Microbiologist and his working DomainsThe present day clinical microbiologist attached to a

Microbiologist and his working DomainsThe present day clinical microbiologist attached to a hospital is expected to work in two domains.One domain is lab component another is in hospital area. The first Domain involves accurate lab diagnosis of infections,mainly the bacterial ones by reporting on antibiotic sensitivity to clinicians. This he will do as a team involving technicians and support Staff.Another domain is role in hospital the work is supposed to be infection control and antibiotic guidance going by international guidelines He is generally satisfied with his role, in the first domain,While in second domain he is not satisfied with his performance ,sees many hurdles , many grey areas.So generally he is not happy , and even starts blaming others or system. Many international groups are talking about success of antibiotic prescription guidelines-antibiotic policy or implementation of it and Antibiotic Stewardship programs,(AS) .In our country , He is already given up and convinced about failure of As considering high degree of multi drug resistant bacteria .Concerns of present day clinical microbiologist in infection Control (IC)1 Feels left out in IC- lack of provision of infection control nurse by the hospital, lack ofstructured training in IC practices etc.2 Faces non cooperation of clinicians3 Feels that hospital administration is not supporting him in IC activities.Are the concerns of Microbiologist are genuine?However these concerns are sometimes genuine but many a times is due to pessimism built around him by himself.Also he should realise the two domains of his are interdependent , synergy is required if he has to achieve some degree of success in second domain, first he should relook in to the first domain.Is he getting right samples, is he generating meaningful report s to clinicians, whether he presents his antibiogram periodically in clinical forumEtc . Most important does he takes feedback from clinicians on sample processing and reporting. Does he practice in his culture sensitivity report,some sort of restrictions in antibiotic prescriptionsAntibiotic Stewardship should Start from hospital LaboratoryAs one of our international colleague incisively remarked in one of the digital platform that AS should Start from the laboratory. Very well said and time for introspection required by we the microbiologists.For this program there should be actionable AP. Why there is failure ofImplementation in spite of so many excellent learning materials available ?Why there are many non-starter hospitals in AP and AS?Is it really impossible? 2What attributes should there in a microbiologist for hospital to succeed in AP & AS.I will illustrate the stories of Five kinds of microbiologists, then let us reflect on what has gone wrong with us and how to improve.Microbiologist AGood in bench bacteriology, serology QC practices. Attends CMEs and conferences on antibiotic policy when ever opportunity is there..Collects all literature relevant to AP,AS including international guidelines on varoius IC practices and systematically files. In the lab releases the AST as per SOP with out any explanatory comments in the Report form.Spends all working hours in lab Does not part step in to hospital premises., Not in the habit of sharing lab information in clinical Forum.Microbiologist B Similar to Microbiologist A, collects information on AP,AS , guidelines on IC practices. Attends a CME on antibiotic Policy .The hospital has no infection Control Nurse. On hearing about high end antibiotic restriction gets enthused comes back to the lab the next day and starts restricting about ten high end antibiotics based on AST meaning not mentioning in the Report form .Over a period of time ,He became so strict that pharmacy started complaining that many antibiotics in the Shelf are not getting utilised, Clinicians also start airing their concerns that their prescription freedom is heavily curtailed .Based on clinians in put ,Hospital administration got the restriction lifted on all high end antibiotics Microbiologist now continues to report sensitivity for all antibiotics.Microbiologist CAlso a good bench microbiologist.Attends CMEs, workshops on antibiotics and bugs but selectively.Collects information on various national and international guidelines , but recommends after modification if need be depending on local AST data available to him from the excel sheet and discussion in the clinical forum.. Also confident to present AST data to clinicians and administration when asked. Tries his best to answer queries.He does not go on infection rounds. Infection Control Nurse is not available in Hospital. He asked for one , but hospital said to utilise existing Staff nurses for IC purpose.He advises on antibiotics prescription when asked only by clinicians. Checks with ward in case of doubt about bacteria isolated is pathogen or not by eliciting patient history. He prepared a protocol for screening patients transferred from other hospital for screening nasal swab for MRSA. He also prepared an Antibiotic Justification form and sent to hosp administration for acceptance so that clinicians can fill with justification for high end antibiotic. Both screening policy and antibiotic justification form were turned down by administration.Microbiologist DGood bench microbiologist. Has good knowledge of infection control practices.experienced, well versed in clinical pharmacology of antibioticsBut he finds that instead of interpreting Culture Sensitivity report , some clinicians were practising irrational antibiotic therapies.His clarification did not yield any results.Also doctors were not interested antibiotic sensitivity data presentation, when wanted to take a class on sample collection for culture like blood, urine,pus for new doctors, they too did not 3volunteer saying they are busy in ward.But the microbiologist was not relenting with hospital administration was able to present in well attended clinical forum sensitivity data of bacteria and stressed the need for Rational prescribing of antibiotics,He also took a class on need for proper sample collection for MicrobiologyMicrobiologist EHe is also well trained bench microbiology techniques. He is having ten years experience in IC practices, he proactively presents Six monthly antibiotic Sensitivity in clinical forum, volunteers for investigation and management of difficult to mange infections .Issues advisories periodically regarding MRSA /VRE screening,protocols implementation of H1NI categorisation during outbreak. Seeing no IC nurse involved in training .He identifie with the help of hospital administration a motivated staff nurse to take up IC.He works in tandem with IC nurse and goes on IC rounds. Helps IC nurse in organising training program also participates actively by taking few classesHe studies antibiotic prescription practices, prepared a n antibiotic Justification (AJ )form having a list of high end antibiotics with a spaces to fill details by clinician on justification, clinical diagnosis, culture ,sensitivity data to support.He was also active in monitoring antibiotic therapy of ward patients and to alert clinicians when to stop antibiotics. He is also involved in quality assurance practices of not only lab but also Hospital and developing StandardsDiscussionMicrobiologist A and B are not proactive and nonstarters and administration was not helpful.they have no IC nurse.But what is lacking is lack of aeertive attitude .May be by constant persuation of higher ups in Hospital these Microbiologists would have implementated AS &IC practices.In Antibiotic Stewardship programs of the Microbiologist should be the driving force.He may face varoius hurdles in Implementation of AS but should be patient enough to to persuade the administration and clinical Heads byrepeated representations. .It may take time but ultimately he will be successful as seen in Microbiologists D and E. Microbiologist C is also proficient , But having a single negative reply from administration .He was content to give up! .This type of scenerio is commonly seen .But they also can scale up the ladder by repeated representation to administration of Hospital,. .Ithis skill comes by experience and not willing to give up attitude.Note that Category D and E are having some dgeree of experience.Iam not stating all freshers are non starters but experience and interaction with peers teaches a lot of lessons and helps in problem soving in difficult scenerios.So let us be assertive and be optimistic to achieve success In AS.Conclusions. Time has come for us to should shed pessimism and recognise ourselves as more as a clinical speciality., This attitude helps to work towards persuading hospital administration, mobilise clinician opinion towards achieving success.microbiologists should seize the opportunity towards giving more time to clinical areas, do IC rounds, win clinicians confidence, such proactive microbiologist will go along way in executing AS in a way appropriate to the local problems and in an evidence based approach. I am confident such pool of microbiologists with their team as a new department rightly called as Infection and 4Prevention Advisory Services (IPA),will definitely help to mitigate AMR and offer best advice in AS. Also by constantly reading getting updated in the field of clinical pharmacology of antibiotics,including use of judicious combinations, new antibiotics etc they will be able to offer ultimately the best management of infections even with highly antibiotic resistant bacteria.

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