Cryptococcosis is an opportunistic fungal infection caused by Cryptococcus neoformans. Diagnosis of cryptococcosis in the laboratory is based on direct demonstration, culture, and cryptococcal antigen (CrAg) detection tests such as latex agglutination (LAT), enzyme immunoassay (EIA) and lateral flow assays (LFA). In the repertoire of EQA schemes available, there was the need for an EQA CrAg detection.
Following the very promising results attained from the pilot studies conducted in 2016/2017 involving participating laboratories worldwide, UK NEQAS dispatched the first distribution in July 2018 to 76 registered participants. The second was distributed in October 2018 to 77 participants. The third distribution is due to be dispatched in March 2019. Each distribution consists of two specimens.
Simulated specimens (serum) spiked with levels of CrAg were dispatched to participants worldwide, to assess the absence or presence of the antigen. Results were collated and analysed (Table 1).
Table 1: Cryptococcal antigen titre values and results.
|Distribution Number||Specimen number||Titre values||Interpretation:
Absence (-) /(presence (+) of antigen)
Participants demonstrated excellent concordance (100%) with intended results, with specimens 4522, 4523 and 4700, (serum samples containing either high levels of CrAg or no CrAg). Specimen 4699, which was designed to have a low concentration of the antigen, to challenge laboratories, demonstrated a good concordance (92.4%) with the intended result by our participants.
Participation in this EQA scheme will help the continued monitoring of performance in laboratories providing a service in the detection of CrAg in clinical specimens.
A questionnaire was sent to our General bacteriology participants in August seeking to assess interest in a new scheme for blood culture specimens.
We are very grateful to the 472 participants who responded to the questionnaire, providing valuable input.
The vast majority of respondents reported to use either BACT/ALERT or BD BACTEC blood culture machines, with an even split between the two. Very few laboratories reported the use of molecular techniques for diagnosing sepsis.
A total of 215 participants reported that they would be interested in participating in an EQA for sepsis. Of these, 167 stated that they have the facilities and are willing to spike their own blood culture bottles with blood and a freeze dried simulated specimen.
With this in mind, we are planning to distribute a pre-pilot to approximately 50 interested laboratories to trial this format of simulated specimen. This is our preferred format as it includes assessment of the blood culture machine as part of the analysis. We hope to dispatch the pre-pilot in Spring 2019.
There has been a great interest in ß-D-Glucan (BDG) testing from our participants. Additionally, the vast majority of literature publications highlight the importance of a non-invasive method for the diagnosis and monitoring of invasive fungi. There is an increasing incidence of fungal infections, including primary and opportunistic pathogens, particularly in patients with a compromised immune system.
The main polysaccharide groups of most fungi include glucan, chitin and mannan, with glucan being the most essential and abundant polysaccharide. During an invasive fungal infection (IFI), BDG is released in limited but detectable quantities in the circulation of fungi infected patients. Detection of BDG is a highly effective and sensitive presumptive diagnostic method, and is imperative in immunocompromised patients whom acquire an IFI.
A mini questionnaire was distributed to participants registered for our mycology schemes in the September distributions to ascertain the degree of interest in the BDG pilot studies. Over 10% of participants provide the service for BDG detection in various clinical samples (figure 1), with frequency of testing illustrated in figure 2.
Several reference laboratories have already conducted BDG testing using the simulated serum specimens distributed in the Fungal biomarker scheme for galactomannan detection. Data analysis of the results from the five reference laboratories have demonstrated promising results for homogeneity and stability of BDG. These preliminary results have supported the preparation of a pre-pilot BDG study to commence in January 2019.
The laboratory diagnosis of gastrointestinal parasites has traditionally been performed by microscopy. However, such procedures are time consuming and require highly specialised training plus experience. Antigen detection ELISAs can process large number of samples; however, their sensitivity can vary between various kits used. The emergence of molecular methodologies has enabled the detection of multiple faecal pathogens and mitigates the subjective nature of identifying parasites by morphology. Such methodologies have the potential to improve sensitivity and specificity rates and provide rapid and accurate diagnosis.
UK NEQAS Parasitology are in the advanced stages of launching their first global free-of-cost pilot EQA scheme towards molecular detection of faecal pathogens. The scheme will include Giardia intestinalis, Cryptosporidium spp and Entamoeba histolytica in the first instance. The first pilot should be distributed in March 2019.
Hepatitis E virus (HEV) is seen as an emerging viral infection causing liver disease. HEV is a small virus, with a positive-sense, single-stranded ribonucleic acid (RNA) genome. The virus has at least 4 different types: genotypes 1, 2, 3 and 4. Genotypes 1 and 2 have been found only in humans. Genotype 3 and 4 viruses circulate in several animals (including pigs, wild boars and deers, without causing disease), and occasionally infect humans. HEV is transmitted via oro-faecal route, mainly through contaminated water or food.
World Health Organization (WHO) estimates 20 million HEV infections worldwide, with the highest prevalence in East and South Asia, resulting to an estimated 3.3 million symptomatic cases of hepatitis E. In 2015 there were approximately 44,000 deaths attributed to HEV.
With the number of cases rising worldwide, diagnostic investigations of infection have become increasingly important. Many laboratories have added diagnostic HEV investigations to their testing repertoires.
UK NEQAS for Microbiology has been offering 2 new External Quality Assessment (EQA) schemes for HEV markers since April 2018. These 2 schemes are becoming increasingly popular with more laboratories subscribing.
Hepatitis E serology HEV (IgM and IgG)
- 3 distributions per year containing 4 specimens
- Each distribution will contain specimens to be tested for HEV IgM and IgG
- Specimens supplied as liquid human serum (0.5mL)
- Country-specific performance is available where there are greater than 10 participants in a country
- Three week period for examination and reporting results
Molecular detection of HEV RNA
- 3 distributions per year containing 2 specimens
- Specimens to be tested for HEV RNA and scored for qualitative interpretation (quantitative and genotype results can be given in addition but currently will not be scored)
- Specimens supplied as freeze dried human plasma (1.2mL)
- Country-specific performance will be available where there are greater than 10 participants in a country
- Three week period for examination and reporting results
For further information, please contact the Virology Scheme Manager
Tel: +44 (0) 208 905 9890 or Email: email@example.com
Mycology Teaching Workshop
Participation in the UK NEQAS Mycology Teaching Workshop can help increase accuracy of identification skills and confidence in reporting for a range of fungi. This teaching programme is intended to complement the educational aspects of the UK NEQAS for Microbiology mycology schemes.
After a successful run of Mycology workshops in 2017, coupled with overwhelming interest for participation, a series of three one-day workshops were conducted in September 2018.
A total of 108 delegates had the opportunity to examine over 35 different species of fungi, including a range of dermatophytes, non dermatophytes, a variety of Aspergillus species, fungi causing phaeohyphomycosis and hyalohyphomycosis and members of the mucoraceous moulds. Delegates were shown how to prepare slide mounts of the fungal cultures for microscopic examination prior to practising the technique for themselves. The identification was facilitated with a uniquely prepared booklet of images illustrating the macroscopic and microscopic images of each of the isolates available for examination. Experienced and skilled mycologists were available to help with queries and demonstrations. A quiz was held to provide delegates to test their newly acquired skills from the day’s teaching and the majority returned 100% correct results thus infusing confidence.
The positive feedback from the evaluation questionnaires received from delegates proved again that the workshop was a huge success. Due to the high demand for participation, the one-day workshops will be held again on three separate dates in 2019.
Venue: University of Westminster, London
Date: To be confirmed
Please contact firstname.lastname@example.org for details including cost, availability and registration for any of the designated dates.
It is strongly recommended to express interest in attendance at the annual re-registration (January-February) of our schemes to avoid disappointment.
Launch of UK NEQAS Parasitology teaching website: http://parasitologyprogramme.org.uk/
The new website includes a calendar of events with details of dates and venues of each course offered. Learning tools to help participants will continue to be added to this website. Watch this space!
The UK NEQAS Parasitology Teaching Programme organises regional courses in different geographical areas throughout the UK and the Republic of Ireland. The regional venues endeavour to cover the wider areas where our UK NEQAS Parasitology participants are employed. Currently, the following locations are used: Birmingham, Cardiff, Dublin, Dundee, Exeter, London, Preston and Newcastle.
Antimicrobial susceptibility scheme update, Dec 2018
Participants will have noticed that we have made some changes to the Antimicrobial Susceptibility scheme this year. This is a work in progress, aiming to introduce a wider range of specimen types, and therefore antimicrobial susceptibility tests, to the scheme. In April 2018 we started to introduce one non-blood specimen in addition to a blood specimen for each distribution. We also started to provide the organism identification, so that this aspect is no longer scored. So far we have distributed the following specimen types: blood (9); bronchoalveolar lavage (1), urine (1); cerebrospinal fluid (1); wound swab (2); skin swab (1); sputum (2); and faeces (1). For most of these distributions we have continued to request and report our traditional panel of antimicrobial agents. Over time, we plan to tailor this panel to be more appropriate to the specimen type. This will allow us to introduce new agents and breakpoints, particularly for urine testing and where oral breakpoints differ from intravenous ones. This may mean that we will have to request test results and reported results in a different format in the future. However, this will also allow us to explore new areas, such as the use of clindamycin for skin and soft tissue infections where there is dissociated macrolide resistance. We may also request a more restricted panel for some specimen types, such as cerebrospinal fluid.
A review of inclusion of agents in testing panels, including potential new agents, is made for the coming year when our expert advisory group meets in November each year. The advisory group also looks at the implications of any changes to EUCAST/CLSI guidance for the scheme. We have received and taken on board some feedback from participants that the scheme includes perhaps too many challenging organisms and that we also need to include some more sensitive isolates. Clearly this is an issue of balance and, moving forward, we will try to maintain a mixture of both easy and difficult organism-test combinations and also an appropriate selection of both common and emerging phenotypes.
There will be the opportunity to enter the method used for the carbapenemase detected. A drop down menu of methods will facilitate web entry. There will also be field available for participants who identify the genotype and wish to report it.
Due to unforeseen circumstances there have not been any comments accompanying the reports since May 2018. We can only apologise and reassure participants that efforts are ongoing to resolve this issue in the near future. We have taken the decision to issue interim performance reports as soon as we can, with full reports, with the expert comments added, to follow in due course.
Fungal biomarkers EQA scheme, Dec 2018
Invasive aspergillosis (IA) is a severe fungal infection caused by Aspergillus species, often in immuno-compromised individuals. Aspergillus fumigatus species complex is the most prevalent pathogen responsible. Galactomannan (GM) antigen detection as a criterion in the diagnosis of IA is recommended by the European Organization for Research and Treatment of Cancer (EORTC) and the Mycology Study Group (MSG) (2008).
An external quality assessment (EQA) scheme was warranted to assess the performance of laboratories providing a service in the detection of GM, due to variabilities in specimen storage, antigen stability and analysis of results.
Three pilot distributions were dispatched between June 2016 and January 2017. A high level of interest was maintained throughout the pilots and the full scheme was launched with the first dispatch in June 2017. A further four distributions have since been sent.
Participant results have shown excellent concordance with intended results for specimens with high levels of galactomannan. Participant performance has shown a decline in concordance with intended results for specimens with index values close to the cut off value for the BioRad Platelia Aspergillus ELISA.
Each distribution now consists of three simulated specimens. The majority of specimens have comprised of simulated serum specimens, however we will aim to include more simulated broncho-alveolar lavage specimens in future distributions.
Interpretive Comments scheme
The Interpretive comments scheme has continued to run as a pilot, with recent distributions on; possible cutaneous diphtheria, neonatal chlamydia, Helicobacter pylori in pregnancy, enterovirus infection, rinse water testing and hepatitis E infection.
Following the introduction of a £60 charge for each registration in April, more than 340 participants registered for the scheme this year and mean participation is running at 196 participants per distribution. The UK NEQAS Microbiology Steering Committee have endorsed Interpretive comments to run as a live scheme, with performance monitoring, from April 2019.
ISO 17043:2010 accreditation for UK NEQAS Parasitology: All findings cleared and accreditation maintained.
ESVC Annual Meeting
Beatrix Kele and Stuart Whitmore attended the 21st annual ESCV (European Society for Clinical Virology) Congress in Athens, Greece. The ESCV Annual Meeting is a major event for the Clinical Virology scientific community.
We presented two poster abstracts at this event out of the total 318 posters displayed at the poster sessions, “First year review of the Molecular detection of Respiratory viruses EQA scheme” and “How do we investigate an EQA failure? Lessons learnt from a Hepatitis C RNA detection distribution”. Both posters were well received and the event was a good opportunity to discuss these topics with other delegates, to interact with our participants, to meet with potential participants providing them with information about our EQA schemes and to meet with our Greek distributor. Additionally we gained information on new assays that will potentially be used by participants in our schemes and on the need for new EQA schemes for the future.
The European Organisation for External Quality Assurance Providers in Laboratory Medicine (EQALM) 2018
Adam Uldall was a Danish Clinical Chemist who founded EQALM in 1996 and in honour of his role in the Organisation there is an annual lecture awarded in his name. This year the speaker, Professor Greg Miller, spoke about the role of EQA samples and the results obtained from them in identifying areas that need harmonisation and standardisation and also as indicators for the success (or lack of) in the work to standardise clinical testing. UK NEQAS for Microbiology is a full member of the Organisation.
We were lucky enough to attend the annual conference of EQALM in October this year. This took place in Zagreb, Croatia – a beautiful city with friendly people who acted as the hosts of a very interesting conference. The conference started with the specialist working groups covering virtual microscopy – one of the areas UK NEQAS are keen to move into, microbiology and chemical pathology to name a few. We attended the microbiology, of course, where the chair distributed the paper on antimicrobial susceptibility testing using the data provided from the various members of the organisation, ourselves included. The next collaborative project is examining outcomes from EQA rounds for gastro-intestinal pathogenic bacteria. This has so far shown some really interesting outcomes. Of particular interest was the emphasis that clinical laboratories should recognise and understand the limitations of automated/newer platforms or technologies.
Further presentations on haemoglobinopathies, harmonisation and commutability, traceability (very understandable for the non-chemists!), assistance to developing countries and pre-analytical EQA were all equally stimulating even though not necessarily related to microbiology. Other presentations and posters covered numerous topics including the organisation of EQA in Croatia, Failure Mode Effect Analysis as a tool for quality improvement and new schemes developed by some of the EQA providers at the meeting.
By: Shân Lloyd and Aneta Stranc – the Quality girls…:‑) 🙂
ECDC Workshop on Laboratory diagnosis of C. diphtheriae: 9th-11th November 2018
Priya Patel and Shila Seaton from UK NEQAS for Microbiology, presented on Quality and EQA at the ECDC Workshop (endorsed by WHO) on Laboratory Diagnosis of diphtheria, held in Nicosia, Cyprus.
The workshop was organised by Androulla Efstratiou (PHE) and ECDC and attended by European delegates wishing to enhance and maintain skills of laboratory diagnosis of toxigenic and non-toxigenic strains of C. diphtheriae using conventional and molecular techniques.
The presentation described the role and importance of EQA in the Quality Assurance system, with focus on errors that occur beyond the analytical stages of testing and how UK NEQAS are starting to address this through their new PREPQ EQA. This new scheme monitors the incidence of errors in the pre- and post-analytical phases of the total testing process in diagnostic clinical laboratories.
Data was presented on EQA performance on C. diphtheriae reporting on distributions dispatched between November 1997 and September 2014, which included reporting of the presence or absence of toxigenic strains of this respiratory pathogen. Interestingly, common misidentifications reported were using conventional testing methods. With introduction of method capture in our general bacteriology scheme, trends in methods reported showed semi-automated systems, e.g. VITEK 2 and MALDI-ToF were increasingly used. This has resulted in a significant decrease in the reporting of incorrect species for C. diphtheriae.
UK NEQAS Parasitology – attendance of ASTMH (American Society of Tropical Medicine and Hygiene) in Baltimore.
Prof Peter Chiodini and Dr Jaya Shrivastava organised a symposium on Parasitology EQA at the 67th Annual meeting of ASTMH, held at New Orleans, USA (October 28 – November 1, 2018).
The topic of the symposium was Quality in Parasite Diagnostics- How good is it really?
Until now, Parasitology has lagged behind bacteriology and virology diagnostics, as most parasites cannot be cultured in vitro and most parasitic disease is found in resource-poor settings where empirical treatment has often been given instead of test-based diagnosis and treatment. Molecular and lateral flow techniques now permit accurate species diagnosis in a clinically useful time frame. In non-endemic areas, where expertise in classical Parasitology is confined to specialist centres, the new technologies have the capacity to make accurate parasite detection much more widely available. The pros and cons of these methodologies were evaluated for three key parasitic diseases, with a strong emphasis placed on quality.
The panel was comprised of experts Parasitologists with added unique knowhow in the field of Molecular biology and lateral flow techniques.
The panel of speakers included: Professor Bobbi Pritt (Mayo Clinic/College of American Pathologists, USA); Dr Jaco Verweij (Elisabeth Tweesteden Hospital, Netherlands); Dr Bernhard Weigl (Intellectual Ventures/Global Good, USA); Professor Sitara Rao (Christian Medical College, India) and Dr Jaya Shrivastava (UK NEQAS Parasitology, UK).
Meetings attended: Healthcare Infection Society International meeting, November 2018
Paul Chadwick attended and presented a poster in Liverpool at the Healthcare Infection Society’s international meeting in November, which reviewed the trends in methodologies used to identify organisms distributed in the General bacteriology scheme from 2014 to 2018.
Key findings were laboratories had invested in new technologies, notably changing from conventional to MALDI-ToF identification methods. This change has been greatest for non-enteric specimens.
In addition it was demonstrated that a review of performance over time is useful to identify areas where participants have experienced difficulties with a certain organism. The most common reason for overall poor performance was a failure to isolate the target organism, but there has been a reduction in the frequency of overall poor performance in recent years.
UK NEQAS SCIENTIFIC MEETING 2018
UK National External Quality Assessment Service Microbiology Division Scientific Meeting
Holiday Inn, Coram St, London
Friday 30th November 2018
Placement student: Mariam Habib
UK NEQAS Microbiology welcomes its participants to a day themed around Rapid Diagnoses. There were six external speakers and talks from several staff from within the UK NEQAS consortium. The meeting was chaired by Professor Peter Hawkey and Professor Andrew Lovering
Introduction by the new President of UK NEQAS - Liam Whitby
The introduction highlighted UK NEQAS status as a registered educational charity and the composition of the consortium which constitutes specialist departments, including chemistry, haematology, immunology, histopathology and microbiology. The importance of pathology networks was discussed to ensure consistency in methodology, reporting patient issues, new modes of EQA and referral models. Point of Care Testing (POCT) was discussed and its importance for rapid diagnosis and how the devices/tests are on the increase with better outcomes and treatment with fast, reliable results. The significance of the UK NEQAS EQA scheme for Pre- and Post-Analytical Quality Monitoring Service (PREPQ) was described as a web based EQA programme to enable laboratories to report errors in the pre and post analytical phases and how PREPQ helps laboratories meet the requirements of ISO 15189.
Rapid ID/AST in clinical microbiology: promise or reality? - Alex van Belkum, BioMérieux
This talk described antimicrobial susceptibility testing (AST) using whole genome sequencing (WGS) as an alternative method to phenotypic AST for resistance detection and how it is not ready for certain organisms. The continuation of database development for use with AST via WGS was discussed and its utilisation for “difficult to grow” organisms of public health concern. Discussions were held around future applications such as robotic replacement for standard human manipulations and actions and for MALDI-ToF MS being the new, rapid gold standard (in comparison to API strip tests and the VITEK). Next generation sequencing (NGS) is being considered currently for the routine laboratory.
Molecular diagnostics for the detection of antimicrobial resistance- can this assist the stewardship agenda? -Beryl Oppenheim, Cepheid
Antimicrobial resistance (AMR) is a global problem where 700,000 people die annually from antimicrobial resistant infections. The talk described how molecular detection of AMR is currently an adjunct rather than a replacement for phenotypic methods and that molecular detection could provide the possibility of rapid results, identification of multiple mechanisms and identification of molecular mechanisms of resistance. Methods of molecular detection of resistance were described that included PCR (and multiplex PCR), DNA microarrays, WGS and MALDI ToF. This methodology may lead to better use of infection prevention measures and improved antibiotic treatments strategies.
Fast or sensitive? Which diagnostic procedure best to use for “test and treat” schistosomiasis? – Lisette van Lieshout, Leiden University Medical Centre
There are 200-250 million worldwide cases of schistosomiasis. Microscopy is used for diagnosis, however there is a lack of sensitivity and it is time consuming. The talk described the point of care circulating cathodic antigen (POC-CCA) urine-based test for the diagnosis of chronic S. mansoni infection and the phosphor lateral flow circulating anodic antigen (UCP-LF CAA) test used to diagnose all Schistosoma species, which is not very fast and is ultra-sensitive.
Individualised approaches to infection management - Frankie Bolt, Imperial College, London
The varying methodologies in management of infections was discussed; minimally invasive monitoring (system used to manage infection using microneedles); continuous infusion with a 30% lower risk of death in sepsis patients by prolonged infusion. Other approaches were discussed, included in-vivo monitoring (using voltage) an aptamer-based sensing technique that uses single-stranded DNA/RNA sequences and Rapid Evaporative Ionisation Mass Spectrometry (REIMS) for microbial diagnostics which utilises an iKnife during an electro-surgical procedure to differentiate between malignant tissue and normal tissue.
Diagnosing early infection with Pseudomonas aeruginosa in people with cystic fibrosis: challenges and future solutions - Jane Davies, Imperial College, London
The talk described collaborations with the University of Amsterdam involving a spirometry machine to detect P. aeruginosa in people with cystic fibrosis, with the optoelectronics research centre where small channels in paper devices are used to load a dye with antibodies to P. aeruginosa, to detect how broad they are against the clinical strains. Another approach discussed was a project using Medical detection canines to detect P. aeruginosa. Results showed 94.2% sensitivity and 98.5% specificity.
Tuberculosis and therapeutic drug monitoring - Alan Noel, UK NEQAS for Antibiotic Assay
The talk focussed on how Therapeutic drug monitoring (TDM) and optimised therapy detects variability in patient Pk and how this shortens time to resolution and reduces transmission to others. One optimising therapy strategy uses dried blood spots (DBS) with its advantages of convenient transport and storage; minimal invasive technique (finger or heel prick); a small volume requirement.
Quality related aspects of point of care testing - Shân Lloyd, UK NEQAS for Microbiology
Shân Lloyd described the importance of ensuring that quality management with POCT and the users of POCT takes into account the environment and backgrounds of its users. Therefore people carrying out POCT need to understand the purpose for POCT, understand why IQA, EQA and IQCs are used. Staff should understand that POCT devices are not infallible.
Retirements, leavers and new starters
2019 will see the following imminent retirements:
Professor Andrew Lovering, Organiser for the UK NEQAS Antibiotic Assay schemes, will be retiring at the end of Jan 2019. Andrew made fantastic and invaluable contributions to UK NEQAS Microbiology, helping organise and run the Microbiology Scientific day for several years (presenting and chairing) and being an active member of the Steering Committee.
We wish Professor Andrew Lovering and Professor Peter Hawkey all the very best in their retirements and future pursuits and thank them for all their contributions over the years.
We would like to welcome the following to the Steering Committee:
- Dr Rohini Manuel will be joining the UK NEQAS for Microbiology Division, taking up the position as Chair.
- Dr Katie Hardy will be joining a s a member of the steering committee
Both Rohini and Katie bring a wide range of experience and expertise in Clinical Microbiology to the team.
We would like to welcome the following new starters
Margaret Babutunde- Laboratory Support Staff
Shabana Bi – Information Officer/ IT
Natasha Bundock – Healthcare Scientist
Nikita Chauhan – Laboratory Support Staff
Michael Akintunde – Operations Administrator
Mariam Habib – Placement student
We wished farewell to the following staff:
Stuart Whitmore – Healthcare Scientist
Rupa Rai – Healthcare Scientist