How the clinical microbiologist should report the laboratory Results

REPORTING�IN� DIAGNOSTIC �MICROBIOLOGY by Dr.T.V.Rao MD

1. REPORTING IN DIAGNOSTIC MICROBIOLOGY Dr.T.V.Rao MD 5/1/2018 Dr.T.V.Rao MD

2. FROM PAST TO FUTURE WE ARE IN TRANSITION 5/1/2018 Dr.T.V.Rao MD

3. WHAT IS A REPORT Writing lab reports is part of learning to be a scientist, and provides you with experience in writing in a scientific style similar to that used in articles published in Text books scientific journals. 5/1/2018 Dr.T.V.Rao MD

4. Future of Biology Changed with PCR 5/1/2018 Dr.T.V.Rao MD

5. Career in Transition from Clinics to Laboratory 5/1/2018 Dr.T.V.Rao MD

6. Infectious Diseases are many limited by our knowledge, facilities and ignorance? Bacterial Viral Fungal Parasitic 5/1/2018 Dr.T.V.Rao MD

7. 3 great ideas to improve the diagnostic microbiology Were the reports provided are accurate? Were they clinically relevant? Could we improve? 5/1/2018 Dr.T.V.Rao MD

8. Supporting Laboratory Results Viral Identification of virus Normal or Decreased WBC Count Increased Lymphocyte Count Parasitic Identification of parasite Increased Eosinophil Count Bacterial Identification of bacteria Increased WBC Count Increased Neutrophil Count Left-shift in Neutrophil Cell Line Increased CRP Increased Sed -Rate Fungal KOH Prep Test Identification of fungal elements 5/1/2018 Dr.T.V.Rao MD

9. Think before reporting Microbiology results we perform has many limitations To determine significance of result requires knowledge of the patient’s clinical status The report should encourage communication between clinician and medical microbiologist 5/1/2018 Dr.T.V.Rao MD

10. Microbiology is not a accurate Science To determine significance of result requires knowledge of the patient’s clinical status The report should encourage communication GOOD COMMUNICATION ? Makes a difference 5/1/2018 Dr.T.V.Rao MD

11. Key points - 1 Microbes are infectious agents not visible to the naked eye Widespread in nature and some cause human disease Diagnosis of infection by the microbiology laboratory has two important functions Clinical Epidemiological surveys within and outside the Hospital The laboratory should determine the most frequent microbes causing infections, including HAI pathogens 5/1/2018 Dr.T.V.Rao MD

12. Why Plan? Laboratory requirements relate to investigation objectives confirm a diagnosis to document an infection? document a common source? provide information to help clinical management (antibiotic resistance)? What laboratory tests help answer the objective(s)? What specimens are required for the laboratory test(s)? What’s the sampling strategy? 5/1/2018 Dr.T.V.Rao MD

13. Definition of Terms Normally sterile site: sites in the human body that are normally free from organisms or foreign material, e.g. blood, joint, brain, etc. Unsterile site: sites in the human body that generally harbor microorganisms, e.g . gut, oral cavity, nose, skin, etc Specimen : a sample of tissue (blood, urine, etc.) that may or may not contain organisms Isolate: a population of organisms (bacteria) that has been separated from a mixture Serotype : a group of closely related organisms with distinct characteristics. Assay: A test to detect or quantify a substance in a sample. Dr.T.V.Rao MD 5/1/2018

14. Laboratory Reports 5/1/2018 Dr.T.V.Rao MD

15. Simplifying Laboratory Test Interpretation WE SHOULD REPORT THE LABORATORY TEST RESULTS AND MAKE MATTERS SIMPLE WE ADVICE AND SUGGEST WE IGNORE TOO 5/1/2018 Dr.T.V.Rao MD

16. Laboratory Tests Detection Methods Microscopy Culture Antigen test* Identification Methods PCR* Viral load* PFGE Genotyping Serology Antimicrobial susceptibility Ancillary tests Dr.T.V.Rao MD 5/1/2018

17. DEFINITION of Critical results are results that are considered potentially life threatening unless acted upon promptly. Fast communication matters ? Urgent results are results that are not critical but sufficiently significant to alert the health care provider 5/1/2018 Dr.T.V.Rao MD

18. Culture The process of growing and propagating organisms in a media that is conducive for their growth. Pros: Confirm the organism Reproduce the organism and use for additional testing Cons: Delay in confirmation Require viable organism Difficult for fastidious organisms S. pneumoniae on blood agar plate Dr.T.V.Rao MD colony 5/1/2018

19. HOW TO USE THE LABORATORY Reports to the clinician from the clinical microbiology service can provide comments that interpret isolate significance, provide antimicrobial susceptibility interpretation and provide antimicrobial management advice 5/1/2018 Dr.T.V.Rao MD

20. Microbiology Differs from other Laboratory services 'How is this result to be explained to the clinician?' is an equally important question, as yet little discussed. 5/1/2018 Dr.T.V.Rao MD

21. Tips when reviewing a laboratory report IS IT A INFECTION Is the organism (or disease) reportable? When was the specimen obtained in relation to onset of illness? Was the source from a normally sterile site? Were antibiotics used prior to specimen collection ? Dr.T.V.Rao MD 5/1/2018

22. LIST OF CRITICAL RESULTS · Positive results from direct examination (e.g., Gram stain) of normally sterile body fluids/sites, including blood, CSF and tissue.Positive culture results for normally sterile body fluids/sites, including blood, CSF and tissues. · Malaria 5/1/2018 Dr.T.V.Rao MD

23. 'Is it significant 'Is it significant?' is the question posed, implicitly or rexplicitly, whenever a culture from a patient has yielded a micro-organism. 5/1/2018 Dr.T.V.Rao MD

24. Antimicrobial Susceptibilit y MIC (minimum inhibitory concentration) lowest concentration of antimicrobials that will inhibit the growth of organisms. MICs are important to confirm resistance of organisms to an antimicrobial agent. Methods: Disk diffusion test E test Broth dilution test Dr.T.V.Rao MD MIC Zone of Inhibition 5/1/2018

25. Reporting susceptibility reports Consider: Recommendations for therapy at each stage of reporting Adding interpretive comments Keep it clinically relevant 5/1/2018 Dr.T.V.Rao MD

26. Utilization of Culture Report s Review of culture reports in 1050 hospitalized patients Only 7% of culture results resulted in a change of therapy Ref Edwards et al Arch Intern Med 1973 5/1/2018 Dr.T.V.Rao MD

27. Why many Antimicrobial susceptible results are not used by clinicians? Information overload multiple specimens from different sources eg from ICU in a critical patient, Reports more allied to the laboratory than to the clinician Confusion between accuracy and clinical relevance Common laboratory terms cause confusion Ref Edwards et al Arch Intern Med 1973 5/1/2018 Dr.T.V.Rao MD

28. a laboratory result cannot be confusing factor try solving the problem 5/1/2018 Dr.T.V.Rao MD

29. MEDICAL LABORATORY PROFESSIONALS WEEK APRIL 22-28, 2018 Medical Laboratory Professionals Week (MLPW) provides the profession with a unique opportunity to increase public understanding of and appreciation for clinical laboratory personnel. MLPW, which takes place the last full week in April each year, is coordinated by a collaborative committee with representatives from 17 national clinical laboratory organizations, including ASCLS. Now in it's 43rd year, 5/1/2018 Dr.T.V.Rao MD

30. Faster Results in ICU Care The establishment of best practice procedures for rapid microbiological evaluation is critical to delivering timely and accurate information 5/1/2018 Dr.T.V.Rao MD

31. Laboratory reports in ICU Care Intensive care units are an area of particular importance, as the control of resistance in these units can affect other areas of the hospital. The clinical microbiology service should therefore pay particular attention to services provided to these areas. 5/1/2018 Dr.T.V.Rao MD

32. How Surveillance Data helpful The clinical microbiology service provides surveillance data on resistant organisms for infection control purposes. Try implement the WHONET software with inclusion of CLSI GUIDELINES , 5/1/2018 Dr.T.V.Rao MD

33. The Wisdom of Microbiologists a great contribution Microbiology reports should also include a range of comments to help clinicians distinguish infection from contamination or colonisation (i.e. antimicrobial therapy is therefore not required) 5/1/2018 Dr.T.V.Rao MD

34. Challenges with Automation Rushing to introduce automation without careful planning to account for existing clinical processes is the Achilles’ heel of any health IT implementation 5/1/2018 Dr.T.V.Rao MD

35. Interpretative reporting of microbiology Interpretative reporting of microbiology results entails the addition of a comment to the report, giving the likely significance of the organism(s) isolated and, where necessary, specific advice on therap y. 5/1/2018 Dr.T.V.Rao MD

36. How much our Reports accepted ???? The use of interpretative comments appended to microbiology reports has been shown to allow clinicians to make informed decisions based on such reports . 5/1/2018 Dr.T.V.Rao MD

37. Parasitology & Mycology Direct Examination Macroscopic and Microscopic 5/1/2018 Dr.T.V.Rao MD

38. Education of Clinicians a challenging task There is clearly a need for education of clinicians regarding indications for sending specimens and applying results to patient management . 5/1/2018 Dr.T.V.Rao MD

39. Alert organism reports Identify possible agreed ‘alert’ microorganisms Methicillin-resistant Staphylococcus aureus (MRSA) Vancomycin-intermediate S.aureus (VISA) Vancomycin-resistant enterococci (VRE) MDR Pseudomonas aeruginosa MDR Acinetobacter baumannii MDR Mycobacterium tuberculosis ESBL enterobacteria Clostridium difficile 5/1/2018 Dr.T.V.Rao MD

40. 5/1/2018 Dr.T.V.Rao MD

41. Writing style in lab reports When writing a lab report it is important you use a scientific writing style. This means you should aim for writing that is clear, objective, accurate and brief. It is best to use short simple sentences rather than long complicated ones that have the potential to confuse the reader. Although you will need to use specialist terms in your report, you should also use familiar non-technical terms where possible 5/1/2018 Dr.T.V.Rao MD

42. Communication solves many ill understood ideas Encourage two way communication with laboratory Employ terms that are readily understood Communicate clinically relevant results (probable infection or probable contamination) State when further clinical assessment required 5/1/2018 Dr.T.V.Rao MD

43. Documenting and Auditing with WHO NET The clinical microbiology service provides surveillance data on resistant organisms for infection control purposes. Try implement the WHONET software with inclusion of CLSI GUIDELINES , 5/1/2018 Dr.T.V.Rao MD

44. GRWOING DEMANDS ON CLINICAL MICROBIOLOGISTS The clinical microbiology laboratory is being challenged to do more work, identify more microorganisms, report complex and changing drug-related information, automate procedures, 5/1/2018 Dr.T.V.Rao MD

45. Technology developing faster than we understand the pitfalls With change, though, as always, there are challenges: technology is developing at an almost too-rapid pace, vast amounts of information which are difficult to manage and communicate are being generated, standards either do not exist or are not adequately useful for many targets/platforms, 5/1/2018 Dr.T.V.Rao MD

46. Growing Challenge to Medial Microbiologists Many decisions in clinical microbiology practice are not being made using evidence based information. Ultimately, we need to be able improve how we communicate so that we are more effective in our ability to report results and ensure appropriate interpretation 5/1/2018 Dr.T.V.Rao MD

47. Using laboratory evidence to confirm a diagnosis during an outbreak Short list potential etiologic agents (hypothesis generating) according to: Epidemiological characteristics Clinical characteristics Setting Test for agents short listed (hypothesis testing) Positive test Negative test Use predictive values positive and negatives 5/1/2018 Dr.T.V.Rao MD

48. Whats the Clinical Benefit of our reporting 'How is this result to be explained to the clinician?' 5/1/2018 Dr.T.V.Rao MD

49. A test was negative only for the pathogens that were looked for If the culture on a specific medium was not done, the test cannot be interpreted as negative for the specific pathogen If you did not ask for Campylobacter culture, the “negative” stool culture is not really “negative” for Campylobacter 5/1/2018 Dr.T.V.Rao MD

50. Reporting Results Clinical microbiology laboratory needs include reporting nonnumerical results, such as the genus and species name of an identified organism., 5/1/2018 Dr.T.V.Rao MD

51. qualitative, semiquantitative, and/or quantitative data, Microbiology results often include qualitative, semiquantitative, and/or quantitative data, 5/1/2018 Dr.T.V.Rao MD

52. laboratory REQUEST is consolation Every microbiology sample is a consultation, Making sure the report it is accurate is good Making sure the report is clinically relevant and clear is better Making sure the report optimizes clinical outcome is best 5/1/2018 Dr.T.V.Rao MD

53. Err is Human Sources of potential cases of laboratory-related adverse events include internal laboratory incident reports, risk management incident reports, physician complaints and other forms of physician collaboration, and a variety of daily information system reports 5/1/2018 Dr.T.V.Rao MD

54. Correction is Divine In the testing process areas involving non-laboratory personnel, interdepartmental communication and cooperation are crucial to avoid errors. 5/1/2018 Dr.T.V.Rao MD

55. TEAM EFFORT MAKES A GREAT DIFFERENCE Therefore the entire health care system must be involved in improving the total testing process. There must be adequate and effective training of personnel throughout the institution 5/1/2018 Dr.T.V.Rao MD

56. Who will Sign Laboratory Reports 5/1/2018 Dr.T.V.Rao MD

57. Solving Laboratory conflicts Very simply, Scott believes that the first step should be to get rid of the emotions behind the issue.. Step two is a close examination of the issues behind the conflict. This rational thought process is then (in step three) supplemented by your intuition about the choices in front of you. Overcoming Conflicts in the Lab—and Beyond 5/1/2018 Dr.T.V.Rao MD

58. HUMAN NEEDS MORE IMPORTANT THAN OUR EGOSTIC FIGHTING You can't solve the problem without understanding the human needs and interests of the people involved in the conflict. 5/1/2018 Dr.T.V.Rao MD

59. Summary Basic understanding of a laboratory test is key to maximizing its use. Laboratory tests have ‘strengths’ and ‘weaknesses ’. Timing is everything! ( between disease onset and specimen collection ) 5/1/2018 Dr.T.V.Rao MD

60. LIFE IS A GREAT FIGHT TO SURVVIE MORE QUESTIONS THAN ANSWERS 5/1/2018 Dr.T.V.Rao MD

61. Younger Microbiologists Under stress and accountability 5/1/2018 Dr.T.V.Rao MD

62. Program Created by Dr.T.V.Rao MD for benefit of Medical and Clinical Microbiologists in the Developing world Email [email protected] 5/1/2018 Dr.T.V.Rao MD