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Page 1: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory ,Tehran Iran

Page 2: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

QC program The laboratory director is primarily

responsible for QC and QA programs. However all laboratory personnel must actively participate in both program

Page 3: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Positive Patient Outcome in the Microbiology laboratoryReduced length of stayReduced cost of stayReduced turn-around time for diagnosis of

infection Change to appropriate antimicrobial therapyCustomer ( physician or patients )satisfaction

Page 4: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

The basic elements of QC

Specimen collation Standard operating procedures (SOPM). Personnel Proficiency testing Antimicrobial Susceptibility tests Eminence of QC procedures Maintenance of QC stocks Patients reports

Page 5: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

SPECIMEN COLLECTION AND TRANSPORT The laboratory is responsible for

providing instructions for the proper collection and transport of specimens .These instructions should be available to the clinical staff for use when specimens collected.

Page 6: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Written collection instructionTest selection criteriaPatients selection criteriaTiming of specimen collection (e.g. before

antimicrobial are administration)Optimal specimen collection siteApproved specimen collection methodSpecimen transport medium

Page 7: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continue…Specimen transport time and temperatureSpecimen holding instructions if it cannot

be transported immediately (e.g. hold at 4C for 24 hours)

Availability of test (on –site or sent to reference laboratory )

Hours test performed (daily or batch)Turn-around timeResult reporting procedures

Page 8: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Information should be filled

Patient nameHospital or laboratory numberOrdering physicianWhether the patient receiving

antimicrobial therapySuspect agent or syndrome

Page 9: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Criteria for Unacceptable SpecimensUnlabeled or mislabeled specimensUse of improper transport medium Excessive transport timeImproper temperature during transport or

storageImproper collection site for test requestSpecimen leakage out of transport containerSera that are excessively

hemolyzed ,lipemic, or contaminated with bacteria

Page 10: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Standard Operating Procedure Manuel (SOPM)

The SOPM is considered part of QC program. The SOPM should define test performance , tolerance limits, reagent preparation, required quality control ,result reporting and references.The SOPM should be written in CLSI format and must be reviewed and signed annually by the microbiology director.

Page 11: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continue.. The SPOM should be available in the work area .It is the definitive laboratory reference and is used often for questions relating to individual test .Any obsolete procedures should be dated when removed from SPOM and retained for at least 2 years.

Page 12: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

PersonnelIt is laboratory director's responsibility to

employ sufficient qualified personnel for the volume and complexity of the work performed.

Document competency and training twice a year

Continuing education program should be provided

All documentation should maintained in personnel file.

Page 13: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Proficiency TestingLaboratories are required to participate in

an external proficiency testing (PT) The laboratory must maintain an average

score of 80% to maintain licensure in any subspecialty area.

The laboratory's procedures, reagents, equipments and personnel are all checked in the process of proficiency testing.

Page 14: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

PT or External quality controlProvide laboratory management with an

insight into their performanceImprove both local and national standardsReveals unsuspected area of difficultyProvides an educational stimulate for

improvementsActs as a check on the efficacy of internal

quality control proceduresDemonstrates to colleagues and

customers a commitment to quality

Page 15: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Performance Checks

InstrumentEquipment logs should contain the

following informationInstrument name, serial number,

and date put useProcedure and periodicity( daily,

weekly, monthly) for routine function check)

Page 16: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continue…Acceptable performance rangesInstrument function failure ,including

specific details of steps taken to correct the problems (corrective action)

Date and time of services requests and response.

Date of routine preventive maintenance (PM) which should follow manufactures recommendations.

Page 17: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 18: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continue..Maintenance records should be

retained in the laboratory for the life of instrument. Specific guidelines regarding periodicity of testing for autoclaves, biological safety cabinets ,centrifuges ,incubators, microscope, refrigerators ,freezers, water bathes , heat blocks and other microbiology laboratory can be found in reference books .

Page 19: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Quality control of Culture Meda Commercially prepared culture mediaIn house prepared culture media (User-

Prepared)

Page 20: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Commercially Prepared Culture Media The CLSI subcommittee on media

quality control collected data over several` years regarding the incidence of QC failure of commonly used microbiology media Based on its finding the subcommittee published a list of media that did not require retesting in the user's laboratory if purchased from a manufactures who follow CLSI guidelines

Page 21: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continue..The laboratory must inspect each shipment

forCracked mediaExcessive bubblesClarityHemolysisFreezingUnequal fillingVisible contamination

Page 22: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

User-Prepared and ,commercially prepared MediaQC forms for user-prepared media

should contain:The amount of preparedThe source of each ingredientThe lot numberSterilization methods

Page 23: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continue..The preparation date The expiration date (Usually 1

month for agar plate and 6 month for tube media)

The name of prepareAll user prepared colures media also

should checked for:

Page 24: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continue.Proper colorDepthSmoothnessHemolysisExcessive bubblesContamination

Page 25: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Sterility CheckA representative sample of the lot

should be test for sterility;5%of any lot is tested when a batch of 100 or fewer unit is received and maximum of 10 units are tested in large batches.Sterility is routinely checked by incubating the medium for 48 hours at the temperature at which it will be used.

Page 26: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Performance testingWhen medium dose need to quality

controlled because it was prepared “in house (in the laboratory) or because it is complex, several basic rules must be followed :

All media must be tested before useEach medium must be tested with organisms

expected to give positive reaction as well as with organism expected either not to grow or produce a negative reaction

Page 27: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 28: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 29: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 30: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 31: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 32: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continue..The medium should be tested for sterility and pHThe organisms selected for QC should represent

the most fastidious organisms for which the medium was designed

Testing technique should be different for primary plating media that for biochemical or subculture media. Primary plating media should be tested with dilute suspensions of organisms, whereas biochemical media can be tested with undiluted organisms

QC testing should be performed according to CLSI recommendation

Expiration date must be established

Page 33: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Media failure logDate 2/14/2014Media Urea AgarLot# In house preparation 2/13/2014Expiration date 6 month from preparationQuantity 2 racksFailure failure to give proper reaction with P.mirabilis

Action taken QC repeated with P.mirabilis failed All tubes discarded .New Urea agar preparedTechnologist MAR

Page 34: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Use of Stock CulturesTo operate a quality control program in

Microbiology lab. stock culture must be maintained by all laboratories .They are available from many sources.

Commercial sourcesProficiency testing sourcePatients isolatesAmerican Type Culture Collection (ATCC)

Page 35: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continue… When quality control testing

appears have failed, it is usually the stock culture rather than the test itself that has failed. Organisms may mutate with repeated sub culturing. for best results ,a stock culture should be grown in a large volume of broth ,then divided among enough small freezer vials to last a year.

Page 36: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continue..With this technique a new vial can be

removed from the freezer weekly so that organism do not have to be continually subcultured .An organism may need to be subcultured twice after thawing to return it to a healthy state. Media selection for freezing is at the discretion of individual laboratories but should not contain sugar. If organism utilize sugar while being maintained ,the acid products that result may kill organism with time.

Page 37: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Popular Media for Stock CulturesSchaeler broth wit glycerolChopped meat (anaerobes)Tryptic Soy agar deeps (at room

temperature) Tryptic Soy Broth (with 15 % Glycerol ) at -70

C ْCystein-tryptic agar (CTA) without

carbohydrates

Page 38: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continue…Nonfastidious (rapidly growing), aerobic

bacterial organisms can be saved up to 1 years on TSA slants .Long –term storage of aerobes or anaerobes can be accomplished either by lyophilizartion (freeze drying) or freezing ,at -70C.Frozen ,no fastidious organism should be thawed ,reisolated and refrozen every 5 years; fastidious organisms should be thawed reisolated ,and refrozen every 3 years. Stock isolated may be maintained by freezing them in 10% skim milk ,Trypticase Soy Broth (TSB) with 15% glycerol .

Page 39: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Stain and Reagents Containers of stains and reagents

should be labeled as to contents, concentration ,storage requirements, date prepared (or received) date placed in service ,expiration date, source (commercial manufacture or user prepared) and lot number .All stains and reagents should be stored according manufacture's recommendations and tested with positive and negative controls before use.

Page 40: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continue.All stain Hippurate Instrument

failureBacitracin Nitrate inoculumB-lactamase Optochin TemperatureCAMP PYR Moisture Catalase Typing se Difficulty in Coagulase VP determining FeCl3 X and V strips endpointGelatin Cation contentGerm tube Thymidin

Page 41: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Antisera The lot number, date received,

condition received ,and expiration date must be recorded for all shipments of antisera.In addition ,the antisera should be dated when opened .New lots must be tested concurrently with previous lots, and testing must include positive and negative controls.

Page 42: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 43: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 44: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 45: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 46: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 47: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Antimicrobial Susceptibility TestingFor antimicrobial susceptibility testing, control organisms must

be tested with each new lot or batch of antimicrobials or media, and daily thereafter.

However, the frequency of test monitoring may be reduced to weekly (including the testing of new lots or batches of antimicrobials or media) if the laboratory can document satisfactory performance with daily control tests as suggested by CLSI guidelines.

Page 48: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continued..

Single isolates or pure cultures only should be used for final performance of antimicrobial susceptibility testing (i.e., no mixed susceptibilities).

There must be stated criteria to determine the presence of an endpoint or zone size in the antimicrobial susceptibility testing system.

The laboratory may use CLSI (NCCLS) criteria, but the use of other validated criteria is acceptable.

Page 49: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continued..

The inoculum used for antimicrobial susceptibility testing (i.e., inoculum size) must be controlled using a turbidity standard or other acceptable method.

Antibiotic susceptibility may be substantially affected by inoculum size.

The microbiology department should consult with the medical staff and pharmacy to develop a list of antibiotics to be reported for organisms isolated from different sites.(number and type of antibiotics)

Page 50: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continued..

The goals of a quality control program are to monitor the precision (repeatability) and accuracy of susceptibility test procedures.

Multiple parameters are monitored by following quality control recommendations such as :

Reagents & equipments used in the tests  Persons who carry out the tests and read the

result

Page 51: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continued..

Tools of QC:

Reference strains Reagents & EquipmentsChart of acceptble limits for quality control strainsQuality control chart

Page 52: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 53: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 54: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continued..

Corrective Action:

Out-Of Control Result due to an obvious error

Use of the wrong diskUse of wrong control strainObvious contamination of strainWrong procedure

Page 55: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continued..

Reference Strains for Quality Control:

Enterococcus Faecalis Escherichia Coli Escherichia Coli Staphylococcus aureus Strep. Pneumoniae P. aeruginosa Kleb.Pneumonia Haem. influenzae

• ATCC 29212

• ATCC 25922

• ATCC 35218

• ATCC 25923

• ATCC 49619

• ATCC 27853

• ATCC 700603

• ATCC 49247

Page 56: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Maintence of QC records All QC results should be recorded on an

appropriate QC form. Corrective action should be noted on this form .If temperature is adjusted or a biochemical test repeated, the new reading within the tolerance limits should be listed. In many laboratories the supervisor reviews and initials all forms weekly and the director then reviews each one monthly. QC records should be maintained for at least 2 years except those on equipment ,which must be saved for the life of instrument

Page 57: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Patient ReportThe laboratory should established a

system for supervisory of all laboratory repots. This review should involve checking the specimens workup to verify that the correct conclusion were drawn and no clerical errors were made in reporting results. Reports should be given only given only authorized by law to receive them.

Page 58: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.

Continue.. Clinician should be notified about

‘’panic values’’ immediately. Panic values are such as :potential-threatening results, for example positive Gram stain for CSF or AFB and positive blood culture. All patients records should be maintained for least 2 years.

Page 59: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 60: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.
Page 61: Mohammad Rahbar (Ph.D) Professor of clinical Microbiology Department of Microbiology Iranian Reference Health Laboratory,Tehran Iran.