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Contents:
The
Kentucky Commonwealth Fall Meeting “Years and Other
Beasts”
Julie A. Ribes, M.D., Ph.D., Kentucky State Director
The Kentucky Meeting was held on a very wet Friday October 27th at the Buffalo Trace Distillery, where yeast take on a particular significance to microbiologists, distillers, and those who partake of fermented beverages. Preregistration neared 100 participants, with several last minute attendees. Participants originated from Kentucky, Ohio, Indiana, Tennessee, and there were speakers from Kentucky, Ohio and Michigan. There were 16 attendees from 11 vendors supporting this meeting.
The day started off with the trots, as Brent Barrett (SCACM’s Significant Contributor in Microbiology for 2006) from the Indiana State Department of Health discussed the clinical presentation, epidemiology and laboratory detection of toxigenic E. coli. The timing could not have been better in light of the spinach-associated outbreak with E. coli 0157H7. Brent started out with an update on this spinach outbreak, including information that the contamination of the crop was likely linked to wild pigs foraging in the fields. Brent used his Department of Health expertise as he discussed the nuances of detection of infection with this difficult to detect group of organisms.
In keeping with the theme of “yeasts”, Dr. Geraldine Hall, from the Cleveland Clinic, updated attendees on what was new in the clinical laboratories for identification and susceptibility testing. More and more, our laboratories are challenged to extend their scope of testing, and many are being asked to perform or refer yeast susceptibility testing. Dr. Hall discussed both automated and non-automated identification systems for yeast and then discussed the performance and interpretation of yeast susceptibility testing. Microbiologists need to be prepared to accommodate increasing requests for yeast susceptibility testing and subsequently provide assistance in interpreting these findings. CLSI guidelines are available for some yeast-drug combination.
Dr. Richard Van Enk from Bronson Hospital in Kalamazoo Michigan gave an excellent update on what is new from CLSI with regards to bacterial susceptibility testing. Among Dr. Van Enk’s take home messages were the recommendations to pay attention to the yearly changes in the CLSI M100 document, and make the indicated changes to your laboratory susceptibility testing procedures on a yearly basis. He stressed that the CLSI M100 document is your friend and that if it is not well worn by the end of the year, you are not paying enough attention to it.
Dr. Julie Ribes presented clinical cases again this year. Attendees fermented differential diagnoses on topics ranging from bioterrorism (not) to yeasts and other beasts like moulds, bacteria and parasites causing disease in some real life patients.
Dr. James McCormick closed out the program by speaking on ventilator associated pneumonia (VAP), speaking from the perspective of a Pulmonologist and intensivist. In addition to covering the epidemiology and agents involved in VAP, Dr. McCormick stressed the role of the laboratory in assisting patient by providing the critical data needed to help the physicians to select therapy.
Attendees had a chance to tour the distillery and even sample some of the products of the yeast’s fermentative labors. With the efforts of many SCACM members in Kentucky, an excellent group of speakers, and the support of our vendors, a good time was truly had by all.
Mary Ann
Schlacks, Illinois State Director
October
3rd, 2006
Maywood,
IL
“Clinical
Microbiology, the Triad: Detection, Diagnosis and
Treatment”
“It was a dark and stormy night…” The night before the Illinois fall meeting, rainfall in record numbers added to an already waterlogged sewer system in the Maywood area. I received a call at 6:30 am the day of the meeting that the building where our meeting was supposed to be held was flooded and without power! After much worry and discussion, we were able to gather together for refreshments, then with help from administration, we were assigned a wonderful lecture hall usually used by the Medical Students. The effects of this flood of our main building basement and subbasement and of the Maguire center have already cost the Medical Center millions of dollars.
Our first speaker that day was Dr Paul
Schreckenberger, who is our medical director in Microbiology at Loyola. Dr
Schreckenberger addressed the effect of “Pan-Resistant” Acinetobacter infections
on Microbiology labs. He explained the microbiology of the organism, including
mechanisms of resistance. He discussed how the organism must be detected in the
Microbiology laboratory. Dr Schreckenberger talked about the “Scourge of the
CRABS”, in other words, carbapenem resistant Acinetobacters. He explained what
extra antibiotics should be added when performing susceptibilities for this
organism, and the reasons for doing this.
Dr. Teresa Zembower, from Northwestern University, who is an Infectious
Disease physician and an Infection Control Practitioner, spoke to us about how
patients infected with pan-resistant Acinetobacter must be treated. Dr. Zembower
related interesting features of the infections seen in soldiers returning from
Iraq. She also presented statistical data obtained during the outbreak at her
hospital, and the efforts that were made to stop the spread of the resistant
organisms. Dr. Zembower also warned of the approach of the “CRABS’, and what
that will mean for clinical microbiology.
Dr. Mark Martens from the Oklahoma School of Medicine in Tulsa is an
OB-GYN Specialist who also is very interested in the microbiology of infectious
diseases in women. He used humor and statistics from his hospital to show how
the diagnosis of infectious disease in women is best accomplished, with the
laboratory playing a key role.
Dr Gerri Hall survived the turmoil of arriving in the midst of one of the
many storms of the previous night. She gave a brief overview of the Cleveland
Clinic campus, and then presented an excellent description of what labs should
be doing to aid in diagnosis of infectious diseases in women. She listed many
molecular methods and explained some of the characteristics of the tests
available. Dr. Hall also reviewed the common types of OB-GYN infections, how
they are detected, and some aspects of treatment.
Our final speaker was Dr. Julie Ribes, who also was delayed by our
wonderful Chicago weather. Dr. Ribes presented some intriguing cases. She gave
us some preliminary information, showed some slides and waited to see if we
would know the answers. Many attendees were able to analyze the data but others
were surprised by the final results. Dr. Ribes case studies exemplified why we
had chosen our program title. The clinical microbiology triad of infection,
detection and diagnosis depends on input from the patient, the physician, other
lab results, and finally our Microbiology results, whether they include
identification, and/or susceptibility testing. We are in an era where testing is
evolving at a rapid rate, and so are the organisms! Interaction between
clinicians and laboratorians is more essential than ever.
In spite of the complications, approximately 110 (very patient) attendees
were energized and enlightened by our excellent speakers.
We wish to thank the following corporate
sponsors who provided Educational Grants: Dade-Behring, Inc. and
Gen-Probe.
INDIANA STATE FALL MEETING
2006
Mary
Stepney, Indiana State Director
Clinical Microbiology Beyond the Basics
II
Fifty-five attendees, and speakers demonstrated the flexibility and patience common to clinical microbiologists, since hospital construction forced a change in meeting rooms. Visiting the exhibits and food functions between talks, provided the opportunity to walk and stretch, contributing to the recommended 30 minutes of exercise per day.
The theme of the Indiana State meeting was to address current topics of interest in the clinical microbiology laboratory at the intermediate level: antimicrobial resistance, MRSA, viral antigen testing and small Gram–negative rods in blood cultures
Gerald Denys, Ph.D. D(ABMM) from Clarian Health Partners, in Indianapolis, began the meeting with “Antimicrobial Resistance Among Gram-negative Bacilli: A Laboratory Perspective Beyond Routine Susceptibility Testing.” When automated systems are used for antimicrobial susceptibility testing, the most frequent errors involve Pseudomonas aeruginosa and certain Enterobacteriaceae. The mechanisms that lead to resistance include Extended-spectrum-Beta-Lactamase production (ESBL), hyperproduction of AmpC, broad-spectrum ß-lactamases (carbapenemases), decreased outer membrane permeability (porin loss) and active efflux.
Detecting resistance mechanisms with routine testing is often difficult due to the following: 1) MICs and zones of ESBL and normal populations overlap, inoculum effect, substrate variation and the presence of multiple enzymes.
Strategies for supplemental testing must be developed in each laboratory. Recommendations for detecting and reporting decreased susceptibility presented at the 2006 ICAAC meeting were summarized.
a. Screening methods for the detection of AmpC ß-lactamase: Tris-EDTA Disk Test, disk induction test, and new E-test strips for AmpC detection.
b. An indirect disk test for the detection of carbapenem hydrolyzing enzymes, e.g., KPC-type class A carbapenemases in Klebsiella pneumoniae
c. Direct Tris-EDTA disk test or the E-test strip for the detection of metallo-ß-lactamases in Pseudomonas aeruginosa and Acinetobacter baumanii.
The trends in the United States for antimicrobial resistance to trimeth/sulfa and fluoroquinolones in community-acquired urinary tract infections were also reviewed. Dr. Denys concluded with a reminder that in vitro activity does not necessarily correlate with clinical results. An example was displayed of a Comprehensive Multidisciplinary Antibiotic Management Program cited from the American Journal of Infection Control June 2006 34(5) S1-S80.
Mark Schomogyi, MD, an Infectious Disease practitioner in Fort Wayne, spoke on the “Aspects of Community Acquired MRSA versus Healthcare Associated MRSA”. A historical perspective was presented for the growing problem of antimicrobial resistance:
|
Antimicrobial |
Introduced |
Resistance |
25% HA
rates |
25% CA
rates |
|
Penicillin |
1941 |
<2
yrs |
6
yrs |
15-20
yrs |
|
Vancomycin |
1956 |
40
yrs |
? |
? |
|
Methicillin |
1961 |
<1
yr |
25-30
yrs |
40
yrs |
The cost of MRSA vs. MSSA was also compared. For surgical site infections not only is the cost of therapy higher for MRSA infections vs. MSSA, but also higher are the mortality within 90 days (20.7% vs. 6.7%) and the median length of stay (23 days vs. 14 days) respectively. For bloodstream infections, the cost of MRSA was cited as $5,878 per patient day vs. $2,073 per patient day for MSSA.
While healthcare-associated MRSA has risk factors of recent hospitalization or surgery, dialysis or central lines, it occurs more often in respiratory tract infections of older patients and is highly resistant to antimicrobials. Community-associated MRSA has risk factors of tobacco usage, dermatological conditions and diabetes. It occurs as skin/soft tissue infections in younger patients and is less resistant to antimicrobials. Several images were shown of the various presentations of skin/soft tissue infections requiring incision and drainage: boils, folliculitis, cellulits and also spontaneously draining abscesses.
In conclusion, Dr. Schomogyi emphasized the importance of hand washing, the use of alcohol based gel cleaners when soap is not immediately available, and protective clothing such as gowns, gloves and masks where appropriate. The judicious use of antimicrobials was also stressed, as it applied to the older drugs (clindamycin, erythromycin, doxycycline, rifampin and trimeth/sulfa) and newer drugs with activity against MRSA (daptomycin, linezolid, quinupristin/dalfopristin, tigecycline and vancomycin).
Diane Leland, Ph.D., MT(ASCP)SM, Indiana School of Medicine, continued the meeting after lunch with her presentation “Rapid Viral Antigen Based Testing”. The advantages and disadvantages were reviewed for the methods of rapid viral antigen detection: immunofluorescence (DFA), membrane enzyme immunoassay (EIA), optical immunoassay (OIA), and immunochromatography/Lateral flow.
Immunofluorescence allows the sample quality to be evaluated. Sensitivity is high because the staining pattern of cells is evaluated. Sensitivity is very good compared to cell culture for RSV, influenza A and B, and parainfluenza. Its disadvantages are the technical expertise required for interpretation, a fluorescence microscope is required, and adenovirus sensitivity is poor compared to cell culture.
Cassette membrane enzyme immunoassays require very little technical expertise, and no special equipment. The test can be performed in 20-30 minutes. However, the disadvantages include the multiple step methods requiring some attention from the technologist, these assays are only available for RSV and influenza A and B, the cost per test may be high, specimen quality cannot be evaluated and the sensitivity may be low compared to cell culture.
Immunochromatography/lateral flow requires virtually no technical expertise (waived test), no special equipment is needed and the test can be performed in 15-30 minutes. The disadvantages are comparable to those of EIAs.
For patients with respiratory virus infections diagnosed by a rapid antigen detection method, compared to patients that have not been diagnosed by a rapid antigen method, there is, overall a decrease for each of the following: length of stay in the hospital, antibiotic use and lab assays. However, emergency room physicians, aware of a positive rapid result for influenza, do not necessarily order fewer lab tests or withhold prescribing antibiotics (Bonner et al, 2003, Pediatrics. 112:363-367).
Several problems exist with waived tests or point of care testing (MMWR, Nov 11, 2005): personnel are inadequately trained and have no director oversight, 12% do not have current instructions for testing, 21% do not perform quality control testing, 6% ignore expiration dates of reagents, 45% maintain no documentation and 6% ignore follow-up testing.
In summary Dr. Leland recommended following the published recommendations for rapid influenza testing and point of care waived tests (WHO, July, 2005).
Tuesday
September 19, 2006
Brighton,
MI
“Nuts and Bolts II - Basic Tools for the
Microbiologist”
Marty Boehme, SCACM Director for Michigan
How to make better use of antimicrobials – the “Big Guns” in the microbiology arsenal of tools –-- was the dominant topic at the Michigan fall meeting. Dr. Gerri Hall from Cleveland Clinic spoke about why, how, and when to prepare your laboratory antibiogram. Her talk was loaded with tips and examples demonstrating how to make our antibiogram understandable and more useful to prescribing physicians. Janet Hindler from UCLA in Los Angeles and also working with the APHL (Association for Public Health Laboratories) presented an in-depth guide “Tools for Antimicrobial Susceptibility Testing and Reporting of Multi-Drug Resistant Bacteria”. Janet’s talks are always full of practical strategies and excellent resources, and this was no exception.
A basic tool for anyone in the workforce is understanding what makes coworkers “tick”. Linette Granen from the National Laboratory Training Network provided some insights with her presentation “Working Across the Generation Gap(s)”, giving the predominant “Baby Boomer” laboratorians much food for thought. One attendee described this as a “great after lunch lecture, kept [my] attention and interest”. Marty Boehme from Michigan Department of Community Health (MDCH) Bureau of Laboratories wrapped up the day with a report on the MDCH four-year project to derive a statewide antibiogram from laboratory antibiogram data.
Excitement for the spring 2008 meeting was raised a notch as Carol Young, University of Michigan Health System, gave us a glimpse at the beautiful St. Johns Inn location in Plymouth , MI. Carol managed to recruit many enthusiastic committee volunteers in the process. (It’s not too late to get involved – please contact her at youngc@umich.edu).
Attendees expressed their gratitude that SCACM sponsored the fall meetings at no cost, and Michigan attendance included 112 people from 48 laboratories. SCACM was noted by one person as “best value for group membership”. We concur!
During periods of low flu activity, interpret positive rapid test results with caution (confirm by FA, culture or RT-PCR),
During periods of high flu activity use clinical judgment rather than test everyone
If influenza surveillance is not available then do not use rapid tests; if rapid tests are used then confirm all results
Insist on high quality specimens
Ensure that personnel are trained and are aware of the limitation of testing
Insist on good quality control data
Do not test adults who have had symptoms for 4-5 days or longer
Interpret rapid test results in conjunction with clinical history, signs, symptoms, further laboratory testing and surveillance information about circulating flu levels
Robert Jacobson, MT(ASCP), Reference Bacteriology Laboratory, Michigan Department of Community Health presented the last talk “What to Do with Those Small Gram-negative Rods In Blood Cultures”.
Small Gram-negative coccobacilli account for a very small percentage of positive blood cultures, but they are almost always significant when isolated and belong to one of the following genera: Actinobacillus, Pasteurella, Haemophilus, Oligella, Brucella or Francisella. These small coccobacilli are all facultative anaerobes, non-flagellated, nutritionally fastidious, most do not grow on MacConkey and there are no CLSI standards for antimicrobial susceptibility interpretation. They cause endocarditis of long duration, with large vegetations and a tendency for embolization. These organisms can be screened by rate of growth, colony morphology and minimal conventional biochemical tests such as oxidase, urea and the porphyrin (ALA) test. While a reference laboratory or the state public health laboratory will confirm identification of these unusual organisms, it is important to be aware of the range of possible organisms before beginning any manipulation of these cultures. Laboratory acquired infections can be associated with both Brucella and Franciscella. They are also potential agents of biological warfare and are included in select agent protocols.
Actinobacillus actinomycetemcomitans is more closely related to Haemophilus than the other Actinobacillus species. It occurs with Actinomyces spp. in soft tissue. Pasteurella sp. can cause septicemia, meningitis and endocarditis. It can be identified by commercial systems, however, it may be inconsistent and require conventional biochemicals. Haemophilus influenza in bloodstream infections can result in osteomyelitis, septic arthritis, cellulitis and pericarditis. Biotyping and serotyping can be performed at a reference laboratory
The symptoms and pathogenicity of Francisella tularensis and Brucella spp. were reviewed along with the culture characteristics. The mode of transmission, medical considerations, laboratory hazards, safety precautions and disposal/decontamination procedures were also discussed. Refer to the CDC Emergency Preparedness and Response website, http://www.bt.cdc.gov/ , the CDC Laboratory Response Network Protocols for Sentinel Laboratories, and the Manual of Clinical Microbiology, 8th edition.
The meeting concluded with a raffle of numerous door prizes generously provided by our sponsors.
Ike Northern, Ohio State Director
On October 2, approximately 90 registrants and speakers gathered in Columbus for the fall SCACM meeting.
Gerri Hall, Ph.D., from the Cleveland Clinic Foundation, started out the day by discussing “What To Do With a Vaginal Sample in the Clinical Microbiology Lab”. The main agents of infectious vaginitis include Trichomonas, Candida albicans, and organisms associated with bacterial vaginosis (BV). The methods for detecting Trichomonas include wet mount, culture, cytological stains, EIA’s, and molecular techniques. Candida albicans can be detected by KOH/calcofluor white stain,
Gram stain, culture, and molecular techniques. BV is caused by a shift in normal vaginal flora. Some laboratory assays look for organisms such as Gardnerella vaginalis as a marker for BV (wet mount, scored gram stain, DNA probe) while others look for amines and pH in the vaginal fluid. It was suggested that routine vaginal culture should not be done unless there is consultation with the microbiology department. A specific organism to look for should accompany all requests for vaginal cultures.
Larry Gray, Ph.D. from TriHealth Laboratories in Cincinnati, talked about ocular infections and how they are diagnosed in the laboratory. Blepharitis is an infection of the glands in the eye lids and is characterized by irritation, burning, redness, and itching. The main etiologic agents include Staphylococcus aureus, coagulase-negative Staphylococci, and Gram-negative bacilli (especially Pseudomonas). Conjunctivitis (or pink eye) is an infection and inflammation of the lining of the eyelid. The most common agents associated with this infection are Staphylococcus aureus, Streptococcus pneumoniae, Neisseria gonorrhoeae, Haemophilus influenzae, and viruses. Keratitis is an ulceration of the cornea accompanied by pain and loss of transparency. There are many etiologic agents for this infection: Bacteria – 41%, Fungi – 8%, Parasites – 1%, Viruses and culture-negative – 50%. Cultures from surface swabs may contain normal skin flora while intraocular samples should be sterile. Cumitech 13A, published by ASM Press, describes ocular infections and microbiology work-up.
Joel Mortensen, Ph.D., from Cincinnati Children’s’ Hospital, discussed the “Lean” process and how it can be applied to microbiology. Some suggestions for making stool cultures lean include:
Screen for Yersina without using CIN agar – Use MacConkey at room temperature instead
Do not use enrichment broth except when looking for asymptomatic carriers
Eliminate serotyping of Salmonella and Shigella. Let the state health lab do that for you.
Use methods other than culture to detect stool pathogens – EIA, PCR
Use Rapid tests when possible – C. difficile toxin
Joseph Gastaldo, MD, Riverside Infection Consultants, presented a lecture on endocarditis. Endocarditis is an infection of the heart valve with actively proliferating microorganisms. Patients who have conditions that cause turbulent flow of blood across the heart valve are at risk for endocarditis. Symptoms usually include fever, weight loss, anorexia, and cardiac symptoms. The majority of infections are caused by organisms normally found in the oral cavity (Streptococci, Staphylococci, Enterococci, CNS, Corynebacterium). Treatment is typically prolonged (4-6 weeks) and dependant upon the etiologic agent.
Laurie Elder, Ph.D., Wright State University, finished up the day with “Susceptibility Testing Jeopardy”. Her categories included: Beta-lactamases, Antibiotic Mechanisms of Action, Antibiotic Trade Names, Resistance Mechanisms, Pattern Recognition, and Miscellaneous Stuff. Many of the questions were a good review. However, one topic was recently reported in CDC journal, Emerging Infectious Diseases. There is a new strain of Klebsiella pneumoniae that expresses a KPC-2 beta-lactamase gene that causes the organism to be resistant to carbapenems. This resistance may be difficult to detect. Higher inoculation sizes and the use of ertapenem as a screen can improve detection.
The West Virginia Mini-SCACM Fall Meeting was held on September 25, 2006 at the Stonewall Resort and Conference Center in the scenic mountains of West Virginia. There were 57 attendees from 6 states, representing 15 institutions. The topic was “Back to Basics – Six”, which continued the theme developed several years ago of primary care diagnostic microbiology. A two-day format was used; one that has proven to be most successful. The meeting opened on Sunday afternoon with a “mini-workshop” with one topic followed by a very social, relaxing evening. Then on Monday, a traditional a 40-50- minute presentation was held, starting early, allowing people to return to their institutions having been away only one week-day.
Gerri Hall, PhD provided the workshop on Sunday entitled: “Surviving the ‘Walk-in’ CAP Inspection”. It was well received with a significant number of questions and answers, spilling over into the social hour.
Monday morning started with “Point of Care Testing for Microbiology” by Dr. Robert Sauter from the Carolina Medical Center. He described a number of key points with solutions that all laboratorians face.
Dr. Gerri Hall gave the second presentation, “Pathogens in Urogenital Cultures”. She reviewed the “dos and don’ts” and changes driven by cost effective microbiology. She described what testing/protocols can be beneficial and what methods should be eliminated.
Dr. Joseph Campos from the Children’s National Medical Center in Washington D.C. focused on “Unusual Gram-Negative Rods” via his world-acclaimed ‘Case Presentations’ with music, etc., etc. As usual, it was wonderful. And as usual, Joe provided a disk for every participant.
Dr. John Thomas, from West Virginia University, finalized the morning and afternoon meetings with a “late-breaker”, 5-minute update on “Seven Topics of Interest”. These included: MRSA Screening, Influenza, Cath-tips and Noravirus.
In the afternoon, Dr. Richard Thompson from Northwestern University School of Medicine described “What’s Your MIC IQ?” emphasizing the clinical relevance of an MIC vs. standardized Kirby Bauer Testing and places where its value could be maximized:
Our final speaker, Nadine Fydryszewski, MS, used case presentations in parasitology with the unique title, “Arthropods and Anisakines (Parasites and Pets)”. It was a lively presentation that generated significant discussion and it was best saved for last.
It was interesting to note that on the Summary and Suggestions for Next Year, the following topics seemed to hold the greatest interest for participants: Influenza, Wounds, Anaerobes, Fungi, and Genital Isolates.
The Fall Program will be on Sept. 30 – Oct. 1, 2007, with several speakers and topics already identified, including: “Boot Camp for Wound Care” (Dr. James Snyder) on Sunday afternoon, “Influenza and Rapid Reporting” (Dr. Joan Barenfinger), “Global Warming and Microbiology”, “Emerging Stool Pathogens, Gram-Positive Rods, Sputum Cultures” and “Colonization vs. Infection” (Dr. Yeagle).
The
election results for this year are in and the results are:
President: Richard Van
Enk
President Elect: Mary Plenzler
Secretary: Joy
Graff
Treasurer: Penny
Camp
Director at Large: Tim Overman
Director at Large: Laurie
Elder
Illinois State Director:
Mary Ann Schlacks
Indiana State Director:
Christine Mieher
Kentucky State Director: Jim
Butler