Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Archana Dambal

"Journal of clinical and diagnostic research is a welcome change in publishing practices. It aims to reach out to the grass-root level researchers who do not lack in experience, clinical material and ideas, but lack in their knowledge in English language and statistics. The journal achieves it's aim by supporting in these exact domains.
It also gives due credit to all research designs like descriptive and qualitative studies while many journals ignore these important study designs. The rigorous review process does not allow any compromise in quality
It is indexed in many indexing agencies and the articles are available under creative commons licence free of cost
The frequency of publication supports many aspiring authors from India and other countries.
It's wide scope welcomes articles across various specialities in medicine. In an era when there is an unscientific insistence on speciality specific research by regulatory bodies in medical education, JCDR supports collaborative research across specialities. I wish the publisher all the best in his future endeavors."



Dr. Archana Dambal
Department of General Medicine,
Belgaum Institute of Medical Sciences,Belgaum, Karnataka,INDIA,
On 30 Nov 2018




Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Letter to Editor
Year : 2011 | Month : December | Volume : 5 | Issue : 8 | Page : 1699 - 1700

Sputum Gram Stain Assessment in Relation to Sputum Culture for Respiratory Tract Infections in a Tertiary Care Hospital

Mariraj J., Surekha Y. Asangi, Krishna S., Suresh B. Sonth, Ramesh, Shanmugum

Vijayanagar Institute of Medical Sciences, Bellary, India.

Correspondence Address :
Mariraj J
Professor in Microbiology,
Department of Microbiology,
VIMS, Bellary.
Phone: 9845233215.

Keywords

Mariraj J., Surekha Y. Asangi, Krishna S., Suresh B. Sonth, Ramesh, Shanmugum

How to cite this article :

Mariraj J., Surekha Y. Asangi, Krishna S., Suresh B. Sonth, Ramesh, Shanmugum. SPUTUM GRAM STAIN ASSESSMENT IN RELATION TO SPUTUM CULTURE FOR RESPIRATORY TRACT INFECTIONS IN A TERTIARY CARE HOSPITAL. Journal of Clinical and Diagnostic Research [serial online] 2011 December [cited: 2019 Sep 17 ]; 5:1699-1700. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2011&month=December&volume=5&issue=8&page=1699-1700&id=1804

Introduction
Sir,

One of the most important uses of the Gram stain is to evaluate the quality of expectorated sputum received for routine bacteriological culture. An acceptable sample yields less than 10 squamous epithelial cells per low power field (1). The simplest and least expensive sample for the diagnosis of lower respiratory infections is expectorated sputum. The utility of this approach is the subject of controversy, as the sample is contaminated by oropharyngeal flora as it passes through the mouth. When the sample is collected carefully, it can provide useful information for initial therapy of community acquired pneumonia (2).

Direct Grams stain of clinical material may be used to determine whether a sample is representative of the site of infection. This technique has been applied for evaluation of sputum samples. From the relative numbers of squamous epithelial cells and segmented neutrophils in direct Gram’s stains of sputum samples, Bartlett has devised a grading system for evaluating sputum samples (2).

Gram staining is considered key in the work up of sputum from patient with community acquired pneumonia and other lower respiratory tract infections. The sputum samples are often contaminated with saliva and contains resident oropharyngeal microbial flora. Culture of such a sputum sample might yield the organisms present in the saliva (3).

When significant oropharyngael contamination is evidenced in the cellular content of Gram stained sputum smears, the second sample representing lower respiratory tract must be collected (4).The microbiology laboratory must use objective criteria by Gram stain screening for purulence before inoculation into culture media (5). Unless microscopic examination is routinely included, half of all microbiological information rendered on sputum samples is meaningless and subject to misinterpretation of culture results. Hence culture must be guided by microscopic findings. When there is no correlation between culture and smear, the culture report may not indicate the aetiology of lower respiratory tract infection. The present study was designed to examine whether the clinical microbiology laboratory should play an active role in interpreting the quality of sputum specimens based on Gram stained smears.

Material and Methods

The 100 unselected expectorated sputum samples were examined in the central microbiology laboratory. Samples were evaluated by gross appearance and subjectively categorized into mucus (mucus strands present) and watery (saliva present) (3).

Each specimen was first mixed with an applicator swab and then inoculated on to blood agar, chocolate agar and Mac Conkeyagar plates and a smear was prepared for Gram staining. Each stained smear was examined microscopically under low power, oil immersion and the cellular components were evaluated. All the samples were processed regardless of the appearance of the stained smears. Organisms were identified by standard protocols and antibiotic susceptibility of recommended drugs was performed by Kirby Buer disc diffusion method. Viridians group streptococci, CoNS and some Neisseria species were considered as normal respiratory flora (5).

Results

According to the Bartlett’s screening criteria, 79 (79%) samples were accepted and 21(21%) samples were rejected from 100 samples. Potential pathogens were recovered from 50(63.2%) samples out of 79 accepted samples. Two (9.5%) samples yielded pathogens from 21 rejected samples. The most common organism isolated was Klebsiella spp, followed by Pseudomonas spp, Streptococcus pyogenes, Staphylococcus aureus, Enterobacter spp, Escherichia coli, Citrobacter spp and Acinitobacter spp.

Discussion

Clinicians are interested in rapid, simple, inexpensive and readily available tests that will assist them in prescribing proper medications for lower respiratory tract infections. Sputum Gram stain served this function in the management of lower respiratory tract infection (6).

When potential pathogen is isolated from the sputum sample, it is often difficult to decide whether the potential pathogen is an etiological agent or represents oropharyngaeal contamination. The amount of oropharyngeal contamination can be judged by evaluating the relative number of squamous epithelial cells in the samples. The samples that are contaminated are less likely to yield interpretable results (7). Without microscopy, culture results are of unknown relevance and results may be misleading. Hence diagnosing respiratory infection by sputum culture without microscopic examination invites confusion and misinformation (8). To minimise the effect of oropharyngael contamination on lower respiratory tract secretions, Bartlett, Murray and Washington devised screening criteria based on quantitation of leucocytes and squamous epithelial cells (5). The use of gram stained smears to assess the quality of sputum samples has received considerable attention as a means for improving the reliability of sputum culture. In 1974, Bartlett proposed that purity of sputum samples be rated according to the relative concentration of polymorphonuclear neutrophiles, squamous epithelial cells and mucus in gram stained smears (4). Even though sputum culture has been criticised for lack of sensitivity and specificity, comparability of a positive yield on sputum culture with transtracheal aspiration has been demon-strated when the sputum samples have been microscopically adequate (9). Murray and Washington initially reported that 45% of their specimens were rejected (7). Joseph and David reported rejection rate of 23 to 25% (5). In our study, 21% sputum samples were unacceptable. Isolation rate in present study is 63% which is higher compared to 57% isolation rate reported by Jean and Mohammed (10) (11),(12),(13),(14),(15).

Conclusion

Our data support the notion that clinical microbiology laboratories may reject for culture, those sputum specimens which fail to meet the criteria of Bartlett for purulence. Sputum cultures must be ordered judiciously for documented episodes of lower respiratory tract infection to provide meaningful report. The microbiology laboratory must use objective criteria by Gram stain screening for purulence before inoculation in to culture media. Hence the routine sputum Gram stain is essential to provide meaningful culture report.

References

1.
Forbes BA, Sahm DF, Weissfeld AS. Bailey and Scott’s Diagnostic Microbiology; 12th edn. Missouri: Mosby; 2007.
2.
Koneman EW, Allen SD, Janda WM, Schrekenberger PC. Color Atlas and Text book of Diagnostic Microbiology; 6th edn. Philadelphia: JB Lippencott; 2006.
3.
Bindu Nair, Jenny Stapp, Lynn Stapp, Linda Bugni, Jill Van Dalfsen, and Jane L. Burns. 2002. Utility of Gram staining for evaluation of the quality of cystic fibrosis sputum samples. J. Clin. Microbiol. Vol 40. No 8.
4.
Howard H Mizrachi and Paul N. Valenstein 1, 2. 1987 Randomized Trial Interpreting Sputum Quality in a Clinical Laboratory. J. Clin. Microbiol. Vol 25. No.12.
5.
Joseph R Lentino and David A. Lucks. 1987 Nonvalue of sputum culture in the management of lower respiratory tract infections. J. Clin. Microbiol. Vol 25. No 5.
6.
Richard Gleckman, James De Vita, Debra Hibert, Carol Pelletier, and Ronald Martin. 1988. Sputum Gram stain assessment in community acquired bacteremic pneumonia. J. Clin. Microbiol. Vol.26. No 5.
7.
Lester K. Wong, Arthur L.Barry and Susan M. Horgan.1982. Comparison of Six Different Criteria for Judging the Acceptability of Sputum Specimens. J. Clin. Microbiol. Vol 16. No. 4.
8.
Herbert S. Heineman, Jagjit K. Chawla, and Wendell M.Lofton. 1977. Misinformation from sputum cultures without microscopic examination. J. Clin. Microbiol. Vol 6. No 5.
9.
N Arora, MK Daga, R Mahajan, S Krishna Prakash and N Gupta. 2001. Microbiol Pattern of acute infective exacerbation of chronic obstructive airway disease in a hospital based study. Indian J chest dis allied sci 2001; 43: 157-62.
10.
Jean Jacques Lloveras, Mohammed Issam Shukr, Claude Pinos, Anissa Lindoulsi, Philippe Grima. 2010. Usefulness of sputum Gram stain and culture for diagnosis of pneumonia in a geriatric institution. Journal of IMAB.
11.
Miriam B Buenvije MD. 1989. Quantitative sputum culture and and Gram stain: Pulmonary infection vs colonization. Phil J Microbiol infect dis 1989: 18(1): 28-35.
12.
Beatriz Roson, Jordi Carratala, Ricard Verdaguer, Jordi Dorca, Frederic Manresa and Francesc Gudiol. 2000. Prospective study of the usefulness of sputum Gram stain in the initial approach to the community- acquired pneumonia requiring hospitalization. Clinical infectious diseases. 2000:31:869-74.
13.
Geckler RW, DH Gremillion, CK McAllister and E Ellenbogen. 1977. Microscopic and bacteriological comparison of paired sputa and transtracheal aspirates. J. Clin. Microbiol. 6: 396-99.
14.
Murray, PR and JA Washington II 1975. Microscopic and bacteriologic analysis of expectorated sputum. Mayo Clin. Proc. 50: 339-44.
15.
Heineman, HS and RR Radano 1979. Acceptability and cost savings of selective sputum microbiology in a community teaching hospital. J. Clin. Microbiol. 10: 567-73.

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