Key 6:Blood culture gram stains in the context of Biofire BCID and

Nanosphere Verigene

At the end: Automated processors, automated stainers, acridine orange

stain information

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Fast gram stain report = less death!

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Am J Clin Pathol 2008:130:870-876

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If you have the ID faster?

• What tool can the physician use to treat the patient in a more focused way?

– ___________________

• Are there any outcome studies comparing patients who got BCID or Verigene versus only Gram stain?

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Questions

• Do you call only the gram, or only the PCR, or both to the floor?

• Do you only run molecular once per patient?

• How soon do you run again if patient has more positives?

• Do you repeat molecular if growth does not match molecular results?

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More questions

• Do you run only MRSA/MSSA if only GPC clusters seen?

• Do you run molecular if blood culture instrument says positive but gram stain is no organisms seen?

• Do you run molecular if only GPR seen?

– Since Listeria is so rare!

• Do you always sub positive blood cultures to the same media?

• Or do the gram stain and/or molecular tests change the medias to which you sub the bottles?

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Cepheid GeneXpert MRSA/MSSA

• MRSA

• MSSA

• If neither, then some kind of CNS, but could be anaerobic GPC such as Finegoldia magna, or could be S. lugdunensis

• Or could be a combination!

• Immediate impact, at least on day shift:

– _______________________

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Questions to ask:

• How long did it take for bottle to turn positive?

– Watch out for the 3-5 day incubation positives

– Some examples on next slides

• Only anaerobic bottles are positive?

• Only aerobe bottles are positive?

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What to report when no targets detected?

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“No targets detected”

• We know what that means.

• Does the doctor know what that means?

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No targets detected

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Reported as NOS all weekend long x 3!

No targets detected

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Reported as yeast

Morphed into this

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No targets detected

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One target detected, but two bugs?

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No targets detected

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References • Barenfanger, J, Drake, C. Interpretation of Gram Stains for the

Nonmicrobiologist. Laboratory Medicine July 2001, number 7, volume 32

• Dallas, S. D. “Gram Stain Errors”. ASCP TechSample Series, Generalist No. G-12 2004, ASCP Press, 2004.

• Rand, K. and Tillan, M. Errors in Interpretation of Gram Stains from Positive Blood Cultures, Am J Clin Pathol 2006: 126: 686-690

• Munson, E., Block, T., Basile, J., Hryciuk, J., Schell, R. Mechanisms to Assess Gram Stain Interpretation Proficiency of Technologists at Satellite Laboratories, J Clin Micro, Nov 2007 3754-3758

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Supplemental Things

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Robo-grammer: COPAN WASPLab

• https://www.youtube.com/watch?v=Tp9TTVwYfZg

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Robo-grammer: BD Kiestra WLA

• http://www.bd.com/scripts/europe/labautomation/productsdrilldown.asp?CatID=455&SubID=1836&siteID=20309&d=&s=europe%2Flabautomation&sTitle=Lab+Automation&metaTitle=Total+Lab+Automation&dc=europe&dcTitle=Europe

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BioMerieux Previ Isola

• Automated plating but no Gram stains

• http://www.biomerieux-usa.com/clinical/previ-isola/?gclid=CKrNjoq348cCFQENaQod5EQJOA

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AGS-1000

• AGS-1000, Quick Slide, GG & B company

• One slide at a time 3-5 minutes each

• Good for a small stat lab • https://www.youtube.com/watch?v=XuXoqVgjbWU

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MGS-80

• https://www.youtube.com/watch?v=srqBhxcVCcU

• 80 slides an hour.

• Batch or single stat slide

• Offer 1 year subscription to Gram stain training course

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Hardy Diagnostics bought this company in May, 2016

Biomerieux Previ Color Gram

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https://www.youtube.com/watch?v=BdE47TTue9I

ELITech Aerospray Gram

• Combines cytocentrifuge

• https://www.youtube.com/watch?v=Lwl6XpDtztE

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When in doubt: Acridine Orange?

• Faster than Gram stain but need fluorescent scope.

• Air dry, methanol fix, air dry

• AO stain 2 minutes

• Rinse well

• Air dry, protect from light

• Use FITC filter, View on low, then oil

• Use type F low fluorescence oil • Can remove oil with xylene and gram stain the very same slide,

right over the AO

• Can do AO wet mount, one drop of specimen, one microliter of stain and coverslip

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Acridine Orange

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What is AO good for?

• Positive blood culture bottles when the Gram stain is negative

• Vitreous fluid, bug or pigment granule?

• Bloody wounds, is it a bug or an artifact?

• Mycoplasma suspected

• Done correctly, human cells are green, bacteria are orange

174 http://www.scionpublishing.com/shop/ProductImages/1.JPG

Mini-review of AO technique • http://ki.se/sites/default/files/goran_kronvall

_ao_staining_mini-review.pdf

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