Michigan 2014 CAP LPX – B Survey Analysis · CTERIST d wound s n his right ICS AT 24 5% Po C Po pecimen fro arm and a HOURS: SHEEP B or/scant gr HOCOLAT or/scant g MACCONK No growth

Michigan Department of Community Health Bureau of Laboratories

1

Michigan 2014 CAP LPX – B Survey Analysis Introduction The College of American Pathologist (CAP) Laboratory Preparedness Exercise (LPX) survey provides clinical laboratories with an educational exercise that can be used to help prepare for the detection of pathogens of public health importance, including pathogens that might be used as biothreat (BT) agents. Another purpose of the LPX is to prepare participant laboratories for effective and efficient communication of critical information related to the detection of potential BT agents to public health authorities.

The LPX survey consists of organism identification (rule out) plus a notification component to test communications between Laboratory Response Network (LRN) Sentinel Laboratories and LRN Reference Labs. In these exercises, LRN Sentinel Labs are required to contact their LRN Reference Lab if, after following the established ASM Sentinel Level Clinical Laboratory Guidelines on a challenge isolate, they are unable to rule out an agent of bioterrorism.

Approximately 40% of Michigan sentinel labs participated in the 2014 LPX exercises. We congratulate participating laboratories for a job well done and encourage all laboratories to consider enrolling in this worthwhile educational activity.

This report includes a detailed laboratory analysis and growth characteristics for each LPX challenge sample and also summarizes the results of the Michigan LRN Sentinel Laboratories on the 2014 LPX-B survey panel in aggregate and compares participating labs throughout the country. The 2014 LPX-B survey contained the following samples:

LPX-04 Yersinia enterocolitica, in pure culture LPX-05 Yersinia pestis, in pure culture LPX-06 Francisella tularensis, in pure culture

Correct Result Reporting LPX-B N = 37 Sample Number

% of MI Labs with Intended Response

LPX-04

100.0% (34/34)

LPX-05

67.6% (25/37)

LPX-06

94.6% (35/37)

2

2014 L This chaand feve CULTUR

LPX-B-04

allenge waser after atte

RE CHARA

s a simulateending a pic

ACTERISTI

ed stool specnic.

ICS AT 24

5% SSmathe a

CHOAs bhour

MACCPinpoi

ecimen from

HOURS:

SHEEP BLOall, shiny graagar at 24 h

OCOLATE Alood agar, bs.

CONKEY AGnt non-lacto

Michigan De

m a 10-yea

OOD AGARay opaque hours.

AGAR: but slightly

GAR: ose fermen

epartment of CBure

r old with w

R: colonies w

larger colo

nter at 24 h

Community Heau of Labora

watery diarr

ith greening

onies, at 24

ours.

Health atories

hea

g of

3

CULTUR

RE CHARAACTERISTIICS AT 48

5% SNon-edge

CHLaredg

MASligat 4

HOURS:

SHEEP BLOhemolytic,

e at 48 hour

OCOLATErge, shiny, wge at 48 ho

ACCONKEYghtly pink, n48 hours.

Michigan De

OOD AGARwhite opaq

rs. (slight gr

E AGAR: white, opaqurs.

Y AGAR: non-lactose

epartment of CBure

R: que coloniesreening of t

que colonie

e fermentin


s with entirthe agar)

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g colonies

Health atories

e

re

4

CULTUR


5L72

CAho

MAho

HOURS:

% SHEEP arge, white2 hours.

CHOCOLATAs 48 hour c

ours.

MACCONKEAs 48 hour M

ours.

Michigan De

BLOOD AGe, opaque c

TE AGAR:chocolate a

EY AGAR:MacConkey

epartment of CBure

GAR: colonies wit

agar, but lar

y agar, but


h entire edg

rger at 72

larger at 72

Health atories

ge at

2

5

GRAM S

LABOR CATALAA catalaformatiocatalaseBiologic

STAIN:

RATORY TE

ASE (3% HYase test wason of bubblee test on anal Safety C

ESTING:

YDROGENs performedes upon theny suspect aCabinet due

N PEROXIDd in the BSCe addition oagent of bioto the pote

Short, str

This Grampresent owith whatBrucella The othenegative further te

DE) TEST:C and was f 3% hydrooterrorism sential of aer

Michigan De

raight, Gram

m stain, ason MacCont would be species or

er potential srods would

esting.

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epartment of CBure

m-negative

well as thenkey agar is

expected wFrancisellaselect agen

d need to be

s indicated de. (SAFEays be perfoon.)


e rods.

e growth s not consiswith either aa tularensisnt Gram-e ruled-out

by the ETY NOTE: ormed in a

Health atories

stent a .

with

the


6

OXIDASE TEST: An oxidase test was performed and was oxidase negative. This rules out Burkholderia pseudomallei and further rules out a Brucella species.

Oxidase positive Oxidase negative Oxidase negative control control LPX-B-04 Further testing following the ASM Sentinel Lab procedures were performed, specifically the spot indole test, the urease test, the motility test, and growth characteristics at 42°C. SPOT INDOLE TEST: A spot indole test was performed and was positive, as indicated by the development of a blue color around the smear of the isolate on filter paper upon addition of the reagent. This result rules out both Burkholderia mallei and Burkholderia pseudomallei, as well as Yersinia pestis.

Spot indole positive Spot indole negative Spot indole positive control control LPX-B-04


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UREA TEST:

The test for urease was performed and was urease positive. This result further rules out Yersinia pestis.

Urease positive Urease negative Urease positive control control LPX-B-04


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MOTILITY TEST: (performed at 25°C)

A semi-solid medium was used to detect motility and was positive, indicated by noticeable growth diffusion in the medium surrounding the stab line. This provides yet another test to rule out Yersinia pestis.

Motility positive Motility negative Motility positive control control LPX-B-04 42°C GROWTH:

A 5% sheep blood agar plate was inoculated and incubated at 42°C, and growth was visible within 24 hours. This test further rules out Burkholderia mallei.

SUMMARY:

2014 LPX-B-04 was catalase positive, oxidase negative, motile, non-hemolytic, MacConkey positive, non-lactose fermenting Gram-negative bacillus. These results, along with the positive spot indole, positive urea slant, and growth at 42°C, rule out all of the gram-negative agents of bioterrorism.

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2014 LThis cha CULTUR

LPX-B-05 allenge was

RE CHARA

s a simulate

ACTERISTI

ed blood sp

ICS AT 24

pecimen fro

HOURS:

5% SPinp

CHOAs b

MACPinphou

Michigan De

om a 58-yea

SHEEP BLOpoint colonie

OCOLATE Alood agar a

CCONKEYpoint non-la

urs.

epartment of CBure

ar old farme

OOD AGARes at 24 ho

AGAR: at 24 hour.

Y AGAR: actose ferm


er with feve

R: urs.

menter at 24

Health atories

er.

4

10

CULTUR

RE CHARAACTERISTIICS AT 48 HOURS:

5% SHEEPNon-hemola slight gre

CHOCOLAAs blood a48 hours.

MACCONKPinpoint no

Michigan De

P BLOOD Alytic, small,

eening of th

ATE AGAR:agar, but sli

KEY AGARon-lactose f

epartment of CBure

AGAR: , shiny, whihe agar at 4

: ghtly larger

R: fermenter a


te colonies48 hours.

r colonies, a

at 48 hours

Health atories

with

at

.

11

CULTUR


5%Ngr

CA

MS

HOURS:

% SHEEP Bon-hemolytreening of t

CHOCOLATAs blood aga

MACCONKSmall, non-

Michigan De

BLOOD AGtic, shiny, wthe agar at

TE AGAR:ar at 72 hou

KEY AGAR:lactose ferm

epartment of CBure

GAR: white coloni72 hours.

urs.

menter at 7


ies with

72 hours.

Health atories

12

GRAM S

LABOR CATALA A catalaformatiocatalaseBiologic

STAIN:

RATORY TE

ASE (3% HY

ase test wason of bubblee test on anal Safety C

ESTING:

YDROGEN

s performedes upon theny suspect aCabinet due

N PEROXID

d in the BSCe addition oagent of bioto the pote

Shortnegat This GMacCwhat BruceThe onegatwith f

DE) TEST:

C and was f 3% hydrooterrorism sential of aer

Michigan De

t, Gram-negtive coccob

Gram stainConkey agawould be e

ella speciesother potenttive rods wofurther testi

positive, asogen peroxidshould alwarosol creatio

epartment of CBure

gative rods bacilli.

, along withar, is not coexpected wis or Francistial select aould need tng.

s indicated de. (SAFEays be perfoon.)


and Gram-

h growth onnsistent witith either a sella tularenagent Gramto be ruled

by the ETY NOTE: ormed in a

Health atories

-

n th

nsis. m-

out

the


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OXIDASE TEST: An oxidase test was performed and was oxidase negative. This rules out Burkholderia pseudomallei and further rules out a Brucella species.

Oxidase positive Oxidase negative Oxidase negative control control LPX-B-04 Further testing following the ASM Sentinel Lab procedures were performed, specifically the spot indole test, the urease test, the motility test, and growth characteristics at 42°C. SPOT INDOLE TEST: A spot indole test was performed and was negative, as indicated by the lack of development of a blue color around the smear of the isolate on filter paper upon addition of the reagent. This result supports the potential identification of Yersinia pestis.

Indole positive Indole negative Indole negative control control LPX-B-05


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UREA TEST:

The test for urease was performed and was urease negative. This result also helps rule out a Brucella species, and provides further support of the potential identification of Yersinia pestis.

Urea positive Urea negative Urea negative control control LPX-B-05 MOTILITY TEST: (performed at 25°C) A semi-solid medium was used to detect motility and was negative, with no growth diffusion in the medium surrounding the stab line. This result provides an addition rule-out test for Burkholderia pseudomallei, and provides further support for the potential identification of Yersinia pestis.


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Motility positive Motility negative Motility negative control control LPX-B-05 42°C GROWTH: A 5% sheep blood agar plate was inoculated and incubated at 42°C, and growth was visible, albeit poorly, within 24 hours. This result helps rule out Burkholderia mallei, and provides further support for the potential identification of Yersinia pestis. SUMMARY: 2014 LPX-B-05 was a catalase positive, oxidase negative, non-motile, non-hemolytic, MacConkey positive non-lactose fermenting Gram-negative bacillus. These results, along with the negative indole test, the negative urea slant, and growth at 25°C and 35°C cannot rule out the possibility of Yersinia pestis based on the ASM Sentinel Laboratory Guidelines. The intended response for Sentinel Laboratories was either “Suspect Yersinia pestis, refer for confirmation,” “Yersinia sp., refer to rule out Yersinia pestis,” or “Gram-negative bacillus, refer to rule out Yersinia pestis.” Participants in the LPX exercises were required to contact their LRN Reference Laboratory on this isolate. The CAP Laboratory Preparedness Exercise Final Critique identified LPX-B-05 as Yersinia pestis in pure culture.

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2014 L This chawith an u CULTU

LPX-B-06

allenge wasulcerated s

URE CHARA

s a simulatekin lesion o

ACTERIST

ed wound son his right

TICS AT 24

5% Po

C

Po

specimen froarm and a

4 HOURS:

% SHEEP Boor/scant gr

HOCOLAToor/scant g

MACCONKNo growth

Michigan De

om a 38-yelow-grade

BLOOD AGrowth at 24

TE AGAR:growth at 24

KEY AGARat 24 hour

epartment of CBure

ear-old huntfever.

GAR: 4 hours

4 hours

R: rs


ter from Te

Health atories

exas

17

CULTUR

RE CHARAACTERISTI

ICS AT 48

HOURS:

5% SHEPinpoint

CHOCOBest grodiameteopaque,

MACCONo grow

Michigan De

EEP BLOODt growth at 4

OLATE AGAowth at 48 her colonies, , with entire

ONKEY AGAwth at 48 ho

epartment of CBure

D AGAR: 48 hours

AR: hours: shiwhite to gr

e edges

AR: ours


ny, flat, 1 mray-white,

Health atories

mm.

18

CULTUR


HOURS:

5% SHEShiny, fto gray-72 hou

CHOCOShiny, flto gray-w72 hours

MACCONo grow

Michigan De

EEP BLOOflat, 1 mm. -white, opars

OLATE AGAlat, 2-3 mmwhite, opaqs

ONKEY AGAwth at 72 ho

epartment of CBure

OD AGAR: diameter c

aque, with e

AR: m. diameter que, with en

AR: ours


colonies, whentire edges

colonies, wntire edges

Health atories

hite s at

white at

19

GRAM S

LABOR CATALAA catalanumber of bioterpotentia

STAIN: (of

RATORY TE

ASE (3% HYase test was

of bubbles rrorism shol of aerosol

f 48 hour ch

ESTING:

YDROGENs performedobserved.

uld always l creation.)

hocolate ag

N PEROXIDd in the BSC (SAFETY be perform

gar)

Veryµm),nega This reseBrucneed

DE) TEST: C and was NOTE: the

med in a Bio

Michigan De

y small (0.2 , faint-stainative cocco

Gram stramble either

cella specieded.

weakly pos

e catalase tological Saf

epartment of CBure

to 0.5 µm xing, pleomobacilli.

in could ber Francisell

es. Further

sitive, with test on anyfety Cabine


x 0.7 to 1.0orphic Gram

interpretedla tularensisr testing is

only a smay suspect aget due to the

Health atories

0 m-

d to s or

all gent e


20

OXIDASE TEST: An oxidase test was performed and was oxidase negative. This rules out a possible Brucella sp. The negative oxidase test supports a potential identification of Francisella tularensis.

Oxidase Oxidase Oxidase Positive negative negative control control LPX-B-06 Further testing following the ASM Sentinel Lab procedures for Francisella tularensis were performed. This includes urea, satellite test, and beta-lactamase.


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UREA TEST: The test for urease was performed and was urease negative. This result supports the potential identification of Francisella tularensis.

Urease Urease Urease positive negative negative control control LPX-B-06 SATELLITE TEST:

Satellite test negative. This isolate is growing on Sheep Blood Agar well away from the Staphylococcus aureus ATCC 25923 streak. There is no enhanced growth along the Staph streak as would be seen with a Haemophilus species. This result supports the potential identification of Francisella tularensis.

NOTE: per ASM Sentinel guidelines, Sheep Blood Agar can support the growth of Francisella on initial culture but not upon subculture. This isolate continued to grow on SBA upon subculture but the best growth was upon chocolate agar.


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BETA-LACTAMASE TEST: A beta-lactamase test (nitrocefin-based) was performed and was beta-lactamase positive. This result supports the potential identification of Francisella tularensis. Aggregatibacter species (a common misidentification of F. tularensis) would be beta-lactamase negative.

β-lactamase β-lactamase β-lactamase positive negative positive control control LPX-B-06 SUMMARY: 2014 LPX-B-06 was oxidase negative, weakly catalase positive, urease negative, satellite test negative, and beta-lactamase positive. Combined with the Gram stain, colony morphology and growth characteristics, as well as the clinical diagnosis, these results cannot rule out the possibility of Francisella tularensis based on the ASM Sentinel Laboratory Guidelines. The intended response for Sentinel Laboratories was “Suspect Francisella tularensis, refer for confirmation,” “Francisella sp., refer to rule out Francisella tularensis,”or “Gram-negative bacillus/coccobacilli, refer to rule out Francisella tularensis”. Participants in the LPX exercises were required to contact their LRN Reference Laboratory on this isolate. The CAP Laboratory Preparedness Exercise Final Critique identified LPX-B-06 as Francisella tularensis, the live vaccine strain (LVS).


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Aggregate Performance Summary: Michigan Laboratory Results Compared to All Participants

LPX–04 Yersinia enterocolitica

Submitted Answers Michigan

Participants All

Participants

* Non-BT Culture 32/34 94.1%

1267/1361

93.1% *Yersinia sp., refer to rule out Yersinia pestis

1/34 2.9%

59/1361

4.3% *Gram-negative bacillus, refer to rule out Yersinia pestis

1/34 2.9%

26/1361

1.9 *Acceptable responses for Sentinel Laboratories

LPX–05 Yersinia pestis


Participants All

Participants *Yersinia pestis, confirmed

0/37 0.0%

57/1382 4.1%

*Suspect Yersinia pestis, refer for confirmation

7/37 18.9%

302/1382

21.9%

*Yersinia sp., refer to rule out Yersinia pestis

6/37 16.2%

173/1382

12.5%

*Gram-negative bacillus, refer to rule out Yersinia pestis

12/37 32.4%

532/1382 38.5%

Non-BT Culture 7/37 18.9%

203/1382

14.7%

Burkholderia sp.

5/37 13.5%

*Acceptable responses for Sentinel Laboratories


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LPX–06 Francisella tularensis


Participants All

Participants *Francisella tularensis, confirmed

0/37 0.0%

64/1387 4.6%

*Suspect Francisella tularensis, refer for confirmation

9/37 24.3%

383/1387

27.6% *Francisella sp., refer to rule out Francisella tularensis

6/37 16.2%

123/1387

8.9% *Gram-negative bacillus/ coccobacillus, refer to rule out Francisella tularensis

26/37 70.3%

733/1387

52.9%

Non-BT Culture

2/37 5.4%

67/1387 4.8%

*Acceptable responses for Sentinel Laboratories Notification Drill

Michigan Laboratories Notifying their LRN Reference Laboratory N = 37

Sample Number

Notification

Required?

%MI Labs Indicating Notification to the

LRN Reference Lab

% MI Labs Actually Notified the LRN Reference Lab

LPX-04 No Not required

-

LPX-05 Yes

100.0% 72.2%

LPX-06 Yes 100.0% 80.6%

Final Comments Public health happens every day in clinical laboratories in Michigan. The work you do effects not just the patients in your facilities but can impact the lives of all the citizens in your local community, Michigan and the nation. It is your continued preparedness that ensures the health and safety of Michigan. Thank you for participating in this CAP LPX exercise.

Documents

Michigan 2014 CAP LPX – B Survey Analysis · CTERIST d wound s n his right ICS AT 24 5% Po C Po pecimen fro arm and a HOURS: SHEEP B or/scant gr HOCOLAT or/scant g MACCONK No growth