Limitation of Diagnostic Microbiology Departments

What Clinicians Should Know?

Dr.T.V.Rao MD

Majority of the Diagnostic Microbiology laboratories are utilised for Diagnosis of Bacterial, Fungal and Virus Infections, which have rapid solutions if promptly treated. The word Infection still confuses many Clinicians and Microbiologists, and they send the specimens to laboratories for immediate solutions. The malady of Microbiology starts with few qualified nurses to collect specimens, every specimen makes the difference in bacterial flora and contamination continues to hamper the quality of services. Blood collection for blood cultures remain the grey area and major loss of specimen value. The doctors and nurses fail to give proper instructions to the patient. I am certain very few laboratories get an ideal sample, rejecting the sample creates conflict between a clinician and laboratory personal. Everyone at the end of the day accepts all the specimens and processed as we practice a path of least resistance. A microorganism is judged as sensitive or resistant according to the diameter of the zone of inhibition of from purified isolate from cultural growth, which is then correlated statistically with the minimal inhibitory concentration (MIC). The degree of correlation depends on both the antibiotic and the species tested; between 71% and 90% of the results of disc diffusion were consistent with the Minimum inhibitory concentration, which is not done routinely in majority of the laboratories as at it costlier and processing of specimen will

increases to more than 10 times. The expected error distribution cannot be reliably predicted by regression analysis. Especially those bacteria which are classified as having intermediate sensitivity in their inhibition zones, based on their MIC values, have, in fact, intermediate sensitivity in less than 50% of the cases. It is also necessary to use methods which take the biological and methodological variations of daily routine into account. In critical cases such as life-threatening infections or apparent failure of the patient to respond to antibiotic therapy, the MICs of selected agents should be determined. The tests are performed under standardized conditions so that the results are reproducible. The test results should be used to guide antibiotic choice. When a microorganism is isolated from a patient, the microbiology laboratory will often perform susceptibility testing. There is often confusion about what these results mean and how it can be used by the clinician to guide the treatment of the patient. The results of antimicrobial susceptibility testing should be combined with clinical information and experience when selecting the most appropriate antibiotic for your patient. We and Many in the Developing world receive the requests without any proper clinical information about the patients, many do not write whether he is on any Antibiotic treatment. I request all the Clinicians to remember the patients specimens are vital samples and not subjects for blind studies. We Microbiologists report as, the "susceptible" category implies that isolates are inhibited by the usually achievable concentrations of antimicrobial agent when the recommended dosage is used for the site of infection.' (CLSI

definition) Our reports are based on peer reviewed major studies please do note that this definition says nothing about the chances of clinical success; in fact predicting clinical outcome based on susceptibility testing and the use of drugs shown to be in the susceptible category is very imprecise. This imprecision is due to the effect of host responses, site of infection, toxin production by bacteria that is independent of antimicrobial susceptibility, the presence of biofilms as in catheterised patients, drug pharmacodynamics and other factors. The clinicians should note when reported as resistant it means, the "resistant isolates are not inhibited by the usually achievable concentrations of the agent with normal dosage schedules, and/or that demonstrate zone diameters that fall in the range where specific microbial resistance mechanisms (e.g. beta-lactamases) are likely, and clinical efficacy of the agent against the isolate has not been reliably shown in treatment studies.' (CLSI definition). However, with the exception of urinary bladder infections and some mycobacterial infections, most clinicians avoid the use of a "resistant" category drug to treat infection. Many clinicians demand Zone sizes of sensitivity and resistance to different antibiotics, they wish to choose the antibiotic showing higher size of inhibition for an effective consideration. All clinicians should be familiar, bigger zone do not mean they are choosing the right choice of Antibiotic; ( example if I give a zone of Nitrofurantoin 30mm and Cephalosporin as 23 mm which are we choosing in a serious patient with established infection) They have to think which among many classes of antibiotic suits to his present clinical condition. Many clinicians do

believe laboratories giving a Zone sizes are doing a great service however they are doing a great harm to your patient and in fact they are not following the basic principles in Diagnostic Microbiology. Factors affecting the reliability of in vitro testing systems include the limitations in interpreting MIC data, because in vitro test conditions cannot duplicate the host environment. In vitro testing systems do not consider the pharmacokinetics of the antimicrobial agent or the post antibiotic effect, whereby microbial growth is suppressed even when the antibiotic concentration falls below the MIC. Many clinicians expect some positive results from Microbiology reports please do remember humans contain 10 times more normal flora than our cells together in the body If we start testing antibiotic sensitivity for all normal isolates, the wards and hospital will be flooded with resistant strain the future of Hospitals will be in jeopardy. We all should be familiar, majority of the patients coming to a teaching hospitals are treated for several days as output patients by private practitioner, many prescribe without rationalism the antibiotics influenced by commercial interests. Majority have already used several antibiotics including the third generation cephalosporins. We have no existing facilities to neutralise the antibiotic in the blood or in any specimen and economically not feasible to process the sample as in in developed countries. Many pathogens like chlamydia, mycoplasmas and tuberculosis need defined conditions to process and culture as they are harmful to laboratory workers. They can be processed only in upgraded diagnostic and reference laboratories. It is important to understand the limitations of

antimicrobial susceptibility testing. It should be recognized that resistance patterns will change and guidelines will be subject to periodic revision. The interpretation of an antimicrobial susceptibility test result on a laboratory report must never be taken in isolation. It is important that all factors are taken into account and that it should be remembered that there is no substitute for sound clinical judgment. The expectation of clinicians from Microbiologists is a mismatch in majority of the Laboratories in developing countries, as we have no Antibiotic policy and few hospitals invest for the changing needs, lack of trained technicians and apathy among the many Microbiologists. Conflicts widens with time between clinicians and microbiologists if proper investment are not done and committed Microbiologists take over the Profession, however the serious infected patients life is at risk.

Dr.T.V.Rao MD Professor and HOD Department of Microbiology Travancore Medical College, Kollam Kerala
Email; doctortvrao@gmail.com