Czytelnia Medyczna » Nowa Medycyna » 2/2009 » Cooperation between the clinical microbiologist and the clinician during the process of diagnosis and treatment of respiratory tract infections – how it works in Denmark

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*Alice Friis-Mřller

Cooperation between the clinical microbiologist and the clinician during the process of diagnosis and treatment of respiratory tract infections – how it works in Denmark

Department of Clinical Microbiology, Hvidovre University Hospital, Copenhagen Denmark

Streszczenie
Denmark has a population of 5.3 million people. We have 15 departments of Clinical Microbiology.
All laboratories are public service laboratories located in public hospitals. The Departments of Clinical Microbiology (DCM) are serving the hospitals and the private hospitals, the private doctors and the medical specialists. The staff consists of clinical microbiologists (CM-RMD), i.e. registered medical doctors with a specialist degree in clinical microbiology after 5 years training in clinical microbiology (1), further more the staff consists of molecular biologists and technicians with bachelor degrees.
The Departments of Clinical Microbiology vary in size and services. Dept. of Clinical Microbiology Hvidovre Hospital is one of the biggest in the country receiving 450 000 specimens per year from 6 hospitals with a total of 2100 beds, and from 580 doctors and specialists. DCM investigates the specimens, make the microbiological diagnoses, send out the answers by electronic laboratory system to the costumers. All the doctors at the DCM also function as consultants both for the hospital wards and the private doctors. DCM has a staff of 15 medical doctors of whom 8 are specialists in clinical microbiology and 7 doctors under clinical microbiological training. All doctors have telephone conferences with clinicians and practitioners and the specialists visit the wards for clinical conferences and patient rounds together with the clinicians.

Słowa kluczowe: clinical microbiologist, clinician, process of diagnosis.

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The main tasks for the clinical microbiologists are:

– To diagnose infectious diseases in the laboratory using specimens from patients.

– To give advise to clinicians and nurses in the hospital wards in connection with diagnostic procedures, treatment of infections and prevention of infections.

– To make and implement hospital infection control programs.

– To make antimicrobial treatment policies in collaboration with the clinical wards taking the local sensitivity patterns into account.

– To educate medical microbiologists, hygiene nurses and technicians.

– To educate doctors and nurses.

– To participate in research.

Cooperation taking the specimens

For the clinicians to make the definite diagnosis of the infections of the patients it is essential that the DCM receives the appropriate specimens. Specimens should be correctly taken and transported to the laboratory and processed timely in the correct way. To achieve this, it is necessary to have easy accessible datasheets from the DCM explaining to the wards/practitioners how to take the specimens, what transport media to use, and what clinical information´s should be given to the DCM. The datasheets also indicate how long the expected processing time would be for the specific sample, and when an answer could be expected.

To diagnose infections of the upper and lower respiratory tract, the DCM would get some of the following type of specimens: throat swabs, sputum´s, tracheal suctions and bronchial lavages for culture and sensitivity testing and event. PCR: for virus, L. pneumophila, Mycoplasma, Chlamydia sp., blood cultures for aerobic and anaerobic culture and urine for antigen detection can if positive also give the diagnosis of the respiratory tract infection.

Choosing the diagnostic procedures for the specimens, and clinical investigations

The DCM has standard procedures for investigations of the majority of ordinary specimens. From some wards the patients and thereby their specimens require special attention and treatment.

Many patients in intensive care units (ICUs) and lung departments have acute life threatening infections where the correct empiric, treatment before the diagnosis of the infection is confirmed, can be life saving. Here it is essential that there is a close contact and dialog between the clinician and the clinical microbiologist. The contact may be by telephone or at clinical conferences.

For pneumonia the antimicrobial treatment should always cover Streptococcus pneumonia,both for community acquired and hospital acquired pneumonia.Up to now, 2009, there are only few penicillin resistant Pneumococci in Denmark. Depending on the history of the patient, selective cultures and other antimicrobial agents could be added. If the patient has been travelling, the clinical microbiologist would suggest investigation for Legionnaires disease, influenza A+B and may be TB. If the patient is known to have chronic obstructive pulmonary disease (COL) the most common bacteria would will be H. influenzae, Moraxella catarrhalis, and Pseudomonas aeruginosa, and treatment would be suggested accordingly. Had the patient been working with birds, the clinical microbiologist would suggest investigation for Chlamydia psittaci and perhaps bird influenza. If the clinician suspected the patient to be immunocompromised the DCM should investigate the BAL for Pneumocystis jerovecii, fungi and TB.

Information about the history of the patient is essential to investigate the specimens in a logical and sensible manner. As consultants, the clinical microbiologist could also suggest antigen detection in urine, sputum or blood, or antibody testing late in the course of disease. Together with the clinician the clinical microbiologist could discuss results of leucocyte scintigraphy or X-ray or CT-scan of the lungs or sinuses to find the focus of infection and/or the possibilities for biopsies or puncture of a focus to get material for culture and sensitivity testing to be able to give the correct antimicrobial treatment.

Clinical problems where the clinician and the clinical microbiologist collaborate

– Differentiation between colonising bacteria and pathogens.

– Choice of antimicrobial agents, dosage, administration route, duration of therapy.

– Persistent fever despite multiple antimicrobial therapy.

– Choice of antimicrobial combinations in treatment inpatients with organ failures.

– Choice of antimicrobials in allergic patients.

Discussing treatment

DCM have Rational Antimicrobial Treatment Guidelines (3), that are given to all doctors occupied in the 6 hospitals DCM are servicing. The guidelines are written by the clinical microbiological specialists in DCM in collaboration with the clinicians in the different specialities, taking into account the local patterns of antimicrobial resistance and international guidelines (4). The Rational antimicrobial treatment guidelines are also on the Hvidovre Hospitals intranet accessible for everybody. Surveys have shown that the clinicians do follow the guidelines.

The whole process writing the guidelines have had a tremendous teaching effect both on the clinical microbiologists and on the clinicians.

Clinical conferences in ICUs and departments for lung medicine

All ICUs have clinical microbiologist clinical conferences once or twice a week. The departments for lung medicine once a month, plus telephone consultations daily.

The close contacts are essential for the intensive care patients where acute lung infections as well as a rising number of Candida infections are both antimicrobial problems and economic problems. The prevalence of MRSA in Denmark is now again low, only ca 1% of S. aureus, after a couple of years where it rose to 2%. The surveillance and eradication programmes are efficient, but very laborious. E. coli and Klebsiella pneumonia ESBL and Amp C are on the rise, also in the ICUs and departments of lung medicine where DCM are involved not only in the treatment, but also in the infection control, and the isolation procedures and Chloride-cleaning instructions (6).

Needs Analysis in the clinical wards

All the wards in the hospitals are every other year visited and interviewed at meetings with clinicians and nurses to access their satisfaction or complaints with the service from DCM.

DCM can suggest changes in the collaboration or get suggestions from the ward. This form for collaboration works well.

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Piśmiennictwo

1. Professional Affaires ESCMID News 03/2008, 20-24. 2. S.Grosek. What does a clinician expect from a microbiologist? Towards an effective joint policy Journal of hospital infection. 1999, 43 (Supplement): S293-S296. 3. Jenny Dahl Knudsen et al. Rationel anvendelse af antibiotika. 2008. Hvidovre Hospital www.hvidovrehospital.dk 4. Burke A. Cunha. Antibiotic essential. 7.th edition 2008. 5. Ky Yuenet al. The role of clinical microbiologists in infectious disease management. HKMJ, 1995 vol.1, no2: 123-128. 6. Kolmos H.J.. Role of the clinical microbiology laboratory in infection control - a Danish perspective. Journal of Hospital Infection. 2001, (Supplement A): S50-S54.

otrzymano: 2009-03-10
zaakceptowano do druku: 2009-04-02

Adres do korespondencji:
*Alice Friis-Mřller
Department of Clinical Microbiology, Hvidovre University Hospital, Kettegĺrda Alle 30, 2650 Hvidovre DK
tel.: +45 363-224-11
e-mail: alice.friis-moeller@hvh.regionh.dk

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