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Microbiology without culture - is this the future?. Professor Brian Duerden Inspector of Microbiology and Infection Control, Department of Health. Historical perspective. 1850 – 1900 1850s: Pasteur; liquid culture 1870-80s Koch: solid media 1894 Gram’s stain 1900 – 1980

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microbiology without culture is this the future

Microbiology without culture - is this the future?

Professor Brian Duerden

Inspector of Microbiology and

Infection Control,

Department of Health

historical perspective
Historical perspective
  • 1850 – 1900
    • 1850s: Pasteur; liquid culture
    • 1870-80s Koch: solid media
    • 1894 Gram’s stain
  • 1900 – 1980
    • Serotyping; phage typing
    • DNA discovered
  • 1980s Biochemical analyses
    • Metabolic products (GLC)
    • Proteins – whole cell; cell wall (SDS-PAGE)
    • Whole cell (pyrolysis)
  • All needed culture first
1990s age of immediacy
1990s – age of immediacy!
  • Rapid tests
  • Same day results
  • Short turnaround times
  • Immediate answers
  • Point of care (POC) testing
  • And automation; computerisation

………non-culture methods

methods
Methods
  • Molecular detection – nucleic acid
    • Probes
    • PCR
  • Antigen detection

......who does the tests?

where are they done?

why are we doing the tests
Why are we doing the tests?
  • Cost?
  • Diagnosis
    • Guide treatment
      • Antibiotic or not? Which? eg. GpA streptococcus
    • Start infection prevention and control action
    • Take public health actions
  • Screening for carriage/colonisation
    • Infection control & public health actions
    • Prophylaxis (eg. GpB streptococcus)
  • Speed is of the essence
how urgent are the answers
How urgent are the answers?
  • Primary care
    • While the patient is there?
    • Organisation?
  • STDs – GUM clinics; strong history
    • Now in pharmacies???
  • Public health – TB
    • Days not hours
  • Healthcare Associated Infections (HCAI)
    • Treatment; isolation; infection control action
nb primary culture then non culture
NB. Primary culture then non-culture?
  • Identify organisms in primary cultures
    • Rapid non-culture methods
    • Probes; PCR; rRNA
    • Resistance genes
  • How vital?
    • Blood cultures
    • Early CORRECT antibiotic improves survival
    • But will clinicians change antibiotic?
mrsa screening
MRSA screening
  • DH requirement – all admissions to be screened before or on admission
    • All elective admissions by March 2009
      • Includes day cases
      • Not ophthalmic day cases; not maternity
    • All admissions asap, at latest by March 2011
  • Methods – conventional culture; rapid; automated?
    • Needs clinical organisation; ability to take action
    • Laboratory? Point of admission? Pre-admission clinic?
c difficile diagnosis
C. difficile diagnosis
  • DH target – 30% reduction by 2010-11
    • Baseline 2007-8: c. 60,000
    • SHA and PCT targets based on population
      • Standardised to 8.4 cases per 10,000 as target
    • Acute trust targets within PCT packages
      • Standardised to admissions
  • Surveillance figures depend upon accurate diagnosis
  • Infection control actions depend upon rapid results in all healthcare settings
  • Methods: toxin detection (A+B); +/- antigen?
norovirus
Norovirus
  • Major cause of ward closure
  • Respond to clinical diagnosis
    • Isolation; cohorting; closed to admissions
    • Staff restrictions (cohorting)
    • Cleaning and disinfection
  • Quick confirmation needed to reassure actions
  • Not every case needs testing
pandemic or seasonal flu
Pandemic (or seasonal) flu?
  • Primary care
    • Confirm diagnosis for antiviral use?
  • Current policy
    • Diagnose on clinical grounds when flu known to be circulating
    • Keep infected patients away from GP surgeries
cautionary tales
Cautionary tales
  • Loss of epidemiological and surveillance data
  • Antimicrobial susceptibility data?
  • POC – whose responsibility
  • Quality and standards
  • Serendipity
loss of data
Loss of data
  • Antimicrobial susceptibility
    • Few non-culture tests
  • Epidemiology
    • Typing
      • Can it be done on non-culture testing?
      • Most needs the isolate
  • Surveillance
    • POC – loss of data
      • Unless systems linked to reporting systems
poc testing
POC testing
  • Who does it?
    • What training? Who assesses competence?
    • Who manages them?
  • Equipment maintenance
    • Who is responsible?
  • QC and QA?
  • Links to the laboratory
  • Reporting system?
  • Accreditation?
quality issues
Quality issues
  • Quality control
    • Records; links to laboratories
  • EQA
    • NEQAS programmes?
  • Accreditation
    • CPA; UKAS
current developments
Current developments
  • POC Accreditation
    • Pathology modernisation project
    • Working with UKAS
  • Benchmarking
    • Primary care use of Pathology services
    • Keele team
    • Microbiology pilots soon
    • ??? Impact of POC; rapid results
serendipity
Serendipity
  • What could be causing that?
  • I would not have thought of that?
  • We don’t have a DNA probe for that!
  • Where is experience, ‘nose’, knowledge?
  • With non-culture tests

……..you only find what you know you are looking for