ORIGINAL ARTICLE

Effect of sodium bicarbonate 8.4% on respiratory tract pathogens

El Badrawy MK1, Elela MA2, Yousef AM1, Abou El-Khier NT2, Abdelgawad TT1, Abdalla DA1, Moawad A1

El Badrawy MK, Elela MA, Yousef AM, et al. Effect of sodium bicarbonate small volume to avoid dilution and for detection of the organisms before the
8.4% on respiratory tract pathogens. Chest Lung Res. 2018;1(1):3-7. effect of SB) followed by BAL with 50 mL SB (in vivo). All samples were subjected
ABSTRACT to pH measurement and microbial detection.
Results: There was a statistically significant decrease in median number of colony
Background and aim: Microbes grow within a particular range of external pH, forming unit for bacteria and fungi in SB samples when compared to saline
change of this pH may affect the respiratory pathogens. Our aim was to evaluate samples in group1 (in vitro) and in group 2 (in vivo). As regard to Mycobacterium
the effect of sodium bicarbonate (SB) 8.4% on the retrieved lower respiratory TB, the number of positive cases for acid fast bacilli and culture for TB was less
tract pathogens. in SB samples when compared to saline samples in both groups. No significant
Patients and methods: One hundred and twenty two patients with suspected complications related to the procedure were reported.
lower respiratory tract infections were assigned randomly into 2 groups; 66 Conclusions: SB 8.4% is a safe material and inhibitory for bacterial, fungal, and
patients in group 1, who were subjected to broncho alveolar lavage (BAL) with 50 mycobacterial growth in the specific cultures and affects acid fast bacilli staining
mL of 0.9% saline, then the retrieved BAL was divided into two equal volumes; with Ziehl Neelsen.
one diluted with equal volume of saline and the other diluted with equal volume
Key Words: BAL; Respiratory pathogen; Sodium bicarbonate
of SB (in vitro) and 56 patients in group 2, BAL with 10 mL of saline (a relatively

INTRODUCTION 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,
P ulmonary infections are caused by bacteria, viruses, fungi, and parasites
[1]. All microbes grow within a particular range of external pH which
mycobacteria and fungi.
affects many biological actions as enzyme activity, reaction rates, protein PATIENTS AND METHODS
stability and structure of nucleic acids [2].
Patients
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 This is a prospective randomized case control study carried out at Chest
defense. The composition of ASL is critical for antimicrobial effectiveness Medicine and Medical Microbiology and Immunology departments;
[1]. Changes in the local media occur with inflammation or infection as Mansoura University, Egypt; in the period from March, 2014 to July, 2016.
local acidosis that is attributed to the local increase of lactic-acid production It included 122 patients with clinical and radiological signs suggestive of
by the anaerobic, glycolytic activity of infiltrating neutrophils and to the lower respiratory tract infections (LRTI) as consolidation, lung abscess
presence of short chain fatty acid by-products of bacterial metabolism [3]. or infiltration with or without cavitation either community or hospital
The abnormally acidic pH partially inhibits bacterial killing by ASL. In acquired. Patients with no radiological signs of LRTI and those unfit for
addition, Gram-negative bacteria have increased resistance to antimicrobial FOB according to Waxman [13] were excluded from the study.
peptides when grown at low pH [4]. After approval of the local ethical committee of Faculty of Medicine,
The pH of the macrophage compartment, in which Mycobacterium tuberculosis Mansoura University and registration of the study on PACTR with unique
bacilli resides, ranges from pH 6.2 to 4.5, depending on the activation identification number (PACTR201508001233590), all patients signed their
state of the macrophage. M. tuberculosis bacilli can resist killing by low pH written consents after detailed explanation of the study protocol.
in macrophages [5]. In empyema, bacterial metabolism and neutrophil All patients were subjected to
phagocytic activity induced by bacterial cell wall-derived fragments and
proteases lead to increased lactic acid production and a fall in pleural a) Thorough clinical history taking and physical examination.
fluid pH and glucose [6]. Sodium bicarbonate (SB) is frequently used b) Chest X-ray and computed tomography.
in cardiopulmonary resuscitation after establishment of ventilatory and
circulatory support and in hyperkalemia [7-10]. However, administration c) Complete blood count, liver enzymes, serum creatinine and bleeding
of SB may lead to metabolic alkalosis, pulmonary edema, congestive profile.
heart failure, hyperosmolar syndrome, hypervolemia, hypernatremia, and
d) Fiberoptic bronchoscopy (FOB) and collection of bronchoalveolar
hypertension [11,12].
lavage (BAL) samples:
THEORY
Before bronchoscopy, the orophayngeal cavity was cleaned according to oral
In respiratory tract infections caused by bacteria, viruses, fungi and hygiene instructions. The FOB (Pentax FB 19 TV; Tokyo, Japan) was used
mycobacteria, there will be an expected local acidic medium in the lung after local instillation of 2% lidocaine and IV 5-10 mg midazolam 5 min
secretions. Changing the local pH of lower respiratory tract secretions to before the procedure. Through the oral route, FOB was wedged into the
alkaline side by adding SB 8.4% can affect growth and/or may be lethal targeted segment or lobe with suspected infection as localized with CT chest.

1
Chest Department, Faculty of Medicine, Mansoura University, Egypt; 2Medical Microbiology and Immunology Department, Faculty of Medicine, Mansoura University,
Egypt
Correspondence: Yousef AM, Chest Department, Faculty of Medicine, Mansoura University, Egypt, e-mail: [email protected]
Received: July 29, 2018, Accepted: November 22, 2018, Published: November 29, 2018
This 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 [email protected]

Chest Lung Res Vol 1 No 1 December 2018 3

El Badrawy et al.

The enrolled patients were randomly assigned into two groups according the procedure. c) ECG was monitored for one hour after the procedure. d)
to the mode of application of SB to the expected respiratory pathogens; Systemic side effects as nausea, vomiting, muscle twitches and camps for one
Group (1) 66 patients in group 1, who were subjected to BAL with 50 mL hour. e) Arterial blood gases immediately after the procedure.
saline, then the retrieved BAL samples were divided into two equal volumes; Statistical analysis
one sample diluted with equal volume of saline (group 1a) and the other
sample diluted with equal volume of SB (group 1b in vitro) and 56 patients The statistical analysis of data was done using SPSS program version 21.0.
in group 2, BAL was done with 10 mL of saline (group 2a for detection of The normality of data was first tested with one-sample Kolmogorov-Smirnov
the organism(s) before application of SB and small volume to avoid dilution) test. Categorical data were presented as numbers (percentage). Chi-square
followed by BAL with 50 mL SB (group 2b). (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
The retrieved BAL was collected in sterile containers with tight seal and used to calculate mean  standard deviation (SD); independent samples t test
transported immediately in ice tank to Microbiology and Immunology was used to compare the results between 2 groups. For data without normal
laboratory, Faculty of Medicine, Mansoura University. distribution; descriptive statistics were used to calculate median; non-
parametric two-related-samples test (Wilcoxon type) was used to compare
Methods
the results in the same group. Mc Nemar Test was used to compare paired
All BAL samples were subjected to pH measurement (Jenway 3305 pH meter; proportions. Statistical significance was defined as p value less than 0.05.
UK), Gram staining, aerobic bacterial culture and antibiotic susceptibility
RESULTS
testing, Ziehl–Neelsen (ZN) staining for acid fast bacilli (AFB) and M.
tuberculosis culture on Lowenstein Jensen medium, fungal wet mount stain Sixty six pateints in group 1 and 56 patients in group 2 were enrolled in the
and fungal culture on Sabouraud dextrose agar (SDA) slants. study. Table 1 illustrates demographic, clinical and radiological data for both
groups. Apart from fever, patients in both groups were well matched with no
Gram staining statistically significant difference.
After the BAL container was vortexed, 5 μL loopful sample was spread on 2 Consolidation was the most common radiologic abnormality in both groups
cm2 diameter area on microscopy slides. The smears were allowed to dry then (62.1% and 41.1 % in group 1 and 2 respectively), followed by cavitary
fixed and stained with Gram stain. lesions (27.3% in group 1 and 35.7% in group 2) Table 1.

Aerobic bacterial culture 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
BAL specimens were neither diluted nor concentrated prior to culture. Semi- P<0.001
quantitative loop method was used for culture using a 0.01 mL calibrated
Klebsiella pneumoniae was the most common organism detected in group
loop to streak sample on Mac Conkey’s agar, chocolate agar (plate kept in
1 (21.2%) and Pseudomonas aeuroginosa was the most common in group 2
candle jar) and blood agar plates and incubated aerobically at 37°C. Culture
(17.9%) Table 2. Candida albicans was the most common fungus detected in
plates were examined 24 and 48 hours later. Colony counts were determined both groups (37.9%, 42.9% in groups 1 and 2 respectively) Table 2. Mixed
from the blood agar plate with one visible colony representing 100 cfu/mL bacteria and fungi were reported in 42.4 % in group 1 and 42.86 % in group 2.
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 There was a statistically significant decrease in median colony forming unit
standard procedures Antimicrobial susceptibility was tested for the isolated (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).
bacteria according to CLSI recommendations using disc diffusion method
on Muller-Hinton agar plates [14]. 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
M. tuberculosis study difference was statistically insignificant (p=0.125) Table 5 and Figure 3. But,
ZN staining for AFB: Five to ten mL of BAL samples were centrifuged at there was a statistically significant difference between saline (a1) and SB (b1)
4000 RPM for 20 min and the deposit was stained with ZN staining for AFB in M.TB culture (7 versus 1, p=0.031) Table 5. Also in group 2, the number
while the remaining amount of the deposit was stained for fungi. Grading 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
of positive BAL for AFB was performed according to Lohmann et al. [15].
between the two samples (p=0.250 (Table 6). There was a reduction in
Culture on Lowenstein Jensen (LJ) slants: After decontamination and
concentration, LJ slants were inoculated for mycobacterial culture. LJ tubes TABLE 1
were incubated at 37°C in 5% CO2 for one week, at 37°C in air for another Demographic clinical and radiological data of the studied
7 weeks and thereafter were checked once a week for mycobacterial growth. groups
Growth of mycobacteria was confirmed by typical colony morphology and Group 1 Group 2
  P value
microscopy for AFB. (n =66) (n =56)
  48.62
Fungus study Age (mean ± SD) 45.41± 17.17 0.364
±15.16

Staining with wet mount stain: The deposit after centrifugation used for Male 43 (65.2%) 40 (71.4%)
Gender (n (%)) 0.459
Dimethyl Sulfoxide-Potassium Hydroxide (DMSO-KOH) wet mount by Female 23 (34.8%) 16 (28.6%)
adding KOH 10% to the deposit with cover slips and examine with X10 Fever (n (%)) 49 (74.2%) 32 (57.1%) 0.046
and X40 lenses. Cough (n (%)) 53 (80.3%) 44 (78.6%) 0.813
Expectoration (n (%) 53 (80.3%) 41 (73.2%) 0.353
Fungal culture Hemoptysis (n (%) 24 (36.4%) 20 (35.7%) 0.941
Dyspnea (n (%) 42 (63.6%) 35 (62.5%) 0.897
For fungus culture; Sabouraud dextrose agar (SDA) plates were used for
Chest pain n (%) 19 (28.8%) 16 (28.6%) o.999
fungus culture. Plates were incubated aerobically at 25°C and 37°C for at
Consolidation (n (%) 41 (62.1) 23 (41.1)
least 48 hours and was identified according to the standard method.
Cavitary lesions (n (%) 18 (27.3) 20 (35.7)
Safety assessment of the procedure Bronchiectasis (n (%) 5 (7.6) 2 (3.6)
Lobar collapse (n (%)   2 (3) 2 (3.6) 0.564*
Patients 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, *: Fischer Exact Test
The mean of pH of saline samples was 6.39 ± 0.32 and for bicarbonate samples
cough, heamoptysis and chest pain. b) Chest X ray was done 2 hour after was 8.22 ± 0.33, with a significant difference between both groups P<0.001.

4 Chest Lung Res Vol 1 No 1 November 2018

 Effect of sodium bicarbonate 8.4% on respiratory tract pathogens

TABLE 2 TABLE 3
Organisms detected in the retrieved BAL samples of the studied CFU for bacteria and fungi in the retrieved BAL samples of
groups group (1)
Group1 Group 2 Group 1 (n=66) Test of sig.
Items
Type (n = 66) (n = 56) Median Min-Max p-value
n (%) n (%) Bacteria (n=46)
Bacteria Saline (a1)CFU/ml 1X105 3X102-1X108 Z =6.03
No growth 14 (21.2) 19 (33.9) SB (b1) CFU/ml 1X102 0-1X107 P <0.001
K.pneumoniae 14 (21.2) 5 (8.9) Fungi (n=27)
P.aeuroginosa 8 (12.1) 10 (17.9) Saline (a1) CFU/ml 1X104 0-1X107 Z = 3.99
E. coli 6 (9.1) 4 (7.1) SB (b1) CFU/ml 0 0-1X107 P <0.001
Alpha-hemolytic
Streptococci
5 (7.6) 0 CFU; colony forming unit
Staph. aureus (MSSA) 2 (3) 3 (5.4) TABLE 4
Proteus mirabilis 4 (6.1) 5 (8.9) CFU for bacteria and fungi in the retrieved BAL samples of
Serratia marcescens 2 (3.0) 1 (1.8) group (2)
Strept. Pneumonia 2 (3.0) 5 (8.9) Group (2) n=56 Test of sig.
Items
Enterococci 1 (1.5) 0 Median Min-Max p-value
H.influenzae 0 (0) 4 (7.1) Bacteria (AS TABLE 3)
Mixed bacteria: 8 (12.1) 0 Saline (a2) CFU/ml 1X104 1X102-1X107 Z=5.256
Fungi SB (b2) CFU/ml 1X103 0-1X 107 P<0.001
No growth 36 (54.5) 23 (41.1) Fungi (AS TABLE 3)
Candida albicans 25 (37.9) 24 (42.9)
Saline (a2) CFU/ml 1X105 10- 107 Z=4.867
Aspergillus 5 (7.6) 5 (16.1)
SB (b2) CFU/ml 50 0-1X 105 P<0.001
MSSA: methicillin-sensitive Staph aureus.
TABLE 5
Ziehl–Neelsen staining and TB culture results for patients in
group (1)
Group(1) n=66 Test of sig.
  Saline (a1) SB (b1) p-value
N % n %  
Ziehl–Neelsen staining
Positive 7 10.6 3 4.5 McNemar Test
Negative 59 89.4 63 95.5 P=0.125
Culture for TB
Positive 7 10.6 1 1.5 McNemar Test
Negative 59 89.4 65 98.5 P=0.031*

Figure 1) Bacterial culture; A: saline sample, B: Sodium bicarbonate sample.

There was confluent bacterial growth in saline sample with minimal growth in
sodium bicarbonate sample

Figure 2) Fungal culture for Candia; A: saline sample, B: Sodium bicarbonate

sample. There was confluent fungal growth in saline sample with no growth in
sodium bicarbonate sample

median grading for AFB by ZN staining with no statistically significant

difference between saline and SB samples in both groups (p=0.066) Table 7.
Figure 3) ZN stain acid fast bacilli; A: saline sample, B: Sodium bicarbonate
Regarding safety of the procedure, immediately after instillation of SB sample. There is a significant decrease in number of AFB in sodium bicarbonate
through FOB for BAL, all patients developed mild cough for one to 5 sample compared to saline sample
minutes and no other side effects.
Chest Lung Res Vol 1 No 1 December 2018 5
El Badrawy et al.

TABLE 6 collected from patients with LRTI. They found that a bacterial cause was
Ziehl–Neelsen staining and TB culture results for patients in established in 43 (30%), and a viral cause in 57 (39%) of the 145 patients
group (2) with a LRTI.
Group(2) n=56 Test of sig. In the present study; Candida albicans was the most common isolated fungus
  Saline sample (a2) SB sample (b2) p-value in the two groups 37.9%, 42.9% respectively Table 2. These results are
N % N %   similar to that reported by Shin et al. [27] who studied 691 BAL samples and
Ziehl–Neelsen staining found that Candida albicans was the most common isolated fungus [106 cases
Positive 6 10.7 3 5.4 (15.34 %)]. In our study, the median value of CFU/mL in SB samples were
P = 0.250 lower than saline samples with statistically significant difference for bacteria;
Negative 50 89.3 53 94.6
as for group 1 the median CFU/mL was 1 X 105 for saline samples versus 1
Culture for TB
X 102 for SB samples with p value < 0.001. For group 2; the median CFU/
Positive 7 12.5 4 7.1 mL was lower in SB samples than in saline samples (1 X 103 versus 1 X 104)
P = 0.250
Negative 49 87.5 52 92.9 with statistically significant difference (p value <0.001). To the best of our
knowledge, no previous studies addressed the effect of alkalanization by SB or
TABLE 7 other alkaline materials used in medicine on different respiratory organisms.
Median grading of positive BAL for AFB in both groups However; AbouAlaiwa et al. [1] studied human β-defensin-3 (hBD-3), and
Saline AFB (a SB AFB (b
the cathelicidin-related peptide LL-37 which are components of ASL and
  P value have broad antimicrobial spectrum, including activity against Staphylococcus
samples) samples)
aureus and P. aeruginosa. At neutral pH, they are cationic and kill bacteria by
Median 4 0 Z= 1.841 disrupting the phospholipid membrane and dissipating the electrochemical
(Min-Max) (1-5) (0-4) P=0.066 gradient. It was found that a reduced pH inhibits their individual and
synergistic actions and could therefore impair airway defense.

DISCUSSION In this study, the median value of CFU/mL for fungi was lower in SB
samples than in saline samples in both groups; as for group 1 the median
Inflammation leads to local acidosis, which is attributed to the local increase CFU/ mL value was 1 X 104 for saline samples and zero for SB samples with
of lactic-acid production by the anaerobic, glycolytic activity of infiltrating p value < 0.001 Table 3. For group 2; the median CFU/ mL was 105 for
neutrophils and to the presence of short chain, fatty acid by-products saline samples to 50 for SB samples with p value <0.001 (Table 4). In a study
of bacterial metabolism [3]. The interstitial fluid of tumors and abscesses by Elin and Wolff [28] who evaluated the effect of pH and concentration of
also has shown pH values of less than 6.0, averaging 0.2–0.6 units lower iron on the ability of Candida albicans to grow on human serum, they found
the mean extracellular pH of normal tissues [16]. Adaptation of pH is that the growth of Candida albicans in human sera is inversely proportional
essential to enable organisms to invade the blood stream and tissues that to the pH and directly related to the percentage of iron saturation in the
cause infection dissemination [17]. The acidic microenvironments may play serum. Aboellil and Al-Tuwaijri [29] studied the effect of different pH on
growth of Candida albicans and found that the acidic pH (5.6 - 6) leads
a role in inhibiting immune function in certain respiratory conditions such
to the maximum growth and its growth decreases with increasing pH [30].
as cystic fibrosis [16,18,19].
Vacuolar acidification is clearly linked to the pathogenicity of the yeast [31].
Sodium bicarbonate (SB) 8.4% is an alkaline solution of pH of approximately Antifungal drugs target mainly yeast vacuole preventing it from becoming
8.5. It is used in clinical practice as an alkalinizing agent in the treatment of acidic. So, yeast-to-hyphal transition is blocked [32] with inhibition of
metabolic acidosis which may occur in many conditions including diabetes, V-ATPase by emptying yeast membranes of ergosterol. This causes alkalization
starvation, severe dehydration, renal insufficiency and severe diarrhea of the vacuole [33].
[20,21]. Aspergillus fumigatus grows optimally at 37°C and a pH 3.7 to 7.6, it can
be isolated wherever decaying vegetation and soil reach temperatures range
The aim of this study was to assess the effect of SB 8.4% on the retrieved between 12o and 65oC [34] and the pH ranges between 2.1– 8.8 [35]. For
lower respiratory tract infectious agents as aerobic bacteria, fungi and M. growth and survival, M. TB requires an optimal pH range of 6.2 to 7.3 [36].
tuberculosis bacilli. We found that seven patients in group (1) were positive by ZN stain for
In group (1), we performed BAL with 50 mL saline, then the retrieved BAL AFB on saline samples and 3 only were positive by ZN stain for AFB on
SB samples, with no statistically significant difference between saline and
was divided into two equal volumes; one diluted with equal volume of saline
SB (p=0.125) Table 5. In addition, there was no statistically significant
(group 1a) and the other diluted with equal volume of SB (group 1b in vitro), difference between saline and SB samples in the median grading of positive
and 56 patients in group 2, BAL was done with 10 mL of saline (group samples for AFB (grade 4 for saline and grade 0 for SB with p=0.066) Table
2a for detection of the organism (s) before the effect of SB and a relatively 7. However, while 7 patients in group (1) demonstrated positive TB culture
small volume to avoid dilution) followed by BAL with 50 mL SB (group 2b). on saline; only one patient of them demonstrated positive M.TB culture on
By measurement of pH of the investigated samples, there was a significant SB samples, with statistically significant difference between saline and SB
increase of pH in SB samples versus that with saline samples (8.22 ± 0.33 samples (p=0.031) Table 5. Also, although there was reduction in number
versus 6.39 ± 0.32). This indicates that BAL with SB 8.4% is effective in of patients with smear positive TB in group 2 (6 in a2 vs. 3 in samples b2);
alkalinization of respiratory tract secretions. K. pneumoniae and P. aeruginosa there was no statistically significant difference between the two samples
were the most common isolated Gram negative organisms, it was isolated (p=0.250) Table 6. Iivanainen and colleagues [37] studied the occurrence
from 15.57% and 14.75% of patients respectively. of mycobacteria in aerobic brook sediment. They found that the culturable
counts of mycobacteria correlated negatively with water and sediment pH and
Streptococcus pneumoniae was the most common single Gram positive bacteria with alkalinity of water, and that acidity increases the count of mycobacteria.
(5.74%) Table 4. These results were near to that reported by Okesola and Also Parashar et al. [38] studied the effect of neutralization of the gastric
Ige [22] who studied bacterial isolates from the sputum of patients with aspirate with SB in children with intrathoracic tuberculosis. Gastric aspirates
LRTI. The most prevalent single pathogen was K. pneumoniae (38%). Also, were divided into two aliquots, and only one aliquot was neutralized with
Vishwanath and colleagues [23] studied sputum and BAL samples from 1% SB. Both aliquots were processed for smear and culture examinations.
patients with LRTI. K. pneumoniae was the most common Gram-negative There were no differences in smear positivity rates from samples with or
bacilli (37%) in their study followed by P. aeruginosa (28.6%). On the other without neutralization. The yield of MTB on a Bactec MGIT 960 culture
hand, Khan and colleagues [24] studied 426 patients with suspected LRTIs, system was significantly lower in the neutralized samples (16.3% [38/232])
the samples used in their study were sputum, endotracheal aspirates and than in the non-neutralized samples (21.5% [50/232]) (P=0.023).
bronchial washings; and Gram-negative bacteria were isolated in 80.9% of CONCLUSION
the cases with P. aeruginosa was the most predominant pathogen (47.2%)
followed by H. influenzae (27.6%), K. pneumoniae (14.6%) and E. coli (10.6%). -Sodium bicarbonate 8.4% is inhibitory for bacterial, fungal and mycobacterial
Also, Shrestha et al. [25] studied 240 sputum specimens and found that growth in the specific cultures and disturbs staining of Mycobacteria by ZN
Pseudomonas spp. was the most common isolates obtained followed by K. stain.
pneumoniae. Graffelman and colleagues [26] studied the aetiology of LRTI -BAL with SB 8.4% is safe to the patients in group 2 with no considerable
in general practice in Netherlands; sputum, blood and throat swabs were side effects.
6 Chest Lung Res Vol 1 No 1 November 2018
 Effect of sodium bicarbonate 8.4% on respiratory tract pathogens

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- Application of SB can be used as an adjuvant to the antimicrobial,
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lower respiratory tract are in need for more researches for titration
and adjustment. 21. https://www.drugs.com/cdi/sodium-bicarbonate-injection.html
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