A Guide to Specimen Management in Clinical Microbiology. J. Michael Miller

      Preface

      From syndrome-based molecular panels to total lab automation, clinical microbiology has evolved rapidly over the past 18 years since the previous edition of this book. We have witnessed increases in infections due to multidrug-resistant organisms, have overcome a major Ebola outbreak, and are currently tackling the geographic expansion of Zika virus and its potentially devastating effects. Aside from these more contemporary headliner agents, we continue to battle the threat of microorganisms that have been plaguing our world for decades, including HIV, syphilis, and influenza, just to name a few. And while the laboratory processes, diagnostic methods, and diseases may be more advanced and exotic, one unwavering aspect is the need for appropriate, well-collected specimens. In a world where we find ourselves trying to do more each day within the same 24-hour period, it is imperative that time not be wasted on correcting issues that are easily remedied with upfront attention to quality of specimens.

      For some reason, clinical microbiologists seem to get more formal training in appropriate specimen selection, collection, preservation, and transport than nurses, physicians, and other medical personnel who are actually obtaining the specimens. Microbiologists can usually agree that a poor specimen, regardless of how it is transported or stored, will provide poor, even inaccurate, results for the physician. Physicians must be able to trust the microbiology laboratory to deliver accurate, clinically relevant results; so it must be emphasized that the quality of the specimen submitted for culture and, ultimately, the person selecting, collecting, labeling, preserving, and transporting it, are essential first steps to achieve this. Therefore, this book is for every member of the health care team—the partnership.

      The overall aim of this edition was not to reinvent the wheel when it comes to providing guidance on specimen collection and management, because not much has changed since prior editions. Rather, it is meant to make the content more readable and accessible for its users, both specimen collectors and laboratory personnel, as well as to provide updates in specimen collection for newer methodologies (e.g., nucleic acid amplification tests) that are now in almost every laboratory. In the age of molecular testing in microbiology, the principles of specimen selection, collection, and transport are certainly no less important than they have been over the years. Close attention must be paid to the manufacturer recommendations for specimen collection and management, and unless the laboratory is prepared to validate an alternative process, one must follow these recommendations. Additionally, for labs based in the United States, the imminent threat of stricter FDA regulations on these modified tests is a reminder to us all that we must do our due diligence to prove the reliability and value in the tests we perform daily.

      While the paradigm of the conventional gold standard may slowly be shifting away from cultures and organism isolation and on to more rapid, molecular-based methods, it is critical that we, as a laboratory community, continue to insist upon specimen collectors to follow collection guidelines so we can contribute what is expected of us. Anything less borders on malpractice and should be addressed before aberrant and potentially harmful results are reported. Regardless of the issue, we must remember, even in the era of decentralized labs, the specimen is not just a swab or a tube of fluid passing through our doors; it represents a sick patient, a concerned family member, and a treating physician, desperately depending on us to provide accurate, significant, and clinically relevant data. It is our mission to ensure that what comes to our lab in the form of a specimen and what leaves our lab in the form of results is of the highest quality. Please share these policies and processes with all of the medical staff involved in specimen management, share your knowledge, and spread this important information. If you don’t do it, who will?

      J. Michael Miller

      Shelley A. Miller

Acknowledgments

      The valuable reviews and constructive criticisms of John McGowan, Robert Jerris, Mark Neumann, Ellen Jo Baron, Craig Smith, Lynne Garcia, Ben Gold, Don Finnerty, Louis Wilson, and William Reichert are greatly appreciated. We are thankful for the direct and invaluable assistance and contributions of two internationally known pediatric microbiologists, Karen Krisher and Joseph Campos. We acknowledge and appreciate the developmental work done on the summary tables by Dr. Harvey T. Holmes. We wish to thank the laboratory staff of Children’s Healthcare of Atlanta, under Dr. Robert Jerris, and UCLA, under Dr. Romney Humphries, for their cooperation and willingness to participate in many of the photographs illustrating this book. We are also indebted to dozens of colleagues who have been so generous with their advice and knowledge over the years and are always working for the best outcomes for their patients—our thanks goes out to you. And finally, to the countless other microbiologists whose work in the laboratory has made significant contributions to the clinical relevance of laboratory results—we salute you.

About the Authors

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