To address Gram stain interpretation proficiency in a satellite/centralized microbiology laboratory paradigm, two programs were devised. In quality assurance program 1, nonmicrobiology technologists at satellite laboratories were required to interpret standardized Gram-stained specimens of clinical material prepared by an experienced microbiologist at a central laboratory. In quality assurance program 2, clinical Gram stains prepared and read by the satellite laboratorians were reviewed by experienced microbiologists at the central laboratory. Satisfactory performance (94%) was achieved in quality assurance program 1. In contrast, quality assurance program 2 had a significantly lower overall performance (89%; P < 0.0001) due to poorer identification of host cells (93%) and bacteria (84%). A variety of intervention mechanisms, including continuous monitoring, resulted in overall performance improvement (P < 0.006). While a technologist challenge has educational merit, having a microbiologist review previously read slides is a better indicator of the technologist's Gram stain interpretation proficiency.
A 41-year-old male with a past medical history significant for sarcoidosis (treated on a chronic basis with corticosteroids), congestive heart failure, chronic obstructive pulmonary disease, and hypertension presented to an emergency department with a 2-day history of fever, chills, shortness of breath, and a cough producing blood-tinged sputum. The social history provided by the patient included the use of tobacco and alcohol in the distant past. The travel history appeared noncontributory.Upon physical examination, vital signs indicated tachycardia (heart rate of 121), tachypnea (respiratory rate of 60), and hypotension (blood pressure of 87/53). The patient was extremely hypoxic at presentation (pO 2 of 50%), but the pO 2 reading improved to 93% after administration of 15 liters of oxygen. The patient was noted to be in obvious respiratory distress; soft crackles were observed at the bases of his lungs. Laboratory data of significance included a leukocyte count of 31,000/l with a left shift, a serum creatinine level of 1.7 mg/dl, and a serum glucose level of 263 mg/dl. Imaging studies included a chest X-ray finding of dense consolidation in the left lower chest consistent with congestive heart failure and a computed tomography (CT) finding of lingular consolidation consistent with pneumonia.Due to recent hospitalization (1 week previous), the patient was empirically treated with piperacillin-tazobactam for suspected nosocomial pneumonia. Azithromycin was added to account for previous isolation of Haemophilus sp. and to cover etiologies of pneumonia in immunosuppressed individuals. A specimen collected by bronchoscopy was submitted for culture and direct microscopic examination (Fig. 1).
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