THIS PRESENTATION WAS

PRESENTED AT APOLLO INTERNATIONAL

FORUM ON INFECTION CONTROL

(AIFIC’ 2013), CHENNAI

The presentation is solely meant for Academic purpose

ROLE OF MICROBIOLOGY LABORATORY IN INFECTION CONTROL

ROLE OF MICROBIOLOGIST IN ORGANIZING THE LAB

Lab results form an integral part of the complex decision making process and may influence upto

70% of medical diagnosis

To ensure the same, the lab has to issue quality reports

Quality of report relies on quality of clinical specimen submitted

To avoid pre-analytical errors, lab has to putforth

Specimen acceptance & Rejection criteria

Specimen to be submitted with relevant clinical details

Open and free communication between Clinicians & Microbiologist / Micro Lab essential

Facility to access patient records preferred (healthcube)

CRITERIA FOR REJECTION OF SPECIMEN

Problem Action

Improper or no label Telephone the nurse or physician , process the specimen but do not issue the report

Prolonged transport Alert the concerned staff & request a repeat specimen

Improper container Do not process & request a repeat specimen

Leaking container Do not process & request a repeat specimen. Protect the laboratory staff

Oropharyngeally contaminated

Do not report or process. Indicate the discrepancy & request another specimen

Obvious foreign contamination

Alert the concerned staff & request a repeat specimen

Problem Action

Duplicate specimens submitted on same day for same request

Refrigerate the specimen, contact the concerned staff. Culture on request only

Specimen unsuitable for culture request e.g., anaerobe request with aerobic transport

Contact the concerned staff, indicate the discrepancy, request a proper specimen

Quantity not sufficient For blood: if < 5ml for an adult, inform the concerned staff, request another specimen. Process but add note on report

For other specimens: if quantity not sufficient for multiple requests, call the physician and determine the priority of request

Specimen Collection, Transport and Processing:

General Instructions for collection of culture specimens

Select the correct anatomic site

Collect the specimen using proper technique & supplies

Package the specimen in appropriate container

Transport promptly to the lab within 2 hrs of collection

Conditions of transport & storage of samples

Profound influence on their usefulness

Follow standard techniques to process samples

Fulfill quality control requirements

Quality Control check for media and stains

Potency testing for antibiotic disk

Sterility check for collection containers

Identify causative organism to species level

Use of automation helps speedy isolation &

identification

- Automated blood culture systems

Automated ID & sensitivity systems

Interpret results judiciously

Differentiate commensals / colonizers from

pathogens

Perform quantitative cultures wherever required

ANTIBIOTIC SENSITIVITY TESTING

Kirby-Bauer Disk Diffusion Method – Points to remember :

McFarlands Standard for inoculum preparation

Depth of the media and pH

Proper storage of antibiotic disk

Proper placing of the disk- use template

16 – 18 hrs of incubation

24hrs for Staph and Entero

- Oxacillin & Vancomycin

Selection of Anti microbial disk :

Based on type of organism & source of isolate

Formulate Inhouse Antibiotic Policy with reference to

international guidelines

Use 1st line of antibiotics for out patient isolates

2nd line to be used if resistance noted to 1st line & for

isolates from critically ill patients

Use of E-strips for fastidious organisms / CSF isolates /

Ciprofloxacin to Salmonella

Interpret according to International Guidelines

SMF Antibiotic Policy – Restrictive Policy

1ST & 2ND LINE ANTIBIOTICS FOLLOWED AT SMF

1st line of Antibiotics 2nd line of Antibiotics (Restricted)

Penicillin-G Ampicillin Cephalexin Ciprofloxacin Ofloxacin Nitrofurantoin Nalidixic acid Gentamycin Tobramycin Azithromycin Norfloxacin Cotrimoxazole Ofloxacin Amoxy/clav Cefuroxime Cefixime Ceftriaxone (Salmonella) Clindamycin

Amikacin

Ceftazidime

Cefotaxime

Cefepime

Piperacillin/tazo

Cefaperazone/sul

Imipenem

Meropenem

Ertapenem

Aztreonam

Vancomycin

Linezolid

Teicoplanin

Polymixin-B

Colistin

Looking for Resistance patterns: (to guide

antibacterial therapy)

Lab to detect common resistant mechanisms

β-lactamase detection with Cefinase disk

Screening for ESBL & Amp 'C' β-lactamase with

Cefpodoxime & Cefoxitin disk

Performing DDPT for phenotypic confirmation of ESBL

Can be performed while testing 2nd line of antibiotics

Oxacillin & Cefoxitin disk for Staph. isolates

Look for Inducible Clindamycin resistance in Staph isolates

- D Test

Quinolone resistance in Salmonella

- Nalidixic Acid disk as marker

- E-strip to Ciprofloxacin

Detection of Carbapenamase

- Modified Hodge test

- EDTA disk synergy test

Other methods for resistance detection

- Automated ID & Sensitivity System (Vitek 2)

- Molecular methods

Infection Control Critical Values (Early Warning Systems)

Micro lab to inform ICN on a daily basis:

- MDR GNB, MRSA, VRE

- Sputum AFB + cases

Microbiologist to note suspected HAI in HAI chart

Convey to ICN for data collection in surveillance form

Inform notifiable diseases to MRD Chennai Corporation

- Dengue

- Typhoid

- Chikungunya

- Malaria

- Swine flu

Role of Microbiology lab in Hospital Infection

Control

Identifying outbreaks early- Pseudo or true outbreak

Conveying information to ICT & concerned ward/unit

Charting down action plan, control measures

Implementation through ICT

Monitoring effectiveness of control measures

Stock isolates from patients & suspected source

Source identification using phenotypic & molecular

methods

Designing the HIC Plan in accordance with

infrastructure & consensus of user departments

Monitoring key infection control measures along with

ICN

- Hand hygiene practices

- Standard & Isolation precautions

Compiling Culture & Sensitivity Data of hospital

isolates

Periodical review of culture & sensitivity patterns

Analyze sensitivity pattern of isolates from :

- Out patients & inpatients separately

- Pediatric age group and adults separately

- Resistant isolates from that of sensitive isolates

Prepare a chart at the end of the year

To help Clinicians

- to know the common pathogens &

their sensitivity pattern

- to formulate Empirical Antibiotic of Choice

OCCUPATIONAL EXPOSURES – REPORTING

& POST EXPOSURE PROPHYLAXIS

Needle Stick Injuries – Reporting Protocol

Reported immediately to ER Medical Officer

Assess injury & takes action

Enter details in Occupational Exposure Form

Inform ICN & Microbiologist

Source (if known) & Staff evaluation for viral

markers

Micro lab to process samples as Stat

Reports conveyed to Microbiologist & ICN

Counseling done

Post Exposure Prophylaxis:

If source negative for viral markers - only counseling

If source positive consult ID & initiate PEP

If employee vaccinated for HbsAg assess

AntiHBs titres

If titre low booster dose

If negative Re vaccination

If source unknown Anti HBs tires for Staff &

follow up

Employee Health:

Pre employment health check up

Staff in direct patient care tested for :

- HBsAg

- HIV at entry time

- HCV

Vaccination details collected

Vaccination for Hepatitis B (3 doses) if not

vaccinated

Canteen & Dietary staff – Typhoid, Hepatitis A & B

Maintenance staff - Typhoid, Hepatitis B

Bio Medical staff - Hepatitis B

Lab staff – Hepatitis B, Microbiology – Typhoid

Influenza vaccine if there is outbreak

Food handlers health check up once in a year

Anti HBs titres checked after vaccination

Bio Medical Waste management:

ICT to educate hospital staff on waste segregation

Included in the induction training for House Keeping,

Nursing & other para medical staff

Re-education as & when required

ICN monitors segregation on a daily basis

HK Supervisor ensures safe transportation

Handing over to Central facility

Records maintained by HK Supervisor

Thank

You