A lot of antibiotic treatment of infectious diseases is still “empirical” in nature. “Empirical” generally means “based on experience”, so to administer an empirical antibiotic means to give the antibiotic that is most likely to work based on previous experience with that infection.
Antibiotic treatment has traditionally been empirical because waiting for culture and susceptibility results was simply far too slow. Only a generation ago the average turnaround time for a microbiology culture test was 3 days and counting….
A lot of antibiotic treatment is still empirical in nature. If you go to your GP with a sore throat or a urinary tract infection, chances are high you will receive an empirical antibiotic. If you attend your local Sexual Health clinic with symptoms of gonorrhoea, you will likely be getting some empirical ceftriaxone long before the diagnosis is established. If you go to your local hospital with pneumonia, you will likely get a macrolide antibiotic (to cover atypical pathogens) as well as a beta-lactam.
However microbiology labs are improving all the time. We now have the potential in many areas to make empirical treatment redundant for certain infections. Check out the following examples:
- Rapid antigen and PCR tests are now available for the laboratory diagnosis of sore throat, with a turnaround time of minutes to a few hours.
- Bacteriology automation, such as Kiestra TLA, can reduce turnaround times for urine cultures to less than a day, and a day and a half for wound swabs. I suspect a lot of patients with straightforward UTIs and wound infections can wait that long for a result without outcomes being adversely affected.
- Rapid PCR tests for atypical respiratory pathogens (Legionella spp., Mycoplasma pneumoniae, Chlamydia pneumoniae) can mean that macrolide coverage for community acquired pneumonia can be stopped early, or not even started.
- Ultra-fast PCR tests for influenza can prevent any antibiotics being prescribed in patients who present with Upper Respiratory Tract Infection (URTI).
- PCR tests with genotypic antimicrobial susceptibility information (e.g. Neisseria gonorrhoeae, Mycoplasma genitalium) can avoid the use of empirical antibiotics and selection pressure for antibiotic resistance.
Costing silos, resistance to change, and a lack of vision are amongst the main reasons that it takes so long for treatment protocols to move to “directed therapy” wherever possible.
There are still areas where empirical antibiotics will continue to be necessary. The acutely septic patient presenting to hospital is one such example. However large swathes of infections, particularly in the community setting are still managed by empirical antibiotic therapy. This is the way it always has been. However that doesn’t mean it is the way it always should be…
The next big revolution in clinical microbiology labs should be to challenge the dogma of empirical antibiotic treatment. This would be a huge step forward towards counteracting the development of antibiotic resistance.
Whether you are a microbiology student undertaking exams, a lab manager considering a business case, or a scientist wondering just what exactly the future holds, you need to know something about bacteriology automation.
We have now had the Kiestra TLA in place for 18 months at the lab where I work. It would be foolish to say it has all been plain sailing. Far from it. There have been breakdowns, computer malfunctions, and interfacing problems, particularly in the early days.
The learning curve is very steep.
But would I ever go back to traditional “manual” bacteriology processing? No way! In fact, I would go as far as to say that I would be very reluctant to ever work in a microbiology lab in the future that didn’t have automation of the bacterial culture process.
It would simply be a backward step…
With some great feedback from staff members (and expanding on a previous post), I have listed below an honest account as to what I think are the advantages and disadvantages of a bacterial automation system like Kiestra:
- Standardised incubation times: Personally I think this is one of the strongest advantages of the system. No matter when the plate was inoculated, the system will image the plate after a pre-set incubation time, and thus allow plate reading. This in turn will allow reduction in turnaround times for specimens. The old concept of Day 1, Day 2, etc. plate reading should disappear and be replaced by 1st reading, 2nd reading….
- Plate Tracking: Each plate has a comprehensive electronic audit trail attached to it, including when it was inoculated, incubated, imaged and read, and by whom. The audit trail is encyclopaedic, if not a little complex in nature.
- Less menial tasks: Gets rid of finding appropriate plates for each sample, carrying the plates to and from the incubator, “putting up” of specimens, and other repetitive, manual tasks.
- Better plate spreading: Automated spreading performed by machine will almost always succeed in better use of the whole agar plate and improved isolation of single colonies. It will also be a standardised procedure. Kiestra TLA uses the magnetic rolling bead method. It occasionally needs a bit of tweaking, but when it works, it is beautiful!
- Less plate contamination: As the plate has less manual handling and less time spent with its lid off, the risk of plate contamination is almost certainly much reduced, which is very important for those “sterile site” specimens. A study in this area would make a nice research project for someone.
- Storage of digital images of plates: Plates eventually deteriorate, images do not, and images can be stored to be viewed again at any stage in the future depending on how long you want to store them for. Great for presentations!
- Less time out of the incubator: The plate goes straight into the incubator when it is inoculated, and essentially stays in the incubator whilst it is being examined. No hanging around and very little downtime. The advantage is twofold; shortened turnaround times, and a decreased chance of “losing” fastidious organisms.
- Remote plate reading: The system should allow you to view the plate images from anywhere, including home. The possibility of microbiology scientists working from home in the near future is a real one.
- Plate interpretation: This is still in the developmental stage but software is now available allowing rapid detection of plates with no growth, and (chromogenic)plates with colonies of a particular colour. Further development in such software will eventually lead to massive gains in efficiency.
- Redundancy of staff: Whether staff members are made redundant or not due to the implementation of a system like Kiestra TLA, the simple fact is that this type of automation will get through (far) more specimens with less labour. Some (managers) might see this as an advantage, but from a people point of view it is a big downside. I personally find this aspect of automation very difficult to deal with.
- Dependency on the automation: What happens if it breaks down? Because of the above, and because it is a complex operation, the consequences can be potentially serious if the system goes down. Fortunately as the Kiestra TLA is modular in nature, it is very unusual for the whole system to go down at once. We are also fortunate to have excellent engineering support at our lab.
- Loss of ownership: Because the majority of the culture process is automated, staff members are less involved with the clinical sample from start to finish. This can lead to a loss of “ownership” of the sample.
- Loss of continuity: Even with Kiestra TLA, there are still a few steps in the process that are still to be automated. Those steps are batched together in lists (e.g. MALDI-TOF spotting, susceptibility testing). Staff members are often only involved with one step in the whole culture process for any one patient sample. Continuity, which I regard as important, can therefore be lost…
- More knowledge required: Not only do the staff now need to know about microbiology, they also need to know about Kiestra, how the system works, and how to troubleshoot any issues. Therefore a lot of new learning is required, as well as keeping up core knowledge in microbiology.
Change always comes with downsides as well as upsides.
But having said that, change is utterly inevitable, and I believe that Kiestra TLA or similar systems ( Biomeurieux, Copan Wasp) will be as ubiquitous as MALDI-TOFs in our clinical microbiology laboratories in 10 years time.
And if you understand both the pros and the cons of such systems before you start, it makes that change just a little bit easier…
A couple more posts coming on microbiology automation over the next week!
The Kiestra TLA audit trails are really quite amazing in their detail. You can track down where every plate is at any time throughout the whole culture process. Because everything is automated and digital, more or less everything has an audit trail. There is no hiding place for anything, or anyone.
The accreditation agencies love it…
And you can even view how many plates an individual staff member reads per hour, every hour of the day. You could even hazard a guess at when they went to have a coffee.
Too much information perhaps…?
Everybody works at their own pace in the laboratory. Some people are naturally fast, some people are naturally slow.
Some people like to have a chat between samples, and some people like to daydream. Some people even like to go for a wander every 10 minutes.
…and that’s ok as well.
The point being that to try and force people to work harder or faster is almost always both unsuccessful and counterproductive.
It is all about trust. If you trust people to do a job to the best of their ability, then the vast majority will.
It is a bit like those companies who have recently adopted a policy to give unlimited annual leave to their employees. What seems illogical at first glance actually works very well. Most people will work a sufficient number of weeks to provide benefit to their employer, whilst taking enough annual leave to both retain their sanity and have sufficient time with their family.
So I don’t care how many plates person X reads per hour. I have absolutely no interest in it whatsoever. What I do care about is that they are happy, and they are able to produce quality results.
Some audit information is best just ignored…