FROM THE BENCH
Expanding partnerships and
efficiencies
MHDL’s year one validation and utilization
of the two transport systems expanded
MHDL capacity to serve high risk
populations beyond the proximal STD
clinic. During Project Years 2 and 3, the
MHDL collaborated with SURRG Program
partners to enroll community based
non-STD clinics throughout the city of
Milwaukee to participate in surveillance
for resistant GC infections.
Participating clinicians and laboratorians
received training in GC culture collection
and transport, laboratory identification
procedures, AST and interpretation of test
result reports. Building these partnerships
also helped accomplish the SURRG goal of
providing resources to other jurisdictions
as a next step.
In Project Year 2, MHDL progressed
from manual to fully automated data
management through the use of SQL
and Python scripting. This contributed to
timely quality assurance and evaluation
through monthly and yearly performance
metrics, including patient demographics,
TAT and timely reporting of RS isolates
to local DIS, clinical partners and
epidemiologists, state and CDC (Table 1).
Using data to drive improvement
practices
In 2019 MHDL began providing all clients
with a customized requisition to save
time, lower transcriptional error rate
and gather required demographics.
Customized requisition forms also
capture culture criteria and other
required SURRG project clinical and
epidemiological data elements. Procuring
precise demographics, specimen source,
collection and follow-up TOC status is
essential to ensuring accurate patient
information in the laboratory information
system, as well as clinical management
of the disease and fulfillment of grant
deliverables.
To improve recovery of GC isolates
and decrease the volume of negative
specimens, collection criteria were
modified to include only clients reporting
symptoms or, if asymptomatic, reporting
contact to a confirmed case of GC, and
GC NAAT-positive patients returning
for treatment and/or TOC visits.
TABLE 1: Milestones Achieved in GC-AST Workflow
Milestone achieved
Implementation of Etest for AST
Use of eSwab ™ collection and transport system at
non-STD clinics
Use of InTray™ GC instead of MTM plates with
limited self-life in candle jar at STD clinics
Detection of first isolate with RS to azithromycin
using Etest ®
Use of LEAN principles to improve GC workflow,
achieving optimum turnaround time of <5 days
Milestone achieved
Addition of two non-STD clinics
Automated generation of CDC monthly metrics with
required clinical and laboratory data elements
PROJECT YEAR 1
Project Impact
Moved from Disc diffusion Kirby Bauer (Qualitative)
to Etest (Quantitative)
No requirement for prior incubation before transport
within 24 hrs.
Direct specimen collection and inoculation onto
selective media w/ 5% CO 2
environment
Replacement for time consuming and laborious gold
standard method, agar-dilution
Helped initiate rapid field investigations of RS
isolates to stop spread of resistant GC
PROJECT YEAR 2
Project Impact
Increased surveillance to monitor resistance in a
diverse population
Increased bench time for GC laboratorians, lower
error rate, more opportunity for data analysis
Detection of first isolate with RS to ceftriaxone Part of first-line treatment regimen
PROJECT YEAR 3
Milestone achieved
Project Impact
Partnership with MSM clinic and third
Brought high-risk population under surveillance
non-STD clinic
Revised culture collection criteria for non-STD and
MSM partner clinics
Customized lab requisition form to capture data
elements
Weekly comparison of NAAT vs Culture at same site
of infection
Better utilization of resources and testing
capabilities
Improved efficiency for clinics and laboratory
Determine culture viability or overgrowth issues of
non-GC isolates particularly at non-genital sites
PROJECT YEAR 4
Milestone achieved
Project Impact
Detection of first isolate with RS to cefixime Treatment alternative to ceftriaxone
Instituted option for patient-collected vaginal and
penile meatal swabs for culture
Additionally, genital and extragenital
culture specimens were only collected at
anatomic sites of reported sexual activity.
Efficiency of culture collection criteria
at both STD and non-STD clinics was
evaluated quarterly (# Patients cultured/#
NAAT+ by anatomic site at STD and
non-STD). Adoption of the new collection
criteria significantly decreased the volume
of specimens yielding negative results
while increasing the yield of isolates.
(Figure 1).
Option for clients with privacy concerns or
otherwise unwilling to undergo pelvic exam,
screen high-risk clients including MSM unwilling to
undergo invasive collection
Monthly meetings with partners and
clinics addressed collection criteria,
and allowed for ongoing discussion of
workload and findings, supply needs,
epidemiological needs and process
improvement at clinics and the
laboratory. Local SURRG successes include
assisting with testing for disseminated
gonococcal infection (DGI) cases. MHDL
performed culture and AST on specimens
from disseminated sites of infection
(e.g., skin, synovial fluid, blood or
cerebrospinal fluid). Both susceptible and
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