HOW THE MEDICAL FACULTY CONTRIBUTED TO DOWN FALL OF MEDICAL EDUCATION 
There is no day without something about the ongoing matters in Medical education in India, so many matters were discussed much to corruption in MCI / Ministry of Health, Amassing wealth collection of huge sums by private Management However I certainly feel it is just not few above factors, there is a greater fall of morals on highly educated teachers doctors and consultants, Medical council knows well that there are few qualified faculty to be Professors in Many branches including the non-clinical specialties
1 Many doctors and teachers, who belong to be relatives and near and dear of the management do really do nothing, It is a fact there are private college where many professors who have rarely taken a lecture demonstration and become professors and Principals and Vice Principal and Hospital administrators and even MD and MS examiners with putting the name in the roles as faculty
2 Many seniors the retired Professors are born to be lucky as Professors in many private colleges, everything is their choice, they are shameless but live without consciousness all the time demanding for many things huge salaries, unlimited leave 2 to 3 days presence in the Institutes, However they live by creating group-ism local and non-local and regional politics, It is unfortunate they think there are no rules for them as the Medical colleges need any body living with a MD or MS with past teaching experience Management are helpless they can stay up to 70 years as they need the support of these people to increase the seats and getting Postgraduate permission. MCI biometry faces great challenges with introduction of Biometry even today more than 305% oppose the biometry as the truth is difficult to hide
3 Most inefficient senior’s heads try to bluff the Internal assessment system by giving Internal assessment marks by boosting marks up to 90 % if one does a true analysis private medical college, deemed universities get better averages than government colleges when the things are free in manipulate by internal assessment marks
4 We find (Many times or Most of the Times) few or no seniors in colleges after 2pm on most days and so few seniors from Wednesday days it is free for all for many juniors, and there are no controls the manipulative research they are doing PhD and papers and publication, and the HOD’s have no role as they are most insincere to the work
5 Some (not all universities it is just pay and pass my experience is that people talk more morals than doing any work and students mange many things locally and practically it is becoming difficult to fail as long you are rich enough to manage the matters
6 However there are great Medical Colleges and Universities which made great progress when they invested in academics and better of the morality
The matters are endless just MONEY MONEY MONEY
No Conflict of interest
Dr.T.V.Rao MD

WHAT IS CASCADE LABORATORY REPORTING IN MICROBIOLOGY 
Dr.T.V.Rao MD
Topic of Importance for Post graduate students in Microbiology Many Microbiology laboratories which practice with scientific spirit to reduce the antibiotic misuse and follow stewardship follow the Cascade system of reporting on bacteriological specimens sent for culture and sensitivity, Most of the times the Physicians wish to read the essence of the laboratory reports, they have little time to consider many matters we mean as Microbiologists The reporting of microbiology results can have a significant influence on antimicrobial selection; in this way, the microbiologist and microbiology laboratory can play an important role in antimicrobial stewardship, every patient with infection do not need a new generation of antibiotics, many follow Cascade reporting is recommended by laboratory standard groups; as such, at least some form of cascade reporting has been implemented by most microbiology laboratories ( in USA and European laboratories ). Cascading microbiology laboratory reporting, as defined by the Clinical and Laboratory Standards Institute, is a “strategy of reporting antimicrobial susceptibility test results in which secondary (e.g., broader-spectrum, more costly) agents may only be reported if an organism is resistant to primary agents within a particular drug class (cascade reporting is one type of selective reporting).”In this way, susceptibilities are performed for a panel of antimicrobial AGENTS but reported for only the narrowest-spectrum drugs while suppressing the susceptibilities of more broad-spectrum agents, higher-cost agents, high-toxicity agents or those with the potential for over prescription (secondary agents). The rationale behind cascade reporting is that if the secondary agents are not reported, it is less likely they will be prescribed
INCORPORATION INTO ANTIBIOTIC POLICY -Ideally, the institution’s microbiologist and microbiology laboratory should decide which agents to report routinely and which to report selectively. These decisions should be made in consultation with the institution’s antimicrobial management committee, subcommittee of pharmacy and therapeutics, and/or the antimicrobial stewardship team. Institutions with outsourced laboratory services should understand how their laboratory performs cascading and if necessary, inquire about customization. Today many Hospitals outsource the microbiology services so they have to informed what they truly need to practice policy so to restrict antibiotic misuse
HOW CLSI GUIDELINES HELP An example of a cascade reporting algorithm is as follows: “1) if an E. coli is susceptible to gentamicin, amikacin is not reported; 2) if an E. coli is susceptible to ceftriaxone, then meropenem is not reported
HOW ANTIBIOTIC STEWARD SHIP PROGRAMS IMPROVED WITH PRACTICE OF CASCADE SYSTEM OF REPORTING -Decisions about strategic reporting should be made collaboratively by the microbiologist and the antimicrobial stewardship team. It is important to ensure that any comments added to the reports are written clearly to reduce the chance of misinterpretation by the end user.
Many laboratories practice cascade system of reporting for many out patients and the patients being with trivial infection and not needing toxic and new generation of Antibiotics ,Many can be treated with minor group of narrow spectrum antibiotics References -1 Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing; twenty-fifth informational supplement. Wayne, PA: CLSI; 2015. CLSI document M100-S25. 2 Antimicrobial Stewardship Strategy: Cascading microbiology susceptibility reportingFor further information Antimicrobial Stewardship Program, Infection Prevention and Control, Public Health Ontario.
Formulated by Dr.T.V.Rao MD for benefit of online university resources @ Antibiotic resistance

LIFE AT RISK IN ICU CARE -HOW INFECTION RULES - Today India has many ICU Care units with progress of the health care the major problem remain with getting the well qualified and truly caring professionals, and nursing education too no better in the country, most trained with theory than practicing nursing certainly need to rethink how we train nurses with practicality rather than theoretical examinations, Certainly the medics need more training on caring and practicing aseptic practices a major revelation says Elderly patients treated with central catheter and/or mechanical ventilation devices in intensive care units (ICUs), admitted from the emergency department or as an urgent case, are at very high risk for hospital-acquired infection (HAI), according to the results of research presented here at the 22nd European Congress of Clinical Microbiology and Infectious Diseases.In-hospital mortality in ICU patients with HAI was 4 times higher than in those without HAI, according to this analysis of an American hospital database."These data...confirm the current burden of HAI on ICU patients and the role of known risk factors, mainly invasive devices, to which this population is highly exposed, although in this study, the exposure rate to mechanical ventilation is unusually low," "The studies emphasize the importance of infection-control practices in critically ill patients that are currently implemented at many hospitals,"Although many issues of infection control can be countered by technology (gloves, sharp's covers, air exchanges), none of these aids work without constant vigilance on the part of healthcare workers (HCWs). Caution is especially critical in the intensive care unit (ICU). ICU patients' severe illnesses and injuries necessitate much more hands-on care than in normal wards,
Today much of ICU care is handled by Nursing and Junior residents, we certainly need to have changed curriculum in Microbiology for Nursing and Medical graduates on caring more for Humans than on uncommon microbes
Hope it is time that all teaching institutes should implement the methods to train the young graduates
Ref Hospital-Acquired Infections Quadruple ICU Mortality Becky McCall
Dr.T.V.Rao MD Freelance Reporter

HAZARDOUS CHEMICALS AND IMPACT ON HEALTH CARE WORKERS -Dr.T.V.Rao MD We have no true guidelines which are mandatory on preventing the impact of chemicals we use in the Hospitals, on health care workers who are always with risk of Infectious diseases and indiscriminate use of chemicals, Health-care procedures and equipment require the use of a wide range of chemical, biological and radio logical materials with growing economy and corporate culture and mushrooming of hospitals in private sectors, many chemicals are pushed with many conflicts, apart from Patients the largest health burden often fall upon healthcare workers exposed to hazardous agents day in and day out for many years.
What types of hazards health care workers face?
Healthcare workers face a number of serious safety and health hazards. They include bloodborne pathogens and biological hazards, potential chemical and drug exposures, waste anesthetic gas exposures, respiratory hazards, ergonomic hazards from lifting and repetitive tasks, laser hazards, workplace violence, hazards associated with laboratories, and radioactive material and x-ray hazards. Some of the potential chemical exposures include formaldehyde, used for preservation of specimens for pathology; ethylene oxide, glutaraldehyde, and paracetic acid used for sterilization; and numerous other chemicals used in healthcare laboratories.
Nursing aides, orderlies, and attendants had the highest rates of musculoskeletal disorders of all occupations in 2010. The incidence rate of work related musculoskeletal disorders for these occupations was 249 per 10,000 workers.
Health care workers are at risk with
Anaesthetic gases
Asbestos, urea-formaldehyde and other unhealthy building materials
Cleaners, disinfectants and sterilants Hospital cleaners and disinfecting chemicals can cause respiratory and reproductive disorders, eye and skin irritation, central nervous system impairment, cancers and other human health effects. Ethylene oxide, a cold sterilizing agent is a known carcinogen
Drug-related cancer or reproductive risks
Mercury
Phthalates in IV tubing
Radiation exposure
TIME TO THINK WITH WISDOM _ Leave many matters, still very well known carcinogenic agents Formalin and aldehydes is used for fumigation other sterilization practices without opting on newer generation of agents as we see many seniors and administrators with rigid minds do not wish to change to safer with methods with proven efficiency in sterilization of operation theaters
It is time that Ministry of health in India and MCI must come with practical solutions to ratify misuse of chemicals without establishing human safety used in Indian market,
Certainly the Hospital's administrators are responsible for brining in human safety in health care workers/ how much happening is too low to true needs?
It is not far many Health care worker may bring in compensatory claims if they fall victims to the consequences of hazardous chemicals as many will be incapacitated with chemical hazards before they can compete term of service
Ref Chemical, biological and radiological exposures, Health and sustainable development World Health Organization WHO
Dr.T.V.Rao Freelance reporter on Human safety in Health care

HOW MUCH AUTOMATION WE NEED IN DIAGNOSTIC MICROBIOLOGY ? 
Dr.T.V.Rao MD 
Topic of Interest to Medical Microbiologists The world of laboratory medicine is for a change, when we are not having any methods to automate we will be fascinated to handling the automation, and ignorant minds think many headaches are over and some machine takes care of the matters, truly the scenario is more different, Laboratories today face increasing pressure to automate their operations as they are challenged by a continuing increase in workload, need to reduce expenditure, and difficulties in recruitment of experienced technical staff.,Microbiology is getting automated In the twenty-first century, the clinical microbiology laboratory plays a central part in optimizing the management of infectious diseases and surveying local and global epidemiology. This pivotal role is made possible by the adoption of rational sampling, point-of-care tests, extended automation and new technologies, including mass spectrometry for colony identification, real-time genomics for isolate characterization, and versatile and permissive culture systems, you spend most of your day doing something that is likely to be automated a few years down the track you should be concerned. But if you are doing lots of things daily that could be getting carried out by someone else less qualified, you should be even more worried. Matter soon go out of your control, truly we have to dependent on a persons who produce faster results, without understanding the true content of the test . The great problem we face in India like many developing countries or even developed countries is technical support which continues to be a continuous bottleneck, and also we encounter hardware and software problems, “When it works, it’s the best thing in the world, but when it doesn’t, it’s stressful. You have to spend time on the phone with technical support and can’t work.” If the system is down for any length of time, priority and stat specimens can still be run on the system’s, We must have good planning to start and do the things with automation , “Return on investment” is the driving force behind most systems purchased today. The private managements think how fast they get returns in the new purchases, The philosophy is No Loss only Profit , Not to forget Most of the machines get outdated, After all, Japan operates with far fewer staff than US laboratories of similar size. With proper planning and a willingness to alter current processes, “With microbial resistance to antibiotics on the rise, laboratories are faced with new challenges. Rapid detection of resistance is critical to the proper treatment of patients. Many hospitals are on the path to rapid culture of Blood and other body fluids which are inherently sterile as CSF Pericardial and peritoneal fluids etc with Bactec and Vitek 2 and (MALDI-TOF) technologies , the true problem in India continues to be costs ,Automated microbiology is fast, but the costs per test, and initial capital investment is quite high, as with progress of more technologies we will see more automation and many doctors will utilize the credited and automated laboratories CAN WE AUTOMATE MICROBIOLOGY IN TOTO Microbiology is too complex to automate.In comparison to chemistry and hematology specimens of laboratories, most of which are blood or urine based and utilize a limited selection of tube sizes, microbiology specimens are much more complex. Think with wisdom can we automate totally
1 Urine
2 Sputum
3 Fecal specimens
4 Wound swabs, and post surgical site infections
5 Parasitic and Fungal infections
No machine can replace a human in the microbiology laboratory.A long-standing mantra is that humans are generally considered capable of performing tasks faster than machines and that machines cannot think. The perception that machines cannot exercise the critical decision-making skills required to process microbiology specimens has persisted. Specifically, human observation of organism growth on agar plates is still considered essential by many. While machines are programmable, humans are more flexible.
WHAT IS FUTURE OF DIAGNOSTIC MICROBIOLOGY Over the next decade, microbiology labs will see significant transformation from discrete manual processes to fully / partially automated systems, allowing labs to increase throughput, enhance traceability, reduce costs, and, ultimately, improve patient care.Whatever is said Microbiological diagnosis is a complex task truly it will be dangerous to take decisions and treatment on just automated results, we are entering an age of monumental change for clinical microbiology laboratories. While a precise assessment of the full impact of these changes is in its infancy, there is no doubt in our minds that the benefits of automation on laboratory efficiency and indirectly on clinical care will be profound.
Postgraduate and Newer Generation of Microbiologists to read more at
Ref and Resource Automation in Clinical Microbiology Paul P. Bourbeaua and Nathan A. Ledeboerb Journal of Clinical Microbiology
Dr.T.V Rao MD

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Answered by Dr.T.V.Rao MD Medical Microbiology needs a good thinking and execution of the knowledge it explores the various microbial life forms that comprise the sciences of bacteriology, mycology, virology and parasitology, and illustrates the impact microbes have on our lives by explaining how they function as distinct entities within a complex biosphere. The critical role of the microbiology laboratory in infectious disease diagnosis calls for a close, positive working relationship between the physician and the microbiologists who provide enormous value to the health care team Evaluating cause and effect relationships, such as microbial causes of disease, by the scientific method are good exercises for developing critical thinking skills. At an elementary level, the physician needs answers to 3 very basic questions from the laboratory: Is my patient’s illness caused by a microbe? If so, what is it? What is the susceptibility profile of the organism so therapy can be targeted? To meet those needs, the laboratory requires very different information
Let us start with Basic work we can start doing in our Laboratory
The practical use of Microscope is immense in making vital decisions in Bacteriology parasitology, and Mycology
THE GREAT STEP IN MICROBIOLOGY REAMIN WITH SCEINTIFIC USE OF A MICROSCOPE
Mastering the Gram’s staining and observation lead to mastering of Bacteriology and putting little more efforts in staining for Acid Fast staining further enhances our diagnostic capabilities to practical working,
Microscopy using the microscope - The setting up of a microscope is a basic skill of microbiology yet it is rarely mastered. Often entrusted to most junior staff and technicians, Only when it is done properly can the smaller end of the diversity of life be fully appreciated and its many uses in practical microbiology, from aiding identification to checking for contamination, be successfully accomplished. However when we look at CSF specimens in night hours, the utility is immense even if we find few bacteria, and helps in taking the vital decisions in time of crisis, The amount of magnification of which a microscope is capable is an important feature but it is the resolving power that determines the amount of detail that can be seen. The microscope is absolutely essential to the microbiology lab: most microorganisms cannot be seen without the aid of a microscope, save some fungi. And, of course, there are some microbes which cannot be seen even with a microscope, unless it is an electron microscope, such as the viruses
As soon as you see the specimen, STOP using the coarse adjustment, and switch over to the fine adjustment knob. After focusing at the beginning with the coarse adjustment knob, it is NOT TOUCHED AGAIN. All focusing will now be done with the fine adjustment knob.
Bacteria and yeast - Yeast can be seen in unstained wet mounts at magnifications ×100. Bacteria are much smaller and can be seen unstained at ×400 but only if the microscope is properly set up and all that is of interest is whether or not they are motile. A magnification of ×1,000 and the use of an oil immersion objective lens for observing stained preparations are necessary for seeing their characteristic shapes and arrangements. The information gained, along with descriptions of colonies, is the starting point for identification of genera and species, but further work involving physiology, biochemistry and molecular biology is then needed.
Moulds Routine identification of moulds is based entirely on the appearance of colonies to the naked eye and of the mycelium and spores in microscopical preparations. Mould mycelium and spores can be observed in unstained wet mounts at magnifications of ×100 although direct observations of ‘mouldy’ material through the lid of a Petri dish or specimen jar at lower magnifications with the plate microscope are also informative (but keep the lid on!). Routine identification of moulds is based entirely on the appearance of colonies to the naked eye and of the mycelium and spores in microscopical preparation helps support fungal etiology.
NEVER FORGET THAT THE MASTERING OF DIGANOSTIC MICROBIOLOGY STARTS WITH OPTIMAL USE OF MICROSCOPY
NEVER FORGET SIMPLE PATEINCE MAKE YOU A BETTER MICROBIOLOGIST
Ref – Basic use of Microscope in Diagnostic Microbiology WEB RESOURCES
Dr.T.V.Rao MD Professor of Microbiology

WISH TO BE A CLINICAL MICROBIOLOGIST ?– Many Microbiologists working in the healthcare wish to be clinical Microbiologists, certainly it is the need to be accepted as a clinical colleague, much of the developed countries have realized the clinical importance of a Microbiologist who has a great role to interpret the diagnostic reports and guide the clinicians to change the antibiotic usage as a matter of optimal antibiotic policy, still we have to catch and but all can try to prove their competence in the system we work If you are a clinical microbiologist and spend a good chunk of your day signing out/authorizing routine urine and wound swab results, specimen arising from the critically ill patients with sepsis and not forgetting the infectious etiologies of ventilator associate pneumonia's you should be worried. We need to make sure that we are performing tasks that justifies both our position and our qualifications. If we are not, then we need to do something about it, or we are forgotten soon in the system very soon, As I said to many colleagues a Professional or professor of Microbiology, who cannot do simple things in laboratory and or not having good interaction with clinical colleagues are most ignored not forgetting It is easy to get very comfortable when you fall into comfort zone “This is easy money, I can do this with my eyes closed, there is no need to change anything.” It’s a dangerous mindset to get into however, because in one’s experience, such scenarios as described above are never left hanging indefinitely in the long term, A truly committed Microbiologist working in a poor infrastructure worried missing something very important, a professionally conscious Microbiologist fears missing something, of not diagnosing that long shot… But sometimes it is best just to trust good clinical acumen, if you are medically qualified with MD form a credited Institute and try visiting patients in critical care units, serious with sepsis, and ICU’s we WILL soon realize the importance of bed side medicine, and know the critical puzzles can be cracked, and appreciate that laboratory testing can occasionally cause more harm than good… more testing without rationalism leading to confusion in delivering the laboratory reports . Today Diagnostic medical laboratories are businesses nowadays, and employers are always on the lookout for ways they can get the same job done for less money, And compromise on many matters, 
GETTING BACK TO OUR CLINICAL KNOWLEDGE ON INFECTIOUS DISEASES A GREAT PRIORITY WITH MANY UNDEPENDABLE TESTS MANY PERFORM JUST READ/ REFER THE BEST OF MENDEL'S INFECTIOUS DISEASES WE CAN TRULY PERFORM AS CLINICAL MICROBIOLOGISTS
Read better articles on Microbiology matters by Michael
Dr.T.V. Rao MD

CAREER DEVELOPMENT IN DIAGNOSTIC MICROBIOLOGY - I receive many mails from friends and junior colleagues, the question is – is it interesting to be a Medical Microbiologist, and lucrative, certainly it is interesting provided you have skills and ability to be creative, the curriculum of MD with MCI has become static we all read more theory than practice certainly it lead to monotonous laboratories and certainly we diagnose few clinically important diseases, lack of funding, Many think doing bench work is below the standards to be a Medical Microbiologist , however it is not possible to control the technical manpower without ourselves handling the matters in time of critical management of laboratories, Clinicians rule the system with empirical choice of Antibiotics, and ultimately lead to fall of the confidence , Today Medical microbiology certainly need better skilled people to run the system to the changing priorities of the advancing medical challenges
What are the skills required by a microbiologist?
As a microbiologist you need to have various skills handling technology:
-One should be updated with the latest scientific developments.
- One should have an inquiring mind with clear and logical thinking.
- One should have the ability to solve problems and even to lead a team.
- A high level of accuracy and attention is also required.
- One should have a good team work and able to demonstrate skills .
- An excellent spoken and written communication skill is also required.
- One should have the ability to work with statistics and computer skills, one with on line search abilities can organize and correct the errors faster, and timely information can be delivered to the critical care of the patients
Quickly make efforts to, combine, and organize information into meaningful patterns.
Above all the Microbiologists should be Competent Team workers
Try being a leader in Interpersonal and Communication Skills organizing
Leadership and Personal Effectiveness is the need of the Hour
Career success is both about what you do applying your technical knowledge, skills, and ability and how you do it the consistent behaviors you demonstrate and choose to use while interacting and communicating with others. Hopefully, by studying the essential competencies, identifying your developmental opportunities, and working to refine your own competence, you can take charge of your career!
Certainly not lucrative in India as the Majority clinicians dependent on ANTIBIOTICS AND NOT ON COMPETENCY OF THE DIAGNOSTIC MICROBIOLOGY
The world is changing to automation and molecular trends for faster diagnosis of infectious diseases
Ref changing trends in Diagnostic Microbiology Digital resources@ CDC and NIH
Dr.T.V.Rao MD@Carrer Development

Fungal Disease Awareness Week - We are more aware of bacterial infections, and think less of fungus and concentrating on detecting methods of MDR Bacterial strains, Many developed countries face many challenges with fungal infections as the cause of terminal illness The CDC organized the event to highlight the importance of considering fungal diseases, which often go undiagnosed, when treating an infection. The agency is asking physicians and patients with infections to “Think Fungus” if patients’ symptoms persist despite treatment. “Fungal diseases can cause serious illnesses and death, yet often go undiagnosed because their symptoms look like those of other diseases,” Clinicians who fail to correctly diagnose fungal infections may over prescribe antimicrobial, increasing drug resistance worldwide, according to a study published in Emerging Infectious Diseases.
The report describes four commonly misdiagnosed fungal diseases that require attention to improve antimicrobial treatment:
• Many patients with smear-negative tuberculosis may have Aspergillus spp. infection, which is diagnosed with a simple antibody test and is treated with less-expensive antifungal drugs vs. TB drugs;
• An inaccurate diagnosis of fungal sepsis can lead to invasive candidacies and prescriptions of inappropriate broad-spectrum antibacterial drugs;
• Fungal asthma, often misdiagnosed as chronic obstructive pulmonary disease, does not respond to antibacterial drugs, but can be treated with antifungal agents after diagnosis with skin and blood tests; and
• Over treatment/under treatment of Pneumocystis pneumonia in patients with HIV.
The week is an opportunity for partners to get people with infections to 'think fungus' if their symptoms are not getting better with treatment and to talk to their doctor about the possibility of a fungal infection," said the CDC. "Doctors are encouraged to 'think Fungus' if patients have symptoms that are not improving with treatment, particularly patients with weakened immune systems."
We need to pay attention when specimens come to our laboratories and we are reporting as sterile however they are only in relation to bacterial pathogens we are less on to think of fungus and certainly need more attention to imagine and try to think on emerging fungal pathogens
Resources -The CDC Fungal Disease Awareness Week from Aug. 14–18, 2017.
Topic if interest to New generation of Medical Microbiologists
Dr.T.V.Rao Freelance reporter / Clinical Microbiologist on Afro Asian resources

FUMIGATION IS HAZARDOUS PRACTICE TIME TO CHANGE FOR SAFER METHODS IN STERILIZATION OF OPERATION THEATERS
Post created by Dr.T.V.Rao MD Copyright 2017 © Docplexus Time to end fumigation of operation theaters look for better alternatives. Fumigation aims to create an environment, which will contain an effective concentration of fumigant gas at a given temperature, for a sufficient period of time to kill any live infestations.
Aldehyde are potentially carcinogenic and it is therefore recommended that other agents such as hydrogen peroxide, hydrogen peroxide with silver nitrate, peracetic acid and other chemical compounds of formaldehyde should be used in place of the currently prevalent practice of using formaldehyde.
One of the best answers receive from
Dr. A. Kumar MBBS, MD, FMMC, Fellowship in Infection Control USA d Former student MD Microbiology of CMC Vellore

Thank you Dr. Rao for bringing the topic for discussion. Infact the current Centres for Disease Control, Atlanta, Georgia, USA, doesn't recommend for routine fumigation with any of the available disinfectants. The operating theaters are not classified any more for clean and dirty infected surgical procedures. If adequate terminal cleaning is performed any operating room can be used for any kind of surgery. During our internship we used to have septic theaters for handling dirty/infected operative procedures. Here, we currently operate even transplant surgical procedures following an abdominal lapartatomy procedure as well but after adequate terminal cleaning. For cleaning & disinfection of the operating room, the right disinfectant is chosen and is usually done with infection control committee consultation & we currently use clorox solution which is diluted to 40% and if there is obvious spill of blood or body fluids we disinfect with 10% clorox solution or we could even use any of the Quaternary ammonium compounds viz. present tablets 4 tablets in 5 liters of potable water. Each tablet contains 250mgm quarterly ammonium compound. This product approved environmental protection agency (EPA). This disinfection procedure takes just around 25-30 minutes before a new patient is taken in. the most important thing to be remembered is that right disinfectant is chosen and right contact time is observed before cleaning is performed. The mops used for these cleaning process should be frequently changed and if a known infected patient is operated, color coded single use mop heads are used. But, if at all a patient following road traffic accident is brought into the OR, where during evaluation, you find that the patient is diagnosed with an airborne infectious disease such as open pulmonary tuberculosis, or a chicken pox with florid lesions, we make sure we use disinfection with fumigation machine available from Johnson & Johnson (USA) now take over by the French company & this machine uses calculated amount of hydrogen peroxide mixed with silver ions and this destroys aerosols suspended in air. This procedure takes around 30-45 minutes and this product doesn't damage any of the electronic devices and doesn't leave any residual toxic chemical following the procedure. Of course this fumigation process is initiated after thorough terminal cleaning. This product destroys even spores as per the manufacturer's report. we do face increasing number of patients affected with Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) & we utilize this fumigation process with good effect and this product has prevented occurrence of cross infection among patients with MERS-CoV as it was evident that after patient discharge from a room, this virus lives in the aerosol for almost 36 hours even after terminal cleaning. In addition, its mandatory for having all the environmental and engineering controls in place to have a safe operating room for handling surgical procedures. Restricted entry of Unwarranted staff to the OR. Color coded zone line demarcation for permitting staff with street dress and recommendation to change to the OR dress code beyond the red line. Always keep the OR closed during surgical procedure Make sure that the OR is continuously monitored electronically for positive air pressure (> 18 air exchange / hour). Keep equipment's and machines necessary only for the designated surgical procedure. because many times we have noticed that c arm machines, operating microscopes for a neurosurgical procedure or an ENT procedure will be kept in the OR during an unrelated procedure. If kept unrelated to the procedure, these unused machines could get colonized from infectious aerosols and if not adequately disinfected as per the manufacturers recommendation cross infection could occur between patients. Many at times, we have noticed that the exhaust vents within the OR would be obstructed by the OR nursing staff without realizing the importance of the vent. Always perform surveillance for surgical site infections for all surgical procedures performed and if you find a cluster of patients with surgical site infection with a similar organism and antibiogram will warn that some kind of cross infection has occurred and needs immediate investigation. Even re-admission of surgical patients will be a cause of concern for cross infection and surgical site infection or even catheter associated urinary tract infection or hospital acquired pneumonia or even central line associated blood stream infections. So, its a team work where the OR chief should get involved in prevention of infections by working closely with the hospital housekeeping staff, hospital engineering services who controls the operating room air ventilation system, involve the hospital infection control team, and others as needed. The above team should be involved in the decision making before a disinfectant product is purchased by the hospital management or authorities.
HOPE WE ALL CAN CHANGE FOR BETTER PRACTICES
Dr.T.V.Rao MD Freelance Clinical Microbiologist On line contributor on Infectious disease portals
Please Visit Docplexus @Dr,T,V,Rao MD
Copyright 2017 © Docplexus

WHY THE EMPIRICAL ANTIBIOTIC THERAPY OVER RULES DIAGNOSTIC MICROBIOLOGY?
In spite many advances in Pharmacokinetics and clinical Microbiology there is no ideal Antibiotic of choice in any given clinical situation even the most common problems in antibiotic treatment do not have simple solutions. Today Antimicrobial agents are some of the most widely, and often injudiciously, used therapeutic drugs worldwide. Important considerations when prescribing antimicrobial therapy include obtaining an accurate diagnosis of infection; understanding the difference between empiric and definitive therapy; identifying opportunities to switch to narrow-spectrum, cost-effective oral agents for the shortest duration necessary; understanding drug characteristics that are peculiar to antimicrobial agent, accounting for host characteristics Choosing one antibiotic drug from among several candidates entails balancing the benefits and the detriments associated with each. Never forget very few patients in the society are evaluated with Diagnostic Microbiology to identity the true pathogen, just it means how many attend the teaching hospitals and good institutes with quality control in Antibiotic sensitivity test methods. We believe that empirical antibiotic treatment matching the in vitro susceptibility of the pathogen will afford the patient the best chance of survival and an uneventful recovery.3–5 However, we have been told repeatedly by senior consultants of the department that the budget is limited and third generation cephalosporins and Imipenam are disproportionately expensive. At end the of treatment generate multi drug resistant and superbugs in the hospital .We need a framework that enables us to balance the benefits and detriments of antibiotic drugs in any given situation. Cost effectiveness analysis can provide such a framework, but it must take into account the consequences of future resistance. However, even in the absence of a complete framework and complete data, approximations can be usefully made it means that we treat majority of the patients and empirical basis,
However the clinicians have to take faster decisions the timing of initial therapy should be guided by the urgency of the situation. In critically ill patients, such as those in septic shock, febrile neutropenic patients, and patients with bacterial meningitis, empiric therapy should be initiated immediately after or concurrently with collection of diagnostic specimens. In more stable clinical circumstances, antimicrobial therapy should be deliberately withheld until appropriate specimens have been collected and submitted to the microbiology laboratory. Important examples of this principle are subacute bacterial endocarditis and vertebral osteomyelitis/ other septic condition including the surgical site infections because microbiological results do not become available for 24 to 72 hours, initial therapy for infection is often empiric and guided by the clinical presentation. It has been shown that inadequate therapy for infections in critically ill, hospitalised patients is associated with poor outcomes, including greater morbidity and mortality as well as increased length of stay. Therefore, a common approach is to use broad-spectrum antimicrobial agents as initial empiric therapy with the intent to cover multiple possible pathogens commonly associated with the specific clinical syndrome. This is true for both community- and hospital-acquired infections when a pathogenic microorganism is identified in clinical cultures, the next step performed in most microbiology laboratories is antimicrobial susceptibility testing (AST). Antimicrobial susceptibility testing measures the ability of a specific organism to grow in the presence of a particular drug in vitro and is performed using guidelines established by the Clinical and Laboratory Standards Institute, (CLSI) a non-profit global Organization that develops laboratory process standards through extensive testing and clinical correlation. The goal of AST is to predict the clinical success or failure of the antibiotic being tested against a particular organism.
To convince the Clinicians continues to be greater challenge, they are many times guided by present status of the serious patients and any means take the optimal advantage of all available antibiotics and Pharmaceutical promotions leading to conflicts out of scientific promotions, there is growing trend of gram negative bacterial isolates in the clinical setting with emerging drug resistance, We should educate the clinicians on rationalism in antibiotics prescribed what consequences to the rest of the patients in the wards, and critical areas, Today world of Medicine face grave threat from Durg resistant Microbes as we call SUPERBUGS , Antibiotic resistance is a quickly growing, extremely dangerous problem. World health leaders have described antibiotic-resistant bacteria as "nightmare bacteria" that "pose a catastrophic threat" to people in every country in the world. Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die each year as a direct result of these infections. Many more people die from other conditions that were complicated by an antibiotic-resistant infection. Many wonder whether it is possible bring in Antibiotic policy in India, I wonder it is humanly difficult task as the reasons
1 There are few credited laboratories, which do Antibiotic Sensitivity with scientific approaches
2 Lack of coordination in the Diagnostic Microbiology laboratories many Seniors and Professors are out of reach to the practical work in the laboratory
3 Least money spent on Improvement in developing infrastructure of Diagnostic Microbiology laboratories
4 Many Private Microbiology laboratories work with least infrastructure with maximal gains and kick backs as routine practice
5 Above all great danger awaits the Private laboratories cater to whims and fancies of physician’s with commercial interests report any antibiotic against any isolate whether it is a pathogenic or commensals
HOWEVER IF THE MATTERS GOING ASTRAY IT IS CERTAIN THAT IN MANY DEVELOPING COUNTRIES INCLUDING INDIA WE HAVE TO TREAT THE FUTURE PATIENTS ON RANDOM AND EMPIRICAL BASIS BRINING IN GRAVE CHALLENGES IN FUTURE MEDICAL CARE JUST MEANS THE LIVES AT RISK JUST AT OUR LUCK INSPITE OF MANY QUALIFIED MICROBIOLOGISTS ?
DR.T.V.RAO MD PROFESSOR OF MICROBIOLOGY FREELANCE WRITER

ACADEMIC PROGRESS WITH SOCIAL MEDIA Today we are more influenced by the social circumstances and the social media portals are catching to the trends, and promotes you to express your thoughts and innovative ideas to many which we are not possible in the past, and took few years many took to interact with social media many times with the unknown people all around the globe ,As it happens Social media is an increasingly important part of academic life that can be a fantastic medium for promoting your work, networking with colleagues and for demonstrating impact. However, alongside the opportunities it also poses challenging questions about how to engage online, and how to represent yourself professionally.
HOW I MADE MYSELF TO SOCIAL MEDIA - We find, many students are living in the virtual world and it is happening for a generation who spends their maximum time in the virtual space, focus must lie on the key interests and needs of students while using social media in education. Also, social media provide ways to enhance connection with students as it brings them closer by alleviating the necessity of physical presence. I find many requests from everywhere in the world when we relate to progress of medicine and science
TECHNOLOGY EVERYWHERE -We teachers are using technology in classrooms, the young generation is paving a new way of education and learning. Students are too getting a chance to explore and experience the world not only by books and assignments but also by adapting a new form of communication. In a world where your networks and connections are important, graduates enter the workplaces with a lot more to offer.
HOW WE CAN MAKE OUR SOCIAL PRESENCE WITH TEACHING AND ACADEMICS
1 Make your thoughts known to many and being social captures attention of students
2 Provide effective collaboration and communication
3 Build an online learning community
4 Extends learning beyond scope of class our better ideas can communicate 24x7x365 days
5 Platform for learning through social constructivism
Never to forget the wrong ideas we post are rebuffed faster and gives us an opportunity to correct ourselves, it all means we can make even learning and our academics and research for the progress of the society with social acceptance
Visit me at many places in Social media and contribute your better ideas for progress of your chosen academics and Teaching
TIME TO SHARE YOUR IDEAS CAN BENEFIT SOME ONE SOME WHERE WE ALL LIVE IN A FAST CONNECTED WORLD
Dr.T.V.Rao MD

TEACHING BETTER WITH POWER POINT PRESENTATIONS 
Dr.T.V.Rao MD We teachers are always being in dilemma how well we are received by our own students, however it is difficult get the attention of every student, in a distorted world, and many getting back to our lecture is difficult however we can try with scientific principles, today more than 70% of the teachers in the developing world teach with power point, anyhow it is the order of the day , we all dependent on presenting with power point, much of the success with power point dependent on how make the program and deliver the matter suiting the situation TEACHING A CHALLENGE BE PREPARED WITH ACTION - Decide in advance what you think you want to teach and how; SOON you will know your own strengths and weaknesses, both in terms of knowledge and style, and how you presented the matters, In credited and academic Universities are very keen for their students to receive quality teaching and are generally very supportive, so you can also call on their resources many advanced universities are providing web resources what the students excepted from the teachers, yet we have , not much of resources in many of our universities Don’t limit yourself to PowerPoint slides—a visual aid can be anything you show your audience to support your message. Slides are great, but for an important presentation where you need to make an impact, the power point should not take over you and we should be smart we have a control what we teach, think about what other visual aids you could use to get your audience engaged, never forget you are the master of the game If you’re using slides in your presentation, don’t fall into the trap of writing out your speaking notes and then projecting them onto a screen. Even bullet points are a turn off to an audience because they need to switch their concentration between what you’re saying and what you’ve written. NEVER FORGET A FLAVOR OF HUMOR - Not everyone feels comfortable using humor when they’re presenting, but even a light-hearted comment at the beginning can help break the ice and make you and your audience feel more relaxed. And the students are happy that you are flexible and hilarious teacher.
REACHING BETTER GOALS IN LIFE AS A MEDICAL TEACHER - Educational excellence, along with clinical excellence, is increasingly being recognized and rewarded appropriately. However, we cannot rest on our laurels and must continue to strive to improve how we teach and to embrace new ways of delivering teaching, presenting with power point presentations are certainly flexible we can alter the matters at the click of a button / mouse while not losing sight of the main goal: to be better at treating patients and delivering high quality healthcare
BEST OF YOUR PRESENTATIONS CAN BE SHARED WITH MANY IN THE WORLD
Dr. T.V. Rao MD @PowerPoint presentations

Sterilization of Operation Theaters-: Newer Methods to Replace Fumigation

In spite of brief stay of patients in the operation theater, the environment of Operation Theater plays
a great role in the onset and spread of infections, because of multi factor causation of infections. It is usually necessary to study
the epidemiology of infection as a multidisciplinary approach. In resource poor
circumstances as in most developing countries, people work in isolation and few
facilities to make any epidemiological surveys. Many believe that routine
Microbiological monitoring is most essential but in reality it is not
practicable. But every hospital should pay good attention in proper maintenance
of air conditioning plants, ventilator systems, and to have greater control on
mechanisms and personnel involved in disinfection and sterilization of
materials used in the theaters in operative procedures
Fumigation is an age old process of
sterilization, of the environment, may be a sick room or operation
theaters. It is usually done with formalin fumes, which are are very
pungent and harmful. So when a room is fumigated, it is tightly closed and
sealed before fumigation. The room is opened after fumigation (12 - 24 hours).
The room can be used once all fumes are ou
OSHA indicated that
formaldehyde should be handled in the workplace as potential carcinogen and set
an employee exposure standard for formaldehyde that limits an 8-hour time-
weighted average exposure concentration of 0.75ppm. Formaldehyde is the
commonly used agent. Formaldehyde gas is generated from liquid formalin
utilizing potassium permanganate crystals. 40% formalin liquid is added to
potassium permanganate crystals to generate gas. Alternately, formalin liquid
can be dispersed by a sprayer like device in the theatre environment. After a
contact time of at least 6-8 hours, the formaldehyde needs to be neutralized by
using ammonia, allowing at least 2 hours contact time for ammonia to neutralize
the formaldehyde prior to the use of theater.
Fumigation is obsolete in many developed nations in view of toxic nature of Formalin. too frequent use and inhalation is hazardous. Several new safe chemicals are emerging but constrains
of economy limit the use and several hours of closure of operation theatres can
be curtailed as with Fumigation. Aldehydes are potentially carcinogenic and it is thereforerecommended that other agents such as hydrogen peroxide, hydrogen peroxide with
silver nitrate, peracitic acid and other chemical compounds of formaldehyde
should be used in place of the currently prevalent practice of using
formaldehyde. These agents are dispersed with the aid of a fogger-like device
inside the theater environment. The contact time is about an hour and the
theater can be used immediately after the contact time.
Emerging
Compounds in use for Sterilization of Operation theater
Bacillocidrasant:
A newer and effective compound in
environmental decontamination with very good cost/benefit ratio, good material
compatibility, excellent cleaning properties and virtually no residues. It has
the advantage of being a Formaldehyde-free disinfectant cleaner with low use
concentration.
AdvantagesProvides complete asepsis within 30 to 60 minutes.Cleaning with detergent or carbolic acid not required.
-
Formalin fumigation not required.
Shutdown of O.T. for 24 hrs. Not required.
Other Newer and Non Toxic compounds:
A Chemical compound - VIRKON is gaining importance
as non-Aldehyde compound. Virkon is proved to be a safe virucidal
bactericidal, fungicidal, mycobactericidal and non-toxic compound. It
contains oxone (potassium peroxymonosulphate), sodium dodecylbenzenesulfonate,
sulphamic acid; and inorganic buffers. It is typically used for cleaning up
hazardous spills, disinfecting surfaces and soaking equipment. Though Virkon is
shown to have wide spectrum of activity against viruses, some fungi, and bacteria,
it however is less effective against spores and fungi than some alternative
disinfectants. Several other compounds are emerging in the Market for safer
use, may need better resources for utility and implementation.
Today markets are flooded
with many chemicals and need to think to select the needed disinfectant in the
circumstances they work
HOWEVER IT IS NECESSARY TO KNOW THE WORD
STERILIZATION OF OPERATION THEATERS IS NEVER A ABSOLUTE, DEPENDENT MORE ON HYGIENIC CONDITIONS
STANDARDS AND THE BEHAVIOR OF THE MEDICAL AND PARAMEDICAL STAFF
NO CONFLICT OF INTEREST
Dr.T.V.Rao MD Professor of Microbiology
Freelance reporter on Infectious diseaseThis topic needs more contributions and corrections