ICT asked Loretta Litz Fauerbach, MS, FSHEA, FAPIC, CIC, of Fauerbach & Associates, LLC, about the imperatives relating to infection preventionists' grasp of clinical microbiology in their HAI-prevention work.
Q: How would you describe the current relationship between IPs and their clinical microbiology labs? How can it be enhanced?
A: When the new IP has his/her first encounter with the micro lab, it can be quite intimidating. The lab is shrouded in mystery for the non-laboratorian since it is usually tucked away from the main thoroughfare in a restricted access area. The IP may feel like he/she is going on a scavenger hunt in the world of medical pathogens. The world of microbiology will open new horizons for the IP and be a rewarding experience. It should become one of the most valuable relationships for the IP. The new IP or even a seasoned IP should spend time in the lab to improve or maintain their understanding of laboratory results. The micro lab of the past has significantly changed due to the constantly evolving new tests and evolving technology in laboratory science.
Observation of automatic techniques, site reading of cultures, inoculation for chemical analysis are features of the microbiology lab which are important to understand. Although the IP will need to commit time to learn what the micro lab has to offer may, the IP will realize that is well worth it. One key to the success of a new IP’s practice is becoming familiar with and actively working with the microbiology laboratory. Even if the IP had been familiar with the lab, the IP must expand his/her understanding of the critical role microbiology lab plays in a successful infection prevention and control program and build new communication and linkages to the area.
The microbiology laboratory has these main functions: patient diagnosis of infection by identifying the causative agent; provide rapid and accurate identification of the agent for appropriate treatment and finally to provide epidemiological trending of the microbial organisms that are associated with infections especially healthcare-associated infections (HAIs). It is also critically important that the laboratory establishes and maintains quality assurance procedures to assure accurate data.
The partnership between the lab and the IP is mutually beneficial since both professions have knowledge and information to share. The IP can provide the clinical case information that makes the microbial culture results come “alive”. The microbiologist can discuss the uniqueness of the isolated microbe and the optimal culture techniques and timing of cultures for the best results. They also can identify antimicrobial susceptibility results to aid in selecting the ideal antibiotic. Regularly scheduled plate rounds in the micro lab with the infectious disease and infection prevention teams participating is a wonderful opportunity to learn, teach and improve understanding. Unit rounds led by the infectious disease physicians with the micro lab personnel and infection preventionist also enhances understanding and promotes effective communication. Everyone benefits from these activities; they learn the what is important to each group and these interactions promote teamwork.
The IP can also share his/her knowledge of surveillance and definitions of healthcare associated infections with the microbiology team. From my experience, the technologists appreciate learning more these components of an infection prevention program. Over the years, I have seen these educational exchanges lead to some technologist seeking to become infection preventionists.
A representative of the microbiology laboratory staff should be a member of the infection prevention and control committee and work with the antimicrobial stewardship program to provide pertinent information. The microbiologist should confer with the clinicians related to antimicrobial susceptibility testing to make sure the right antibiotics are being tested on the right microbial isolates. I like to think of the relationship between the infection prevention team and microbiology laboratory should be supportive and dependent on each other in order to optimally achieve their goals.
Q: How critical is it for IPs to have a good grounding in clinical microbiology and how it applies to their work?
A: IPs use their knowledge of clinical microbiology daily in their practice. Together with the laboratory staff they identify the best test to order to provide a diagnosis. It may be routine cultures of specimens such as urine, blood, wound secretions, and respiratory secretions. Traditionally, these cultures routinely take 48 to 72 hours for results. However, modern technology has improved turn-around time by new technology that can identify the organism directly from the blood without have to culture it on agar plates. One of the rapid diagnostic tests may provide the best information. The IP also needs to understand the specificity and sensitivity of the diagnostic tests.
Knowing the different bacterial genus and species helps to provide a contextual interpretation of the microbial culture results. Is the isolated organism part of normal upper respiratory flora or is it a known pathogen such as Group A Streptococci (Streptococcus pyogenes)? The IP must apply his/her knowledge of microbiology when he/she is performing surveillance for healthcare associated infections. Certain antibiotics are effective only against Gram-positive organisms or Gram-negative organisms. They also should be able to recognize when abnormal susceptibility patterns are identified for bacteria isolated from a clinical specimen. It may be an error, or it may be a sentinel event forecasting a potentially new resistance.
Q: What are the clinical microbiology-related knowledge gaps among IPs and how can these be mitigated?
A: There are several shared challenges for both microbiologist and the infection prevention. Staying abreast of the evolving technology and tests and evaluating the need to implement in their facility is a major responsibility of the lab, but the IP and ID must also understand the impact of these new tests on patient care. They must understand what a new test can or cannot do, its sensitivity and specificity and how the results relate to the previous tests. With the introduction of respiratory virus PCR testing new panels were developed and results tested for 20 different viruses. When introducing new tests, the laboratory, infection preventionists and infectious disease physicians need to learn about the test and be able to answer questions for the healthcare providers. Presenting at grand rounds, posting a notice on the electronic medical record, linking to a self-study program or presenting at department or unit meetings would help assure a smooth transition to a new test.
Infectious disease departments usually have case conferences where staff present cases involving a specific patient. The microbiologist and the infection prevention are often invited to attend and share their knowledge of the case or the particular organism or the infection. It provides a forum for learning, sharing critical information and team building.
Changing nomenclature is also a challenge for both professions - what was once called by one name are being renamed based on better genetic identification through whole genome sequencing. For example, Pseudomonas capacia is now Burkholderia cepacia or Moraxella (Branhamella) catarrhalis was formerly Neisseria or Micrococcus catarrhalis. Branhamella was created in honor of the work done by Sara E. Branham.
Q: Do you have other observations related to the imperatives between infection prevention and clinical microbiology?
A: Today’s modern microbiology laboratory communicates their results through an electronic information system. Labs in limited resource areas may not have a sophisticated reporting system. Nevertheless, the communication of microbiological results is paramount to patient care, infection prevention and antimicrobial stewardship programs. The importance of Informatics continues to grow contributing to improvement in workflow, timeliness and cost. The IP should be included in the discussion related to the informatics and what is needed to facilitate infection prevention. There must be agreement on what is to be reported for clinically important specimens such as cerebral spinal fluid and epidemiologically significant organisms, the timing of these report and who should be notified. These reports should be done through verbal notification and followed up with the usual reporting mechanism.
Infection prevention and microbiologists need very similar epidemiological data to provide the best information and interpretation of the microbiological data. The W’s of epidemiology reflect the critical information needed: where the patient is, when was the specimen taken, what type of specimen was submitted to the laboratory; who is the patient and was the specimen collected at the right time, was the specimen the best to diagnose the suspected infection and was it collected appropriately and transported to the laboratory. The microbiology laboratory, infection prevention and the infectious disease physicians must collaborate to be assure that these key pieces of information are available and that the best procedural processes for collecting a specimen are used. Inappropriate collection and transport practices including delays in getting the specimen to the lab can adversely impact the efficacy of the laboratory results.
With the advent of direct laboratory electronic data reporting, the epidemiological/public health role of the clinical microbiology laboratory and the infection preventionist are further aligned in response to mandatory reporting. Sentinel organism surveillance data for Clostridium difficle and multidrug-resistant organisms (MDROs) such as carbapenem-resistant Enterobacteriaceae (CRE) are reported to government agencies via the lab electronic medical database. Analysis of the trends in microorganisms can often identify outbreaks and assist in outbreak investigations, not only at the local level but at state and regional levels as well. The CDC has funded regional public health reference laboratories to expand surveillance data and improve identification of microorganisms and antimicrobial susceptibility testing that can identify common microorganisms and determine when additional testing such as molecular typing would be useful. It is very helpful to talk to the regional laboratory to understand how they function and how they should be contacted when needed. It will be helpful to have the procedure defined prior to an outbreak or the occurrence of an emerging pathogen. Finally, the review and analysis of microbiology data can provide and interpret accurate antimicrobial susceptibility patterns for use in treatment and antimicrobial stewardship activities.
Unfortunately, many labs are not funded to cover the cost of working up clusters and outbreaks especially in resource limited settings. Both the laboratory and infection prevention would benefit with improved funding for these functions. Typing of isolates can determine the relatedness of organisms to identify/confirm clusters or outbreaks. Not all facilities have the capacity to preform typing, if a facility does not have the capability, they should have a procedure developed for using a reference lab or the state or regional public health lab as appropriate. Typing can identify common reservoirs and potential carriers. Typing can also identify that even though the same genus and species has been isolated from a common area that the isolates are genetically different. Knowing if isolates are related or not allows the micro IP teams focus on prevention and control activities. It can determine prevalence and mode of transmission which will assist in controlling and containing the outbreak causative microbe.
In conclusion, infection prevention and microbiology are partners in infection prevention and control as well as antimicrobial stewardship programs. They should collaborate in developing policies and procedures, setting up communication work flow, assuring quality practices, and educating other healthcare professionals on infection prevention and the agents of causing healthcare associated infections and other infectious diseases.
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