2-3-10 Laboratory Diagnosis of Infection 1. Describe the types and sources of clinically significant bacteremias.

Most common sources of bacteremias: genitourinary tract, respiratory tract, abscesses, surgical wounds, biliary tract Most common types of bacteremias: !"I, acute #iral $epatitis %&, ', (, D) 2. List the factors that govern the sensitivity and specificity of blood cultures for diagnosis of bacteremia. *actors t$at go#ern sensitivity of blood cultures: determined by t$e rate of positi#ity of blood culture sets wit$in a series of blood cultures *or a culture series ta+en o#er a 2, $our period: "$e first culture $as a sensiti#ity of -0. "$e second culture $as a sensiti#ity of /0. "$e t$ird culture $as a sensiti#ity of //. "$us, 0ust doing one culture is not sensiti#e enoug$ to confirm1e2clude bacteremia 3t$er factures t$at influence sensiti#ity are prior treatment wit$ antibiotics %w$ic$ lowers positi#ity rate) and #olume of blood cultured %increasing #olume increases sensiti#ity4 infants1c$ildren re5uire smaller #olumes) *actors t$at go#ern specificity of blood cultures: t$ings t$at reduce specificity by increasing t$e c$ance of false positi#es are contamination of t$e flora by t$e s+in %6!M'78 367 cause of false positi#ies) and drawing blood cultures from indwelling #enous or arterial lines 3ne s$ould loo+ at blood cultures and decide w$et$er an organism is consistent wit$ t$e suspected infection and obser#e patterns of positi#ity of blood culture sets wit$in a series of cultures %contaminants are generally not found in repeat cultures) *alse positi#e rates in blood culture are around 1-, 9. "$us, specificity is about /9//. 3. State the principles of appropriate use and interpretation of blood cultures. & single blood culture $as a pre-test probability of 9., sensiti#ity of -0., specificity of /9., and post-test probability of ,:. "$us, it $as little diagnostic #alue, and single blood cultures s$ould be a#oided 3ccasionally, you will encounter patients wit$ a +nown I; drug $istory and pulmonary infiltrates <uc$ a patient may start wit$ a $ig$ pre-test probability %i e 90.) & single positi#e blood test will yield post-test probability of /,., and doing two more tests yielding positi#e results will not increase post-test probability by much %probably only t o about /9.) =owe#er, if t$e same patient gets a single negati#e blood test result, you s$ould continue doing more tests> ?it$ t$e first test, post-test probability drops to about 1@. "wo additional negati#e results will drop t$e post-test probability to an astounding 1. "$is effecti#ely e2cludes bacteremia, and t$e doctor s$ould start loo+ing for ot$er differential diagnoses

8ules of t$umb: "wo cultures may suffice if t$e pat$ogen suspected is different from usual contaminants and t$e pre-test probability is low to moderate %i e patient doesnAt $a#e I; drug $istory or gigantic abscesses) "$ree cultures are needed w$en pre-test probability is high or continuous bacteremia is suspected %i e infecti#e endocarditis) *our-si2 cultures are needed to e2clude bacteremia w$en pre-test probability ishigh and t$e anticipated organisms are common contaminants %can occur in prost$etic #al#e endocarditis) More cultures are also needed for patients w$o $a#e received antibiotic therapy within the preceding two weeks %antimicrobials lower t$e positi#ity rate) 4. Discuss the common types of UT and the associated symptoms. "$e most common causes of !"I are: 7nterobacteriaceae and gram negati#e aerobic rods %present in t$e normal colon and perineum) !"Is are di#ided based on anatomic site in#ol#ed: !ystitis: infection of bladder urethritis: infection of uret$ra pyelonephritis: infection of +idneys (ystitis and uret$ritis may be difficult to separate clinically and are often considered toget$er as infection of t$e lower urinary tract <ymptoms of !"I range from asymptomatic to catastrop$ic Most patients will present wit$ increased urination fre5uency, dysuria %pain wit$ peeing), uregency, suprapubic discomfort, cloudy1blood-tinged urine, flan+ pain, cost#ertebral angle tenderness %t$in+ +idneys), fe#er, and c$ills <uc$ symptoms will usually not $elp in differentiating cystitis and uret$ritis =owe#er, sudden onset of fe#er1c$ills, costo#ertebral tenderness, flan+ pain, and sepsis are indicati#e of pyelonep$ritis <epticemia complicating pyelonep$ritis may produce $ypotension, s$oc+ and deat$ ". Define the concept of #significant bacteriuria$. #significant bacteriuria$ denotes finding sufficient bacteria in urine to indicate acti#e infection rat$er t$an contamination "$e amount depends on t$e site of infection, manner of collection, and type of organism found %. Describe the #clean catch$ midstream voiding techni&ue used to collect urine specimens for culture. #clean catch$ midstream voiding techni&ue in#ol#es t$e following steps: 8etract fores+in or separate t$e labia (leanse t$e periuret$ral area wit$ two separate soap1water was$es %donAt use antiseptics because residual antiseptic may be carried by urine)

&#oid t$e first 29 mL of urine <ubse5uent urine is collected in a sterile container for culture "$e sample must be processed and cultured by 20-30 minutes from t$e time of collection, or be refrigerated "$is is to a#oid multiplication of bacteria %i e gram negati#e rods $a#e a doubling time of 20 minutes, so t$e concentration of bacteria would increase dramatically by -2 o#er one $our>) & concentration of 100,000 organisms1mL establis$es bacteriuria Intermediate concentrations of 1-10,000 can be interpreted as bacteriuria if t$e same organisms is isolated on repeat cultures and t$e patient $as pyuria 6ote t$at organisms ot$er t$an 7nterobacteriaceae %i e fungi, gram positi#e bacteria) may not reac$ 100,000

'. Define criteria for significant bacteriuria for diagnosing a UT (hen a gram)negative enteric organism is isolaged in a clean catch urine specimen vs specimens obtained by suprapubic aspiration or catheteri*ation. !rine obtained by suprapubic aspiration is usually so sterile t$at finding any organism in culture indicates significant bacteriuria In contrast, bladder cat$eteriBation can produce cultures ranging from sterile to containing less t$an 100 %allows for #ery low concentrations) <till, low concentrations of organisms obtained by cat$eter may represent significant bacteriuria +. Describe findings of urinalysis in UT and state the significance of pyuria or bacteriuria on urinalysis for diagnosis of UT . ,yuria is arbitrarily defined as 10C leu+ocytes per $ig$ power field "$e presence of wbc casts indicates pyelonephritis *inding bacteria in a gram stain of a drop of uncentrifuged fresh urine e2amined at 10002 mag indicates t$e presence of 100,000 organisms1mL "$e ca#eat is t$at t$e urine must be *87<=, processesed wit$out delay -. Describe the bacteriology of the most common UT s. 'acteriologic findings of urinalysis on !"I: most common organism are 7nterobacteriaceae, wit$ E. coli accounting for o#er -0. of uncomplicated cases Proteus, Klebsiella, Enterobacter, Pseudomonas, enterococci and Staph are found in patients w$o $a#e $ad pre#ious infection or instrumentation Serratia marcescens, Acinetobacter, Candida albicans, and Cryptococcus neoformans are found in t$e immunocompromised Chlamydia trachomatis is a rare one in !"I =owe#er, itAs easily o#erloo+ed because it does not grow in standard bacterial culture media> "$us, a sterile finding in a patient wit$ dysuria and pyuria %pus) s$ould raise suspicion for ($lamydia, and it s$ould be tested for using molecular tec$ni5ues &not$er differential w$en getting negati#e cultures is ! tuberculosis &t least t$ree morning specimens s$ould be cultured to e2clude tuberculous pyonep$ritis

1.. State the post)test probability of UT if the urine culture is positive and if t(o urine cultures are positive. Dost-test probability of one positi#e urine culture: /,. Dost-test probability of two positi#e urine cultures: /9. 11. List the ma/or etiologies of acute viral hepatitis. 7arly symptoms %w$ic$ are non-specific): low grade fe#er, malaise, fatigue, nausea, anore2ia <mo+ers lose taste for cigarettes Later Eicteric p$aseF: stools become lig$t1clay colored, urine becomes dar+, scleral icterus, and fran+ 0aundice "$is is all due to li#er in0ury from t$e $epatitis Li#er tests: ele#ated transaminase enBymes alanine aminotransferase 01LT2 and aspartate aminotransferase 01ST2, rising 10-100 times !L "ypically, &L"G&<" EL before <F &lso, al3aline phosphatase 01L,2 is moderately ele#ated 'ilirubin le#els are #ariable wit$ t$e $eig$t of ele#ation correlating wit$ t$e se#erity of li#er in0ury 12. Describe the diagnostic approach to serodiagnosis of the etiology of acute viral hepatitis. =epatitis & %=&;) <$ort incubation, fecal-oral transmission, comes only in acute form 1nti)415 g6 is detectable around w$en symptoms first appear and persists for 3w+s9mont$s Dositi#e Anti-"A# $g confirms the diagnosis for acute hepatitis A 1nti)415 g7 appears ,-: wee+s after illness A positive Anti-"A# $g% indicates past infection with and immunity to "A# Many adults test positi#e for anti-=&; IgH, and do not $a#e clinical illness consistent wit$ acute $epatitis "$us, IgH $as little utility for diagnosis of =ep & %positi#e result indicates eit$er recent or remote infection, negati#e result does not e2clude =ep &) =epatitis ' (aused by D6& #irus, $as a protein coat containing hepatitis 8 surface antigen %48s1g) and a core containing D6&, D6& Dolymerase, and hepatitis 8 core antigen %48c1g) (omes in bot$ acute and c$ronic forms, must differentiate between t$em using mar+ers %see IgM below) ='; can be isolated not only from blood but from all body fluids and e&creta Long incubation period of 90 days4 transmission is #ia parenteral means %accidental needle stic+s), close personal contact, and 63" really orally Detectable at 2-9 wee+s, prior to t$e onset of symptoms

48s1g is detectable before any enBymes li+e &<" or &L" present , and lasts for about 1-9 mont$s, pea+ing at t$e time of symptom onset 1nti)48s %antibodies to ='s&g) appear two to fi#e wee+s after t$e disappearance of ='s&g, during t$e con#alescent p$ase "$e inter#al between ='s&g disappearance and anti-='s appearance is +nown as t$e (indo( period 3nce present, anti-=' and anti-='s persist for t$e life of t$e patient "$us t$eir presence does not necessarily indicate acute =ep ' infection A better indicator of acute "ep ' infection is IgM form of the antibody 1nti)48c g6 usually becomes positi#e early on in t$e course of =ep ' and is present during t$e window period =owe#er, it can also appear during an acute e&acerbation of c$ronic =ep ', so anti-='c IgM by itself does not establis$ acute =ep '

=epatitis ( Li+e =ep ', =ep ( $as a long incubation period of 90 days (linical illness is also similar to =ep ' %massi#e $epatic necrosis) and comes in bot$ acute and c$ronic forms =owe#er, =ep ( produces c$ronic carrier states and c$ronic $epatitis muc$ more fre5uently t$an =ep ' 6early -9. cases of =ep ( progress to c$ronic Li+e =ep ', transmission #ia parenterally %piercing of s+in) and from close personal contact &lso watc$ for #ertical mot$erinfant transmission Dost-transfusion $epatitis is a problem wit$ =(; 1nti)4!5 is useful for detecting t$e c$ronic carrier state, w$ic$ is useful for pretransfusion blood testing 6ote t$at t$e presence of anti-=(; does not indicate immunity against "C# 'lood donations are screened by nucleic acid testing for =(; 86& D(8 for =(; 86& is used w$en anti-=(; tests are negati#e or as a confirmatory test for positi#e anti-=(; by 7I& &nti-=(; becomes positi#e by 1- wee+s after onset of clinical illness =epatitis D 8e5uires co-infection wit$ ='; Diagnosis relies on finding antibodies against =D;: anti)4D5 g6 in t$e acute p$ase and anti)4D5 g7 in t$e c$ronic p$ase Iey points: =&; and ='; account for t$e bul+ of &(!"7 #iral $epatitis "$e initial approac$ to suc$ serodiagnosis re5uires a combo of anti)415 g69 48s17 and anti)48c g6 tests If anti-=&; IgM is positi#e, t$e presumpti#e diagnosis is =ep & If anti-=&; IgM continues to be negati#e into t$e con#alescen p$ase, =ep & can be e2cluded If ='s&g is positi#e, t$e presumpti#e diagnosis is =ep ' &nti-='c s$ould also be positi#e &nti-='c may be t$e only test positi#e during t$e Ewindow periodF Dositi#e anti-='c IgM fa#ors acute =ep ', but watc$ out for c$ronic =ep ' reactivation t$at also leads to a rise in anti-='c IgM

If anti-=&; IgM, ='s&g, and anti-='c are all negati#e, =ep ( s$ould be considered 6ote t$at anti-=(; is not always positi#e in early acute =ep ( If post-transfusion hepatitis is suspected, initial testing s$ould include anti-=(;, ='s&g, and anti-='c IgM &nti-=&; IgM s$ould not be done "$ere is not point in testing for =ep D because it re5uires co-infection wit$ =';Junless ='<&g is also positi#e &nti-=D; IgM is indicati#e of acute &nti-=D; IgH is indicati#e of c$ronic