- Email: [email protected]
Revision of quality control limits for cefotaxime disk susceptibility tests
Correspondence
Unfortunately, no control of the CSF was obtained because the patient left Paris and returned to Niger. This report documents subacute polyradiculoneuritis due to confirmed syphilis in a non-HIV-infected African patient. He presented with symptoms mimicking Guillain–Barre´’s syndrome in association with bilateral Argyll Robertson’s sign, hypergammaglobulinemia in the CSF and positivity of both TPHA and the TPHA index ×100 in the CSF [7]. The clinical presentation of neurosyphilis has changed. Indeed, classical forms such as general paresis and tabes dorsalis have decreased, while meningovascular and meningoencephalitis forms have increased in frequency, especially in HIV-infected patients [7,8]. In contrast, syphilitic polyradiculoneuropathy has rarely been reported (Table 1). Lanska et al [4] described an HIV-infected man in whom syphilitic polyradiculopathy occurred 4 months after the rash of secondary syphilis. Two other cases have been recently described in HIVnegative patients. In one, polyradiculopathy occurred simultaneously with a maculopapular rash [5]. In the other, a tertiary or late symptomatic neurosyphilis presented as a motor polyradiculoneuropathy without any previous skin rash [6]. All these three cases recovered after penicillin therapy. In conclusion, infection due to T. pallidum is a curable cause of polyradiculoneuritis which may occur in HIV-negative patients; appropriate tests in both serum and CSF should be performed in patients with polyradiculoneuritis. C. Darras-Joly, L. Belec and O. Lortholary* *Service de Me´decine Interne, Hoˆpital Avicenne, CREPIT 93, Universite´ Paris-Nord, 125, route de Stalingrad, 93009 Bobigny Cedex, France Tel: +33 1 48 95 54 51 Fax: +33 1 48 95 54 50 E-mail: [email protected]
REFERENCES 1. Tramont EC. Treponema pallidum (syphilis). In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases, 4th edn. Harlow: Churchill Livingstone, 1995: 2117–33. 2. Merritt HH, Adams RD, Solomon RC. Neurosyphilis. New York: Oxford University Press, 1946. 3. Chemouilli P, Belec L. Manifestations neurologiques de la syphilis. Nevraxe 1991; 1: 51–60. 4. Lanska MJ, Lanska DJ, Schmidley JW. Syphilitic polyradiculopathy in an HIV-positive man. Neurology 1988; 38: 1297–301. 5. Byrne TN, Bose A, Sze G, Waxman SG. Syphilitic meningitis causing paraparesis in an HIV-negative woman. J Neurol Sci 1991; 103: 48–50. 6. Caponnetto C, De Maria A, Solara C, Abbruzzese M, Primavera A. Late symptomatic neurosyphilis presenting as a motor polyradiculoneuropathy. Ital J Neurol Sci 1997; 18: 62.
285
7. Burke JM, Schaberg DR. Neurosyphilis in the antibiotic era. Neurology 1985; 35: 1368–71. 8. Simon RP. Neurosyphilis. Arch Neurol 1985; 42: 606–13.
Revision of quality control limits for cefotaxime disk susceptibility tests In the past few years, we have experienced difficulty when cefotaxime disks were tested against the control strain of Streptococcus pneumoniae (ATCC 49619), because zones were frequently too large. As part of a recent multilaboratory study, we were able to re-evaluate the quality control ranges for cefotaxime disks tested against five different control strains, including S. pneumoniae ATCC 49619. The 10 participating laboratories are identified in the Acknowledgments. Each participant was provided with agar plates containing Mueller–Hinton agars from three different manufacturers (Acumedia lot 9808187, Difco lot 107846JG and BDMS lot 10 D1GE). For testing the pneumococcus, 5% sheep blood was added to the agar media. For testing Haemophilus influenzae, the Mueller–Hinton agars were prepared as Haemophilus Test Medium [1]. The participants were also provided with 30-mg cefotaxime disks from two manufacturers (Remel lot 30–836 5502 and BDMS lot 711558). Either cefaclor (BDMS lot 1006610611) or cefixime (Remel lot 30–134 5508) disks were used for internal control purposes. If zones around the control disks were not within the established limits, the tests were to be repeated, and if they remained out of control, cefotaxime zones produced on that test plate were excluded from our analysis. Because of space limitations, a Pseudomonasactive control disk could not be tested against Pseudomonas aeruginosa ATCC 27853, but only two of 600 cefotaxime zones were outside the current control range of 18–22 mm [2] and no changes are proposed. Each participant independently tested all five control strains on 10 different test days, following the disk test procedure of the National Committee for Clinical Laboratory Standards (NCCLS) [1]. On each test day, one inoculum suspension was prepared for each control strain and the turbidity was adjusted to match that of a McFarland 0.5 turbidity standard. Then, three agar plates were inoculated, each from a different lot of Mueller–Hinton agar. Each plate received two 30-mg cefotaxime disks and one control disk (5 mg of cefixime or 30 mg of cefaclor). The test plates were incubated for 18–20 h at 35 °C in ambient air or for 20–24 h in 5–10% CO2 for the S. pneumoniae and H. influenzae control strains [1]. In this way, all 10 laboratories reported 600 cefotaxime zone diameters for each control strain. Unsatisfactory control disk results excluded 0.3– 3.3% of those determinations. The excluded cefotaxime zones were all within the current or proposed control ranges for cefotaxime disk tests. The results of this exercise are summarized in Table 1. The current control ranges for 30-mg cefotaxime disk tests [2] against
© 2000 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 6, 283–288
286
Clinical Microbiology and Infection, Volume 6 Number 5, May 2000
Table 1 Results of a 10-laboratory collaborative study to reassess quality control limits for cefotaxime disk susceptibility tests
Control strain Pseudomonas aeruginosa ATCC 27853 Escherichia coli ATCC 25922 Staphylococcus aureus ATCC 25923 Haemophilus influenzae ATCC 49247 Streptococcus pneumoniae ATCC 49619 NCCLS quality control limits Proposed range
Current quality control limits
Observed zone diameters
No. zones evaluateda
Rangeb
Midpoint
Median (mm)
% in range
600 592 580 580
18–22 29–35 25–31 31–39
20 32 28 35
21 33 28 34
99.7% 97.8% 98.6% 98.1%
598 598
30–35 31–39
32.5 35
35 35
60.2% 96.3%
a Of the 600 determinations, some tests were excluded because the control disk gave zones outside of the established control ranges: for different control strains, 3.3–0.3% of all cefotaxime zones were excluded. The control disk for the Streptococcus pneumoniae and Haemophilus influenzae strains was cefixime, whereas cefaclor was the control disk for the Staphylococcus aureus and Escherichia coli strains. A pseudomonas-active control disk could not be included because of space limitations. b Range of acceptable zone diameters (mm) listed in the current NCCLS document, M100-S9 [2]. For Streptococcus pneumoniae ATCC 49619, an alternative control range is also listed. The midpoint between the upper and lower limits is an idealized target value.
four of the five control strains were reconfirmed, since 98.1– 99.7% of the 600 zones fell within the established ranges and the modal values were within 1 mm of the midpoint between the two extremes. This included a narrow 5-mm range for P. aeruginosa ATCC 27853 and a broader 9-mm range for H. influenzae ATCC 49247. However, when S. pneumoniae ATCC 49619 was tested on Mueller–Hinton blood agar, only 60% of the zones were within the narrow 6-mm range of 30–35 mm, and the modal value was at the outer limit of 35 mm. The current zone size limits are clearly inappropriate, and we propose a broader range of 31–39 mm for the S. pneumoniae control strain. For that strain, other extended-spectrum cephalosporins have 7- or 8-mm ranges [2], and this is compatible with the 9mm range that we are proposing for cefotaxime disk tests. Our proposed change in zone size limits has recently been approved by the NCCLS subcommittee on antimicrobial susceptibility tests, and the new limits will appear in future NCCLS publications. This report describes the data that supported that change in QC limits.
Medical Center, Albuquerque, New Mexico, USA; R. Rennie, University of Alberta Hospital, Edmonton, Alberta, Canada; M. Saubolle, Good Samaritan Hospital, Phoenix, Arizona, USA. A. L. Barry* and S. D. Brown *The Clinical Microbiology Institute, 9725 SW Commerce Circle, Suite A-1, Wilsonville, Oregon 97070, USA Tel: +1 503 682 3232 Fax: +1 503 682 2065 E-mail: [email protected]
REFERENCES 1. National Committee for Clinical Laboratory Standards. Performance standards for antimicrobial disk susceptibility tests. Approved standard M2–A6. Wayne, PA: NCCLS, 1997. 2. National Committee for Clinical Laboratory Standards. Performance standards for antimicrobial susceptibility testing. Ninth Informational Supplement M100–S9. Wayne, PA: NCCLS, 1999.
ACKNOWLEDGMENTS We wish to thank the following individuals for collaborating in this exercise: M. Bauman, St Vincent Hospital, Portland, Oregon, USA; S. Brown, The Clinical Microbiology Institute, Wilsonville, Oregon, USA; M. J. Ferraro, Massachusetts General Hospital, Boston, Massachusetts, USA; D. Hardy, University of Rochester Medical Center, Rochester, New York, USA; J. Hindler, UCLA Medical Center, Los Angeles, California, USA; S. Jenkins, Carolinas Medical Center, Charlotte, North Carolina, USA; C. Knapp, AccuMed International, Westlake, Ohio, USA; G. Overturf, University of New Mexico
Ascites and pleural effusion accompanying hepatitis A infection in a child Up to 1992, seven children were reported with acute hepatitis A associated with ascites [1–3]. Pleural effusion also represents a rare complication of acute type A viral hepatitis [4]. I report a recent observation on a rare presentation of both ascites and pleural effusion accompanying hepatitis A infection in a child. A 4-year-old boy was hospitalized because of abdominal distension and jaundice of the skin and sclerae. Four days earlier,
© 2000 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 6, 283–288
Copyright of Clinical Microbiology & Infection is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Unfortunately, no control of the CSF was obtained because the patient left Paris and returned to Niger. This report documents subacute polyradiculoneuritis due to confirmed syphilis in a non-HIV-infected African patient. He presented with symptoms mimicking Guillain–Barre´’s syndrome in association with bilateral Argyll Robertson’s sign, hypergammaglobulinemia in the CSF and positivity of both TPHA and the TPHA index ×100 in the CSF [7]. The clinical presentation of neurosyphilis has changed. Indeed, classical forms such as general paresis and tabes dorsalis have decreased, while meningovascular and meningoencephalitis forms have increased in frequency, especially in HIV-infected patients [7,8]. In contrast, syphilitic polyradiculoneuropathy has rarely been reported (Table 1). Lanska et al [4] described an HIV-infected man in whom syphilitic polyradiculopathy occurred 4 months after the rash of secondary syphilis. Two other cases have been recently described in HIVnegative patients. In one, polyradiculopathy occurred simultaneously with a maculopapular rash [5]. In the other, a tertiary or late symptomatic neurosyphilis presented as a motor polyradiculoneuropathy without any previous skin rash [6]. All these three cases recovered after penicillin therapy. In conclusion, infection due to T. pallidum is a curable cause of polyradiculoneuritis which may occur in HIV-negative patients; appropriate tests in both serum and CSF should be performed in patients with polyradiculoneuritis. C. Darras-Joly, L. Belec and O. Lortholary* *Service de Me´decine Interne, Hoˆpital Avicenne, CREPIT 93, Universite´ Paris-Nord, 125, route de Stalingrad, 93009 Bobigny Cedex, France Tel: +33 1 48 95 54 51 Fax: +33 1 48 95 54 50 E-mail: [email protected]
REFERENCES 1. Tramont EC. Treponema pallidum (syphilis). In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases, 4th edn. Harlow: Churchill Livingstone, 1995: 2117–33. 2. Merritt HH, Adams RD, Solomon RC. Neurosyphilis. New York: Oxford University Press, 1946. 3. Chemouilli P, Belec L. Manifestations neurologiques de la syphilis. Nevraxe 1991; 1: 51–60. 4. Lanska MJ, Lanska DJ, Schmidley JW. Syphilitic polyradiculopathy in an HIV-positive man. Neurology 1988; 38: 1297–301. 5. Byrne TN, Bose A, Sze G, Waxman SG. Syphilitic meningitis causing paraparesis in an HIV-negative woman. J Neurol Sci 1991; 103: 48–50. 6. Caponnetto C, De Maria A, Solara C, Abbruzzese M, Primavera A. Late symptomatic neurosyphilis presenting as a motor polyradiculoneuropathy. Ital J Neurol Sci 1997; 18: 62.
285
7. Burke JM, Schaberg DR. Neurosyphilis in the antibiotic era. Neurology 1985; 35: 1368–71. 8. Simon RP. Neurosyphilis. Arch Neurol 1985; 42: 606–13.
Revision of quality control limits for cefotaxime disk susceptibility tests In the past few years, we have experienced difficulty when cefotaxime disks were tested against the control strain of Streptococcus pneumoniae (ATCC 49619), because zones were frequently too large. As part of a recent multilaboratory study, we were able to re-evaluate the quality control ranges for cefotaxime disks tested against five different control strains, including S. pneumoniae ATCC 49619. The 10 participating laboratories are identified in the Acknowledgments. Each participant was provided with agar plates containing Mueller–Hinton agars from three different manufacturers (Acumedia lot 9808187, Difco lot 107846JG and BDMS lot 10 D1GE). For testing the pneumococcus, 5% sheep blood was added to the agar media. For testing Haemophilus influenzae, the Mueller–Hinton agars were prepared as Haemophilus Test Medium [1]. The participants were also provided with 30-mg cefotaxime disks from two manufacturers (Remel lot 30–836 5502 and BDMS lot 711558). Either cefaclor (BDMS lot 1006610611) or cefixime (Remel lot 30–134 5508) disks were used for internal control purposes. If zones around the control disks were not within the established limits, the tests were to be repeated, and if they remained out of control, cefotaxime zones produced on that test plate were excluded from our analysis. Because of space limitations, a Pseudomonasactive control disk could not be tested against Pseudomonas aeruginosa ATCC 27853, but only two of 600 cefotaxime zones were outside the current control range of 18–22 mm [2] and no changes are proposed. Each participant independently tested all five control strains on 10 different test days, following the disk test procedure of the National Committee for Clinical Laboratory Standards (NCCLS) [1]. On each test day, one inoculum suspension was prepared for each control strain and the turbidity was adjusted to match that of a McFarland 0.5 turbidity standard. Then, three agar plates were inoculated, each from a different lot of Mueller–Hinton agar. Each plate received two 30-mg cefotaxime disks and one control disk (5 mg of cefixime or 30 mg of cefaclor). The test plates were incubated for 18–20 h at 35 °C in ambient air or for 20–24 h in 5–10% CO2 for the S. pneumoniae and H. influenzae control strains [1]. In this way, all 10 laboratories reported 600 cefotaxime zone diameters for each control strain. Unsatisfactory control disk results excluded 0.3– 3.3% of those determinations. The excluded cefotaxime zones were all within the current or proposed control ranges for cefotaxime disk tests. The results of this exercise are summarized in Table 1. The current control ranges for 30-mg cefotaxime disk tests [2] against
© 2000 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 6, 283–288
286
Clinical Microbiology and Infection, Volume 6 Number 5, May 2000
Table 1 Results of a 10-laboratory collaborative study to reassess quality control limits for cefotaxime disk susceptibility tests
Control strain Pseudomonas aeruginosa ATCC 27853 Escherichia coli ATCC 25922 Staphylococcus aureus ATCC 25923 Haemophilus influenzae ATCC 49247 Streptococcus pneumoniae ATCC 49619 NCCLS quality control limits Proposed range
Current quality control limits
Observed zone diameters
No. zones evaluateda
Rangeb
Midpoint
Median (mm)
% in range
600 592 580 580
18–22 29–35 25–31 31–39
20 32 28 35
21 33 28 34
99.7% 97.8% 98.6% 98.1%
598 598
30–35 31–39
32.5 35
35 35
60.2% 96.3%
a Of the 600 determinations, some tests were excluded because the control disk gave zones outside of the established control ranges: for different control strains, 3.3–0.3% of all cefotaxime zones were excluded. The control disk for the Streptococcus pneumoniae and Haemophilus influenzae strains was cefixime, whereas cefaclor was the control disk for the Staphylococcus aureus and Escherichia coli strains. A pseudomonas-active control disk could not be included because of space limitations. b Range of acceptable zone diameters (mm) listed in the current NCCLS document, M100-S9 [2]. For Streptococcus pneumoniae ATCC 49619, an alternative control range is also listed. The midpoint between the upper and lower limits is an idealized target value.
four of the five control strains were reconfirmed, since 98.1– 99.7% of the 600 zones fell within the established ranges and the modal values were within 1 mm of the midpoint between the two extremes. This included a narrow 5-mm range for P. aeruginosa ATCC 27853 and a broader 9-mm range for H. influenzae ATCC 49247. However, when S. pneumoniae ATCC 49619 was tested on Mueller–Hinton blood agar, only 60% of the zones were within the narrow 6-mm range of 30–35 mm, and the modal value was at the outer limit of 35 mm. The current zone size limits are clearly inappropriate, and we propose a broader range of 31–39 mm for the S. pneumoniae control strain. For that strain, other extended-spectrum cephalosporins have 7- or 8-mm ranges [2], and this is compatible with the 9mm range that we are proposing for cefotaxime disk tests. Our proposed change in zone size limits has recently been approved by the NCCLS subcommittee on antimicrobial susceptibility tests, and the new limits will appear in future NCCLS publications. This report describes the data that supported that change in QC limits.
Medical Center, Albuquerque, New Mexico, USA; R. Rennie, University of Alberta Hospital, Edmonton, Alberta, Canada; M. Saubolle, Good Samaritan Hospital, Phoenix, Arizona, USA. A. L. Barry* and S. D. Brown *The Clinical Microbiology Institute, 9725 SW Commerce Circle, Suite A-1, Wilsonville, Oregon 97070, USA Tel: +1 503 682 3232 Fax: +1 503 682 2065 E-mail: [email protected]
REFERENCES 1. National Committee for Clinical Laboratory Standards. Performance standards for antimicrobial disk susceptibility tests. Approved standard M2–A6. Wayne, PA: NCCLS, 1997. 2. National Committee for Clinical Laboratory Standards. Performance standards for antimicrobial susceptibility testing. Ninth Informational Supplement M100–S9. Wayne, PA: NCCLS, 1999.
ACKNOWLEDGMENTS We wish to thank the following individuals for collaborating in this exercise: M. Bauman, St Vincent Hospital, Portland, Oregon, USA; S. Brown, The Clinical Microbiology Institute, Wilsonville, Oregon, USA; M. J. Ferraro, Massachusetts General Hospital, Boston, Massachusetts, USA; D. Hardy, University of Rochester Medical Center, Rochester, New York, USA; J. Hindler, UCLA Medical Center, Los Angeles, California, USA; S. Jenkins, Carolinas Medical Center, Charlotte, North Carolina, USA; C. Knapp, AccuMed International, Westlake, Ohio, USA; G. Overturf, University of New Mexico
Ascites and pleural effusion accompanying hepatitis A infection in a child Up to 1992, seven children were reported with acute hepatitis A associated with ascites [1–3]. Pleural effusion also represents a rare complication of acute type A viral hepatitis [4]. I report a recent observation on a rare presentation of both ascites and pleural effusion accompanying hepatitis A infection in a child. A 4-year-old boy was hospitalized because of abdominal distension and jaundice of the skin and sclerae. Four days earlier,
© 2000 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 6, 283–288
Copyright of Clinical Microbiology & Infection is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.