Agreeing to disagree

Medical Laboratory Observer, March, 2005

I would like to make a few comments on the recent MLO article, "Responsible reporting in microbiology: improving quality of care through better communication," December 2004 [p. 18]. I do not believe some of the points of the article are well delivered or appropriate.

First, the case reports actually indicate a failing on the part of the clinician, not the laboratory. In Case 1, the clinician should have realized that a U-bag specimen has a high likelihood of contamination based on the method of collection alone. To treat such a low colony count knowing contamination is possible without a urinalysis to identify contamination with or without associated pyuria to verify true infection is poor medical care, though unfortunately common.

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The second case identified Candida glabrata (aka Torulopsis glabrata) [which] is well known in medical literature to have high rates of resistance to fluconazole. Even without sensitivities performed, the clinician should have known this and either utilized fluconazole and changed after short course if no improvement or, more appropriately, in most cases [have gone] directly to an alternative agent.

Both of these cases are more a failure of the clinician than the lab personnel.

The other areas of concern focus on the recommendations made to the microbiologist. Many of these recommendations are brash and unwarranted. In fact, many can open the lab to liability.

Gram-stain recommendations are best suited to reporting morphologies and leaving proposed identification to the clinician. In cases where preliminary identification is inaccurate, inappropriate treatment may be initiated, only to be changed when final identification is made, which may be another 24 to 72 hours later. This leaves the lab with "egg on its face" if the clinician wishes to take the lab to task.

Finally, urine-culture handling is an area of particular concern. "Rule 1" recommends an evaluation to determine the presence or absence of leukocyte esterace or microscopic evaluation to identify pyuria before proceeding with culture. There are two problems with this recommendation. First, there are several situations where a culture is warranted, even in the absence of identifiable pyuria that may require treatment. Examples are patients with chronic colonization, identifying patients with "sub-clinical" infections who have urinary symptoms but no pyuria, or patients with urinary calculi to identify possible organism correlates with calculus type or calculi with bacterial "trapping."

The second issue raised with "Rule 1" focuses on the practice of medicine. For a laboratory to initiate a policy or procedure allowing or restricting certain testing based on certain parameters constitutes the "practice of medicine." Only a licensed physician can make such decisions, and for a laboratory professional to make those decisions to perform or not perform a test constitutes medical decision making, which [he is] not licensed or authorized to do. This policy would open the lab to certain liabilities.

"Rule 2" also raises some questions. Again, including organism-based comments--while noble in ideal--can be considered to be outside the scope of laboratory reporting and actually [can] be included in medical decision making. In addition, if not properly worded, these comments can be misleading to clinicians, and open to other possibilities.

The best method to avoid problems and avoid miscommunication would be to avoid definitive language, avoid medical decision making, list several possibilities for identifications or diagnoses, add a disclaimer to all reports, or have the laboratory director (i.e., the covering physician, usually a pathologist) countersign all reports leaving the lab, though this is highly impractical. Laboratory reporting needs to be accurate and timely, but overzealousness on the part of the lab can be just as misleading.

Of note, I am a private practice urologist [and] a private consultant in healthcare issues, and my personal background involves several years as a medical technologist at a community hospital and acting as the officer-in-charge (aka lab manager) for a lab at a military treatment facility. Thank you.

--Jonathan Block, MD, PhD, MBA

Utica, NY

Editor's notes: Read Colleen Gannon's response in the April 2005 issue of MLO.

Also, in the December 2004 Clinical Issues article "Responsible reporting in microbiology" by Colleen Gannon, credit for the information under "Nasopharyngeal (NP) cultures--Why do them?" was inadvertently omitted. The source of the material is a presentation by Ann Robinson, PhD, DABMM, entitled "Assessing Microbiology Test Orders and Specimen Quality: It's What's Up Front That Counts." Dr. Robinson presented this lecture at the annual American Society for Microbiology general meeting in May 2004. An article detailing the information included in this presentation will be published in the Clinical Microbiology newsletter in 2005.

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