Updates to the Diagnosis and Clinical Management of Helicobacter pylori Infections.

BACKGROUND: Helicobacter pylori (H. pylori) affects nearly half of the world's populations with high incidence and prevalence rates in developing countries. Infection with H. pylori increases the risk of developing peptic ulcer disease and gastric cancer. This review provides a summary of the prevalence and microbiology of H. pylori with emphasis on the current diagnostic methods and clinical management strategies. CONTENT: This review discusses current options and developments in H. pylori diagnosis with the challenges and advantages associated with both noninvasive and invasive methods. The advantages of molecular methods for the diagnosis of H. pylori infection and prediction of clarithromycin resistance directly from stool or tissue biopsies are discussed. In addition, we provide a brief review on the treatment for H. pylori indicated in patients with evidence of active infection with the organism's antimicrobial resistance patterns taken into consideration. SUMMARY: Testing for H. pylori has largely centered around fecal antigen testing, urea breath testing, and immunohistochemical staining from tissue biopsies. Culture-based diagnostics followed by phenotypic antimicrobial susceptibility testing is the gold standard for detection of resistance patterns. Due to the fastidious nature of the organism, culture methods are time consuming and labor intensive. Rapid nucleic acid amplification tests for H. pylori identification from direct specimens and molecular determination of drug resistance markers are accurate alternatives for H. pylori diagnosis but are not widely adopted. H. pylori antimicrobial resistance rates are on the rise due to the widespread use of antibiotics. Antibiotic regimens including the quadruple therapy and non-clarithromycin triple therapies have a higher success rate, with newer vonoprazon-based regimens showing promising eradication rates.

Where Have All the Diagnostic Morphological Parasitologists Gone?

Advances in laboratory techniques have revolutionized parasitology diagnostics over the past several decades. Widespread implementation of rapid antigen detection tests has greatly expanded access to tests for global parasitic threats such as malaria, while next-generation amplification and sequencing methods allow for sensitive and specific detection of human and animal parasites in complex specimen matrices. Recently, the introduction of multiplex panels for human gastrointestinal infections has enhanced the identification of common intestinal protozoa in feces along with bacterial and viral pathogens. Despite the benefits provided by novel diagnostics, increased reliance on nonmicroscopy-based methods has contributed to the progressive, widespread loss of morphology expertise for parasite identification. Loss of microscopy and morphology skills has the potential to negatively impact patient care, public health, and epidemiology. Molecular- and antigen-based diagnostics are not available for all parasites and may not be suitable for all specimen types and clinical settings. Furthermore, inadequate morphology experience may lead to missed and inaccurate diagnoses and erroneous descriptions of new human parasitic diseases. This commentary highlights the need to maintain expert microscopy and morphological parasitology diagnostic skills within the medical and scientific community. We proposed that light microscopy remains an important part of training and practice in the diagnosis of parasitic diseases and that efforts should be made to train the next generation of morphological parasitologists before the requisite knowledge, skills, and capacity for this complex and important mode of diagnosis are lost. In summary, the widespread, progressive loss of morphology expertise for parasite identification negatively impacts patient care, public health, and epidemiology.

Proceedings of the Clinical Microbiology Open 2018 and 2019 - a Discussion about Emerging Trends, Challenges, and the Future of Clinical Microbiology.

Clinical Microbiology Open (CMO), a meeting supported by the American Society for Microbiology's Clinical and Public Health Microbiology Committee (CPHMC) and Corporate Council, provides a unique interactive platform for leaders from diagnostic microbiology laboratories, industry, and federal agencies to discuss the current and future state of the clinical microbiology laboratory. The purpose is to leverage the group's diverse views and expertise to address critical challenges, and discuss potential collaborative opportunities for diagnostic microbiology, through the utilization of varied resources. The first and second CMO meetings were held in 2018 and 2019, respectively. Discussions were focused on the diagnostic potential of innovative technologies and laboratory diagnostic stewardship, including expansion of next-generation sequencing into clinical diagnostics, improvement and advancement of molecular diagnostics, emerging diagnostics, including rapid antimicrobial susceptibility and point of care testing (POCT), harnessing big data through artificial intelligence, and staffing in the clinical microbiology laboratory. Shortly after CMO 2019, the coronavirus disease 2019 (COVID-19) pandemic further highlighted the need for the diagnostic microbiology community to work together to utilize and expand on resources to respond to the pandemic. The issues, challenges, and potential collaborative efforts discussed during the past two CMO meetings proved critical in addressing the COVID-19 response by diagnostic laboratories, industry partners, and federal organizations. Planning for a third CMO (CMO 2022) is underway and will transition from a discussion-based meeting to an action-based meeting. The primary focus will be to reflect on the lessons learned from the COVID-19 pandemic and better prepare for future pandemics.

Multicenter Evaluation of a Gradient Diffusion Method for Antimicrobial Susceptibility Testing of Helicobacter pylori.

Helicobacter pylori is an important human pathogen associated with peptic ulcer disease, dyspepsia, and gastric malignancy. Antimicrobial susceptibility testing (AST) is often requested for patients who fail eradication therapy. The Clinical and Laboratory Standards Institute (CLSI) reference method, agar dilution (AD), is not performed in most laboratories and maintaining organism viability during transit to a reference laboratory is difficult. We assessed the performance of the Etest (bioMérieux) as a method for H. pylori AST in comparison to AD. Etest MICs were determined for 83 H. pylori isolates at ARUP and Cleveland Clinic (CC). Categorical agreement (CA), very major, major, and minor errors (VME, ME, and mE) were determined for Etest using AD performed at Mayo Clinic Laboratories as the reference method. Testing on isolates with errors was repeated to determine final results summarized below. For clarithromycin, 66.3% of isolates were resistant (R) by AD; Etest results at each laboratory showed 1mE (1.2%) and 1 ME (3.8%). For tetracycline, only 2 isolates were R by AD; a single VME occurred at both sites (98.8% CA, 50% VME) with the same isolate. Applying EUCAST levofloxacin breakpoints to interpret ciprofloxacin results, 60.2% of isolates were R by AD; ARUP CA was 97.6% (1 ME (3%), 1 VME (2%)) and CC CA was 96.3% (1 ME (3%), 2 VMEs (4%)). Despite high error rates, the categorical agreement was acceptable (>90%) for all three antibiotics between AD and Etest. In-house susceptibility testing by gradient diffusion can allow for testing of fastidious organisms that may not survive transport to specialized laboratories; however, the method is not without technical challenges. Characterization of resistance mechanisms, increased AD dilutions, and testing from the same inoculum may determine if the observed errors reflect technical issues or breakpoints that need optimization. IMPORTANCE Routine antimicrobial susceptibility testing (AST) of Helicobacter pylori by agar dilution is difficult to perform and not practical in most clinical microbiology laboratories. The Etest gradient diffusion method can be a reliable alternative for H. pylori AST with the advantage of being a less laborious quantitative method. This work reveals that an optimized Etest method can provide acceptable performance for H. pylori AST and describes the challenges associated with this methodology.

Human Acanthocephaliasis: a Thorn in the Side of Parasite Diagnostics.

Acanthocephala is a phylum of parasitic pseudocoelomates that infect a wide range of vertebrate and invertebrate hosts and can cause zoonotic infections in humans. The zoologic literature is quite rich and diverse; however, the human-centric literature is sparse, with sporadic reports over the past 70 years. Causal agents of acanthocephaliasis in humans are reviewed as well as their biology and life cycle. This review provides the first consolidated and summarized report of human cases of acanthocephaliasis based on English language publications, including epidemiology, clinical presentation, treatment, and diagnosis and identification.

Evaluation of 3 SARS-CoV-2 IgG Antibody Assays and Correlation with Neutralizing Antibodies.

BACKGROUND: As serologic assays for SARS-CoV-2 become more widely utilized, it is important to understand their performance characteristics and correlation with neutralizing antibodies. We evaluated 3 commonly used SARS-CoV-2 IgG assays (Abbott, DiaSorin, and EUROIMMUN) for clinical sensitivity, specificity, and correlation with neutralizing antibodies, and then compared antibody kinetics during the acute phase of infection. METHODS: Three panels of samples were tested on every assay. Sensitivity was assessed using a panel of 35 specimens serially collected from 7 patients with RT-PCR-confirmed COVID-19. Specificity was determined using 100 sera samples collected in 2018 from healthy individuals prior to the outbreak. Analytical specificity was determined using a panel of 37 samples from individuals with respiratory illnesses other than COVID-19. RESULTS: Clinical sensitivity was 91.43% (95% CI 76.94-98.20%) for Abbott, and 88.57% (95% CI 73.26-96.80%) for both DiaSorin and EUROIMMUN. Clinical specificity was 99.00% (95% CI 94.55-99.97%) for Abbott and DiaSorin and 94.00% (95% CI 87.40-97.77%) for EUROIMMUN. The IgG assays demonstrated good qualitative agreement (minimum of 94%) and good correlation between the quantitative result for each combination of assays (r2 ≥ 0.90). The neutralizing antibody response did not necessarily follow the same temporal kinetics as the IgG response and did not necessarily correlate with IgG values. CONCLUSION: The 3 IgG antibody assays demonstrated comparable performance characteristics. Importantly, a qualitative positive IgG result obtained with any of the assays was associated with the presence of neutralizing antibodies; however, neutralizing antibody concentrations did not correlate well with signal to cutoff ratios.

Application, Verification, and Implementation of SARS-CoV-2 Serologic Assays with Emergency Use Authorization.

Interest continues to grow regarding the role of serologic assays for the detection of prior infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The U.S. Food and Drug Administration (FDA) has granted emergency use authorization (EUA) status to many SARS-CoV-2 serologic assays. In this document, expert recommendations from clinical microbiologist members of the American Society for Microbiology (ASM) concerning detailed verification strategies for SARS-CoV-2 serologic assays with FDA EUA are provided, as are insights into assay limitations and reporting considerations for laboratories. Assessments concerning single-antibody and multiantibody isotype detection assays, which may provide either differentiated or nondifferentiated (i.e., total antibody) antibody class results, are addressed. Additional considerations prior to assay implementation are also discussed, including biosafety, quality control, and proficiency testing strategies. As the landscape of SARS-CoV-2 serologic testing is rapidly changing, this document provides updated guidance for laboratorians on application of these assays.

The Role of Antibody Testing for SARS-CoV-2: Is There One?

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) brought with it rapid development of both molecular and serologic assays for identification of COVID-19 infections. While Food and Drug Administration (FDA) emergency use authorization (EUA) is required for clinical application of SARS-CoV-2 molecular tests, submission for EUA is currently a voluntary process for manufacturers of serologic assays. The absence of FDA oversight of serologic tests is concerning given that the commercially available serologic assays are highly variable, differing in their format, the antibody class detected, the targeted antigen, and the acceptable specimen types. An added complication is the lack of a clear understanding for how such assays should be utilized and what the reported results ultimately indicate or, perhaps more importantly, what they do not indicate. Here, we provide a brief summary of the performance of a number of serologic assays reported in the literature, comment on what we do and do not know regarding our immune response to SARS-CoV-2, and provide a number of scenarios for which serologic testing will play a role during our global response to this pandemic.

Detection of Intestinal Protozoa in Trichrome-Stained Stool Specimens by Use of a Deep Convolutional Neural Network.

Intestinal protozoa are responsible for relatively few infections in the developed world, but the testing volume is disproportionately high. Manual light microscopy of stool remains the gold standard but can be insensitive, time-consuming, and difficult to maintain competency. Artificial intelligence and digital slide scanning show promise for revolutionizing the clinical parasitology laboratory by augmenting the detection of parasites and slide interpretation using a convolutional neural network (CNN) model. The goal of this study was to develop a sensitive model that could screen out negative trichrome slides, while flagging potential parasites for manual confirmation. Conventional protozoa were trained as "classes" in a deep CNN. Between 1,394 and 23,566 exemplars per class were used for training, based on specimen availability, from a minimum of 10 unique slides per class. Scanning was performed using a 40× dry lens objective automated slide scanner. Data labeling was performed using a proprietary Web interface. Clinical validation of the model was performed using 10 unique positive slides per class and 125 negative slides. Accuracy was calculated as slide-level agreement (e.g., parasite present or absent) with microscopy. Positive agreement was 98.88% (95% confidence interval [CI], 93.76% to 99.98%), and negative agreement was 98.11% (95% CI, 93.35% to 99.77%). The model showed excellent reproducibility using slides containing multiple classes, a single class, or no parasites. The limit of detection of the model and scanner using serially diluted stool was 5-fold more sensitive than manual examinations by multiple parasitologists using 4 unique slide sets. Digital slide scanning and a CNN model are robust tools for augmenting the conventional detection of intestinal protozoa.

Evaluation of a Novel High-Definition PCR Multiplex Assay for Simultaneous Detection of Tick-Borne Pathogens in Human Clinical Specimens.

The incidence of tick-borne infections in the United States has risen significantly in the past decade. Ticks can transmit a variety of pathogens, including bacteria, protozoa, and viruses, that can cause serious illnesses. Therefore, the use of rapid, sensitive, and specific multiplex tests is important to identify the pathogen(s) in the acute phase and determine appropriate treatment to minimize the severity of the disease. The purpose of this study was to evaluate ChromaCode's research use only (RUO) nine-target high-definition PCR (HDPCR) tick-borne pathogen (TBP) panel using 379 retrospective, remnant whole-blood and synovial fluid specimens previously submitted to Associated Regional and University Pathologists (ARUP) Laboratories and tested by clinically validated real-time PCR assays for Ehrlichia spp., Anaplasma phagocytophilum, Babesia spp., or Lyme Borrelia spp. The performance characteristics evaluated included positive percent agreement (PPA) and negative percent agreement (NPA) with the ARUP laboratory-developed tests (LDTs). All tested targets had an initial PPA greater than 97.0%, except Ehrlichia ewingii, with a PPA of 88.9%. The NPAs for all targets were between 98.8% and 100%. The TBP panel detected three coinfections, with two of Babesia microti and A. phagocytophilum and one of B. microti and E. chaffeensis, which were confirmed by the LDTs. There were 16 samples with discordant results compared to the LDT results, five of which were resolved by repeat testing on the TBP panel and bidirectional sequencing. Following discrepant resolution, the final PPA and NPA for the TBP panel were 97.7% (95% confidence interval [CI], 95.2% to 99.0%) and 99.6% (95% CI, 99.3% to 99.8%), respectively, with an overall agreement of 99.5% (95% CI, 99.2% to 99.7%) with the LDTs.

Impact of IVIG therapy on serologic testing for infectious diseases.

Intravenous immunoglobulin (IVIG) is used to treat an increasing number of conditions. The anti-inflammatory and immunomodulatory effects of IVIG can be life-saving; however, recent administration may complicate evaluation for infection. To assess the impact of IVIG therapy on a variety of common viral, bacterial, fungal, and parasitic serologies we prospectively evaluated serologic changes pre- and post-IVIG infusion in 7 participants. The number of new antibody detections ranging from 2 to 5. New detections included positivity for Epstein-Barr virus early D antigen, herpes simplex virus, West Nile virus, cytomegalovirus, and the endemic mycoses Histoplasma and Coccidioides. The greatest number of newly positive serologies was observed in subjects receiving cumulative doses of IVIG in excess of 100 g. Our results illustrate the difficulty in serologic interpretation following IVIG therapy and suggest a dose-response to new positive results. These findings may be a helpful resource to clinicians facing similar circumstances.

Direct-from-Specimen Pathogen Identification: Evolution of Syndromic Panels.

This article describes the current state of the art with regards to commercially available syndromic panels for blood stream infections, gastrointestinal pathogen detection, respiratory tract infections, and central nervous system infections, while providing a provocative and speculative look into the future of syndromic panel testing for infectious diseases.

Diagnostic Identification and Differentiation of Microfilariae.

The morphologic similarities of the microfilariae and their infrequency in clinical specimens in settings of endemicity present challenges to clinical laboratories in maintaining competence for accurate identification and differentiation. We present here a review of the primary filarial nematodes causing human infection, including an illustrated key, which we hope will improve the diagnostic capabilities of hematologists, microbiologists, medical technologists, and similarly qualified laboratorians.

Raillietiniaisis in a Toddler From Hawaii: A Case of Mistaken Tapeworm Identity.

We present the first reported case from the United States of human infection with the intestinal cestode Raillietina, a parasite primarily of rodents and poultry. As the differential diagnosis between the morphologically similar Dipylidium caninum was challenging, we discuss the biology, epidemiology, and clinical management of this rare parasite.