Comparison of non-culture-based methods for detection of systemic fungal infections, with an emphasis on invasive Candida infections

The accepted limitations associated with classic culture techniques for the diagnosis of invasive fungal infections have lead to the emergence of many non-culture-based methods. With superior sensitivities and quicker turnaround times, non-culture-based methods may aid the diagnosis of invasive fungal infections. In this review of the diagnostic service, we assessed the performances of two antigen detection techniques (enzyme-linked immunosorbent assay [ELISA] and latex agglutination) with a molecular method for the detection of invasive Candida infection and invasive aspergillosis. The specificities for all three assays were high (> or = 97%), although the Candida PCR method had enhanced sensitivity over both ELISA and latex agglutination with values of 95%, 75%, and 25%, respectively. However, calculating significant sensitivity values for the Aspergillus detection methods was not feasible due to a low number of proven/probable cases. Despite enhanced sensitivity, the PCR method failed to detect nucleic acid in a probable case of invasive Candida infection that was detected by ELISA. In conclusion, both PCR and ELISA techniques should be used in unison to aid the detection of invasive fungal infections.

‘Spiking’ as a rapid method for differentiation of Candida albicans from other yeast species

This paper describes a simple and rapid method for the differentiation of Candida albicans from other yeast species in primary cultures based on colonial morphology following incubation in carbon dioxide. The technique has superior sensitivity to the traditional germ-tube method and requires no additional laboratory tests. In a busy laboratory, this can result in significant savings in cost and time, as well as improvements in patient care.

Detection of Candida in concentrated oral rinse cultures by real-time PCR

The incidence of oral candidosis has increased in recent years, largely as a result of the emergence of human immunodeficiency virus infection and the more widespread use of immunosuppressive chemotherapy. This development has been associated with a need for more reliable methods for the detection of Candida. The present study assessed the performance of a real-time PCR and two block-based PCRs for the detection of Candida in 193 concentrated oral rinse culture (CRC) specimens. A total of 102 CRC specimens were positive by culture for Candida; and 96, 90, and 75 of these were also positive by real-time, N18-specific, and internal transcribed spacer (ITS)-specific PCRs, respectively. The five false-negative results by the real-time PCR were all non-Candida albicans positive by culture. Of the 91 culture-negative CRC specimens, 20, 41, and 44 were positive by the real-time PCR and the N18- and ITS-specific PCRs, respectively. All three PCRs detected fungal DNA in 8 culture-negative CRC specimens, with a further 30 being positive by two of the three PCRs. A total of 32 CRC specimens were Candida free by all methods. In summary, a real-time PCR that provides a sensitive, specific, and rapid alternative technique for detection of Candida in the mouth is described.

New developments in antifungal strategy

The increasing importance of invasive fungal infection as a cause of severe morbidity and mortality in immunocompromised patients has fuelled the development of new antifungal agents, including new triazole agents and echinocandins. Failure to diagnose fungal infection adequately has hampered the evaluation of these drugs in clinical trials. Consequently, the evidence base behind many prophylactic and empirical treatment strategies has been poor. Recent advances have improved diagnostic criteria and opened the way for more rational usage of these expensive preparations. The proven efficacy and improved safety profile of newer agents is a major advantage. Furthermore, better understanding of the immune response may allow novel strategies of adjunctive therapy and immunomodulation.

New antifungal agents

With the relentless increase in invasive fungal infections, particularly in critically ill and immunocompromised patients, it is good to know that there are new additions to the antifungal armamentarium. These include not only new formulations of existing drugs and the development of new triazole agents, but also the introduction of a new class of antifungal drug.

Management and outcome of bloodstream infections due to Candida species in England and Wales

This two-year prospective hospital population-based study of candidaemia is the first to be conducted in the UK. It was carried out on behalf on the British Society for Medical Mycology (BSMM) as part of the European Confederation of Medical Mycology (ECMM) epidemiological survey of candidaemia. Six hospitals in England and Wales acted as sentinel hospitals. Main outcome measures were hospital population-based incidence and 30-day mortality. There were 18.7 episodes of candidaemia per 100,000 finished consultant episodes or 3.0/100,000 bed days and 45.4% cases occurred in intensive care unit (ICU) patients. Candida albicans was isolated in 64.7% of confirmed cases. The majority of isolates were sensitive to standard antifungal agents, including fluconazole. The overall 30-day mortality was 26.4% and removal of the central venous catheter was associated with a significant reduction in mortality. In conclusion, the incidence of candidaemia in England and Wales is similar to that of the USA, the majority of isolates remain sensitive to commonly used antifungal agents and mortality associated with this infection appears to be falling.

British Society for Medical Mycology proposed standards of care for patients with invasive fungal infections

Outcomes for invasive fungal infections have greatly improved in the past decade, and several new antifungal drugs have been or will be licensed in the next few years. Early accurate diagnosis and appropriate treatment have major impact on survival. In a 1995 survey of laboratory practice in the UK for mycology, major disparities were seen, with many laboratories not undertaking even simple diagnostic procedures. Delays in processing and inadequate procedures for handling samples, incomplete or delayed reporting of results, or a combination of these, compromise the care of patients. In randomised trials of antifungal chemotherapy, optimum treatments and good alternatives for others have been defined for some infections. High-quality care requires a multidisciplinary approach to diagnosis and management. In this review, we propose microbiology, histopathology, radiology, and clinical auditing standards, with the evidence base for each reviewed. The standards are absolutes, and, therefore, provide a straightforward basis for improving services to patients if they are all implemented.

Detection of seven Candida species using the Light-Cycler system

Due to the limitations of classical methods for the detection of systemic fungal infections and the high mortality rates associated with these infections, it has become essential to develop a quick, sensitive and specific detection assay. By using the Idaho Technologies Light-Cycler system, a qualitative real-time PCR system has been developed for the detection of the leading causes of systemic infection within the genus Candida. The sensitivity of the assay was comparable to previously described PCR methods (1-5 c.f.u. ml(-1)) and, by the use of a single Candida probe, it was able to detect, but not differentiate between, seven species of Candida (Candida albicans, Candida dubliniensis, Candida glabrata, Candida kefyr, Candida krusei, Candida parapsilosis and Candida tropicalis). Single-round amplification on the Light-Cycler allowed rapid turn-around of clinical samples (within one working day) and it was shown to be more sensitive than classical procedures, exposing 39 possible systemic infections that were not detected by blood culture.

Preface

The clinical problems caused by life-threatening, deeptissue fungal infections affect many different medical and surgical specialities where immunosuppression through disease or therapeutic advance has created a substantial sub-category of patients at risk of mycosis. Amphotericin B remains one of the first-line agents for treatment of almost all systemic mycoses, but the agent in its conventional deoxycholate formulation carries a serious penalty in terms of nephrotoxicity. Novel, lipid-associated formulations of amphotericin B have been introduced to combat the toxicity problem without loss of therapeutic efficacy.

This supplement is based upon papers presented at an international symposium held in Australia on 8–9 July 2000. It focuses on AmBisome, a liposome-encapsulated formulation of amphotericin B, and draws together information on many general aspects of the diagnosis and treatment of deep tissue mycoses as well as providing a comprehensive set of reviews of all aspects of AmBisome —its pharmacology, toxicology, pharmacokinetics and clinical efficacy in a variety of mycoses and patient types. There is now considerably more clinical experience with lipid forms of amphotericin B than when the previous supplement on AmBisome was published by the Journal of Antimicrobial Chemotherapy in October 1999.1

Because the topic of the supplement is a formulation of an antifungal agent, not the agent itself, and because lipid-based formulations can vary in composition even when they are nominally prepared in the same way, we have taken the unusual step of referring to the various amphotericin B lipid formulations, and to ‘conventional’ amphotericin B-deoxycholate for injection, by their trade names.

The editors would like to thank Christine Burley of the JAC Editorial Office, and Regine Buffels of Gilead Sciences for their untiring support and assistance in the preparation of this supplement.

Reference

1. Speller, D. C. E. & Warnock, D. W. (Eds). (1991). Liposomal amphotericin B (AmBisome) in the treatment of systemic fungal infection. Journal of Antimicrobial Chemotherapy28, Suppl. B, 1–118.

Calibration of SeaWiFS. II. Vicarious techniques

We present an overview of the vicarious calibration of the Sea-Viewing Wide Field-of-view Sensor (SeaWiFS). This program has three components: the calibration of the near-infrared bands so that the atmospheric correction algorithm retrieves the optical properties of maritime aerosols in the open ocean; the calibration of the visible bands against in-water measurements from the Marine Optical Buoy (MOBY); and a calibration-verification program that uses comparisons between SeaWiFS retrievals and globally distributed in situ measurements of water-leaving radiances. This paper describes the procedures as implemented for the third reprocessing of the SeaWiFS global mission data set. The uncertainty in the near-infrared vicarious gain is 0.9%. The uncertainties in the visible-band vicarious gains are 0.3%, corresponding to uncertainties in the water-leaving radiances of approximately 3%. The means of the SeaWiFS/in situ matchup ratios for water-leaving radiances are typically within 5% of unity in Case 1 waters, while chlorophyll a ratios are within 1% of unity. SeaWiFS is the first ocean-color mission to use an extensive and ongoing prelaunch and postlaunch calibration program, and the matchup results demonstrate the benefits of a comprehensive approach.

Calibration of SeaWiFS. I. Direct techniques

We present an overview of the calibration of the Sea-viewing Wide Field-of View Sensor (SeaWiFS) from its performance verification at the manufacturer's facility to the completion of its third year of on-orbit measurements. These calibration procedures have three principal parts: a prelaunch radiometric calibration that is traceable to the National Institute of Standards and Technology; the Transfer-to-Orbit Experiment, a set of measurements that determine changes in the instrument's calibration from its manufacture to the start of on-orbit operations; and measurements of the sun and the moon to determine radiometric changes on orbit. To our knowledge, SeaWiFS is the only instrument that uses routine lunar measurements to determine changes in its radiometric sensitivity. On the basis of these methods, the overall uncertainty in the SeaWiFS top-of-the-atmosphere radiances is estimated to be 4-5%. We also show the results of comparison campaigns with aircraft- and ground-based measurements, plus the results of an experiment, called the Southern Ocean Band 8 Gain Study. These results are used to check the calibration of the SeaWiFS bands. To date, they have not been used to change the instrument's prelaunch calibration coefficients. In addition to these procedures, SeaWiFS is a vicariously calibrated instrument for ocean-color measurements. In the vicarious calibration of the SeaWiFS visible bands, the calibration coefficients are modified to force agreement with surface truth measurements from the Marine Optical Buoy, which is moored off the Hawaiian Island of Lanai. This vicarious calibration is described in a companion paper.

Severe infections after bone marrow transplantation

Bone marrow transplantation and stem cell transplantation have become standard therapies offering potential cures for a number of hematologic malignancies and immunologic disorders. Severe infection remains a life threatening complication after transplantation, contributes significantly to morbidity, and may necessitate admission to the ICU. It is estimated that between 20 and 40% of patients receiving bone marrow transplant will require ICU admission in the initial posttransplantation phase. Historically, survival rates after admission to the ICU are dismal, particularly if mechanical ventilation is required for respiratory failure. Other organ involvement worsens the prognosis still further and has led to proposals for rationing or restricting access to critical care units and supportive measures. Recent studies have reported small but significant improvements in outcome after critical illness. Whether this improvement is a result of changes in levels of supportive care or a more defined patient selection is uncertain. Moreover, risk factors identifying patients who will benefit most from intensive support are poorly defined. However, it is generally accepted that respiratory failure requiring invasive mechanical ventilation is associated with a poor prognosis in this patient group. Early involvement of intensivists in the management of critical illness in transplant recipients is likely to continue to improve survival in this group of patients.

Effects of Spectral Bandpass on SeaWiFS-Retrieved Near-Surface Optical Properties of the Ocean

A simple correction method to remove the spectral bandpass effects of the Sea-viewing Wide Field-of-view Sensor (SeaWiFS) on the derived normalized water-leaving radiances and ocean-near-surface chlorophyll concentration is developed and implemented in the SeaWiFS data-processing system. SeaWiFS has not only in-band response structures but also significant sensor out-of-band contributions. The effects of the SeaWiFS out-of-band contribution at the green bands is particularly significant for the derived normalized water-leaving radiances and therefore for the retrieved ocean-near-surface chlorophyll concentration. With the sensor spectral bandpass corrections, the low chlorophyll concentration is even lower in the clear ocean regions, whereas there are almost no changes for the oceans with a chlorophyll concentration of >0.2 mg/m(3).

Detection of meningococcal antigen by latex agglutination

Meningococcal meningitis and septicemia are serious infections with significant morbidity and mortality. A sensitive affordable test is required to provide evidence of meningococcal disease at the earliest opportunity to improve local management and give early warning of potential outbreaks of disease. Culture of organisms is considered the gold standard for diagnosis but is slow (24 h or more) and increasingly influenced by prior antibiotic treatment. Recently, the development of polymerase chain reaction (PCR) has improved diagnosis but this sensitive assay is costly, is not available at most primary care institutions and is not feasible for developing countries. Conventional latex agglutination (LA) enables rapid detection of bacterial antigen in cerebrospinal fluid (CSF) (1,2) and can also be used to test specimens of blood (3,4) or urine (5) and for serogroup determinations on primary cultures (6,7). We discuss here test-card agglutination and also describe a new technique based upon LA in an ultrasonic standing wave that retains the speed of direct antigen testing while significantly increasing sensitivity.

Approaches to antifungal therapy in the intensive care unit

The risk of fungal infection is increasing in intensive care unit patients and the spectrum of pathogens is changing. A number of new antifungal agents are becoming available, but their use in critically ill patients has not been assessed in randomized controlled trials. Furthermore, distinguishing colonization from infection is problematic in intensive care unit patients. Clinicians who are involved in the management of intensive care unit patients must remain vigilant and devise a risk-based antifungal strategy that is based on local experience and susceptibility patterns.

SeaWiFS transfer-to-orbit experiment

We present the results of an experiment designed to measure the changes in the radiometric calibration of the Sea-viewing Wide Field-of-view Sensor (SeaWiFS) from the time of its manufacture to the time of the start of on-orbit operations. The experiment uses measurements of the Sun at the manufacturer's facility to predict the instrument outputs during solar measurements immediately after launch. Because an onboard diffuser plate is required for these measurements, the experiment measures changes in the instrument-diffuser system. There is no mechanism in this experiment to separate changes in the diffuser from changes in the instrument. For the eight SeaWiFS bands, the initial instrument outputs on orbit averaged 0.8% higher than predicted with a standard deviation of 0.9%. The greatest difference was 2.1% (actual output higher than predicted) for band 3. The estimated uncertainty for the experiment is 3%. Thus the transfer-to-orbit experiment shows no changes in the radiometric sensitivities of the SeaWiFS bands--at the 3% level--from the completion of the instrument's manufacture to its insertion into orbit.

Rapid screening of natural products by high-resolution high-temperature gas chromatography

The crude ethanol extracts from the leaves of three Croton hemiargyrus hemiargyreus plants are fractionated by thin-layer chromatography, yielding five fractions. The fractions and the crude extract are analyzed by high-temperature high-resolution gas chromatography coupled with mass spectrometry (HT-HRGC-MS). Several natural products, including thermolabile components, can be characterized directly in the samples, such as alkaloids, terpenes, flavonoids, acids, alcohols, etc. The cold on-column technique proves to be appropriate for the injection of these thermolabile compounds. HT-HRGC-MS is shown to be a valuable tool and an alternative technique to classical phytochemical procedures for the simple and fast routine analysis of natural products in crude extracts.

Meningitis antigen detection: interpretation of agglutination by ultrasound-enhanced latex immunoassay

Detailed instructions for performance and interpretation of ultrasound-enhanced latex agglutination tests for the rapid identification of bacteria causing meningitis are described. This recently developed technique, which enhances the sensitivity of most latex immunoagglutination assays, has been studied mainly in the context of detection of antigens of meningitis-causing bacteria. The test concentrates on the Wellcogen bacterial antigen kit (Murex Diagnostics Ltd) that contains five latex suspensions specific for Haemophilus influenzae type b, Neisseria meningitidis ACYW135, N. meningitidis B/Escherichia coli K1, Streptococcus group B and Streptococcus pneumoniae. Light photomicrographs of positive agglutination are shown. Particular attention is paid to the appearance of the latex in negative control samples following exposure to ultrasound. Guidance is given on interpretation and assessment in clinical samples.

Predictors of hypothermia during spinal anesthesia

BACKGROUND

Body temperature often is ignored during regional anesthesia, despite evidence that hypothermia occurs commonly. Because hypothermia is associated with adverse clinical outcomes, it is important to recognize predictors of hypothermia and to monitor and control body temperature in patients at risk. The current study was designed to determine the predictors of core hypothermia in patients receiving spinal anesthesia for radical retropubic prostatectomy.

METHODS

Forty-four patients undergoing radical retropubic prostatectomy were studied. A lumbar intrathecal injection of 18-22 mg bupivacaine, 0.75%, with 20 microg fentanyl was given. No active warming measures were used other than intravenous fluid warming. The following clinical variables were assessed as potential predictors of core (tympanic) temperature at admission to the postanesthesia care unit: duration of surgery, average ambient operating room temperature, body habitus, age, and spinal blockade level.

RESULTS

The mean core temperature at admission to the postanesthesia care unit was 35.1 +/- 0.6 degrees C (range, 33.6-36.3 degrees C). Duration of surgery, ambient operating room temperature, and body habitus were not predictors of hypothermia. A high level of spinal blockade and increasing age were predictors of hypothermia. For each incremental increase in block level, core temperature decreased by 0.15 degrees C, and for each increase in age, core temperature decreased by 0.3 degrees C.

CONCLUSIONS

Although high-level spinal blockade has been associated with decreased thermoregulatory thresholds, no previous study has shown that a higher level of blockade is associated with a greater magnitude of core hypothermia in the clinical setting. As with general anesthesia, advanced age is associated with hypothermia during spinal anesthesia.

Measurement of serum antigen concentration by ultrasound-enhanced immunoassay and correlation with clinical outcome in meningococcal disease

The distribution of Neisseria meningitidis serogroup B and C polysaccharide antigen in blood and the prognostic significance of antigen concentration was examined by ultrasound-enhanced immunoagglutination of coated microparticles. Specimens (169 sera/plasma from 145 patients with confirmed meningococcal disease) were tested retrospectively. The ultrasonic immunoassay detected serum antigen in 136 samples from 112 patients. Titration of antigen-positive specimens allowed estimation of blood antigen concentration. The modal blood antigen titre was 1/16, corresponding to an estimated polysaccharide concentration of 0.85 microg/ml. The lowest mean blood antigen concentration found ultrasonically was 0.05 microg/ml; compared to the 1.98 microg/ml found by conventional latex agglutination, this represents an approximately 30-fold improvement in sensitivity. Three grades of outcome were correlated with the presenting antigen titre in 83 patients: (i) <2 weeks hospitalisation, (ii) > or =2 weeks hospitalisation and (iii) mortality. High polysaccharide concentrations correlated with mortality. Nine of 15 patients with a serum antigen titre of 1/64 or greater (> or =3.4 microg/ml polysaccharide) died, whereas no patient with titres equal to or less than 1/4 (< or = 0.21 microg/ml) died, including those patients in whom antigen was undetectable by ultrasonic immunoassay. Increasing antigen concentration significantly correlated with severity of outcome (P<0.001). Ultrasound-enhanced agglutination provides a rapid prognostic indicator by sensitive measurement of serum antigen level.

The diagnosis of ventilator-associated pneumonia using non-bronchoscopic, non-directed lung lavages

OBJECTIVES

(1)To assess the diagnostic utility of quantitative cultures of non-bronchoscopic lung lavage (NBL) in ventilator-associated pneumonia and evaluate the role of the Bacterial Index; (2) To assess the predictive value of NBL surveillance quantitative cultures in ventilated patients; (3) To evaluate the Clinical Pulmonary Infection Score (CPIS) system in ventilated patients.

DESIGN

A prospective comparison of NBL with bronchoscopic bronchoalveolar lavage and protected specimen brush.

SETTING

Three intensive care units in academic tertiary care centres.

PATIENTS

145 adults ventilated for 72 h, with and without clinical signs of pneumonia.

INTERVENTIONS

Sampling of lower airway secretions by NBL, bronchoalveolar lavage and protected specimen brush.

MAIN OUTCOME MEASURES

Diagnostic reliability of quantitative cultures, Bacterial Index and CPIS.

RESULTS

34 episodes of clinical ventilator-associated pneumonia were documented in 32 patients. 9 episodes were confirmed by concordant blood/pleural culture or post-mortem lung examination. Qualitative concordance of the predominant pathogen between sequential NBL: bronchoalveolar lavage and protected specimen brush was 83 %. Sensitivity and specificity of non-directed bronchial lavage at a threshold of 10(4) CFU/ml were 68 % and 70 % respectively (p = 0. 003) and were comparable with the bronchoscopic methods. However, the low positive predictive value of NBL indicates that quantitation in the absence of clinical signs is unlikely to be useful. Bacterial Index did not improve discriminatory power of quantitation compared with bacterial load of predominant organism. Mean CPIS for confirmed pneumonia cases was 8.4 +/- 1.01, significantly higher than for non-pneumonia observations (p = < 0.0001).

CONCLUSION

NBL is a simple, safe, cheap, readily-available method of diagnosing ventilator-associated pneumonia with comparable diagnostic accuracy to bronchoscopic techniques. Quantitation of respiratory tract cultures can exclude pneumonia in patients with equivocal clinical signs. The diagnostic threshold should vary depending on the length of ventilation, likelihood of pneumonia and antibiotic administration. The Bacterial Index is a flawed mathematical device that has no contributory role in pneumonia diagnosis. The CPIS has some diagnostic role in selected cohorts of ventilated patients.

Changes in the Radiometric sensitivity of SeaWiFS determined from lunar and solar-based measurements

We report on the lunar and solar measurements used to determine the changes in the radiometric sensitivity of the Sea-viewing Wide Field-of-view Sensor (SeaWiFS). Radiometric sensitivity is defined as the output from the instrument (or from one of the instrument bands) per unit spectral radiance at the instrument's input aperture. Knowledge of the long-term repeatability of the SeaWiFS measurements is crucial to maintaining the quality of the ocean scenes derived from measurements by the instrument. For SeaWiFS bands 1-6 (412-670 nm), the change in radiometric sensitivity is less than 0.2% for the period from November 1997 through November 1998. For band 7 (765 nm), the change is approximately 1.5% and for band 8 (865 nm) approximately 5%. The rates of change of bands 7 and 8, which were linear with time for the first eight months of lunar measurements, are now slowing. The scatter in the data points about the trend lines in this analysis is less than 0.3% for all eight SeaWiFS bands. These results are based on monthly measurements of the moon. Daily solar measurements using an onboard diffuser show that the radiometric sensitivities of the SeaWiFS bands have changed smoothly during the time intervals between lunar measurements. Because SeaWiFS measurements have continued past November 1998, the results presented here are considered as a snapshot of the instrument performance as of that date.

Ultrasound-enhanced latex immunoagglutination and PCR as complementary methods for non-culture-based confirmation of meningococcal disease

Preadmission administration of antibiotics to patients with suspected meningococcal infection has decreased the likelihood of obtaining an isolate and has stimulated development of rapid and reliable non-culture-based diagnostic methods. The sensitivity of the conventional test card latex agglutination test (TCLAT) for detection of capsular polysaccharide has been reported to be suboptimal. In the United Kingdom meningococcal DNA detection by PCR has become readily available and is now used as a first-line investigation. Recently, the performance of latex antigen detection has been markedly improved by ultrasound enhancement. Three tests for laboratory confirmation of meningococcal infection, (i) PCR assays, (ii) TCLAT, and (iii) ultrasound-enhanced latex agglutination test (USELAT), were compared in a retrospective study of 125 specimens (serum, plasma, and cerebrospinal fluid specimens) from 90 patients in whom meningococcal disease was suspected on clinical grounds. Samples were from patients with (i) culture-confirmed meningococcal disease, (ii) culture-negative but PCR-confirmed meningococcal disease, and (iii) clinically suspected but non-laboratory-confirmed meningococcal disease. USELAT was found to be nearly five times more sensitive than TCLAT. Serogroup characterization was obtained by both PCR and USELAT for 44 samples; all results were concordant and agreed with the serogroups determined for the isolates when the serogroups were available. For 12 samples negative by USELAT, the serogroup was determined by PCR; however, for 12 other specimens for which PCR had failed to indicate the serogroup, USELAT gave a result. USELAT is a rapid, low-cost method which can confirm a diagnosis, identify serogroups, and guide appropriate management of meningococcal disease contacts. A complementary non-culture-based confirmation strategy of USELAT for local use supported by a centralized PCR assay service for detection of meningococci would give the benefits of timely information and improved epidemiological data.