Association of BK virus with failure of prophylaxis against hemorrhagic cystitis following bone marrow transplantation.

PURPOSE: Hemorrhagic cystitis (HC) after bone marrow transplantation (BMT) has been ascribed to cyclophosphamide metabolites. HC has also been associated with excretion of the BK type of polyomavirus. The relative contributions of cyclophosphamide metabolites and BK virus in the development of HC following BMT are unknown. PATIENTS AND METHODS: We conducted a randomized trial to compare mesna with forced diuresis for prophylaxis against HC in 147 BMT recipients. We studied the association of BK virus with HC in 95 consecutive BMT recipients by prospectively monitoring urinary excretion of BK virus using polymerase chain reaction amplification of viral gene sequences. RESULTS: HC occurred in 37 of 147 (25.2%) transplant recipients. The incidence of HC was similar in patients given mesna (26.8%, 19 of 71) or forced diuresis (23.7%, 18 of 76), and in recipients of allogeneic (27.2%, 18 of 64) or autologous marrow (22.9%, 19 of 83). The incidence of HC was unrelated to primary disease, preparative regimen, or occurrence of graft-versus-host disease (GVHD). Excretion of BK virus was demonstrated in 50 of 95 patients (52.6%); 38 patients (40%) had persistent BK viruria (> or = two consecutive positive samples). HC occurred in 19 of 38 patients (50%) with persistent BK viruria, in one of 12 (8.3%) with only a single urine sample positive for BK virus, and in none of 45 who did not excrete BK virus (P < .0001). Shedding of BK virus also had a strong temporal correlation with onset of HC (r = .95). CONCLUSION: Mesna and forced diuresis are equally effective in abrogating the urothelial toxicity of preparative regimens for BMT. Since HC after BMT is virtually always associated with persistent BK viruria, strategies aimed at the prevention or elimination of viruria in BK seropositive recipients are warranted.

"Acute chest syndrome" in adults with sickle cell anemia. Microbiology, treatment, and prevention.

Fifty-two episodes of fever, chest pain, increased leukocytosis, and pulmonary infiltrate ("acute chest syndrome") were studied in 28 adults with sickle cell anemia. Possible bacterial pathogens were identified in sputum cultures from less than half of the episodes; no pneumococci were found, and Staphylocococcus aureus was the only bacterium associated with a longer illness than that seen when only normal flora were recovered. Much disease diagnosed as "pneumonia" in adults with sickle cell anemia is probably pulmonary infarction. Many of these patients will recover with no more than modest supportive care; if antibiotics are used they should be directed against S aureus (and possibly Hemophilus species). Pneumococcal polysaccharide vaccine has great potential for preventing life-threatening infection in children with sickle cell anemia, but may not change the incidence or severity of the acute chest syndrome in adults.

Management of pneumonia in the prospective payment era. A need for more clinician and support service interaction.

We compared the diagnostic and therapeutic management of pneumonia during 1970 and 1971 with that during 1979 and 1980 in clinically similar populations at The Johns Hopkins Hospital, Baltimore. More patients received aminoglycoside and cephalosporin therapy during 1979 and 1980. Guidelines for the use of chest roentgenograms and cultures were exceeded in 14% to 24% of cases. Patients whose cases were judged to be suboptimally managed had significantly higher charges and length of stay. Aged patients and those requiring thoracentesis also used resources more intensively. Given the technologic explosion, clinicians cannot know the performance characteristics of all tests and medications they can order. To minimize inefficient and ineffective practices, it is essential that clinicians and support service directors develop guidelines for testing and antibiotic use. Deviations should trigger timely interventions. Management under prospective payment will also require identifying specific patient subgroups to verify appropriate utilization and to assure equitable reimbursement.

Hemorrhagic cystitis associated with adenovirus infection in bone marrow transplantation.

A retrospective study of bone marrow transplant recipients shedding adenovirus type 11 in the urine was carried out to determine the association between viral shedding and hemorrhagic cystitis in this population. Weekly urine virology surveillance cultures were obtained during the first 100 days following transplantation. Adenovirus type 11 was cultured from five of 502 bone marrow transplant recipients from 1977 through 1984. In four of these five patients there was associated hemorrhagic cystitis. This contrasts with an overall incidence of hemorrhagic cystitis of 20% in this bone marrow transplant population. A case of hemorrhagic cystitis occurred in a patient following bone marrow transplantation. Recognition of a viral origin of hemorrhagic cystitis may explain the occurrence of late hemorrhagic cystitis in patients despite interventions designed to prevent cyclophosphamide-induced hemorrhagic cystitis. Hemorrhagic cystitis may be the presenting sign of a lethal adenoviral infection.

Empiric use of vancomycin during prolonged treatment-induced granulocytopenia. Randomized, double-blind, placebo-controlled clinical trial in patients with acute leukemia.

Because gram-positive infections cause morbidity following intensive antileukemic chemotherapy, the effects of vancomycin versus placebo were evaluated in a randomized, double-blind, placebo-controlled trial in 60 adult patients with acute leukemia and first infectious fever during prolonged (mean of 32 days) granulocytopenia. Gram-positive sepsis was associated with first fever in 17 (28 percent) of the 60 patients. None of 31 patients randomly assigned to receive vancomycin demonstrated gram-positive infection, whereas 16 of 22 patients randomly assigned to receive placebo subsequently had gram-positive infection (seven had sepsis, and nine had local infections; p less than 0.005). All patients with gram-positive infection were then given vancomycin, and all showed prompt clinical responses. The predominant gram-positive organism causing infection was beta-lactam-resistant Staphylococcus epidermis (19 of 44 isolates). Patients randomly assigned to receive vancomycin had more rapid resolution of first infectious fever and fewer total febrile days during the granulocytopenic course than did patients randomly assigned to receive placebo. Although vancomycin had no effect on the presence or absence of documented fungal infection, patients treated with vancomycin received empiric amphotericin B for recurrent or persistent fever later (mean of 14 days after initial antibiotic coverage was begun) than did patients receiving placebo (mean of 9.9 days; p less than 0.005), and thus received fewer total days of empiric amphotericin B therapy (mean of 16.3 days) than did patients given placebo (mean of 24.6 days; p less than 0.01). These data demonstrate that empiric use of vancomycin reduces the morbidity of gram-positive infections following intensive antileukemic therapy and decreases the need for empiric use of toxic amphotericin B.

Incidence of cytomegalovirus disease in cyclosporine-treated renal transplant recipients based on donor/recipient pretransplant immunity.

We retrospectively reviewed the clinical data of all renal transplant patients treated with cyclosporine as their main chronic immunosuppressive agent between 12/83 and 11/85 to identify cytomegalovirus-negative patients at our institutions who received cytomegalovirus (CMV)-positive kidneys. Using a latex agglutination test, twenty-two such patients were identified, of whom 2 were excluded due to early death and lack of posttransplant follow-up serology. Of the remaining 20 patients, 12 developed CMV antibody in the first 4 months posttransplant, and of these, 11 were hospitalized with complications related to primary CMV disease. Two of these seroconverting patients eventually died, and one lost her kidney. Of the 8 persistantly CMV-negative patients, 1 lost his kidney soon after transplantation, and one had a febrile illness 4 months posttransplant caused by a bacterial pneumonia. Concomitantly, 145 renal transplants (CMV-negative recipient receiving a CMV-negative kidney or CMV-positive recipient receiving either positive or negative kidneys) given to 142 patients functioned for at least 4 weeks. Only 3 cases of CMV reactivation disease occurred in previously antibody-positive patients. We conclude that the transplantation of a cytomegalovirus-positive kidney into a CMV-negative recipient carries a high risk of mortality/morbidity from primary cytomegalovirus disease. On the other hand, reactivation of CMV disease was uncommon early in the posttransplant course of cyclosporine-treated patients.

Radiometric identification of Streptococcus Group A in throat cultures.

Streptococcus Group A may be identified in simulated and patients' throat cultures by the selective inhibition of Group A streptococcus carbohydrate metabolism in the presence of specific antisera.

Radiometric detection of herpes simplex viruses.

Two radiometric techniques were investigated as possible means of detecting viruses in clinical specimens. The effect of herpes simplex virus on DNA synthesis by monolayers of human embryonic lung fibroblasts was monitored by the incorporation of [3H] thymidine or [125I] iododeoxyuridine ([125I] IdU). Radiometric results were compared with those obtained from visual examination for cytopathic effects in the same cell line. Cells infected with herpes simplex virus type-2 (HSV-2, 10(6.8) virions) showed a marked increase in [3H] thymidine incorporation 2--6 hr after infection. Types 1 and 2 herpes simplex virus yielded similar results, uith increased incorporation of tracer being observed 72 hr after infection with 10 virions. The [3H] thymidine technique was used successfully to assay mouse brains infected with HSV-1. Increased [125I] IdU incorporation was observed 6 hr after infection with 10(5)--10(6.8) HSV-1 virions, 24 hr after 10(4) virions, 48 hr after 10(3) virions, and 72 hr after 10--100 virions. The increased [125I] IdU incorporation was completely inhibited by preneutralization with immune serum. These radiometric techniques for detection of viral effect on cellular metabolism are simple, objective, and quantitative.

Simple radiometric techniques for rapid detection of herpes simplex virus type 1 in WI-38 cell culture.

Two radiometric techniques were developed for detecting the presence of herpes simplex virus type 1 in stationary monolayers of the diploid cell line WI-38. The time of detection was compared to that obtained from visual examination for cytopathic effects in the same cell line. Oxidation of 14C-1-glucose in infected and uninfected cells was determined by 14CO2 production, measured by an ionization chamber, and DNA synthesis was determined by 3H-thymidine incorporation, measured by scintillation counting. Compared to uninfected cells, infected cells showed a 23-26% reduction in 14C-1-glucose oxidation and a 355-498% increase in DNA synthesis 4-6 hr after infection. These changes in cellular metabolism were observed 14 hr before visible signs of cytopathic effects. The increase in DNA synthesis was completely inhibited by viral neutralization with herpes simplex antiserum. Increased DNA synthesis was observed 5 hr after infection with 10,000-3,200,000 TCID50 units of virus. These radiometric methods for the detection of viral effect on cellular metabolism are simple, fast, and objective.

Comparison of nasal brush and nasopharyngeal aspirate techniques in obtaining specimens for detection of respiratory syncytial viral antigen by immunofluorescence.

Diagnosis of respiratory syncytial virus by antigen detection is dependent on obtaining adequate respiratory epithelial cells. Two specimen collection methods, nasopharyngeal aspiration (NPA) and nasal brushing (NB), were compared. Thirty-two pediatric patients with presumed viral pneumonia or bronchiolitis (34 episodes) had both NPA and NB performed. Of 34 specimens 15 were culture-positive for respiratory syncytial virus. Of these 12 NPA samples and 10 NB samples had viral inclusions by immunofluorescent antibody staining (IFA). Of culture-negative samples, 1 of 17 NB was positive by IFA. One specimen obtained by NB had too few cells to read by the IFA method. Sensitivity and specificity were 80 and 100% for NPA and 67 and 94% for NB. Total respiratory cells and IFA-positive cells (classified as few, moderate, or many) were greater with NPA; however, NB was also an effective procedure and was better tolerated by children, less expensive and easier to perform.

Cytomegalovirus retinitis and viral resistance. Prevalence of resistance at diagnosis, 1994. Cytomegalovirus Retinitis and Viral Resistance Study Group.

OBJECTIVE: To determine the prevalence of cytomegalovirus (CMV) isolates resistant to ganciclovir sodium or foscarnet sodium at the time of diagnosis of CMV retinitis, prior to the initiation of therapy. DESIGN: Prospective epidemiologic study. SETTING: An acquired immunodeficiency syndrome ophthalmology clinic. PATIENTS: Patients with acquired immunodeficiency syndrome and newly diagnosed CMV retinitis. INTERVENTION: Culturing blood and urine samples for CMV and testing of all positive isolates for sensitivity to ganciclovir and foscarnet. MAIN OUTCOME MEASURE: Prevalence of the following: blood culture isolates resistant to ganciclovir (inhibitory concentration 50% [IC50] > 5.5 mumol/L) or foscarnet (IC50 > 400 mumol/L) and urine culture isolates resistant to ganciclovir or foscarnet. RESULTS: Forty-nine patients were enrolled during a 13-month period. Forty-four patients had blood culture samples that could be evaluated; of these, 66% were positive (59% of patients). Thirty-four patients had urine cultures that were evaluable; of these, 82% were positive (57% of patients). Overall, 78% of patients had either a urine or blood culture sample positive for CMV. No blood culture isolates were resistant to ganciclovir, and only 1 urine culture isolate (2% of patients) was resistant to ganciclovir. Three percent of blood culture isolates and 4% of urine culture isolates (2% and 2% of patients, respectively) were resistant to foscarnet. Overall, 4% of patients had either a blood or urine culture isolate resistant to foscarnet. CONCLUSION: Resistance to ganciclovir or foscarnet at the time of diagnosis of CMV retinitis is uncommon.

Limits of applicability of the firefly luminescence ATP assay for the detection of bacteria in clinical specimens.

ATP measurement can be used as an indicator of biological mass, and the extreme sensitivity of the firefly ATP assay has led to its use in bacterial detection systems. Clinical specimens present problems not encountered with cultured isolates of known bacterial species. The lower limit of sensitivity for detecting bacteria using the firefly assay is 100,000 bacteria per ml. Non-bacterial ATP, which is probably present in all clinical specimens, produces false-positive results unless it is completely destroyed, and this destruction must be carried out under conditions that do not affect bacterial ATP. A cause of false-negative results is the presence in all urine specimens of unidentified materials that inhibit the luminescent enzymic reaction. These considerations indicate that application of the firefly ATP assay in bacterial detection systems for clinical specimens is feasible only if a preparatory step separates bacteria from interfering materials and from non-bacterial sources of ATP, and concentrates microorganisms to measurable levels. These limitations sharply curtain the applicability in diagnostic microbiology of this exotic chemical reaction.

Cryptosporidiosis in an immunosuppressed renal-transplant recipient with IgA deficiency.

Cryptosporidia are sporozoan parasites that infect epithelial cells of the gastrointestinal tract. Infection with cryptosporidia has been found most commonly in a variety of animal species and only rarely in man. The authors report a case of an immunosuppressed renal-transplant recipient with IgA deficiency who experienced diarrhea and fever and was found to have cryptosporidia in a jejunal biopsy specimen and in air-dried smears of the specimen. By electron microscopy, trophozoite, schizont, and macrogamete forms were identified, and these forms ahd morphologic features similar to those of cryptosporidia previously found in guinea pigs. Treatment of the cryptosporidial infection in this case was with trisulfapyrimidines. The efficacy of this treatment could not be evaluated because of complications.

Comparison of two methods for same-day identification of Enterobacteriaceae.

Two commercial methods, API 20E (as modified for same-day enterobacterial identification) and Micro-ID, were evaluated for ability to provide useful same-day information of 368 clinically isolated Enterobacteriaceae. Organisms included Escherichia coli (54), Shigella (7), Edwardsiella tarda (1), Salmonella enteritidis (10), Citrobacter (30), Klebsiella (55), Enterobacter (68), Hafnia alvei (2), Serratia (33), Proteus (64), Morganella morganii (24), Providencia (18), and Yersinia enterocolitica (2). Methods were those of manufacturers without supplemental tests. API at five hours identified 78.5% of strains to species, 9.5% to genus only, 10.1% as part of a spectrum of identifications (SI), and 1.9% incorrect. Micro-ID at four hours yielded 90.0% correct identification to species and 3.3% to genus only, 4.0% SI, and 2.7% incorrect. API identification of many Serratia, Citrobacter, Providencia strains was to genus only; most incorrect results occurred in Serratia marcescens. Micro-ID identified most organisms to species; incorrect identifications were mainly S. marcescens and Klebsiella pneumoniae. Both systems provided excellent identification of E. coli. Both methods sacrifice a degree of accuracy that varies with the species tested, as compared to overnight systems, but both provide rapid information of potential clinical value.

Detection of surgical pathogens by in vitro DNA amplification. Part I. Rapid identification of Candida albicans by in vitro amplification of a fungus-specific gene.

The management of candidemia and disseminated candidiasis depends on rapid, unambiguous identification of Candida. Such identification is retarded by the slow growth of Candida from clinical specimens. Administration of effective but potentially toxic antifungal therapy is often withheld pending identification. To circumvent this slow growth and thus to expedite diagnosis and therapy, the polymerase chain reaction (PCR) was used to amplify a segment of fungal DNA coding for the cytochrome P450L1A1 (lanosterol-14 alpha-demethylase) in vitro. The technique provides unambiguous evidence of C. albicans in as few as 6 hours with a detection threshold of 10 organisms in a 100 mu specimen. Clinical specimens of urine (n = 4), sputum (n = 6), wound fluid (n = 1, and blood (n = 2) were collected from patients, and C. albicans was conventionally documented at these sites; in each case, PCR was confirmed. Of 17 additional specimens that were culture negative, PCR suggested the presence of yeast in two of the specimens. PCR-based detection of surgical pathogens may have broad application in rapid screening for the presence of organisms either indigenous to a particular surgical intensive care unit or peculiar to selected patient populations.

Group B streptococcal colonization in a developing country: its association with sexually transmitted disease and socioeconomic factors.

Group B Streptococcus (GBS) is an important infectious organism in pregnant women and their neonates. Although excellent data are available from the developing world, little epidemiologic information is available from Latin America. To evaluate the prevalence of GBS colonization in a developing country, a prospective study was performed in Lima, Peru. We found a relatively low prevalence of GBS colonization of 6.0% in parturient women and 10.6% in nonpregnant women. No association of GBS colonization was made with previously identified risk factors such as age, parity, or birth control practices. We did find a positive association between GBS colonization and chlamydial carriage (P < 0.05). We also report an even distribution of GBS serotypes: Ia/c = 35%, IIc = 18%, III = 29%, and V = 18%. Our study provides evidence for a low prevalence of GBS maternal carriage in this urban Latin American population.

Culture confirmation of cytomegalovirus and herpes simplex virus by direct enzyme-labeled DNA probes and in situ hybridization.

Using probes consisting of horseradish peroxidase (HRP) directly attached to DNA, scrapings or trypsinized cells from 217 adequate clinical samples were cultured and analyzed in 3 blind studies by in situ hybridization for the presence of cytomegalovirus (CMV) and herpes simplex virus (HSV). Sixty samples were judged inadequate due to insufficient cell numbers; however, this problem was significantly decreased during the course of the study. One hundred and eighteen samples were found positive and 70 samples were found negative for CMV. Scrapings of cultured cells from 29 clinical samples revealed 9 samples which were positive and 20 samples which were negative for HSV. Forty-two additional samples, containing either uninfected cells or cells infected with various strains of CMV, were analyzed for the ability of the HRP-DNA CMV probe to detect such isolates. Twenty samples were positive and 22 negative for CMV. No false-negatives or false-positives were observed for either CMV or HSV. In addition to the specificity noted above neither the CMV nor the HSV DNA probe hybridized to potential contaminants found in clinical specimens.

Viral sensitivity testing in patients with cytomegalovirus retinitis clinically resistant to foscarnet or ganciclovir.

PURPOSE: Resistance to antiviral therapy is a potential cause of progression of cytomegalovirus retinitis in patients with the acquired immunodeficiency syndrome. We investigated the results of viral sensitivity testing in a series of patients with clinically resistant retinitis who had positive results of blood or urine cytomegalovirus cultures. METHODS: All patients with newly diagnosed cytomegalovirus retinitis between January 1990 and December 1991 were prospectively studied. Blood and urine cultures for cytomegalovirus were obtained in a nonrandomized subgroup of this group. The results of in vitro sensitivity to foscarnet and ganciclovir, determined by a DNA hybridization assay, were then analyzed in seven patients with clinically resistant cytomegalovirus retinitis and whose blood or urine culture results, or both, were positive for cytomegalovirus while on a treatment regimen. RESULTS: Foscarnet-resistant cytomegalovirus (ID50 > 300 microM) was isolated from two patients, one of whom was being treated with foscarnet. Ganciclovir-resistant cytomegalovirus (ID 50 > 6.0 microM) was isolated from four patients, three of whom were being treated with ganciclovir. Foscarnet- and ganciclovir-resistant cytomegalovirus occurred with previous ganciclovir therapy in one patient. Clinical improvement occurred in three patients whose change in therapy was based on viral sensitivity testing. In general, prolonged therapy with one drug was associated with a progressive increase in the ID 50 for that drug. CONCLUSIONS: Viral resistance to foscarnet or ganciclovir may explain refractory cytomegalovirus retinitis in some patients.

Viral resistance and CMV retinitis: design and methods of a prospective study. CRVR Research Groups. Cytomegalovirus Retinitis Viral Resistance Research Group.

A prospective study following a cohort of patients with newly diagnosed, previously untreated cytomegalovirus (CMV) retinitis is being conducted to study drug resistant CMV. Prior to initiation of treatment, patients undergo a baseline eye examination, fundus photography, and blood and urine culture for presence of CMV, and drug susceptibility testing against positive isolates. Patients are followed monthly with a detailed eye examination to diagnose progression of retinitis, and for fundus photography. Cultures are repeated at 1 and 3 months after enrollment, every 3 months thereafter, and at the time of treatment reinduction for the progression of retinitis. This study was designed to determine the prevalence and incidence of drug resistant CMV, as well as risk factors for the development of resistant CMV. It also will determine the correlation between clinical outcome, as measured both by eye examination and fundus photography, and viral resistance.

A comparison of subcutaneous and intraperitoneal oxytetracycline injection methods for control of infectious disease in the rat.

After receiving once daily intraperitoneal (i.p.) or subcutaneous (s.c.) injections of oxytetracycline (15 mg/100 g bodyweight) for 7 days, laboratory rats had significantly different oxytetracycline serum levels depending on the method of injection. Regardless of injection method, the biological half-life of the antibiotic was 4.25 h and serum antibiotic levels never fell below therapeutic levels for certain rat pathogens during 24 h post-injection. Severe peritonitis and cellulitis were found in rats whether injected s.c. or i.p. and some animals lost bodyweight. It appeared that either injection method would be an effective treatment for certain infectious diseases of laboratory rats but tissue damage, probably from oxytetracycline's acidity, made both methods unattractive.