Category Archives: Confessions of a Microbiologist

“Susceptibility to Influenza”

If you live in the Northern Hemisphere you may have found that your laboratory was swamped by incoming influenza tests this season?

You would not be alone.

Influenza is an unpredictable beast. In my own neck of the woods, New Zealand, the 2015 season was busier than usual, the 2016 season was almost non-existent, and the 2017 season was very average.

Nobody knows what will happen with influenza during 2018.. (Note that as NZ is in the Southern Hemisphere, our winter is June, July , August, right in the middle of the year).

Often you will see Influenza “experts” on TV making predictions about how severe the forthcoming influenza season will be. However such predictions come with huge pinches of salt. You might well be better off predicting the stock market…

The truth is that we don’t really know how bad the forthcoming influenza season is going to be, whether you are an expert or just an interested bystander.

And as a result we have no idea how much each influenza season is going to cost a diagnostic laboratory that performs influenza testing.

Let’s say a bog standard Influenza/RSV PCR costs approximately $30. In a quiet season 1000 tests might get performed in a medium sized hospital. However in a busy season 5000 tests might be required, with an excess cost of $120000. This would of course cause the laboratory manager some sleepless nights!

I am glad I am not a laboratory manager..

And then there might be an influenza pandemic…

The same goes for Public Health Laboratories. The numbers of samples coming in for antigenic sub-typing will be closely related to the severity of the influenza season.

Contracts that laboratory providers have with healthcare funders need to take this unpredictability into account. Some sort of clause like “The diagnostic laboratory will perform up to X Influenza PCRs during the Influenza season. If this number is exceeded, further funding will be negotiated”. Unfortunately this is often not the case. Often laboratory providers will be so desperate to get the contract signed and sealed that they will accept these risks, and manage such problems reactively.

From a financial point of view, microbiology laboratories are very susceptible to influenza test volumes, just like they are susceptible to emerging diseases and MDROs, cohorts where “unexpected testing” may need to take place.

There will of course be some laboratories who are reimbursed per test performed (fee for service). Those places of course would be hoping for a pandemic every year!, but such laboratories/funding arrangements are getting less and less common. The funders are not daft!

I hope for a quiet influenza season this year, and that is nothing to do with my personal risk! (I look forward to receiving the quadrivalent vaccine in the next couple of months).

Michael

“Back pocket antibiotic prescriptions: Good or Bad?”

Whenever my children get taken to the GP for a suspected chest/ear/throat/sinus infection, more often than not we are given a “back pocket”/delayed antibiotic prescription to be used only if the child does not improve over the next couple of days.

Is this a good policy?

My analytical way of thinking deduces the following assertions from the decision to prescribe a “back pocket” antibiotic prescription.

  • The doctor has decided that based on the current clinical presentation, the patient doe not require an antibiotic immediately.
  • The patient/guardian now has the primary responsibility as to whether the antibiotic is actually given or not. Is this really a good thing?

Studies have shown that back pocket prescriptions are acted upon about half the time, maybe a bit less than that. Whether or not a back pocket policy reduces antibiotic prescribing depends entirely on what you are comparing it against. If you say that all these patients would otherwise have received an antibiotic straightaway, then of course you can demonstrate a reduction! (Lies, damned lies and statistics…)

So what seems like a good idea may in reality may not be so perfect after all.

Given that only a small minority of such infections ever really need an antibiotic I prefer an educational approach (check out this leaflet), along with advice to come back if not settling in a couple of days’ time for clinical reassessment.

I remain to be convinced that back pocket prescriptions are a truly effective means of antimicrobial stewardship. To me it is more a way of the GP showing that they are doing something for the patient, a bit of a halfway house as such. It may even give out the completely wrong message to the patient. i.e. “I am not interested in seeing you again.”

If we are really serious about antimicrobial stewardship, then I think we need to review the back pocket policy. I think antibiotic prescribing for minor infections needs much tighter regulation. I also think including the clinical indication for the antibiotic on the prescription should be mandatory.

So the antibiotic prescription in my back pocket hardly ever comes out, and my gut feeling is that it shouldn’t even be there in the first place…

Michael

Here is an article with a bit more detail on this debate.

“Face to face”

Sometimes your chair can be just too comfortable

It can be all too easy to sit in front of a computer all day, allowing yourself to be sucked in by a vortex of emails, playing to the tune of other people’s agendas, and from which it is difficult to escape as work fatigue sets in. We become hypnotised by the screen and frozen to our chairs.

Or if you are a scientist, you might feel compelled to sit all morning at the bench reading agar plates, without any hope of reprieve…

So one of my resolutions for 2018 is more face to face time. Less time in front of a screen and more time talking to people, building relationships, and breaking down barriers. By this I don’t mean more formal meetings, just more informal chats, and not necessarily about work!

Sure, there will always be periods where I need to be in front of a computer:- reading articles, reviewing or writing laboratory policy, checking emails, analysing data, etc. But I want to ensure that this is the minority of my working day, not the majority.

The same applies if you are working at a bench. If you have a mountain of culture plates to read, or samples to set up, then the risk of boredom and consequent errors is a genuine one. Make sure such work is punctuated by occasional wandering and chats to your colleagues. Discuss possible ways to make the laboratory process more efficient, or just talk about what you got up to at the weekend! And never, ever feel compelled to stay at your bench just because your boss is sitting in the office nearby. This is not school anymore!

Being an introvert, I am not a natural conversationalist, but this year I am going to force myself out of my comfort zone. Disagreements with colleagues, which are inevitable from time to time,  are so much easier to navigate through if you have a good working relationship with them.

To quote the often used cliche. “Nobody has ever said on their deathbed ‘I wish I had spent more time in the office/at the bench.‘”

But it’s absolutely true.

So in 2018 I will endeavour to seek more face to face time, assuming I can find somebody who is not busy sending emails or reading plates…

Michael