Role of Microbiology Lab Automation in Transforming Hospital Efficiency and Sustainability

Bassem Hamdy. Microbiology PhD, Product Manager for Microbiology & Lab Automation, Becton Dickinson, BD Life Sciences – Integrated Diagnostic Solutions, Middle East & North Africa..

Meshari Alabdullatif. Microbiology & Immunology PhD, Medical Affairs Manager, Becton Dickinson, BD Life Sciences – Integrated Diagnostic Solutions, Saudi Arabia

The clinical microbiology laboratory plays a vital role in any healthcare setting to report timely, accurate and validated results to identify and determine appropriate treatment of various bacterial pathogens based on a variety of tests and processes. These procedures and methods have primarily required human manipulation and intervention, while manual non-value added steps related to specimen transport, manual streaking of agar plates, manual incubation and reading of plates, etc. Through automating many manual processes in the clinical microbiology lab via; automated labeling and streaking of agar plates, transport to automated incubators, digital reading of plates coupled with web-based informatics access to results. Allows for standardization of sample processing, specimen tracking (chain of custody), workflow monitoring and efficiency data, while focusing on the most critical steps of reviewing and verifying results to transform efficiency and accuracy in the clinical microbiology lab. In alignment with this strategy, BD Kiestra™ Automated Microbiology Systems were initially introduced in Europe and currently operating in many countries globally. While on the regional level, 14 systems in five Gulf countries; four in Saudi Arabia, one in Bahrain, seven in Kuwait, one in United Arab Emirates, and one in Qatar. 

Since 2004, a study has substantiated the need for overall efficiency in providing results is now given the same importance as accuracy. This means that laboratories must be able to produce quality results in less time with the capacity to interpret the results clinically. To improve the clinical impact of microbiology results, the new challenge facing the microbiologist has become one of process management instead of pure analysis. A proper project management process designed to improve workflow, reduce analytical time, and provide the same high-quality results without losing valuable time treating the patient, has become essential¹. The diagnosis of infectious diseases and the role of the microbiology laboratory are crucial complex and fascinating process of change. If managed correctly, this change could have a positive impact on the treatment of infectious diseases both clinically and therapeutically¹.

Several publications are discussing needs for improving the efficiency for microbiology laboratory, at the University Hospital Campus Bio-Medico of Rome in Italy shared their one year of experience for the laboratory automation and intra-laboratory turnaround time² (TAT). Stating, TAT represents a key factor influencing patient care². The delay in urgent exams has been reported to have a major impact on the diagnosis and management of patients and on length of stay in the emergency department³. Laboratory automation has been described as an important means of improving the efficiency of the laboratory and TAT observance². Therefore, total laboratory automation has a positive impact on the laboratory service and helps to provide mean TAT reduction as well as the percentage of outlier decrease².

In 2015, the Journal of Clinical Microbiology, which belongs to the American Society for Microbiology (ASM) published a comparison between the automated inoculation systems and manual method. They have found that 3- to 10-fold higher yield of discrete colonies was observed following automated inoculation systems than that with manual inoculation. The inoculation with the InoqulA system allowed them to obtain significantly more discrete colonies than the WASP system at concentrations of >10⁷ bacteria/ml. The analysis of cloudy urine specimens showed that InoqulA inoculation system provided a statistically significantly higher number of discrete colonies than that with WASP and manual inoculation. Consequently, the automated InoqulA inoculation greatly decreased the requirement for bacterial subculture and thus resulted in a significant reduction in the time to results, laboratory workload, and laboratory costs⁴ (figure 1).

(A) One discrete colony was required to perform identification by MALDI-TOF MS at day 1 post-inoculation. Re-isolation was performed when at least one colony was not obtained, leading to a delayed time to results of 1 working day (ID report at day 2). An additional laboratory cost of 3.3 EUR (3.6 USD) per re-isolation was calculated for each subculture, and the results were extrapolated to 100 samples for clarity.
(B) A minimum number of 6 discrete colonies grown on BBL chromogenic agar was required (i) to perform an ID by MALDI-TOF and (ii) to make a bacterial suspension in 2 ml of saline solution equivalent to a 0.5 McFarland standard turbidity to complete AST at day 1 and to report the results at day 2. Thus, each sample containing <6 colonies needed re-isolation, leading to a delayed time to AST results of 1 working day (AST report at day 3). Similar to identification, an additional laboratory cost of 3.3 EUR (3.6 USD) per re-isolation was calculated for each subculture, and the results were extrapolated to 100 samples for simplicity.

In 2018, a total of 35,564 microbiological urine cultures with and without incubation and processing with BD Kiestra™ Total Laboratory Automation (TLA) for a 6-month period each retrospectively, the time to report was significantly lower in the TLA processed samples by 1.5 hour in addition to TLA showed enhanced growth of non-classical and rarely cultured bacteria from urine samples. Especially Enterococci and Gram-positive rods were isolated more frequently with TLA in general cultivation does not need special media or conditions but time to inoculation may play a role in these cases, as with TLA the samples are processed faster and continuously throughout the working hours⁵. The polymicrobial specimens are classically regarded as contaminated by vaginal or periurethral microbiota. Particularly about the growing number of immunocompromised patients or patients with altered urinary tracts, the current diagnostic algorithms may not be adequate as they don’t consider the possibility of polymicrobial urinary tract infection in highly susceptible patients like solid organ/stem cell recipients or patients with special urologic conditions⁶.

Similarly in 2022, the American Association for Clinical Chemistry published a review addressing the current state of laboratory automation in clinical microbiology laboratory due to increasing pressure to reduce costs while maintaining or improving quality created a demand for automation. At the same time, overall testing volumes have been increasing 5%–10% every year, driven by an aging population, increased numbers of immunocompromised patients, infection control demands, and the growing challenge resulting from detection of multidrug-resistant microorganisms⁷. 

The way to truly capitalize on the value offered by automation is to evaluate every current process and determine whether and how it should change. They concluded that a significant number of prescribing decisions are made based on the results generated by the laboratory and optimization of those results may influence timelier clinical decisions⁷. Moreover, among participated facilities, annual savings per year ranged from $270,000 to $1,200,000⁸.

Those new technologies will allow earlier detection of microbial growth, automated detection, and auto release of sterile samples, identification and quantification of bacterial colonies, or even automated reading of antibiotic susceptibility testing disk diffusion assays and thus further decrease TATs and increase productivity⁹.

BD Kiestra™ Solutions Expanding your laboratory’s capabilities.

Does your laboratory experience challenges such as?

• Increasing sample volumes and staffing shortages.
• Financial pressures from reduced budgets and smaller reimbursements.
• Resistant organisms demanding accurate detection.
• Lack of access to relevant data for simplified workflow management, analytics, and instrument integration.

When hospitals and health systems evaluate automation platforms, they must recognize the potential impact these technologies have on the capacity of microbiology lab operations. Automation provides laboratories with an opportunity to do things in ways that were previously impossible and to address the challenges of today while preparing for the future.

Discover how BD Kiestra™ Solutions can help you:

• Enhance laboratory operations.
• Maximize financial efficiencies.
• Advance laboratory outcomes.

BD Kiestra™ Solutions are enabling laboratories such as yours to meet these changing demands by:

• Offering scalable solutions from sample processing to results reporting
• Leading to accurate, timely and cost-effective testing, enabling you to expand your laboratory’s capabilities.
• Enabling secure access to data, on-demand access to analytics with BD Synapsys™ informatics solution, for simplified workflow management and instrument integration
• Improving laboratory productivity, efficiency and turnaround time and helping enable staff efficiency by reducing rework.

Combine high-speed performance and standardized image acquisition to enable dynamic diagnostic imaging:

• See details invisible to the human eye, BD Kiestra™ ReadA contains a 25-megapixel camera with a telecentric lens and ensures plates are oriented for consistency of images
  over time.
• Improve colony detection and reduce image variability, BD Kiestra™ Optis technology acquires up to 22 images of each plate and determines the optimal value for each pixel using three light sources: top, bottom and side.

The BD Kiestra™ ReadA, maintains consistent temperature and gas levels with negligible heat and CO₂ gas loss enabling the first plate images for culture interpretation to be ready as early as after 10 hours for urine specimens and 8 hours for positive blood culture broth subcultures⁷.

BD Kiestra™ Urine Culture Application (UCA)

The BD Kiestra™ UCA uses digital imaging and software algorithms to determine the amount of growth on a urine culture plate from clean caught and catheterized samples, helping labs maximize their productivity by:

• Auto and Batch reporting samples with no growth or non-significant growth based on user-defined rules.
• Allows for direct identification and differentiation without confirmation testing for some species with BD BBL™ CHROMagar™ media.
• Prioritizing and focusing on the critical and complex specimens by organizing those specimens into meaningful worklists in BD Synapsys™ informatics.
• Freeing up staff’s time to focus on critical and complex specimens.

BD Synapsys™ Informatics Solution

Power your automated lab with BD Synapsys™ today to get the right data to the right people at the right time.

Simple, anytime anywhere access to workflow and intuitive personalized user interface, to help you drive productivity.

• Virtual bacteriology enables access to digital reading workflow anytime, anywhere; share information with expert bacteriology staff.
• Intuitive personalized user interface helps you streamline digital reading.
• A single, browser-based informatics platform for microbiology supports multiple instrument types in the workflow.
• Analytics offer actionable insights that help you drive productivity and may impact your lab performance including time to read plates.
• Customize and share worklists by patient demographics and specimen type, to guide staffing needs and streamline productivity.

Smart, intelligent rules engine and actionable insights help you streamline and facilitate decision making.

• Integrated workflow for positive blood cultures across BD BACTEC™, BD Kiestra™ IdentifA and BD Bruker MALDI Biotyper Sirius IVD system.
• Maintain complete specimen and plate traceability for blood culture and MALDI organism ID.
• Integrates imaging applications developed with Artificial Intelligence (AI) for automated review of urine culture growth and chromogenic plate screening for MRSA (only available in EU and Canada), standardizing culture interpretation.
• Sophisticated customizable rules engine helps with connectivity, workflow management, and laboratory operations.
• Guided test ordering (by organism, specimen, or culture criteria) standardizes laboratory protocols.

Safe, designed to support data security and privacy control requirements.

• Designed to support data security and privacy control requirements and standards, including GPDR, HIPAA and NIST; BD Synapsys™ is UL CAP and SOC 2 certified (US).
• User activity is stored automatically, creating an audit trail to help support your accreditation, compliance, and QA requirements.

BD Kiestra‮*‬ offers comprehensive services that build upon and enhance your automation investment, giving you access to experienced teams of lean workflow consultants, project managers, application specialists, and field service representatives. In conclusion, BD Kiestra‮*‬ delivers a timely implementation of your solution to help maximize your system’s uptime, utilization, and laboratory performance.

References:
1.Camporese A. The impact of automation on organizational changes in a community hospital clinical
microbiology laboratory. Infez Med. 2004 Jun;12(2):118-25. PMID: 15316298.
2. Angeletti S, De Cesaris M, Hart JG, Urbano M, Vitali MA, Fragliasso F, Dicuonzo G. Laboratory Automation
and Intra-Laboratory Turnaround Time: Experience at the University Hospital Campus Bio-Medico of Rome.
J Lab Autom. 2015 Dec;20(6):652-8. doi: 10.1177/2211068214566458. Epub 2015 Jan 21. PMID: 25609253.
3. Holland, L. L.; Smith, L. L.; Blick, K. E. Reducing Laboratory Turnaround Time Outliers Reduces Emergency
Department (ED) Patient Length of Stay (LOS): An 11 Hospital Study. Am. J. Clin. Pathol. 2005, 124,
672–674.
4. Croxatto A, Dijkstra K, Prod&#39;hom G, Greub G. Comparison of Inoculation with the InoqulA and WASP
Automated Systems with Manual Inoculation. J Clin Microbiol. 2015 Jul;53(7):2298-307. doi:
10.1128/JCM.03076-14. Epub 2015 May 13. PMID: 25972424; PMCID: PMC4473203.
5. Klein S, Nurjadi D, Horner S, Heeg K, Zimmermann S, Burckhardt I. Significant increase in cultivation of
Gardnerella vaginalis, Alloscardovia omnicolens, Actinotignum schaalii, and Actinomyces spp. in urine
samples with total laboratory automation. Eur J Clin Microbiol Infect Dis. 2018 Jul;37(7):1305-1311. doi:
10.1007/s10096-018-3250-6. Epub 2018 Apr 13. PMID: 29651616; PMCID: PMC6015101.
6. Kline KA, Lewis AL. Gram-Positive Uropathogens, Polymicrobial Urinary Tract Infection, and the Emerging
Microbiota of the Urinary Tract. Microbiol Spectr. 2016 Apr;4(2): 10.1128/microbiolspec.UTI-0012-2012. doi:
10.1128/microbiolspec.UTI-0012-2012. PMID: 27227294; PMCID: PMC4888879.
7. Antonios K, Croxatto A, Culbreath K. Current State of Laboratory Automation in Clinical Microbiology
Laboratory. Clin Chem. 2021 Dec 30;68(1):99-114. doi: 10.1093/clinchem/hvab242. PMID: 34969105.
8. Culbreath K, Piwonka H, Korver J, Noorbakhsh M. Benefits derived from full laboratory automation in
microbiology: a tale of four laboratories. J Clin Microbiol 2021; 59:3.
9. Croxatto A, Marcelpoil R, Orny C, Morel D, Prod’hom G, Greub G. Towards automated detection, semi-
quantification, and identification of microbial growth in clinical bacteriology: a proof of concept. Biomed J
2017; 40:317–28.
10. Yue P, Zhou M, Zhang L, Yang Q, Song H, Xu Z, Zhang G, Xie X, Xu Y. Clinical Performance of BD Kiestra
InoqulA Automated System in a Chinese Tertiary Hospital. Infect Drug Resist. 2020 Apr 1;13:941-947. doi:
10.2147/IDR.S245173. PMID: 32280250; PMCID: PMC7132006.

BD-134281 August 2024
CHROMagar is a trademark created by Dr. A. Rambach and is the property of Company BALEL.
BD, the BD Logo, BD BACTEC, BD BBL, BD Kiestra and BD Synapsys are trademarks of Becton, Dickinson and Company or its affiliates. All other trademarks are the property of their respective owners. ^©2024 BD. All rights reserved
MALDI Biotyper Sirius IVD system is a trademark of Bruker Daltonics GmbH.
Not all products, services, claims or features of products may be available or valid in your local area. Data on file and available upon request, please contact your local BD representative for more details. This is intended for Health Care Professionals only.