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IMMUNE RESPONSE TO MICROORGANISMS Antibody can also diminish infectivity of viruses by pre-
exposed during its lifetime. It is necessary to characterize cation required ensures optimal functional activity; charac-
painstakingly each polyclonal antibody to ensure that it is terization of the specificity needs to be done only once
detecting only the desired antigen. Still, the high percentage instead of each time an animal is immunized; MAbs gener-
(85 to 90%) of undesired antibodies increases the occurrence ally do not bind to human IgG Fc receptors; and they
of nonspecific binding of conjugated (but irrelevant) antibod- generally are unencumbered by nonspecificity or cross-
ies in test systems. reactivity (93).
Affinity-purified antibodies. To eliminate the antibodies of The disadvantages of MAbs are more subtle: a single
undesired specificity, the IgG fraction of a polyclonal anti- specificity does not enable effective cross-linking of antigens
body can be purified by binding to and eluting from an with antibodies so one MAb cannot be used in agglutination
insolubilized form of the antigen. This is performed by or precipitation reactions, although "cocktails" of several
column chromatography, using a matrix to which the immu- MAbs can overcome that limitation; murine MAbs do not
nizing antigen is coupled with a spacer molecule (an inert efficiently bind Clq to activate complement so are not useful
molecule that serves as a carrier). The spacer is covalently in assays that rely on complement activation; the single
coupled to the antigen and to the insoluble matrix to pre- antigenic determinant to which a MAb binds may not be
serve optimally the relevant antigenic determinants. The expressed under certain conditions of antigen presentation
hydrate allows long-term storage. Treated tanned RBCs irrelevant, but species-specific antibody. Coagglutination
coated with protein antigens have been used for detection of reagents have a much shorter shelf life than latex reagents
antibodies to toxins, e.g., diphtheria toxin or tetanus toxin due to deterioration of the bacteria upon storage. Many of
(16). Treponemal antibodies are detected by using trepone- the clinical laboratory applications of coagglutination have
mal antigens adsorbed to tanned RBCs in the micro-hemag- been essentially replaced by LA or immunoassay tech-
glutination assay for Treponema pallidum (MHA-TP) (98). niques.
HI assays. Hemagglutination inhibition (HI) assays used in
infectious disease serology are based on the capacity of Lytic Assays
certain viral antigens to agglutinate RBCs of selected species
spontaneously. Antibodies present in patient sera prevent CF. Complement fixation (CF) is a two-step procedure
the spontaneous agglutination of the RBCs, thus resulting in which uses complement to lyse indicator RBCs. The first
inhibition of agglutination, indicating a positive test for the step involves reacting antigen with antibody in the presence
presence of antibody. HI was the original method used to of complement in fluid phase. The complement used must be
detect antibodies to rubella virus (76). HI tests cannot from a standard source, e.g., rabbit serum which has been
distinguish between IgM and IgG classes of antibodies. appropriately collected and stored to preserve the hemolytic
Antigens
.*.,.D....
C MATRIX ~ ~ D MATRIX:
FIG. 2. Amplification immunoassay systems. (A) Indirect IFA (shown for comparison) uses 'labeled goat anti-human immunoglobulin as
the indicator molecule to detect bound patient antibody. (B) Double-indirect IFA uses 'labeled rabbit anti-goat immunoglobubin to detect
unlabeled goat anti-human immunoglobulin which has bound to patient antibody. Fewer patient antibody molecules can be detected with
amplification techniques, thereby increasing sensitivity. (C) Anti-complement IFA uses 'labeled F(ab')2 goat anti-human immunoglobulin as
the indicator molecule to detect guinea pig 'complement bound to patient antibody. (D) Avidin-biotin complex reactions use 6biotinylated goat
anti-human immunoglobulin to bind to patient antibody. The indicator system is the 'labeled avidin which binds to the biotin.
by well-trained technologists; and (iv) in indirect IFA, the microorganism, but also to evaluate whether the correct
same conjugate and dilution of patient sera can be used to and/or appropriate specimen was collected.
detect antibody to many different organisms or antigens. Treponema pallidum can be detected by direct IFA during
The disadvantages of IFA are that it: (i) requires fresh or early stages of the disease when the organisms are concen-
frozen tissue or cells (processed tissue or smears fixed for trated in the chancre (primary) or in the mucocutaneous
Grams stain are not usable); (ii) requires special equipment lesions (secondary). Direct IFA, using conjugate to T. palli-
and conditions (a fluorescence microscope and a dark room dum which has been absorbed with Reiter treponemes, has
for reading); (iii) is labor intensive, even when the substrate essentially replaced dark-field examination as a diagnostic
for indirect IFAs can be purchased (reagent dilution, multi- test for early stages of syphilis before reaginic antibodies are
ple incubation and wash steps, and cover slips are required); produced (4).
(iv) is subjective, requiring extensive training to read the Direct IFA has been used successfully for detection of
reactions and multiple controls to ensure test specificity and Legionnella spp. (22) and for many viruses, including herpes
sensitivity; and (v) has not been successfully automated. simplex virus (HSV) types 1 and 2, cytomegalovirus (CMV),
Immunohistochemical assays have been developed that RSV, influenza virus types A and B, parainfluenza virus 1, 2,
use enzyme-conjugated antibodies (e.g., horseradish perox- and 3, varicella-zoster virus (VZV), and adenovirus (D.
idase) with correponding substrates that yield different col- Scholes, J. R. Daling, A. S. Stergachis, S. P. Wang, and J. T.
ors when hydrolyzed to contrast with the colors of typical Grayston, Program Abstr. 28th Intersci. Conf. Antimicrob.
histochemical strains. Immunoperoxidase techniques may Agents Chemother., abstr. no. 1171, 1988). Enzyme-conju-
avoid the first two disadvantages of IFA, but the subjective gated antibodies have also been used to detect these micro-
interpretation and labor intensiveness of immunoperoxidase organisms in histologic tissue sections.
methods are even greater than with IFA. The systems Indirect IFAs for total antibody. Indirect IFA is used to
described below for direct and indirect IFA also apply to detect antibodies in patient sera (Fig. 2A). Standardized
immunoperoxidase techniques which have generally not antigens (organisms or virus-infected cell cultures) are fixed
been used for microbiology applications. to glass slides. Patient serum is diluted, layered over the
Direct IFAs. Direct IFA is used to detect antigens or substrate, and incubated to allow the antigen-antibody com-
organisms present in cells or tissues, using fluorochrome- plex to form. Unbound antibody is washed away, leaving
conjugated antisera (conjugate) specific for the antigen(s) in only bound antibody, which is then incubated with the
question. Microbiologic applications of direct IFA include fluorescent conjugate. When antibodies are present in the
detection of Chlamydia trachomatis elementary bodies in patient's serum, a second antigen-antibody reaction will take
columnar epithelial cells from the cervical canal, urethra, place, with the conjugate becoming the third layer on the
eye, or rectum (2). Direct IFA is useful not only to detect the slide.
138 JAMES CLIN. MICROBIOL. REV.
Labeled Anti-IgM
Patient antibodies
AnBige M
|B-; "if: 't' - . . -'. . '-"'.-' " .'-"'""-'...'.'..........
10
t
;
-
FIG. 3. Sources of error in specific IgM assays. (A) False-positive IgM assay due to patient RF binding to patient specific IgG. (B)
False-negative (or decreased intensity resulting in a borderline result) due to specific IgG competing with specific IgM for antigen-binding
For general testing, fluorescein-conjugated anti-human The IgM RF binds to these newly exposed IgG determinants.
immunoglobulin is usually anti-IgG with reactivity to both Unless separation methods are used, IgM RF cannot be
kappa and lambda light chains. This light chain reactivity distinguished from organism-specific IgM. Distinguishing RF
also detects antibodies of the IgA or IgM class or both, from organism-specific IgM is particularly important in neo-
which would be advantageous to detect all classes of anti- natal sera since a high percentage of congenitally infected
body reactive with microorganisms. neonates have detectable RF (31). False-positive IgM assays
The classic indirect IFA is the fluorescent treponemal due to heterotypic antibody responses between herpesvi-
antibody absorption (FTA-ABS) test. The antigen, T. palli- ruses may also be detected; i.e., patients infected with
dum Nichols, is fixed to glass slides. Prior to incubation with Epstein-Barr virus (EBV) or VZV may demonstrate CMV
the antigen, the patient's serum is absorbed with the non- IgM antibodies without evidence of CMV infection (56).
pathogenic T. pallidum Reiter. This absorption step signifi- IgM assays can also be subject to false-negative results if
cantly increases the specificity of the test (18); however, IgG antibody inhibits or competes with IgM for binding sites
false-positive reactions can still occur in patients with au- on the antigen (Fig. 3B). To avoid any possibility of false-
toimmune diseases (55) and hypergammaglobulinemia and in positive or false-negative reactions in most methods, IgG
those with Lyme disease due to immunological cross-reac- should be separated from IgM before the assays are per-
tivity with antigenic sites on the spirochetes (60). formed. Separation methods will be discussed below.
Other commonly performed indirect IFAs include The demand for assays that detect IgM antibodies to CMV
TORCH titers for evaluating the immune status of pregnant and HSV has recently increased due to infections in organ
women. TORCH tests include toxoplasma (TO), rubella transplant patients. The immunosuppressed state of trans-
virus (R), CMV (C), and HSV (H). These organisms cause plant patients increases their susceptibility to these oppor-
significant congenital infections resulting in stillbirths or a tunistic viruses since both humoral and cell-mediated immu-
spectrum of congenital diseases, although infections in nity are required for optimal viral immunity. Although
adults or children frequently are mild or even subclinical. specific IgG antibody may be present, it may not be as
Although once ordered as a panel of tests, current preferred effective in controlling viral infections in patients whose
practice is to perform only the specific test based on the cell-mediated immunity has been abrogated to prevent trans-
mother's clinical and exposure history. plant rejection. The production of IgM antibodies is T
Indirect IFAs for IgM antibody. If the test system is independent, i.e., does not require the presence or cooper-
designed to detect antibodies produced during acute infec- ation of T cells (77). IgM antibodies are produced in immu-
tion, the conjugate must be specific for IgM heavy chains nosuppressed patients and can be useful indicators of acute
with no light-chain or other heavy-chain reactivity. When infection.
congenital infections are suspected as the cause of stillbirth Amplification IFAs. The sensitivity of IFAs is limited by
or abnormalities of a newborn, indirect IFAs for IgM anti- the level of fluorescence detectable by the human eye. The
body should be used to detect IgM antibodies produced by optimal fluorescein/protein ratio of a polyclonal antibody
neonates. Unlike maternal IgG, IgM does not cross the conjugate is 2.5 (34), i.e., two to three fluorescein molecules
placenta, so any specific IgM antibodies detected would for each immunoglobulin molecule, which is satisfactory for
have been produced by the fetus in response to a congenital detecting high-density antigens such as bacterial or proto-
infection. Healthy newborns have 5 to 15% of the adult level zoan cell surface antigens. Directly conjugating antibodies at
of total IgM since the in utero environment is essentially a higher fluorescein/protein ratio results in significantly
sterile. If an organism is transmitted to the fetus from the increased nonspecific staining. Detection of low-density
mother during gestation, the fetus will develop its own IgM antigens or using MAbs or both may require a higher
response to the organism, which would be detectable in an fluorescein/protein ratio to achieve desired sensitivity.
IgM-specific indirect IFA. Indirect or double-indirect IFA has been used to amplify
False-positive and false-negative IFAs for IgM antibody. the fluorescent signal and improve sensitivity. If the antigen
Indirect IFAs for IgM antibody are subject to false-positive can be detected by direct IFA, indirect IFA increases the
reactions attributable to the presence of rheumatoid factor test sensitivity. If the test antibody is difficult to detect by
(RF) activity in the serum being tested (Fig. 3A). RF binds to indirect IFA, a double-indirect IFA would increase the
IgG when IgG is bound to antigen. The process of binding to sensitivity of detection (Fig. 2B). For example, if organisms
an antigen causes a confirmational change in IgG which were not visible in the T. pallidum direct IFA, the test could
exposes new antigens on the Fc region of the IgG molecule. be repeated with unconjugated rabbit antibody to the
VOL. 3, 1990 IMMUNOSEROLOGY OF INFECTIOUS DISEASES 139
treponemes, any unbound antibody could be washed off, and presence or absence of an antigen by a color change of liquid
the bound rabbit antibody could be detected by using a in a test tube, of a matrix on a stick or a paddle, or of a
fluorochrome-conjugated goat anti-rabbit IgG as the conju- matrix on a plastic reaction vial (e.g., ICON; Hybritech Inc.,
gate. Each rabbit IgG molecule contains multiple antigenic San Diego, Calif.). Most of these methods were developed to
sites which would be recognized by the goat anti-rabbit IgG. meet the demands for more rapid test results. The tech-
If four goat anti-rabbit IgG molecules bind to the rabbit IgG, niques were reported to be simple enough to be performed
the fluorescent intensity would be magnified four times. by nontechnical employees such as those in a doctor's office
Additional controls would need to be included in each assay setting. Although the price per test was high, the EIA
to ensure that the extra step did not decrease the specificity technology represented a cost savings to doctors' offices
while increasing the sensitivity. because the results were available before the patient left the
Complement-amplified IFA, also called anticomplement office. This was particularly beneficial for rapid testing for
IFA, has been used primarily for detection of herpesviruses streptococcal pharyngitis since the physician could prescribe
(74). Herpesvirus-infected tissue culture cells have an en- or withhold antimicrobial agents based on the test results
hanced expression of IgG Fc receptors that nonspecifically rather than providing empirical treatment or telephone fol-
a surface. The second layer of the sandwich is antibody from EIAs for IgM use either absorption with anti-human IgG (44)
the patient serum. The third layer is an enzyme-conjugated or aggregated human gamma globulin (AHGG) (47). Anti-
anti-human IgG or IgM. The indicator system is the color IgG binds to IgG in the sample, removing the IgG reactivity
change resulting from cleavage of the substrate by the to the antigen; if no IgG is available to bind to the antigen,
conjugated enzyme. The intensity of the color is directly RF would not be bound to IgG. AHGG neutralizes RF, but
proportional to the amount of patient antibody bound to the does not eliminate the potential for false-negative results by
antigen. IgG competing with IgM for binding sites on the antigen.
Another interesting approach to EIA systems is FAST One study that compared various methods of removing IgG
ELISA (Falcon Assay Screening Test ELISA; Becton Dick- from patient sera found anti-IgG treatment superior to
inson Labware, Oxnard, Calif.), which uses coated polysty- AHGG for eliminating nonspecific IgM activities without
rene beads attached by a tine to the lid of a microdilution impairing specific activities (31), but this finding needs
tray (39). The advantage of the FAST system is that the same confirmation. The simultaneous dilution of serum and ab-
dilution of patient sera, conjugated antibody, and enzyme sorption with either anti-IgG or AHGG, as used in several
substrate could be used for multiple tests by simply using commercial ETAs, is more efficient than ion-exchange sepa-
TABLE 1. Commercially available assays for TABLE 2. Commercially available assays for detecting
detecting VZV antibodies rubella virus antibodies
Method Antibodyb Company Method Antibodyb Company
Micro-ELISA IgG Diamedix Corp., Miami, Fla. Macro-ELISA IgG, IgM Abbott Laboratories Diagnostics
Div., Abbott Park, Ill.
IFA IgG Gull Labs, Salt Lake City, Utah
Agglutination Total Becton Dickinson Microbiology Sys-
Micro-ELISA Total, IgM Pharmacia ENI Diagnostics, tems, Cockeysville, Md.
IFA Total Fairfield, N.J.
Micro-ELISA Total Biotrol USA, Inc., West Chester, Pa.
Micro-ELISA IgG Sigma Diagnostics, St. Louis, Mo.
Micro-ELISA IgG, IgM Clinical Sciences, Inc., Whippany,
Agglutination Total Wampole Laboratories, Cranbury, N.J.
N.J.
Micro-ELISA IgG, IgM Diamedix Corp., Miami, Fla.
TABLE 3. Commercially available assays for TABLE 4. Commercially available assays for detecting
detecting CMV antibodies Toxoplasma antibodies
Method Antibodyb Company Method Antibodyb Company
Macro-ELISA Total, IgM Abbott Laboratories Diagnostics Macro-ELISA IgG, IgM Abbott Laboratories Diagnostics
Div., Abbott Park, Ill. Div., Abbott Park, Ill.
Agglutination Total Becton Dickinson Microbiology Agglutination Total Ampoor, Inc., Bridgeport, N.J.
Systems, Cockeysville, Md.
Micro-ELISA Total, IgM Biotrol USA, Inc., West Chester,
IFA IgG, IgM Bion Enterprises, Park Ridge, Pa.
Ill.
Micro-ELISA IgG, IgM Clinical Sciences, Inc., Whippany,
Micro-ELISA IgG, IgM Clinical Sciences, Inc., Whip- IFA Total, IgM N.J.
IFA Total, IgM pany, N.J.
IFA Total, IgM Diagnostic Technology, Inc.,
TABLE 5. Commercially available assays for anti-IgG with kappa and lambda light-chain reactivity. The
detecting HSV antibodies results can be expressed as an index relative to a negative
control or converted to standard international units, if estab-
Method' Antibodyb Company lished. Reference ranges have been established to correlate
HSV-1 and -2 to immune status as indicated by the reference methods (HI
combined for rubella virus; IFA for toxoplasma, CMV, and HSV).
IFA Total Clinical Sciences, Inc., Since the antigens have been extracted from organisms
Whippany, N.J. growing in tissue culture, ETAs should be evaluated for the
same factors that cause false-positive reactions in indirect
Micro-ELISA IgG, IgM Diamedix Corp., Miami, Fla. IFAs. These include nuclear and cytoplasmic autoantibodies
or cross-reactions with antibodies to other organisms in the
Stick-ELISA Total General Biometrics, San Diego, same genus or class. When EIAs are being considered to
Calif. replace indirect IFAs, they must be extensively validated to
determine the specificity and sensitivity of the proposed
IFA Total, IgM Gull Labs, Salt Lake City, Utah method compared with the existing method. There are
both pre- and posttransplant. If IgM antibodies are undetect- role in human disease. A positive ASO titer is useful in
able prior to transplant or prior to appearance of symptoms, establishing the diagnosis of acute rheumatic fever or acute
detection of IgM antibodies would confirm a currently active poststreptococcal glomerulonephritis which may occur
viral infection. Although specific IgM generally does not weeks or months after resolution of a streptococcal infection
persist for longer than 4 to 8 weeks, IgM antibodies to (51). ASO is produced by most strains of group A strepto-
viruses (especially CMV) have been reported to be detect- cocci and elicits a strong antibody response during 80% of
able for months or years after a documented infection due to pharyngeal streptococcal infections, but in only 25% of
the continued intracellular presence of the virus (42). Detec- streptococcal pyoderma skin infections (E. M. Ayoub, Clin.
tion of CMV IgM is convenient for diagnosing CMV infec- Immunol. Newsl. 3:107-109, 1982). An LA kit is available
tions in transplant patients; however, there is conflicting for ASO testing (Behring Diagnostics, Inc., Somerville,
evidence about whether the detection of CMV viremia is a N.J.) which yields results equivalent to those by the neutral-
better indicator of clinically significant infection (J. Nelson, ization assay but much more efficiently (unpublished obser-
F. Strie, C. Benson, J. Pottage, and H. Kessler, Abstr. Clin. vations).
Res. 464A, 1988; G. A. Storch, E. D. Spitzer, L. Marsano, Anti-DNase B is the assay most frequently used to confirm
TABLE 7. Commercially available assays detect the viral capsid antigen. IgM-EBV-viral capsid anti-
for heterophile antibodies gen-specific serologic tests should be performed to diagnose
Differential primary infections in young children and atypical disease in
Indicator particles absorption Company adults (70, 86). Since CMV can present with symptoms
similar to EBV, if EBV-IgM tests are negative, CMV-TgM
Horse RBC GPK only Access Medical Sys- should be evaluated. In cases of CMV negative- and EBV-
tems, Branford, viral capsid antigen-negative IM, or to detect antibody levels
Conn. from patients with EBV-induced malignancies, or to assess
Horse RBC (1 reagent) Blocked Ampoor, Inc., reactivation of EBV in immunocompromised patients, it
stroma Bridgeport, N.J. may be useful to evaluate the presence of antibodies to the
Horse RBC (3 reagent) GPK/BRBC EBV early antigen, restricted or diffuse (86).
LegioneUa antibodies. Antibodies to Legionella spp. may
Latex (IM-Latex) No Microscan, Div. of provide current as well as retrospective evidence of an
Horse RBC (IM-RBC) No Baxter, Bellevue, infection with this organism (100). IgM antibodies can be
toms or documented exposure to the spirochete. A properly Antibodies to Campylobacter pylon may be useful in the
performed negative test rules out Lyme disease, but a differential diagnosis of gastritis and peptic ulcer disease
positive test should be interpreted cautiously. A rise in titer (S. P. Holland, M. F. Go, B. I. Hirshowitz, W. J. Koops-
after acute onset of symptoms would be diagnostic. The man, and S. M. Michalek, Abstr. Annu. Meet. Am. Soc.
difficult diagnoses are in patients with chronic progressive Microbiol. 1988, Abstr. E85, p. 123); patients with gastric
symptoms that could be those of Lyme disease. Cross- ulcer had elevated levels of Campylobacter pylori-specific
reactivity can occur with antibodies to other spirochetes; IgM antibodies.
e.g., Treponema pallidum, which can result in a biologic Until recently, detecting high titers of cold agglutinins was
false-positive FTA-ABS (60). The RPR or VDRL test or considered an appropriate screening test for Mycoplasma
both, however, would not be falsely reactive. Although not pneumoniae, although this test was positive in only 50% of
yet commercially available, a Western blot (immunoblot) documented cases. IgG and IgM indirect IFAs have been
assay to confirm questionable antibody reactions is being developed (7, 87) and are now available commercially (Zeus
used at major medical centers located in endemic areas (12). Scientific Inc., Raritan, N.J.). Recently, an LA method
As with serologic tests for syphilis, there is a need for two (Access Medical Systems, Bradford, Conn.) has been intro-
tests for Lyme disease antibodies: (i) one that uses washed duced as an effective screening test for antibodies to Myco-
whole organisms or sonicated B. burgdorferi as a screening plasma pneumoniae (D. L. Smalley and C. E. Dunn, Abstr.
test (analogous to RPR or VDRL); and (ii) an absorption test Annu. Meet. Am. Soc. Microbiol. 1988, V12, p. 419).
(analogous to FTA-ABS) or Western blot for confirmation. Other viral antibodies. A number of other viral antibodies
Antibodies to other microorganisms. Chlamydial antibodies have diagnostic or prognostic significance. IgM antibodies to
can be found in a high proportion of individuals who are not hepatitis B core antigen are diagnostic, as are IgM antibodies
currently infected, thus limiting the usefulness of serologic to hepatitis A virus. An abundance of literature is already
methods (2). An ELISA which detects IgM antibodies has available about interpreting hepatitis antigen and antibody
been reported to be more useful than the detection of tests (14, 82). Diagnostic testing for detecting antibodies to
chlamydial antigen for diagnosing chlamydial pneumonitis in and antigens of human immunodeficiency virus are used to
infants (61). A recent report indicates that an IFA antibody determine exposure to this virus. These tests have recently
titer to Chlamydia trachomatis correlates with the incidence been extensively reviewed (43). EIA tests for human T-
of pelvic inflammatory disease in women of childbearing age lymphotrophic virus type antibodies are used to screen the
(Scholes et al., 28th ICAAC). These data support the role of blood supply to minimize the possiblity of transfusion-
prior chlamydial infection in pelvic inflammatory disease, acquired exposure to this virus which has been etiologically
but this finding remains to be confirmed. Recently, a test associated with adult T-cell leukemia or lymphoma (66).
system to detect chlamydial antibodies has become commer- Other, less prevalent viral antibodies can be detected by CF
cially available (Labsystems, Inc., Research Triangle Park, methods at reference laboratories such as state department
N.C.). of health laboratories or the Centers for Disease Control.
148 JAMES CLIN. MICROBIOL. REV.
TABLE 9. Commercially available assays for Lyme immune system develops sufficiently to combat infectious
disease antibodies processes. Neonates are markedly susceptible to group B
Method Antibodyb Company beta-hemolytic streptococci during the first 2 months of life
(17). Group B streptococcal antigen can be rapidly detected
Rapid-ELISA Total Access Medical Systems, in urine, CSF, and other body fluids. In the absence of
Branford, Conn. detectable group B streptococcal antigens, the differential
diagnosis of neonatal sepsis would include the other organ-
Micro-ELISA Total, IgG, Cambridge BioScience Corp., isms to which newborn infants are particularly susceptible,
IgM Worcester, Mass. e.g., Listeria monocytogenes and E. coli. Neonates lack
IFA Total, IgM Diagnostic Technology, transplacentally acquired antibodies from the mother in
Hauppauge, N.Y. virtually every instance of serious disease caused by these
microbes.
Micro-ELISA Total Diamedix Corp., Miami, Fla. Infants 3 months to 2 years old are susceptible to menin-
gitis caused by three groups of bacteria that possess polysac-
TABLE 10. Commercially available assays for RSV antigens techniques or both, have potential for standardizing the
Method Company laboratory diagnosis of infectious diseases. These new tech-
nologies will permit and promote sharing of resources.
Macro-ELISA Abbott Laboratories Diagnostic Div., Consensus conferences will be held to define better the
Abbott Park, Ill. relationships between test results in various laboratories as
they relate to documented infectious diseases.
IFA Bartels Div. of Baxter, Bellevue, Wash. Current definitions of infectious diseases can be somewhat
DFA vague and depend on culturing the organism, detecting
Rapid-ELISA Becton Dickinson Microbiology Systems, antigens from the organisms, detecting IgM antibodies to the
Cockeysville, Md. organisms, or detecting an increase in antibody titer after the
acute phase of the infection has passed. Commercially
IFA Difco Laboratories, Detroit, Mich. available reagents have been approved by the Food and
Drug Administration for use in the clinical laboratory, but
Macro-ELISA Kallestad Diagnostics, Austin, Tex. consistent methods (e.g., proficiency testing, clinical corre-
lations, etc.) to validate the results have not yet been
Gewurz. 1977. Interactions of C-reactive protein with the first of clinical microbiology, 4th ed. American Society for Micro-
component of human complement. J. Immunol. 119:187-192. biology, Washington, D.C.
11. Clements, M. L., J. S. Dumler, and P. Fiset. 1983. Serodiagno- 31. Fung, J. C., and R. C. Tilton. 1985. TORCH serologies and
sis of Rocky Mountain spotted fever: comparison of IgM and specific IgM antibody determination in acquired and congenital
IgG ELISA and IFA tests. J. Infect. Dis. 148:876-880. infections. Ann. Clin. Lab. Sci. 15:204-211.
12. Coleman, J. L., and J. L. Benach. 1987. Isolation of antigenic 32. Garcia, L. S., T. C. Brewer, and D. A. Bruckner. 1987.
components from the Lyme disease spirochete: their role in Fluorescence detection of Cryptosporidium oocysts in human
early diagnosis. J. Infect. Dis. 155:756-765. fecal specimens by using monoclonal antibodies. J. Clin.
13. Corrall, C. J., J. M. Pepple, E. R. Moxon, and W. T. Hughes. Microbiol. 25:119-121.
1981. C-reactive protein in spinal fluid of children with menin- 33. Gerber, M. A., L. L. Wright, and M. F. Randolph. 1987.
gitis. J. Pediatr. 99:365-369. Streptozyme test for antibodies to group A streptococcal
14. Coslett, G. D. 1988. Hepatitis learning guide. Abbott Diagnos- antigens. Pediatr. Infect. Dis. J. 6:36-40.
tics, Abbott Park, Ill. 34. Goding, J. 1976. Conjugation of antibodies with fluoro-
15. Coyle, P. K. 1989. Borrelia burgdorferi antibodies in multiple chromes: modifications to the standard methods. J. Immunol.
sclerosis patients. Neurology 39:760-761. Methods 13:215-226.
16. Craig, J. P. 1976. Immune response to Corynebacterium 35. Guesdon, J. L., T. Ternynck, and S. Avrameas. 1979. The use
in blood donors. Lab. Med. 20:103-105. 72. Petola, H. 0. 1982. C-reactive protein for rapid monitoring of
51. Klein, G. 1976. Immune response to streptococcal infection, p. infections of the central nervous system. Lancet i:980-982.
264-273. In N. R. Rose and H. Friedman (ed.), Manual of 73. Pollak, R., P. L. Barber, B. F. Prusak, and M. F. Mozes. 1987.
clinical immunology, 1st ed. American Society for Microbiol- Cytomegalovirus as a risk factor in living-related renal trans-
ogy, Washington, D.C. plantation. Ann. Surg. 205:302-304.
52. Kniseley, C. V., A. J. Bednarz-Prashad, and L. K. Pickering. 74. Preissner, C. M., S. P. Steinberg, A. A. Gershon, and T. F.
1986. Detection of rotavirus in stool specimens with monoclo- Smith. 1982. Evaluation of the anticomplement immunofluo-
nal and polyclonal antibody-based systems. J. Clin. Microbiol. rescence test or detection of antibody to varicella-zoster virus.
23:897-900. J. Clin. Microbiol. 16:373-376.
53. Kohler, G., and C. Milstein. 1975. Continuous cultures of fused 75. Pruneda, R. C., and J. C. Dover. 1986. A comparison of two
cells secreting antibody of predefined specificity. Nature (Lon- passive agglutination procedures with enzyme-linked immu-
don) 256:495-497. noadsorbent assay for rubella antibody status. Am. J. Clin.
54. Kohler, R. B., W. C. Winn, and L. J. Wheat. 1984. Onset and Pathol. 86:768-770.
duration of urinary antigen excretion in Legionnaires disease. 76. Rawls, W. E., and M. A. Chernesky. 1976. Rubella virus, p.
J. Clin. Microbiol. 20:605-607. 452-455. In N. R. Rose and H. Friedman (ed.), Manual of
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