.
6.
Rapid detection with monoclonal antibodies of Chlamydia trachomatis in urethral smears and urine sediments. Lancet i:960-961.
I.
Syva. Revised
8.
Tam, M. R. et al. 1984.
9.
Uyeda, C. T. et al. 1984. Evaluation of MicroTrakTM direct specimen test for identification of Chlamydia trachomaris in clinical specimens (abst.). Abstracts of the Annual Meeting of the American Society for Microbiology. p. 254.
July 1985. MicroTrak. Chlamydia trachomatis direct specimen test technical information brochure 8H 184-8. Culture indcpendent diagnosis of Chlamydia trachomatis using monoclonal antibodies. N. Engl. J. Med. 310:1146-l 150.
Anthony D’ Auria, M.S. Chief Microbiologist St. Peter’s Medical Center New Brunswick, Nenj Jersey
References
1. Forsgoen,
A., and J. Sjoquist
Protein A from I. Pseudoimmune gamma-globulin. 827.
a
08903
1966.
Staphylococcus aureus. reaction with human J. Immunol. 97:822-
David Alcid, M.D. Chief, Infectious Disease St. Peter’s Medical Center New Brunswick, New Jersey
08903
Question and Answer
Q: Our laboratory routinely receives vaginal smears from ER patients for Gram stain primarily to determine the presence of gram-negative diplococci. What is the current recommendation regarding the value of vaginal Gram stains in light of the fact that other gram-negative organisms can morpho-
82
0196-4399/X6/$0.00
+ 02.20
logically
resemble
Neisseria
gonor-
rhoeae?
Denise DeMattie, MHS, MT (ASCP) SM Manager, Silrler Joliet.
0 1986 Elsevier
A: Gram stains prepared from
\vag-
inal swab specimens are usually not
Microbiolog) Cross Hospital Illinois 60432
Science Publishing Co..
Inc.
very helpful in detecting gonococcal infection, because the vagina does not represent the site of infection in pubertous females. Neisseria gonorrhoeae preferentially adheres to and infects the transitional and columnar
Chnical
Microbiology
Newshmer
8: I I. I986
epithelial cells of the cervix and endocervical canal. The adult female vaginal epithelium, composed primarily of stratified squamous epithelial cells overlying connective tissue, is generally not susceptible to gonococcal attachment and growth. In prepubescent females. however, the vaginal mucosa may become infected with gonococci, and these patients may develop “gonococcal vaginitis,” presenting with itching and a crusting vaginal discharge as the predominant symptoms. While Gram stains of vaginal secretions may be noncontributory or even misleading in the diagnosis of gonorrhea in women due to the presence of morphologically similar organisms (e.g.. Mo~a.re//~ species), a Gram stain of carefully collected endocervica/ material may indeed be very useful in the diagnosis. Specimens should be col-
lected from the endocervical canal under direct visualization with a speculum in place. Vaginal and cervical mucous should first be removed with cotton or gauze. The swab should be inserted into the cervical OSand moved from side to side, allowing time for organisms to become adsorbed to the swab surface. Any obvious mucopurulent cervical discharge should also be collected. Frequently, purulent discharge containing organisms may be expressed from the urethra and periurethral glands, providing excellent specimens for microscopic and cultural examination. Gram-stain smears are prepared by gently rolling the swab on a glass slide, thereby causing minimal disruption of the morphology of cells and organisms in the specimen. Properly collected endocervical Gram-stained smears have a sensitivity
of anywhere from 50 to 70%. An endocervical Gram-stained smear showing gram-negative diplococci within polymorphonuclear cells, particularly from a woman with other signs and symptoms (lower genital tract pain, dysuria, abnormal pelvic examination), is highly predictive of gonococcal infection. In asymptomatic women, however, the predictive value of the Gram stain is much lower. Of course, culture of this material should also be performed in addition to a Gramstained smear. Examination of vaginal specimens is preferred for the diagnosis of Candida and Trichomonas vaginalis vaginitis, and is helpful in the clinical diagnosis of nonspecific vaginosis.
Q: Our lahorrrtor-T bcwuld like to trcyuire reji~rence mcitericil. particularly kodtrchr0nie.s for- general microbiology. rn~cology. nl~c.~~bLI~.tCrioIog~. and pwusitolog!. Are you twwre of N source from \chich rc*emight be cable to obttrin them?
$80.00 and they are available from the Educational Products Division of the American Society of Clinical Pathologists (2100 W. Harrison Street, Chicago, IL 60612). Atlas of Diagnostic Medical Parasitology. This three-volume series of slides encompasses blood and tissue parasites, intestinal protozoa, and intestinal helminths. As with the Arfus of Clinical Mycology, both laboratory and clinical slides are included. This set was published in 1976 so that newly described organisms such as Cryprosporidium are not included. Each volume costs $100.00 and is available from the American Society of Clinical Pathologists at the address listed above. Centers for Disease Control Laboratoy Updates. The Laboratory Update series is produced by the Laboratory Training and Consultation Division at the Centers for Disease Control. The series includes slide/tape sets covering all areas of clinical microbiology. These sets are available on loan from most state public health laboratories. Write to your state laboratory for a list of sets that are currently available. American Society for Microbiology Slide Collection. The ASM has a series of kodachromes available, most
of which deal with clinical microbiology and are sold individually. A catalog can be purchased for $1 .OOfrom the Publication and Sales Department, American Society for Microbiology, 1913 I St., N. W., Washington, DC 20006. Listen, Look, and Learn Series on Clinical Microbiology. This newly published (1985) collection of slides is the end product of a collaborative effort of the American Society for Microbiology and Health Education Resources, a nonprofit educational organization. The slide/tape collection covers all areas of the clinical microbiology laboratory, including bacteriology, parasitology, mycology, and virology. Chlumydiu, mycoplasmas, and rickettsias are also included in the series. The set contains more than 700 slides organized into 24 lectures with a printed text of test questions and answers. Inquiries about this series should be made to Health Education Resources, Inc., 4733 Bethesda Ave., Suite 735, Bethesda, MD 20814.
Sandra Travis. M.S. M.T. (ASCP) Sr. Mtrrj. Mc~lic~trl Ccwret Wtrllo Wtrlltr . Wtr.vlli~~g/o~~ 99362 A: Several sources are available for obtaining slide sets for all areas of clinical microbiology (including virology!). Some of these sets are part of slide/tape presentations for continuing medical laboratory education. Slide bets currently available include: Atltrs of‘C/inictrl Mycology. This hix-volume collection of more than 500 kodachrome slides covers aerobic actinomyceteh. yeasts, systemic mycoses, opportunistic fungi. laboratory contaminants, subcutaneous mycoses, and dermatophytes. In general, the slides are of high quality and include both laboratory and clinical photographs. The set was published in 1979, so that the accompanying slide index is somewhat out-of-date, particularly regarding taxonomy. Each volume is priced at
Climcal
Microbiology
Newleucr
8: I I. 19X6
B 1986 Elsevirr
Science Publishing Co.. Inc.
William M. Janda, Ph.D. Department of Medical Laboratory Sciences University of Illinois at Chicago Chicago, Illinois 60612
William d. Janda, Ph.D. Department of Medical Laboratory Sciences University of Illinois at Chicago Chicago. Illinois 60612
0196-4399/86/$0.00
+ 02.20
83
Invitation to Contributors Case Reports Reports documenting. interesting case presentations are invited for possible publication in the CIinicaf Microbiology Newsletter. Submitted case reports should be written concisely and should contain: a) a brief clinical history summarizing the symptoms and course of the illness; b) a description of how the organism(s) were cultured and differentiated from closely associated organisms; and c) the resultsof susceptibilitytesting for the isolate(s). Referem Authors are responsible for the accuracy of references, which should include complete publication information. References should be listed in alphabetical order by the fit author’s last name, numbered consecutively, and cited in the text by these numbers. Some typical examplesof referencesare listed below. Consult this issuefor additional examplesof Newsletter referenceformat. 1. Edwards, P. R., and W. H. Ewing. 1972. Identification of Enterobacteriaceue. 3rd ed. Burgess Publishing Co., Minneapolis. (Underline only words italicized in the original.) 2. Hoeprich, P. D., M. A. Saubolle, and A. C. Houston. 1977. Susceptibility testing of fungi, pp. 101-106. In A. Bondi, et al. @Is.). The clinical laboratory asan aid in chemotherapyof infectious disease.University Park Press,Baltimore. (List all editors if fewer than three.) 3. Rubin. S. J. et al. 1976. Combined serotyping and biotyping of Serrutiu marcescens. J. Clin. Microbial. 3582-585. (List all authors if fewer than four.) Letters ’ Letters expressing opinions or offering helpful technical hints will be considered for publication (subject to editing) provided they are signed by all authors and do not exceedtwo typewritten (double-spaced)pages. Questiotis and Answers Questions about microbiologic techniques or about general problems in clinical microbiology may be submitted. They will bc answeredby the editorial board or by other individuals in the field. Preparation and Submission of Material All material submitted for publication in the Newsletter should bc typed double-spaced (including references) on standard 8’/2 x 11 paper. The original typescript and four copies should be sent to: J. G. McRelvic Clinical Microbiology
Newsletter
ElsevierSciencePublishing Co., Inc. 52 Vanderbilt Avenue New York, New York 10017
Editors
Subscription Information Clinical Microbiology Ncwslerrer
Marie B. Coyle
is published
52 Vanderbilt Avenue, New York, postage and handling in the United
Paul A. Granato
Co.,
Inc.,
NY 10017. Subscription rate is $70.00 for 24 issues including States. Canada, and Mexico. Add $25.00 for postage (airmail)
twice
monthly
by Elsevier
Science
Publishing
in
Europeand $28.00for the restof the world.
Josephine A. Morello
This newsletter copying articles
R. J. Zabransky
has been registered with the Copyright Clearance Center, Inc. Consent is given for for personal or internal use, or for the personal or internal use of specific clients. This
consent is given on the condition that the copier pay through the Center the per-page fee stated in the code on each page for copying beyond rhat permitted by the U.S. Copyright Law. If no code appears on an article. the author has nof given broad consent fo copy. and permission fo copy must be obtained directly from the author. This consent does not extend lo other kinds of copying, such as for general distribution.
Q 1986ElsevierSciencePublishingCo., Inc. ISSN0196-4399 CMNEEJ8(11)77-84, 1986 Elsevier
Address Elsevier missing foreign Elsevier
resale,
0196-4399/86BO.O0
+ 02.20
and promotional
Postmaster: Co., Inc.,
Send address changes 52 Vanderbilt Avenue,
Editorials necessarily
and letters printed in this newsletter reflect the opinions of the editors.
Clinical Microbiology and Communicable
84
advertising
purposes,
or for creating
new collective
works
orders, changes of address, and claims for missing issues to Journals Fulfillment Department. Science Publishing Co., Inc.. 52 Vanderbilt Avenue, New York, NY 10017. Claims for issues can be honored only up to three months for domestic addresses and six months for addresses. Duplicate copies will nor be sent lo replace ones undelivered due to failure to notify of change of address.
Newsletter Diseases.
10 Chico/ New York,
is abstracted
0 1986 Elsevicr Science Publishing Co.. Inc.
Microbiology NY 10017. are published
in Tropical
Newslerrer.
Elsevier
for the interest
Diseases
Bulletin
Clinical
Science
Publishing
of the readers
and do not
and Absrracrs
on Hygiene
Microbiology
Newslener
8: 1 I, 1986