Let's Talk Micro
TBT: Respiratory cultures
[MUSIC PLAYING] Welcome to Let's Talk Micro. Hello, everyone. Welcome to another episode of Let's Talk Micro. As always, I hope you had a great week. And you can always find Let's Talk Micro on Apple Podcasts Spotify, Google Podcasts, Amazon Music, Pandora, Stitcher, Tune in Radio, Good Parts, whatever you listen to podcasts, you can find Let's Talk Micro. As far as social media, I am on Instagram as Let's Talk Micro, no apostrophe, on Twitter as Let's Talk Micro 1, on LinkedIn as Louise Plaza, and I am also on TikTok as Let's Talk Micro. So go ahead and subscribe to the podcast. That's always very important. If you subscribe and you listen to the episodes, make sure you go ahead and rate them. Leave some feedback. That's always good for the podcast. Also, any suggestions, any possible topic suggestions? Anything at all. So feedback, suggestions. They are always welcome and appreciated. So you can use any of the platforms that I'm on. And leave the feedback and always just rate the episodes. And thank you for listening. I always like to post pictures of organisms and give updates as to when the next episode is coming out. So definitely stay tuned via social media. And if you haven't listened to the previous episode, go ahead and do so. Last week, I released an episode about Wolfhard Timonas, Kennie Klastica. And it was a great episode, a great conversation with Dr. David Gaston and Dr. Yember Amad. Our other case of Wolfhard Timonas, Kennie Klastica, we talked about biochemicals, morphology, susceptibility, and so much more. It was a great episode. And then this week, I released a re-release an episode that I had released on February of this year about Wolfhard Timonas, Kennie Klastica. That one was an interview with Dr. Paul Luthney from the University of Maryland Medical Center. And I re-released it so you could compare and contrast both cases. One was a monomicrobial. In nature, the other one was polymicrobial. They were identified via two different MS platforms. So overall, two great cases. So I re-released the other one so they could be together when you're looking for podcast episodes. And you can have them side by side. And just learn more about this very fascinating organism. So if you haven't listened to either of them, go ahead and do so. And today is a great episode. This one is really tuned for the medical laboratory scientist that I work in on microbiology. And it is about respiratory cultures. So in this episode, Dr. Andrea Princey joins the podcast to talk about respiratory cultures. Great conversation about sources. You know, what types of respiratory cultures do we have in the lab? About pathogens, about sputum rejection, about the significance of yeast in respiratory cultures. Those of you that are involved with micro that are active in social media with different microbiology pages. You know that Dr. Princey is very active in the microbiology world. You know, she is a microbiologist, always sharing information and publishing articles. She is a great guest. And then she was a previous guest in this podcast on a great episode about breakpoints, about susceptibility breakpoints. If you haven't checked that one out, go ahead and do so. But overall, great information. That way, hopefully we can maybe answer some questions that we as medical laboratory scientists have when we are working on the respiratory bench and dealing with all these organisms. So I really enjoyed recording it. I hope you enjoy listening to it. So let's go ahead and listen. So today's episode, we are talking about respiratory cultures. I know this is a great topic. Those of you that work in the lab, you definitely sometimes, you know, I have questions from fellow technologists asking about, maybe you can find out why we do some things we do. Maybe we can shed some light. So basically understanding the whole process about respiratory cultures, you know, pathogens versus a referential flora. That way, as we work in the bench, we can have a better understanding of the whole process. So with me today, I have a great guest with great experience. She has been in this podcast before on an episode about breakpoints. So with me, I have Dr. Andrea Prinzi again. Dr. Prinzi, welcome to Let's Talk Micro. - Hey Louise, thanks so much for having me back. I love being here. - Definitely my pleasure. You know, that episode was great. And like I said before, through social media, you know, I love the fact, you know, the energy you put into this profession and sharing information. And I definitely appreciate the work you do. And I was very happy when I asked and you agreed to come back here. - It's my pleasure. And honestly, thank you for all the work that you do. I love your podcast and I think it's really fabulous. So I hope lots of people are listening. - Yes, and if you haven't listened to it, you haven't checked it out. And this is your first time listening. Yeah, you can, it's called Let's Talk Micro and you can find it on all podcast platforms. So since, you know, it's been a while since you've been here, can you introduce yourself against, again to the audience, please? - Sure. So I, I'll keep it pretty brief here, but I am a clinical microbiologist by training. I was a med tech at Children's Hospital Colorado for many years, almost 13 years. While I was there, I went and got my masters in public health and epidemiology. Did many more years of work in the clinical lab and then ultimately went and got my PhD in clinical and translational science, which I finished in like December or January of 2022. So pretty recently. All of my work in that PhD program really focused on diagnostic stewardship of respiratory diagnostics and mechanically ventilated patients. So I've spent a lot of time thinking about things like pneumonia, respiratory cultures. And in fact, we just wrapped up a study not too long ago here that looked at reporting from respiratory cultures. Specifically tracheal aspart cultures and the impact that has on antibiotic prescribing. And that was just published in Journal of Clinical Microbiology this month. So very excited about that. - Yes, you know, I, I, I rather than it was definitely a great article. So for you, the audience out there, if you go, you know, just ASM microbiology and even if you, if you type, you know, because I tried this before like Andrea Brinzi, ASM, you know, I post a list of the articles and this one was very recent. So if you go to a Journal of Clinical Microbiology, you can find it there. Okay. Well, let's go ahead and start with an overview of the types of respiratory cultures. So this is something that they may be some variants from lab to lab as far as the how they order this place but you have different types of respiratory cultures. So let's go ahead and talk about those. - So I'll, I'll start all of this off by saying, just like you just touched on, there's a lot of variability with respect to these cultures and how things are ordered and processed. So definitely keep that in mind as we work through this topic is that it's, that's the biggest challenge with these kinds of cultures is that there's a ton of variability on the laboratory side, right? So just keep that in mind. I would say that if we start with, I think sputum versus like endotracheal aspirate is a good place to start, sputum specimens are kind of the classic ideal specimen for diagnosis of pneumonia. So this is mucus from deeper in the lungs and it's not the same as saliva or spit. It's a much deeper specimen that is produced in the lungs typically when someone has an infection in the lungs. So this can be pretty diagnostic if you get a good sample. Adults are usually able, if they really do have something going on like an infectious process, they're able to cough this up pretty readily. But in children, we actually have a much harder time getting sputum. So if you work in a pediatric hospital, seeing an actual sputum from a child is pretty uncommon unless they've done what's called an induced sputum kind of procedure. So we don't see sputums as often from children unless there's been some sort of like induction there. Tracheal aspirate samples are taken from patients that are on mechanical ventilators. So patients that are typically very, very ill, critically ill in the ICU and are unable to breathe on their own are put on ventilators and that machine is doing the breathing for them and they will have a tube inserted down either their trachea or put, well, it's always through the trachea but it's either inserted through the mouth, sometimes the nose and itty-bitty babies and sometimes surgically implanted through an incision in the front of the throat. That's called a tracheostomy. Either way, this breathing tube goes down the trachea and then deeper down closer to the lungs. Once those people, once those patients are ventilated and this tube has been in place, mucus starts to build up down in that tube and it's believed that what gets suctioned down from deep in that tube might approximate what's happening in the lungs and so a sample will be collected from that tube to assess for possible infection if the patient looks like maybe they've developed pneumonia while they're on a ventilator. These specimens are pretty tricky and very challenging because it's really hard to differentiate between colonization and infection and we can talk about that more a little later if you wanna do a deeper dive into that. The other specimen to think about would be a BAL or a bronchial wash. So bronchial alveolar lavage is a BAL. That is a specimen where they have gone down during a bronchoscope procedure and flushed a bunch of saline through the very tiny spaces in the lungs or the alveolar spaces and collected a specimen out of there. A bronchial wash is a little bit different and they're typically getting the sample from larger lung spaces. So you get different things from each of these procedures but in the lab it's really not possible for us to tell if it's a bronch wash or a BAL unless it's labeled as such like just by looking at the specimen you're not able to tell. They just look like a whole lot of saline in a sterile container. So it's important that those get labeled appropriately. I think we had talked about touching on like esophageal brushings. Those are a little, I don't wanna say less common but for infectious diseases we don't see those quite as often those are typically I think being collected when they're looking for causes of inflammation in the esophageal area. And so we used to see these a lot when I worked in pediatrics especially if they thought that the patient maybe had thrush or like a Candida. I guess infection is the word maybe I wanna use but if they thought there was Candida there these are, this is like a very different specimen type than the other three I mentioned and use a little less often for infectious etiologies. And then cystic fibrosis cultures are a totally different type of respiratory culture specifically ordered in patients that have cystic fibrosis and a sputum is typically what you're getting from those patients. They can produce a lot of sputum because they frequently get infections and are not always able to clear this mucus. So there's usually a lot of that kind of material present. We can also get BALs from these patients but that workup looks very different because the pathogens in those patients are quite different. So there's actually a very specific set of organisms you're looking for in the cystic fibrosis population that is not the same as someone without cystic fibrosis. So different media types are used when those cultures are set up. It's kind of a brief overview. Did I get them all? Let me say (laughs) - Yes, yes, you definitely did. And definitely our great information and now that you mentioned for the cystic fibrosis. So for the audience on there and definitely texts that work in micro, you're familiar with this, but basically your standard respiratory culture set up, it gets blood, it gets chocolate, it gets maconky. And then when you have patients that you get cystic fibrosis cultures order, they add a manitose salt auger for staph aureus and they also add a cepesia auger for boracoldaria cepesia. But we'll talk more about pathogens in a second. So that is actually bringing my next question. You mentioned pathogens and a set of pathogens for cystic fibrosis. So let's talk about the major pathogens in respiratory cultures, let it be your regular respiratory cultures or your cystic fibrosis cultures. - Okay, so this is also not quite as straightforward as one would hope because some of the organisms that we know cause pneumonia may also be opportunistic organisms. So I will touch on that a bit. But if you just refer, for example, to like the reporting guidelines from the clinical microbiology handbook from ASM, they outline very nicely the organisms we should think about always reporting. Then the organisms we should think about reporting depending on pre-dominance in culture or gram state. And then the things that we probably should never be calling out or reporting. It's all just touch on some of those just according to those guidelines so that it's a little more data driven in not just my opinion, which could be biased, right? So the guidelines recommend group A strap, although I think some folks might say, you could certainly be colonized with group A strap and not be sick. Group A strap is something that's always recommended that we report from a respiratory culture. So I think a lot of operating procedures in the lab will recommend that if you see this pretty little clearish gray colony with a large zone of beta homolysis that you would sub that out or try to make sure you roll out group A strap. Group B strap in the pediatric population, it's actually recommended that you do identify and report that. And then all sorts of things that maybe are pretty unusual but that would be important to identify. So things like Francisella Tularensis, we're really not actively looking for that in respiratory cultures. But Clint Micra handbook does recommend that we always report it. For obvious reasons, patients could have a pretty severe respiratory focus infections with Francisella Tularensis. Things like your cinnia pestis and nocardia and bacillus anthracis. I mean, so these are things that we really don't see all that often, but that you should kind of have in the back of your mind. And if you saw potentially report. Now, the ones that we think of most often with respiratory disease are the ones that we also need to be careful in terms of just reporting no matter what. So these things would include like streptococcus pneumoniae, for example, a major, major pathogen can cause very serious disease, but also normally colonizes the oral pharyngeal space. So clinical Micra handbook and ASM will recommend, you know, report this organism if in significant amounts. So usually that means like few or more or three plus, maybe two plus three plus of this organism and making sure it was seen in the gram stain. So that's also true for organisms like homophilus influenza, which is used to be an enormous pathogen, but less so after the vaccine came along. Moroxelicateralis, Staphylococcus aureus, Pseudomonas aeruginosis, a big one. Cenetrophomonas multifilia and things like Acenetobacter and Berkeldaria. Now, Acenetobacter, Berkeldaria, Stenotrophomonas, we see those a lot less often in patients that do not have cystic fibrosis, but we would think about those organisms more in patients that perhaps have been on a ventilator or have something in place where that colonization could occur and then they're more at risk of acquiring these kind of aggressive, resistant gram negative organisms. But again, whether or not those are acting as a pathogen will really depend on the clinical picture of the patient, what we see in the original gram stain and the quantity or predominance on the plate. And then we have to be really careful with organisms like beta-hemolytic streptococci that are not group-based rap, for example, or endobacter alleys that are in rare quantities are not seen on the gram stain. These bugs can seem kind of scary when we grow them in culture, but it's really important to understand that they are not always pathogens. And so that's why these cultures are really challenging because we're going to have to combine what we see on the gram stain with predominance and clinical picture to really decide if it's something we should be telling the clinician to act on. - Yes, definitely. And I can understand, yeah, how text they see something as, like you said, like you said, then drop back to realize as E. coli, where they are taught to, you know, like when you're working on other areas, you report it. So I can see why that's, you know, sometimes, you know, confuse them a little bit or, you know, understand why they are not reporting. And now you mentioned stenotrophomonas, they definitely seen a lot. And yeah, that respiratory event with all those cultures, it's definitely, it keeps the tech very busy. It just, especially in a large hospital, they are working there the whole day. And sometimes, you know, you need someone else to help them read their positive cultures because you get all these organisms. And a lot of them also tend to be multi-drug resistant. So you have all this reflex testing and well, that's another topic for another episode. So let's talk about sputum rejection. I think that's one, sometimes, you know, that the technologies they don't like because you have to make a phone call, you know, and they don't like sputums in general. And I always, I tell students and from my own experience, to me as sputum, especially the sputum gram stain, it's a perfect quality control slide because you see pretty much everything. So it's a great place where you can see gram negative double cocs, you see gram positive rods, you see gram positive cocs, you see gram negative rods, you see yeast, so everything side by side. So you can see all these organisms at once. So especially to train your eyes, to evaluate the quality of your staining, you know, for me personally, you know, it's a great sample. So let's talk about that, about the great tree for sputum rejection. - Okay, so that, so I completely agree with the complexity of the gram stain for respiratory specimens. And I think one of the most challenging things currently is with the volume of testing that's happening in laboratories and the lack of staffing reading gram stains like this can be really challenging because it feels like you don't have enough time to sit with one slide for the amount of time needed to really catch every organism in that particular specimen and get everything quantitated. So it's just exceptionally challenging across the board. I will say once again that while there are some recommendations for specimen rejection for respiratory culture, it really is going to depend on the institution, clinician preferences, the kind of bandwidth that the laboratory has, workflow, things like that. So I will highlight the kind of the current recommendations but just note that of course this is going to vary from lab to lab. There is a pretty classic paper published in Journal of Clinical Microbiology from 1982, actually, that walks through six different rejection methods for respiratory specimens and weighs the pros and cons of each. And you know, I can send that out to you, Luis, if you'd like to give that to listeners, just to reference or direct folks towards it. But the idea is to take both the presence of epithelial cells which would suggest a poor quality specimen and weigh that against the amount of polymorphic nuclear cells you're seeing which would suggest inflammation or infection and try to decide does this look like this is a quality representative sample or not. The reason we're looking at the number of epithelial cells is that if you get a sample that's more likely to be saliva and less sputum, you're going to see a lot more epithelial cells in there. And we don't want that because that's not representative of what's actually happening down in the lungs. It's just spit. It's going to grow all sorts of oral flora and you're not going to know what to do with that result. It's going to be very confusing, right? And certainly we don't want to report a bunch of streptococcus pneumoniae from a spit sample and then have a clinician treat that if that's not the problem, right? So then you also want to consider the polymorphinicular cells or the PMNs because those are really suggestive that something's going on. But what number is the right number for those? And there's a lot of different things to consider. So the current guidelines, at least the ones that are available to us in like clinical microbiology handbook, for example, is that for sputum, you should be looking at the sample on low power and greater than 10 squamous epithelial cells per low power field should be rejected. And the idea there is that that's a pretty junky specimen, it's going to be messy, it's not going to mean much clinically, we shouldn't even set it up. It's going to give a bunch of information that's going to confuse. You will see that there's this caveat to this recommendation that says if the number of white blood cells is 10 times the number of the epithelial cells and there's three to four plus of a single morphotype of bacteria except the specimen for culture. So this is where it starts to get messy, right? So you may see a lot of epithelial cells, but then there's a lot of polys and you see one type of organism, maybe it's okay. So this is where a lot of the weighing of the different factors comes in when you're looking at the Gram stain and deciding what you want to reject or accept. The other one would be for tracheal aspirates, they get rejected far less often. We actually did a study on this particular subject. We sent a survey to microbiology labs all over the United States and asked about their process for tracheal aspirate cultures from start to finish. And only if it was about 20 to 23% of labs or rejecting these specimens based on any sort of criteria. And then when we asked the labs which criteria they were using, it was highly variable. So folks were using all sorts of different criteria. No one was really doing anything the same way. So this does come with a lot of variability and will really just depend on the local setting. - Yeah, that variability, sometimes it even comes down all the way to it's interesting the way that the whole process is. And all the way from the way sometimes someone trains you and you learn and then one tech shows you how to do one thing one way. And then another tech shows you another way. It just makes it sometimes challenging for new techs coming on the bench. It's like they're learning something and then someone is telling them something else. As far as that article, yes, please send it and I'll put it on the show notes for the listeners. And you mentioned some great resources and I mentioned them also on my, when I'm talking on the podcast about the manual of clinical microbiology on the handbook from the ASM. So those are definitely great resources. If you work in the lab and I recommend for, you know, if you have the funds and if you want to, I mean, they're a little bit pricey but they're definitely great resources. So if you have the opportunity, go ahead and definitely purchase them. - Absolutely. I would say too, especially for respiratory cultures, there's not a ton of guidelines for us in the laboratory with respect to how to manage these. And then there's a lot of clinician pressure to report things a certain way. And so guidelines like from clinical microbiology handbook that specifically reference literature that helps support these particular recommendations. It's really helpful to refer to those when making the SOPs or editing SOPs in the lab just because it backs us up in terms of, you know, specimen rejection or what we may or may not report. It's really helpful to review those and refer to those as often as you can. - Yes. And now that you mentioned about the physicians, yeah, we do sometimes you know, you see it and you have certain physicians that you see it on the culture that there's always little message saying, please report all organisms, please, you know, uncover all susceptibility. So we do get those types of requests depending on who it is. - Oh boy, yeah. I would just say like, I want to give a nod to my clinician friends out there who are absolutely trying to take care often of a very sick patient, especially if this patient is ventilated. And so they're just doing what they need to do to take care of the patient. And I completely honor and respect that. I will say though, respiratory specimens are a very unique challenge, especially in like the stewardship world because it's one of these very complex specimens where we really have to think critically about what could really be causing the infection and we have to take so much of the context into account to make the decision from both the clinical side and the laboratory side. And we actually do some harm when we overreport things that really are just colonizers or if it was a junkie specimen, we see lots of excessive antimicrobial use related to that. And so I think it's really great for us to always revisit our procedures and try to follow as many guidelines as possible for reporting of organisms from these kinds of cultures. - I agree. So let's go ahead and talk about yeast. So definitely, oh no, this is one that, with the technologies, sometimes, you know, seeing it and not reporting it, it causes them a little, make them a little hesitant and the one I understand, you know, as to why. So let's talk about yeast, about it being more of flora and the significance of seeing it in the respiratory culture. And, you know, a great example is, for example, like if you see three plus yeast growing on the plates. So based on the guidelines and what, how should you report that? - So, yep, this is one that always, I know when I was training other microbiologists on this, this would always trip people up and I think as a microbiologist, like you mentioned, it's really hard if you see a predominant or pure culture of something and you're like, oh, I just feel so weird not reporting this out. I feel like I'm doing something bad if I don't report this out. What I will say is that the current recommendation and the literature really support the fact that cryptococcus should be ruled out. So we should make sure that it is not anything like that. But we should not be routinely reporting Candida species that is a recommendation through, again, the like clinical microbiology handbook guidelines. Candida actually is not known. Candida organisms are not known causes of pneumonia, potentially in immunosuppressed patients. So oncology patients, like patient with leukemia, for example, or lung transplant patients, maybe in neonates, this may be a significant actual cause of disease, but even in those cases, growth of Candida in these lower respiratory specimens doesn't really correlate with disease. And there's literature to support that. So yeast, they normally live in our mouth. Sometimes they can kind of take over, particularly if the patient's been under some sort of therapy and you might see what seem like really significant amounts in a respiratory culture. But as far as the recommendations go, what we have available to us right now is that it doesn't really align with true respiratory disease and we should be looking for something else. So again, the SOP is going to differ between laboratories and clinician preference. How that gets reported will look different. So some labs may prefer to say this is a Candida species, three plus with some sort of note that says, maybe directly from guidelines that are available. Hey, the literature doesn't really support that this correlates with disease. If you really feel like it's the cause of disease and your patient, please call us and we could do further identification, susceptibility, whatever. Maybe it's a full Denison species report because the clinicians really want that. Maybe it's simply a note that says, we grew something that's representative of normal oral or oral for angioflora. Call us if you'd like it identified. It just really depends on your institution. But I think it's important to have the background information from the guidelines that supports the fact that you are not necessarily doing anything that is not supported by the literature. If you don't suggest that this is a major pathogen from a respiratory sample. - Okay, definitely, thank you for that explanation and that helps you know, clear for a lot of texts. And that's something, you know, not only you mentioned, you know, like documents and resources, that's something always that I really advocate, especially in this podcast that, to make sure that you know what your resources are. And that's why I always mentioned, you know, the handbook and the manual of clinical microbiology. That way, you know, technologies they understand, you know, where all of this information comes from. You know, because it's always difficult. You know, you go in, you're working eight hours, you're swamped, especially under staff. So, you know, it's kind of hard to understand some things, but you know, you have your resources and I know where to look for them. And that will definitely help you with better understanding and do a better job. - You know, I love that, Louise, because I think if you've been in laboratory medicine for a while, there's this kind of this, I guess old adage that it's like, we do things because it's always the way it's been done. And so I love to, this is why I love doing research in this space because I love to try to take the challenges we face in clinical laboratory medicine and tie it back to what's happening clinically, tie those things together, keep up with the clinical literature and then hopefully revise and, you know, restructure SOPs in the laboratory according to what's happening clinically now. And so that's what I love when they update, you know, the clean micro handbook or whatever. They're always referencing whatever literature is available to us from laboratory medicine and otherwise. We want to be data driven and that's like one of the hardest things about medicine, right? Is that sometimes you're making decisions that seem a little counterintuitive. Like as a microbiologist, if you have pure growth of something on a plate from a very, you know, from a very potentially a very sick person, that feels like something we should be working up fully and putting our resources into. But we want to make sure we're, you know, designing our SOPs around available data and what we know and what's available to us in any guidelines and understand that those things could certainly change, right? With more research and development and things maybe we find that, you know, Canada or us becomes much more prevalent and we need to start making sure we're ruling that out on every respiratory culture, you know, maybe some SOPs are already built that way. So remaining flexible and I think understanding that it's hard for us on the lab side because we don't always have the full clinical picture and that a clinician does see the patient and does know what, you know, what the patient probably needs. So we're there to help guide, provide information and help formulate and support a diagnosis but that ultimately they're going to make the decision on what they need and they can always contact the lab and talk to us about what they need hopefully and we can keep lines of communication open and help work through these cultures together. - Yes, you know, definitely, you talk about change and yeah, they do change constantly and I feel like so many things have changed so much and like I like talking about my episodes, you know, especially now with instruments, you know, like with Molotov and we know we see so many names and definitely a lot of changes in micro and the organisms, you know, like how we always like to say they don't read books, they don't go to school so they will do whatever they want. So that's the way it is. So let's go ahead and, you know, we talked about sputum rejection. So I just have a little scenario and see what your thoughts are on it. So we have a sputum, it was rejected and typically when you reject it, when you discard the plates but what if, you know, the phone call was made because, you know, we have been talking here about been busy and typically the way this works, when you have things to reject and when things go wrong, it's just, it's always on the worst day. So you're probably swap on that bench, you make that phone call, you forget to discard your plates, they make it to the respiratory bench. So then the tech sees three plus, sputum on us aeruginosa, let's say. So what is the advice course of action? At this point in time, do you go back and review your smear? Do you proceed with working in the culture? I just wanna hear your thoughts on that. - This is a really important scenario and we actually thought through this quite a bit when we were doing at my old institution, we were working on a quality improvement initiative around specimen rejection for like tracheal aspirate cultures, for example. And when we were doing our literature review and trying to find data to support some of the things we wanted to do, we found that the literature really describes like good sensitivity for gram stain when it comes to gram positive organisms in these types of specimens, but not necessarily, it's not as great for gram negative organisms, particularly things like pseudomonas, which can be these like very fine, faint, kind of wimpy looking gram negative rods in the gram stain, they can be a little easy to miss, especially if there are a lot of polymers more pinnicular cells or PMNs in the smear. So we actually talked about this quite a bit, thinking through what would we do here? So for example, if we were doing, using specimen rejection criteria that involved rejecting this specimen if no organisms were detected, like so say, there weren't a ton of epithelial cells and there were some polys, but we didn't see any organisms reject. We would actually hold on to those plates because there is a chance you could be missing a predominant something like a pseudomonas that's kind of buried under these polys and the smear and you just never saw it. So in this scenario, if you look at the plates next day and there's a significant amount of pseudomonas aeruginosa growing, I mean, I think the best thing you could do is really go back and revise, review the gram stain, see what you can find, especially if it's like a moderate or heavy amount of growth, you're probably gonna find the gram negative rod if you go dig a bit harder. So if you're able to remake the gram stain or revisit the gram stain, I think that would probably be the best course of action if what you have growing on the plates does look like significant. I mean, and at that point, you would wanna correlate what you're seeing on the plates with the gram stain anyway. So it would be a good idea to go back and revisit the gram stain and, you know, I think not making any formal recommendations here, but if you went back and looked at the gram stain and did see the organism, you'd wanna revise the gram stain and probably change that report, you know, make sure things match up with the culture. - Okay, yes. You know, and that's a whole separate challenge that I have experienced in many places about the gram stain not matching the culture. So that's something that maybe, you know, I don't know, I'm not familiar, but maybe someone should either, if it hasn't been done yet, some sort of a study or see what can we do to solve that? Because it makes it challenging, especially sometimes, you know, you have a playful growth and then your gram stain says NOS, or you have, you know, gram negative roots and nothing is growing. So it makes it challenging on the workspace. But definitely thank you for the explanation for the advice and the scenario. - Sounds like a study we should, sounds like a study we should do together, Louise. - Oh, I mean, okay, let's chat. - Yeah, I think it will be very helpful because the amount of time that it's spent, sometimes, you know, going back and revising stuff. And so, yeah, it's definitely something worth looking into. So I'm definitely in. - All right. - Well, is there anything else that you want to add about this? - I would just add, you know, I think that this is a wonderful space for labs. I know labs are under a tremendous amount of pressure and strain right now, but this is a really great area for quality improvement. Just like some of the things you already highlighted, trying to improve the process for workflow and then organism reporting from respiratory cultures, I think is a really wonderful initiative for laboratories to try to tackle. I think there's some new literature coming out, especially in the diagnostic stewardship realm that really helps support this. And why I recommend labs consider doing this is because historically, like we talked about clinician pressure and a lot of pressure to maybe report things we shouldn't be reporting from these cultures. When we do these quality initiatives and collect data, it's really empowering, it helps support the laboratory and making SOP changes because academics like to see data. So if you can, you know, pull some sort of data for your processes, change something up to improve quality and then measure that in some way, that's really, really powerful and can help support your SOPs. So if you're noticing challenges around these cultures, I have lots of thoughts about, you know, collecting data on this and doing it internally. And it doesn't have to be a big study per se. Quality improvement initiatives can actually be really rigorous and tell us a whole lot and they are publishable. So, you know, I think that that's something to maybe think about. I know that's a little off topic, but just it really, the complexity of these cultures really begs for laboratories to kind of do that and start thinking about their SOPs and how we could maybe improve the processes for these. - Yes, definitely and, you know, it's challenging 'cause sometimes, you know, the situation of the staffing and everyone is moving fast, but yeah, I definitely agree with what you said. Well, you know, Dr. Prince, you know, it's been great having you again, you know, this was so educational and so informative. So I hope that technology is out there or if you're an MLS student, you're starting to study or anyone, you know, this podcast is for every audience, from a PhD to a micro student. So I hope that all of you enjoyed it because this is definitely some great information. It has been a pleasure having you here. Thank you for taking the time to come and do Let's Talk Micro. - Thank you. - All right, my pleasure. - Thanks, please. (upbeat music) (upbeat music) And that, my dear audience, it's the end of this episode. I hope you enjoy learning about respiratory cultures. As always, I enjoy sharing this information with you. Please continue bringing that passion to what you do. It's so important, you know, it makes you so much better at your job. For me, there is nothing greater than the workspace that's starting your day with a whole bunch of cultures, finding out all those organisms and helping out those patients. So this is what we do this job for, for them. So as always, stay motivated, stay safe, and of course, continue talking micro. Until the next time, bye. [MUSIC PLAYING]