|Year : 2020 | Volume
| Issue : 2 | Page : 67-75
Use of comments in clinical microbiology reporting: The need of the hour
R Deepashree1, Sandhya Bhat2, Apurba Sankar Sastry1
1 Department of Microbiology, JIPMER, Puducherry, India
2 Department of Microbiology, Pondicherry Institute of Medical Sciences, Pondicherry, India
|Date of Submission||27-Jan-2021|
|Date of Acceptance||28-Jan-2021|
|Date of Web Publication||5-Apr-2021|
Dr. Apurba Sankar Sastry
Associate Professor, Department of Microbiology, JIPMER, Puducherry
Source of Support: None, Conflict of Interest: None
The clinical microbiology reporting (CMR) for culture and antimicrobial susceptibility test (C and AST) is the most important investigation reported from a microbiology laboratory. However, majority of Indian microbiology laboratories generate a basic level C and AST report comprising of identification of the organism isolated with a list of antimicrobials and their susceptibility results, without any additional comments or messages. This leads to improper communication between the laboratory physicians and clinical physicians. This may further lead to irrational use of antimicrobials, improper specimen collection practices, inappropriate filing of requisition forms and poor infection control practices, which are mainly due to either unawareness or negligence of clinicians. Therefore, it is essential that the laboratory microbiologists of India should uplift themselves to clinical microbiologists and foster their CMR to higher standards by incorporating specific comments, suggestions and advices in the C and AST report, as recommended by the regulatory agencies such as Clinical and Laboratory Standards Institute and European Committee on Antimicrobial Susceptibility Testing. The comments may be of several types which include report categories, in-progress reports, requisition form filling, specimen collection, footnotes in the AST table, infection control advices, antimicrobial agent-related suggestions, predicted susceptibility related and intrinsic resistance comments, etc. The use of comments will greatly help the clinicians to rationalise their antimicrobial practice, improvise practices of specimen collection, requisition form filling and finally instituting the appropriate infection control practices. These comments mentioned in this article are only author's recommendations; the end users may incorporate according their local practice and need.
Keywords: Antimicrobial susceptibility comments, clinical microbiology reporting, culture comments
|How to cite this article:|
Deepashree R, Bhat S, Sastry AS. Use of comments in clinical microbiology reporting: The need of the hour. J Acad Clin Microbiol 2020;22:67-75
| Introduction|| |
The clinical microbiology reporting (CMR) for culture and antimicrobial susceptibility test (C and AST) is the most important investigation reported from a microbiology laboratory., Majority of the Indian microbiology laboratories generate a basic level C and AST report, which comprise of only identification of the organism isolated with a list of antimicrobials and their susceptibility results. The absence of specific comments, suggestions and advices in the C and AST report lead to improper and irrational use of antimicrobials, poor practices related to specimen collection, improper filing of requisition forms and poor infection control practices; mainly due to either unawareness or negligence of clinicians. Therefore, it is essential that the laboratory microbiologists of India should uplift themselves to clinical microbiologists and foster their CMR to higher standards by incorporating specific comments, suggestions and advices in the C and AST report.,
The regulatory agencies such as Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing (EUCAST) provide several therapy-related recommendations in their guidelines. Both CLSI and EUCAST are the scientific committee that provide the guideline for defining breakpoints to interpret antimicrobial susceptibility test results. CLSI M100 standard is followed in the most parts of the world, whereas EUCAST guideline is followed primarily in European countries.,,
The potential benefits of using comments or additional messages to enhance C and AST reports have not been studied extensively in the Indian settings, though this approach is widely used on the basis of local experience. Therefore, this article reviews various comments, advices and additional messages (developed based on CLSI, EUCAST and other relevant guidelines and research publications) that can be incorporated in the clinical microbiology reports. These are only author's recommendations; the end users may incorporate according their local practice and need.
| Comments in Clinical Microbiology Reporting|| |
For the sake of making the understanding simple, all comments have been framed keeping blood culture as a prototype. The same can be modified and framed accordingly for other culture reporting.,,,,,,,,,,,
Comments for various report categories
Most of the times, the microbiologists express the final report in several types such as 'sterile specimen, contaminated specimen or pathogen grown in specimen.' Clinicians often get confused to read such shorter reports as they will not have an idea how this report has been arrived. Therefore, it is better if the same report is elaborated in a manner that the message will be clear to the clinicians. [Table 1] depicts the elaborated comments for various report categories such as sterile at 48 h, sterile at 7 days, sterile (false positive), contaminant, pathogen and pathogenicity uncertain. The author suggests the microbiologists to incorporate such elaborated comments in their culture reports.
Comments for in-progress reports
In most microbiology laboratories, the culture report is sent to the clinicians only at the final stage, after the susceptibility report is prepared. This practice is inappropriate as it delays the institution of pathogen-directed therapy. Stage-wise communication of culture report is the pressing priority in today's world of CMR. The microbiologists should communicate the clinicians at the every stage of culture report, with a note on what part of the report is awaited. Stage-wise reporting with comment for in-progress reports not only helps in early institution of directed therapy but also gives a clear message to the clinicians to review the report subsequently for further action.
Comments if parameters are missing in culture requisition form
Mentioning of various patient-related parameters in culture requisition form is of paramount importance. Information such as patient's diagnosis, history of empirical antibiotic and source of blood specimen (central line or venepuncture), etc., greatly helps the microbiologists in various ways. For example, if the diagnosis is not mentioned in the requisition form, the comment can go as “Kindly mention the diagnosis in the requisition form. This will help in ascertaining the site-specific pathogenicity of the organism and thereafter for testing appropriate antimicrobial susceptibility testing.”
Comments related to specimen collection,,,,
Specimen collection is the most crucial step, which the clinicians often tend to neglect either due to unawareness or carelessness. Inappropriate specimen collection in terms of quality or quantity or collection technique results in false-negative culture report. Therefore, it is extremely important to inform the clinicians about the appropriateness of the specimen collected [Table 2]. For example, if the specimen has been collected after antibiotic start, then a footnote can be added to the report as “Always collect the culture specimen before antimicrobial start. If patient is already on antimicrobial, then collect the culture specimen just before the next dose. This helps in better yield of organisms.” Another comment in case of inappropriate volume for blood culture can be, “Inappropriate blood volume may lead to false-negative or false-positive result or a delay of blood culture positive report.”
Comments as footnotes in the AST (antimicrobial susceptibility)
The AST (antimicrobial susceptibility testing) results are generally represented in abbreviations such as S, I, SDD and R. Clinicians many times do not understand the true meaning of these abbreviations, especially I and SDD. Therefore, it is necessary to expand the abbreviations as a footnote below the AST table [Table 3].
|Table 3: Comments as footnotes in the antimicrobial susceptibility table,,|
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The concept of therapeutic Index
When the test isolate is susceptible to >1 antimicrobials of similar spectrum, it is often difficult to choose the most appropriate antimicrobial for directed therapy. In this situation, the antimicrobial with higher therapeutic index should be preferred for therapy. Therapeutic index of an antimicrobial for an organism is defined as the ratio of susceptible breakpoint divided by minimum inhibitory concentration (MIC) of the test isolate. Lower the therapeutic index, better is the therapeutic efficacy.
If laboratories report only the raw MIC values, the clinicians get misguided and select the antimicrobial with lowest MIC for therapy. For example, if Klebsiella pneumoniae is reported by a laboratory with amikacin MIC of 2 μg/mL and meropenem MIC of 0.5 μg/mL, it appears as if meropenem being having lower MIC is more effective than amikacin. However, in reality, amikacin is more effective in this case, as it has a higher therapeutic index (susceptible break point is 16 μg/mL, therefore therapeutic index is 16/2 = 8); as compared to that of meropenem (susceptible break point is 1 μg/mL, therefore, therapeutic index is 1/0.5 = 2). For that reason, it is always advisable for the microbiologists to report therapeutic index along with the raw MIC values.
Comments specific to site-specific culture reporting
Clinical microbiologists sometime need to mention certain comments which are specific for a site-specific culture report [Table 4]. In a blood culture report, it is essential to mention about the time-to-positivity (TTP). TTP refers to the time taken for the blood culture bottle to flag positive by the automated blood culture equipment. The clinicians must be aware that lower the TTP; higher is the organism load in the specimen, and therefore, worse is the clinical outcome. It is also important for the microbiologist to report when a catheter-related blood stream infection is diagnosed; laboratory criteria of which is fulfilled when central line blood culture specimen is flagged more than 2 h earlier than the venepuncture specimen. Here, the comment should go as Kindly correlate with clinical parameters to confirm the diagnosis. Consider removal of central line and ensure proper infection control measures.
|Table 4: Comments related to site-specific culture reporting,,,,,,|
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Infection control advice
Institution of appropriate infection control measures helps in containment of the organism and prevention of spread or organisms between patients. Although standard precaution states that infection control measures need to be implemented for all patients suspected to harbour infections, when the infection is confirmed, it warrants an urgent need to augment the infection control measures to highest standard. However, clinicians seldom practice infection control measures, which may be either due to lack of awareness or negligence or due to forgetfulness because of increased workload. Mention of set of infection control advices in the culture report reinforces the clinicians to practice while giving care to the infected patients. [Table 5] enlists the comments related to infection control measures which can be incorporated in microbiology culture report.
Specific organism-antimicrobial agent-related comments
This is the most important component of an ideal CMR. The microbiologists should properly prepare a list of organisms-antimicrobial agent-related comments so that they can just copy paste the comments into their culture report and thereby with minimal effort they can produce effective informative culture reports. Several antimicrobials when reported for a particular organism carry an important message, which should be communicated to the clinicians for better patient care. For instance, if Staphylococcus aureus is reported as resistant to oxacillin, an additional comment can be incorporated as 'Methicillin-resistant S. aureus has grown in culture. Vancomycin is the drug of choice. Kindly avoid all beta lactams except fifth generation cephalosporins such as ceftaroline and ceftobiprole'. Similarly, there are several other comments [Table 6] which can be added to the report for various organism-antimicrobial agent results which include comment of increased therapeutic dosage if cefepime is reported as SDD for Enterobacteriaceae, comment on synergy when high-level gentamicin and ampicillin/penicillin are reported for Enterococcus, colistin warning comments as per CLSI 2020, comment for repeat AST after 3–4 days of initiation of therapy for certain drug-bug combinations, comment for renal adjustment when nephrotoxic drugs are reported, comments on inducible clindamycin when reported, etc.
|Table 6: Specific organism-antimicrobial agent-related comments,,,,,|
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Predicated susceptibility-related comments,
Both CLSI and EUCAST guidelines suggest that the susceptibility testing of few antimicrobials can be used to predict the susceptibility results of another antimicrobial(s) [Table 7]. As the clinicians will not be aware of these facts, the clinical microbiologist should ensure that such comment should appear either as a footnote of AST table or as a part of antibiotic specific comment in the culture report. For example, if ceftriaxone is reported for Enterobacteriaceae family, the comment should go as 'Ceftriaxone susceptibility test result can be extrapolated for cefotaxime for Enterobacteriaceae family'.
Intrinsic resistance comments,,
Intrinsic resistance is the innate ability of bacteria to resist the action of an antimicrobial agent. It is impractical for the clinicians to memorise which organism is intrinsically resistant to which antimicrobials, as the list of intrinsic resistance is very exhaustive. Therefore, it is essential that the clinical microbiology report should incorporate the comment on intrinsic resistance. For instance, when Stenotrophomonas maltophilia is reported, the additional comment can be incorporated as 'S. maltophilia is intrinsically resistant to penicillin, amoxicillin, ampicillin, amoxicillin-clavulanic acid, ampicillin-sulbactam, ticarcillin, piperacillin, piperacillin-tazobactam, cefazolin, cefalotin, cefadroxil, cephalexin, cefoxitin, cefotetan, cefotaxime, ceftriaxone, aztreonam, ertapenem, imipenem, meropenem, aminoglycosides, trimethoprim, fosfomycin, tetracycline, clindamycin, daptomycin, fusidic acid, glycopeptides (vancomycin and teicoplanin), linezolid, quinupristin-dalfopristin and rifampin.' Intrinsic resistance comments for Enterobacteriaceae family
Gram-negative bacilli and Gram-positive cocci are enlisted in [Table 8].
[TAG:2]Two Stage Reporting: The UK Model,[/TAG:2]
Conventionally, in Indian settings, the microbiology culture reporting involves identification which is carried out either by taking the reading of conventional biochemical reactions or by automated identification systems (e.g., VITEK2 or MALDITOF); followed by taking the AST reading and preparing the final culture report that contains direct smear result, identification and AST report. The AST report contains a list of antimicrobials and their susceptibility result expressed as S, I or R; without any additional messages/comments.
On the contrary, the CMR, which is often a practice in Western countries such as the UK involves a two-stage reporting. In the first stage (technical reporting), the technical culture report is prepared which consists of identification and AST report (this is similar to what is reported in Indian settings). Subsequently, a second stage reporting is carried out (clinical reporting), where specific comments and advices are incorporated to the culture report such as antimicrobial specific comment, organism-related comment, infection control advices and intrinsic resistance comments. The clinical reporting team also correlates the pathogenicity of the organism identified with respect to the specimen type, diagnosis and associated comorbidities such as immunocompromised status. Afterward, the clinical microbiology team goes for clinical rounds and follow-up the patients, discuss with the clinical team and give the necessary antimicrobial and infection control advices.
It is the imperative that this practice should be adopted in the Indian settings. In larger bedded hospitals with good workforce support and medical teaching institutes can have two different teams for technical reporting and clinical reporting. The composition of each team can vary depending upon the infrastructure and staff availability. The team for technical reporting can include a senior technical supervisor, a laboratory technician and postgraduate student(s). The team for clinical reporting may include a senior resident, postgraduate student(s) and microbiology consultant (faculty). In smaller hospitals with lesser workforce support can have only one team comprising of technician and MD Microbiologists who can do both the stage of reporting together. The microbiology team must conduct clinical rounds and communicate with the clinicians and provide the advices and suggestions as required.
| Conclusion|| |
There is an urgent need for the microbiology laboratory to upgrade the standards of their CMR to higher level by incorporating various comments, advices and additional messages. The comments may be of several types which include report categories, in-progress reports, requisition form filling, specimen collection, footnotes in the AST table, infection control advices, antimicrobial agent-related suggestions, predicted susceptibility-related and intrinsic resistance comments. The use of comments will greatly help the clinicians to rationalise their antimicrobial practice, improvise practices of specimen collection, requisition form filling and finally instituting the appropriate infection control practices.
The laboratory can implement most of these comments even with limited instrumentation and infrastructure support. Two stage reporting of C and AST (technical reporting followed by CMR) and thereafter conducting the clinical rounds will certainly bring a revolution in the field of clinical microbiology gaining back its importance in clinical field. It will also help in generating a clear distinction between clinical microbiologists and other non-clinical microbiologists.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]