Modernising diagnostic
medical microbiology
services
Professor Brian I. Duerden CBE,MD
Emeritus Professor of Medical Microbiology,
Cardiff University
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
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.
…….2011
Microbiology and Virology service
– Infection
Service
Health Protection
– Public Health
Slow progress….why?
Pathology modernisation
– 2005 visits and report
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”
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
1990s – the backroom days
Increasing
– HCAI
MRSA
Clostridium difficile
Acinetobacter
Norovirus
– 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!!
BUT……..
….we did not help ourselves
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
Results
Traditional methods
Lack of investment in
– new technology, IT
Lack of specialisation
Isolated services
Where do we go from here?
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?
Post-Carter developments
Various models – same aims
– Consolidation, centralisation
– Enable technology development
Automation - conventional tests; new technology
Molecular, post-genomic – sequencing, micro-array, MALDITOF
– Concentrate staff expertise
– Extended (24/7) working
– Cost effectiveness
………maintain the quality of patient care and
public health support
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
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
Technology developments
Automation
– Conventional tests
– Molecular, post-genomic
Which technologies
– Next generation sequencing
– Micro-arrays
– MALDI-TOf
– ??????
…we need a strategy for their use
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
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
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
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