Near-fatal grape aspiration with complicating acute lung injury successfully treated with extracorporeal membrane oxygenation.

OBJECTIVE: In this report of a near-fatal case of grape aspiration successfully treated with extracorporeal membrane oxygenation (ECMO), we highlight the danger of feeding seedless grapes to young children and demonstrate that ECMO can provide cardiopulmonary support for cases of acquired large-airway disruption and can facilitate therapeutic intervention. DESIGN: Case report. SETTING: A tertiary pediatric intensive care unit and ECMO center. PATIENT: A healthy 14-month-old boy aspirated a seedless grape while playing at home and suffered a cardiopulmonary arrest of 15 mins in duration. He responded to advanced life support with return of cardiac output but developed intractable cardiopulmonary failure secondary to aspirated grape particles and postobstructive pulmonary edema. INTERVENTIONS: The patient was emergently transferred to the regional ECMO center and placed on venoarterial ECMO. Bronchoscopies were performed in the stable environment provided by ECMO, aspirated particles were removed from the large airways, and lung recovery was facilitated. MEASUREMENTS AND MAIN RESULTS: End-organ perfusion was restored via ECMO during a period of severe intractable cardiopulmonary failure. Pulmonary recovery occurred during a 6-day ECMO run and was facilitated by therapeutic bronchoscopy. The patient was reviewed 1 yr later and has made a full neurodevelopmental recovery, despite a 15-min out-of-hospital cardiac arrest. CONCLUSIONS: Aspiration of a seedless grape is a life-threatening event in a small child. This danger is not fully appreciated by parents in the UK. ECMO may be life saving in cases of acquired large-airway disruption resulting in severe cardiopulmonary failure, including foreign body aspiration, as long as end-organ perfusion is maintained.

Inhaled nitric oxide and prevention of pulmonary hypertension after congenital heart surgery: a randomised double-blind study.

BACKGROUND: Pulmonary hypertensive crises (PHTC) are a major cause of morbidity and mortality after congenital heart surgery. Inhaled nitric oxide is frequently used as rescue therapy. We did a randomised double-blind study to investigate the role of routinely administered inhaled nitric oxide to prevent pulmonary hypertension in infants at high risk. METHODS: We enrolled 124 infants (64 male, 60 female; median age 3 months [IQR 1-5]), 76% with large ventricular or atrioventricular septal defects, who had high pulmonary flow, pressure, or both, and were undergoing corrective surgery for congenital heart disease. They were randomly assigned continuous low-dose inhaled nitric oxide (n=63) or placebo (n=61) from surgery until just before extubation. We measured the numbers of PHTC, time on study gas, and hours spent in intensive care. Analysis was done by intention to treat. FINDINGS: Compared with placebo, infants receiving inhaled nitric oxide had fewer PHTC (median four [IQR 0-12] vs seven [1-19]; relative risk, unadjusted 0.66, p<0.001, adjusted for dispersion 0.65, p=0.045) and shorter times until criteria for extubation were met (80 [38-121] vs 112 h [63-164], p=0.019). Time taken to wean infants off study gas was 35% longer in the nitric oxide group than in the placebo group (p=0.19), but the total time on the study gas was still 30 h shorter for the nitric oxide group (87 [43-125] vs 117 h [67-168], p=0.023). No important toxic effects arose. INTERPRETATION: In infants at high risk of pulmonary hypertension, routine use of inhaled nitric oxide after congenital heart surgery can lessen the risk of pulmonary hypertensive crises and shorten the postoperative course, with no toxic effects.

Correlation between phenotypic characteristics and DNA relatedness within Enterococcus faecium strains.

We noted that a number of enterococcal strains isolated from human clinical specimens resembled Enterococcus faecium but were able to produce acid from glycerol, raffinose, and/or sorbitol, while others failed to form acid from mannitol. An additional concern was that many of these strains with atypical phenotypic characteristics also appeared to acquire vancomycin resistance. In order to determine if such atypical strains were variants of E. faecium or new Enterococcus species, 35 E. faecium or E. faecium-like strains (grouped into 10 phenotypes on the basis of the results of the following tests: capacity to form acid from glycerol, mannitol, raffinose, or sorbitol and susceptibility to vancomycin) and four strains of Enterococcus faecalis were taken from our culture collection, analyzed for their whole-cell protein profiles by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and identified to the species level by DNA-DNA reassociation experiments. All E. faecium-like strains, including four mannitol-negative variants, conformed to at least two of three DNA-DNA relatedness criteria: they were 70% or more related to the type strain of E. faecium at optimal conditions, they had less than 5% divergence within the related sequences, and they had a relatedness of 60% or greater under stringent conditions. The protein profiles of atypical strains were similar to those of typical strains and were easily distinguishable from those of E. faecalis and other enterococcal species. The five E. faecalis strains were 12 to 16% related to the E. faecium type strain. These results indicate that the phenotypic description of E. faecium should include all of these variable characteristics.

Evaluation of three disk tests for identification of enterococci, leuconostocs, and pediococci.

Simple rapid tests for presumptive identification of catalase-negative non-beta-hemolytic cocci (i.e., enterococci, leuconostocs, and pediococci) have not previously been available. Seven hundred thirty-four strains of aerobic and facultatively anaerobic, catalase-negative, non-beta-hemolytic gram-positive cocci were tested for susceptibility to vancomycin (Vans) by a screening procedure and production of leucine aminopeptidase (LAPase) and pyrrolidonylarylamidase (PYRase) in disk tests. Three unique patterns of activity in response to the three disks (30 micrograms of vancomycin, PYRase, and LAPase) can be used to presumptively identify the vancomycin-resistant (Vanr) enterococci (Vanr and PYRase and LAPase positive), leuconostocs (Vanr and PYRase and LAPase negative), and pediococci (Vanr, PYRase negative, and LAPase positive). The results indicate that, together with Gram stain characteristics and the catalase test, the vancomycin, LAPase, and PYRase disk tests can be used to presumptively identify Vanr strains of enterococci as well as Leuconostoc and Pediococcus strains from human infections.

Identification of Streptococcus porcinus from human sources.

Streptococcus porcinus is normally associated with infections in swine. Cultures of this streptococcal species are rarely reported from human infections. In the past 10 years, we have identified 13 cultures of S. porcinus from human sources from persons living in the United States and Canada. Seven of the strains were identified in the past 15 months. Nine of the strains were of a single serogroup, provisionally called C1. In addition, nine of the strains were isolated from the genitourinary tract of reproductive-age female patients, some with delivery problems. S. porcinus strains could be identified by hemolytic, serologic, and physiologic characteristics. All strains were susceptible to penicillin, erythromycin, and other antimicrobial agents. Fifty-four percent of the strains were resistant to tetracycline. These findings suggest that we may be seeing a change in the flora of the genitourinary tract of humans. Whether these isolates are significant pathogens is unknown at this time.

Molecular epidemiology of group B streptococcal infections: use of restriction endonuclease analysis of chromosomal DNA and DNA restriction fragment length polymorphisms of ribosomal RNA genes (ribotyping).

Epidemiologic investigation of group B streptococcal (GBS) infections has been limited by the lack of a discriminatory typing system. Therefore, the use of restriction endonuclease analysis of chromosomal DNA (REAC) and DNA restriction fragment length polymorphisms of rRNA genes (ribotyping) to subtype molecularly GBS isolates associated with human invasive disease was investigated. Chromosomal DNA of selected GBS isolates was initially digested with 24 different restriction enzymes. HhaI gave the best discrimination of hybridization banding patterns (ribotypes) and was used with all study isolates. Ribotyping and REAC differentiated among isolates of the same and different serotypes. Nine ribotype patterns were noted among the 76 isolates studied, including 4 among serotype Ia/c and 4 additional ribotypes among serotype III isolates. Epidemiologically related isolates (e.g., mother-infant or twin-twin pairs) had identical REAC and ribotype patterns. Epidemiologically unrelated isolates with the same ribotype usually had different REAC patterns, suggesting that REAC may be a more sensitive technique for strain differentiation. REAC and ribotyping were reproducible and proved to be successful molecular epidemiologic methods for subtyping GBS.

Antimicrobial susceptibility patterns of common and unusual species of enterococci causing infections in the United States. Enterococcal Study Group.

We collected 705 isolates of enterococci (1 per patient) from cultures of a variety of anatomic sites from patients at eight tertiary-care hospitals in six geographic regions of the United States. A total of 632 (90%) Enterococcus faecalis, 58 (8%) E. faecium, 5 E. gallinarum, 4 E. avium, 3 E. casseliflavus, 1 E. raffinosus, and 1 E. hirae isolate and 1 biochemical variant of E. faecalis were identified; 606 (86%) of these isolates were associated with clinical infections. The most common sites of isolation were the urinary tract (402 [57%]), nonsurgical wounds (94 [13%]), the bloodstream (74 [10%]), and surgical wounds (62 [9%]). High-level resistance to gentamicin or streptomycin or both was detected in 265 (38%) of the isolates. We identified two E. faecalis isolates resistant to vancomycin (MICs, 32 and 128 micrograms/ml) and 11 beta-lactamase-producing E. faecalis isolates. E. faecium isolates were significantly more resistant than E. faecalis isolates to penicillin, ampicillin, piperacillin, imipenem, and ciprofloxacin (P less than 0.001). The MICs for the 15 non-E. faecalis, non-E. faecium enterococci indicated variable resistance to ciprofloxacin and the penicillins. Antimicrobial susceptibility patterns vary among species of enterococci, and these organisms, while commonly resistant to high-level aminoglycosides, can also acquire resistance to vancomycin or the ability to produce beta-lactamase. Because of these diverse antimicrobial resistance mechanisms, successful treatment and control of enterococcal infections with current antimicrobial agents are becoming increasingly difficult.

Differentiation of Lactococcus lactis and Lactococcus garvieae from humans by comparison of whole-cell protein patterns.

We tested 12 reference and 24 clinical strains of lactococci for physiologic characteristics using a conventional test system, the Gen-Probe Enterococcus 2 chemiluminescence assay (Gen-Probe Inc., San Diego, Calif.), the Rapid Strep identification system (Analytab Products, Plainview, N.Y.), and whole-cell protein analysis. The Gen-Probe Enterococcus 2 chemiluminescence assay for Enterococcus identification was negative with all strains. Neither the conventional test nor the Rapid Strep identification system could differentiate between the two Lactococcus spp. most commonly isolated from humans. A simple procedure, based on sodium dodecyl sulfate-polyacrylamide gel electrophoresis, was developed for comparing the whole-cell protein patterns of Lactococcus spp. L. lactis and L. garvieae were differentiated by unique protein patterns.

Enterococcus dispar sp. nov. a new Enterococcus species from human sources.

The partial 16S rRNA sequences of two unknown human enterococcal isolates were determined by reverse transcription in an attempt to clarify their taxonomic position. The sequence data indicate that they belong to a hitherto unknown species of Enterococcus, for which the name Enterococcus dispar sp. nov. is proposed. The type strain is NCIMB 13000.

Major subtypes of invasive Haemophilus influenzae from 1983 to 1985 in Atlanta, Ga.

We compared outer membrane protein (OMP) patterns of Haemophilus influenzae isolated in metropolitan Atlanta, Ga., from July 1983 to June 1985. Of 74 randomly selected H. influenzae serotype b, biotype I, isolates (24% of the total number of H. influenzae, and 32% of the total number of H. influenzae serotype b, biotype I, isolates), 66 (89.2%) had the same OMP pattern. Of the remaining eight, five (6.7%) had an identical OMP pattern. The other three isolates had separate and distinct patterns. A greater diversity of OMP patterns was found with H. influenzae serotype b, biotype II, and nonserotypeable H. influenzae. Of the 18 H. influenzae serotype b, biotype II, isolates (5.8% of the total number of H. influenzae isolates), 1 had an OMP pattern similar to that of the predominate biotype I OMP type, 6 (33% of the biotype II) had the same pattern, and 11 had heterogeneous patterns. Of the 19 recoverable, nonserotypeable biotype II isolates (6.8% of the total number of H. influenzae), 18 had different OMP patterns, and no pattern was similar to those observed with serotype b. These findings indicate that most H. influenzae strains isolated during this 2-year period were indistinguishable by serotype, biotype, or OMP patterns.

Panel of reference strains for evaluating serologic reagents used to identify gonococci.

A panel of strains for evaluating Neisseria gonorrhoeae serologic reagents was developed. The strains selected for the panel were antigenically diverse and representative of strains isolated worldwide and had been isolated from a variety of anatomic sites. A few strains with characteristics that can cause problems in serologic tests were included. The panel of 52 gonococcal and 20 nongonococcal strains was used to evaluate two commercially produced kits with monoclonal antibody reagents, GonoGen and Phadebact, and one Phadebact kit with absorbed rabbit antiserum. The GonoGen reagent correctly identified all gonococcal strains and did not react with any of the nongonococcal strains. The Phadebact absorbed antiserum reagent correctly identified 47 of 48 gonococcal strains but reacted with 2 of the 20 nongonococcal strains. The Phadebact monoclonal antibody reagent correctly identified all the gonococcal strains; however, it gave positive reactions with 8 and trace reactions with 4 of the 20 nongonococcal strains.

Comparison of serologic screening tests for brucellosis.

The slide agglutination test (SAT), microagglutination test (MAT), and card agglutination test (CAT) were compared with each other, using the tube agglutination test (TAT) as the standard method, by two reference laboratories to determine effectiveness as screening tests for human brucellosis. TAT titers of 1,253 sera tested in both laboratories were compared. In one laboratory, 1,270 sera were tested by the TAT and SAT, while the other laboratory tested 1,261 sera by both methods. Of these sera, 1,155 were tested in one laboratory by the CAT and 187 sera were tested by the MAT. Compared with that of the TAT (greater than or equal to 160 positive), the sensitivities were 97 to 100% (SAT), 90% (CAT), and 88% (MAT). The specificities were 88 to 89% (SAT), 98% (CAT), and 88% (MAT). For populations with a low prevalence of disease, increased specificity offers higher predictive value, so the CAT and MAT are preferable for screening purposes and the choice between tests depends on the number and frequency of tests performed. All sera reactive in the CAT and MAT should be retested with the TAT.

The development by the Centers for Disease Control of a specification for streptococcal serogrouping kits and its application to Streptex and to the Phadebact Streptococcus Test.

A Centers for Disease Control (CDC) specification for evaluating commercially produced streptococcal agglutination reagents was developed and used to test Streptex and Phadebact Streptococcus Test kits. Evaluation methods and performance requirements were based on product claims made in the package labelling. Except for the reagent for Streptococcus group D, reagents of both systems identified 100% of the blind-coded reference strains when follow-up methods were done according to the manufacturers' directions. Streptex group D reagent did not identify all group D strains, but the manufacturer instructed the user to test with other methods in certain circumstances. The interaction of personnel of the Center for Infectious Diseases (CID), CDC, with commercial producers and consumers in a pre-market evaluation program is described.

Use of acetone-dried vaccines for preparing capsular antisera against the Klebsiella group and the lyophilization of Klebsiella cultures.

Capsular antisera against the 72 types of Klebsiella have been prepared in rabbits by using an acetone-dried vaccine. It was shown that encapsulated cells dried with acetone and ground to a fine powder with a mortar and pestle retain their capsules. Antisera obtained from rabbits vaccinated with these vaccines had quellung titers ranging from 1:16 to 1:64. The dried vaccine was stable after storage for over 2 years at room temperature. Encapsulated cultures lyophilized in the presence of 5% sucrose, 5% sodium glutamate, and 5% polyvinylpyrrolidone remained viable and retained their capsules after storage for 10 months at room temperature.

Preparation of agglutinating antisera and fluorescent-antibody conjugates against Pasteurella tularensis in equines.

The serological response in burros and horses to the viable LVS strain of Pasteurella tularensis was studied. High-titered agglutinating antisera and fluorescent-antibody conjugates were obtained in both groups of animals. Maximum titers were obtained in horses 14 to 21 days after the start of vaccination and in burros 21 to 28 days after the start of vaccination. The use of Woodhour's adjuvants or booster inoculations did not result in increased titers.