FOREWORD
This document has been drawn up by a committee appointed by The Swedish Society for Medical Microbiology. It is intended to give a professional, clinical and microbiological perspective on health care and infectious disease control. This document can serve as a basis for discussion about the contents and design of activities within microbiology as well as which professional direction the posts of clinical bacteriologist and clinical virologist can have in the laboratories run by the county council.
April, 1998
Urban Forsum
Chairman
The Section for Medical Microbiology
The Swedish Society of Medicine
Address:
Professor Urban Forsum
Department of Clinical Microbiology
University Hospital
S-581 85 Linköping
Sweden
INFECTIONS AND COMBATING THEM - A GLOBAL PERSPECTIVE ON THE EVE OF THE 21st CENTURY
In the last few decades, new and reemerging infectious diseases have begun to appear in different parts of the world. The significance of reservoirs in food supplies and the environment has increased, and this implies new threats to public health. To identify the pathogenic contagions and chart their characteristics necessitates an international collaboration that could not have been previously predicted.
WHO and the United States government, among others, have identified treatment measures, as well as a number of efforts which are necessary to stop the spread of emerging infectious diseases. It is imperative to strengthen surveillance systems and border control between different regions, both internationally and nationally, to use modern information technology for early warning systems, to increase research efforts in order to manage diagnostics and treatment, to understand causal connections, to develop vaccines and diagnostics, as well as, work to increase public awareness of the risks of these contagions.
In this perspective, it is urgent to ask the question where Swedish microbiology stands today and how we can best use our resources to meet the very real threat presented to public health by both emerging as well as reemerging infectious diseases.
CLINICAL MICROBIOLOGY IN SWEDEN
Background
In the 1960’s and 70’s in Sweden, clinical microbiological laboratories were expanded so that practically all university hospital and county hospitals, or equivalent thereof, now have access to clinical microbiological service. The reason for the expansion was the realization of the importance of infectious agents in medical care and consequently, the need for having expertise available in microbiology. Through this investment, Sweden and the Nordic countries as a whole, have become a model in the world for how infectious diseases and inadequate hygiene should be combated.
There is an evident need for maintaining high competence in the fields of infections and infectious disease control, at the same time as the technological and economical development during the 1990’s has created new conditions for clinical microbiological service. The directors of clinical microbiological laboratories have therefore reason to consider how one can use laboratory resources for diagnostics, hospital infection control, research and teaching, in the most cost-efficient manner possible. The necessary technological prerequisites for services by laboratories change rapidly and at present, there are greater possibilities for decentralized diagnoses in close proximity to patients, as well as high volume analysis with measurement "platforms" which can be used for the needs of several different specialties. Competence in microbiology must be continually emphasized and developed, but at the same time, costs have to be reduced and high standards maintained. With this objective, and with the help of technical and methodological advances, we will meet the challenges in microbiology at the turn of the century.
Clinical microbiology - content and tasks
Present structure and work assignments
Clinical microbiology is comprised of clinical bacteriology, clinical virology, parasitology and mycology as well as hospital infection control. At present, clinical microbiology consists of two specialties: clinical bacteriology and clinical virology. Diagnostics are run by university/regional hospitals, county hospitals, and within primary health care at local laboratories. In addition, microbiological diagnostics are performed at a couple of private laboratories.
Specialists in clinical bacteriology or virology lead the work and focus on 1) diagnosing and interpreting laboratory data as well as providing expert advice to colleagues at clinics, 2) test follow-ups and evaluations, 3) hospital infection control and epidemiology, 4) validation of the importance of analytical results for the health care situation, and 5) communicable disease control in cooperation with units for the same.
In the last five-year period, the operations of medical laboratories have gone through considerable structural changes, and have been subjected to great demands for cost reductions. Such demands have been accomplished by, for example, increasing efficiency in the handling of analyses, better utilization of available facilities, increased automation/computerization, and in some cases, through the consolidation of laboratories. Access to molecular biological methodology has also provided greater possibilities to identify infectious agents as well as to find genes which, for example, carry resistance to antimicrobial drugs.
Perspective on the future
A main task for the specialist in microbiology is to pursue and lead development of microbiological diagnostics. The specialist has an important role in the development and introduction of medically relevant methods as well as the validation of these. Molecular biological technology offers great possibilities and there is a larger need to introduce such diagnostics. The clinical microbiologist will need to be increasingly competent in the field of molecular biology as well as the in the fields of technology and computers. A larger part of diagnostics will be run with commercial reagents and testing kits and patient self-diagnosis will surely become a reality. This will place greater demands on validation and quality assurance. Bacteriological culture diagnostics still have, however, a prominent position and within the next few years, will probably not be replaced by automatized methods. On the other hand, an increased automation and concentration of serological diagnostics is anticipated.
Another important role for the specialist in microbiology is that of consultant in order to:
A third function is supervision and quality assurance of the diagnostics in close proximity to patients which is run by primary health care. External quality assurance panels distributed by Equalis have discovered great inadequacies, for instance in the case of diagnosing urinary tract infections. The clinical microbiologist is needed for quality assurance of the diagnostics. This can be done through continual staff training at local laboratories as well as through follow-up and control of diagnostics which are run there.
The fourth function is research and education. This forms the foundation of all microbiology and must be seen as an absolutely necessary investment for the future. Research is needed to further our knowledge about contagions, to chart their pathogenic qualities, to understand the pathogenical mechanisms, shed light on the interaction between contagion and host, gain insight on methods of treatment and resistance mechanisms. Basic education in microbiology, as well as advanced courses, should be a part of training in a number of health care fields, for example, physicians, dentists, nurses, biomedical technicians, biomedical PhD’s and microbiologists. In addition, it is important to inform and educate other health care staff within inpatient as well as outpatient care in matters related to microbiology, to share relevant microbiological knowledge in such diverse areas as food-, water-, and construction-issues, emergency services, travel medicine, and international health. Research and basic education are run primarily at the country’s educational centers, but all those with microbiological competence have a responsibility to educate within health care.
Clinical microbiology - present situation
Clinical microbiological diagnostics are run today under the auspices of the county council or at private laboratories. The county council runs microbiological diagnostics at three levels:
The private laboratories run diagnostics equivalent to the county hospital laboratories. For confirming diagnostics and specialized diagnostics, regional laboratories are used as subcontractors.
Clinical microbiological laboratories at university hospitals
University hospitals should, according to current understanding, offer practically complete medical service to residents in larger geographic regions. It is therefore obvious that university hospitals should have as complete clinical microbiological service as possible. University hospital laboratories must be at society’s disposal with relevant research in order to meet the threats which were mentioned in the beginning of this document. Laboratories should play a prominent role in renewing methods and introducing new research findings in diagnostics as well as actively working so that new findings in infectious disease control and epidemiological research will be utilized by health care.
Clinical microbiological laboratories are also necessary at county hospitals
It is increasingly common that patients with lowered immune defense (due to treatment of a disease or the disease itself) are entering health care and many patients go through advanced intensive care treatment. The problems related to infections are great in these patients and an adequate treatment of infection is often of vital importance for the patient’s survival. Through an often uncritical use of antibiotics the development of resistant bacteria has increased and the risk for spreading of multiresistant bacteria is today a reality and a threat. Health care’s most effective weapon in this struggle is an adequate surveillance of resistance and a well prepared policy regarding antibiotics. Proximity to diagnostics is also an important prerequisite so that tests can be taken at all. An increased centralization may impair the surveillance of resistance to antimicrobial drugs.
Why clinical microbiology at county hospitals?
Microbiological diagnostics at county hospitals - which activities
The bacterial culture diagnostics form the foundation for a microbiological laboratory’s activities. Bacterial culture diagnostics are largely manual with reading and judging of each agar plate. Economical gains due to centralization of parts of these diagnostics are most likely marginal. Any possible profit can lead to impaired service because large parts of the bacterial culture diagnostics are dependent on proximity to patients and clinics. Blood, wound and CNS cultures are some examples where prompt reporting of positive findings as well as evaluating of findings by experts in microbiology is of vital importance for adequate treatment.
So-called rapid diagnostics of, for example, RSV and rotavirus should be performed at county hospital levels and the result has a crucial role in the care and treatment of the patient.
Hepatitis and HIV diagnostics can be automated and adapted for centralization from an analytical point of view. On the other hand, there is flexible equipment today with random access possibilities which makes cost-effective analyses possible to perform in smaller volumes. The analyses can be coordinated with other medical laboratory specialties which accounts for the fact that hepatitis and HIV diagnostics are run at the county hospital microbiological laboratories. These diagnoses are sometimes urgent and are associated with the need of interpretation of the analysis results and with advisory service, which is why physicians with adequate competence must be on the staff. Analysis equipment can also be used for other bacteriological and virological serology which should then be performed locally.
Testing of blood products regarding hepatitis B and C, HIV and HTLV I/II can be performed at the microbiological laboratories, or alternatively, the laboratory can provide competence for blood transfusion services.
Less frequent serology as well as clinical immunology can on the other hand, with advantage, be centralized but can also, depending on local competence and the wishes of clinics, be performed at local laboratories.
Mycobacteriological diagnostics as well as mycology should be concentrated to certain university hospital laboratories.
ORGANIZATIONAL FORMS FOR CLINICAL MICROBIOLOGY
The demands for cost reductions in health care have been largely focused on the area of medical laboratories. The Stockholm area, especially, has been subjected to much competition with the bidding of medical laboratory diagnostics to primary care and private practitioners which has resulted in considerable cost reductions. These have, for instance, been acquired through the consolidation of laboratories and formation of medical laboratory centers. In 1993, there were five county council microbiological laboratories in Stockholm as well as three private laboratories. Today there are only three county council laboratories in clinical microbiology (bacteriology and virology) within the two medical laboratory centers and two private laboratories.
Different organizational forms for the test-related laboratory activities are being discussed and tried. At several university hospitals these activities are organized in a so-called division, headed by a division director, doctor or person with another background. In these organizations, every specialty is represented by a director of operations. Clinical bacteriology and clinical virology sometimes constitute separate workings but can also be organized together in a common clinic. At certain county hospitals, medical laboratories make up one clinic and at others the operations are run in the form of separate clinics.
Those demands placed upon reducing costs imply that possible profits of consolidation must be taken into consideration and utilized. Profits of consolidation can be attained with joint transport and customer organization, joint testing offices and test sampling centers, as well as joint computer systems with a customer and patient database. In some organizations, although probably not all, profits of consolidation can be attained through the joint using of analysis equipment in so-called production platforms.
A necessary condition for these consolidated organizations to maintain their quality in diagnostics is that doctors within the respective specialties have the medical responsibility for the analyses which are performed in the production platforms. It is important that the consolidated parts comprise, and are experienced as, a common unit and that the activities are not devoured by, for example, the clinical chemists. The director of the medical laboratory operations can be a clinical bacteriologist as well as clinical virologist, clinical chemist or clinical immunologist. Independent of organizational form, the clinical bacteriological and virological specialist competence must exist, with responsibility for microbiological diagnostics and its development, for expertise in maintaining optimal microbiological diagnostics and test sampling, for interpretation and judging microbiological findings, for sharing microbiological knowledge with clinics as well as bringing about the scientific use of antibiotics and running hospital infection control.
CLINICAL MICROBIOLOGY AND HOSPITAL INFECTION CONTROL
Activities within hospital infections
There is international consensus on the components which should be included in hospital infection control. These are listed below.
Placement and competence
The area of hospital infection control, as related to clinical microbiology, must be strengthened. Hospital infection control require microbiological laboratory support so that emergency examinations can be initiated without delay, epidemiological identification work can be performed, teaching with laboratory experiments can be held for all types of personnel and continual technical control of equipment can take place. It is up to the head of the county council or municipality to make sure that the microbiological laboratory is actively used. This can be controlled by, for example, agreements which specify the level of service and necessary qualifications. Because a close collaboration between hospital infection control and the microbiology laboratory is necessary, the hospital infection control unit should be placed in, or in connection with the microbiological laboratory. Most appropriate is that the hospital infection control physicians (primarily, specialists in clinical bacteriology or virology with adequate advanced knowledge of hospital infection control) have their base by the clinical microbiology laboratory. There should be at least one hospital infection control unit per present county council and there should be hospital hygienists and infection control nurses at the hospital infection control unit. There should be full-time hospital infection control experts at regional hospitals/university hospitals and the training of researchers is desirable. There should be a physician competent in hospital infection control even at county hospitals.
FUTURE AVAILABILITY OF CLINICAL MICROBIOLOGISTS?
Background
The average age of clinical bacteriologists is over 50 years. Virologists are somewhat younger. At present, there are 6.5 bacteriologists and 8 virologists in residency. In the foreseeable future only 1-2 new residencies are being planned. There are approximately 90 posts as specialists within bacteriology and 35 in virology. 24 new clinical bacteriologists and 6 virologists are needed up to the year 2004, if only inevitable retirements are taken into account. The discovery of new contagions and increased resistance to antimicrobial drugs will at the same time, convey greater need for microbiological competence. It is therefore likely to be most economical to increase the number of clinical microbiologists from the present level.
Consequently, the situation is disastrous, especially in clinical bacteriology. How the present situation has arisen and what can be done to strengthen the clinical microbiological specialties is analyzed below.
How did the present situation arise?
Cuts in finances
All health care has suffered from budget cuts. We have no immediate evidence that microbiology has been affected more than many other specialties, but because of their character, activities in microbiology have been exposed to competition in a way other specialties have not. Bids on different tests have been collected from private and county council laboratories. During purchasing, prices have been the most important factor and consideration has not been taken to the public laboratory’s responsibility for education, quality control, epidemic follow-ups and unusual diagnostics. The prices which have been set have implied overexploitation of existing competence and often, there have not been economic provisions to establish posts in education.
The work at many microbiology laboratories has also changed through the cuts; developmental work has not fit in within the economic framework and there has not been enough time for the clinical contacts which are vital for the continued existence of the specialties.
Location of residencies
Most of the residencies exist at university hospitals. A handful (we are not sure how many) of those who have become specialists in bacteriology and virology are not working today in these specialties, despite the fact that there are vacant posts.
One of the reasons for this is the specialist’s confined mobility. The specialist has served five years as resident after certification and is often well-established at that location, and therefore, reluctant to move. University hospitals do not have posts for everyone and those who must stay in the university cities often change their fields.
Recruitment to the specialties
Many are recruited to the microbiological specialties by way of research, either by the fact they performed basic research in microbiology at an early stage, or clinical research. Some specialists come from infection or pediatric specialties and become interested in microbiology during their residencies or while they do research. Fewer residencies at divisions for infectious disease and less funds for residents in microbiology influences the number of specialists in microbiology. One can neither exclude the fact that education in microbiology has possibly not managed to interest students.
How can the situation be changed?
More resources
More residencies must be created. Education and development must be freed from competition - either through the fact that residencies are created, or by for example, a certain part of diagnostic revenues, even at private laboratories, goes to education and development.
Residencies at laboratories which will be needing specialists
In order to recruit doctors, it is appropriate that residencies are located at hospitals where vacancies are expected. One cannot expect that county councils in university cities will take economic responsibility for education of specialists for the rest of the country without compensation.
Finances for supplementary, necessary service at larger clinics must be available for those who have residencies at smaller laboratories. One can also consider exchange of doctors between different kinds of laboratories during schooling. University laboratories can offer guidance for research and develop projects which can be placed at smaller laboratories.
Residencies must exist at the laboratories, since such provide much of the clinical thinking and increase understanding between specialties. Doctors with long clinical experience are invaluable as laboratory specialists and those with combined specialties, for example infection/microbiology should be encouraged. Combined posts could be considered.
Programs for residents
The committee for education in the Swedish Society for Microbiology has outlined programs for residency within clinical bacteriology and clinical virology. The training is partly overlapping, so that one has basic knowledge within each respective specialty, but the field of competence in each specialty has been judged to be too large to merge these educations. Desirable courses in the specialties have been specified and other forms of classes considered because resources from the Swedish National Board of Health and Welfare are insufficient. Clinical microbiology procedures handbooks exist and the function of training supervisor has begun to be improved. Consequently, we believe that a good foundation for specialists in clinical bacteriology and clinical virology has been laid.
SUMMARY
The need for microbiological competence is large, at county hospitals as well as at university hospitals. Competence is necessary to guarantee high quality microbiological diagnostics, good epidemiology and activities within hospital infections. Flaws in these functions can be very expensive for health care.
Clinical bacteriologists and clinical virologists must continually develop and evaluate methods for microbiological diagnostics and surveillance in order to be able to meet new problems in the field of infection and to be able to adapt the microbiological workings to current needs in health care.
In recent years, severe budget cuts have taken place in medical laboratories, mainly through consolidations and structural reorganizations. When new organizational forms are tested it is of great importance that the specific microbiological competence is maintained.
The number of specialists in clinical bacteriology and clinical virology must be secured. The county council and private laboratories must take responsibility so that enough residencies are established.
REFERENCES