Effects of SODIUM BICARBONATE , 8.4% on
Respiratory Tract Pathogens
ORIGINAL ARTICLEChest Lung Res Vol 1 No 1 December 201831Chest Department, Faculty of Medicine, Mansoura University, Egypt; 2Medical Microbiology and Immunology Department, Faculty of Medicine, Mansoura University, EgyptCorrespondence: Yousef AM, Chest Department, Faculty of Medicine, Mansoura University, Egypt, e-mail:
aymanhusen2002@yahoo.comReceived: July 29, 2018, Accepted: November 22, 2018, Published: November 29, 2018This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (
http://creativecommons.org/licenses/by-nc/4.0/), which permits reuse, distribution and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes. For commercial reuse, contact
reprints@pulsus.comEffect of sodium bicarbonate 8.4% on respiratory tract pathogensEl Badrawy MK1, Elela MA2, Yousef AM1, Abou El-Khier NT2, Abdelgawad TT1, Abdalla DA1, Moawad A1INTRODUCTIONPulmonary infections are caused by bacteria, viruses, fungi, and parasites [1]. All microbes grow within a particular range of external pH which affects many biological actions as enzyme activity, reaction rates, protein stability and structure of nucleic acids [2].The airway surface liquid (ASL) contains a complex mixture of antimicrobial factors that kill inhaled or aspirated organisms and act as a first line of defense. The composition of ASL is critical for antimicrobial effectiveness [1]. Changes in the local media occur with inflammation or infection as local acidosis that is attributed to the local increase of lactic-acid production by the anaerobic, glycolytic activity of infiltrating neutrophils and to the presence of short chain fatty acid by-products of bacterial metabolism [3]. The abnormally acidic pH partially inhibits bacterial killing by ASL. In addition, Gram-negative bacteria have increased resistance to antimicrobial peptides when grown at low pH [4].The pH of the macrophage compartment, in which Mycobacterium tuberculosisbacilli resides, ranges from pH 6.2 to 4.5, depending on the activation state of the macrophage. M. tuberculosis bacilli can resist killing by low pH in macrophages [5]. In empyema, bacterial metabolism and neutrophil phagocytic activity induced by bacterial cell wall-derived fragments and proteases lead to increased lactic acid production and a fall in pleural fluid pH and glucose [6]. Sodium bicarbonate (SB) is frequently used in cardiopulmonary resuscitation after establishment of ventilatory and circulatory support and in hyperkalemia [7-10]. However, administration of SB may lead to metabolic alkalosis, pulmonary edema, congestive heart failure, hyperosmolar syndrome, hypervolemia, hypernatremia, and hypertension [11,12].THEORYIn respiratory tract infections caused by bacteria, viruses, fungi and mycobacteria, there will be an expected local acidic medium in the lung secretions. Changing the local pH of lower respiratory tract secretions to alkaline side by adding SB 8.4% can affect growth and/or may be lethal for the respiratory tract pathogens. The aim of this study was to evaluate the effect of SB 8.4% on the retrieved lower respiratory tract bacteria, mycobacteria and fungi.PATIENTS AND METHODSPatientsThis is a prospective randomized case control study carried out at Chest Medicine and Medical Microbiology and Immunology departments; Mansoura University, Egypt; in the period from March, 2014 to July, 2016. It included 122 patients with clinical and radiological signs suggestive of lower respiratory tract infections (LRTI) as consolidation, lung abscess or infiltration with or without cavitation either community or hospital acquired. Patients with no radiological signs of LRTI and those unfit for FOB according to Waxman [13] were excluded from the study.After approval of the local ethical committee of Faculty of Medicine, Mansoura University and registration of the study on PACTR with unique identification number (PACTR201508001233590), all patients signed their written consents after detailed explanation of the study protocol. All patients were subjected toa) Thorough clinical history taking and physical examination.b) Chest X-ray and computed tomography.c) Complete blood count, liver enzymes, serum creatinine and bleeding profile.d) Fiberoptic bronchoscopy (FOB) and collection of bronchoalveolar lavage (BAL) samples:Before bronchoscopy, the orophayngeal cavity was cleaned according to oral hygiene instructions. The FOB (Pentax FB 19 TV; Tokyo, Japan) was used after local instillation of 2% lidocaine and IV 5-10 mg midazolam 5 min before the procedure. Through the oral route, FOB was wedged into the targeted segment or lobe with suspected infection as localized with CT chest. El Badrawy MK, Elela MA, Yousef AM, et al. Effect of sodium bicarbonate 8.4% on respiratory tract pathogens. Chest Lung Res. 2018;1(1):3-7.ABSTRACTBackground and aim: Microbes grow within a particular range of external pH, change of this pH may affect the respiratory pathogens. Our aim was to evaluate the effect of sodium bicarbonate (SB) 8.4% on the retrieved lower respiratory tract pathogens.Patients and methods: One hundred and twenty two patients with suspected lower respiratory tract infections were assigned randomly into 2 groups; 66 patients in group 1, who were subjected to broncho alveolar lavage (BAL) with 50 mL of 0.9% saline, then the retrieved BAL was divided into two equal volumes; one diluted with equal volume of saline and the other diluted with equal volume of SB (in vitro) and 56 patients in group 2, BAL with 10 mL of saline (a relatively small volume to avoid dilution and for detection of the organisms before the effect of SB) followed by BAL with 50 mL SB (in vivo). All samples were subjected to pH measurement and microbial detection.Results: There was a statistically significant decrease in median number of colony forming unit for bacteria and fungi in SB samples when compared to saline samples in group1 (in vitro) and in group 2 (in vivo). As regard to Mycobacterium TB, the number of positive cases for acid fast bacilli and culture for TB was less in SB samples when compared to saline samples in both groups. No significant complications related to the procedure were reported. Conclusions: SB 8.4% is a safe material and inhibitory for bacterial, fungal, and mycobacterial growth in the specific cultures and affects acid fast bacilli staining with Ziehl Neelsen.Key Words:BAL; Respiratory pathogen; Sodium bicarbonate
El Badrawy et al.Chest Lung Res Vol 1 No 1 November 20184The enrolled patients were randomly assigned into two groups according to the mode of application of SB to the expected respiratory pathogens; Group (1) 66 patients in group 1, who were subjected to BAL with 50 mL saline, then the retrieved BAL samples were divided into two equal volumes; one sample diluted with equal volume of saline (group 1a) and the other sample diluted with equal volume of SB (group 1b invitro) and 56 patients in group 2, BAL was done with 10 mL of saline (group 2a for detection of the organism(s) before application of SB and small volume to avoid dilution) followed by BAL with 50 mL SB (group 2b).The retrieved BAL was collected in sterile containers with tight seal and transported immediately in ice tank to Microbiology and Immunology laboratory, Faculty of Medicine, Mansoura University.MethodsAll BAL samples were subjected to pH measurement (Jenway 3305 pH meter; UK), Gram staining, aerobic bacterial culture and antibiotic susceptibility testing, Ziehl–Neelsen (ZN) staining for acid fast bacilli (AFB) and M. tuberculosis culture on Lowenstein Jensen medium, fungal wet mount stain and fungal culture on Sabouraud dextrose agar (SDA) slants.Gram stainingAfter the BAL container was vortexed, 5 μL loopful sample was spread on 2 cm2 diameter area on microscopy slides. The smears were allowed to dry then fixed and stained with Gram stain.Aerobic bacterial cultureBAL specimens were neither diluted nor concentrated prior to culture. Semi-quantitative loop method was used for culture using a 0.01 mL calibrated loop to streak sample on Mac Conkey’s agar, chocolate agar (plate kept in candle jar) and blood agar plates and incubated aerobically at 37°C. Culture plates were examined 24 and 48 hours later. Colony counts were determined from the blood agar plate with one visible colony representing 100 cfu/mL of the original specimen (1 col. x multiplication factor of 100 [0.01 cal. loop] = 100 cfu/mL). Gram positive and gram-negative bacteria were identified by standard procedures Antimicrobial susceptibility was tested for the isolated bacteria according to CLSI recommendations using disc diffusion method on Muller-Hinton agar plates [14].M. tuberculosis studyZN staining for AFB: Five to ten mL of BAL samples were centrifuged at 4000 RPM for 20 min and the deposit was stained with ZN staining for AFB while the remaining amount of the deposit was stained for fungi. Grading of positive BAL for AFB was performed according to Lohmann et al. [15]. Culture on Lowenstein Jensen (LJ) slants:After decontamination and concentration, LJ slants were inoculated for mycobacterial culture. LJ tubes were incubated at 37°C in 5% CO2 for one week, at 37°C in air for another 7 weeks and thereafter were checked once a week for mycobacterial growth. Growth of mycobacteria was confirmed by typical colony morphology and microscopy for AFB.Fungus studyStaining with wet mount stain:The deposit after centrifugation used for Dimethyl Sulfoxide-Potassium Hydroxide (DMSO-KOH) wet mount by adding KOH 10% to the deposit with cover slips and examine with X10 and X40 lenses. Fungal cultureFor fungus culture; Sabouraud dextrose agar (SDA) plates were used for fungus culture. Plates were incubated aerobically at 25°C and 37°C for at least 48 hours and was identified according to the standard method.Safety assessment of the procedurePatients in group 2 were followed up for 24 hours for the following: a) Chest symptoms as new or exacerbation of the present symptoms as fever, cough, heamoptysis and chest pain. b) Chest X ray was done 2 hour after the procedure. c) ECG was monitored for one hour after the procedure. d) Systemic side effects as nausea, vomiting, muscle twitches and camps for one hour. e) Arterial blood gases immediately after the procedure.Statistical analysisThe statistical analysis of data was done using SPSS program version 21.0. The normality of data was first tested with one-sample Kolmogorov-Smirnov test. Categorical data were presented as numbers (percentage). Chi-square (or Fisher’s Exact Test if needed) were used to compare the results between the two groups. For data with normal distribution; descriptive statistics were used to calculate mean standard deviation (SD); independent samples t test was used to compare the results between 2 groups. For data without normal distribution; descriptive statistics were used to calculate median; non-parametric two-related-samples test (Wilcoxon type) was used to compare the results in the same group. Mc Nemar Test was used to compare paired proportions. Statistical significance was defined as p value less than 0.05.RESULTSSixty six pateints in group 1 and 56 patients in group 2 were enrolled in the study. Table 1 illustrates demographic, clinical and radiological data for both groups. Apart from fever, patients in both groups were well matched with no statistically significant difference.Consolidation was the most common radiologic abnormality in both groups (62.1% and 41.1 % in group 1 and 2 respectively), followed by cavitary lesions (27.3% in group 1 and 35.7% in group 2) Table 1.The mean of pH of saline samples was 6.39 ± 0.32 and for bicarbonate samples was 8.22 ± 0.33, with a significant difference between both groups P<0.001Klebsiella pneumoniae was the most common organism detected in group 1 (21.2%) and Pseudomonas aeuroginosa was the most common in group 2 (17.9%) Table 2. Candida albicans was the most common fungus detected in both groups (37.9%, 42.9% in groups 1 and 2 respectively) Table 2. Mixed bacteria and fungi were reported in 42.4 % in group 1 and 42.86 % in group 2.There was a statistically significant decrease in median colony forming unit (CFU)/ mL in SB (b) samples when compared to saline (a) samples in both groups for bacteria and fungi (Figures 1, 2 and Tables 3, 4). In group 1, the number of positive cases for AFB by ZN staining in SB samples (b1) was less than that of saline samples (a1) (3 versus 7), but this difference was statistically insignificant (p=0.125) Table 5 and Figure 3. But, there was a statistically significant difference between saline (a1) and SB (b1) in M.TB culture (7 versus 1, p=0.031) Table 5. Also in group 2, the number of positive cases for AFB by ZN staining was less in SB samples (b2) than in saline samples (a2) (3 versus 6); with no statistically significant difference between the two samples (p=0.250 (Table 6). There was a reduction in TABLE 1Demographic clinical and radiological data of the studied groupsGroup 1 Group 2 P value(n =66)(n =56)Age (mean ± SD)48.62 ±15.1645.41± 17.170.364Gender (n (%))Male43 (65.2%)40 (71.4%)0.459Female23 (34.8%)16 (28.6%)Fever (n (%))49 (74.2%)32 (57.1%)0.046Cough (n (%))53 (80.3%)44 (78.6%)0.813Expectoration (n (%)53 (80.3%)41 (73.2%)0.353Hemoptysis (n (%)24 (36.4%)20 (35.7%)0.941Dyspnea (n (%)42 (63.6%)35 (62.5%)0.897Chest pain n (%)19 (28.8%)16 (28.6%)o.999Consolidation (n (%)41 (62.1)23 (41.1)Cavitary lesions (n (%)18 (27.3)20 (35.7)Bronchiectasis (n (%)5 (7.6)2 (3.6)Lobar collapse (n (%)2 (3)2 (3.6)0.564**: Fischer Exact TestThe mean of pH of saline samples was 6.39 ± 0.32 and for bicarbonate samples was 8.22 ± 0.33, with a significant difference between both groups P<0.001.
