“The Paradox of COVID 19 and ECCMID 2020”

ECCMID is probably the biggest microbiology and ID conference in the world, attracting over 12000 delegates, and is being held this year in Paris, in six weeks time.

ECCMID seems like the ideal forum to discuss COVID19, bringing together a lot of the world’s experts, and may even lead to breakthroughs or at the very least, research collaborations on how to answer questions regarding the infection.

The only problem is that you are going to have 12000 people from all over the world meeting in the one place! This is hardly conducive to minimising the risk of coronavirus transmission, with a potential risk to both the attending delegates and also to the areas they will return to.

As of today, there have been 285 confirmed cases of coronavirus in France, the numbers having climbed significantly in the past few days. The French government have banned all public gatherings of more than 5000 people in closed spaces. However it is not known whether ECCMID will be an exception to this ruling.

The ECCMID organisers have been conspicuously quiet with regards to whether the ECCMID conference will go ahead this year. This conference is now big business, with a huge exhibition hall and representation from hundreds of infection related industries from around the world. Furthermore, thousands of delegates have booked travel and accommodation for a week in one of the most beautiful cities in the world, many of whom will be enjoying their yearly junket!

There are an awful lot of people with a vested interest in seeing this conference go ahead…

Personally (and purely by chance) I am not planning to go to ECCMID this year,  but I look on with considerable interest at whether this mega-conference goes ahead, and if it does, how will the organisers justify this decision in the current environment?

Michael

Building the CDC in your community

I am not referring here to the Centre for Disease Control, which is a great resource which I use often to look up things I should know anyway, but don’t.

I am referring to the acronym “Clinical Details Culture”, an equally important CDC in my mind.

At the laboratory I work in, we have just implemented a mandatory clinical details policy for all microbiology samples. The only exceptions are those “difficult to obtain” samples taken from sterile site areas. For everything else, if there are no clinical details supporting the testing, then no testing is performed by the laboratory.

Now when I sign out a list of microbiology results I have clinical details on each and every request form. This is wonderful! In a good percentage of cases it changes both the testing and reporting of results. In other words the quality of results being produced has improved. And no longer will I get staff complaining to me that there are no clinical details on forms!

This has not been an easy policy to implement. Even after several months of preparation, there have been a few (almost inevitable) teething¬† problems which have had to be worked through. One key area is ensuring that all the staff members assess the clinical details provided in a consistent and standardised fashion. This has involved a lot of protocol development and these protocols are still in a process of evolution. For example “Erythema and increased pain leg ulcer” are acceptable details whilst “chronic leg wound” is not, and then there is the myriad of word variations in between. It is not straightforward!

Although most of the clinicians have been supportive of such a policy and indeed have embraced it by including excellent clinical details, there remains a small cohort who refuse to believe that the inclusion of clinical details on microbiology request forms is important. There are a few others that believe in the policy in principle but have concerns over the logistics.

The goal over the next year or so will be to continue to build a clinical details culture amongst clinicians so that clinical information on microbiology forms (and all laboratory request forms) is the expected norm. This represents a positive step for all the involved stakeholders; clinicians, laboratory staff and patients alike.

Along the same lines I hope that many other diagnostic microbiology laboratories both nationally and internationally adopt a similar stance. The presence of clinical details is a key element of effective diagnostic stewardship. Without them, you are already on a hiding to nothing…

Michael

 

“Taking the crap out of enteric microbiology”

Just because a stool sample turns up at your microbiology laboratory, it doesn’t mean you have to test it… This is old style microbiology reasoning, testing for everything in the hope that you will find something!

There are many different microbiology tests that one can do on a stool sample. Here is a sample list of what is offered at the lab I work at:

  • PCR for common bacterial pathogens, e.g. salmonella, campylobacter, shigella, VTEC, yersinia.
  • Culture for more opportunistic bacterial pathogens such as Aeromonas
  • EIA for cryptosporidium and giardia
  • GDH/PCR for C. difficile toxin
  • Faecal concentration and trichrome stain for ova, cysts and parasites
  • Immunochromatographic assay for rotavirus
  • Multiplex PCR for other enteric viruses (e.g. noro, astro, sapo)
  • Faecal antigen test for H. pylori.

With appropriate clinical details present, we can then choose objectively from the list above which tests are appropriate to perform for a specific sample.

However, without clinical details, it would be utterly unreasonable for the lab to do all of these tests, and without clinical details there is no way of deciding which tests we should be doing.

Yet so many microbiology labs still take this approach. Receive a stool sample and test it for something! This is blindfold microbiology.

Extending this philosophy further, clinical details of “diarrhoea” doesn’t really cut the mustard either. That is to some extent stating the obvious!

Fit healthy adults who present with a short history of diarrhoea in general do not require laboratory testing. Personally I get 2 or 3 episodes of loose stools every year. I am sure the rest of the world has a similar experience! I do not need laboratory testing. So clinical details simply of “diarrhoea” or “loose stools” is insufficient to justify testing. There needs to be more than that…

The lab I work at will only test stool samples if one of the following applies, even when clinical details of “diarrhoea” or something similar is on the form:

  • Something to indicate an illness on the more severe end of the spectrum, such as prolonged diarrhoea, bloody diarrhoea, hospitalised, systemic symptoms, etc.
  • Or something that suggests there might be a public health issue, e.g. food handler, group meal, overseas travel, farm worker, etc.

“Carte blanche” approaches to enteric microbiology are hideously costly, and also give rise to quality issues such as overdiagnosis and overtreatment.

If you test every stool sample you receive for putative pathogens such as Blastocystis hominis or Dientamoeba fragilis, you are going to end up overdiagnosing and overtreating a whole heap of people. Don’t go there!

By taking a considered and objective approach to microbiology testing of stool samples you can dramatically reduce the amount of testing that you perform, and increase the quality of results at the same time.

Michael