Ospedale di Circolo e Fondazione Macchi,Varese

9 Novembre 2011

Dott. Luigi Ruffo Codecasa, Responsabile Centro Regionale di Riferimento per la

Tubercolosi, Villa Marelli, A.O. Ospedale Niguarda Cà Granda, Milano

Dott. Giorgio Crosta, Dirigente Medico U.O. Pneumologia, A.O. Ospedale di

Circolo e Fondazione Macchi, Varese

Dott. Giovanni Gesu, Direttore Laboratorio Virologia e Microbiologia

A.O. Ospedale Niguarda Cà Granda, Milano

Dott.ssa Ester Mazzola, Dirigente Medico, Laboratorio di Virologia e Microbiologia

A.O. Ospedale Niguarda Cà Granda, Milano

Prof. Luigi Nespoli, Direttore Clinical Pediatrica - Ospedale F. del Ponte, Ospedale

di Circolo e Fondazione Macchi, Varese

Dott. Agostino Rossi, Dirigente Medico, Laboratorio di Microbiologia,

A.O. Ospedale di Circolo e Fondazione Macchi, Varese

Dott.ssa Franca Sambo, Responsabile Servizio di Medicina Preventiva delle

Comunità, ASL Varese

Prof. Antonio Toniolo, Direttore Laboratorio di Microbiologia, Ospedale di Circolo e

Fondazione Macchi, Varese

14.15 Saluto del Direttore Generale - Walter Bergamaschi

14.30 Introduzione scientifica - Antonio Toniolo

14.45 Diffusione della tubercolosi nella Provincia di Varese - Franca Sambo

15.15 La malattia tubercolare: aspetti clinici - Luigi Ruffo Codecasa

15.45 La malattia tubercolare nel paziente pediatrico - Luigi Nespoli

16.15 La malattia tubercolare: epidemiologia e diagnostica - Giorgio Crosta

16.45 Screening immunologico della infezione tubercolare - Giovanni Gesu

17.15 Discussione

17.25 Pausa

17.40 Diagnostica microbiologica e antibiogramma - Agostino Rossi

18.00 Aspetti molecolari: diagnostica, antibiogramma,epidemiologia –

Ester Mazzola

18.25 Discussione e conclusioni

18.45 Compilazione customer satisfaction

Laboratory diagnosis of TB infection

One third of the world’s population is infected with organisms of the Mycobacterium tuberculosis complex

Each year:

- Two million people die

- Eight million people are newly infected

22 Countries Account for 80% of Global TB Cases

No estimate

0–999

10,000–99,999

100,000–999,999

1,000,000 or more

1,000–9,999 ITALY

Estimated number of new TB cases (all forms)

WHO CLASSIFICATION OF TB LABS

District-LevelSmear Microscopy

Regional-LevelCulture Laboratories

Central Laboratory -DST for all who

start treatment

CentralCentral

DSTDST

National Reference

Laboratory

Standards for Laboratory

Diagnosis of Tuberculosis

TB diagnosis and management depend

upon a reliable and prompt laboratory

service

Guidance and Standards

• National SOP

– How to do the tests

• NICE guidance

– How to manage the patient

• DH programme

– What service should be delivered

– 3 working groups

TB monitoring and laboratory services

working group

• Surveillance standards

• Standards for laboratory diagnosis

– Current best practice

– Simple and straightforward

– Not replicate or replace the National SOP

Standards to cover

• Samples

• Transfer to laboratory

• Immediate tests

– Microscopy

• Culture, isolation and

identification

• Laboratory facilities and

expertise

• Transport

• Susceptibility testing

• Molecular

fingerprinting/typing

• Notification

• PCR detection of Mtb

• Immunodiagnostic tests

• Histopathology

Samples

• Type of sample

– Sputum (resp. sample), CSF (spinal/para-spinal/intra-cerebral), gastric washings, lymph nodes (tissues), urine, faeces

• Number of samples

– 2 or 3 for sputum? Consecutive days.

– Early morning or any time?

– True LRT specimen

• Documentation

Transfer to laboratory

• Within 24h (or 1 working day, max 48h)

– Minimise overgrowth

– Maintain AFB character

• Potentially infected clinical sample

– Routine procedure

Immediate tests

• Microscopy

– Auramine fluorescent staining

– 6-day service (not on call)

– Perform microscopy and issue result within 24h (1 working

day) of receipt

– Telephone positive result to senior member of clinical

team

– Notify lead TB nurse, lead clinician, CCDC

• Accreditation; IQC programme; satisfactory EQA

performance; staff CPD/peer review

Culture, isolation and identification

• Automated liquid culture on all samples

– Set up within 24h of receipt (6 day service)

– Plus conventional solid culture

• Send all isolates to RCM on day found to be

positive

– Reach RCM within 24h

• Complete identification of most mycobacterial

isolates within 21 days

Identification and reporting

• NAAT (PCR, LCR) or hybridisation gene probe

for MTB complex

– On the day culture shows positive OR

– Within 24h of receipt at RCM

• Other probes and/or phenotypic tests

• Report on day of test to

– Senior member of clinical team

– Lead TB nurse, lead TB clinician, CCDC

Laboratory facilities and expertise

• Safety – Category 3 for culture

– HSE approved

– Contingency plan for accidental dispersal

– Continuity plan for closure

• Accredited

– IQC programme, satisfactory EQA

• Sufficient number – daily service, competence

• Named Consultant and BMS for advice

Transport

• Samples

– Potentially infected samples (routine)

• Positive cultures

– Category A but exemption to treat as B for clinical

and diagnostic purposes

• UN 3373 – marked Diagnostic or Clinical

• P650 packaging

• Do not send by Royal Mail

Susceptibility testing

• Complete within 30 days of initial receipt of clinical

sample for primary agents

– Isoniazid, rifampicin, pyrazinamide, ethambutol

• Takes 10-20 days by liquid proportion (automated) or resistance

ratio

• Molecular detection

– Rifampicin within 24h if MDRTB suspected

– Isoniazid under development

• Done at RCM with accreditation, IQC, EQA

Molecular fingerprinting/typing

• ALL ISOLATES

– 15-loci MIRU-VNTR

• Mycobacterial Interspersed Repetitive Units – Variable

Number Tandem Repeats

– Results to national database

– Other techniques as appropriate

• Done at RCM

Laboratory notification

• HPA

– Via CoSurv from laboratory that identifies a

positive culture

– Confirmation of positive from RCM within 24h (1

working day) of receipt

– RCM reports culture and susceptibility results to

MycobNET within 24h of report to clinician

PCR detection of MTB

• Not routine

• Available from RCM for particular samples

– High suspicion

– Definitive diagnosis deemed to be urgent

– Liaise in advance – Consultany Microbiologist to

RCM

Immunodiagnostic tests

• Interferon γ (QuantiFERON-TB Gold)

• Activated specific T-cells (T-SPOT.TB)

– Standard under development

• Which patients?

• How long should it take?

• Who provides it?

• What do the results mean and who interprets them?

Histopathology

• Report within 3 days of receipt

• Inform the Microbiology service

– Ensure same reporting as for positive microscopy

and culture results

• Send autopsy samples to Microbiology

without formalin!!

• [Role of PCR to be determined]

Implementation of standards

• Local responsibility

– What is done where?

• Microscopy; culture; identification

– What throughput is needed?

– Equipment – cost-effectiveness

– Personnel

• Maintain skills; CPD; peer review

• Named individuals for advice

• Back-up and cover

– IQC, EQA

Standards for Quality

Only do what you can do properly!