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The microbiology laboratory — an essential part of the infectious diseases services line
Netherlands Journal of Medicine 52 Ž1998. 295–301
The microbiology laboratory — an essential part of the infectious diseases services line H.A. Verbrugh Instituut Õoor Klinische Microbiologie, Afdeling Bacteriologie, Erasmus UniÕersiteit Rotterdam, Postbus 1738, 3000 DR Rotterdam, The Netherlands
As a medical microbiologist I study the lives of microbes. We have now realised that microbial diseases have not disappeared from our societies, but that they seem to have, for various reasons, reemerged as a problem for individual patients and that they may again pose a threat to the health of the public at large. None of this should really surprise us if we realise that this world is not what it seems to present to our eyes: one big happy family of human beings on an extended holiday through evolutionary time that will ultimately bring us paradise on earth. To the contrary, we have learned that this planet is now 4.6 billion years old and that we humans are a relatively new species on this planet, a fragile species, as Lewis Thomas wrote: ‘‘a species that is only tentatively set in place, error-prone, at risk of fumbling, and in real danger at the moment of leaving behind only a thin layer of our fossils’’. Microbes, especially bacteria, are the oldest living creatures on this world, they are estimated to be 3.5 billion years old, much older, thus, than human species that has been around for only 1–2 million years. For at least 2.5 billion years no other forms of life but bacteria have existed on this planet, and today more than half of the biomass on earth is represented by this prokaryotic form of life. One can, therefore, easily understand the statement of Stephen Jay Gould ‘‘this is truly the age of bacteria, as it was in the beginning, as is now and ever shall be’’. In this slide one of such a species of bacteria is depicted, taken up in vacuoles within a eukaryotic cell. One of those
species of bacteria that probably has been on earth for a very long time but one that we have only learned about some twenty years ago, is the legionnaires’ bacillus that killed many elderly participants in a legionnaires’ conference in Philadelphia in 1976. For me, this event marks the beginning of the emergence of infectious diseases that has resulted in this conference today in the Netherlands. Legionnaires’ disease is a prime example of how human development has lead to new interactions of mankind with the microbial world that surrounds it. Only after the introduction of warm water systems and air-conditioning systems we have created an opportunity to encounter large numbers of legionella that may cause us to become ill. In this view, expressed in an elegant paper by Henry Isenberg ŽNew York. in 1988, infectious diseases are nothing but one of the outcomes of our multiple ecological interactions with the microbial world that dominates the biosphere.
1. Metaphors We may well encounter new microbes on other planets and then, for sure, we will have to admit that bacteria have always been a step ahead of mankind, and that we should pay more attention to the lives of microbes, to microbiology in general and to medical microbiology as a science that is crucial to our understanding and management of infectious dis-
0300-2977r98r$19.00 q 1998 Elsevier Science B.V. All rights reserved. PII S 0 3 0 0 - 2 9 7 7 Ž 9 8 . 0 0 0 4 6 - 1
296
H.A. Verbrughr Netherlands Journal of Medicine 52 (1998) 295–301
eases. The science that apparently also needs to be considered and consulted if you want to continue to build and reorganise our societies, and embark upon new journeys into space. What we do not need is the re-introduction of metaphors from war-making in which we depict microbes as our enemies that should be eradicated at all costs. Although these war-metaphors are powerful media-tools and will convince the public to pay more for the struggle against infectious diseases, such a frame of mind is likely to trouble our view and may lead to inappropriate strategies for the management of infectious diseases. Certainly, the introduction of antimicrobial agents has paradoxically backfired into widespread resistance partly because we have used them indiscriminately as weapons against microbes. The wider their spectrum of destruction the more they were appreciated by medical and non-medical personnel who, as generals in a mortal combat, deployed them in very high payloads to their patients. New strategies have been developed both locally and internationally. What then are the roles for medical microbiologists and their laboratories in these strategies?
2. Strategy On a global scale the WHO strategy contains four major lines of action, three of which do require the involvement of microbiology laboratories; laboratories are needed for the surveillance of infectious disease agents and for the surveillance of resistance against antimicrobial agents among those microbes that are relevant for the diagnosis, treatment and prevention of microbial diseases. Thirdly, new knowledge is required, thus more research is needed, into the pathogenesis of emerging of infections and to elucidate the spread of organisms at the molecular level. Similar initiatives have been taken in the Netherlands to cope with the emergence of infectious diseases over the past few years. These initiatives also focus on surveillance as surveillance is at the heart of any type of infection control. Surveillance will be partly based on laboratory data, and laboratories will be asked to participate in national networks and to communicate with the public health sector in a much more frequent and detailed fashion. Initiatives taken
in the private sector in the Netherlands have also regularly involved medical microbiologists and their laboratories. It is of great importance that such initiatives taken in the Netherlands or any other country in Europe become embedded within international activities. Thus, laboratory surveillance for resistance in the Netherlands should preferably be tied within international surveillance systems, those supported by WHO or other European parties involved. The RIVM of the Netherlands, in collaboration with medical microbiologists and their laboratories, is currently setting up a surveillance system based on the comprehensive output of medical microbiology laboratories, an interesting and unique initiative.
3. Medical microbiology What then is the role for medical microbiology and the medical microbiologist in improving the future management of infectious diseases? First we have to realise that Europe is different from the USA. In many European countries, medical microbiology is a distinct medical speciality just as internal medicine, surgery and paediatrics. Not all European countries, however, have medical microbiology as a monovalent speciality. Some countries only recognise a polyvalent speciality in laboratory medicine. Also, the practice of medicine varies greatly across Europe and, for instance, in the southern part of Europe, polyvalent specialists prevail that have private practices and commercially oriented laboratories, whereas in the northern part of Europe medical microbiology is usually a monovalent speciality with the medical microbiology laboratories being incorporated in non-profit institutions. One can understand that harmonisation is needed in order to have a European initiative. Such harmonisation efforts are underway and are, in part, coordinated by the European Union of Medical Specialists ŽEUMS.. For the monovalent speciality of medical microbiology the EUMS has defined a 5-year training programme, as have been the eight major tasks of the speciality of medical microbiology. Thus a medical microbiologist should be able to provide professional leadership in the medical microbiology laboratory; he should be a reliable consultant for those physicians who directly care for individual patients with
H.A. Verbrughr Netherlands Journal of Medicine 52 (1998) 295–301
infectious diseases; he should be able to provide managerial skills as head of an infectious diseases or medical microbiology laboratory; he should be able to provide professional leadership in the control of hospital-acquired infections; he should also be an expert consultant on hospital-wide policies regarding the use of antibiotics and the isolation of patients; and important for today, he should be professionally involved in public health with regard to the control of microbial threats to the community; finally, he or she should contribute to the advancement of science in the field of microbiology and help train and educate the medical microbiologist of the future, as well as other infectious disease specialists and professionals in the field of microbial diseases. Having these eight tasks the medical microbiologists Žand their laboratories. are part of a hospital or other healthcare institution. It is, therefore, also necessary to define the roles for such institutions in the management of emerging infections. There are many roles for hospitals to play in the management of emerging infections.
4. Hospitals and the infectious diseases service line Of course, hospitals should continue to cure and care for individual patients with serious infections. Importantly, since hospitals have to provide isolation facilities for patients suffering from communicable diseases, one may wonder whether most hospitals today are sufficiently equipped to meet the isolation requirements for the future. Also, hospitals should help control the use of antimicrobial agents, although they can certainly not do this without the help of doctors and veterinarians outside the hospital, and without proper legislation across Europe that restricts the access to these types of drugs. Hospitals also have a crucial role in the education and training of professionals, which is partly done in their facilities. Of prime importance is their ability and need to communicate with, what they may see as outsiders in the public health arena; especially the electronic data interchange systems now available should allow efficient communication to be realised for instance between hospitals and health care authorities in their region, in order to exchange information that is
297
needed for the proper management of infectious diseases. And, finally, hospitals should continue to foster clinical research in this area. Importantly, the medical microbiology laboratories in such institutions need to be part of what Lucy Tompkins of the San Francisco General Hospital called ‘The Infectious Diseases Service Line’. The infectious diseases service line of hospitals should provide comprehensive services by specifically trained professionals including medical microbiologists, infectious diseases clinicians, infection control practitioners and laboratory technologists. Such a service line should be responsible for formulating and executing hospital-wide policies regarding infectious disease management, including protocols to diagnose infections, protocols that regulate the use of antimicrobial agents and protocols that reduce the risk of nosocomial infections. Finally, the infectious diseases service line should incorporate hospital facilities and personnel needed to fulfil its mission, including the medical microbiology laboratory, the infection control team and dedicated facilities for infectious diseases within the hospital. Its organisation would promote the integrated delivery of care for patients with community and hospital-acquired infections. In such a setting, I think, the medical microbiology laboratory of the future can blossom and keep abreast with the developments in medical microbiology.
5. Trends in the laboratory The quality of laboratories should be better controlled and assured. We are certainly entering into a phase, at least in the Netherlands, where medical laboratories need to be certified. In the Netherlands there are at least two systems that can be followed to become certified as a medical microbiology laboratory. However, to be able to become certified a fair amount of work still needs to be done in order to make quality assurance an integral part of laboratory life. Another important trend in medical microbiology laboratories is the implementation of electronic information systems that help the management of patients and that help the management of the laboratory itself. It is these information systems that should also allow them to communicate with outsiders for instance with those that are in need of data
298
H.A. Verbrughr Netherlands Journal of Medicine 52 (1998) 295–301
for their surveillance systems. Several new forms of technology have been developed and are being developed. Technological innovation and development nowadays emerges mostly from the R & D departments of commercial companies, and, does not seem to rely on efforts of microbiological laboratories in medical centres. Emphasis is now placed, and rightly placed, on timely testing and timely reporting back of results to primary care physicians in the clinics. Rapid tests are, thus, of prime importance and have become a selling point for these commercial suppliers of new technology. Automation is part of these rapid tests, as is a focus on quality control. However, such innovation is expensive and many hospitals worry about the cost increase that comes along with these new technologies. In the Netherlands, for instance, the government has recently decided that they will allocate money for the new drugs for HIV treatment, but they still hesitate about underwriting the extra money needed for monitoring viral loads in these same patients. The extra costs of such testing then becomes a significant burden for those hospitals that have taken up the care of AIDS patients, a task assigned to them years ago by the government. In the seventies, cultures were done in a very classical fashion. Bacteria were isolated from agarplates and then identified using biochemical tests. Their sensitivity to antibiotics were read from inhibition zones around pieces of paper impregnated with antibiotics. Such a report, from the laboratories was neither timely nor reliable and certainly not always reproducible. Today we are culturing blood in machines that have improved speed and sensitivity and we are now using fluorescence probes to much earlier come up with answers regarding the identification and susceptibility of micro-organisms. Does this really matter for patient care? Gary Doern of the United States seems to think so. He has published a study in the Journal of Clinical Microbiology in 1994 where he used these new technologies and compared them with an overnight classical way of doing microbiological tests, and found a tremendous reduction in mortality and cost associated with rapid testing in his setting w1x. The studies of Gary Doern have been criticised, however, and should be repeated in an European setting. We have also learned how to handle DNA. Now
we can use a patient specimen, as simple as urine, and apply a sensitive DNA-based test for the detection of Chlamydia or Trichomonas infection. These tests have sensitivities that are quite high compared to the classical method of cell culture of cervical or urethral specimens. Such new technologies imply that we can now develop new public health strategies that were not feasible before because urine is, of course, a specimen that is more easily collected than cervical and urethral specimens. We have also learnt that the 16S RNA gene can be used to identify new microbes. It was already mentioned this morning by Relman that this gene has been used to study the evolution. We have placed ourselves now in a new universal filogenetic tree, where we are only part of a large spectrum of life on earth, life that remains dominated by the prokaryotes. Medical microbiology and the microbiology laboratories thus remain crucial in our response to the microbial challenges ahead.
6. Discussion
McGowan (USA): In the United States today individual laboratories are competing hard for business as health care merges into new entities in institutions. A second development is to privatise the public health laboratories. Public health laboratory functions are being handed out to commercial or other individual laboratories. In some parts of the European community what is happening in the US could also happen. Who should do what function? Do you envisage a merge of the two functions? Verbrugh: I am not certain where health care organisation is going to in The Netherlands or in other parts of the European community. I am sure that many people in Europe do not really want to directly follow the United States in the way they have handled their health care system. But we have to have an open mind. I think that reorganisation is good, as long as
H.A. Verbrughr Netherlands Journal of Medicine 52 (1998) 295–301
it is functional; these functions should find their reason in their relationship with the patient and not with anything else. My hope is that we will keep the patient in mind and that we should deliver the care that is needed around this primary process of infectious diseases as our primary organisation principle. Should laboratories be privatised and try to compete for the patients’ specimens at the lowest possible price at any type of quality or should it be integrated and kept integrated in our hospitals? Lucy Tompkins said she was forced to think about reorganisation of her laboratory and she came up with the Infectious Disease Services Line as her answer. Then they joined forces of the infectious disease services and their microbiology laboratory and from that moment on there was no question anymore within the administration of the hospital.
Solberg (Norway): You mentioned that the clinical microbiologist should have many duties and should be closely involved in the care of patients. I agree. Could I ask you: what is the average clinical training of the clinical microbiologists today in Western Europe?
Verbrugh: Yes, this is part of the harmonisation efforts within Europe. It is now defined that medical microbiologists should have a training programme that takes at least five years and that it should include at least one clinical year. Although the medical microbiologists should be trained to be able to do that, to my opinion not every medical microbiologists should do all these things. Just like clinicians, they are trained in many things but in practice they do not do all the things that they have been trained for.
Hoepelman (The Netherlands): I think we should skip the discipline of medical microbiology and skip the discipline of infectious diseases. I think the best way to go further is to train everyone in two years in internal medicine, then train everyone for one year in medical microbiology and in infectious disease and then let them choose what
299
they want: either be in medical microbiology or in infectious disease. But keep it combined and keep it as one group. Not what you stated as a monovalent speciality, that is driven by who is in power: either the medical microbiologists or the infectious disease specialist. Basically we need to combine forces. So therefore stop training in a current way, when there are medical microbiologists who are more interested in working in the clinic and have the capabilities, they should be allowed to do that, and when some infectious diseases specialists really want to work in the laboratory, let them do it, but stop fighting.
Verbrugh: I think it is a provocative idea.
Finch (UK): I think we are actually entering revolution. It will not be long before major pharmaceutical companies move into health care delivery in terms of running diagnostic services. These companies start to have huge diagnostic dimensions, and it is unclear how the professional is actually going to function within that private arrangement of diagnostic delivery. In the UK we have harmonised within Europe and we have this five years of training and we can differentiate into medical microbiology or into infectious diseases. There is time spent in each other’s discipline but the major expression of one’s professional function goes along another route. What we discussed recently was creating a new training programme in clinical microbiology and infectious disease; these people would function in both areas.
Neyens (The Netherlands): The infectious disease specialist and the microbiologist have to work together. They have their own capacities and function. What are your thoughts about this?
Verbrugh: The status for me is that the infectious disease specialists are trained to take care of the primary
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responsibility for patients. That is their uniqueness in medicine as opposed to the uniqueness of the medical microbiologists who can manage professionally and also manage a laboratory. What they should be able to do together, at more or less the same level of quality, is to consult with other physicians who run into trouble with their patients who have infectious diseases. So the consultation is what they share and that is also the basis for the remarks of Finch and Hoepelman: there should be a future for a new training programme. Goossens (Belgium): I would also like to make a provocative statement. I was interested to see the situation of medical microbiologists in Europe. There are countries where medical microbiology is a monovalent speciality and in other countries it is a polyvalent speciality: part of a chemistry laboratory or a haematology laboratory, and not so directly related to infectious diseases. In the northern part of Europe, it is mostly a monovalent speciality and in the southern part it is mostly polyvalent. If you look at the map of antibiotic resistance in the north, there is less resistance and in the south there is more resistance. In a simplistic way, is a monovalent speciality better for society, for the control of infectious disease and antibiotic susceptibility than a polyvalent speciality? Verbrugh: This comparing of resistance and monovalent speciality also came to my mind. However, there are many other determinants; nobody has really figured out which are the independent determinants versus the interdependent. Somebody has to do this multideterminant study on the resistance in Europe from south to north. What are the factors that drive these differences? Concerning the training programmes, there is no question that both the polyvalent specialist and the monovalent specialist should be trained for five years. They will learn a lot, they will learn a little about many things in the polyvalent speciality. The monovalent specialists spend all of these five years in this single discipline of medical microbiology. The outcome can not be otherwise than that they know much more about medical microbiology as a monovalent microbiologist than as a polyvalent
specialist. The question as to whether you should change practice is a different one. Peters (Germany): In Germany Žnow 85 million inhabitants, 34 medical faculties., there is no infectious disease speciality. So, who is going to deal with the patients? About twenty years ago, when I started my training, the medical microbiologists were just laboratory people. They sat on the bench and refused to deal with patients. What is the reason that there is no infectious disease in Germany? The reason is not that the bad and angry microbiologist opposes the clinical specialists of developing infectious diseases; the problem is that of the general paediatrician and the general internist — they fear they may loose something. Due to this state of affairs, a promising doctor, who wants to do research in infectious disease in internal medicine or in paediatrics, has decided to stop his academic career as he will never get a chair in internal medicine or paediatrics in Germany. This situation is very wrong. But the problem is that we have infected patients and somebody has to deal with them. At the University of Munster we have people who trained in Genevaon in the US; they have been trained in internal medicine or paediatrics, then come to do medical microbiology and research, clinical microbiology and infectious diseases. With regard to public health and infection control on a federal level, the states are closing down all the operational laboratories and the federal government tries to start a new infection control programme. How are we going to manage this if we have no operational basis? For the time being, only the universities provide the basis. Bergan (Norway): The situation is that microbiology is becoming more and more specialised. There is so much challenge requiring basic natural science that we need to allow people to diversify into the basic natural science. Verbrugh: It is true that there is more science to be crunched, and we need perhaps more diversity. On the other hand, we have to integrate all these data for patient
H.A. Verbrughr Netherlands Journal of Medicine 52 (1998) 295–301
care. So even though we learn more we should keep it as a whole. Feldman: Regarding public health, one of the anxieties I have is that regardless of how you describe the structure of microbiology and the training of microbiologists, the element that has to do with public health and surveillance does not necessarily make any money. It does not necessarily save any patients. So the collection of information that relates to public health control, a surveillance system that Chris
301
Bartlett talked about, is potentially going to collapse. Unless you somehow include the fact that it is the responsibility of the governments of the various countries to make sure that the public health function of microbiology is not lost.
References w1x Doern GY, Vatour R, Gaudet M, Levy B. Clinical impact of rapid in vitro susceptibility testing and bacterial identification. J Clin Microbiol 1994;32:1557–1562.
The microbiology laboratory — an essential part of the infectious diseases services line H.A. Verbrugh Instituut Õoor Klinische Microbiologie, Afdeling Bacteriologie, Erasmus UniÕersiteit Rotterdam, Postbus 1738, 3000 DR Rotterdam, The Netherlands
As a medical microbiologist I study the lives of microbes. We have now realised that microbial diseases have not disappeared from our societies, but that they seem to have, for various reasons, reemerged as a problem for individual patients and that they may again pose a threat to the health of the public at large. None of this should really surprise us if we realise that this world is not what it seems to present to our eyes: one big happy family of human beings on an extended holiday through evolutionary time that will ultimately bring us paradise on earth. To the contrary, we have learned that this planet is now 4.6 billion years old and that we humans are a relatively new species on this planet, a fragile species, as Lewis Thomas wrote: ‘‘a species that is only tentatively set in place, error-prone, at risk of fumbling, and in real danger at the moment of leaving behind only a thin layer of our fossils’’. Microbes, especially bacteria, are the oldest living creatures on this world, they are estimated to be 3.5 billion years old, much older, thus, than human species that has been around for only 1–2 million years. For at least 2.5 billion years no other forms of life but bacteria have existed on this planet, and today more than half of the biomass on earth is represented by this prokaryotic form of life. One can, therefore, easily understand the statement of Stephen Jay Gould ‘‘this is truly the age of bacteria, as it was in the beginning, as is now and ever shall be’’. In this slide one of such a species of bacteria is depicted, taken up in vacuoles within a eukaryotic cell. One of those
species of bacteria that probably has been on earth for a very long time but one that we have only learned about some twenty years ago, is the legionnaires’ bacillus that killed many elderly participants in a legionnaires’ conference in Philadelphia in 1976. For me, this event marks the beginning of the emergence of infectious diseases that has resulted in this conference today in the Netherlands. Legionnaires’ disease is a prime example of how human development has lead to new interactions of mankind with the microbial world that surrounds it. Only after the introduction of warm water systems and air-conditioning systems we have created an opportunity to encounter large numbers of legionella that may cause us to become ill. In this view, expressed in an elegant paper by Henry Isenberg ŽNew York. in 1988, infectious diseases are nothing but one of the outcomes of our multiple ecological interactions with the microbial world that dominates the biosphere.
1. Metaphors We may well encounter new microbes on other planets and then, for sure, we will have to admit that bacteria have always been a step ahead of mankind, and that we should pay more attention to the lives of microbes, to microbiology in general and to medical microbiology as a science that is crucial to our understanding and management of infectious dis-
0300-2977r98r$19.00 q 1998 Elsevier Science B.V. All rights reserved. PII S 0 3 0 0 - 2 9 7 7 Ž 9 8 . 0 0 0 4 6 - 1
296
H.A. Verbrughr Netherlands Journal of Medicine 52 (1998) 295–301
eases. The science that apparently also needs to be considered and consulted if you want to continue to build and reorganise our societies, and embark upon new journeys into space. What we do not need is the re-introduction of metaphors from war-making in which we depict microbes as our enemies that should be eradicated at all costs. Although these war-metaphors are powerful media-tools and will convince the public to pay more for the struggle against infectious diseases, such a frame of mind is likely to trouble our view and may lead to inappropriate strategies for the management of infectious diseases. Certainly, the introduction of antimicrobial agents has paradoxically backfired into widespread resistance partly because we have used them indiscriminately as weapons against microbes. The wider their spectrum of destruction the more they were appreciated by medical and non-medical personnel who, as generals in a mortal combat, deployed them in very high payloads to their patients. New strategies have been developed both locally and internationally. What then are the roles for medical microbiologists and their laboratories in these strategies?
2. Strategy On a global scale the WHO strategy contains four major lines of action, three of which do require the involvement of microbiology laboratories; laboratories are needed for the surveillance of infectious disease agents and for the surveillance of resistance against antimicrobial agents among those microbes that are relevant for the diagnosis, treatment and prevention of microbial diseases. Thirdly, new knowledge is required, thus more research is needed, into the pathogenesis of emerging of infections and to elucidate the spread of organisms at the molecular level. Similar initiatives have been taken in the Netherlands to cope with the emergence of infectious diseases over the past few years. These initiatives also focus on surveillance as surveillance is at the heart of any type of infection control. Surveillance will be partly based on laboratory data, and laboratories will be asked to participate in national networks and to communicate with the public health sector in a much more frequent and detailed fashion. Initiatives taken
in the private sector in the Netherlands have also regularly involved medical microbiologists and their laboratories. It is of great importance that such initiatives taken in the Netherlands or any other country in Europe become embedded within international activities. Thus, laboratory surveillance for resistance in the Netherlands should preferably be tied within international surveillance systems, those supported by WHO or other European parties involved. The RIVM of the Netherlands, in collaboration with medical microbiologists and their laboratories, is currently setting up a surveillance system based on the comprehensive output of medical microbiology laboratories, an interesting and unique initiative.
3. Medical microbiology What then is the role for medical microbiology and the medical microbiologist in improving the future management of infectious diseases? First we have to realise that Europe is different from the USA. In many European countries, medical microbiology is a distinct medical speciality just as internal medicine, surgery and paediatrics. Not all European countries, however, have medical microbiology as a monovalent speciality. Some countries only recognise a polyvalent speciality in laboratory medicine. Also, the practice of medicine varies greatly across Europe and, for instance, in the southern part of Europe, polyvalent specialists prevail that have private practices and commercially oriented laboratories, whereas in the northern part of Europe medical microbiology is usually a monovalent speciality with the medical microbiology laboratories being incorporated in non-profit institutions. One can understand that harmonisation is needed in order to have a European initiative. Such harmonisation efforts are underway and are, in part, coordinated by the European Union of Medical Specialists ŽEUMS.. For the monovalent speciality of medical microbiology the EUMS has defined a 5-year training programme, as have been the eight major tasks of the speciality of medical microbiology. Thus a medical microbiologist should be able to provide professional leadership in the medical microbiology laboratory; he should be a reliable consultant for those physicians who directly care for individual patients with
H.A. Verbrughr Netherlands Journal of Medicine 52 (1998) 295–301
infectious diseases; he should be able to provide managerial skills as head of an infectious diseases or medical microbiology laboratory; he should be able to provide professional leadership in the control of hospital-acquired infections; he should also be an expert consultant on hospital-wide policies regarding the use of antibiotics and the isolation of patients; and important for today, he should be professionally involved in public health with regard to the control of microbial threats to the community; finally, he or she should contribute to the advancement of science in the field of microbiology and help train and educate the medical microbiologist of the future, as well as other infectious disease specialists and professionals in the field of microbial diseases. Having these eight tasks the medical microbiologists Žand their laboratories. are part of a hospital or other healthcare institution. It is, therefore, also necessary to define the roles for such institutions in the management of emerging infections. There are many roles for hospitals to play in the management of emerging infections.
4. Hospitals and the infectious diseases service line Of course, hospitals should continue to cure and care for individual patients with serious infections. Importantly, since hospitals have to provide isolation facilities for patients suffering from communicable diseases, one may wonder whether most hospitals today are sufficiently equipped to meet the isolation requirements for the future. Also, hospitals should help control the use of antimicrobial agents, although they can certainly not do this without the help of doctors and veterinarians outside the hospital, and without proper legislation across Europe that restricts the access to these types of drugs. Hospitals also have a crucial role in the education and training of professionals, which is partly done in their facilities. Of prime importance is their ability and need to communicate with, what they may see as outsiders in the public health arena; especially the electronic data interchange systems now available should allow efficient communication to be realised for instance between hospitals and health care authorities in their region, in order to exchange information that is
297
needed for the proper management of infectious diseases. And, finally, hospitals should continue to foster clinical research in this area. Importantly, the medical microbiology laboratories in such institutions need to be part of what Lucy Tompkins of the San Francisco General Hospital called ‘The Infectious Diseases Service Line’. The infectious diseases service line of hospitals should provide comprehensive services by specifically trained professionals including medical microbiologists, infectious diseases clinicians, infection control practitioners and laboratory technologists. Such a service line should be responsible for formulating and executing hospital-wide policies regarding infectious disease management, including protocols to diagnose infections, protocols that regulate the use of antimicrobial agents and protocols that reduce the risk of nosocomial infections. Finally, the infectious diseases service line should incorporate hospital facilities and personnel needed to fulfil its mission, including the medical microbiology laboratory, the infection control team and dedicated facilities for infectious diseases within the hospital. Its organisation would promote the integrated delivery of care for patients with community and hospital-acquired infections. In such a setting, I think, the medical microbiology laboratory of the future can blossom and keep abreast with the developments in medical microbiology.
5. Trends in the laboratory The quality of laboratories should be better controlled and assured. We are certainly entering into a phase, at least in the Netherlands, where medical laboratories need to be certified. In the Netherlands there are at least two systems that can be followed to become certified as a medical microbiology laboratory. However, to be able to become certified a fair amount of work still needs to be done in order to make quality assurance an integral part of laboratory life. Another important trend in medical microbiology laboratories is the implementation of electronic information systems that help the management of patients and that help the management of the laboratory itself. It is these information systems that should also allow them to communicate with outsiders for instance with those that are in need of data
298
H.A. Verbrughr Netherlands Journal of Medicine 52 (1998) 295–301
for their surveillance systems. Several new forms of technology have been developed and are being developed. Technological innovation and development nowadays emerges mostly from the R & D departments of commercial companies, and, does not seem to rely on efforts of microbiological laboratories in medical centres. Emphasis is now placed, and rightly placed, on timely testing and timely reporting back of results to primary care physicians in the clinics. Rapid tests are, thus, of prime importance and have become a selling point for these commercial suppliers of new technology. Automation is part of these rapid tests, as is a focus on quality control. However, such innovation is expensive and many hospitals worry about the cost increase that comes along with these new technologies. In the Netherlands, for instance, the government has recently decided that they will allocate money for the new drugs for HIV treatment, but they still hesitate about underwriting the extra money needed for monitoring viral loads in these same patients. The extra costs of such testing then becomes a significant burden for those hospitals that have taken up the care of AIDS patients, a task assigned to them years ago by the government. In the seventies, cultures were done in a very classical fashion. Bacteria were isolated from agarplates and then identified using biochemical tests. Their sensitivity to antibiotics were read from inhibition zones around pieces of paper impregnated with antibiotics. Such a report, from the laboratories was neither timely nor reliable and certainly not always reproducible. Today we are culturing blood in machines that have improved speed and sensitivity and we are now using fluorescence probes to much earlier come up with answers regarding the identification and susceptibility of micro-organisms. Does this really matter for patient care? Gary Doern of the United States seems to think so. He has published a study in the Journal of Clinical Microbiology in 1994 where he used these new technologies and compared them with an overnight classical way of doing microbiological tests, and found a tremendous reduction in mortality and cost associated with rapid testing in his setting w1x. The studies of Gary Doern have been criticised, however, and should be repeated in an European setting. We have also learned how to handle DNA. Now
we can use a patient specimen, as simple as urine, and apply a sensitive DNA-based test for the detection of Chlamydia or Trichomonas infection. These tests have sensitivities that are quite high compared to the classical method of cell culture of cervical or urethral specimens. Such new technologies imply that we can now develop new public health strategies that were not feasible before because urine is, of course, a specimen that is more easily collected than cervical and urethral specimens. We have also learnt that the 16S RNA gene can be used to identify new microbes. It was already mentioned this morning by Relman that this gene has been used to study the evolution. We have placed ourselves now in a new universal filogenetic tree, where we are only part of a large spectrum of life on earth, life that remains dominated by the prokaryotes. Medical microbiology and the microbiology laboratories thus remain crucial in our response to the microbial challenges ahead.
6. Discussion
McGowan (USA): In the United States today individual laboratories are competing hard for business as health care merges into new entities in institutions. A second development is to privatise the public health laboratories. Public health laboratory functions are being handed out to commercial or other individual laboratories. In some parts of the European community what is happening in the US could also happen. Who should do what function? Do you envisage a merge of the two functions? Verbrugh: I am not certain where health care organisation is going to in The Netherlands or in other parts of the European community. I am sure that many people in Europe do not really want to directly follow the United States in the way they have handled their health care system. But we have to have an open mind. I think that reorganisation is good, as long as
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it is functional; these functions should find their reason in their relationship with the patient and not with anything else. My hope is that we will keep the patient in mind and that we should deliver the care that is needed around this primary process of infectious diseases as our primary organisation principle. Should laboratories be privatised and try to compete for the patients’ specimens at the lowest possible price at any type of quality or should it be integrated and kept integrated in our hospitals? Lucy Tompkins said she was forced to think about reorganisation of her laboratory and she came up with the Infectious Disease Services Line as her answer. Then they joined forces of the infectious disease services and their microbiology laboratory and from that moment on there was no question anymore within the administration of the hospital.
Solberg (Norway): You mentioned that the clinical microbiologist should have many duties and should be closely involved in the care of patients. I agree. Could I ask you: what is the average clinical training of the clinical microbiologists today in Western Europe?
Verbrugh: Yes, this is part of the harmonisation efforts within Europe. It is now defined that medical microbiologists should have a training programme that takes at least five years and that it should include at least one clinical year. Although the medical microbiologists should be trained to be able to do that, to my opinion not every medical microbiologists should do all these things. Just like clinicians, they are trained in many things but in practice they do not do all the things that they have been trained for.
Hoepelman (The Netherlands): I think we should skip the discipline of medical microbiology and skip the discipline of infectious diseases. I think the best way to go further is to train everyone in two years in internal medicine, then train everyone for one year in medical microbiology and in infectious disease and then let them choose what
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they want: either be in medical microbiology or in infectious disease. But keep it combined and keep it as one group. Not what you stated as a monovalent speciality, that is driven by who is in power: either the medical microbiologists or the infectious disease specialist. Basically we need to combine forces. So therefore stop training in a current way, when there are medical microbiologists who are more interested in working in the clinic and have the capabilities, they should be allowed to do that, and when some infectious diseases specialists really want to work in the laboratory, let them do it, but stop fighting.
Verbrugh: I think it is a provocative idea.
Finch (UK): I think we are actually entering revolution. It will not be long before major pharmaceutical companies move into health care delivery in terms of running diagnostic services. These companies start to have huge diagnostic dimensions, and it is unclear how the professional is actually going to function within that private arrangement of diagnostic delivery. In the UK we have harmonised within Europe and we have this five years of training and we can differentiate into medical microbiology or into infectious diseases. There is time spent in each other’s discipline but the major expression of one’s professional function goes along another route. What we discussed recently was creating a new training programme in clinical microbiology and infectious disease; these people would function in both areas.
Neyens (The Netherlands): The infectious disease specialist and the microbiologist have to work together. They have their own capacities and function. What are your thoughts about this?
Verbrugh: The status for me is that the infectious disease specialists are trained to take care of the primary
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responsibility for patients. That is their uniqueness in medicine as opposed to the uniqueness of the medical microbiologists who can manage professionally and also manage a laboratory. What they should be able to do together, at more or less the same level of quality, is to consult with other physicians who run into trouble with their patients who have infectious diseases. So the consultation is what they share and that is also the basis for the remarks of Finch and Hoepelman: there should be a future for a new training programme. Goossens (Belgium): I would also like to make a provocative statement. I was interested to see the situation of medical microbiologists in Europe. There are countries where medical microbiology is a monovalent speciality and in other countries it is a polyvalent speciality: part of a chemistry laboratory or a haematology laboratory, and not so directly related to infectious diseases. In the northern part of Europe, it is mostly a monovalent speciality and in the southern part it is mostly polyvalent. If you look at the map of antibiotic resistance in the north, there is less resistance and in the south there is more resistance. In a simplistic way, is a monovalent speciality better for society, for the control of infectious disease and antibiotic susceptibility than a polyvalent speciality? Verbrugh: This comparing of resistance and monovalent speciality also came to my mind. However, there are many other determinants; nobody has really figured out which are the independent determinants versus the interdependent. Somebody has to do this multideterminant study on the resistance in Europe from south to north. What are the factors that drive these differences? Concerning the training programmes, there is no question that both the polyvalent specialist and the monovalent specialist should be trained for five years. They will learn a lot, they will learn a little about many things in the polyvalent speciality. The monovalent specialists spend all of these five years in this single discipline of medical microbiology. The outcome can not be otherwise than that they know much more about medical microbiology as a monovalent microbiologist than as a polyvalent
specialist. The question as to whether you should change practice is a different one. Peters (Germany): In Germany Žnow 85 million inhabitants, 34 medical faculties., there is no infectious disease speciality. So, who is going to deal with the patients? About twenty years ago, when I started my training, the medical microbiologists were just laboratory people. They sat on the bench and refused to deal with patients. What is the reason that there is no infectious disease in Germany? The reason is not that the bad and angry microbiologist opposes the clinical specialists of developing infectious diseases; the problem is that of the general paediatrician and the general internist — they fear they may loose something. Due to this state of affairs, a promising doctor, who wants to do research in infectious disease in internal medicine or in paediatrics, has decided to stop his academic career as he will never get a chair in internal medicine or paediatrics in Germany. This situation is very wrong. But the problem is that we have infected patients and somebody has to deal with them. At the University of Munster we have people who trained in Genevaon in the US; they have been trained in internal medicine or paediatrics, then come to do medical microbiology and research, clinical microbiology and infectious diseases. With regard to public health and infection control on a federal level, the states are closing down all the operational laboratories and the federal government tries to start a new infection control programme. How are we going to manage this if we have no operational basis? For the time being, only the universities provide the basis. Bergan (Norway): The situation is that microbiology is becoming more and more specialised. There is so much challenge requiring basic natural science that we need to allow people to diversify into the basic natural science. Verbrugh: It is true that there is more science to be crunched, and we need perhaps more diversity. On the other hand, we have to integrate all these data for patient
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care. So even though we learn more we should keep it as a whole. Feldman: Regarding public health, one of the anxieties I have is that regardless of how you describe the structure of microbiology and the training of microbiologists, the element that has to do with public health and surveillance does not necessarily make any money. It does not necessarily save any patients. So the collection of information that relates to public health control, a surveillance system that Chris
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Bartlett talked about, is potentially going to collapse. Unless you somehow include the fact that it is the responsibility of the governments of the various countries to make sure that the public health function of microbiology is not lost.
References w1x Doern GY, Vatour R, Gaudet M, Levy B. Clinical impact of rapid in vitro susceptibility testing and bacterial identification. J Clin Microbiol 1994;32:1557–1562.