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Stepwise Success

A Tale of Two Smears

Published August 4, 2010 6:06 AM by Scott Warner

Two sputum Gram stains tell different stories. The first is loaded with white cells and Gram positive cocci, the blood plate overrun with staph. The second has a few white cells and mixed flora, and the plates show some staph colonies without predominant growth.

In both cases, surveillance nares cultures are collected and grow MRSA. In both cases, physicians want the staph colonies identified, which are both MRSA. And, in both cases the patients are told they have MRSA and put on precautions.

Issues:

  • The second culture likely picked up MRSA in the throat, and so reflects colonizing bacteria and not bacteria causing an infection.
  • “MRSAphobia” may cause techs, nurses, and docs to overreact to what may be colonizing bacteria. Nearly everyone is frightened of this wee beast.
  • Putting both patients on precautions drains resources better conserved for the first patient, who may really have a MRSA infection.
  • Labeling a patient with MRSA -- unnecessarily, perhaps -- can affect all future hospital stays and be a psychological burden for patients and families.
  • Depending on collection time, MRSA may be the hospital’s fault when it might have come from anywhere or even brought in by a family member.
  • If the patients don’t talk about how they “got MRSA” at the hospital, their families and friends will.
  • Hospital personnel are washing hands, gowning up, and otherwise being careful to prevent the spread of contagion, but who is watching visitors?

Results like these are opportunities to educate. Within the lab, they highlight the need to evaluate sputum specimens carefully and let Gram stain results guide workups. For nursing, they show how important it is to collect a proper specimen that has a risk of contaminated from colonizing flora. For physicians, it’s a chance to open a dialog to learn the reasoning behind laboratory policy. And for patients and families, it’s an opportunity to ask questions about MRSA and get answers. The lab can play a key role in all these.

Some days, I think there has never been a better time to work in the laboratory. This may be one of those days.

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About this Blog


    Scott Warner, MLT(ASCP)
    Occupation: Laboratory Manager
    Setting: Critical Access Hospital
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