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Foundations of TB Nurse Case Management
El Paso, TexasMarch 27 – 28, 2012
An Overview of the Laboratory’s Role in TB Diagnosis and TreatmentRole in TB Diagnosis and Treatment
Thor Elliott, MT (ASCP), AASMarch 27, 2012
Thor Elliott, MT (ASCP), AAS has the following disclosures to make:
•No conflict of interests•No relevant financial relationships
with any commercial companies pertaining to this educational pertaining to this educational activity
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Practical Guide to the Laboratory
Thor Elliott MicrobiologistTB Lab/Program [email protected]@
Objective
To describe the current laboratory methods for the detection, identification, drug susceptibility testing, and genotyping of Mycobacterium tuberculosis.Mycobacterium tuberculosis.
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Requirements to get a high quality specimen to the lab
Collection
Labeling
Requisitions
ShippingShipping
Collection
Garbage in Garbage outout.
Sputum not Spit
5 – 10 mls
Other fluids
Why do they always fill it when they submit urine?
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Labeling
UF Sticker
N Name
DOB
Date
Seal with parafilm or tape.
Requisitions
One Universal Form per specimen, not patient.
Fill out completely.
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Universal Forms
Shipping
Universal Form outside of plasticoutside of plastic container
Seal box with tape
Always follow local/state/federal shipping guidelinesshipping guidelines.
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Standard diagnostic techniques for the detection and identification of Mycobacteria
ReceivingP i Processing
Smears Cultures Probes HPLC HPLC Colonies Reports
Receiving
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Processing
BSL – 2 with BSL – 3 practicespractices
Very controlled and safe
Unpacked/Sorted Digested Concentrated Concentrated Set up Storage 3- 4 hour process
Smears
Read within 24 hours
P iti Positives are contacted by phone and faxed report
Negatives mailed out
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Nucleic Acid Amplification Test-NAAT
New PatientM t b iti ( lMust be a positive smear (unless extenuating circumstances)
Respiratory (sputum or bronch wash) No Tb meds Performed within 24 hours of smearPerformed within 24 hours of smear 4 hour process Very delicate
Cultures
Liquid culture (MGIT) on all specimens
M it d 24/7 d h Monitored 24/7 read every hour
Grown for six weeks or until positive
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Positive MGIT
St k d 7H11S Streaked on 7H11S media
Kinyoun stained
Positive stains are Identified
Negative stains are monitored
Kinyoun Stains
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The Monster
Cording
HPLC
Selection and SaponificationSaponification
Extraction
Sample Preparation
Chromatographs
4+ hours
2 days
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Chromatograph
Colonies
Slow grower
Rough Rough
Non-pigmented
35◦ C - 37◦C
Morphology is the final answer
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Report Timeline
PreliminarySmear Negative
PreliminarySmear Positive ( Smear Negative (same
day)
Final Final at 6 weeks
Smear Positive (same day)
Probe (if applicable 24hrs)
Identification (approx. 2 weeks)
Sensitivity if TB (10 days to 2 weeks))
Final If NTM final with ID
TB biochem report and final ID (batched)
Importance of acid-fast bacilli smear microscopy as a primary diagnostic tool
Primary tool for determining risk and treatment The hardest call we make is a 1+
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Smear Negative
Smear Positive
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Quantifying
Observed AFB Report
4 – 40 per 100 fields*1+
4 – 40 per 10 fields* 2+
4 – 40 per field*3+3+
> 40 per field* 4+
(using 40X objective)
Drug susceptibility testing of M. tb
Set up from positive MGITMGIT
Growth tube Done as a set Streptomycin
1.00ug/ml Isoniazid 0.10ug/ml Isoniazid 0.10ug/ml Rifampin 1.00ug/ml Ethambutol 5.00ug/ml Pyrazinamide
100.0ug/ml
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Drug susceptibility testing of M. tuberculosis
10 days to 2 weeks to complete (if growth is pure)pure)
Resistant results are rerun and sent to CDC for confirmation and second line drug testing.
MDR-TB Resistant to at least isoniazid and rifampin
XDR-TB Resistant to any floroquinolone, and resistant to at
least 1 of 3 injectible 2nd line drugs (ex: amikacin, kanamycin, or capreomycin)
Rapid methods for the identification and drug susceptibility testing of M. tuberculosis as they compare to the traditional methods
Genetic testingM l l B C lif i ( t b t Molecular Beacon – California (must be at least 3+)
MDDR – CDC
Special circumstance
Result will show predisposition not Result will show predisposition not definitive
Cost and labor prohibitive to do all patients.
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CDC program for genotyping M. tb isolates
1 specimen from every patientevery patient
Spoliogotype
Miru 1
Miru2
CDC program for genotyping M. tb isolates TBGIMS – TB
Genotype InformationGenotype Information management System
ubmitter Numb RVCT Number spoligotype Miru Cluster_nameed_false_Date Shipped Date Received patient_dob4113439 20040001 000000000003771 223325173533 KS 002 24 Mar 04 30 Mar 04 16 Feb 584113439 20040001 000000000003771 223325173533 KS_002 24-Mar-04 30-Mar-04 16-Feb-584237023 20060029 000000000003771 223325173533 KS_002 N0 25-May-06 26-May-06 09-Sep-804243582 20060024 000000000003771 223325173533 KS_002 N0 25-May-06 26-May-06 01-Jan-5610009689 20060028 000000000003771 223325173533 KS_002 NO 02-May-06 04-May-06 08-Sep-824223101 20050038 000000000003771 223325173533 KS_002 NO 19-Oct-05 20-Oct-05 05-Nov-534159793 20040064 000000000003771 223325173533 KS_002 NO 01-Sep-04 02-Sep-04 12-Nov-774108219 20040006 000000000003771 223325173533 KS_002 24-Mar-04 30-Mar-04 08-Aug-624132391 20040009 000000004020771 225313153223 KS_003 NO 03-Jun-04 04-Jun-04 18-Sep-674132405 20040035 000000004020771 225313153223 KS_003 NO 03-Jun-04 04-Jun-04 29-Sep-634113415 NAC 676773777777600 2z2324253322 KS_004 22-Jan-04 26-Jan-04 18-Jan-304113415 NAC 676773777777600 2z2324253322 KS_004 24-Mar-04 30-Mar-04 18-Jan-304231948 20050039 777776777760771 123325153323 KS_005 NO 19-Oct-05 20-Oct-05 20-Apr-554143550 20040013 777776777760771 123325153323 KS_005 NO 03-Jun-04 04-Jun-04 12-Nov-674072030 20030085 777776777760771 123325153323 KS_005 22-Jan-04 26-Jan-04 12-Dec-474092066 20030087 777776777760771 123325153323 KS_005 22-Jan-04 26-Jan-04 20-Feb-594092063 20040004 777776777760771 123325153323 KS_005 24-Mar-04 30-Mar-04 26-Oct-644235856 20050043 777776777760771 123325153323 KS_005 No 01-Dec-05 02-Dec-05 12-Aug-674152967 20040033 777776777760771 123325153323 KS_005 19-Aug-04 20-Aug-04 21-Aug-644167148 20050006 777776777760771 123325153323 KS_005 NO 09-Feb-05 10-Feb-05 29-Mar-62
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Questions?
La Senorita Margarita Guadalupe Hernandez
Contact InformationContact Information
Thor Elliott, MicorbiologistTB Laboratory/Program Consultanty g
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