Efforts of the United States' National Marrow Donor Program and Registry to improve utilization and representation of minority donors.

SUMMARY: Haematopoietic stem cell transplantation is often used as a therapy for patients with certain blood, metabolic or immune system disorders. The United States' National Marrow Donor Program (NMDP) works to facilitate such life-saving transplants by coordinating the donor search and match process. However, concern exists that the NMDP Registry is underutilized and under-representative of racial and ethnic minorities. African-Americans and Hispanics are somewhat under-represented within the total number of donors, and it is estimated that the Registry is used by only approximately one-third of patients needing transplants. The NMDP has instituted programmes that address such concerns, resulting in an increase in both the total number of donors and the minority representation on the Registry. It has also increased efforts to recruit donors of umbilical cord blood, often a viable alternative source of haematopoietic stem cells. Over the past 8 years, the Registry has grown by more than 30% to contain over seven million donors, and the proportional distribution of racial and ethnic groups on the Registry has steadily approached their proportional distribution in the US population. Continued efforts on the part of the NMDP to maintain a Registry that is large in number and ethnically diverse should help ensure access to haematopoietic stem cell transplants for all patients who need them. The procedures and experience of the NMDP and its Registry may have implications for registries elsewhere in the world as they confront similar issues of number and diversity.

Ertapenem versus cefepime for initial empirical treatment of pneumonia acquired in skilled-care facilities or in hospitals outside the intensive care unit.

The study presented here compared the efficacy and safety of ertapenem and cefepime as initial treatment for adults with pneumonia acquired in skilled-care facilities or in hospital environments outside the intensive care unit (ICU). Non-ventilated patients developing pneumonia in hospital environments outside the ICU, in nursing homes, or in other skilled-care facilities were enrolled in this double-blind non-inferiority study, stratified by APACHE II score (15) and randomized (1:1) to receive cefepime (2 g every 12 h with optional metronidazole 500 mg every 12 h) or ertapenem (1 g daily). After 3 days of parenteral therapy, participants demonstrating clinical improvement could be switched to oral ciprofloxacin or another appropriate oral agent. Probable pathogens were identified in 162 (53.5%) of the 303 randomized participants. The most common pathogens were Enterobacteriaceae, Streptococcus pneumoniae, and Staphylococcus aureus, isolated from 59 (19.5%), 39 (12.9%), and 35 (11.6%) participants, respectively. At the test-of-cure assessment 7-14 days after completion of all study therapy, pneumonia had resolved or substantially improved in 89 (87.3%) of 102 clinically evaluable ertapenem recipients and 80 (86%) of 93 clinically evaluable cefepime recipients (95% confidence interval for the difference, -9.4 to 11.8%), fulfilling pre-specified criteria for statistical non-inferiority. The frequency and severity of drug-related adverse events were generally similar in both treatment groups. In this study population, ertapenem was as well-tolerated and efficacious as cefepime for the initial treatment of pneumonia acquired in skilled-care facilities or in hospital environments outside the ICU.

Antimicrobial susceptibility patterns in Pseudomonas aeruginosa: data from a multicenter Intensive Care Unit Surveillance Study (ISS) in the United States.

The objectives of this study were to analyze susceptibility rates and patterns in Pseudomonas aeruginosa isolates from patients in intensive care units (ICU). A total of 2209 isolates in 1995/1996 and 2672 in 2001/2002 were tested at United States sites participating in the ICU Surveillance Study. In both periods, of the agents tested, amikacin was the most active and ciprofloxacin, the least. Resistance to common antipseudomonal agents tested increased from 1995/1996 to 2001/2002; the rise was least for amikacin (2%) and greatest for ciprofloxacin (16%). The proportion of isolates susceptible to all six antipseudomonal agents tested since 1996 decreased from 60.4% to 48.9% in 2001/2002. Examination of MIC distributions for the two periods showed that for some drugs, e.g. imipenem and ceftazidime, the populations of susceptible and resistant isolates remained distinct, although the resistant population increased. For other drugs, e.g. amikacin and piperacillin-tazobactam, the MIC distribution shifted upward over time. The categorical agreement between agents of the same or like classes for isolates tested in 2001/2002 was highest for ciprofloxacin and levofloxacin (93.2%, with 1.2% major errors) and lowest for the aminoglycosides (81.3%, with 10.2% major errors). We can conclude that resistance to antipseudomonal agents among ICU isolates of P. aeruginosa, especially fluoroquinolones, is increasing. The resistance rate for some antipseudomonal agents may not accurately reflect shifts in the MIC distribution curve.

Management of complicated appendicitis and comparison of outcome with other primary sites of intra-abdominal infection: results of a trial comparing ertapenem and piperacillin-tazobactam.

A post-hoc analysis of data from a trial of complicated intra-abdominal infection was performed to compare the demographic and disease characteristics of patients with complicated appendicitis to those whose primary infection involved other intra-abdominal sites, assess the impact of site of primary infection on outcome, and compare the efficacy and safety of ertapenem 1 g daily with piperacillin-tazobactam 3.375 g every 6 h for treatment of complicated appendicitis. Compared with patients who had primary infection of the colon or another site in the abdomen, patients with complicated appendicitis were younger, had less severe disease (based on lower APACHE II score and lower proportion with generalized peritonitis), and were less likely to be managed by percutaneous drainage of an abscess or to have a postoperative infection. Patients with complicated appendicitis were more likely to have a favorable outcome than were patients with infection of the colon (OR, 3.02; 95% CI, [1.54-5.901; P = .001). At the test-of-cure assessment, 109/123 (88.6%) microbiologically evaluable patients with complicated appendicitis who received ertapenem and 102/113 (90.3%) who received piperacillin-tazobactam had a favorable combined clinical and microbiologic outcome. The frequency and severity of drug-related adverse events were similar in the two treatment groups.

Expression of the uterine Mx protein in cyclic and pregnant cows, gilts, and mares.

Pregnancy and interferon-tau (IFN tau) upregulate uterine Mx gene expression in ewes; however, the only known role for Mx is in the immune response to viral infection. We hypothesize that Mx functions as a conceptus-induced component of the anti-luteolytic mechanism and/or regulator of endometrial secretion or uterine remodeling during early pregnancy. This study was conducted to determine the effects of early pregnancy on uterine Mx expression in domestic farm species with varied mechanisms of pregnancy recognition. Endometrium from cows, gilts, and mares was collected during the first 20 d of the estrous cycle or pregnancy, and total messenger RNA (mRNA) and protein were analyzed for steady-state levels of Mx mRNA and protein. Northern blot analysis of Mx mRNA detected an approximately 2.5 Kb of mRNA in endometrium from each species. In pregnant cows, steady-state levels of Mx mRNA increased 10-fold (P < 0.05) above levels observed in cyclic cows by d 15 to 18. In cyclic gilts, slot blot analysis indicated that endometrial Mx mRNA levels did not change between d 5 and 18 of the cycle. However, in pregnant gilts, Mx levels tended (P = 0.06) to be elevated two-fold on d 16 only, and in situ hybridization indicated that this increase occurred in the stroma. In mares, Mx mRNA was low, but detectable, and did not change between ovulation (d 0) and d 20, regardless of reproductive status. Western blot analysis revealed multiple immunoreactive Mx protein bands in each species. One band was specific to pregnancy in cows. As in ewes, in situ hybridization analysis indicated that Mx mRNA was strongly expressed in the luminal epithelium, stroma, and myometrium by d 18 in cows. However, on d 14 in gilts, Mx was expressed primarily in the stroma, and on d 14 in mares, low levels of Mx expression were confined largely to the luminal epithelium. The uteruses of cows, gilts, and mares express Mx, and expression is upregulated during pregnancy in cows and gilts--animals whose conceptuses secrete interferons during early pregnancy, but that possess different mechanisms for pregnancy recognition.

A rapid immunochromatographic assay for hepatitis B virus screening.

Simple, rapid and accurate assays for hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) are helpful for clinical diagnosis and field epidemiological surveys. A commercially developed, rapid immunochromatographic test for simultaneous detection of HBsAg and HBeAg was evaluated using a total of 2463 selected samples (827 frozen sera, 1011 fresh sera, and 625 whole blood samples). Results of the rapid test were compared with standard enzyme immunoassay (EIA) methods for HBsAg and HBeAg detection. The accuracy of the rapid test was excellent and was similar for frozen sera, fresh sera and whole blood. The overall sensitivity and specificity for the detection of HBsAg were 95 and 100%, and the corresponding positive and negative predictive values were 100 and 99.7%, respectively. The sensitivity and specificity for the detection of HBeAg were slightly less than that for HBsAg, and were 80 and 98%, with positive and negative predictive values of 91 and 94%, respectively. Thus, compared with the EIA method, the rapid test was highly sensitive and accurate for the detection of HBsAg although somewhat less sensitive and specific for detection of HBeAg. Because of its speed, simplicity and flexibility, the rapid test is ideally suited for HBsAg and HBeAg screening in population-based epidemiological studies and in low risk populations, particularly in regions of the world where hepatitis B is endemic.

In vitro activity of ertapenem against common clinical isolates in relation to human pharmacokinetics.

The in vitro activity of ertapenem against bacterial pathogens isolated from patients with moderate to severe complicated intra-abdominal, complicated skin/skin structure, acute pelvic, or complicated urinary tract infection or community acquired pneumonia was compared to ceftriaxone and piperacillin-tazobactam and related to known plasma concentrations of the three agents. Ertapenem was more potent against methicillin-susceptible Staphylococcus aureus (MSSA) than ceftriaxone and piperacillin-tazobactam and was more potent and more active than both of these agents against Enterobacteriaceae and anaerobes. Piperacillin-tazobactam was the most active agent against enterococci and Pseudomonas aeruginosa. All isolates of Enterobacteriaceae (n=1088), Streptococcus pyogenes (n=37), Streptococcus agalactiae (n=48), MSSA (n=187), Haemophilus influenzae (n=59), and Moraxella catarrhalis (n=9) were susceptible to ertapenem; < 1% of 1284 anaerobes and only 1 of 113 Streptococcus pneumoniae (a penicillin-resistant isolate) were resistant to ertapenem. The MIC value at which 90% of all Enterobacteriaceae, streptococci, MSSA, H. influenzae, M. catarrhalis, and anaerobes were inhibited (MIC90) was < or = 1 microg/ml and below the mean plasma concentration of total ertapenem following a 1 g intravenous infusion for at least 24 hours, i.e., the entire recommended dosing interval, and below the free drug concentration for at least 8 h.

Comparative in vitro activity of ertapenem against bacterial pathogens isolated from patients with lower respiratory tract infections.

This study compared the in vitro activity of ertapenem, ceftriaxone, cefepime, ciprofloxacin and amoxicillin-clavulanate against 381 aerobic and facultative bacterial pathogens isolated from 320 patients with acute bacterial exacerbation of chronic bronchitis or community-acquired pneumonia. Streptococcus pneumoniae and Haemophilus influenzae accounted for 54.6% of the isolates. The ertapenem MIC was < or =2 mg/L for 98.4% of isolates and > or =8 mg/L for 1.0% (all methicillin-resistant Staphylococcus aureus). Ertapenem had the most potent activity against Enterobacteriaceae, Moraxella catarrhalis, and methicillin-susceptible S. aureus, and its activity against H. influenzae and H. parainfluenzae, all strains of which were susceptible, was not altered by beta-lactamase production. Only one S. pneumoniae strain, a penicillin-resistant isolate, was resistant to ertapenem. Ertapenem was highly active in vitro against pyogenic bacteria recovered from patients with community-acquired lower respiratory tract infections.

Comparative in-vitro activities of ertapenem against aerobic bacterial pathogens isolated from patients with complicated intra-abdominal infections.

The in vitro activities of ertapenem, ceftriaxone, amoxicillin-clavulanate, ampicillin-sulbactam, and piperacillin-tazobactam were compared against 1018 aerobic bacterial pathogens isolated from 531 patients with complicated intra-abdominal infection. Enterobacteriaceae accounted for 66.3% of the aerobic bacteria; Escherichia coli was the most common isolate. The ertapenem minimal inhibitory concentration was < or = 2 microg/mL for 74.6% of isolates and > or = 8 microg/mL for 21.9% (including isolates of enterococci, methicillin-resistant Staphylococcus aureus, Acinetobacter baumannii, and Pseudomonas aeruginosa). Against Enterobacteriaceae, ertapenem was the most potent and the most active drug evaluated (100% susceptible), followed by ceftriaxone (98% susceptible), piperacillin-tazobactam (96% susceptible), amoxicillin-clavulanate (80% susceptible), and ampicillin-sulbactam (64% susceptible). Piperacillin-tazobactam was the only drug evaluated with clinically useful activity against P. aeruginosa. In summary, ertapenem was highly active in vitro against many clinically important aerobic intra-abdominal bacterial pathogens, especially Enterobacteriaceae.

Effect of homologous preovulatory follicular fluid on in vitro maturation of equine cumulus-oocyte complexes.

The objective of this study was to test the hypothesis that incubating equine cumulus-oocyte complexes (COCs) in medium containing 50% or 100% homologous preovulatory follicular fluid would improve cumulus expansion and nuclear maturation. Oocytes were incubated in one of three media: 1) supplemented TCM-199 (control), 2) 50% (v/v) follicular fluid in control medium or 3) 100% follicular fluid. Cumulus expansion was evaluated subjectively, and nuclear maturation was evaluated by staining oocytes with Hoechst 33258. The hypothesis that incubating COCs in medium containing follicular fluid would improve cumulus expansion was supported. More (P < 0.05) compact COCs incubated in 50% or 100% follicular fluid developed a moderately to completely expanded cumulus after 24 and 36 h of incubation and more (P < 0.05) expanded COCs incubated in 100% follicular fluid developed a moderately to completely expanded cumulus after 36 h of incubation compared to control medium. The hypothesis that incubating COCs in medium containing follicular fluid would improve nuclear maturation was not supported. Although more (P < 0.05) compact COCs incubated in 50% follicular fluid reached polar body-stage compared to those in control medium, the nuclear maturation rate in the control medium was lower than it was when the same medium was used in a preliminary experiment (described in main text); therefore, the apparent superiority of 50% follicular fluid must be interpreted cautiously. Based on these results, future studies are warranted to further address the value of adding preovulatory follicular fluid to equine IVM culture systems.

Evaluation of the Vitek card GPS105 and VTK-RO7.01 software for detection of oxacillin resistance in clinically relevant coagulase-negative staphylococci.

The performance of Vitek cards GPS105 with software version VTK-R07.01 for detection of oxacillin resistance in coagulase-negative staphylococci (CoNS) was compared to disk diffusion and PCR detection for mecA. The sensitivity and specificity of the Vitek GPS105 method were 97.6 and 85.5%, respectively.

Clinical and pathologic features of Mycobacterium fortuitum infections. An emerging pathogen in patients with AIDS.

The clinical and pathologic features of Mycobacterium fortuitum infection in 11 patients with AIDS were characterized. Nine patients had cervical lymphadenitis; 2 had disseminated infection. The infection occurred late in the course of AIDS, and the only laboratory abnormality seen in more than half of patients (7/11) was relative monocytosis. Absolute monocytosis also was seen in 4 of 11 patients. In both cytologic and histologic preparations, the inflammatory pattern was suppurative with necrosis or a mixed suppurative-granulomatous reaction. M fortuitum, a thin, branching bacillus, stained inconsistently in direct smear and histologic preparations. Staining was variable with Gram, auramine, Brown-Hopps, Gram-Weigert, Kinyoun, Ziehl-Neelsen, modified Kinyoun, and Fite stains. Organisms, when present, were always seen in areas of suppurative inflammation. Incorrect presumptive diagnosis, based on misinterpretation of clinical signs and symptoms or on erroneous identification of M fortuitum bacilli as Nocardia species, led to a delay in proper therapy for 7 of 11 patients. Definitive therapy after culture identification resulted in complete resolution of infection in all patients except 1.

Confocal microscopy of germinal vesicle-stage equine oocytes.

The objectives were to compare cumulus type with nucleus form in equine cumulus oocyte complexes (COCs), to define the percentage of germinal vesicle (GV)-stage oocytes within a population of mares, and to further define GV nucleus shapes of equine oocytes. Cumulus types were as follows: 1) compact (56/208, 26.9%), 2) slightly expanded (37/208, 17.8%), 3) moderately expanded (27/208, 13.0%), 4) greatly expanded (15/208, 7.2%), or 5) denuded (73/208, 35.1%). One hundred thirty of 208 COCs (62.5%) were GV-stage, 21/208 (10.1%) were condensed chromatin-stage, 8/208 (3.8%) were polar body-stage, 40/208 (19.2%) were negative (nonstaining), and 9/208 (4.3%) were fragmented. Cumulus types were associated with nucleus forms because higher proportions (P < 0.05) of GV-stage oocytes occurred in compact (42/56, 75.0%), slightly expanded (30/37, 81.1%), moderately expanded (16/27, 59.3%), or denuded (40/73, 54.8%) COCs than in greatly expanded (2/15, 13.3%) COCs. In contrast, lower proportions (P<0.05) of condensed chromatin-stage oocytes occurred in compact (3/56, 5.4%), slightly expanded (0/37, 0.0%), moderately expanded (3/27, 11.1%) or denuded (9/73, 12.3%) COCs than in greatly expanded (6/15, 40.0%) COCs, and lower proportions (P < 0.05) of polar body-stage oocytes occurred in compact (0/56, 0.0%) or denuded (2/73, 2.7%) COCs than in greatly expanded (3/15, 20.0%) COCs. Germinal vesicle-stage equine oocytes had 4 distinct shapes, with higher proportions (P<0.05) having large-regular (54/130, 41.5%) than scattered (10/130, 7.7%), small-round (29/130, 22.3%), or large-irregular (37/130, 28.5%) shapes. Lower proportions (P<0.05) of large-regular GVs occurred in compact (11/42, 26.2%) COCs than in slightly expanded (15/30, 50.0%), or moderately expanded (12/16, 75.0%) COCs. Therefore oocytes with the large-regular GV shape are probably more advanced in development.

Increasing culture time from 48 to 96 or 144 hours increases the proportions of equine cumulus oocyte complexes with negative or fragmented nucleus morphology.

The objective was to test the hypothesis that increasing equine oocyte culture time from 48 to 96 or 144 h increases nucleus maturation of equine oocytes. The hypothesis was not supported because condensed chromatin-stage oocytes decreased (P<0.01) from 33/126 (26.2%) at 48 h or 34/95 (35.8%) at 96 h to 11/117 (9.4%) at 144 h, and polar body-stage oocytes decreased (P<0.01) from 65/126 (51.6%) at 48 h to 25/95 (26.3%) at 96 h and (P<0.01) to 1/117 (0.9%) at 144 h. Negative (non-staining) oocytes increased (P<0.01) from 16/126 (12.7%) at 48 h or 15/95 (15.8%) at 96 h to 39/117 (33.3%) at 144 h. Fragmented oocytes (with and without fluorescent areas) increased (P<0.01) from 4/126 (3.2%) at 48 h to 20/95 (21.1%) at 96 h and increased again to 60/117 (51.3%) at 144 h. When fragmented oocytes having 1 fluorescent area were defined as condensed chromatin-stage and fragmented oocytes having 2 fluorescent areas were defined as polar body-stage, condensed chromatin-stage oocytes increased (P < 0.05) from 34/126 (27.0%) at 48 h to 38/95 (40.0%) at 96 h, but decreased (P<0.05) to 19/117 (16.2%) at 144 h. Polar body-stage oocytes decreased (P<0.01) from 66/126 (52.4%) at 48 h to 27/95 (28.4%) at 96 h and decreased again to 7/117 (6.0%) at 144 h. Fragmented oocytes without any fluorescent areas increased (P<0.01) from 2/126 (1.6%) at 48 h to 14/95 (14.7%) at 96 h and increased again to 46/117 (39.3%) at 144 h. Under the conditions of this experiment, the hypothesis that increasing the culture time of equine oocytes from 48 to 96 or 144 h would increase oocyte maturation was not supported. We propose that the culture system needs to be improved before this hypothesis can be adequately tested, because prolonged culture significantly increased the proportions of negative and fragmented equine oocytes.

Clinical Evaluation of the Gen-Probe amplified mycobacterium tuberculosis direct test for rapid detection of Mycobacterium tuberculosis in select nonrespiratory specimens.

The performance of the Amplified Mycobacterium Tuberculosis Direct Test (MTD; Gen-Probe, Inc., San Diego, Calif.) for rapid diagnosis of extrapulmonary tuberculosis was evaluated by testing 178 nonrespiratory specimens from 158 patients. Criteria for specimen inclusion were (i) a positive smear for acid-fast bacilli (n = 54) and (ii) the source if the smear was negative (tissue biopsies and aspirates and abscess material were tested; n = 124). Results were compared to those of mycobacterial culture; clinical history was reviewed when MTD and culture results disagreed. Forty-eight specimens (27.0%) were positive for mycobacteria, including 23 Mycobacterium tuberculosis complex specimens; of which 21 were smear positive. Twenty-five specimens were MTD positive; 20 of these grew M. tuberculosis complex. All of the five MTD-positive, M. tuberculosis complex culture-negative specimens were considered truly positive, based on review of the medical record. Of the three MTD-negative, M. tuberculosis complex culture-positive specimens, two contained inhibitory substances; one of the two was smear positive. Excluding the latter specimen from analysis, after chart review, the sensitivity, specificity, and positive and negative predictive values of the MTD were 92.6, 100, 100, and 98.7%, respectively, by specimen and 89.5, 100, 100, and 98.6% by patient. Given the few smear-negative samples from patients with extrapulmonary tuberculosis in our study, additional similar studies that include more smear-negative, M. tuberculosis complex culture-positive specimens to confirm our data are desirable.

Molecular techniques in mycobacterial detection.

OBJECTIVE: To assess the clinical utility of the commercial nucleic acid amplification (NAA) tests (ie, Amplified Mycobacterium Tuberculosis Direct Test, Gen-Probe, Inc and AMPLICOR Mycobacterium tuberculosis Test, Roche Molecular Systems, Inc) for direct detection of Mycobacterium tuberculosis complex. DATA SOURCES: Review of the English-language literature. CONCLUSIONS: The performance of both NAA tests is excellent (sensitivity, > or = 95%; specificity, 100%) when testing respiratory specimens that are smear-positive for acid-fast bacilli (AFB). Only the Gen-Probe assay is approved for testing respiratory specimens regardless of the AFB smear result. Data from 3 studies showed that the sensitivity of the Mycobacterium Tuberculosis Direct Test in smear-negative patients ranged from 83% to 85%, and that the specificity was 99%. Both NAA tests have been used to test nonrespiratory specimens; in some studies, the performance was comparable to the performance obtained for respiratory specimens, whereas in others, it was lower. The NAA tests also appear to be reliable tools for rapid detection of M tuberculosis complex in positive broth cultures of all specimen types (except blood). The impact of the NAA tests on patient outcome varies based on the result of the AFB smear. In smear-positive patients, public health and hospital infection-control resources are predominantly affected. The potential for influencing patient outcome is much greater when the AFB smear is negative. In smear-negative patients, the NAA test could provide more rapid diagnosis of tuberculosis and subsequent initiation of therapy; eliminate the need for invasive diagnostic procedures, which are both costly and pose an added risk to the patient; and allow earlier discharge of hospitalized patients. Prospective studies concerning the cost-effectiveness of the NAA tests are needed.

Susceptibility testing for mycobacteria.

Mycobacterial susceptibility testing is important for the management of patients with tuberculosis and those with disease caused by certain nontuberculous mycobacteria. To help standardize methods used in the clinical microbiology laboratory for testing susceptibility of mycobacteria, the National Committee for Clinical Laboratory Standards (NCCLS) recently updated NCCLS document M24-T (published in 1995), which is the tentative standard for antimycobacterial susceptibility testing of Mycobacterium tuberculosis. The second edition of the NCCLS tentative standard (document M24-T2) differs considerably from the initial document. It contains revised guidelines for the testing of M. tuberculosis complex and newly proposed guidelines for the testing of some nontuberculous mycobacteria, including the rapidly growing mycobacteria (Mycobacterium fortuitum group, Mycobacterium chelonae, and Mycobacterium abscessus), Mycobacterium avium complex, Mycobacterium kansasii, and Mycobacterium marinum, as well as Nocardia species and other aerobic actinomycetes. The recommendations for mycobacterial susceptibility testing that are outlined in NCCLS document M24-T2 are reviewed.

Comparison of the BACTEC MGIT 960 and ESP culture system II for growth and detection of mycobacteria.

The performances of two continuously monitoring mycobacterial culture systems-ESP Culture System II (ESP II; Trek Diagnostics, Inc. , Westlake, Ohio) and BACTEC MGIT 960 (BD Biosciences, Sparks, Md. )-were compared. In addition to both liquid media, all specimens were plated onto Middlebrook 7H11/7H11 selective agar. A total of 3, 151 specimens of all types (56.3% were respiratory specimens) were cultured; 231 (7.3%) yielded mycobacteria. The most common species recovered were Mycobacterium avium complex (69 isolates) and Mycobacterium tuberculosis complex (MTBC; 65 isolates). The recovery rates for ESP II, BACTEC MGIT 960, and Middlebrook agar, respectively, were 71.2, 63.9, and 61.8% for all mycobacteria; 70.2, 72.6, and 66.3% for all mycobacteria except Mycobacterium gordonae; and 73.8, 84.6, and 87.7% for MTBC. For liquid plus solid medium combinations, recovery rates for all mycobacteria and for MTBC, respectively, were 84.1 and 92.3% for ESP II plus Middlebrook agar and 81.5 and 98.5% for BACTEC MGIT 960 plus Middlebrook agar. The differences in recovery of all mycobacteria by ESP II and by BACTEC MGIT 960 were not significant; for the individual species, the only significant difference was recovery of more isolates of M. gordonae by ESP II. For those isolates recovered in both automated systems, mean times to detection of all mycobacteria and MTBC, respectively, were 15.8 and 17.4 days for ESP II and 12.5 and 11.9 days for BACTEC MGIT 960 (P < 0.05). False-positive signals occurred with 23 (0.7%) BACTEC MGIT 960 cultures and 84 (2.7%) ESP II cultures (P < 0.01). Overall contamination rates were 17.1% for BACTEC MGIT 960, 18.9% for ESP II, and 11.0% for Middlebrook agar. In summary, the ESP II and BACTEC MGIT 960 systems performed comparably with regard to growth and detection of mycobacteria, and the contamination rates were similar. However, with ESP II, times to detection of all mycobacteria and of MTBC were significantly longer, the recovery rate of M. gordonae was significantly higher, and the number of false-positive signals was greater than with BACTEC MGIT 960.

Generalized tuberculosis in the acquired immune deficiency syndrome.

OBJECTIVE: Generalized, or hematogenously disseminated, tuberculosis (TB) in patients with the acquired immune deficiency syndrome (AIDS) has been associated with a high incidence of cases remaining undiagnosed until postmortem. To better characterize generalized TB in the setting of AIDS, this report describes the clinical, laboratory, radiologic, and pathologic features of 20 fatal cases. DESIGN: The medical records, autopsy protocols, and histologic material from patients with AIDS and concomitant TB were reviewed. All patients were autopsied at a tertiary care medical center during the years 1985-1997. RESULTS: In 50% of our 20 cases, diagnosis was not made until postmortem. Signs and symptoms were few, including the absence of fever (temperature > or = 38 degrees C) in 55% of patients. Consistent laboratory abnormalities of a nonspecific nature were limited to hyponatremia (sodium <135 mmol/L) in 60%. Both peripheral and deep (thoracic and abdominal) lymphadenopathy, unusual in adults with TB, occurred in 45% and 95% of cases, respectively. In contrast to previous reports, all of the 6 cases of tuberculous meningitis presented as acute meningitis with a predominance of neutrophils in cerebrospinal fluid. Necrotizing encephalitis with extension of the acute inflammation into the superficial cortex was seen in all cases and tuberculous brain abscesses occurred in 50% of cases, a higher frequency than previously reported. Despite lung involvement in 90% of the cases, 33% of chest radiographs were interpreted as normal and disseminated mycobacterial disease was not suggested in the radiograph report in any of the other cases. Soft tissue abscesses in uncharacteristic locations such as the neck, mediastinum, and perirectal area occurred in these patients. Histologically, 95% of organs sampled showed inflammatory foci characterized by extensive necrosis with numerous neutrophils and/or karyorrhectic debris, numerous acid-fast bacilli, few or no epithelioid histiocytes, and no Langhans giant cells. CONCLUSION: Clinically and pathologically, generalized TB in the setting of AIDS is characterized by either unusual features or a lack of the typical features described for generalized TB in patients who do not have AIDS. This absence of classic features contributes to the high incidence of cases that remain undiagnosed until postmortem examination.

Comparison of four methods for identifying Streptococcus pneumoniae.

Four methods (bile solubility, optochin, latex agglutination, and DNA probe) were compared for identification of clinical isolates of Streptococcus pneumoniae. Of 209 isolates tested, 151 (Group I) were selected based on typical colony morphology of S. pneumoniae, while 58 (Group II) were selected on the basis of alpha-hemolysis alone. Using the DNA probe as a reference method, 141 isolates from Group I and 10 from Group II were identified as S. pneumoniae. The optochin disk test and the latex agglutination test both exhibited a 100% sensitivity and specificity for Group I isolates; bile solubility identified all but 1 isolate in this group. For Group II isolates, the sensitivity and specificity of optochin testing was 100%, 80 and 94% for latex and 80 and 100% for bile. The results of this study indicate that all methods tested give reliable results for isolates with typical colony morphology of S. pneumoniae. Bile solubility and latex may not be as reliable when testing alpha-hemolytic colonies without colony morphology typical S. pneumoniae.