Bacteria with thick cell walls will produce a Gram-positive result. A large percentage of infants and toddlers are colonized. As these secretions pool in the oropharynx, bacteria that live in the respiratory tract can begin to accumulate along the endotracheal tube. However, their presence in such small numbers relative to other bacteria might then raise serious question about their relevance. Take a couple of long, deep breaths. Although lack of normal flora generally has negative effects, it does also result in an absence of dental caries and lower body fat. If an infected tick bites you, you could experience symptoms within a couple of weeks. Daniela Hermelin, MD Assistant Professor of Pathology, St Louis University School of Medicine; Associate Director of Transfusion Medicine, Director of Clinical Apheresis, St Louis University Hospital As mentioned above, Staph. Serum (1,3) beta-d-glucan level was not done. Cases in which Gram stain results did not match culture results were ones in which relatively small numbers of RBPs and large numbers of NRF were detected, so it was easy to overlook the RBPs. Sputum culture on blood agar showed scant growth in first quadrant only. We studied 120 patients hospitalized for CAP who provided a high-quality sputum specimen at, or soon after admission, using Gram stain, quantitative sputum culture, bacterial speciation by matrix-assisted laser desorption ionization time-of-flight, and viral polymerase chain reaction. This difference in the rate of viral coinfection was not significant (P=.26). Forty of 120 (33.3%) patients had PCR evidence for a viral infection, 14 (35.0%) of whom were coinfected with RBP; using different criteria, Falsey et al [22] found that, of 348 patients who were hospitalized for respiratory illness, a similar proportion (136 [39.1%]) had evidence for concurrent viral and bacterial infection. Gram positive bacteria. Patients whose sputum contained 105 colony-forming units (cfu)/mL of a RBP were categorized as having pneumonia due to a RBP [7, 1214]. In addition, the peripheral WBC count was lower in pneumonia due to NRF. Bacterial coinfection was present in 24 of 40 (60%) cases with viral detection: 14 cases with RBP and 10 with NRF. Infection by 2 RBPs occurred in 10 cases and by NRF together with RBPs in 13 cases. Search for other works by this author on: Can an etiologic agent be identified in adults who are hospitalized for community-acquired pneumonia: results of a one-year study, Community-acquired pneumonia requiring hospitalization among U.S. adults, Aetiology of lower respiratory tract infection in adults in primary care: a prospective study in 11 European countries, Efficacy and safety of intravenous-to-oral lefamulin, a pleuromutilin antibiotic, for the treatment of community-acquired bacterial pneumonia: the Phase III Lefamulin Evaluation Against Pneumonia (LEAP 1) Trial, Etiology of community-acquired pneumonia: increased microbiological yield with new diagnostic methods, Improved detection of respiratory pathogens by use of high-quality sputum with TaqMan array card technology, Comprehensive molecular testing for respiratory pathogens in community-acquired pneumonia, Microscopic and baceriologic analysis of expectorated sputum, The diagnostic value of sputum culture in acute pneumonia, Pneumonia and acute febrile tracheobronchitis due to, Bacteriology of the lower respiratory tract as determined by fiber-optic bronchoscopy and transtracheal aspiration, Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults, Integrated analysis of FOCUS 1 and FOCUS 2: randomized, doubled-blinded, multicenter phase 3 trials of the efficacy and safety of ceftaroline fosamil versus ceftriaxone in patients with community-acquired pneumonia, Diagnostic value of microscopic examination of Gram-stained sputum and sputum cultures in patients with bacteremic pneumococcal pneumonia, Validation of sputum Gram stain for treatment of community-acquired pneumonia and healthcare-associated pneumonia: a prospective observational study, Sputum gram stain assessment in community-acquired bacteremic pneumonia, Value of intensive diagnostic microbiological investigation in low- and high-risk patients with community-acquired pneumonia, Sputum Gram stain for bacterial pathogen diagnosis in community-acquired pneumonia: a systematic review and Bayesian meta-analysis of diagnostic accuracy and yield, Bacterial complications of respiratory tract viral illness: a comprehensive evaluation, Transtracheal aspiration in pulmonary infection, Diagnostic accuracy of transtracheal aspiration bacteriologic studies, Rothia bacteremia: a 10-year experience at Mayo Clinic, Rochester, Minnesota, Corynebacteria as a cause of pulmonary infection: a case series and literature review, Pneumonia among adults hospitalized with laboratory-confirmed seasonal influenza virus infection-United States, 20052008, Clinical significance of the infection-free interval in the management of acute bacterial exacerbations of chronic bronchitis, Acute bacterial exacerbations in bronchitis and asthma, Re-evaluation of the taxonomy of the Mitis group of the genus, Autopsy series of 68 cases dying before and during the 1918 influenza pandemic peak, The significance of mixed infections in pneumococci pneumonia, Comparison of Unyvero P55 pneumonia cartridge, in-house PCR and culture for the identification of respiratory pathogens and antibiotic resistance in bronchoalveolar lavage fluids in the critical care setting, Diagnosis and treatment of adults with community-acquired pneumonia. Using quantitative PCR, Gadsby et al [7] demonstrated an RBP in 87% of CAP; these authors did not use primers that could detect NRF. Spit out the sputum into your sample cup. Please check for further notifications by email. There is some evidence that children who are not exposed to a variety of microbes early in life or frequently take antibiotics display the effects of an altered microbiome later on such as allergies, metabolic disorders and obesity, and possibly even certain mental disorders. Streptococcus pneumoniae was identified by screening for sensitivity to optochin and verified by bile solubility (if colony morphology was suspicious but the optochin test was negative, bile solubility was done anyway). <>>> The median WBC count in peripheral blood of patients with pneumonia due to recognized bacteria (with or without viral coinfection) was 13100/mm3, compared with 11200 in patients with pneumonia due to NRF (with or without viral coinfection, P=.06) and 8400 in those with viral pneumonia alone (Table 5); in patients with viral infection, peripheral WBC count was significantly lower than in bacterial pneumonia (P=.01). (4) When NRF were implicated, Gram stains and cultures were similarly free of other organisms (Figure 2A and B). File TM Jr, Low DE, Eckburg PB, et al. Learn what its used for and what to expect. Normal respiratory flora include Neisseria catarrhalis, Candida albicans, diphtheroids, alpha-hemolytic streptococci, and some staphylococci. Typically, gram-negative organisms have the following the traits: The major difference is the outer lipid membrane. The only pathogenic Listeria bacteria is L. monocytogenes. Like bacilli, these bacteria form toxins that lead to serious conditions. Lessa FC, Milucky J, Rouphael NG, et al. The 2007 Infectious Diseases Society of America and American Thoracic Society (IDSA/ATS) consensus guidelines on community-acquired pneumonia (CAP) in adults recommend expectorated sputum specimens for hospitalized patients with signs and symptoms of pneumonia and any of the following conditions: Medical microbiology and infection at a glance. A final reading of the sputum Gram stain was made by 2 observers without knowledge of the culture results, and agreement was reached by consensus. B. anthracis spores produce the anthrax toxin, which causes serious illness. (2012). Ramanan P, Barreto JN, Osmon DR, Tosh PK. [QxMD MEDLINE Link]. Although only a minority of pneumonia patients produce such a sputum in timely fashion, the sensitivity and specificity of Gram stain and culture of such specimens for RBP have previously been shown to be quite good [1721]. Wait until youre ready to collect your sample before opening the lid. 4th edition. In a medical setting, a doctor can send a sample of your blood, urine, or tissue to a lab for Gram stain testing. fdc##LKaE/b{l=o( xncirrW}"Q5V 3=9J M*t"- 90W).N*BIEBbl@Eh8\T^A,3(bF!7Ijo@t`lOZAnZ ?H#Ti'Oh)v))~w@njTY>,YF]LpxpFI~` $\&DD@^o7*Y-CW UK>'{@cZn4pPOH!cEy+G3V X[-[ xg15f?^h}~T8B#h&>- e(-=w( z1Rv{! The placement of the tube disrupts the normal anatomy of the respiratory tract, and prevents the patient from swallowing, coughing or clearing mucus and other secretions normally. Gram stain testing is a method for classifying bacteria based on their cell wall. In some cases, bacterial pneumonia can be more severe and even life-threatening. The term cocci, which means sphere, indicates the bacteria are generally round. (B) Pneumonia due to Corynebacterium pseudodiphtheriticum. The test, which uses a microscope, was created by Hans Christian Gram in 1884. [6], Severe obstructive or structural lung disease, Positive urine antigen test for pneumococcus, Positive urine antigen test for Legionella (special culture media for Legionella needed), Updated IDSA/ATS guidelines from 2019 state that, with regard to CAP, sputum culture is recommended not only for adult patients with severe disease but also for all adult inpatients who have received empirical treatment for methicillin-resistant S aureus and Pseudomonas aeruginosa. Normally, they exist on our skin and mucous membranes without causing problems. The presence of normal upper respiratory tract flora should be expected in sputum culture. The most common pathogens detected with a sputum culture are bacteria such as Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, and Klebsiella species. The American Society for Microbiology Listeria and Corynebacterium species dont make spores. Your doctor can use the results to help diagnose the cause of respiratory symptoms. A nurse will help you cough up sputum. Final Identification of Bacterial and Viral Etiology in 120 Cases of Community-Acquired Pneumonia. 2007 Mar 1. Patients with a positive viral PCR who met criteria for RBP or NRF pneumonia were regarded as having viral/bacterial coinfection. Culture of the sputum on blood agar frequently reveals characteristic colonies, and identification is made by various serologic or biochemical tests. Like bacilli, these bacteria form toxins that lead to serious conditions. Wolff BJ, Bramley AM, Thurman KA, et al. In contrast to the normal composition of the gut microbial community, the microbiota of infants born by caesarean section tend to have a high proportion of bacteria normally found on the skin. Resp rate is 16 to 18 breaths per min. [8]. Bronchoscopy is a simple procedure that usually takes about 30 to 60 minutes. 4 0 obj Last medically reviewed on December 18, 2019. Mean values among groups were compared using analysis of variance. 2019 Oct 1. It allows scientists to determine whether an organism is gram-positive or gram-negative. If specimen is . Do not pool multiple samples in a 24-hr period. Cases in which PCR on a nasopharyngeal swab revealed a respiratory virus were diagnosed with viral pneumonia. You might feel slightly light-headed when you cough deeply, or feel discomfort in your lungs or throat. The quality of sputum samples is determined by the minimum number of squamous epithelial cells and polymorphonuclear leukocytes per low power field. White blood cells per milliliter in liquefied sputum were counted in a hemocytometer. Researchers found bacteria on laundry that was cleaned in consumer-grade washing machines at a German hospital. For example, little to no growth might indicate something odd going on if you haven't been taking antibiotics. %Tyk A respiratory virus was found in 40 (33.3%) of 120 cases of CAP. They might also give you a sedative to help you relax, or medication to put you to sleep, but general anesthesia isnt required. Under a microscope, gram-positive bacteria appear purple-blue because their thick peptidoglycan membrane can hold the dye. Blood cultures were uniformly negative in NRF pneumonia (it should be noted that blood cultures are generally negative in pneumonia caused nontypeable H influenzae or Moraxella). Its found in the cell walls of bacteria, and helps laboratory staff learn if bacteria are present in your sputum. Your doctor may also ask you to avoid eating and drinking anything the night before your procedure. Legal. C. difficile, also called C. diff, usually affects older individuals in hospital. In the area of health and medicine, flora is the term used to describe the microorganisms that exist on or within the . The CCI was significantly greater in patients with NRF pneumonia, consistent with the concept that these individuals were more susceptible to pneumonia caused by less virulent bacteria, and 32.3% of patients with NRF pneumonia had viral coinfection compared with 14.7% in patients with RBPs, suggesting that a second insult may be necessary to allow NRF to cause pneumonia. Streptococcus pneumoniae was present in 26 of 120 (21.7%) casesas the sole bacterial isolate in 20 (Figure 1A) and together with another RBP in 6. In general, other streptococci groups may cause foodborne illnesses with a sore throat. Retrieved from, Pneumonia can be preventedVaccines can help. Daniel M Musher, Sirus J Jesudasen, Joseph W Barwatt, Daniel N Cohen, Benjamin J Moss, Maria C Rodriguez-Barradas, Normal Respiratory Flora as a Cause of Community-Acquired Pneumonia, Open Forum Infectious Diseases, Volume 7, Issue 9, September 2020, ofaa307, https://doi.org/10.1093/ofid/ofaa307. What were common remedies you grew up with to take care of cold, flu, and respiratory problems? [1, 2, 3, 4, 5]. The bacteria and other microorganisms that normally inhabit a bodily organ or part: intestinal flora. Quantitative culture revealed 5107 Lactobacillus gasseri and 510<6 Candida albicans. Collect the expectorated sputum in a leak-proof sterile container. 1752 N St. NW This will help your body make more sputum. It works by interfering with the bacteriums peptidoglycan layer, which kills the organism. Chapot-Chartier MP, et al. West Sussex, UK: Wiley-Blackwell. These studies have all reported coinfections only with RBPs. Many species result in disease and require specific antibiotics. For instance, a persons blood will become bacteremic (contain bacteria) for up to three hours after brushing their teeth. [QxMD MEDLINE Link]. Abbreviations: NRF, normal respiratory flora; RBP, recognized bacterial pathogen. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. ; GRACE consortium. They may order it if you have symptoms of a respiratory infection that might be caused by bacteria. Overall, an etiologic diagnosis was established in 95.8% of cases. x=]sS5O))cA\5;L*{-6oeI+Q I(j@nZ?mjT'_n>owmWzl6Ul7?K~{0f2K2/K4O3._e#, ]rmnM(T! <> Haemophilus influenzae and S mitis (left). Most bacilli arent pathogenic to humans, but the following two can cause severe medical conditions. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. It assists in the diagnosis of respiratory infections, as indicated by the presence or absence of organisms in culture. Among our patients with CAP, streptococci in the mitis group, generally identified by MALDI-TOF as S mitis (oralis), were identified (with or without a respiratory virus) as the sole bacterial pathogen in 6 patients and together with other NRF in an additional 8 patients, thereby potentially implicating this group of organisms as the third most common bacterial cause of CAP (after S pneumoniae and H influenzae). Median colony-forming units per milliliter for S pneumoniae, H influenzae, M catarrhalis, and S aureus were 2106, 4106, 7107, and 3106, respectively, and, after final review, Gram stain results were consistent with quantitative bacterial cultures in all but 4 of 68 (5.9%) cases. Respiratory Viruses in 120 Cases of Community-Acquired Pneumonia. Viruses (e.g. Serious respiratory infections are a risk for all hospitalized patients, but are particularly common in the intensive care unit (ICU). The first introduction of microbiota to a human occurs at birth (a fetus in utero should be microbe-free). The night before you provide a sample, try to drink lots of fluids like water or tea. If you have an infection or chronic illness affecting the lungs or airways, it can make you cough up sputum . these two account for a very large percentage of what we see in pulmonary medicine. Gram-positive phages: From isolation to application. This chemical dye can stain thick peptidoglycan layers. Bacillus bacteria need oxygen to survive (aerobic), while Clostridia bacteria dont (anaerobic). Haemophilus influenzae was detected in 27 (22.5%) cases, alone in 21 (Figure 1B) and together with another RBP in 6. Intense prospective studies using conventional microbiologic techniques and viral polymerase chain reaction (PCR) have failed to establish an etiologic diagnosis in approximately one half of cases of community-acquired pneumonia (CAP) [15]. More recent calculations, however, result in a ratio closer to 1:1, with an estimated 1013 human cells and 1013 1015 bacterial cells. Although the bacterium most commonly associated with the intestines is E. coli, it is actually not the most numerous in the intestine. To learn more, please visit our. And the technician will also look for white blood cells in your sputum, which is a sign of infection. Symptoms depend on the specific. This includes: Enterococci are primarily found in the colon. All rights reserved. The Gram-positive Firmicutes (such as Lactobacillus and Clostridium) and Actinobacteria (including Bifidobacterium) can be equally numerous. (2013). By using our website, you consent to our use of cookies. The reading of Gram stain by the microbiology laboratory was mixed Gram-positive organisms, and the final culture report was normal respiratory flora. (C) Pneumonia due to Candida glabrata. These results support the hypothesis that, just as aspiration of RBPs cause pneumonia after colonization of the nasopharynx, in some proportion of cases, aspiration NRF that colonize the nasopharynx may do the same. The test result is negative. The Gram stain test can help doctors diagnose an illness. colonization can lead to bacteremia, meningitis or septic arthritis. American Society for Microbiology ("ASM") is committed to maintaining your One or more RBPs were identified in sputum from 68 of 120 (56.7%) patients (Table 1); representative Gram stains and quantitative bacteriologic results are shown in Figure 1. The intensity of the inflammatory response in the lungs, as measured by median WBC per milliliter in liquefied sputum, was slightly greater in pneumonia due to recognized pathogens than pneumonia due to NRF (1.7107 vs 1.0107 per mL, P=.04), and far greater when all bacterial pneumonias were compared with viral pneumonias (1.5107 vs 3.2106, P=.01). Then breathe deeply and cough hard until sputum comes up. : From your description, it sounds like the diagnosis was normal flora present. endobj DOI: Characteristics of gram-positive bacteria, cdc.gov/anthrax/medical-care/treatment.html, who.int/news-room/fact-sheets/detail/botulism, mayoclinic.org/diseases-conditions/anthrax/symptoms-causes/syc-20356203, ncbi.nlm.nih.gov/pmc/articles/PMC4184040/, info.achs.edu/blog/gram-positive-gram-negative-bacteria, ndhealth.gov/Disease/Documents/faqs/Strep%20Pneumo.pdf, Your Washing Machine Can Be a Home for Bacteria What You Should Know. A persons microbiota is fully established by about 3 years of age. Potential conflicts of interest. Many respiratory pathogens live normally in the host without causing disease. This is a soft, narrow tube with a light and magnifying glass on the end. (2019). The following organisms are the most prevalent. Organisms that are generally identified only as normal respiratory flora but met quantitative criteria (as defined below) were further studied by matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF). Approximately 25% of children between 3 months and 4 years of age are colonized, and 5-10%% of older and younger people. Manual of Laboratory & Diagnostic Tests (7th Edition): Fischbach, Frances Talaska. The significance of the presence of this organism in culture will rely heavily on the clinical picture, other diagnostic testing and predominance in culture. Gram positive vs. gram negative. In conclusion, this study shows that NRF, alone or with viral coinfection, cause approximately one quarter of cases of CAP and may also contribute to another 11% of cases caused by RBPs. Learn. In a sputum culture test, a laboratory uses a sample of this mucus to try to encourage the growth of any bacteria or other germs that may be causing an infection. Not surprisingly, NRF appeared to be less virulent than RBPs. bacilli and mod.amt of gram positive cocci.few wbc.concerns? Streptococcus pneumoniae and S mitis (right). Identifying one of these organisms as the cause of infection must be done in the context of clinical signs and symptoms of pneumonia*. few polys These criteria were used to stratify pneumonia into 6 etiologic groups: pneumonia due to (1) RBPs; (2) respiratory viruses; (3) coinfection by RBPs and a respiratory virus; (4) NRF; (5) coinfection by NRF and a respiratory virus; and (6) cause undetermined. Certain Clinical Features Related to Etiology. The skin and mucous membranes of the oral cavity, intestines, upper respiratory tract, and vagina have specific, permanent flora. Effect of the Deletion of icl1 Gene and icl2 Gene on the Growth Rate of Mycobacterium tuberculosis and the Specific Regulatory Mechanism Involved. We are deeply indebted to the technologists of the Microbiology Laboratory at the Michael E. DeBakey VA Medical Center, without whose gracious and expert assistance this work could not have been done. Common Gram-positive bacteria detected by the test include: Common Gram-negative bacteria detected by the test include: A normal test result means that few white blood cells and no bacteria have been found in your sputum sample, and your symptoms may be due to other causes. These bacilli are subdivided based on their need for oxygen. Are organisms present simply colonizing the endotracheal tube and surrounding airway without causing harm, or are they the cause of infection? The healthy sinuses are sterile. Majd Ibrahim, MD is a member of the following medical societies: American College of Physicians, American Medical AssociationDisclosure: Nothing to disclose. Patients admitted to the (ICU) are at a greater risk of developing nosocomial pneumonia than patients admitted to other wards in the hospital, and ventilated patients are at a 3-10 times increased risk of developing nosocomial pneumonia compared with those who are not ventilated. Metlay JP, Waterer G, Long AC, et al. Quantitative culture yielded 1.6107 Streptococcus pneumoniae per milliliter of sputum (right); the figure shows colony-forming units in 0.01-mL aliquots of sputum that had been diluted by 101 to 104 after an initial 1:2 dilution with 4% N-acetyl cysteine in 0.9% saline. Diagnostic accuracy of Xpert MTB/RIF Ultra and culture assays to detect Mycobacterium Tuberculosis using OMNIgene-sputum processed stool among adult TB presumptive patients in Uganda. Pneumonia caused by pathogens that do not grow on standard sputum culture media (eg, atypical organisms, viruses, anaerobes). Washington, DC 20036, 2023. The difficulty in diagnosing the cause of VAP comes from the fact that many of these organisms have the potential to cause disease. Sputum Gram stain and culture are indicated for all patients with hospital-acquired pneumonia. Keep coughing up sputum until the cup is filled to the marker, which should equal approximately 1 teaspoon. A normal Gram stain of sputum contains polymorphonuclear leukocytes, alveolar macrophages, and a few squamous epithelial cells. (A) Pneumonia due to Streptococcus mitis (oralis). Ogawa H, Kitsios GD, Iwata M, Terasawa T. Falsey AR, Becker KL, Swinburne AJ, et al. For diagnosing pneumonia due to NRF, we used more stringent criteria. Other NRF included viridans streptococci other than S mitis, Corynebacteria (Figure 2B), Lactobacillus sp, and Candida sp (Figure 2C). The most studied population of normal flora in the microbes living in the intestines, often referred to as the gut microbiota. Because of this difference, gram-negative bacteria are harder to kill. 200 (7):e45-e67. Gram-positive bacilli are further categorized based on their ability to make spores. 2023 Healthline Media LLC. One frequently cited statistic is that there are 10-100 times more bacterial than human cells in the body. Sometimes, severe cases of pneumonia can lead to: Early diagnosis can help your doctor prescribe a treatment plan, which may help improve your outlook. It is often contrasted with the term "fauna," which is used to describe the animal life of the same particular area. Can you please talk about of the common diseases for the respiratory system? Gadsby NJ, McHugh MP, Forbes C, et al. It leads to botulism, including: C. perfringens is usually associated with meat production and processing. Andrea Prinzi, Ph.D., MPH, SM(ASCP) is an infectious disease medical science liaison and works to bridge the gap between clinical diagnostics and clinical practice. Abbreviations: RBP, recognized bacterial pathogen. If you cant cough up enough sputum, try breathing steam in from boiling water, or take a hot steamy shower. We also acknowledge previous National Science Foundation support under grant numbers 1246120, 1525057, and 1413739. Blood cultures were positive in 6 (5.0%) cases, including 6 of 68 (8.8%) patients with pneumonia due to RBP and 0 of 31 (0%) due to NRF (P=.17). You can refrigerate it for up to 24 hours if needed, but you shouldnt freeze it or store it at room temperature. The following types are gram-positive cocci: Staphylococcus grows in grape-like clusters. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Generally, fluid management is required to treat conditions caused by toxins. There tends to be more bacteria present at this time and can help ensure accurate test results. These may include: B. cereus is a spore-forming bacterium thats found in the soil and some foods. Cultures of Mycoplasma are infrequently done; diagnosis is usually confirmed by a rise in antibody titer. Kulkarni AP, et al. <> The relationships between humans and bacteria are immensely complex. If tuberculosis is suspected, an acid-fast stain should be performed immediately, and the sputum cultured on special media, which are incubated for at least 6 weeks. microbiota) of the human body has been an area of increasing interest in both research and the popular media. If youre very sick, you may be in the hospital when your doctor orders a sputum Grams stain. During the procedure, crystal violet dye is applied to a sample of bacteria. Medscape Education, Challenging Case in Nontuberculous Mycobacterial Lung Disease: Going the Distance for Your Patient, 20021941994-overviewDiseases & Conditions, encoded search term (Sputum Culture) and Sputum Culture, Bacteria Causing Rare Disease Melioidosis Found in the United States, CLL Treatment: More Infections Among Real-World Patients, Bilateral Endogenous Bacterial Endophthalmitis. Colonization may be followed by microaspiration of bacteria into the lower airways, a regularly occurring event even in healthy adults [8]. Gadsby NJ, Russell CD, McHugh MP, et al. To minimize selection bias, on each day selected for study, we included every patient who met inclusion criteria.

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