| Review 2 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 | View Page |
| Review 2 Citron DM. Appelbaum PC.:
How far should a clinical laboratory go in identifying anaerobic isolates, and who should pay?
Clinical Infectious Diseases. 16 Suppl 4:S435-8, 1993Identification of anaerobic bacteria in specimens from sites of infection due to mixed organisms can be time-consuming and expensive. Laboratories should limit anaerobic workups by testing only those specimens that have been properly collected and transported to the laboratory.Use of selective and differential media for initial processing can provide rapid and relevant information to the clinician. Anaerobes isolated from normally sterile sites and sites of serious infection should always be completely identified. Group-or genus-level identifications may suffice in other instances.The Bacteroides fragilis group of organisms should always be identified because of their virulence and resistance to many antimicrobial agents.Some of the other organisms that warrant identification include Clostridium septicum (associated with gastrointestinal malignancy); Clostridium ramosum, Clostridium innocuum, and Clostridium clostridioforme (which are resistant to antibiotics); Clostridium perfringens (a cause of myonecrosis and gas gangrene,potentially serious infection); anaerobic cocci (which may be resistant to metronidazole and clindamycin); and fusobacteria (which may be virulent and resistant to clindamycin and penicillin). | View Page |
| Review 2 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. | View Page |
| Review 1 Piscitelli SC., Shwed J., Schreckenberger P., Danziger LH.
Streptococcus milleri group: renewed interest in an elusive pathogen.
European Journal of Clinical Microbiology & Infectious Diseases.11:491-8, 1992The following review examines the bacteriological characteristics, epidemiology, pathogenicity and antimicrobial susceptibility of the "Streptococcus milleri group". "Streptococcus milleri group" is a term for a large group of streptococci which includes Streptococcus intermedius, Streptococcus constellatus and Streptococcus anginosus.Usually considered commensals, these organisms are often associated with various pyogenic infections including cardiac, intra-abdominal, subcutaneous and central nervous system infections, particularly with the formation of abscesses.Organisms of the "Streptococcus milleri group" are often unrecognized pathogens due to the lack of uniformity in classifications and difficulties in microbiological identification. Penicillin G, cephalosporins, clindamycin and vancomycin all possess activity against these streptococci.Use of agents with poor activity may promote infections with "Streptococcus milleri group" and allow it to exhibit its pathogenicity. An understanding of these organisms may aid in their recognition and proper treatment. | View Page |
| Review 2 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. | View Page |
| Review 1 Spencer RC.:
Invasive streptococcEuropean Journal of Clinical Microbiology & Infectious Diseases. 14 Suppl. 1:S26-32, 1995.Before the introduction of antibiotics, serious infections caused by Streptococcus pyogenes (Lancefield Group A streptococci) were common. Before World War II, this bacterium was responsible for as many as 50% of postpartum deaths and was the major cause of death in patients with burns. Also common were the sequelae of streptococcal infections-rheumatic fever and post-streptococcal glomerulonephritis.With the use of penicillin, however, Streptococcus pyogenes was believed to be virtually eliminated as a pathogen. The organism was consigned to the history books, but not for long.In the mid-1980s, focal resurgences of rheumatic fever began to be reported from different areas in the USA, such as Salt Lake City, Utah. In such communities, where increases in cases of rheumatic fever had been reported, the serotypes M-1, 3, 5, 6 and 18 were isolated which, on culture, produced characteristic mucoid colonies. At the same time, reports of increases in invasive streptococcal disease began to surface in both the USA and Europe.Two syndromes were described; invasive streptococcal infection, occurring in previously healthy children and adults, commonly associated with septicaemia resulting from a deep focus of infection such as bone or lung; and streptococcal toxic shock syndrome, involving a cutaneous focus, accompanied by necrotizing or bullous soft tissue changes. Septicaemia is rare in streptococcal toxic shock syndrome, but the most characteristic feature is one of rapidly progressing multi-organ failure. A high proportion of the strains of Streptococcus pyogenes associated with this condition are serotype M-1, and fatality rates approaching 50% have been reported. | View Page |
| Review 3 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. | View Page |
| National Labs 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. | View Page |
| In the LRN hierarchy, large organizations like the CDC, the United States Army Medical Research Institute for Infectious Diseases, and the Naval Medical Research Center are classified as | View Page |
| What if: Biological Attack 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. | View Page |
| In Case of a Biological Attack Listen to the radio for instructions from authorities on whether to evacuate or stay put. If told to stay inside, seek shelter in an internal room or a room with as few doors and windows as possible. Turn off all ventilation and as best as possible seal all openings in windows and doors. Continue to monitor the radio. Some biological attacks may be more immediately apparent than others. Monitor your radio, television, or medical alert for instructions from authorities regarding disease symptoms and how and where to seek medical attention. If you do come in contact with a visible, potentially infectious substance, you should remove and bag your clothes and personal items, wash yourself with warm soapy water immediately, and seek medical assistance. | View Page |
| You Are At Risk! As a healthcare worker, you come into contact with bloodborne pathogens. These are infectious organisms, usually viruses, which live in human blood and other potentially infectious body fluids.The most important ones are...
Hepatitis B Virus (HBV)
Human Immunodeficiency Virus (HIV)
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| Who is infected? 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, and mucous membranes as if they were infectious.That's what the term Standard Precautions means. | View Page |
| How long can HBV be spread? 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. | View Page |
| Blood needed for transmission The amount of blood needed to cause HBV infection is very small.One milliliter of blood contains up to 100 million infectious particles.Of the persons exposed to HBV by needle stick, 30% will get the infection. | View Page |
| Handling Specimens Work practice controls affect the transport of blood and other potentially infectious materials. | View Page |
| Transporting Specimens 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. | View Page |
| Gloves Must be Worn Gloves must be worn:
when there is a reasonable chance of exposure to blood, other infectious body fluids, mucous membranes, or nonintact skin,
during vascular access procedures, including phlebotomy,
or when handling contaminated items or surfaces.
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| Exposure Incident Even after taking all the proper precautions there is still a small chance of an exposure incident.Exposure incident:
Blood or another potentially infectious body fluid coming into direct contact with mucous membranes or nonintact skin.Parenteral exposure:
Needle stick or being cut by a contaminated sharp. | View Page |
| Venipuncture Standard precautions Treat all blood & body fluids as if they were infectious.Always wear gloves during vascular access procedures. | View Page |
| Important bloodborne pathogens The most important bloodborne pathogens are: Hepatitis B and C & Human Immunodeficiency Virus (HIV).
Hepatitis B is very infectious via the blood-borne route. 30% of needle-sticks from patients who are Hepatitis B will result in infection.
Hepatitis C is much more common in the United States.
HIV is rarely transmitted via needle-stick injury. Nevertheless, utmost care is needed, because of its very serious nature. HIV is not transmitted by casual contact.
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| What are bloodborne pathogens? 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.
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| Standard precautions Standard Precautions means treating all body fluids and substances as if they were infectious.
Since you can’t tell which specimen may carry a bloodborne pathogen, use appropriate infection control measures during all patient contacts & when handling all specimens.
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| Standard precautions continued 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.
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| How tuberculosis is spread 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. | View Page |
| Three levels of TB Infection Control Administrative controls reduce the risk of exposure to persons who might have TB disease.Environmental controls prevent the spread and reduce the concentration of infectious droplet nuclei in ambient air.Respiratory protection controls are for situations that pose a high risk of exposure to further reduce risk of exposure of HCWs to infectious droplet nuclei that have been expelled into the air from a patient with infectious TB disease. | View Page |
| Which of the following secondary barriers are recommended for microbiology laboratories that work with Biosafety level 3 agents (e.g., Mycobacterium tuberculosis)? | View Page |
| Biosafety Levels Laboratory workers who handle infectious materials in the microbiology laboratory should be aware of the work practices, safety equipment, and barriers that will protect them and others in the area from infectious agents. The Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) created guidelines to assist laboratories in developing safe practices based on the infectious agents that are handled. These guidelines are referred to as Biosafety Levels 1 through 4. Each increasing number represents increased risk, requiring more stringent work practice and increasingly protective safety equipment and barriers. A copy of the Guidelines can be obtained from the CDC or accessed online at:http://www.cdc.gov/OD/ohs/biosfty/bmbl5/bmbl5toc.htm | View Page |
| Biosafety Level 3 Biosafety level 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. Mycobacterium tuberculosis is assigned to this biosafety level. 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. | View Page |
| Match the letter representing the cell type with the condition in which increased numbers of the cell may be found in the peripheral smear. | View Page |
| An increase in peripheral blood monocytes with an appearance similar to the cell in the photograph is highly suggestive of infectious mononucleosis. | View Page |
| The upper photograph of a peripheral blood smear reveals RBC rouleaux formation. Nucleated cells evident in both upper and lower photographs comprise approximately 5% of the total white blood cell count. The most probable underlying condition is: | View Page |
| A peripheral blood smear illustrated by this photograph is highly suggestive of metastatic carcinoma. | View Page |
| Additional comments on this exercise 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 | View Page |
| The association of increased platelets accompanying neutrophilia and toxic granululation as illustrated in this photograph is called thrombocythemia. | View Page |
| WBC inclusions: summary 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. | View Page |
| A peripheral smear was submitted for morphology/clinical because of the number of monocytes as captured in the upper and lower photographs. This picture is consistent with each of the following conditions except: | View Page |
| Case history 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. | View Page |
| The large blue staining cells represented here in the photographs comprise 50% of the total white blood count.This picture is most consistent with: | View Page |