3/9/2018. The Power of a Gram Stain (and Other Micro Results): What your Infection Preventionist Needs to Know Now

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1 The Power of a Gram Stain (and Other Micro Results): What your Infection Preventionist Needs to Know Now Sara J. Blosser, Ph.D., D(ABMM) Director, Division of Clinical Microbiology Indiana State Department of Health sblosser@isdh.in.gov What is the Role of the Microbiology Laboratory? 1. Clarify the presence of infection. Clinical presentation must guide the microbiological workup and all results must be interpreted clinically! 2. Specify the etiology of infection. 3. Motivate the appropriate selection of antimicrobial agents 4. Assist in identification, control, and prevention of nosocomial or public health infections What is the Role of the Infection Preventionist? 1. Promote practical methods of preventing and controlling the spread of infectious diseases within a specific population the patients, staff, and visitors at a hospital or another health care setting. 2. Reduce the risk of contagious diseases being carried out into the community. 3. Conduct surveillance, investigate cases and outbreaks, develop and enforce infection control policies, and evaluate the effectiveness of their infection control efforts. 1

2 Local Hospital Advertised for an IP: WHAT WE NEED. Infection control freaks. WHO WE ARE LOOKING FOR. Sometimes the term control freak is used negatively. In this job? It's exactly what we need. The Infection Preventionist is our go-to resource for all infection control issues. In Indiana, the following conditions or diseases are immediately reportable upon suspicion: Anthrax Arboviral disease caused by Eastern Equine, St. Louis, La Crosse, West Nile, California, Western Equine, Powassan, or Japanese viruses Botulism Brucellosis Chikungunya virus Cholera Dengue Diphtheria Shiga-toxin producing E. coli Hantavirus pulmonary syndrome Hemolytic uremic syndrome Hepatitis viral, Type A, E Hepatitis viral, Type B (pregnant) HIV infection/disease (pregnant or perinatal) Measles Meningococcal disease Plague Poliomyelitis Q Fever Rabies (human or animal) Rubella Shigellosis Smallpox Tularemia Typhoid or paratyphoid fever Yellow Fever 2

3 There are generally county-specific reporting requirements as well. Then there s the alphabet soup MRSA VRE CRE CP-CRE CRO CP-CRO Cdiff ESBL HBV HCV Noro CLABSI CAUTI.and the Flu When to call the laboratory 3

4 And maybe when the laboratory should be calling the IP too Gram Stains Specimen You Read. Your concern CSF GNDCs Neisseria meningitidis Blood Culture GPRs GNRs GPR with spores Bacillus anthracis Listeria Haemophilus influenzae Bacillus anthracis (and others) Culture Results Source You Read The Concern ANY Bacillus anthracis Anthrax Yersinia pestis The Plague Burkholderia pseudomallei Burkholderia mallei Francisella tularensis Rabbit Fever Brucella sp. Brucellosis Corynebacterium diphtheriae Diphtheria Listeria Wound Clostridium perfringens Sputum Mycobacterium tuberculosis TB Vaginal β-hemolytic Strep Group B Strep (pregnancy) 4

5 . Ordered Tests Source ANY You Read Rule out for Agent of Bioterrorism Parvovirus B19 VZV PCR or Serology Measles PCR or Culture Whenever you think you re seeing something weird, strange, or unusual. Whenever you receive a test request that is weird, strange, or unusual. 5

6 Here s some times Indiana IPs say that working with the microbiology team has been vital: Developing rapid notification of resistant organisms (either through electronic means or by phone) Changing the automatic UA-to-culture protocol (remove RBCs from criteria) Optimizing C. difficile testing (PCR vs. 2-step testing) C. difficile formed stool feedback/education Ebola test collection procedures Zika exposures in lab personnel Antibiotic stewardship team A Case of Confusion (outline) 1. Bacterial meningitis? 2. VRSA? 3. GPR in an Inpatient Blood Culture Case: Bacterial meningitis??? Lab reported Gram negative cocci from a CSF Gram stain IP responded. ISDH epidemiologists consulted. Close contacts investigated and prophylaxed. Messaging developed and news alerted. Several days later, Micro lab reports Acinetobacter sp. Questions arise? Is this a result mis-match? So what happened? 6

7 When the lab report says Gram Negative Cocci Lab Says Could be a few things: Neisseria Moraxella Haemophilus Acinetobacter Won t know for certain until we get the ID Infection Control Says This is (absolutely) Neisseria meningitidis!!! We need to take immediate action! How is the other side feeling? Lab Why are they freaking out? Its too soon to tell you what this is! Infection Control Why aren t they being more proactive? Don t they know this is a HUGE deal? So what can we do? Lab Communication is key! We can be providing education before and during these types of incidents. Hospital IP Says Communication is key! We can learn key pieces of Microbiology before and during these types of incidents. 7

8 Case: VRSA? ISDH Laboratories received an isolate for r/o VRSA (leg wound) Submitting IP was concerned, as patient was currently on Vancomycin, and had just went through surgery. AST report read: Vancomycin 32 µg/ml Background Type MIC (µg/ml) VISA 4-8 VRSA 16 VISA first identified in May 1996 (Japan) Since been identified in US, Europe, Asia Mechanism is non-transferable and is not maintained in the absence of vancomycin VISA seems to develop at a cost to the organism, so strains with VISA are less virulent and less of a public health threat Background Type MIC (µg/ml) VISA 4-8 VRSA 16 VRSA first identified in the USA in 2002 As of May 2015, fourteen VRSA infections have been documented in the USA All contain the vana vancomycin resistance gene commonly found in VRE These have appeared in geographic clusters, but no transmission has been documented. 8

9 Background Type MIC (µg/ml) VISA 4-8 VRSA 16 If a VRSA is suspected... Lab personnel should immediately contact the patient s primary caregiver, care team, and infection control Appropriate infection control precautions should be immediately implemented Notify state/local public health departments Submit the isolate to the public health lab for confirmation Lab Tidbit: Good idea to repeat the susceptibilities while this process is ongoing. Case: VRSA? (continued) Subculture Confirm ID (MALDI) Confirm AST (ETEST) Case: VRSA? (continued) No, this is not a VRSA So what happened? Mixed culture. CLSI M100-S28 Performance Standards for Antimicrobial Susceptibility Testing Appendix B. Intrinsic Resistance NOTE 2: Enterobacteriaeae are also intrinsically resistant to clindamycin, daptomycin, fusidic acid, glycopeptides (vancomycin, teicoplanin), lipoglycopeptides (oritavancin, telavancin), linezolid, tedizolid, qunipristin-dalfopristin, rifampin, and macrolides (erythromycin, clarithromycin, and azithromycin). However, there are some exceptions with macrolides (eg, Salmonella and Shigella spp. with azithromycin). Lab Tidbit: Good idea to perform a check-plate for all AST. 9

10 So what can we do? Lab Focus on communication: we spent some time explaining the microbiology with the IP. Hospital IP Says IP and Lab will touch base to learn more about current processes. Case: GPR in an Inpatient Patient has been in ICU for several weeks Blood culture flags positive (1 of 2) Gram stain read is Gram Positive Rods Patient is very ill, but the Gram stain is questioned What are our assumptions? Case: GPR in an Inpatient (continued) Lab Says This doesn t look like the typical contaminant Infection Control Says Infection control hasn t been contacted, this was considered a contaminant by the care team Meanwhile 10

11 Case: GPR in an Inpatient (continued) MALDI result comes back Listeria monocytogenes Care team is alarmed! They were treating empirically. But maybe would have changed something based on suspicion of Listeria? Infection control is alarmed! Where did this come from? Patient has been inpatient for weeks! Did they get Listeria from our food services? How large is the impact of this scenario going to be? Lab says oh that fits with the Gram stain. Case: GPR in an Inpatient (continued) Lab Says Why didn t you didn t ask? Infection Control Says Why weren t we told? The result? A great opportunity to open up channels of communication. phil.cdc.gov 11

12 Case: GPR in an Inpatient (continued) So what really happened? Many times, your IP needs a lot from you (the microbiologist). But it s not a one-way street Examples of things that some Indiana IPs do for their Micro Lab routinely: Chasing down CDC or ISDH testing results Coordinating testing with other facilities Submitting requisition forms for send out testing Helping to triage testing priorities Helping to direct testing policy 12

13 A Case of Communication (outline) 1. Influenza Triage 2. KPC and the Modified Hodge 3. CP-CRE Colonization Screening Flu Testing Priorities % of Visits for ILI (sentinel providers) Influenza in Indiana * Shortage of influenza test kits Abundance of influenza test requests MMWR week Real Example: Flu Testing Priorities Infection Control & Microbiology Worked together to: Determine which patients/wards to prioritize testing kits when limited Educate providers about test selection criteria Enacted visitor restrictions phil.cdc.gov 13

14 KPC Outbreak & the Modified Hodge IP says I think we have a potential KPC outbreak. Please do Modified Hodge on every carbapenem resistant organism we receive on an inpatient. Microbiologist says Do you know what our census is? How many carbapenem resistant organisms we receive? Are you only talking about Enterobacteriaceae? Don t you know we can t do this test on Pseudomonas? Don t you know what a terrible test this is? How much man power it will take to do this? KPC Outbreak & the Modified Hodge IP says I know I m asking a lot. We do have a very large census and receive a large number of carbapenem resistant organisms. I wouldn t ask if we weren t in the middle of an outbreak I wasn t aware of that information you stated about how terrible the test was, or the fact that you couldn t do this test on Pseudomonas. Could you tell me more? Microbiologist says Nothing (speechless) What happened? The IP lobbied management to bring in a molecular assay to test for KPC The microbiology lab performed MHT for a short period of time while the assay was getting validated Both were happy 14

15 Some time later the same IP asked for the lab to start offering colonization testing for inpatient admits. Instead of the previous reaction, here s what happened Colonization Screening Query Microbiologist says I understand why this is needed. My concern is with how much time this procedure takes. I don t have the staffing resources needed to bring this in for the entire hospital. IP says I understand your concerns. Would you be willing to pilot this procedure for two highrisk wards, so we can collect the data necessary for me to make a case to the hospital administration? Colonization Screening Query Microbiology conducted pilot on two high-risk wards for a number of months IP went to hospital administration to ensure that lab wasn t penalized for this non-reimbursable test At the end of the pilot, estimates were made by the IP and the Lab director on how much staffing would be required to operationalize this for the entire hospital IP went (again) to hospital administration FTE added, dedicated to colonization screening Everyone was happy 15

16 In Conclusion Communication may be hard but its worth it! Contact Information Sara Blosser, Ph.D., D(ABMM) Director of Clinical Microbiology Indiana State Department of Health Laboratories Work: