Difficulties in differentiating Neisseria cinerea from Neisseria gonorrhoeae in rapid systems used for identifying pathogenic Neisseria species

Beyond the usual suspects: Reviewing infections caused by typically-commensal Neisseria species

OBJECTIVE

Few data outside of individual case reports are available on non-meningococcal, non-gonococcal species of Neisseria as causative agents of invasive disease. This review collates disease, organism and patient information from case reports on the topic.

METHODS

A literature search was performed examining articles describing diseases caused by non-meningococcal and non-gonococcal Neisseria.

FINDINGS

Neisseria present as opportunistic pathogens causing a wide variety of diseases including serious presentations, endocarditis being the most common condition described and N. mucosa the most commonly presenting pathogen overall. Disease may occur in otherwise healthy patients, although risk factors for infection include recent surgery, an immunocompromised state, poor oral health, and intravenous drug use.

CONCLUSIONS

Commensal Neisseria infections are rare but can present serious invasive diseases. Further research is required to determine why some species cause disease more than others or why some are inclined towards particular manifestations.

Recurrent Neisseria cinerea bacteremia secondary to cardiovascular implantable electronic device infection

We present the first case of cardiac implantable electronic device (CIED) infection due to Neisseria cinerea in a 64-year-old woman from Panama. She had a history of splenectomy, aortic valve stenosis requiring transcatheter aortic valve replacement (TAVR), and permanent pacemaker placement. She presented with relapsing N. cinerea bacteremia over a 3-month period. Transesophageal echocardiography revealed a lead vegetation in the superior vena cava. She was successfully treated with pacemaker removal and 2 weeks of IV antibiotic therapy. N. cinerea is an aerobic gram-negative commensal diplococcus typically found in the human nasopharynx. Infection in humans is rare with few case reports in the literature.

Colistin Sensitivity and Factor H-Binding Protein Expression among Commensal Neisseria Species

Many bacterial carriage studies utilize colistin-containing media to select for Neisseria meningitidis among the diverse human pharyngeal milieu. These studies commonly report the isolation of Neisseria commensal species, with carriage rates of around 1% or less typically observed. Here, we describe the isolation of N. cinerea and N. polysaccharea from pharyngeal swabs using nonselective agar and confirm they are unable to grow on colistin-containing media. We also demonstrated colistin sensitivity among archived Neisseria commensal strains, including N. cinerea, N. polysaccharea, N. mucosa, and N. subflava. The distribution of lptA among these strains indicated that, while the phosphoethanolamine (PEA) transferase encoded by this gene confers colistin resistance, other mechanisms may lead to reduced susceptibility in some lptA-deficient strains. The majority of the N. cinerea and N. polysaccharea isolates expressed medium to very high levels of factor H-binding protein (fHbp), an important meningococcal vaccine antigen. Sequence analysis showed that the commensal fHbp peptide variants were similar in sequence to fHbp variants typically observed among invasive meningococci. Altogether, these results not only suggest that Neisseria commensal strains could be carried at much higher rates than previously reported but also raise questions about the impact of protein-based meningococcal vaccines on these unencapsulated commensals. IMPORTANCE This study highlights the need for further work to accurately determine the pharyngeal carriage prevalence of Neisseria commensal bacteria (e.g., N. cinerea and N. polysaccharea) among the general population. Previous studies have clearly demonstrated the suppressive effect these commensal species can have on meningococcal colonization, and so the carriage prevalence of these species could be an important factor in the spread of meningococci through the population. Furthermore, the surface expression of the meningococcal vaccine antigen factor H-binding protein by many of these commensal strains could have important implications for the use of fHbp-containing vaccines. Carriage of these commensal species may influence the immune response to these vaccines, or conversely, the immune response elicited by vaccination may induce clearance of these potentially important members of the pharyngeal niche.

Neisseria Cinerea Bacteremia Secondary to a Retropharyngeal Abscess

Neisseria cinerea is a commensal bacteria of the human oropharynx, not thought to be pathogenic, and is rarely associated with serious infections, including bacteremia. Case reports involving invasive N. cinerea infections are uncommon in the literature. Retropharyngeal abscesses are unusual in adults, and are usually attributable to local trauma.Based on a review of the literature, Neisseria cinerea bacteremia secondary to a retropharyngeal abscess has not been described. We present a unique case of an elderly female without clear predisposing factors for a retropharyngeal abscess, who presented with a N. cinerea bacteremia and was found to have an asymptomatic retropharyngeal abscess.

A Critical Evaluation of the Factual Accuracy and Scholarly Foundations of The Witch-Hunt Narrative

We comment on The Witch-Hunt Narrative ( TWHN) by Cheit. As its first hypothesis, TWHN argues that most of the famous ritual child abuse cases of the 1980s and 1990s were not really witch-hunts at all. In response, we criticize the TWHN definition of a witch-hunt as overly narrow and idiosyncratic. Based on the scholarly literature, we propose 10 criteria for identifying a witch-hunt. We rate four well-known ritual child abuse cases with these criteria and show they were classic witch-hunts. As its second hypothesis, TWHN argues that most defendants in child ritual abuse cases were guilty or probably guilty. In response, we point out many instances in which TWHN has omitted or mischaracterized important facts or ignored relevant scientific information running contrary to its hypotheses. We conclude that TWHN is often factually inaccurate and tends to make strong assertions without integrating relevant scholarly and scientific information. Scholars should approach the book with caution.

Medical and legal implications of testing for sexually transmitted infections in children

Testing for sexually transmitted infections (STIs) in children presents a number of problems for the practitioner that are not usually faced when testing adults for the same infections. The identification of an STI in a child can have, in addition to medical implications, serious legal implications. The presence of an STI is often used to support the presence or allegations of sexual abuse, and conversely, the identification of an STI in a child will prompt an investigation of possible abuse. The purpose of this paper is to review the epidemiology of child sexual abuse, including the epidemiology of major STIs including Neisseria gonorrhoeae, Chlamydia trachomatis, syphilis, herpes simplex virus (HSV), Trichomonas vaginalis, and human papillomavirus, and the current recommendations for diagnostic testing in this population.

Dynamics of appearance and expansion of a prolyliminopeptidase- negative subtype among Neisseria gonorrhoeae isolates collected in Sydney, Australia, from 2002 to 2005

Recent studies have demonstrated a wide geographic circulation of isolates of Neisseria gonorrhoeae that fail to produce prolyliminopeptidase (PIP). Tests based on the production of this enzyme are important elements of a number of identification systems for gonococci. We documented the appearance, expansion, and contraction of subtypes of 165 PIP-negative gonococci detected in an extended and systematic sample of the 3,926 N. gonorrhoeae isolates collected in Sydney, Australia, from July 2002 to September 2005. Their appearance, peak, and decline followed an "epidemic" curve. At the peak of their prevalence in 2003, PIP-negative gonococci comprised 22% of all isolates. Closely related phenotypes accounted for 162/165 of the PIP-negative gonococci. Algorithms for confirmation of N. gonorrhoeae should take account of the temporal and geographic variability of gonococci by utilizing two or more distinct confirmatory methods.

Evaluation of commercial kits for the identification of Neisseria gonorrhoeae

Eight identification methods were evaluated against 100 isolates of Neisseria gonorrhoeae and 21 non-gonococcal Neisseria strains. The methods examined included four commercial biochemical kits, API NH, RapID NH, Gonochek II and Neisseria Preformed Enzyme Test (PET), three immunological kits, Phadebact Monoclonal GC test, GonoGen II and MicroTrak, and one in-house carbohydrate-utilization method, cystine trypticase agar (CTA) sugars. The percentage of isolates unambiguously identified as N. gonorrhoeae by each of the methods was as follows: API NH, 66 %; RapID NH, 64 %; GonoChek II, 66 %; Neisseria PET, 66 %; Phadebact Monoclonal GC OMNI test, 99 %; GonoGen II, 100 %; MicroTrak, 100 %; and CTA sugars, 96 %. The low sensitivity of the biochemical kits for the identification of N. gonorrhoeae was due to a lack of the enzyme proline iminopeptidase (Pip) in 34 % of the isolates examined. All the biochemical kits utilized the presence of this enzyme as a marker for N. gonorrhoeae. The Phadebact Monoclonal GC kit, GonoGen II, MicroTrak, CTA sugars and the API NH kit all exhibited high specificity, but non-gonococcal Neisseria were misidentified as N. gonorrhoeae using RapID NH (two strains), Gonochek II (11 strains) and Neisseria PET (11 strains). Whilst the isolates examined in this study may not be truly representative, they do indicate that N. gonorrhoeae isolates lacking the enzyme Pip can give anomalous results when using commercially available biochemical tests and that some non-pathogenic Neisseria species are still being misidentified using some biochemical kits. This further reinforces the recommendation that any dubious biochemical result should be confirmed with an immunological test.

Tricuspid valve endocarditis due to Neisseria cinerea

Reported here is a case of infective endocarditis caused by the saprophytic species Neisseria cinerea. To the best of our knowledge, this etiology has not been documented in the medical literature previously. The patient was an intravenous drug addict who developed tricuspid endocarditis with lung embolism. The disease was cured after treatment with ampicillin/clavulanate that was changed to ceftriaxone after an embolic event.

Evaluation of the BactiCard Neisseria for identification of pathogenic Neisseria species and Moraxella catarrhalis

The BactiCard Neisseria (Remel, USA) is a chromogenic enzyme substrate system for identifying Neisseria gonorrhoeae, Neisseria meningitidis, Neisseria lactamica, and Moraxella catarrhalis. The identification system consists of a card with four test circles impregnated with chromogenic substrates for indoxyl butyrate esterase (IB), prolyl aminopeptidase (PRO), gamma-glutamyl aminopeptidase (GLUT), and ss-galactosidase (BGAL). These substrates permit the identification of Moraxella catarrhalis, Neisseria gonorrhoeae, Neisseria meningitidis, and Neisseria lactamica, respectively. After hydration of the circles with buffer, colonies from growth on selective media or a subculture are applied to the four circles. IB and BGAL reactions are read for a blue-green color after 2 and 15 min, respectively. PRO and GLUT reactions are read at 15 min for a red color after addition of a developer reagent. Identifications obtained with the BactiCard Neisseria were compared with those obtained using conventional procedures for 558 isolates in a blinded fashion. The BactiCard Neisseria identified 100% of 254 Neisseria gonorrhoeae, 100% of 125 Neisseria meningitidis, 53 (98.2%) of 54 Neisseria lactamica, and 123 (98.4%) of 125 Moraxella catarrhalis isolates. The BactiCard Neisseria is an accurate and rapid system for identification of these microorganisms in the clinical laboratory.

Comparative evaluation of AccuProbe culture identification test for Neisseria gonorrhoeae and other rapid methods

The AccuProbe chemiluminescent culture identification test for Neisseria gonorrhoeae (Gen-Probe Inc., San Diego, Calif.) was assessed in a comparative evaluation with other rapid methods by using 269 isolates of oxidase-positive, gram-negative diplococci. Chemiluminescence was read with a PAL luminometer, and results were expressed as PAL light units (PLUs): the cutoff value for a positive identification was 1,500 PLUs. All 200 isolates of gonococci confirmed by carbohydrate utilization and serotyped with monoclonal antibodies were identified correctly by AccuProbe on initial testing. The API Quadferm system (Bio Merieux, Marcy l'Etoile, France) identified 95% (n = 190) of the gonococci correctly on initial testing and 99.5% (n = 199) on repeat testing, while the Phadebact Monoclonal GC test (Kara Bio Diagnostics AB, Huddinge, Sweden) identified 95.5% (n = 191) of the gonococci on both initial and repeat testing; 8 of the Phadebact-negative isolates were all of the same rare serovar (serovar 1B-17). The mean PLU for the gonococcal isolates was 9,014 (range 2,264 to 10,845) compared with a mean of 51 (range, 8 to 109) for the 69 nongonococcal isolates. We conclude that the AccuProbe culture confirmation test provides a rapid and accurate objective means of identifying cultured N. gonorrhoeae isolates.

Screening for pharyngeal gonorrhea in adolescents. A reexamination

The cost-effectiveness of screening for pharyngeal gonorrhea (PG) in an adolescent clinic population was examined in the context of dramatically decreasing prevalence. Chart review revealed that the apparent PG prevalence had decreased from 15/555 (2.7%) 8 years ago to 0/319 (0.0%) recently in the clinic population studied. The earlier high prevalence of PG probably represented poor laboratory test specificity. Cost analysis showed that only at very high prevalence of PG (greater than 8%) would pharyngeal screening be cost-effective unless PG can be shown to be an important source of genital infection. We concluded that continued pharyngeal screening is not justified in our clinic because prevalence is so low.

Branhamella catarrhalis: an organism gaining respect as a pathogen

Branhamella catarrhalis was formerly regarded as a common, essentially harmless inhabitant of the pharynx. This misapprehension was caused, in part, by confusion with another pharyngeal resident, Neisseria cinerea. The two organisms can now be differentiated by the positive reactions of B. catarrhalis in tests for nitrate reduction and hydrolysis of tributyrin and DNase. B. catarrhalis is currently recognized as the third most frequent cause of acute otitis media and acute sinusitis in young children. It often causes acute exacerbations of chronic bronchopulmonary disease in older or immunocompromised adults and is incriminated occasionally in meningitis, endocarditis, bacteremia, conjunctivitis, keratitis, and urogenital infections. Virulence-associated factors, such as pili, capsules, outer membrane vesicles, iron acquisition proteins, histamine-synthesizing ability, resistance to the bactericidal action of normal human serum, and binding to the C1q complement component, have been identified in some strains. beta-Lactamase producing strains, first detected in 1976, have risen to approximately 75% worldwide. Thus far, however, practically all American strains of B. catarrhalis remain susceptible to alternative antibiotics. A possible selective advantage of recent isolates is their reportedly heightened tendency for adherence to oropharyngeal cells from patients with chronic bronchopulmonary disease.

Evaluation of two commercial procedures for rapid identification of Neisseria gonorrhoeae using a reference panel of antigenically diverse gonococci

Two commercial tests for the rapid identification of Neisseria gonorrhoeae were evaluated. Two hundred seventy-nine organisms were tested, including 202 strains of N. gonorrhoeae. The Syva MicroTrak test results were less subjective but required a fluorescence microscope. The Phadebact Monoclonal GC OMNI Test required modification of the manufacturer's interpretive instructions in order to avoid cross-reactions, but it was a practical test. Specificities of both tests were 100%. Sensitivities of the Phadebact Monoclonal GC OMNI and Syva MicroTrak tests were 100% and approximately 100%, respectively.

Ophthalmia neonatorum caused by Neisseria cinerea

Neisseria cinerea is an organism that has only recently been implicated as a human pathogen. In this case, N. cinerea was identified as the cause of ophthalmia neonatorum (conjunctivitis) in a 2-day-old girl.

Evaluation of five rapid systems for the identification of Neisseria gonorrhoeae

Five commercial kit systems for the rapid identification of Neisseria gonorrhoeae were evaluated. The systems were tested with various pathogenic and saprophytic Neisseria and Branhamella strains having reactions typical for their individual species. Three systems (RIM-N, quadFERM, and RapID NH) were found to be 100% sensitive and specific.

Identification of Neisseria spp., Haemophilus spp., and other fastidious gram-negative bacteria with the MicroScan Haemophilus-Neisseria identification panel

The Haemophilus-Neisseria identification (HNID) panel (American MicroScan, Sacramento, Calif.) is a 4-h microdilution format system for identification of Haemophilus and Neisseria spp., Branhamella (Moraxella) catarrhalis, and Gardnerella vaginalis. The HNID panel was evaluated by using 423 clinical isolates and stock strains of these organisms, and HNID identifications were compared with those obtained by conventional methods. In addition, 32 isolates representing six genera not included in the HNID data base were tested to determine whether these organisms would produce unique biotype numbers for possible inclusion in the data base. The HNID panel correctly identified 95.3% of 86 Neisseria gonorrhoeae strains, 96% of 25 G. vaginalis strains, and 100% of 28 Neisseria lactamica strains and 48 B. catarrhalis strains. Only 64.7% of 68 Neisseria meningitidis isolates were identified correctly owing to false-negative or equivocal carbohydrate and/or aminopeptidase reactions. Among the Haemophilus spp., 98.8% of 83 H. influenzae strains, 97.1% of 34 H. parainfluenzae strains, and 80% of 15 H. aphrophilus and H. paraphrophilus strains were correctly identified. Eight strains of Neisseria cinerea, a species not included in the data base, produced profiles identical with those for B. catarrhalis and N. gonorrhoeae. Isolates of other species not included in the data base, including Eikenella corrodens, Kingella spp., and Cardiobacterium hominis, produced unique biochemical reaction patterns on the panel. Modification of interpretative criteria for certain tests, expansion of the data base to include other species, and suggestions for additional confirmatory tests will increase the accuracy and utility of the HNID panel.

Neisseria lactamica and Neisseria meningitidis share lipooligosaccharide epitopes but lack common capsular and class 1, 2, and 3 protein epitopes

Neisseria lactamica, a common human pharyngeal commensal, contributes to acquired immunity to Neisseria meningitidis. To define the surface antigens shared between these two species, we used monoclonal antibodies (MAbs) to study 35 N. lactamica strains isolated in various parts of the world for cross-reactivity with meningococcal capsules, outer membrane proteins, and lipooligosaccharides (LOS). No N. lactamica strain reacted significantly with MAbs specific for capsular group A, B, C, Y, or W, and we were unable to extract capsular polysaccharide from them. Only 2 of 33 strains reacted weakly with MAbs against class 2 serotype proteins P2b and P2c. None reacted with MAbs specific for meningococcal class 1 protein P1.2 or P1.16 or class 2/3 serotype protein P2a or P15. Most N. lactamica strains (30 of 35) bound one or more of seven LOS-specific MAbs. Two LOS epitopes, defined by MAbs O6B4 and 3F11, that are commonly found on pathogenic Neisseria species were found on 25 of 35 N. lactamica. Analysis by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and immunoblotting showed that the LOS of N. lactamica are composed of multiple components that are physically and antigenically similar to the LOS of pathogenic Neisseria species. Among four other commensal neisserial species, only Neisseria cinerea shared LOS epitopes defined by MAbs O6B4 and 3F11. Previous studies have shown that pharyngeal colonization with N. lactamica induces bactericidal antibodies against the meningococcus. We postulate that shared N. lactamica and meningococcal LOS epitopes may play an important role in the development of natural immunity to the meningococcus.

Utility of monoclonal antibody coagglutination to identify Neisseria gonorrhoeae

The Phadebact monoclonal gonococcus coagglutination test was evaluated with 1367 (996 anogenital and 371 pharyngeal) neisserial isolates from patients who gave positive diagnostic test results for Neisseria gonorrhoeae. The overall correlation with carbohydrate utilisation was 99.7%. The Phadebact test had a specificity of 100% (286/286) and a sensitivity of 99.7% (1077/1080). The three non-reactive strains were epidemiologically linked and were of a very unusual serovar. Unlike polyclonal antibody based tests, the monoclonal antibody test provides reliable identification of gonococci from anogenital and pharyngeal sites. Because non-reactive strains are rare, however, negative anogenital isolates from heterosexual patients should be tested biochemically. The use of two reagents comprising separate pools of monoclonal antibodies against gonococcal protein IA and IB permitted the identification of an appreciable number of double infections, which would otherwise have been missed. Genital, rectal, and pharyngeal isolates from the same patient should be identified individually.

Prevalence and persistence of Neisseria cinerea and other Neisseria spp. in adults

Neisseria cinerea is a commensal Neisseria sp. which was first described in 1906 but was subsequently misclassified as a subtype of Branhamella catarrhalis. N. cinerea resembles Neisseria gonorrhoeae in both cultural and biochemical characteristics and, thus, may also have been misidentified as N. gonorrhoeae. Of 202 patients whose oropharynges were colonized by Neisseria spp., N. cinerea was isolated in 57 (28.2%) patients, including 25 (30.1%) of 83 women, 22 (23.9%) of 92 heterosexual men, and 10 (37.0%) of 27 homosexual men in Seattle, Wash., in 1983 to 1984. N. cinerea was isolated from the urethra of only one (1.1%) patient. The oropharynges of many individuals were colonized persistently by strains of N. cinerea and other Neisseria spp.

Evaluation of eight methods for identification of pathogenic Neisseria species: Neisseria-Kwik, RIM-N, Gonobio-Test, Minitek, Gonochek II, GonoGen, Phadebact Monoclonal GC OMNI Test, and Syva MicroTrak Test

The performance of eight methods in identifying Neisseria species, particularly N. gonorrhoeae, was evaluated. These methods included four rapid carbohydrate utilization tests (Gonobio-Test, Neisseria-Kwik, RIM-N, and Minitek); the Gonochek II, a test which is based on the utilization of chromogenic substrates; and three monoclonal antibody tests (Syva MicroTrak, GonoGen, and Phadebact Monoclonal GC OMNI Test). In all, 182 isolates comprised in six species of Neisseria as well as Branhamella catarrhalis and Moraxella sp. were tested. Cystine-tryptic digest agar supplemented with sugars was included for reference purposes. In the carbohydrate utilization tests, the sensitivity and specificity of the Neisseria-Kwik and Minitek tests for the identification of N. gonorrhoeae were 100%. This compared with sensitivities and specificities, respectively, of 100 and 99.1% for the Gonobio-Test and 99.1 and 100% for cystine-tryptic digest agar sugars and the RIM-N test. The sensitivity and specificity of the Gonochek II test were 99.0 and 86.7%, respectively. Although most test kits did not claim to identify all Neisseria species, in several cases isolates of N. subflava were misidentified or could be misinterpreted as N. gonorrhoeae or N. meningitidis. With the monoclonal reagents, the Syva MicroTrak system was 100% sensitive and 100% specific. The GonoGen test was both 99.1% sensitive and specific, while the Phadebact Monoclonal GC OMNI Test was 99.1% sensitive but 91.2% specific. With this latter test, cross-reactions were observed with strains of B. catarrhalis, N. cinerea, and N. lactamica.

Evaluation of a ten-minute chromogenic substrate test for identification of pathogenic Neisseria species and Branhamella catarrhalis

A ten-minute chromogenic substrate test was evaluated for its ability to rapidly identify pathogenic Neisseria spp. and Branhamella catarrhalis. Identifications obtained with this system were compared to those obtained using conventional procedures. The test correctly identified 98.9% of 90 Neisseria gonorrhoeae, 98.3% of 60 Neisseria meningitidis, 96.2% of 26 Neisseria lactamica, and 100% of 36 Branhamella catarrhalis strains. Eight Neisseria subflava strains that grew on modified Thayer-Martin agar were prolyl aminopeptidase positive and were misidentified as Neisseria gonorrhoeae. Other strains of saprophytic Neisseria spp. also reacted with the chromogenic substrates. The system was accurate and reliable for identifying the commonly encountered pathogenic species. In light of recent reports describing new species and atypical Neisseria strains, however, careful attention to the salient features of both common and atypical organisms is necessary for proper use of rapid enzymatic identification tests.

Characterisation of Branhamella catarrhalis and differentiation from Neisseria species in a diagnostic laboratory

To distinguish Branhamella catarrhalis from Neisseria species a study of 140 strains was made on simple laboratory media, with particular reference to deoxyribonuclease (DNase) production, superoxol reaction, and growth characteristics. All 97 clinical isolates of B catarrhalis (58 of which were beta-lactamase positive) and eight strains of B catarrhalis from the National Collection of Type Cultures were DNase positive and superoxol positive. None grew on modified New York City medium, modified Thayer Martin medium, MacConkey agar, crystal violet blood agar, nor under anaerobic conditions. Of the 16 different non-pathogenic Neisseria species tested, all were DNase negative, eight (50%) were superoxol reaction negative, and 13 (81%) grew on crystal violet blood agar. Using simple laboratory media, DNase, and superoxol tests, it was possible to identify B catarrhalis and to distingish it from pathogenic and non-pathogenic Neisseria species.

Phadebact Monoclonal GC OMNI Test for confirmation of Neisseria gonorrhoeae

The Phadebact Monoclonal GC OMNI Test (Pharmacia Diagnostics, Piscataway, N.J.) is used for the definitive identification of Neisseria gonorrhoeae. In this test, boiled organisms are examined by using a 1-min coagglutination technique. A total of 776 Neisseria strains, confirmed to the species level by patterns of acid production from carbohydrates incorporated in cysteine-tryptose agar or morphologically consistent with Neisseria meningitidis and fluorescent antibody negative, were tested by the coagglutination technique. Of the 516 isolates of N. gonorrhoeae, 8 (1.6%) were negative with the OMNI Test. Of the 260 isolates of Neisseria spp. other than N. gonorrhoeae, none showed a positive coagglutination reaction. The Phadebact Monoclonal GC OMNI Test provided rapid, accurate identification of N. gonorrhoeae (sensitivity, 98.4%; specificity, 100%).

API QuadFERM+ with rapid DNase for identification of Neisseria spp. and Branhamella catarrhalis

The QuadFERM+ system (Analytab Products, Plainview, N.Y.), a 2-h carbohydrate degradation method for the identification of Neisseria spp., was evaluated along with a rapid DNase test for confirmation of Branhamella catarrhalis. QuadFERM+ identified 100% of 82 N. gonorrhoeae and 96% of 54 N. meningitidis strains. The two misidentified meningococcal strains were biochemically atypical and were also misidentified by the conventional method. Of 26 N. lactamica strains, 25 (96%) were correctly identified. Of 21 Neisseria spp., 14 (67%) produced carbohydrate reactions in agreement with the conventional procedure, and 7 strains produced detectable acid in the QuadFERM+ from maltose and sucrose but not glucose. All 9 N. cinerea and 30 B. catarrhalis strains were asaccharolytic by QuadFERM+. The rapid DNase test was positive for all B. catarrhalis strains and negative for all other organisms. Two beta-lactamase-positive N. gonorrhoeae strains and 25 (93%) of 27 beta-lactamase-positive B. catarrhalis strains were detected by the 2-h acidometric beta-lactamase test on the strip. QuadFERM+ with rapid DNase is a simple and easily interpretable method for identification of these organisms in the clinical laboratory.