1. WHAT IS IT YOUR TRYING TO TELL ME!!!! or How to Decipher a Microbiology Report By Beverley L. Orr, MT(ASCP)

2. Boston Medical Center 600+ Bed Hospital 600+ Bed Hospital Safety Net Hospital Safety Net Hospital Level 1 Trauma Center Level 1 Trauma Center Boston University Medical Center and Boston City Hospital combined Boston University Medical Center and Boston City Hospital combined Medical School Medical School Dental School Dental School School of Public Health School of Public Health

3. Objectives Interpret /assess the quality of a specimen by gram stain interpretation Interpret /assess the quality of a specimen by gram stain interpretation Correlate results from gram stain to final result Correlate results from gram stain to final result Distinguish between different susceptibility methods Distinguish between different susceptibility methods Identify Resistant Organisms from susceptibility report Identify Resistant Organisms from susceptibility report Identify “suspect” susceptibility results Identify “suspect” susceptibility results

4. Boston Medical Center- Exceptional Care. Without Exception.

5. Dissecting a Culture Report Gram Stain Gram Stain Preliminary Report Preliminary Report Final Report Final Report Susceptibility Report Susceptibility Report

6. Gram Stain WBC WBC SEC’s SEC’s Bacteria Bacteria Notes Notes

7. Gram Stain Info Preliminary result Preliminary result Gram positive cocci Gram positive cocci Clusters Clusters Gram positive cocci suggestive of Staphylococcus-like organism Gram positive cocci suggestive of Staphylococcus-like organism Pairs Pairs Gram positive cocci, lancet forms observed Gram positive cocci, lancet forms observed Chains Chains Gram positive cocci, suggestive of a Streptococcus-like organism Gram positive cocci, suggestive of a Streptococcus-like organism Pairs, chains and clusters Pairs, chains and clusters

8. Gram Stain info Gram Negative Rods Gram Negative Rods Tiny,pleomorphic = Haemophilus, Bacteroides, etc. Tiny,pleomorphic = Haemophilus, Bacteroides, etc. Coccobacillary – Haemophilus, Francisella, Coccobacillary – Haemophilus, Francisella, Brucella, HACEK organism Brucella, HACEK organism Large = Enterobacteriacae (E coli, Kleb, etc.) Large = Enterobacteriacae (E coli, Kleb, etc.) Large, sausage shaped = Pseudomonas Large, sausage shaped = Pseudomonas Let’s talk Acinetobacter….. Let’s talk Acinetobacter…..

9. Gram Stain Info Gram Positive Rods Gram Positive Rods Diptheroid –like Diptheroid –like Large, boxcar Large, boxcar Non-spore forming Non-spore forming Branching Branching Branching, modified afb stain negative/positive Branching, modified afb stain negative/positive

10. Gram Stain Info Yeast Yeast Budding Budding Budding with pseudohyphae Budding with pseudohyphae Encapsulated Encapsulated

11. Gram Stain Q scores Exporated Sputum Exporated Sputum How is it calculated? How is it calculated? What does it mean? What does it mean? What do we do with the score? What do we do with the score?

13. Gram Stain Q Scores Wounds Wounds How is it calculated? How is it calculated? What does it mean? What does it mean? What do we do with the score? What do we do with the score?

14. Wound Q Score

16. Gram Stain Q scores, cont Bacterial vaginosis Bacterial vaginosis How is it calculated? How is it calculated? Lactobacillus present Lactobacillus present Gram negative rods (Gardnerella or Mobiluncus) Gram negative rods (Gardnerella or Mobiluncus) Altered flora Altered flora What does it mean? What does it mean? What do we do with the score? What do we do with the score?

18. Culture Report - Preliminary Presumptive vs Definitive Presumptive vs Definitive Presumptive (not on sterile body fluids) Presumptive (not on sterile body fluids) E coli E coli Proteus Proteus Pseudomonas Pseudomonas Enterococcus Enterococcus Candida albicans or not Candida albicans or not Bacillus sp, not anthracis Bacillus sp, not anthracis

19. Culture report - preliminary Lactose fermenter Lactose fermenter Non-lactose fermenter Non-lactose fermenter Gram positive cocci Gram positive cocci Gram positive rod Gram positive rod Staph species Staph species Strep species Strep species Normal flora Normal flora No Salmonella, Shigella, Campylobacter… No Salmonella, Shigella, Campylobacter…

20. Blood Culture report – PNA Fish Peptide nucleic acid detection by Fluorescent in situ hybridization- positive blood cultures Peptide nucleic acid detection by Fluorescent in situ hybridization- positive blood cultures Staph aureus (Oxoid PBP 2a for mrsa) Staph aureus (Oxoid PBP 2a for mrsa) Candida albicans (use fluconazole, etc) Candida albicans (use fluconazole, etc) Enterococcus faecalis or Enterococcus faecium/duran Enterococcus faecalis or Enterococcus faecium/duran Future – dual probe Coag Neg Staph & Staph aureus, E coli and Pseudomonas aeruginosa Future – dual probe Coag Neg Staph & Staph aureus, E coli and Pseudomonas aeruginosa

21. Culture report - Final Pathogen listed, most numerous first Pathogen listed, most numerous first Normal Flora Normal Flora No SSCEYV No SSCEYV No Strep A, C or G No Strep A, C or G No Group B beta strep isolated – (broth enhanced) No Group B beta strep isolated – (broth enhanced)

22. Susceptibility Reports Where is the methicillin result Where is the methicillin result Oxacillin Oxacillin Cefoxitin Cefoxitin What about inducible clindamycin resistance What about inducible clindamycin resistance D test D test What about Vanco resistance – What about Vanco resistance – Staphs with MIC >= 4, retest by alternate method Staphs with MIC >= 4, retest by alternate method Phoenix has FDA approved mic to detect vrsa Phoenix has FDA approved mic to detect vrsa Enterococcus – BHI with vanco, E test, motility Enterococcus – BHI with vanco, E test, motility E faecium vs E faecalis (penicillin/ampicillin susceptibility) E faecium vs E faecalis (penicillin/ampicillin susceptibility)

23. Susceptibility problems-GNR Gentamicin susceptible/Tobra or Amikacin resistant Gentamicin susceptible/Tobra or Amikacin resistant Ceftriaxone susceptible/Cefepime resistant Ceftriaxone susceptible/Cefepime resistant Cefazolin susceptible/Ceftriaxone resistant Cefazolin susceptible/Ceftriaxone resistant Aztreonam resistant or Ceftriaxone resistant Aztreonam resistant or Ceftriaxone resistant Imipenem resistant Pseudomonas aeruginosa Imipenem resistant Pseudomonas aeruginosa Pip/tazo resistance Pip/tazo resistance Aminoglycoside report on salmonella, shigella-NOT! Aminoglycoside report on salmonella, shigella-NOT! Antibiotic reporting on E coli O157:h7 –NOT!!!! Antibiotic reporting on E coli O157:h7 –NOT!!!!

24. Culture Reports – Corrected Report Any time there is a change to the report there should be a corrected report generated and a call made to unit/physician. Any time there is a change to the report there should be a corrected report generated and a call made to unit/physician. Examples Examples Supplemental reports happen – additional comment, additional organism, additional antibiotic requested, etc. Supplemental reports happen – additional comment, additional organism, additional antibiotic requested, etc.