1. Modernising diagnostic medical microbiology services Professor Brian I. Duerden CBE,MD Emeritus Professor of Medical Microbiology, Cardiff University

2. Inspector of Microbiology - 2003 Champion & promote high quality clinical & public health microbiology –all labs in NHS contribute to surveillance –promote standards & quality –identify gaps in specialist & reference micro. –achieve adherence to SOPs –protocols to reduce the risk of loss/misuse –compliance with security and health & safety

3. Vision and Goal - 2004 An integrated and cohesive, quality assured microbiology and virology service to support clinical care of patients with infection and for health protection.

4. …….2011 Microbiology and Virology service – I nfection Service Health Protection – Public Health

5. Slow progress….why? Pathology modernisation –2005 visits and report highly variable but little concrete action highly variable but little concrete action –Carter review and pilots HPA establishment –Hiatus for public health microbiology 2003-7 HCAI prominence –MRSA and C. difficile targets –Intense effort 30 years in the “backroom”

6. Parting of the ways 1970 - 90 Microbiology & Infection Control –New antibiotics –New societies –New journals –New guidelines –New diseases Infection control was the province of the IC specialists Modern medicine –Increased life expectancy –Cancer treatment Immunosuppression –Complex surgery Cardiac Neurosurgery Orthopaedic –Chronic illnesses Infection – a nuisance

7. 1990s – the backroom days Increasing –HCAI MRSA Clostridium difficile AcinetobacterNorovirus –Antimicrobial resistance ESBL –Pandemic threats –Need for microbiology!! Decreasing –Training numbers –Academic input Reduced medical student impact Effect of RAE Dislocation of academic/service interface –Training in asepsis –Supply of microbiologists!!

8. BUT…….. ….we did not help ourselves

9. Perceived dogmas Laboratory focused –What about patient focus? Individual clinical pathology disciplines A lab in every main hospital/trust Transport too difficult – delays Lab headed by medical microbiologist –Medical microbiologists based in labs –Unwilling to have cover from a distance Daytime (8.30 – 17.30) service –On-call out of hours

10. Results Traditional methods Lack of investment in –new technology, IT Lack of specialisation Isolated services

11. Where do we go from here?

12. Coalition Government & NHS reorganisation Infection (prevention &control) is a priority Commissioning by GP Consortia –Need for support and guidance –Potential role for revised National Standards for Microbiology (standard methods) with Professional bodies’ ownership Public Health Service –Within DH –National and local components –Incorporates HPA functions (incl. labs) How will Public Health Microbiology be delivered?

13. Post-Carter developments Various models – same aims –Consolidation, centralisation –Enable technology development Automation - conventional tests; new technology Molecular, post-genomic – sequencing, micro-array, MALDI- TOF –Concentrate staff expertise –Extended (24/7) working –Cost effectiveness ………maintain the quality of patient care and public health support

14. Public Health responsibility HPA (Public Health England) –Public health, specialist, reference microbiology Clinical/diagnostic laboratories –NHS or commissioned Surveillance reporting Notifiable diseases Outbreak identification and support Standardised methods for infections of public health importance

15. Communicable diseases legislation 2010 Act – Notifiable diseases Requires all diagnostic laboratories to report isolates of pathogens with Public Health significance –Much longer list –In addition to medical practitioners reporting clinical cases –Expectation of accreditation and use of standard methods 2008 Code of Practice for HCAI –Requires microbiology support from an accredited laboratory

16. Technology developments Automation –Conventional tests –Molecular, post-genomic Which technologies –Next generation sequencing –Micro-arrays –MALDI-TOf –?????? …we need a strategy for their use

17. UKCRC - TIRI Oxford –Application of sequencing to diagnostic and public health microbiology; eg, HCAIs Imperial –Changing the culture and embedding HCAI prevention & control in healthcare services –Linked to modern diagnostics for HCAI epidemiology St Georges –POC molecular testing and mobile communication modules for STI Cambridge –Sequencing developments for MRSA and web-based systems for analysing data generated remotely

18. POC testing Healthcare settings –ICU –MRSA screening in A&E etc …need to be integrated with laboratory service “High Street”settings –Increase accessibility for patients/clients –Professional oversight? Interpretation? Advice? –Links to patient record? –Risks loss of surveillance data for public health …Microbiologists need to be involved in pilot projects

19. Transforming medical specialist training Medical roles of infection specialists –Clinical patient care –Consultation/advice What investigations? Interpretation of results Antimicrobial treatment Epidemiology Infection prevention and control Common training pathway –Core infection training –Clinical care, diagnostic & public Health microbiology/virology, infection prevention & control

20. Challenges for the future Keep infection as a patient safety priority in healthcare It will never go away! Use modern technology to deliver a patient-focused service Do not repeat the mistakes of 1970 - 2000