Guidelines on the Prevention and Control of Tuberculosis in Ireland

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<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCRecommendation:Microscopy and culture for TB should only be performed in those laboratories where there issufficient throughput to ensure proficiency.In 1993, Tenover, 118 Huebner 119 and subsequently CDC 120 and Styrt 121 recommended by way of “goals” (notmandates or regulations) that a TB laboratory should report within certain time frames as shown in table4.2.Table 4.2: TB laboratory service goalsGoalsReport results of acid fast stainsDetect growth of mycobacteria in liquid mediumIdentify M. tuberculosis complex by mycolic acid pattern,AccuProbe or Bactec NAP testTime frame*Within 24 hoursWithin 10 daysWithin 3 weeksDetermine and report susceptibilities of new M. tuberculosisisolates to primary drugsWithin 3-4 weeks*Within receipt of specimen in the laboratoryRecommendation:Laboratories should aim to meet the “goals” set down by CDC and others.The Irish Mycobacteria Reference Laboratory (IMRL)The IMRL was established in 2001 to provide a timely reference service in relation to the diagnosis andtreatment of TB (see appendix 7 for contact details). Advice is available from a consultant microbiologist, arespiratory physician with expertise in the treatment of TB and senior laboratory scientists. The Departmentof Health and Children has set out the core functions that the reference laboratory service will be requiredto perform once it is fully developed. The IMRL functions include:• Identification of mycobacterial isolates• Sensitivity testing of isolates to anti-mycobacterial drugs• Assistance with isolation of mycobacteria in difficult cases• Provision of advice to clinicians and laboratories• Provision of clinical advice on diagnosis, treatment and infection prevention and control• Provision of a molecular diagnostic service for rapid identification• Molecular typing of M. tuberculosis• Training of medical/technical staff• Research• Provision of epidemiological information as required, subject to agreement with the HPSC.Some of the above services are currently not available. As the IMRL is developed, all of the services outlinedabove will be provided.-45-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCRecommendation:All mycobacterial isolates should be referred to the Irish Mycobacteria Reference Laboratory(IMRL) for identification and susceptibility testing once its new facility is opened.Recommendation:All M. tuberculosis complex isolates should be referred with immediate effect to the IMRL formolecular typing where typing is now offered.Recommendation:The results of all M. tuberculosis complex isolates which have already had identification,susceptibility and molecular typing performed should be forwarded to the IMRL forincorporation into a national repository of M. tuberculosis complex isolates.4.2 SpecimensAll specimens should be collected and submitted in sterile, clean, plastic, leak-proof, disposable, widemouthed,appropriately labelled, laboratory approved containers, without any fixative. Generally, transportmedia or preservatives are not needed owing to the robust nature of mycobacteria. 122 Swabs are notoptimal for the recovery of AFB. 122 Ideally specimens should be procured before chemotherapy is initiated.Even a few days of therapy can obscure the diagnosis because of the failure to recover mycobacteria. 123Specimens should be transported to the laboratory as soon as possible and refrigerated until processed.The transportation of infectious substances is subject to international legislation, to which laboratories arerequired to comply (section 4.7).Rejection of unsuitable specimensThe best mycobacteriological laboratory practices are frustrated if a poor or unsuitable specimen is presentedfor examination. Processing of inappropriate clinical specimens for mycobacteria can be wasteful, may berejected and the clinician notified.Examples of inappropriate specimens are as follows:• Insufficient amount submitted• Specimens consisting of saliva• Dried swabs• Pooled sputa or urine• Broken sample containers• Interval too long between specimen collection and processing 124• Analysis of urine specimens for the diagnosis of pulmonary TB.Recommendation:Reasonable efforts should be made to obtain the best quality sample possible depending onsite of disease and to deliver it in a timely fashion to the analysing laboratory.-46-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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