Prevalence of Trichomonas vaginalis and coinfection with Chlamydia trachomatis and Neisseria gonorrhoeae in the United States as determined by the Aptima Trichomonas vaginalis nucleic acid amplification assay.

Our aim was to determine Trichomonas vaginalis prevalence using the Aptima Trichomonas vaginalis assay (ATV; Gen-Probe) and the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae coinfections in U.S. women undergoing screening for C. trachomatis/N. gonorrhoeae. Discarded urogenital samples from 7,593 women (18 to 89 years old) undergoing C. trachomatis/N. gonorrhoeae screening using the Aptima Combo 2 assay (Gen-Probe) in various clinical settings were tested with ATV. Overall, T. vaginalis, C. trachomatis, and N. gonorrhoeae prevalences were 8.7%, 6.7%, and 1.7%, respectively. T. vaginalis was more prevalent than C. trachomatis or N. gonorrhoeae in all age groups except the 18- to 19-year-old group. The highest T. vaginalis prevalence was in women ≥ 40 years old (>11%), while the highest C. trachomatis prevalence (9.2%) and N. gonorrhoeae prevalence (2.2%) were in women <30 years old. Coinfection prevalences were 1.3% for C. trachomatis/T. vaginalis, 0.61% for C. trachomatis/N. gonorrhoeae and N. gonorrhoeae/T. vaginalis, and 0.24% for C. trachomatis/N. gonorrhoeae/T. vaginalis and highest in women <30 years old. T. vaginalis prevalence differed by race/ethnicity, with the highest prevalence in black women (20.2%). T. vaginalis prevalence ranged from 5.4% in family planning clinics to 22.3% in jails. Multivariate analysis determined that ages of ≥ 40 years, black race, and patient locations were significantly associated with T. vaginalis infection. T. vaginalis is the most common sexually transmitted infection (STI) in women of >40 years, while C. trachomatis and N. gonorrhoeae prevalence is lowest in that age group. Higher T. vaginalis prevalence in women of >40 years is probably attributed to the reason for testing, i.e., symptomatic status versus routine screening in younger women. Coinfections were relatively low. High T. vaginalis prevalence in all age groups suggests that women screened for C. trachomatis/N. gonorrhoeae, whether asymptomatic or symptomatic, should be screened for T. vaginalis.

Incidence and outcome of vancomycin-resistant enterococcal bacteremia following autologous peripheral blood stem cell transplantation.

A retrospective evaluation of 321 consecutive recipients of high-dose chemotherapy (HDC) and autologous peripheral blood stem cell transplantation (PBSCT) was conducted to ascertain the incidence and outcome of vancomycin-resistant enterococcal (VRE) bacteremia. Ten patients developed VRE bacteremia at a median of 6 days following PBSCT. Nine isolates were Enterococcus faecium and one was E. faecalis. The median duration of bacteremia was 5 days. The central venous catheter was removed in seven individuals. Nine patients were treated with a variety of antimicrobial agents including quinupristin-dalfopristin, chloramphenicol, doxycycline, oral bacitracin, co-trimoxazole, and nitrofurantoin. Bacteremia resolved without adverse sequelae in seven patients. Two individuals who died of other causes had persistent or relapsed bacteremia at the time of death. An additional patient suffered multiple relapses of VRE bacteremia and died as a result of VRE endocarditis 605 days following PBSCT. Mortality as a direct result of VRE bacteremia was 10% in this series. The optimal type and duration of treatment of VRE bacteremia has not been clearly defined. Therefore, we perform weekly stool surveillance cultures for VRE in our hospitalized transplant population and apply strict barrier precautions in those individuals in whom stool colonization has been identified. Furthermore, the empiric use of vancomycin has been restricted. Bone Marrow Transplantation (2000) 25, 147-152.

Cytomegalovirus viremia, viruria and disease after autologous peripheral blood stem cell transplantation: no need for surveillance.

A retrospective evaluation of 200 consecutive recipients of autologous peripheral blood stem cell transplantation (PBSCT) was conducted to ascertain the incidence, risk factors, clinical features, complications, and outcome of cytomegalovirus (CMV) infection. A total of 26 patients (13%) developed CMV viremia (n = 5), DNAemia (n = 3), viruria (n = 18) and/or disease (n = 3) at a median of 45 days following stem cell infusion. None of the patients underwent surveillance testing for CMV. A diagnosis was established by culture and polymerase chain reaction of blood, urine or other tissue samples submitted when patients exhibited clinical features suggestive of CMV infection. Cytomegalovirus seropositivity prior to transplantation was the only statistically significant risk factor predicting subsequent identification of CMV (P < 0.001). The symptoms were severe enough in 23 patients to warrant treatment with intravenous ganciclovir. Three patients developed CMV disease; two developed fatal CMV pneumonia and one developed CMV gastritis which responded to antiviral treatment. Clinical signs and symptoms as well as viremia and viruria resolved with (20 patients) and without (three patients) treatment in the remaining individuals. All instances of CMV viremia, DNAemia, viruria and disease occurred within 3 months of stem cell infusion. These results demonstrate that CMV is a common pathogen after autologous PBSCT and may result in fatality in rare instances. Surveillance programs appear to be neither useful nor cost-effective. Diagnostic evaluation should be performed only in patients exhibiting suspicious clinical features and antiviral chemotherapy should be administered for persistent and severe signs and symptoms.

Southern extension of the range of human babesiosis in the eastern United States.

We sought evidence of babesiosis in three residents of New Jersey who were suspected of local acquisition of Babesia microti infection. We tested serial blood samples from these residents for B. microti antibodies and amplifiable DNA by using immunofluorescent antibody and PCR techniques. All three residents experienced symptoms suggestive of acute babesiosis. The sera of each of the patients reacted against babesial antigen at a titer fourfold or higher in sequentially collected blood samples. PCR-amplifiable DNA, characteristic of B. microti, was detected in their blood. These data suggest that human B. microti infections were acquired recently in New Jersey, extending the range of this piroplasmosis in the northeastern United States.

Comparison of culture and acid-fast bacilli stain to PCR for detection of Mycobacterium tuberculosis in clinical samples.

The major drawback in effective use of polymerase chain reaction (PCR) for detecting Mycobacterium tuberculosis (MTB) in clinical samples is the presence of PCR inhibitors and unique cell components of the organism that complicate DNA extraction and subsequent PCR amplification. A PCR assay with a unique multistep DNA extraction method that minimizes these problems was compared in a prospective study to acid-fast bacilli stain (AFBS) and culture for detecting MTB in clinical samples. A total of 254 clinical specimens in two separate studies were processed for MTB by these techniques. While PCR and culture were 100% sensitive and specific, culture required up to 8 weeks of incubation and additional time to perform biochemical testing to identify the isolated micro-organism. Acid-fast bacilli stain had a specificity of about 87% and did not differentiate among Mycobacterial species. In contrast, the results from PCR were available within 48 h and did not require additional testing to attain a final result. Polymerase chain reaction was highly reliable for detection and confirmation and interpretation of positive AFBS results. The assay was easy to perform with a turn around time of about 2 days.

Outcomes assessment of a residency program in laboratory medicine.

During a down-sizing of residency programs at a State University Medical School, hospital based residents' positions were eliminated. It was determined to find out the characteristics of the residents who graduated from the Laboratory Medicine Program, to compare women graduates with men graduates, and to compare IMGs with United States Graduates. An assessment of a 25 year program in laboratory medicine which had graduated 100 residents showed that there was no statistically significant difference by chi 2 analysis in positions (laboratory directors or staff), in certification (American Board of Pathology [and subspecialties], American Board of Medical Microbiology, American Board of Clinical Chemistry) nor in academic appointments (assistant professor to full professor) when the male graduates were compared with the female graduates or when graduates of American medical schools were compared with graduates of foreign medical schools. There were statistically significant associations by chi 2 analysis between directorship positions and board certification and between academic appointments and board certification. Of 100 graduates, there were 57 directors, 52 certified, and 41 with academic appointments. Twenty-two graduates (11 women and 11 men) attained all three.

Use of AmpliWax to optimize amplicon sterilization by isopsoralen.

The photochemical inactivation of amplicons by isopsoralen (IP-10) has been suggested as a possible means to prevent PCR carryover contamination. To evaluate the technique, serial dilutions of amplicons (10(11) to 10(3)) from the Borrelia burgdorferi OSP A gene were amplified in the presence of 0, 25, 50, and 100 micrograms of IP-10 per ml for 45 cycles. The PCR products were exposed to UV light for 15 min to activate IP-10 and sterilize the amplicons. One microliter of each sterilized sample was reamplified for an additional 45 cycles. The PCR products were then resolved in an agarose gel, blotted onto a nylon membrane, and probed with an alkaline phosphatase-conjugated chemiluminescent probe. Although IP-10 at concentrations of 50 and 100 micrograms/ml effectively sterilized up to 10(11) amplicons, the compound was inhibitory to PCR. IP-10 at a concentration of 25 micrograms/ml had slight inhibitory effect on PCR and did not completely sterilized all of the amplicons. Therefore, in subsequent experiments AmpliWax was substituted for mineral oil, and PCR was performed on 10(9) to 10(3) amplicons as described above. Following the amplification, the PCR tubes were cooled to solidify the AmpliWax and inoculated with various concentrations of IP-10. With this technique, PCR products produced from as many as 10(9) target amplicons were effectively sterilized with 200 micrograms of IP-10 per ml. Similarly, the addition of IP-10 (50 micrograms/ml) before and after PCR was evaluated for the detection of B. burgdorferi in 62 ticks from a region of Southern Connecticut where the organism is highly endemic. PCR performed in the presence of 50 micrograms of IP-10 per ml detected B. burgdorferi-specific DNA in 17 of 62 ticks (27%) following gel electrophoresis and in 34 of 62 ticks (55%) following Southern blot hybridization of the PCR products. In contrast, post-PCR addition of IP-10 detected borrelia-specific DNA in 31 of 62 ticks (50%) following gel electrophoresis and in 46 of 62 ticks (64%) following Southern blot hybridization. We conclude that the replacement of mineral oil with AmpliWax can be useful in eliminating the inhibitory effects of IP-10 and other sterilizing agents for post-PCR sterilization of amplicons.

Oerskovia xanthineolytica infection of a prosthetic joint: case report and review.

Oerskovia spp. are gram-positive, Nocardia-like bacilli which inhabit the soil and rarely cause human infections. Previously reported cases of Oerskovia infection have been characterized by a nonaggressive course and an association with foreign bodies. We report the first case of a patient with a prosthetic joint infection due to Oerskovia xanthineolytica. Our patient presented with a prolonged, indolent course and was thought to have aseptic loosening of his prosthesis until the time of surgery. He was cured of his infection by removal of the prosthesis, antibiotic therapy, and delayed reimplantation. Review of the previous 10 reported cases of Oerskovia infection in humans supports the recommendation that foreign-body-associated infections should be treated with a strategy that includes removal of the foreign material.

Evaluation of PCR and nested PCR for laboratory diagnosis of hepatitis C virus infection.

The detection of hepatitis C virus (HCV) RNA by nested polymerase chain reaction (PCR) is believed to be the most reliable method to diagnose HCV infections. A pitfall of nested PCR is that it is prone to contamination. Single step reverse transcription-PCR (RT-PCR) was performed, prospectively, on 80 sera from 59 patients with a set of primers that amplified a 273 bp sequence unique to the 5' noncoding (NC) region of the HCV genome. Nested PCR, was performed on all PCR negative specimens with a set of primers that amplified a 255 bp internal to the original primers. Single step RT-PCR was positive on 45 sera from 35 patients following gel electrophoresis and on two additional sera from two patients following Southern blot hybridization. Nested PCR was positive on two more sera following gel electrophoresis of the nested PCR products. These two patients were seropositive and subsequent serum from one patient was positive by single step PCR. Three additional sera were positive following Southern blot analysis of the nested PCR products. Two patients were seropositive and had elevated serum alanine aminotransferase (ALT) levels. The third patient was seronegative with normal ALT level and was considered a false positive. The remaining seronegative control specimens were PCR negative by both methods. The majority of PCR positive patients (82%) had elevated ALT levels, while the majority of PCR negative seropositive patients had normal ALT levels. We conclude that single step PCR is a sensitive test for the laboratory diagnoses of the majority of the HCV infections.

Detection of Pneumocystis carinii with direct fluorescence antibody and calcofluor white stain.

Direct fluorescence monoclonal antibody stain (DFA) was compared prospectively, with calcofluor white (CFW) stain for the diagnosis of Pneumocystis carinii in 163 respiratory specimens from 97 patients. The patient population included persons with HIV infection (58%), bone marrow transplant recipients (10%), immunosuppressed patients owing to chemotherapy (21%) and others (11%). Nineteen specimens including 12 sputa, six bronchoalveolar lavage fluids (BALs) and one induced sputum were positive by DFA. In contrast, only six sputa, and five BALs were positive by CFW. All specimens positive by CFW were also positive by DFA. Of 86 sputa that were negative by either method 29 were followed by more invasive sample collections. Three specimens were followed by induced sputum collection, 18 by BAL, six by lung biopsy, and two by pleural fluid aspiration. All the subsequent induced sputa, pleural fluids, and lung biopsies were negative by both methods. However, four of 18 subsequent BALs (22%) were positive by both methods, provided at least two CFW stained slides were examined per specimen. Except for expectorated sputum, it is concluded that CFW is a rapid and inexpensive test to detect P. carinii in most respiratory specimens.

Detection of cystic fibrosis delta F508 mutation by anti-double-stranded DNA antibody.

This study evaluated an enzyme immunoassay (EIA) as a screening tool for detection of the most common mutation (delta F508) in cystic fibrosis (CF). Guthrie card bloodspots were extracted to remove whole blood polymerase chain reaction (PCR) inhibitors. The washed filter paper was directly amplified under standard (98 bp amplicons) or modified PCR conditions (491 bp amplicons) for the delta F508 mutation. Monoclonal anti-double stranded deoxyribonucleic acid antibody was used to detect competent hybrid formation between PCR products and normal (N) and mutant (M) cDNA (deoxyribonucleic acid) probes coated to microtiter plate wells. Under standard conditions, mean relative color production (N/M) via an enzyme-linked horseradish peroxidase secondary antibody was 8.8, 0.6 and 0.04 for individuals normal, heterozygous and homozygous for the CF delta F508 mutation, respectively (n = 27). Comparison of EIA results to those obtained by tris-borate-EDTA/8 percent polyacrylamide gel electrophoresis (TBE-PAGE) yielded excellent correlation (100 percent) for all three genotypes (n = 27). In comparison to TBE-PAGE, the EIA was 5 to 10 fold more sensitive when serially diluted PCR samples were evaluated. Larger PCR products (491 bp amplicons) for the CF delta F508 mutation obtained under modified conditions were not resolved by TBE-PAGE. The EIA, however, demonstrated equal sensitivity to the 98 bp and 491 bp amplicons. Performance time for TBE-PAGE analysis was substantially shorter (25 percent) than the EIA (3.5 to 4 h and 4.5 to 5 h, respectively) when small batches of samples (n = 5) were analyzed. The TBE-PAGE was not, however, convenient for screening large numbers of PCR-amplified samples (n > 15).

Polymerase chain reaction for detection of herpes simplex virus encephalitis.

A patient with herpes simplex virus encephalitis is described. The polymerase chain reaction (PCR) was used to confirm the diagnosis in cerebrospinal fluid. PCR allows the rapid diagnosis of many infectious organisms, such as HSV, in which prompt diagnosis is essential.

Use of polymerase chain reaction for laboratory diagnosis of herpes simplex virus encephalitis.

Polymerase chain reaction was used to detect herpes simplex virus (HSV) specific deoxyribonucleic acid (DNA) sequences in acute and convalescent cerebrospinal fluid (CSF) and brain tissue of a 78-year-old man and in CSF of a neonate who died of complications owing to herpes simplex virus encephalitis (HSVE). Polymerase chain reaction (PCR) was carried out for 35 cycles with a set of primers that bracketed a 92 base pair segment unique to the HSV DNA polymerase gene. Amplified DNA was electrophoresed on 3 percent agarose gel, blotted onto a nylon membrane, and probed with 32p-labeled oligonucleotide internal to the primers. The HSV specific DNA sequences were detected in the specimens from both patients. No HSV specific DNA was detected in CSFs from 20 patients with suspected Lyme disease or neurosyphilis. Polymerase chain reaction is a rapid and noninvasive technique for the diagnosis of HSVE.

Application of hydroxylamine hydrochloride for post-PCR sterilization.

A major problem in the application of polymerase chain reaction (PCR) in diagnostic laboratories is contamination with exogenous nucleic acid, especially aerosolized amplicon, from previous PCR. Although several pre- and post-PCR sterilization techniques have been proposed, an optimal sterilization technique is not yet available. Hydroxylamine hydrochloride is a mutagenic agent that binds to and chemically modifies DNA. In the present study PCR was performed on DNA extracted from Herpes simplex virus (HSV) and Borrelia burgdorferi with two sets of primers that amplified a 92 bp sequence unique to HSV DNA polymerase gene and a 156 bp sequence unique to B. burgdorferi Osp-A gene (35 cycles). Following the amplification, PCR products were treated with 0-500 mM hydroxylamine hydrochloride and incubated at room temperature for 30 min. One microlitre of each hydroxylamine treated PCR product was reamplified for an additional 35 cycles. Pre- and post-hydroxylamine treated PCR products were separated by electrophoresis in 3% agarose gel. Hydroxylamine, at a concentration of 250 mM or higher, was found to effectively modify PCR products and prevent their amplification in subsequent PCR.