ARTIFICIAL INTELLIGENCE IN MEDICINE – HOW GOOGLE CHANGING EDUCATION
Dr.T.V.Rao MD The world has changed with little feature phones, lead to smartphones, never ending technology and the world is moving to intelligent phones with artificial intelligence, It just means that you get anything on Online for learning and teaching or executing the plan, I was fascinated to read on Google Pixel mobile to be launched with artificial intelligence, Artificial intelligence (AI) is intelligence exhibited by machines. In computer science, an ideal "intelligent" machine is a flexible rational agent that perceives its environment and takes actions that maximize its chance of success at some goal. Colloquially, the term "artificial intelligence" is applied when a machine mimics "cognitive" functions that humans associate with other human minds, such as "learning" and "problem solving. For example, optical character recognition is no longer perceived as an exemplar of "artificial intelligence" having become a routine technology. Capabilities currently classified as AI include successfully understanding human speech, competing at a high level in strategic game systems, self-driving cars, and interpreting complex data. I already use the Artificial intelligence from Google store with downloaded application of ALLO, Empowered with Google Assistant , it is just refined research to our needs with a background of your, search History, and your needs, never forget the search design depends upon how to search the matters, When I I ask with voice command what is New in Medicine or whatever you want, it answers better than many, you get a nice ideas on what is happening you get the real Time answer, If you are Microbiologist ask what is the best solutions to treat the patient with Multidrug resistant tuberculosis , or How to deal with MDR Tuberculosis in a developing country We are going to use much faster technology in a few fraction of second you get more intelligent answers with the new innovative intelligent phone, , Today every smartphones can use Google Assistant . Never forget certainly it many prove threat to the Teachers many doubts of the students can be dealt with a voice command, and Google answers all the matters, faster. I wish all the Students and teachers to use GOOGLE ALLO is, a smart messaging app that helps you say more and do more., Get answers. Get the latest info on everything from news, weather, traffic, sports, or your upcoming flights status. Artificial intelligence techniques have the potential to be applied in almost every field of medicine. There is need for further clinical trials which are appropriately designed before these emergent techniques find application in the real clinical setting.
Ask the Assistant to send you daily updates on the information you care about, it helps the postgraduates and researchers to get updated, B E CAUTIOUS IT WORKS AND SEARCHES INFORMATION AS PER YOUR PSYCHOLOGY AND WAY YOU SEARCH WITH LITTLE BASIC INTELLIGENCE WITHOUT DISTORTING THE FACTS
TODAY TOPIC OF ARTIFICIAL INTELLIGENCE IS INCLUDED IN MEDICAL EDUCATION WORKSHOPS EVEN IN DEVELOPING COUNTRIES
TRY ASKING QUESTIONS TO GOOGLE ASSISTANT ?
Ref – Wikipedia and Google on Artificial Intelligence
Dr.T.V.Rao MD @ Artificial intelligence 2017

WE ARE NEVER OLD TO LEARN BETTER THINGS IN LIFE ? The world is progressing faster than what we know, imagine to me and we are outdated soon or later in a system we work, remember our own teachers we remember the great teachers, who had a greater knowledge, and committed to the profession than gossipers and lived by status and power, Knowledge is considered as the state of knowing facts and information acquired with the help of experience and reading books. Evolution of civilization over the years is due to increase in the knowledge base of the human’s A teacher who is sincere to his profession is respected for the knowledge he possesses, the more knowledgeable you are, the more advantage you have over the other people. The better you are equipped to manage yourself and others, the easier your journey of life. More than anything, knowledge must be put to good use. Someone once remarked that while ignorance was the curse of God, knowledge was the important power of wings which carried one to heaven. The power of knowledge lends him such distinction, Knowledge in wrong direction is much harmful than the actions of illiterate man We need to learn the art of life. We must master the techniques of adjusting and accommodating with the changes in our surroundings, as we are surrounded by people who live to meddle in everything, and many life situations. Wish to survive we must move well with the people and persuade them effectively to get things done in our favor. A fascinating fact about knowledge is that despite being shared with others, it grows unlike the wealth and fortunes we possess, Modern knowledge can only be acquired through education as it plays a very important role in enhancing the professional life of the individuals, many learned believe they wish to be the greater learners than the authoritarian teachers?
A great quote to remember by ― Roy T. Bennett, The Light in the Heart
“Let the improvement of yourself keep you so busy that you have no time to criticize others.”
Dr.T.V.Rao MD

ERRORS IN THROAT SWAB COLLECTION , CULTURING AND REPORTING IN PEDIATRIC PATIENTS
Dr.T.V.Rao MD We do receive many specimens in Microbiology departments from young children, and infants, The errors start from collecting the throat, many times the throat is not reached and swabs are collected in erratic ways and laboratories too report the errors, the reasons being very few staff are trained in the meticulous ways in collecting the pediatric specimens, However in developed countries have many trained child caring nurses however we certainly have to work in a compromised conditions in technical and clinical competency in collecting specimens , Coming to analysis much of the reports express either a sterile culture report and many irrelevant microbes are reported from many uncontrolled laboratories, today we see few of the results reporting Moraxella, Pneumococcus, Diphtheroids may be mistaken to be Diphtheria bacillus, however we should do a special stain at least a Albert's stain and culturing the swabs on selective media for Diphtheria, the minimal expectations in throat swab culture from a pediatrician in routine practice is Group A Streptococcal infection as when present with raised ASO levels, and ill-defined arthritis suspected to be Rheumatic fever, However in many developing countries look out about Diphtheria Infection involving throat presenting with pseudo membrane, or fever with toxicity and tachycardia For example, the presence of group A streptococcus bacteria (Streptococcus pyogenes) in throat is a key sign that child may have strep throat. Many cases of sore throat are caused by Virus but mistaken to be bacterial,
TECHNIQUE Of Collecting A THROAT SWAB
The child undergoing the specimen collection for throat culture is asked to tilt his or her head back and open his or her mouth. However, in infants the mother or care taker to be instructed, The health professional will press the tongue down with a tongue depressor and examine the mouth and throat. A clean swab will be rubbed over the back of the throat, around the tonsils, and over any red areas or sores to collect a sample.
Using a sterile cotton swab, touch the infected area with the swab with several strokes to collect any pathogenic or bacteria for a microbiologist to analyze.
Be careful not to touch the tongue, uvula, or lips due to possible contamination.
This should not be a painful procedure but expect your patient to gag since you will touch the back of her throat. At least few people working in the department to be trained
Prepare the swab for transportation to the laboratory for analysis. Always label the sample with patient name, date of birth, and patient ID and not forgetting the clinical details, and possible Antibiotic administration,
ALTERNATIVE APPROACHES -The sample may also be collected using a throat washout. For this test, the patient will gargle a small amount of salt water and then spit the fluid into a clean cup. This method gives a larger sample than a throat swab and may make the culture more reliable. However, it is not possible in infants and non-cooperative groups
CULTURING METHODS and RESULTS - The most portion of a specimen was identified, inoculated onto agar plates by swab and streaked for isolation of colonies. Media inoculated were 5% sheep blood agar, chocolate agar, MacConkey agar, mannitol-salt agar, all from plates were incubated at 35 degrees centigrade for a minimum of 72 hours, and observed for growth of pathogens specified by the SOP available in the laboratory , including Staphylococcus aureus, beta-hemolytic streptococci, Streptococcus pneumonia, Streptococcus milleri group, Haemophilus influenza, Moraxella catarrhalis, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Achromobacter species, Acinetobacter species, Burkholderia species and yeast
It is essential to pick only CLINICALLY essential to be picked for identification and reported as Group A streptococcus. This bacterium can cause strep throat, scarlet fever, and rheumatic fever. A throat culture is more accurate than the rapid strep test. The rapid strep test can give false-negative results even when strep bacteria are present. When the results of a rapid strep test are negative, many doctors recommend doing a throat culture to make sure that strep throat is not present.
Candida albicans. This fungus causes thrush an infection of the mouth and tongue and sometimes of the throat. Bottle fed infants will have much colonization of Candida, the matters left to the pediatrician’s discrimination to treat or not to treat
Neisseria meningitis. This bacterium can cause meningitis. Can be present as colonizer of the throat in times of Epidemics with N meningitides
Obtaining a “standard” culture may lead to identification of a organism, but may be subject to differences in competitive growth patterns in vitro versus in vivo.
NOTE - THROAT SWAB IS MOST ERROR PRONE AT COLLECTION AND REPORTING THE CLINICALLY RELEVANT RESULTS
I wish the new generation of Microbiologists to read 13th edition of Macy Diagnostic Microbiology for optimal reporting on Syndrome based approaches
Formulated by Dr.T.V.Rao MD for Online resources on Improving health care in Developing countries ‘

MICROBIAL SURVEILLANCE IN HEALTH CARE - CHANGING TRENDS WITH EMERGING SUPERBUGS -Infection continues to be a great threat, less perceived even by the Medical personal, even the developed countries estimate many die and become morbid as consequences of infections, the world needs better approaches to control the infections, In addition to improving safety, the approach could significantly improve productivity and reduce health care costs, Technologies advanced, highly competent doctors and nurses care than in the past however Today’s ICU is likely less safe and productive than it was 30 years ago. It is packed with more devices and alarms, and none communicate in scientific day, False alarm rates are extremely high in critical care, Because the number of changes that may benefit the health care system is vast, strategies that focus scarce resources on the promotion of changes with the largest positive impact are essential. The surveillance of health care areas without understanding the implications is much harmful than no surveillance, today internet has become source of information and misinformation too, many Infection control group think /believe in aggressive surveillance, forgetting how much it costs in surveillance culture media swabs and human man power and creating and collecting documents is end of the matters, ultimately nothing will change , Because the number of changes that may benefit the health care system is vast, strategies that focus scarce resources on the promotion of changes with the largest positive impact are essential. Getting back to literature well perceived and peer reviewed, there is no better action like human behavior in health care areas and HAND HYGIENE. Today most important matter in critical care areas is CARING TO PREVENT THE INFECTIONS WITH SUPERBUGS AS The world faces the grave outcomes with Carbapenem-resistant Enterobacteriaceae (CRE) major isolates being Klebsiella species (KRE), MRSA VRE Prevention of nosocomial transmission of KPC has surfaced as an emerging priority. Infections caused by KPC-producing bacteria have resulted in substantial morbidity and mortality because of limited treatment options, and they present significant therapeutic and infection control challenges in health care settings.
As matters stand majority of the Hospitals follow their own dictum every information literature formulated with authors experience, making surveillance REPORTS remain to hospital records and Microbiologists should at least audit the results, to educate on infection trends, PREVAILING TRENDS ON MDR strains and SUPERBUGS in the organization we work, and implications and growing affluence and corporate culture we are spending much on unsafe chemicals rather than investing safe hospital practices, and surveillance is a necessity without follow up or action plans costs huge resources, It is happening that there are few departments who collect the Microbiology surveillance reports, even of critical care areas and Operation theaters ,
THE WORLD IS CHANGING THE PATIENTS AWARENESS IS INCREASING TODAY MANY WISHES TO BE TREATED AT BIO HAZARD SAFE HOSPITALS
References and to learn more at Advances in the Prevention and Control of HAIs Prepared by IMPAQ International, LLC Columbia, MD AHRQ Publication No. 14-0003June 2014 Dr.T.V.Rao MD @ Hospital surveillance matters
Dr.T.V.Rao MD

NEWER METHODS IN DIAGNOSIS OF LYMPH NODE TUBERCULOSIS - UTILITY OF Xpert MTB/RIF 
Dr.T.V.Rao MD 
A topic for Post graduates in Microbiology, Pathology and Medicine Lymph nodes are one of the preferred sites for Infection with tuberculosis many surgeons expressed at least 1 or 2 patients present with lymphadenopathy ( majority Cervical regions ) Not to b forget the tuberculosis continues to be most important cause of cervical lymph nodes enlargement , and it is a dictum the surgeons wish to investigate for tuberculosis, The traditional methods of FNAC for cytology and biopsy of lymph nodes for detection of AF,B most pathologists express the suggestion on histopathological examinations, For histology/cytology in case of “Probable TB”, a specimen was positive if the presence of caseation necrosis and epithelioid granulomas was reported. stood the test of time since the onset of AIDS many pathology departments are testing for identification of Acid fast bacilli , the microbiology departments do get for Microscopy culturing, the procedure is undermined by many technical difficulties and lack of dedicated staff, and lacking proper decontamination procedures made many cultures being contaminated with careless processing lacking supervising by Medical Microbiologists, and we have lost the a very valuable specimens, and frequent reporting contamination by Microbiologists many clinicians stop sending the specimen in Microbiology departments, I have to say my frank opinion in a service of 3 decades I have seen 2 to 3 technicians mind their work sincerity and decontamination was the greatest step and neutralization of decontaminating agents was to bring down the ph. If taken care results are excellent, and the growth was demonstrable on LJ medium rapid growers and atypical bacteria are still difficult to identify by Biochemical methods are difficult and kills the valuable time of technical staff Certainly the above said procedures are getting obsolete.
Current trends WHO RECOMMENDATIONS - The WHO has evaluated the matters of the past and traditional methods and made the new protocols
WHO has issued policy recommendations for the use of Xpert MTB/RIF in the diagnosis of extra pulmonary TB and rifampicin resistance detection
• Xpert MTB/RIF should be used in preference to conventional microscopy and culture as the initial diagnostic test in testing cerebrospinal fluid specimens from patients presumed to have TB meningitis (strong recommendation given the urgency of rapid diagnosis, very low quality of evidence);
• Xpert MTB/RIF may be used as a replacement test for usual practice (including conventional microscopy, culture, and/or histopathology) for testing of specific on-respiratory specimens (lymph nodes and other tissues) from patients presumed to have extra pulmonary TB (conditional recommendation, very low quality of evidence).
The World Health Organization (WHO) has endorsed the Xpert MTB/RIF assay as a replacement for sputum smear microscopy. For the diagnosis of patients presumed to have extra pulmonary TB, Xpert MTB/RIF may be used as a replacement test for usual practice (including conventional microscopy, culture, and/or histology) for testing of specific non-respiratory specimens (lymph nodes and other tissues)
This multi functional diagnostic platform is an automated, closed system that performs real-time PCR and can be used by operators with minimal technical expertise, enabling for the diagnosis of TB and simultaneous assessment of RIF resistance to be completed within 2 h
Preparation of Lymph nodes and other tissues (for Xpert MTB/RIF only) is propriety needs the dedicated man power to handle the matter and in biosafe environments if is advisable to send the specimen to the dedicated laboratories with committed manpower and biosafety consideration.
It truly helps the pathologists, microbiologists and physicians as the possibility of tuberculosis is ruled out and can consider the other possibilities for lymphadenopathy , not forgetting malignancies
yet the clinical acumen of physicians remains a necessity for the wise use of any new diagnostic test. Careful application of these new diagnostic tools should improve clinicians' ability to deliver timely, cost-effective care to patients with suspected EPT throughout the world, an approach that future studies should systematically evaluate.
Caution - These recommendations do not apply to stool, urine or blood, given the lack of data on the utility of Xpert MTB/RIF on these specimens
NOTE- Unresolved issues continue with diagnosis of Atypical mycobacterium many reference laboratories still use the traditional methods supported with.use of Xpert MTB/RIF
Reference and Adopted Form Standard Operating Procedure (SOP)Specimen processing of CSF, lymph nodes and other tissues for Xpert MTB/RIF and WHO Resources
T V Rao MD Freelance Reporter on Infectious diseases formulated online teaching portals on Infectious diseases

Limitation of Diagnostic Microbiology Departments What Clinicians Should Know?
Dr.T.V.Rao MD
Majority of the Diagnostic Microbiology laboratories are utilized for Diagnosis of Bacterial, Fungal and Virus Infections, which have rapid solutions if promptly treated. The word Infection still confuses many Clinicians and Microbiologists, and they send the specimens to laboratories for immediate solutions. The malady of Microbiology starts with few qualified nurses to collect specimens, every specimen makes the difference in bacterial flora and contamination continues to hamper the quality of services. Blood collection for blood cultures remain the grey area and major loss of specimen value. The doctors and nurses fail to give proper instructions to the patient. I am certain very few laboratories get an ideal sample, rejecting the sample creates conflict between a clinician and laboratory personal. Everyone at the end of the day accepts all the specimens and processed as we practice a path of least resistance. A microorganism is judged as sensitive or resistant according to the diameter of the zone of inhibition of from purified isolate from cultural growth, which is then correlated statistically with the minimal inhibitory concentration (MIC). The degree of correlation depends on both the antibiotic and the species tested; between 71% and 90% of the results of disc diffusion were consistent with the Minimum inhibitory concentration, which is not done routinely in majority of the laboratories as at it costlier and processing of specimen will increases to more than 10 times. The expected error distribution cannot be reliably predicted by regression analysis. Especially those bacteria which are classified as having intermediate sensitivity in their inhibition zones, based on their MIC values, have, in fact, intermediate sensitivity in less than 50% of the cases. It is also necessary to use methods which take the biological and methodological variations of daily routine into account. In critical cases such as life-threatening infections or apparent failure of the patient to respond to antibiotic therapy, the MICs of selected agents should be determined. The tests are performed under standardized conditions so that the results are reproducible. The test results should be used to guide antibiotic choice. When a microorganism is isolated from a patient, the microbiology laboratory will often perform susceptibility testing. There is often confusion about what these results mean and how it can be used by the clinician to guide the treatment of the patient. The results of antimicrobial susceptibility testing should be combined with clinical information and experience when selecting the most appropriate antibiotic for your patient. We and Many in the Developing world receive the requests without any proper clinical information about the patients, many do not write whether he is on any Antibiotic treatment. I request all the Clinicians to remember the patients specimens are vital samples and not subjects for blind studies. We Microbiologists report as, the "susceptible" category implies that isolates are inhibited by the usually achievable concentrations of antimicrobial agent when the recommended dosage is used for the site of infection.' (CLSI definition) Our reports are based on peer reviewed major studies please do note that this definition says nothing about the chances of clinical success; in fact predicting clinical outcome based on susceptibility testing and the use of drugs shown to be in the susceptible category is very imprecise. This imprecision is due to the effect of host responses, site of infection, toxin production by bacteria that is independent of antimicrobial susceptibility, the presence of bio films as in catheterized patients, drug pharmacodynamics and other factors. The clinicians should note when reported as resistant it means, the "resistant” isolates are not inhibited by the usually achievable concentrations of the agent with normal dosage schedules, and/or that demonstrate zone diameters that fall in the range where specific microbial resistance mechanisms (e.g. beta-lactamases) are likely, and clinical efficacy of the agent against the isolate has not been reliably shown in treatment studies.' (CLSI definition). However, with the exception of urinary bladder infections and some mycobacterial infections, most clinicians avoid the use of a "resistant" category drug to treat infection. Many clinicians demand Zone sizes of sensitivity and resistance to different antibiotics, they wish to choose the antibiotic showing higher size of inhibition for an effective consideration. All clinicians should be familiar, bigger zone do not mean they are choosing the right choice of Antibiotic; ( example if I give a zone of Nitrofurantoin 30mm and Cephalosporin as 23 mm which are we choosing in a serious patient with established infection) They have to think which among many classes of antibiotic suits to his present clinical condition. Many clinicians do believe laboratories giving a Zone sizes are doing a great service however they are doing a great harm to your patient and in fact they are not following the basic principles in Diagnostic Microbiology. Factors affecting the reliability of in vitro testing systems include the limitations in interpreting MIC data, because in vitro test conditions cannot duplicate the host environment. In vitro testing systems do not consider the pharmacokinetics of the antimicrobial agent or the post antibiotic effect, whereby microbial growth is suppressed even when the antibiotic concentration falls below the MIC. Many clinicians expect some positive results from Microbiology reports please do remember humans contain 10 times more normal flora than our cells together in the body If we start testing antibiotic sensitivity for all normal isolates, the wards and hospital will be flooded with resistant strain the future of Hospitals will be in jeopardy. We all should be familiar, majority of the patients coming to a teaching hospitals are treated for several days as output patients by private practitioner, many prescribe without rationalism the antibiotics influenced by commercial interests. Majority have already used several antibiotics including the third generation cephalosporins. We have no existing facilities to neutralize the antibiotic in the blood or in any specimen and economically not feasible to process the sample as in in developed countries. Many pathogens like chlamydia, mycoplasmas and tuberculosis need defined conditions to process and culture as they are harmful to laboratory workers. They can be processed only in upgraded diagnostic and reference laboratories. It is important to understand the limitations of antimicrobial susceptibility testing. It should be recognized that resistance patterns will change and guidelines will be subject to periodic revision. The interpretation of an antimicrobial susceptibility test result on a laboratory report must never be taken in isolation. It is important that all factors are taken into account and that it should be remembered that there is no substitute for sound clinical judgment. The expectation of clinicians from Microbiologists is a mismatch in majority of the Laboratories in developing countries, as we have no Antibiotic policy and few hospitals invest for the changing needs, lack of trained technicians and apathy among the many Microbiologists. Conflicts widens with time between clinicians and microbiologists if proper investment are not done and committed Microbiologists take over the Profession,
CRITICAL CARE NEEDS BEST OF THE SERVICES OF MICROBIOLOGY
tvraomd

Laboratory Automation in Diagnostic Microbiology:
Dr T.V.Rao. MD
Infectious diseases are now the world's biggest killer of children, young and aged, however effective diagnosis and treatment SAVE many in the world. In recent years, conventional methods of culturing for bacterial infections are found to be slow and the physicians lose vital time to take effective decisions, depending only traditional methods, which were more than many decades old, delays in effective decision in treating patients, are now being replaced by automated methods for identification and culturing, of bacterial and fungal pathogens. On average routine diagnostics can take anywhere from 48-72 hours. This delay can result in incorrect empirical antibiotic therapy, prevents early targeted therapy and can promote nosocomial infections and generate Multidrug resistant bacterial pathogens. Why has it taken until only recently for the microbiology laboratory to move towards total laboratory automation? Frankly change is hard and due to the complexity of testing, cost, and the need for the human factors, needing training of work force The historical perspective has been that, automating microbiology was too much of a challenge to undertake. However, times are changing and there is a quiet revolution afoot in microbiology. With progress of time Automation is replacing the many traditional methods owing to reduced time for culture and ease of laboratory work using machines and helping in higher isolation rate than conventional methods. Automation is not new as Automation has steadily spread throughout the clinical chemistry and clinical hematology areas of diagnostic laboratories, clinical microbiology laboratories have not been upgraded in the same pace, as microbiology is too complex to automate. In comparison to chemistry and hematology, microbiology specimens are much more complex and need better understanding as much of human surfaces and mucosal membranes are associated with normal flora. The great challenge still remain which is a true pathogen or just a normal Human flora, The newer developments in automation wish to address the challenges and cut short in turnaround time for prompt decisions for practice of evidence based medicine. WHAT DELAY IN MICROBIOLOGY REPORTS MEAN IN PATIENT CARE ?
Microbiological delays in isolation identification and antibiotic sensitivity testing will lead to empirical over treatment or inappropriate antibiotic use, a true concern to medical profession with emergence of Multi drug resistant bacterial and fungal pathogens, The increase in resistance can lead to increased acuity of patient presentation, which increases the length of stay and costs of health care, and Automation enables workflow optimization, removing unnecessary delays and better utilizing the skills of trained lab professionals ADVANCES IN PATIENT CARE NEED BETTER FASTER MICROBIOLOGY REPORTS - Many clinical specialties invested much in critical and multi specialty care and most complex procedures are done , driven by a variety of factors, we believe that the level and degree of automation in clinical microbiology laboratories are poised for dramatic change the modern laboratories equipped with newer equipment bringing in automation to the advantages of the timely decision making in critical and advanced care of the patients. The key drivers for growth of the clinical microbiology market are availability of automation, outbreaks caused by novel organisms (Swine flu virus, Ebola virus), the growing menace of antimicrobial drug resistance, the need for performing research to understand re-emerging pathogens, and identifying drugs to combat them. These factors have led to increased public-private partnerships and better funding to conduct research to develop kits for specific pathogen
TRENDS OF CHANGE IN DIAGNOSTIC MICROBIOLOGY - However, systems are emerging for the clinical microbiology laboratory with the potential to automate almost all areas of testing, including inoculation of primary culture plates, detection of growth on culture media, identification of microorganisms, susceptibility testing, and extraction and detection of nucleic acids in clinical samples. As a result, the workflow in the microbiology laboratory is changing at a rapid pace and microbiologists have the challenge of selecting the most appropriate, clinically useful, and cost-effective automation for their laboratories.
NEWER AUTOMATION IN MICROBIOLOGY BACTEC blood culture system - Since the mid-1970s there has been many advances in blood culture practices and technology; these advances have been based largely on well-designed controlled clinical evaluations of blood culture systems and media. Thus, a sound scientific basis for the fundamental principles of blood culturing now exists Instrumented blood culture systems. Until recently, the BACTEC instrumented systems were the only products commercially available in the United States; these systems were initially equipped with radiometric instruments and media, followed in the mid-1980s by the non-radiometric instruments and media. Both systems (as well as in the newer BACTEC and BacT/Alert continuous-monitoring devices) are based on the utilization of carbohydrate substrates in the culture media and subsequent production of CO2 by growing microorganisms, for the radiometric system, the instrument detects 14C02 in the bottle head space, and for the non radiometric system, CO2 is detected by infrared spectrophotometry.
MATTERS INFLUENCING THE NEED FOR AUTOMATION IN MICROBIOLOGY
increasing testing volumes
improved health care/access
Ageing population
Emerging diseases / HIV AIDS produced great challenges to Medical profession Many opportunistic emerging and reemerging infections entering the immunosuppressed patients need testing innovations, certainly created necessity for many innovations in rapid, automated and molecular methods
Infection control demands growing challenges resulting from detection and identification of multidrug-resistant microorganisms
The trend toward increasingly shorter lengths of stay for hospital inpatients has led to increased demand for more rapid turnaround times for infectious disease assays thereby improving patient care The(24/7) with microbiology laboratories support is becoming much more common, and automation that can shorten turnaround time is being viewed more favorably, and certainly greater need of the future
AUTOMATION – IN SEPTIC AND LIFE THREATING CONDITONS – it is utmost priority to save many with critical condition as happens in septic condition, blood culturing is the top priority and culturing the specimens of CSF, ventilator associated pneumonia and surgical site infections as every hour of delay account to faster death and higher morbidity and increasing costs in treating with empirical treatment, and necessities the Automation.
NEWER AUTOMATION METHODS -Although continuous-monitoring blood culture systems, automated microbial identification, and automated antimicrobial susceptibility testing systems are widely utilized in microbiology laboratories, microbiology specimen
BACTEC blood culture system supported with VITEK® 2:
VITEK® 2: Healthcare Optimizing Collection to Care
The VITEK® 2 system has everything the healthcare laboratories need for fast, accurate microbial identification, and antibiotic susceptibility testing.
The innovative VITEK® 2 microbial identification system includes an expanded identification database, the most automated platform available, rapid results, improved confidence, with minimal training time.
The VITEK® 2 system next-generation platform provides greater automation while increasing safety and eliminating repetitive manual operations. The rapid response time means results can be provided more quickly than with manual microbial identification techniques.
Total laboratory automation systems currently are available to handle specimens, streak plates, incubate, and digitally image cultures. “That’s one of the great things about microbiology at the moment, THE WORLD OF AUTOMATION IS PROGRESSING WITH
Automated urine analyzers
• Plate streakers
• Blood cultures
• Automated ID
• Automated susceptibility testing
• Automated molecular platforms. Gene Xpert
MALDI-TOF
Recently the availability of new technologies such as identification by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF), the utilization of liquid-based transport devices and laboratory consolidation have triggered the development of automated solutions designed for microbiology. MALDI/TOF spectra are used for the identification of micro-organisms such as bacteria or fungi. A portion of a colony of the microbe in question is placed onto the sample target and overlaid with matrix. The mass spectra generated are analyzed by dedicated software and compared with stored profiles. Species diagnosis by this procedure is much faster, more accurate and cheaper than other procedures based on immunological or biochemical tests. MALDI/TOF is becoming a standard method for species identification in medical microbiological laboratories. The technology has been readily imbibed by microbiologists who have reported usage of MALDI-TOF MS for several purposes like, microbial identification and strain typing, epidemiological studies, detection of biological warfare agents, detection of water- and food-borne pathogens, detection of antibiotic resistance and detection of blood and urinary tract pathogens etc. The first automated modules to be launched on the market were automated specimen processors. The first generations were developed more than 20 years ago, but only third-generation instruments allowing high-throughput and accurate inoculation were successfully introduced into routine diagnostic laboratories. Many working with MALDI-TOF MS experience it has become a valuable tool for a microbiological laboratory, which might potentially replace molecular identification techniques in near future.
SYNDROME BASED APPROACH IN DIAGNOSIS OF INFECTIOUS DISEASES – Till recently our approach to infectious disease with identification of individual microbial infections, as we are aware a patient can get infected in many ways with many unknown pathogens, to fulfill the desired goal multiple testing are needed, needing many resources and much with the help of the technological staff spending many working hours, and yet the results are difficult to analyze which is true of the identification the problem can be solved with newer methods and Film Array® a emerging technology
The Film Array® Blood Culture Identification (BCID) Panel tests for a comprehensive set of 24 gram positive, gram negative and yeast pathogens and 3 antibiotic resistance genes associated with bloodstream infections. The BCID Panel detects and identifies the most common causes of bloodstream infections. Quickly identifying the cause of sepsis may help clinicians more rapidly and appropriately manage septic patient therapy. Rapid identification of bloodstream pathogens may help reduce the time to appropriate antimicrobial therapy and positively impact patient survival. The FilmArray® Respiratory Panel detects 20 viral and bacterial pathogens known to cause respiratory tract infections. Test results are automatically reported in about an hour. The FilmArray® Trend is a cloud based epidemiology network that exports de-identified results from participating sites across the United States. Data displayed here aggregate results from hundreds of thousands of tests and the graphs are updated daily. Known quality control tests are removed prior to display. There are more than 20 sites contributing data to the FilmArray Trend, about half of the sites are in the East, 20% are in the Midwest and West and 10% are in the South. A manuscript describing the FilmArray Trend project is in preparation
BAR CODING THE LABORATORY SPECIMENS - Accurate identification of patients, their specimens and laboratory test results linked to them is essential in all healthcare settings for providing effective, safe, timely, efficient, equitable and patient-centered healthcare Bar coding is effective for reducing patient specimen and laboratory testing identification errors in diverse hospital settings and is recommended as an evidence-based “best practice.” The overall strength of evidence rating is high and the effect size rating is substantial. Unpublished studies made an important contribution comprising almost half of the body of evidence.
TELE BACTERIOLOGY
Telebacteriology is the use of digital imaging and file storage for on-screen reading and decision making. The laboratory has access to a library of digitally recorded images that can be electronically shared between consultants located at different sites; they may also be used as an educational tool. Thus, diagnostic laboratories can create ‘reading rooms,’ which may offer a comfortable working environment for the reading of the digitalized images. However, such an organization requires a separation of the reading and the downstream applications (i.e. subculture, ID, AST), which should be performed by different technicians for optimized laboratory workflows.
MAN, VERSUS MACHINE- Despite many arguments and counter arguments, 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. However, with progress of technological advances, 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, Automation in clinical microbiology will also have some impact on patient care by improving trace ability, reproducible, and quality and certainly reduce the morbidity and mortality, Finally, while quality of the diagnostic results was mainly based on the experience and expertise of the microbiology staff in the past, in the course of automation it will much more depend on the method or apparatus used, It is certain that next generation of Doctors dependent on Automation as everybody needs faster delivery of laboratory results helping the evidence based Medicine a true reality
References –
1 Automation in Clinical Microbiology Paul P. Bourbeaua and Nathan A. Ledeboerb, J. Clin. Microbiol. June 2013 vol. 51 no. 6 1658-1665
2 Automation and the Future of Microbiology Laboratories Labs Weigh Upfront Investment Against Faster Throughput Author: Julie Kirkwood // Date: MAR.1.2017 // Source: Clinical Laboratory News AACC
3 Laboratory automations in clinical bacteriology: what system to choose? Croxatto A1, Prod'hom G1, Faverjon F2, Rochais Y3, Greub G4. Clin Microbiol Infect. 2016 Mar;22(3):217-35
4 Automation in the Clinical Microbiology Laboratory Carey-Ann D. Burnham, W. Michael Dunne, Gilbert Greub, Susan M. Novak, Robin Patel Published November 2013 CLINICAL CHEMISTRY
5 Seng, P.; Drancourt, M.; Gouriet, F.; La Scola, B.; Fournier, P. E.; Rolain, J. M.; Raoult, D. (2009). "Ongoing revolution in bacteriology: routine identification of bacteria by matrix-assisted laser desorption ionization time-of-flight mass spectrometry". Clinical Infectious Diseases. 49 (4): 552–3. PMID 19583519
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