Infectious Information and Courses from MediaLab, Inc.

Urinary urobilinogen may be increased in the presence of a hemolytic process such as hemolytic anemia. It may also be increased with infectious hepatitis, or with cirrhosis. Comparing the urinary bilirubin result with the urobilinogen result may assist in distinguishing between red cell hemolysis, hepatic disease, and biliary obstruction. Urobilinogen is increased in hemolytic disease and urine bilirubin is negative. Urobilinogen is increased in hepatic disease, and urine bilirubin may be positive or negative. Urobilinogen is low with biliary obstruction, and urine bilirubin is positive. Reagent strips methods however, cannot distinguish normal urobilinogen from absent urobilinogen, as might be seen in complete biliary obstruction.

Suppola JP. Kuikka A. Vaara M. Valtonen VV. Comparison of risk factors and outcome in patients with Enterococcus faecalis vs Enterococcus faecium bacteremia. Scandinavian Journal of Infectious Diseases. 30(2):153-7, 1998.The purpose of our study was to determine retrospectively the risk factors for the acquisition of Enterococcus faecalis vs E. faecium bacteremia, as well as the clinical outcomes of these patients.62 patients with Enterococcus faecalis bacteremia were compared to 31 patients with E. faecium bacteremia. Haematologic malignancies, neutropenia, high-risk source and previous use of aminoglycosides, carbapenems, cephalosporins and clindamycin were significantly associated with E. faecium bacteremia. Instead, urinary catheterization was found to be related to Enterococcus faecalis bacteremia. The mortality rates within 7 d and 30 d were 13% and 27%, respectively, in patients with E. faecalis bacteremia and 6% and 29%, respectively, in patients with E. faecium bacteremia.There was no difference in mortality between E. faecalis and E. faecium bacteremia, nor was there a difference in seriousness of disease at the time of bacteremia. In the subgroups of patients with monomicrobial or clinically significant E. faecalis vs E. faecium bacteremia, the mortality rates were similar to the results of all subjects.Our results do not support the theory that E. faecium would be a more virulent organism than E. faecalis

Hershow RC. Khayr WF. Smith NL.: A comparison of clinical virulence of nosocomially acquired methicillin-resistant and methicillin-sensitive Staphylococcus aureus infections in a university hospital (University of Illinois at Chicago). Infection Control & Hospital Epidemiology. 13(10):587-93, 1992OBJECTIVES: To compare the clinical virulence of nosocomially acquired methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) infections in 1989.DESIGN: A retrospective comparison of host factors, in-hospital exposures, sites of infections, and outcomes of patients with nosocomial MRSA and MSSA infections. PARTICIPANTS: Forty-four adult patients with nosocomial S.aureus infections.RESULTS: The 22 MRSA-infected and 22 MSSA-infected persons were similar regarding mean age, gender, underlying diseases, and exposure to surgery. Before developing infection, MRSA-infected persons were more likely to have received antibiotics and to have stayed in the hospital > 2 weeks. Bacteremia was the most common presentation in the MRSA and MSSA groups (55% and 59%, respectively). Infectious complications and death were infrequent in both groups.CONCLUSIONS: MRSA and MSSA strains infect patients with similar demographic features and underlying diseases, but MRSA infections are significantly more common among patients with previous antibiotic therapy and a prolonged preinfection hospital stay. Clinical presentations and outcomes did not differ significantly between the 2 groups. Thus, similar to studies in the early 1980s, our findings do not suggest greater intrinsic virulence of MRSA.

Gelfand MS. Bakhtian BJ. Simmons BP.: Spinal sepsis due to Streptococcus milleri: two cases and review. Reviews of Infectious Diseases. 13:559-63, 1991We have recently cared for two patients with spinal sepsis secondary to infection with Streptococcus milleri.One patient had a spinal epidural abscess and the other had meningitis as well as a spinal subdural empyema.A review of the English-language literature revealed only two previously reported cases of spinal epidural abscess due to S. milleri and no cases of spinal subdural empyema due to S. milleri. We report two cases of spinal sepsis due to S. milleri and discuss pertinent literature.

Robinson LG. Kourtis AP.: Tale of a toothpick: Eikenella corrodens osteomyelitis. Infection. 28(5):332-3, 2000Tale of a Toothpick is a case of Eikenella corrodens osteomyelitis in a young woman, that resulted from puncture of her foot with a toothpick.The epidemiology, microbiology, common clinical presentations and therapy of E. corrodens are reviewed.A brief summary of the extent of toothpick injuries and their infectious complications are also presented.

Molecular diagnostics have begun to play an integral part in clinical laboratory diagnostic testing. Traditionally, molecular diagnostics have been utilized in three major clinical areas: Infectious diseases Genetics Tumor markers These molecular based diagnostic tests, while historically reserved for specialty/reference labs, have recently seen expansion of their utility within the scope of routine clinical laboratories. Molecular based diagnostics can be utilized by small labs as well as large ones, and can be found in virtually every department of the clinical laboratory.

Molecular methodologies offer numerous advantages to the clinical laboratory. These include:Sensitivity: Amplification methodologies are particularly useful in increasing the sensitivity of a methodology and useful in the identification of target molecules of interest that are only present in low concentrations. Specificity: Molecular methods minimize false positive test results by targeting the specific molecule of interest.Turn Around Time: In comparison with standard traditional culture methods, molecular methodologies usually offer better turn around times from receipt to result reporting.Application: broader application can be found with molecular methodologies such as infectious diseases, genetic testing, forensics, drug resistance, and tumor marker detection and monitoring.

The reason to chose a particular molecular method can be influenced by disease detection, monitoring or therapy in certain patient populations. Molecular methodologies can be used to identify alterations or variations or changes in DNA sequencing that can cause disease. Sequence alterations that are known to cause disease are termed mutations. These changes or mutations can be applied to areas of the clinical lab such as infectious disease, paternity, genetic testing, and pharmacogenetics. Some of the more common alterations are:Deletion: a missing nucleotide or other portion of DNA sequence Insertion: an extra DNA nucleotide or other portion of DNA sequence Missense: a nucleotide or sequence substitution that codes for a different amino acidNonsense: a nucleotide substitution that ends in early termination of the protein manufacturing process; usually due to a stop codon.The most common alteration is a single base change or single nucleotide polymorphism (SNP)

Burtis CA, Ashwood ER, Bruns DE, eds. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4th ed. St. Louis, MO: Elsevier Inc; 2006.Clinical and Laboratory Standards Institute (CLSI). Collection, Transport, Preparation, and Storage of Specimens for Molecular Methods; Approved Guideline. CLSI document MM13-A. NCCLS. Wayne, PA: 2005.Clinical and Laboratory Standards Institute (CLSI). Molecular Diagnostic Methods for Infectious Diseases; Approved Guideline. Second ed. CLSI document MM3-A2. NCCLS. Wayne, PA: 2006.

At the highest level are the “national” laboratories. Examples would include those operated by CDC, the United States Army Medical Research Institute for Infectious Diseases, and the Naval Medical Research Center. These laboratories have very unique resources to handle highly infectious agents and the ability to identify specific agent strains.

Biological attacks involve bacteria, viruses or natural toxins. The effects of toxins can be immediate but for bacteria and viruses the effects may not be apparent for weeks. A bio-terrorist may attack by infecting animals, contaminating food and water, spraying bacteria or viruses into the air. In infections such as smallpox and plague, once a few individuals are infected they can further spread the disease from person to person. An attack could also come from through a building’s ventilation system, the mail, or even through exposure to an infected terrorist seeking to spread disease during an infectious stage.

Commercially prepared controls come in either assayed or unassayed forms. Assayed controls are tested by multiple methods before sale, and are sold with the results of the tests. Assayed controls: are more expensive than unassayed controls are used to evaluate accuracy and precision avoid laboratory errors in determining control values may only be suitable for specific methods or conditionsWhile the manufacturer's control values can be used to some extent to measure accuracy, the best measure of accuracy is certified reference material.Unassayed controls are not tested by the manufacturer before they are sold. The control values for these materials must be determined by the individual laboratory. Unassayed controls: are less expensive than assayed controls are used to evaluate precision only avoid manufacturer error in determining control values control values are customized to the laboratory's own methods and conditionsA final note: although commercially available control materials are screened for hepatitis antigens and HIV antibodies, control materials should still be handled with precautions, since they contain biological materials and could contain infectious agents.

Specialists in microbiology perform testing to diagnose and stop the spread of infectious organisms, including bacteria, viruses, and parasites. Specialists should be able to isolate and identify a wide variety of these organisms. Testing procedures include direction examination and antigen detection methods. Specialists in serology and immunology measure antibodies to infectious organisms. Specialists should be familiar with all serology techniques (except those specific to immunohematology). This specialty includes all lab procedures performed in the specialty of histocompatibility. Specialists in hematology must be able to identify and evaluate cells in blood and bone marrow and identify disorders of these cell. Specialists should be familiar with routine and special tests to determine the number, morphology, and function of cells in body fluid.

As a healthcare worker, you come into contact with materials that may contain bloodborne pathogens. These are infectious organisms, usually viruses, which live in human blood and body fluids.The most important ones are: Hepatitis B Virus (HBV) Human Immunodeficiency Virus (HIV) Hepatitis C Virus (HCV)

Standard precautions mean that all blood and body fluids should be handled as if they were infectious and capable of transmitting disease. Standard Precautions apply to all: Blood Body fluids Secretions (except sweat) Excretions Non-intact skin Mucous membranes

Patients with Hepatitis B and other bloodborne infections can appear healthy, so you can't tell whose blood is infectious.So treat all: blood body fluids secretions (except sweat) excretions non-intact skin mucous membranes as if they were infectious.That's what the term Standard Precautions means.

A person infected with HBV can spread the virus soon after the initial infecting incident, and the infectious period continues through the acute and chronic illness.

Place blood and other infectious specimens ... first in an appropriate sealed container and then in a secondary red or biohazard labeled bag. Or place them in a compartmentalized tray for transport within the institution.

Even after taking all the proper precautions there is still a small chance of an exposure incident. An Exposure incident occurs when: Blood or another potentially infectious body fluid comes into direct contact with mucous membranes or non-intact skin. Parenteral exposure means: Exposure occurring as a result of piercing the skin barrier through needlesticks, cuts, or abrasions.

According to federal and international regulations, all personnel who are involved in the packaging and shipping of infectious materials are required to have training in these procedures. This includes anyone who: Packages, labels, and/or marks the package Is responsible for classifying the materials Is responsible for documenting the package contents on a shipping declaration form, air waybill, etc. Transports hazardous materials by vehicle, plane, or vessel

Training records must include: Employee name Most recent date trained Description of training Description, copy, or location of training materials Name and address of trainerThese records must be maintained throughout employment and 90 days thereafter, according to the US Department of Transportation (DOT). IATA and some laboratory regulatory agencies, including the College of American Pathologists (CAP), require repeat of training every two years. DOT requires training every three years. You will be able to print a certificate when you have completed this course that will certify your completion of training for packaging and shipping Division 6.2 (infectious) materials.

Hazardous material classifications are consistent across all agencies who regulate commercial shipping and are based on criteria developed by the United Nations (UN) Committee of Experts working with the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), medical professionals, microbiologists, transportation professionals, and packaging technical experts. These requirements can be found in the 13th and 14th editions of the United Nations Recommendations for the Transport of Dangerous Goods, the 2005 - 2006 edition of the International Civil Aviation Organization Technical Instructions for the Safe Transport of Dangerous Goods by Air (ICAO Technical Instructions), and the International Maritime Organization (IMO) Dangerous Goods Code. The classification system for Division 6.2 Infectious Substances includes two catergories, known simply as Category A and Category B.

A category B infectious substance is not in a form generally capable of causing permanent disability or life-threatening or fatal disease in otherwise healthy humans or animals when exposure to it occurs. The proper shipping name and Identification number is:Biological substance, Category B, UN 3373

Laboratory specimens that are unlikely to cause disease and do not meet the criteria for category A or B substances are not subject to Division 6.2 regulations. Specimens for which the hazardous materials regulation (HMR) does not apply include human or animal samples (including, but not limited to, secreta, excreta, blood and its components, tissue and tissue fluids, and body parts) being transported for routine testing not related to the diagnosis of an infectious disease. This includes specimens that are being sent for: drug or alcohol testing cholesterol testing blood glucose level testing prostate specific antibody (PSA) testing testing to monitor kidney or liver function pregnancy testing tests for diagnosis of non-infectious diseases such as cancer biopsies

Triple packaging is required for category A substances.The image on this page illustrates the correct packaging scheme. Packaging must include: A watertight primary receptacle A watertight secondary packaging Absorbent material in sufficient quantity to absorb the entire contents. (This is not required if the infectious substance is a solid.) The absorbent material is to be placed between the primary receptacle and the secondary packaging An itemized list of contents, enclosed between the secondary packaging and the outer packaging Rigid outer packaging

Packages that contain category A substances must exhibit these labels.Proper shipping name and UN number(Category A label) or Hazard class 6 infectious substance label that includes this statement:In case of damage or leakage, immediately notify public health authority. In the US, notify the CDC 1-800-232-0124 UN package certification markOrientation arrows (if greater than 50 mL)Contact information (Shipper or Consignee Identification)The contact person (usually the shipper), referred to as the "responsible person" by IATA, must be someone who can be reached 24 hours a day, seven days a week (24/7) and can answer questions about the content of the package. The 24/7 number must reach that person directly and not a pager or answering machine/service. If the contact person that you are listing is the person receiving the specimen, be certain that the person is aware you are listing him/her as the contact person and has consented to it.

A category A infectious substance is in a form that is capable of causing permanent disability or life-threatening or fatal disease in otherwise healthy humans or animals when exposure to it occurs. Exposure would occur if the substance were released from its protective packaging and a human or animal came into contact with it. Therefore, it is critical that a category A infectious substance does not end up in the hands of an unauthorized individual who may purposely or unknowingly release the substance from its protective packaging and endanger humans or animals. Being aware of the people that you interact with in the process of packaging and sending category A substances is vital to the safety of the transport and prevention of a health disaster. An outsider with limited access and system knowledge could constitute a threat, but be aware that insiders could also be a threat, e.g., a disgruntled employee or a person who is angry with his or her supervisor or job or the government. Anyone desiring to do harm could potentially seize the opportunity to steal a hazardous material.Follow these precautionary procedures: When you are questioned about an infectious substance that you are packaging for shipment, it is important that you know the person that is asking AND that he or she has a need to know. If you do not know the person and if you are not aware that the person needs to know about the substance that is being shipped, do not answer the questions. You could refer him or her to your supervisor. Watch for unusual behavior. Secure the package until it is picked up. Check the identification of the courier who will be picking up the package. Use an intralaboratory chain of custody procedure if the specimens are tranferred within the facility or system. Track the package once it has been sent to be sure it arrives safely. Notify the Responsible Official or federal authority if the package does not arrive at its destination.

International Civil Aviation Organization. Technical instructions for the safe transport of dangerous goods by air. Doc 9284; 2005 - 2006 ed with amendment. National Laboratory Training Network. Packaging and shipping Division 6.2 materials. Georgia Public Health Laboratory; 2008. Sentinel Laboratory Guidelines for Suspected Agents of Bioterrorism. Available at: http://www.asm.org/ASM/files/LeftMarginHeaderList/DOWNLOADFILENAME/000000001202/Packing&Shipping11-18-05.pdf Accessed on February 13, 2009.US Department of Transportation Pipeline and Hazardous Materials Safety Administration. Transporting Infectious Substances Safely. Guide to changes effective October 1, 2006. Washington, DC; 2006.

Treat all blood & body fluids as if they were infectious.Always wear gloves during vascular access procedures.

Bloodborne pathogens are infectious micro-organisms which live in the bloodstream.You can be exposed to bloodborne pathogens if you are injured with a contaminated needle.You can also be exposed if your mucous membranes, including eyes, mouth, or the inside of your nose come into contact with contaminated body fluids.

Potentially infectious body fluids include: Blood, Semen, Vaginal Secretion, Peritoneal, pericardial and pleural fluids, and Saliva Sweat and tears are not generally considered infectious. It is important to remember that bloodborne pathogens are not transmitted by casual contact, like a handshake.

The safety of both the phlebotomist and patient is of utmost concern at all times. In the unfortunate event of an accidental needlestick or if you get blood or other potentially infectious materials in your eyes, nose, mouth, or on broken skin, immediately flood the exposed area with water and clean any wound with soap and water or a skin disinfectant if available. Report this immediately to your employer and seek immediate medical attention. It is imperative that the phlebotomist follow facility protocol for reporting the incident. This ensures prompt treatment for the injury. The facility procedure must be followed whether the accidental puncture was from a clean or contaminated needle.The single most important element to prevent an accidental needlestick is for the phlebotomist to fully concentrate during every procedure. Keeping your mind on the task at hand contributes to a successful and safe result.

The basic laboratory skills that you will need to do a semen analysis include: Using a microscopePerforming manual cell counts and doing calculations to determine the concentration of those cells per milliliter of fluidMeasuring volumeMeasuring pHMeasuring viabilityKnowledge of OSHA regulations for handling potentially infectious human fluids

The Mycobacterium tuberculosis organism is spread through infectious droplet nuclei.When a person infected with pulmonary tuberculosis coughs, sneezes, shouts, or sings, the infectious particles are expelled into the air.The risk of infection is related to both concentration of infectious droplet nuclei and duration of exposure.

Biosafety level (BSL) 3 practices, safety equipment, and facility design and construction are applicable to microbiology laboratories that work with indigenous or exotic agents with a potential for respiratory transmission, and which may cause serious and potentially lethal infection. If the laboratory is propagating and manipulating cultures for M. tuberculosis, BSL 3 practices, containment equipment, and facilities are required. Nonaerosol-producing manipulations can be performed using BSL 2 practices, containment equipment, and facilities. At biosafety level 3, laboratory manipulations should be performed in a Class l or Class ll biosafety cabinet (BSC) or other physical containment device. Secondary barriers include controlled access to the laboratory and ventilation requirements that minimize the release of infectious aerosols from the laboratory. Secondary barriers should include self-closing double-door access and negative airflow into the laboratory. Exhausted air must not be recirculated.

The following pages in this presentation includes a series of white blood cell abnormalities that may be identified in a peripheral blood smear. Many of the cases will simulate the practice of a peripheral smear review by a hematology morphologist. He/she must asses what responses in patient care may be triggered by the clinician attempting to interpret the reported findings on a peripheral smearObservations of white blood cell abnormalities in the peripheral blood smear should be reported so as to direct the physician to an immediate specific diagnosis, such as: (1) atypical lymphocytes suggesting infectious mononucleosis rather than leukemia, (2) toxic granules in neutrophils as in acute infections, or atypical granules suggesting a genetic disorder, (3) an unusual mix of cells, such as too many or too few neutrophils, monocytes, or other myeloid cells, and (4) the presence of giant platelets, myelocytes, or other cells suggesting a myelodysplastic syndrome.In summary, laboratory data should be presented to clinicians in a user friendly way to promote effective decision making. The design of the data base of information must be directed toward providing clinically helpful information clearly and quickly in order to facilitate appropriate action in terms of optimizing patient care outcomes.d

The presence of atypical inclusions within the cytoplasm of neutrophils and other leukocytes should lead to a clinical investigation of the setting for these findings.Atypical neutrophil inclusions may be seen in the following disorders: Chediak-Higashi syndrome, May-Hegglin anomaly, Alder-Reilly anomaly, Fechtner , Sebastian, Epstein and Alport-like syndromes and in infectious and toxic conditions (in the form of Doehle bodies).Although a specific entity may not be evident from examination of the peripheral blood alone, it is important that hematology technologists include a comment reporting on the presence of these inclusions or granules. A clinical investigation with further hematologic and genetic studies may then appropriately be considered.Many of the disorders with atypical neutrophil cytoplasmic granules are also associated with platelet abnormalities, particularly giant platelets (lower photograph).Therefore, when atypical granules are recognized, scanning of the peripheral blood smear for atypical platelets may be revealing. These observations serve as readily identifiable markers for acquired and genetic human maladies, and as a guide for unraveling the reasons for a patient's suffering and impaired health.

A 14 year-old boy came to the physician's office with a sore throat that progressively worsened over a three day period. His posterior pharynx was swollen ,shiney and erythematous. The boy complained of pain on swallowing. His temperature was 98.5F. A rapid direct streptococcal antigen test was positive. However, his symptoms did not subside over the next two days while on antibiotic therapy. Anorexia and nausea were persistent and compounded by a frontal headache. Cervical lymph nodes became noticeably enlarged. The results of the CBC were: WBC 11.9/mm3 with 17% segmented neutrophils, 5% bands, 72%(60% atypical--see photograph)lymphocytes and 6%monocytes. All red cell findings were normal. A monospot test was positive. This is a case of group-A streptococcal infection superimposed on infectious mononucleosis. Symptoms subsided in 3 weeks following completion of the antibiotic therapy.