The effect of previous antibiotic therapy on the bacteriology of the tonsils in children.

The bacteriology of the tonsillar surface and core in 30 children undergoing tonsillectomy was studied. Antibiotics taken in the six months before surgery were recorded. Haemophilus influenzae and Staphylococcus aureus were the commonest isolates; Streptococcus pyogenes was relatively rare. Eight children had received no antibiotics, the others had been prescribed 65 different courses of 13 different types. No relationship between the various antibiotic regimens prescribed and tonsillar bacteriology could be demonstrated, and it would appear that the tonsillar bacteriology at the time of tonsillectomy is not altered by antibiotics prescribed in the previous six months.

High prevalence of antifungal resistance in Candida spp. from patients with AIDS.

Three hundred and forty-eight isolates of Candida spp. from patients treated at a regional infectious diseases unit for AIDS, immunocompromised patients admitted to the Hope Hospital and isolates referred from around the North West of England were tested for their in-vitro susceptibility to amphotericin B, fluconazole and flucytosine using standardized methods. Candida albicans comprised 73% of isolates, Candida glabrata 10% and Candida parapsilosis 7%. Ninety-six percent of isolates were susceptible to amphotericin B and resistance to > or = 12.5 mg/L fluconazole was found in 61 (17.5%) of the 348 isolates tested. Among isolates from patients with AIDS the incidence of fluconazole resistance was 33% whereas in other patients the incidence was only 11%. Flucytosine resistance was seen in only 12 (3.4%) isolates, 11 of which were C. albicans and in 6.5% of isolates from patients with AIDS. Resistance to fluconazole and flucytosine is now sufficiently prevalent among Candida spp. isolated from patients with AIDS to warrant routine susceptibility testing of yeast isolates.

Diagnosis of infections with Shiga-like toxin-producing Escherichia coli by use of enzyme-linked immunosorbent assays for Shiga-like toxins on cultured stool samples.

Shiga-like toxin-producing (SLT) Escherichia coli, particularly those belonging to serogroup O157, are responsible for haemorrhagic colitis, haemolytic uraemic syndrome and some cases of gastro-enteritis. The rapid and reliable diagnosis of all these infections is necessary for correct patient management and for epidemiological reasons, but is rarely possible with present methods. We compared the efficacy of two methods, (i) the culture of faeces in broth that contained mitomycin C followed by enzyme-linked immunosorbent assay (ELISA) for SLTs, and (ii) the culture of faeces on sorbitol MacConkey agar (SMA), in the detection of infections caused by SLT-producing E. coli. SLT-producing E. coli O157 strains were isolated on SMA from 42 of 475 faecal samples, but SLTs were detected by ELISA in culture supernates or lysates of 54 of 475 samples. SLT-producing E. coli strains were isolated subsequently from 11 of 12 ELISA-positive, SMA culture-negative samples by a colony blot technique. In four cases, SLT-producing E. coli of serogroups other than O157 were isolated and in seven cases E. coli O157 was isolated in small numbers. The ELISA is a rapid and sensitive technique for the diagnosis of SLT-producing E. coli infection, especially where low numbers of the organism are present in faeces and when the infection is caused by a serogroup other than O157.

The influence of salt concentration on the detection of methicillin resistance in coagulase-negative staphylococci.

The detection of methicillin resistance by the breakpoint method was examined using three different media containing varying quantities of added salt and 4 mg/L methicillin or 1 mg/L oxacillin. Three hundred clinical isolates of eight species of coagulase-negative staphylococci were tested. In 68 strains methicillin resistance was expressed only at certain salt concentrations and four distinct susceptibility phenotypes were observed. A correlation between the susceptibility phenotype and the species of the isolate was found. Testing on Columbia agar (CA) containing 4 mg/L methicillin with 0% and 4% added salt was required to detect resistance in all 68 strains. Resistance was detected less frequently using Balanced Sensitivity Test (BST) agar or Diagnostic Sensitivity Test (DST) agar containing methicillin or CA, BST or DST agar containing oxacillin. Increased production of beta-lactamase was shown to be an unlikely cause of MR in these strains. Disc sensitivity tests were performed on the 68 strains using five different media. Columbia agar gave optimum results as the other media gave enhanced zones of inhibition for some isolates. Further tests were performed on CA containing varying salt concentrations using both oxacillin and methicillin discs. A close relationship between the staphylococcal species, and the influence of increasing salt concentration on zone size was found. Discrepancies were noted between results obtained by breakpoint and the results obtained with methicillin discs particularly with Staphylococcus simulans and some Staphylococcus epidermidis strains. Results obtained with oxacillin discs more closely correlated with those obtained by breakpoint, but only when disc tests were performed on media with low and high salt content. To identify methicillin resistance in strains of CNS by disc tests, the use of Columbia agar with 0% and 5% added salt and oxacillin discs is recommended.

Detection by ELISA of low numbers of Shiga-like toxin-producing Escherichia coli in mixed cultures after growth in the presence of mitomycin C.

Techniques currently available to detect Shiga-like toxin (SLT)-producing Escherichia coli lack sensitivity or require specialised equipment and facilities, and in some cases detect only strains belonging to serotype O157. We have used an ELISA technique, capable of detecting both SLTI and SLTII with crude P1 glycoprotein from hydatid cysts, in combination with enhancement of toxin production by culture with mitomycin C. Supernates of Tryptone Soya Broth cultures containing mitomycin C 200 ng/ml were tested for SLTII. For SLTI, cell lysates pre-treated with polymyxin B were tested. In tests with E. coli O157:H7 in mixed culture with E. coli strain C600 alone, or with E. coli C600, Proteus mirabilis and Enterococcus faecalis, SLTI could be detected when the proportion of toxigenic organisms represented 1% of the mixture, and SLTII when the proportion was 0.025%. When faecal samples with added E. coli O157:H7 were examined in this system, SLTII-producing strains were detected when they comprised less than 0.1% of the coliform population. This technique is a sensitive and specific assay for detecting low numbers of SLT-producing organisms in mixed culture such as occurs in cases of haemolytic uraemic syndrome and haemorrhagic colitis.

Evaluation of Mast-ID 15 system for identification of fresh clinical isolates of Enterobacteriaceae and Acinetobacter.

AIMS: To assess the accuracy of the Mast-ID 15 system compared with API 20 E for the identification of stock and fresh clinical strains of Enterobacteriaceae and Acinetobacter spp; to compare the accuracy of 19 pin and 36 pin multipoint inoculator heads. METHODS: One hundred frozen stock cultures of Enterobacteriaceae and Acinetobacter spp which had previously been identified by the API 20E were classified by the Mast-ID using 19 and 36 pin multipoint inoculator heads. Reproducibility was determined by testing 36 randomly selected organisms in duplicate. Four hundred and sixty nine consecutive fresh clinical isolates of Enterobacteriaceae and Acinetobacter spp were identified by the Mast-ID using a 36 pin multipoint inoculator and by the API 20E. Reproducibility for the fresh isolates was determined by testing 96 randomly selected strains in duplicate. RESULTS: The Mast-ID 15 identified 82% and 85% of frozen strains to species level and reproducibility was 80% and 86% using 19 and 36 pin inoculator heads, respectively. Of the 469 fresh clinical isolates, the Mast-ID identified 70% of strains to species level; 19% were not identified and 11% were identified incorrectly by comparison with the API 20E. The Mast-ID achieved a reproducibility level of 80% with the fresh clinical isolates. CONCLUSIONS: The use of a 36 pin multipoint inoculator head in preference to the standard 19 pin head for the Mast-ID was advantageous as it allowed greater numbers of strains to be identified at a reduced cost. Unfortunately, in our hands, the Mast-ID system was insufficiently accurate for routine use in the clinical laboratory. Modifications to some of the problematic tests may result in a sufficient increase in accuracy and reproducibility to make the system beneficial in the routine clinical laboratory.

Numerical taxonomy of Bacteroides and other genera of Gram-negative anaerobic rods.

A numerical taxonomy was performed on 157 cultures (141 different strains) of species of Bacteroides, Polyphyromonas, Prevotella [not Prevotella (Labroue, 1976)] and Fusobacterium. Isolates were each tested for 111 phenotypic characters which included possession of constitutive enzymes, fermentation of specific carbohydrates, gas chromatographic analysis of metabolic end-products and of cellular carboxylic acid composition. Computation of similarity coefficients was followed by a single-linkage cluster analysis. At the 94% similarity level, the following groupings at genus level were apparent: (1) Bacteroides ureolyticus; (2) Fusobacterium mortiferum, F. necrogenes, F. necrophorum, F. nucleatum and F. varium; (3) B. caccae, B. distasonis, B. eggerthii, B. fragilis, B. merdae, B. ovatus, B stercoris, B. thetaiotaomicron, B. uniformus and B. vulgatus; (4) B. splanchnicus; (5) Porphyromonas asaccharolytica; (6) B. bivius (Prevotella bivia); (7) B. disiens (P. disiens); (8) B. intermedius (P. intermedia);and (9) B. melaninogenicus (P. melaninogenica). Single isolates of B. ruminicola (P. ruminicola), B. denticola (P. denticola) and B. capillosus did not cluster with other strains.

Evaluation of the RAPID ID 32A system for the identification of Bacteroides fragilis and related organisms.

This study evaluated the ability of a rapid identification system for anaerobic bacteria, ATB 32A, now renamed RAPID ID 32A (API-bioMérieux UK Ltd., Basingstoke), to identify accurately 74 strains of the 'B. fragilis group'. ATB 32A identified correctly 78.4% of strains to species level, without supplemental tests. The percentage of strains identified to species level rose to 94.6% when a supplementary test (advised by bioMérieux) for catalase production was used to differentiate between Bacteroides ovatus and Bacteroides uniformis. RAPID ID 32A is a rapid, accurate method for the identification of members of the 'B. fragilis group' isolated within a routine clinical laboratory.

Problems of thermonuclease detection for identifying Staphylococcus aureus in blood culture broths.

The detection of thermonuclease by the Oxford strain and eight clinical isolates of Staphylococcus aureus in a variety of bacteriological broths with and without added blood was examined using a toluidine blue-DNA-agar plate method. In Isosensitest, brain-heart infusion, tryptic soy, nutrient and gas-liquid chromatography broths (all of which do not contain liquoid) thermonuclease detection was uncomplicated. In Bactec broths (containing liquoid) detectable thermonuclease activity was greatly reduced in the absence of blood. The addition of 10% blood to the Bactec broths restored the activity. Liquoid was shown to be responsible for the inhibition of thermonuclease activity, and its effect could be neutralised by the addition of blood, albumin, or haemoglobin. In specimens containing no blood, or insufficient blood to neutralise the liquoid in culture broths, more has to be added to prevent false negative reporting of S aureus. This can be done after growth at the time of thermonuclease testing. Clinical consequences of delayed identification of S aureus in routine blood cultures may be serious. The application of the thermonuclease test to blood culture broths is both fast and specific.

Identification, and susceptibility to seven antimicrobial agents, of 61 gram-negative anaerobic rods from periodontal pockets.

Sixty-one cultures of Gram-negative anaerobic rods were isolated from deep periodontal pockets of patients with rapidly progressive periodontitis. Isolates were speciated as Bacteroides gingivalis (18 isolates), Bacteroides intermedius (8), Bacteroides oris (1), Bacteroides gracilis (17) and Fusobacterium nucleatum (17). Their susceptibilities, to seven antimicrobial agents, were determined in vitro using a plate dilution technique. Amoxycillin and amoxycillin with clavulanic acid were active against all isolates (MIC less than 1 mg/l) and proved the most effective agents tested. F. nucleatum and B. gracilis showed resistance to erythromycin; F. nucleatum had MIC values ranging from 0.03 mg/l up to 128 mg/l when tested with this, least effective agent. Metronidazole was effective against all isolates except for a few strains of B. gracilis (MIC less than 4 mg/l). Tetracycline hydrochloride and minocycline were active against all isolates except for a few strains of B. gracilis (MIC less than 2 mg/l with both minocycline and tetracycline hydrochloride). Penicillin proved less effective than amoxycillin with regard to inhibition of B. gracilis.

Improved detection of Candida albicans in a blood-culture model.

Human blood reduced the numbers of colony-forming units (cfu) of Candida albicans in a blood-culture model so that the detection time was increased by 12 h. Reduction in cfu was accompanied not by reduction in cell mass but by observable clumping of cultures, which was attributable to a heat-stable serum component. The action of the latter component could be negated if the medium were supplemented by a combination of trypsin, 2-phenyl ethanol, liquoid and Tween 80, when a statistically significant improvement was noted in minimum detection time for C. albicans growing in blood-culture medium.

Comparison of three-compartment Petri dishes and individual plates for routine culture of vaginal swabs.

Recovery of aerobes and facultative anaerobes from 200 consecutive randomly selected high vaginal swabs was evaluated using three-compartment Petri dishes containing Sabouraud, dextrose agar, GC selective agar, and chocolate agar. The method was compared with the traditional method using individual Petri dishes. The two methods produced comparable results both in terms and quantities of organisms recovered from the specimens. As three-compartment Petri dishes use less agar, save time in culturing specimens, yet still maintain the same standard of culture, they provide a more economical alternative to the traditional method for routine culture of vaginal swabs.

Bacterial calcification in infective endocarditis.

The present report is the first description to our knowledge of a clinical case of bacterial calcification in human infective endocarditic vegetations. Partial calcification of bacteria within vegetations may be a further mechanism of bacterial protection from host defences and antibiotics. Similar calcification has recently been reported in vegetations formed on porcine valvular prostheses implanted experimentally in sheep.

The improved recovery of Candida albicans from fluid culture media.

This study compares the mean generation time (MGT) and lag period of the growth of Candida albicans in four blood culture media, under a variety of conditions of incubation. The media compared were Bactec 6B, brain-heart infusion, malt extract broth and Sabourauds liquid medium. All four media were incubated under the eight possible permutations of the following conditions: 37 degrees C or 30 degrees C, vented or unvented, unshaken or constantly shaken. Then, using the incubation conditions found to be most favourable, minimum detection times for C. albicans were compared in the four media. The combination of incubation of the cultures at 37 degrees C, venting and constant-shaking, produced the fastest generation time with the minimum lag period. Of the media, Bactec 6B medium had the shortest lag period under these conditions while brain-heart infusion had the lowest MGT overall. Sabourauds liquid medium, which resulted in the most favourable combination of generation time and lag period, proved superior to the other media for the recovery of C. albicans.

Netilmicin in gram-negative sepsis: comparative abilities of a dosage nomogram and clinical microbiologists to predict the preferred individual dose.

The preferred dose of netilmicin was determined in each of 39 patients with severe gram-negative sepsis treated at two centres. The dose was based upon the attainment of recommended serum concentrations. Patient age varied from 18 to 87 years (mean 58), estimated creatinine clearance from 20 to 150 ml/min (mean 71), and the preferred dose from 100 to 750 mg/24 h. The dose generated by a nomogram for netilmicin was compared in retrospect with the initial dose assigned to each patient by the clinical microbiologist concerned. With respect to the preferred dose, the nomogram underdosed, on the average, by 40 mg/24 h, and the microbiologists, by 30 mg/24 h. The correlation with the preferred dose was stronger for the nomogram dose (r = 0.66; p less than 0.001, 37 df) than for the microbiologists' dose (r = 0.47; p less than 0.005, 37 df) but there was no significant difference between the two in the frequency with which they predicted the preferred dose to within 50 mg/24 h (nomogram 19/39; microbiologists 16/39). The prescription of a fixed dose of 450 mg/day to all patients would have had a similar success rate (15/39). The performance of the nomogram was better in patients with serum creatinine concentrations of greater than or equal to 100 microM (r = 0.82; p less than 0.001, 13 df; 10/15 within 50 mg/24 h of preferred dose) than in those with creatinine concentrations less than 100 microM (r = 0.55; p less than 0.01, 22 df; 9/24 within 50 mg/24 h of preferred dose).

More rapid identification of bacteraemia by manual rather than radiometric method.

Results of blood culture examination using the radiometric (Bactec-460) system for one year showed no overall improvement compared with those of the previous three years when a manual system with early blind subculture was used. The isolates from the manual system were available more often on solid media, 24 hours earlier, than when the radiometric system was used. In a further study of 1100 blood cultures the radiometric medium was tested for growth index as well as being subcultured blindly, irrespective of growth index, on the first day. Thirty six out of 54 (67%) of the blood cultures were positive on subculture but negative for growth index at this time. The overall cost of the radiometric system is also considerably more than that of the manual system.