Detection of CTX-M-type extended-spectrum beta-lactamase (ESBLs) by testing with MicroScan overnight and ESBL confirmation panels.

CTX-M extended-spectrum beta-lactamases (ESBLs) have emerged as the most common type of ESBL globally, their incidence easily surpassing those of SHV and TEM ESBLs in most locales. This study compared the performance of two MicroScan dried panels with CLSI reference broth microdilution and disk diffusion methods on a collection of genetically characterized ESBL-producing isolates. These included 64 Enterobacteriaceae isolates that produced CTX-M8, -14, -15, or -16 according to PCR and sequencing of the bla gene, 17 isolates that produced a SHV or TEM ESBL, and 19 that produced both CTX-M and SHV ESBLs. Each isolate was tested by a frozen reference microdilution panel, the MicroScan ESbetaL plus confirmation panel, and a routine dried panel containing streamlined ESBL confirmation dilutions (MicroScan Neg MIC panel type 32) that included cefotaxime and ceftazidime tested alone or with a fixed concentration of 4 microg/ml of clavulanate. Each isolate was also tested by the standard CLSI double-disk confirmation tests. The disk diffusion method detected all ESBL-producing isolates, the frozen reference panel detected 90% of isolates (10 out of 100 could not be analyzed because of off-scale MICs that exceeded the clavulanate combination concentrations in the panel), the ESbetaL plus panel detected 98% (1 missed and 1 off scale), and the streamlined ESBL panel detected 95% (5 off scale). Very high MICs for a few strains that produced SHV or both CTX-M and SHV ESBLs precluded noting the required three twofold-dilution differences with clavulanate needed to confirm an ESBL primarily in the reference panel and the Neg type 32 panel.

Direct bacterial identification from positive BacT/Alert blood cultures using MicroScan overnight and rapid panels.

Studies were conducted on a method of direct inoculation of MicroScan overnight and rapid panels from positive BacT/Alert blood culture bottles containing standard aerobic media to determine the correlation with inoculation of the corresponding panels with a standardized bacterial suspension obtained following subculture to agar. For Gram-negative organisms, 122 of 127 (96%) overnight panels and 85 of 118 (72%) rapid panels showed complete agreement with the standard method for species identification. Highest concordance (99%) occurred with Enterobacteriaceae inoculated directly into overnight panels. For Gram-positive organisms, 70 of 85 (82%) overnight panels and 45 of 86 (52%) rapid panels showed complete agreement. These findings suggest that direct inoculation of Gram-negative overnight MicroScan panels yields results most comparable to standard methods when Enterobacteriaceae are detected and allows reporting of results 18 to 24 h sooner. Direct inoculation of Gram-positive overnight or rapid panels and Gram-negative rapid panels from this blood culture medium did not yield acceptable identification results and is not recommended.

Staphylococcus hominis subsp. novobiosepticus subsp. nov., a novel trehalose- and N-acetyl-D-glucosamine-negative, novobiocin- and multiple-antibiotic-resistant subspecies isolated from human blood cultures.

A new subspecies, Staphylococcus hominis subsp. novobiosepticus, isolated from human blood cultures, a wound, a breast abscess and a catheter tip, is described on the basis of a study of 26 strains isolated between 1989 and 1996. DNA-DNA reassociation reactions, conducted under stringent conditions, and macrorestriction pattern analysis demonstrated that these strains are closely related to previously characterized S. hominis strains isolated from human skin and clinical specimens, but are significantly divergent. S. hominis subsp. novobiosepticus can be distinguished from S. hominis (now named S. hominis subsp. hominis) by its combined characteristics of novobiocin resistance and failure to produce acid aerobically from D-trehalose and N-acetyl-D-glucosamine. Furthermore, all 26 strains of the new subspecies are resistant to nalidixic acid, penicillin G, oxacillin, kanamycin and streptomycin, and were either resistant or had intermediate resistance to methicillin and gentamicin. Most strains were also resistant to erythromycin, clindamycin, chloramphenicol, trimethoprim/sulfamethoxazole and ciprofloxacin. Based on a comparison of the sequences of a 1001 bp mecA amplification product from reference methicillin-resistant staphylococci, the mecA gene present in S. hominis subsp. novobiosepticus was identified as homologue A, commonly found in S. aureus and many coagulase-negative staphylococcal species. The type strain of S. hominis subsp. novobiosepticus is ATCC 700236T. Descriptions of S. hominis subsp. novobiosepticus subsp. nov and S. hominis subsp. hominis are given and the description of S. hominis is emended.

Direct susceptibility testing with positive BacT/Alert blood cultures by using MicroScan overnight and rapid panels.

Studies were conducted on a method of direct inoculation of MicroScan dried overnight and of rapid panels with positive aerobic blood cultures obtained from the BacT/Alert to determine antimicrobial susceptibilities. Inocula were limited to specimens that appeared unimicrobic on Gram stain. Results were compared to those obtained from panels inoculated following subculture. For 133 gram-negative bacilli, there were 94.7 and 93.5% categorical agreements between direct and standard methods for all drugs tested with overnight and rapid panels, respectively. For 104 gram-positive cocci, there were 93.2 and 93.1% categorical agreements for overnight and rapid panels, respectively. The major error (false resistance) rate for gram negatives was 1.4% for overnight versus 0.7% for rapid panels. The very major error (false susceptibility) rate was 2.7% for overnight versus 8.1% for rapid panels. The total error rates were 1.6% for overnight panels and 1.5% for rapid panels. The major error rates for gram-positive direct susceptibility tests were 2.6% for overnight and 2.5% for rapid panels. The very major error rates were 8.8 and 7.2% for overnight and rapid panels, respectively. Total error rates were 3.6% for overnight and rapid gram-positive panels. These findings suggest that susceptibility results obtained from directly inoculated gram-negative overnight panels have the greatest correlation to those obtained by standard methods. When discrepant results occur with direct-susceptibility testing, they are more likely to show false susceptibility than false resistance.

Clinical importance of identifying coagulase-negative staphylococci isolated from blood cultures: evaluation of MicroScan Rapid and Dried Overnight Gram-Positive panels versus a conventional reference method.

We evaluated the clinical usefulness of species identification of blood isolates of coagulase-negative staphylococci as a predictor of the clinical significance of the isolates. In addition, we compared results of species identification obtained with MicroScan Rapid Gram-Positive Identification panels and Dried Overnight (Conventional) Gram-Positive Identification panels with those obtained by a tube reference method. Two hundred eighty-five blood isolates were tested, including 92 judged to represent true bacteremia and 193 judged to represent contamination. The most common species detected were Staphylococcus epidermidis, Staphylococcus hominis, and Staphylococcus haemolyticus. These three species accounted for nearly 98% of the clinically significant isolates and 89% of the contaminants. The isolation of other species almost always represented contamination. However, identification of the three most common species did not help distinguish pathogens from contaminants. Both the Rapid and the Dried Overnight Gram-Positive panels identified S. epidermidis strains accurately, but the panels performed less well for the other species. Analysis revealed that S. hominis was frequently misidentified due to the presence of a previously unknown subspecies. Based on the initial results, revised investigational Dried Overnight Gram-Positive Identification panels (CPID-2) were prepared and tested. The CPID-2 panels identified 85 to 95% of S. epidermidis strains, 76 to 86% of S. hominis strains, and 88 to 92% of S. haemolyticus strains with high probability (>85%) and, overall, represented a significant improvement over the other panels for identification of these staphylococcal species.

Protection against lethal murine coccidioidomycosis by a soluble vaccine from spherules.

The formaldehyde-killed, whole-spherule vaccine, which is protective against lethal challenge of laboratory animals with Coccidioides immitis, was fractionated. It yielded a soluble, multicomponent, subcellular fraction termed the 27K vaccine. This vaccine, when it was accompanied by adjuvant, protected mice against lethal intranasal and intravenous challenge with C. immitis.

Multicenter evaluation of the MicroScan Rapid Gram-Negative Identification Type 3 Panel.

The accuracy and performance of the revised MicroScan Rapid Gram-Negative Identification Type 3 Panel (Dade MicroScan Inc., West Sacramento, Calif.) were examined in a multicenter evaluation. The revised panel database includes data for 119 taxa covering a total of 150 species, with data for 12 new species added. Testing was performed in three phases: the efficacy, challenge, and reproducibility testing phases. A total of 405 fresh and stock gram-negative isolates comprising 54 species were tested in the efficacy phase; 96.8% of these species were identified correctly in comparison to the identification obtained either with the API 20E system (bioMérieux Vitek, Hazelwood, Mo.) or by the conventional tube method. The number of correctly identified isolates in the challenge phase, including new species added to the database, was 221 of 247, or 89.5%, in comparison to the number correctly identified by the conventional tube method. A total of 465 isolates were examined for intra- and interlaboratory identification reproducibility and gave an agreement of 464 of 465, or 99.8%. The overall reproducibility of each individual identification test or substrate was 14,373 of 14,384, or 99.9%. The new Rapid Gram-Negative Identification Type 3 Panel gave accurate and highly reproducible results in this multiple-laboratory evaluation.

Novel method for rapid identification of Nocardia species by detection of preformed enzymes.

The purpose of the present study was to devise a method for the identification of Nocardia species that is more technically simple, accurate, and rapid than current standard methods of identification. We focused on a commercial bacteria identification system that contained chromogenic test substrates. Two MicroScan products were selected for use in the study on the basis of their content of chromogenic and conventional substrates. They were the Rapid Anaerobe Identification and the HNID panels. A total of 85 strains of Nocardia representing five species were used in the study. All isolates were identified as Nocardia species by the use of standard methods. The beta-naphthylamide-labeled substrate L-pyrrolidonyl-beta-naphthylamide (PYR), the nitrophenyl-labeled substrate p-nitrophenyl-alpha-D-mannopyranoside (MNP), and indoxyl phosphate were found to be useful for identification purposes. N. farcinica and N. nova were the only species positive for PYR, whereas N. brasiliensis was the only species that hydrolyzed MNP. All strains of N. brasiliensis, N. otitidiscavarium, and N. farcinica were positive for indoxyl phosphate, whereas strains of N. nova and N. asteroides sensu stricto were always negative. Agreement between the standard and enzymatic identification methods was 100%. In summary, detection of preformed enzymes appears to be a simple and reproducible method for the identification of Nocardia spp.

Serology of coccidioidomycosis.

Serologic tests have assisted in the diagnosis and prognosis of coccidioidomycosis for a half-century. The causative agent, Coccidioides immitis, is a dimorphic fungus existing in a hyphal form with arthroconidia in nature and in the usual culture. The arthroconidia represent the inhaled infective forms which in vivo and under special laboratory conditions form spherules which endosporulate. The culture filtrate/autolysate (coccidioidin) from the hyphal phase has provided antigens of suitable reliability for currently used serologic tests. These tests are primarily to determine the two major antibody responses: the early immunoglobulin M (IgM) response is useful in the diagnosis of acute primary coccidioidomycosis. Later, IgG is produced and usually outlasts the IgM, persisting in chronic coccidioidomycosis. The IgM is detectable by tube precipitin, a corresponding immunodiffusion, or latex particle agglutination tests. The pertinent antigen(s) is heat stable and pronase resistant and appears to be largely carbohydrate, mainly mannose with some 3-O-methyl mannose. The IgG detectable in the serum and other body fluids by complement fixation and a corresponding immuno-diffusion is useful in diagnosis, and its quantitation provides an indicator of progression of disease (increasing titer) or regression (decreasing titer). The pertinent antigen appears to be a heat-labile, pronase-sensitive protein which in an unreduced form has a molecular weight of 110,000. A third very useful serologic procedure is the exoantigen test for identification of putative cultures of C. immitis.

Therapeutic effect of the triazole Bay R 3783 in mouse models of coccidioidomycosis, blastomycosis, and histoplasmosis.

A new triazole, Bay R 3783, was compared with ketoconazole, itraconazole, and fluconazole, which were given via the alimentary tract at three dosages, and amphotericin B, which was given at 1 mg/kg intraperitoneally, in murine models of the systemic mycoses coccidioidomycosis, histoplasmosis, and blastomycosis. In a pulmonary coccidioidomycosis model, Bay R 3783, fluconazole, and itraconazole were essentially equally efficacious and more active than ketoconazole in protecting mice against death; but they were inferior to amphotericin B. In a short-term organ load experiment, Bay R 3783 and amphotericin B were equally effective and were more effective than the other drugs in reducing the amount of Coccidioides immitis in the lungs. Against meningocerebral coccidioidomycosis, Bay R 3783, itraconazole, and fluconazole at 25 mg/kg and amphotericin B prevented death only during therapy, with mortalities ensuing shortly thereafter. In mice with systemic histoplasmosis, Bay R 3783 and itraconazole at 25 mg/kg and amphotericin B prevented death in all mice through a 44-day observation period. Clearance of Histoplasma capsulatum from organs was similar in mice treated with Bay R 3783 and itraconazole; this clearance was greater than that in mice treated with ketoconazole and fluconazole but less than that in mice treated with amphotericin B. In mice with systemic blastomycosis, Bay R 3783 at 25 mg/kg yielded 90% survivors at 60 days, which was greater than that achieved with amphotericin B (60%) or itraconazole (30%). Clearance of Blastomyces dermatitidis from the lungs was greatest with Bay R 3783, followed by that with amphotericin B, itraconazole, fluconazole, and ketoconazole, in that order. Therefore, Bay R 3783 showed effectiveness comparable to or exceeding those of itraconazole and fluconazole and exceeding that of ketoconazole against these systemic mycoses in mice.

Evaluation of nikkomycins X and Z in murine models of coccidioidomycosis, histoplasmosis, and blastomycosis.

Nikkomycins X and Z, competitive inhibitors of fungal chitin synthase, were evaluated as therapeutic agents in vitro and in mouse models of coccidioidomycosis, histoplasmosis, and blastomycosis. In vitro, the nikkomycins were found to be most effective against the highly chitinous, dimorphic fungi Coccidioides immitis and Blastomyces dermatitidis, were less effective against yeasts, and were virtually without effect on the filamentous fungus Aspergillus fumigatus. Additionally, by transmission electron microscopy, nikkomycin Z was highly disruptive to the cell wall and internal structure of the spherule-endospore phase of C. immitis in vitro. In vivo, nikkomycin Z was more effective than nikkomycin X, was also found to be superior on a milligram per milligram basis to the majority of azoles tested in the models of coccidioidomycosis and blastomycosis, and was moderately effective in histoplasmosis. A study of the pharmacokinetics in mice showed that nikkomycin Z was rapidly eliminated after intravenous infusion but that absorption after oral administration was sufficiently slow to allow inhibitory levels to persist for more than 2 h. Results of limited toxicology tests suggest that nikkomycin Z was well tolerated at the dosages employed.

Immunoaffinity isolation and partial characterization of the Coccidioides immitis antigen detected by the tube precipitin and immunodiffusion-tube precipitin tests.

The antigen participating in the tube precipitin (TP) serologic test for coccidioidomycosis was isolated from mycelial-phase antigen (coccidioidin) by immunoaffinity and characterized by various analytical procedures. This was accomplished by first preparing the antigen-antibody precipitate by using antigen and human serum positive for TP (immunoglobulin M) antibody and then liberating the antigen by digestion with pronase. This protease destroyed the antibody and left the antigen intact as indicated by immunodiffusion-TP. The coccidioidal antigen was isolated from the proteolytic digest by using size exclusion chromatography. DEAE chromatography of this antigen yielded two fractions with immunodiffusion-TP reactivity which had average molecular sizes of 225 and 140 kilodaltons, respectively. The presence of carbohydrate and amino acids indicated that the antigen(s) is a glycopeptide. Compositional analysis showed that one fraction contained 3-O-methylmannose, mannose, and glucose in a ratio of 8:1.2:1, whereas the second fraction contained 3-O-methylmannose, mannose, glucose, and galactose in a ratio of 1:1:1:1. The amino acids glycine, alanine, serine, threonine, aspartic acid plus asparagine, and glutamic acid plus glutamine constituted 60 to 70% of the amino acids in both glycopeptides. Neither antigen could be detected entering the gel in sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Lectin affinity provided evidence of a high-mannose asparagine-linked glycopeptide in the first peak and an asparagine-linked glycopeptide with a biantennary complex-type structure in the second peak.

Microtiter method for MIC testing with spherule-endospore-phase Coccidioides immitis.

A method was developed for susceptibility testing with spherule-endospore-phase Coccidioides immitis by using a microtiter format. Isolated endospores were used to inoculate wells containing modified Converse medium with various concentrations of azole or nikkomycin antifungal substances which then were sealed with an acetate film. The plate was incubated at 37 degrees C with shaking for 96 h, after which the control wells had visible turbidity and endpoints were discernible. Microscopic examination revealed that both control and treatment wells maintained cells predominantly in the spherule-endospore phase of growth.

Characterization of a soluble protein of Coccidiodes immitis with activity as an immunodiffusion-complement fixation antigen.

A 48-kilodalton (kDa) electrophoretically distinct antigen from Coccidioides immitis mycelial- and spherule-endospore-phase filtrates was previously associated by immunoblotting with the immunodiffusion band that corresponds to complement-fixing activity (ID-CF). To characterize this antigen and its precursor, both mycelial- and spherule-endospore-phase filtrates were fractionated by size exclusion chromatography, lectin affinity chromatography, and nondenaturing electrophoresis. By size exclusion chromatography, most of the protein and carbohydrate of the crude filtrates eluted in a peak of average molecular size less than 30 kDa, although other components were detected. ID-CF activity was associated with the component at a relative mobility of 110 kDa. Fractions containing the ID band that corresponded to tube precipitin activity occurred from 200 to 40 kDa. The appearance of the 48-kDa band in denaturing sodium dodecyl sulfate-polyacrylamide gel electrophoresis (PAGE) specifically coincided with the fractions containing ID-CF activity. Nondenaturing PAGE of filtrates showed silver-stainable and immunoblot-reactive bands in the region of 110 kDa. Prior treatment with pronase destroyed this electrophoretically separable antigen, whereas periodate had no effect. Trypsin did not affect the 110-kDa band in unheated or unreduced antigen. Mycelial filtrates were chromatographed on lentil lectin or concanavalin A-Sepharose 4B to deplete them of glucose- or mannose-containing carbohydrate. The effluent fraction contained ID-CF activity and, upon denaturing electrophoresis, the 48-kDa antigen. The 110-kDa protein represents the ID-CF antigen which is heat labile and denatured to a 48-kDa band by sodium dodecyl sulfate-PAGE.

Comparison of immunoblot analyses of spherule-endospore-phase extracellular protein and mycelial-phase antigen of Coccidioides immitis.

The extracellular proteins produced by Coccidioides immitis during growth of the spherule-endospore-phase and mycelial-phase antigen (coccidioidin) were studied by polyacrylamide gel electrophoresis followed by immunoblot analysis to detect specific serologic function. Filtrates obtained from 28- and 120-h growth of the spherule-endospore phase were compared with each other and with coccidioidin by using negative, immunoglobulin M (IgM) precipitin-positive, or complement fixation-positive pooled and single human sera followed by peroxidase-labeled anti-human IgA, IgE, IgG, or IgM (heavy chain specific) or peroxidase-labeled concanavalin A to detect the reaction. A total of 35 bands was seen in the stained gels. Different patterns were noted among the two spherule-endospore preparations and unheated and heated coccidioidin. At least 15 electrophoretically separate antigens were detected with positive serum ranging in approximate molecular weight (Mr) from 100,000 to 18,000. Most were clustered between 45 and 60 kilodaltons (kDa). Common bands were noted at 48 and 18 kDa. At least one band at 48 kDa was strongly reactive with complement fixation-positive serum demonstrated by reaction with anti-IgG and anti-IgE. In contrast, doublet bands in the 50- to 65-kDa area were highly reactive with IgM precipitin-positive serum detected by anti-IgM. IgM antibodies present in both positive sera reacted with a band at 46 kDa which was not reactive with IgG. Heating the antigens altered the reactivity of many of the antigens, including the 48-kDa band, but not the 46-kDa band.

Pathogenicity of the basidiospores of Filobasidiella neoformans.

The pathogenicity of the purified basidiospores of Filosbasidiella neoformans was determined. The basidiospores were purified by successive filtration and inoculated into white Swiss female mice via the intracranial and intravenous route. At autopsy, infection was seen with as few as fifty inoculated cells. The brain, liver and spleen were examined culturally and histologically to prove the pathogenicity of the purified basidiospores .

Pathogenicity of the hyphae of Filobasidiella neoformans.

The pathogenicity of the purified hyphae of Filobasidiella neoformans was determined. The hyphal particles were inoculated into white Swiss female mice via the intracranial and intravenous route. Upon autopsy, infection was seen with as few as 25 hyphal elements. The brain, liver, and spleen were examined culturally and the brain examined histologically to prove the pathogenicity of the purified hyphae.

In vitro synergistic activity of ethambutol, isoniazid, kanamycin, rifampin, and streptomycin against Mycobacterium avium-intracellulare complex.

Strains of Mycobacterium avium-intracellulare complex often exhibit in vitro resistance to common antimycobacterial agents. Combinations of etambutol, isoniazid, kanamycin, rifampin, and streptomycin were tested to determine if synergism occurred. Ninety-six percent of the strains were susceptible to a combination of ethambutol and rifampin at concentrations attainable clinically. Other combinations of antimycobacterial agents inhibited 4 to 82% of the isolates tested.

Technique for the purification of the hyphae of Filobasidiella neoformans.

A technique for the purification of the hyphae of Filobasidiella neoformans is described. Cultural conditions and strains for maximal hyphal production were determined. Blastospores were separated from hyphae by sonification of mycelial suspensions. Following this, the initial density ranges of all cell types were determined by isopycnic centrifugation, using Renografin-60 as a supporting medium. Based on these data, rate centrifugation with different density ranges was used to obtain cell separation. The final percentage of non-hyphal cells to total population was 0.007%. These were determined to be still viable at the end of separation.