Tag Archives: microbiological efficiency

“Time Wasters”

If you work in a diagnostic microbiology laboratory, have a look at the list below to see if there is anything that sounds familiar in your workplace:

  • Performing susceptibilities on beta-haemolytic streptococci: Beta-haemolytic streptococci are invariably susceptible to penicillins, everywhere. If the patient has anaphylaxis to penicillin documented on the request form then fair enough. Otherwise, it is all a bit academic.
  • Culturing for anaerobes in areas of the body where anaerobes live (peri-anal area, vagina, oral, gastrointestinal): This is not very wise because if you manage to grow anaerobes from such sites then it may well represent normal colonising flora.
  • Susceptibility testing where topical antibiotics are the mainstay of treatment: Ear swabs and conjunctival swabs are the classic examples of these. It is well documented that in-vitro susceptibility testing correlates poorly with clinical response to topical antimicrobials, so why bother doing them in the first place?
  • Working up individual organisms where the culture plates clearly show”enteric flora”: For superficial swabs, this is a no-brainer. But even in sterile sites, the work up of each individual organism when they clearly represent enteric flora is of little clinical value. The classic example is culture of peritoneal fluid post perforation of the appendix.
  • Culturing sputum samples where there are lots of epithelial cells on microscopy: Because if you do so, you will simply be culturing a sample originating from the mouth or oropharynx, which will bear little relation to what is happening down in the lungs.
  • Culturing for bacteria in vaginal swabs: Vaginal flora contains lots of different colonising bacteria, most of which very rarely causes problems. It is probably only worthwhile looking for staphylococci and streptococci when there has been instrumentation or trauma (e.g. post-natal). The vast majority of vaginal swabs do not need cultured for bacteria.
  • Looking for bacterial vaginosis and yeasts in vaginal swabs where the patient has no symptoms: Vaginal swabs are sent to the laboratory for lots of different reasons. Often we do not get this reason, and when we do it is often not because the patient actually has physical symptoms. Looking for bacterial vaginosis and yeasts in the absence of clinical symptoms is rarely of any value.
  • Testing for Hepatitis A IgM where the liver enzymes are normal or only marginally elevated: Acute hepatitis A infection cause transaminases (ALT & AST) to increase into the hundreds and thousands. Testing for acute hepatitis A because the ALT is noted to be mildly elevated is not a useful exercise, and may cause more harm than good
  • Testing for Epstein Barr virus (EBV) infection when the patient already has positive VCA or EBNA IgG present: A lot of EBV requests come into the lab in patients who have already tested positive for EBV in the past. Symptomatic EBV reactivation in an immunocompetent patient is rare, if such a condition exists at all…
  • Performing a CSF viral PCR  in a patient after they have been discharged: The classic example is a patient who comes into hospital on a Friday with meningitic symptoms, and a CSF examination shows a lymphocytosis. As is often the case with so many molecular departments, the viral PCR will not be performed until Monday… At which point the patient could easily have recovered and be sitting at home or in the pub completely asymptomatic.

Not only are many of the examples above a waste of time, they are also a waste of both money and staff resources.

Furthermore, in many of the cases above, processing such samples may simply give misleading results and lead to inappropriate treatment.

This is only a list of 10. It would not take too much further thought to think of an additional list of 10. In fact the list could go on and on and on…

There are some ridiculously good new microbiology assays coming on to the market nowadays. Highly sensitive and specific PCR tests which can give highly accurate results back to the clinician in less than an hour. These are quite literally game-changers in terms of altering clinical management.

How can we afford to introduce these new modern assays? Only by looking at everything we do in the microbiology department, again and again and again, and assessing whether each test/process that we perform has clinical value.

Let’s not waste time, getting rid of the timewasters…


“Discharged, deteriorating or deceased?”

I have always been a big believer in the philosophy that the importance of a microbiological result is inversely proportional to the time taken to produce that result. (check out this post).

On occasion extra work and time does need to go into a sample in order to produce a “complete report”. But how do we decide when such work is necessary? A large part of this decision should depend on the current status of the patient.

There is not much point in doing a viral PCR panel on the CSF of a patient who has recovered from his meningitis and has gone home.

On the other hand it may well be worthwhile working up that Klebsiella spp. in the sputum of a patient who has gone downhill and is heading towards ICU.

…and there probably is not much point sweating over the borderline susceptibility of an E.coli to co-amoxyclav when the patient has unfortunately passed on.

The clinical status of a patient often changes from day to day. The more the scientists know about the current condition of the patient whose sample they are working on, the more appropriate the laboratory work-up will be.

The laboratory/clinical interface needs to be as seamless as possible….


“Microbiological Efficiency is over-rated…”

We all know of colleagues who seem to be able to do twice as much work as the rest of us, in about half the time…..

However efficiency is only a very minor quality in the world of microbiology. There are other qualities that are much more important;

  • The ability to spot the unusual.
  • The ability to know when to ask for help.
  • The ability to recognise and focus on what is important and to ignore what is unimportant.
  • To be able to stop and look up more information on an interesting micro-organism.
  • To be passionate about microbiology and have the ability to inspire this passion in your colleagues.

I have come across many excellent microbiologists over the years. Some are fast workers, some slow.

In summary, everybody works at their own pace.

It is not a race, nor do we work in a factory….


Efficiency is overrated in life as well as work. Click on the article here for an interesting insight into this…