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Abstract: Introduction: Investigation Into The C-109 ASM 106th General Convention - Orlando, Florida - May 22-24, 2006 INVESTIGATION INTO THE EFFECT OF TEMPERATURE ON THE ViaBILITY OF FaSTIDIOUS AND NON-FaSTIDIOUS BaCTERia IN TWO COMMERCiaL AMIES GEL TRANSPORT SYSTEMS: BD CULTURESWAB MaX V(+) AND REMEL BaCTiSWAB. C. BIGGS, THE CHESTER COUNTY HOSPITAL THE CHESTER COUNTY HOSPITAL West Chester, Pennsylvania ABSTRACT: At The Chester County Hospital we use basic insulated cooler boxes with Downingtown, Exton, Kennett Square, and Lionville, Pennsylvania that ice packs for transport of bacteriology swabs from outreach clinics and include various out-patient labs and drawing stations that collect throat physicians offices. During July 2005 we monitored the internal tempera- cultures and urine samples. In addition to this we collect samples from ture of these coolers using digital temperature recorders. Average daily various physicians’ offices. The microbiology lab utilizes a contract cou- temperatures ranged between 11.4 - 19.8º C with peaks as high as 24.3º rier service that is shared with other hospital departments which manages C. We decided to evaluate viability of fastidious bacteria in two Amies Gel the collection of patient samples throughout the day within the network. swab transports; Becton Dickinson CultureSwab Max V(+) (BD) and Transit times for microbiology specimens can vary from 15 minutes Remel BactiSwab (RE) held at room temperature (RT) 20 – 25º C and to several hours depending on timing and courier routing. Before the refrigerator temperature (RF) 4 – 8º C to understand if upgrading our summer of 2005 we had followed guidelines that appear in microbiology coolers to units with electrical refrigeration might improve recovery of reference manuals which advocate the shipment of microbiology swab organisms from swabs. samples at room temperature. However, after reviewing recent published studies on organism viability in swab transport systems which demon- Using the Swab Elution Method described in CLSI M40-A swabs were strated performance at refrigerator temperature was superior to room inoculated with approx. 106 CFU of each of the following organisms temperature we decided to instigate improvements in our specimen man- Neisseria gonorrhoeae (NG) ATCC 43069, Haemophilus influenzae agement with the goal of lowering the holding temperature during transit (HI) ATCC 10211, Pseudomonas aeruginosa (PA) ATCC 27853 and a to the laboratory down to as near as possible refrigerator temperature clinical isolate of Streptococcus pneumoniae (SP). Each organism/de- (4 – 8°C) 1 - 7. Initially we implemented the use of basic insulated cooler vice combination was tested in triplicate at RT and RF for incubation times boxes filled with ice packs taken from our -20°C freezer and we studied of 24 & 48h. Zero time baseline counts and viability at each time point the effectiveness of this combination to provide cold transport tempera- was quantified by making vortex suspensions and ten fold dilutions from tures during July 2005 using digital temperature recorders. The results each swab then culturing aliquots to perform replicate plate counts. At using this combination were not as good as anticipated so we tested insu- RF all organisms remained viable in both swabs at 24 & 48h but percent lated cooler boxes incorporating a built-in electrical refrigeration system recovery was higher in all cases with BD. At 24h percent recovery for NG together with ice packs from our -80°C freezer in the hope that this was 37.5% with BD, 32% RE; HI 89% BD, 13.7% RE; SP 17.6% BD, 4.8% combination would be more effective at achieving the target temperature RE; PA 67.3% BD and 64.7% RE. At 48h NG recovery was 2.8% with BD, of range of 4 – 8°C. To assess the impact of temperature on organism 1.7% RE; HI 48.5% BD, 9.5% RE; SP 2.4% BD, 1.3% RE; PA 72.2% BD viability in our patient swab specimens and to provide supporting data to and 68% RE. At RT all organisms remained viable in both swabs at 24h help implement a procedural change for our cooler box courier service but at 48h RE failed to maintain NG, HI and SP strains. Percent recovery at CCH, we conducted a comparative viability study. In this study we tested at 24h were NG 42% with BD, 3.4% RE, HI >100% BD, 3.4% RE; SP two brands of Amies Agar Gel; Becton Dickinson CultureSwab Max V(+) >100% BD, 3.6% RE. PA demonstrated overgrowth in both swabs at RT (BD) and Remel BactiSwab (RE). Swabs were tested using a selection and was too numerous to count at 24 & 48h time points. of aerobic and fastidious bacteria at both room temperature (RT) 20 Our study demonstrated that at RF fastidious bacteria are recoverable – 25º C and refrigerator temperature (RF) 4 – 8º C. Using data from our from BD & RE swab transports for up to 48h. Refrigerated cooler boxes cooler box study and viability studies our aim was to draw conclusions could minimize the overgrowth of PA and improve the recovery of NG, HI that would endorse a new specimen handling procedure for our courier or SP from certain swabs. service that would optimize the survival of bacteria and improve labora- tory test results. INTRODUCTION: Specimen collection and transport are processes often overlooked and undervalued but are a critical part of the total microbiology testing pro- cess to deliver quality laboratory information. Bacteriology swab speci- men transport and organism viability is one area of particular interest to us as we believe there is room for improvement that could lead to better quality laboratory results. The Network of The Chester County Hospital (CCH) is like many small community hospitals in this country; the core of CCH comprises a 238 bed hospital with satellite locations in West Chester, Page of 6 C-109 ASM 106th General Convention - Orlando, Florida - May 22-24, 2006 MaTERiaLS: Process Diagram Cooler Box Temperature Study • Rubbermaid 11 x 15 inches - basic insulated cooler box (BCB) 1. Programming 2. Programmed Loggers sent with three ice packs from -20°C freezer. Loggers Microbiology Lab inside specimen coolers • Power Travel Cooler 12 x 17 inches (Mfg. by Power On Board) - insulated cooler box with integrated refrigeration unit - refrigerate cooler box (RCB) with two ice packs -80°C. ETM Escort Temperature Management System • Generic re-usable cooler ice packs 3. Transportation of specimens • Escort Junior Temperature Recorder (EJTR) Model # EJ-IN-D-16-L digital temperature recorder manufac- tured by Escort Data Loggers, Redmond, 5. Downloading WA. Loggers 4. Loggers retrieved from cooler Microbiology Lab boxes at the end of the day COMPARATIVE ViaBILITY STUDY Materials: METHODS: Commercial Amies agar gel without charcoal transport swabs: 1. On 11 days during the month of July and 8 days during the month of BD - CultureSwab Max V(+), Becton Dickinson, Baltimore, MD (Mfg. August 2005 the temperature inside BCB and RCB coolers respectively, by Copan, Brescia, Italy) used for the collection and transportation of specimens were digitally RE - BactiSwab, Remel, Lenexa, KS (Mfg. by Starplex Scientific, recorded at regular time intervals. Ontario, Canada) 2. At the start of each day an EJTR digital recorder was programmed Species Abbreviation Strain using a laboratory PC and software provided by the manufacture. The Neisseria gonorrhoeae NG ATCC® 43069 recorder was programmed to take temperature readings every 10 Haemophilus influenzae HI ATCC® 10211 minutes between approximately 10:30 am and 4:00 or 4:30 pm. This Streptococcus pneumoniae SP clinical strain time frame corresponded to the normal hours of operation of courier specimen transport service to the lab. Pseudomonas aeruginosa PA ATCC® 27853 3. On the morning of each day of the study at least 30 minutes prior to (Quantitative Swab Elution Method1) the first temperature reading the cooler boxes were loaded with ice METHOD packs. For the BCB cooler study they were loaded with ice packs pre- Preparation of inoculum pared overnight in the -20°C freezer. Initially, the RCB coolers were 1. Inocula of test organisms was prepared in 0.85% physiological saline loaded with ice-packs from the -20°C freezer, but the temperature (pH 6.8-7.2) to a concentration of approximately 1.5 x 108 CFU/mL was still too high so the RCB cooler was subsequently loaded with ice (equivalent to 0.5 McFarland standard) from an 18 to 24 hour plate packs prepared overnight in the -80°C. The EJTR recorder was then culture of each organism. placed in the center of the cooler box and the lid was secured. 2. Each inoculum was diluted as described below in 0.85% physiological saline 4. The cooler boxes were collected by the courier at approximately 10:30 (pH 6.8-7.2) solution to provide a concentration of approximately 1.5 am each day. They were used throughout the day for loading, transpor- x 107 CFU/mL. tation and delivery of samples to and from the lab and returnedbackto 3. The inoculum of each test organisms was prepared just prior to trans- the lab with the final delivery of specimens at 4:00 or 4:30 pm. ferring the organism suspension to microtiter plates where the swab 5. At the end of each day the EJTR was removed from the cooler and absorption was performed. The whole procedure did not exceed 20 all the temperature measurements from the device for that day were minutes in order to reduce loss of organism viability in inoculum downloaded via an interface to a PC. prior to incubation of inoculated swabs at the holding temperature 6. The procedure was repeated for each day of the study. Page of 6 C-109 ASM 106th General Convention - Orlando, Florida - May 22-24, 2006 INOCULATION PROCEDURE 4.
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