How the clinical microbiologist should report the laboratory Results

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

FROM PAST TO FUTURE
WE ARE IN TRANSITION

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.

Future of Biology Changed with PCR

Career in Transition from Clinics to Laboratory

Infectious Diseases
are many limited by our knowledge, facilities
and ignorance?
•Bacterial
•Viral
•Fungal
•Parasitic

3 great ideas to improve the
diagnostic microbiology
• Were the reports provided
are accurate?
• Were they clinically
relevant?
• Could we improve?

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

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

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

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

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?

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 MD5/1/2018

Laboratory Reports

Simplifying Laboratory
Test Interpretation
•WE SHOULD REPORT
THE LABORATORY TEST
RESULTS AND MAKE
MATTERS SIMPLE
•WE ADVICE AND
SUGGEST
•WE IGNORE TOO

Laboratory Tests
Detection Methods
oMicroscopy
oCulture
oAntigen test*
 Identification Methods
o PCR*
o Viral load*
o PFGE
o Genotyping
 Serology
 Antimicrobial susceptibility
 Ancillary tests

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

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

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

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.

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?

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.
• ·Malaria5/1/2018 Dr.T.V.Rao MD

'Is it significant
•'Is it significant?' is
the question posed,
implicitly or
rexplicitly, whenever
a culture from a
patient has yielded a
micro-organism.

Antimicrobial Susceptibility
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
5/1/2018

Reporting susceptibility reports
•Consider:
Recommendations for
therapy at each stage
of reporting
Adding interpretive
comments
Keep it clinically
relevant

Utilization of Culture Reports
•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

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

a laboratory result cannot be confusing factor
try solving the problem

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,

Faster Results in ICU Care
•The establishment of
best practice
procedures for rapid
microbiological
evaluation is critical to
delivering timely and
accurate information

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.

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,

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)

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

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 therapy.

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.

Parasitology & Mycology
• Direct Examination
• Macroscopic and Microscopic

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.

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

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

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

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,

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,

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,

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

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

Whats the Clinical Benefit of our reporting
•'How is this
result to be
explained to
the clinician?'

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

Reporting Results
•Clinical microbiology
laboratory needs
include reporting
nonnumerical results,
such as the genus and
species name of an
identiﬁed organism.,

qualitative, semiquantitative, and/or
quantitative data,
•Microbiology
results often
include qualitative,
semiquantitative,
and/or
quantitative data,

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

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

Correction is Divine
•In the testing process
areas involving non-
laboratory personnel,
interdepartmental
communication and
cooperation are crucial
to avoid errors.

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

Who will Sign Laboratory Reports

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

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.

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)

LIFE IS A GREAT FIGHT TO SURVVIE
MORE QUESTIONS THAN ANSWERS

Younger Microbiologists Under stress and
accountability

•Program Created by Dr.T.V.Rao MD for benefit
of Medical and Clinical Microbiologists in the
Developing world
• Email
• doctortvrao@gmail.com

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How the clinical microbiologist should report the laboratory Results