140. Where do your microbiology samples go?

Callum was recently on the Primary Care Knowledge Boost podcast (https://pckb.org/), talking about what happens to microbiology specimens sent in to the lab. He did so well we thought we'd share it with you here! Enjoy... 

Original podcast blurb here: 

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Doctors Lisa and Sara are joined by Medical microbiology and Infectious Diseases Consultant Dr Callum Mutch to follow the journey of a urine sample and a throat swab as they are processed. We discuss the important points to get right in the pre-analytical, analytical and post analytical stages of their journeys. Some fascinating insights (including how the clinical details can affect what is tested for) that have changed our practice for the better.

Transcript

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Jame 0:18

Callum, I have a dilemma, and only you as the microbiologist of the, podcast can solve. I don't know how any of the tests work. What am I to do

Callum 0:31

Oh no,

Jame 0:32

had cheated on me with another podcast about how to do all the microbiological testing from a GP perspective,

Callum 0:39

Jane. This is an open podcast relationship that we've got.

Jame 0:43

Is it okay? That explains a lot actually.

Callum 0:45

Yeah. Uh, well, you wanna say this? I think you did a first when you were often guested on, break points.

Jame 0:51

That's the exception that proves the rule. Callum.

Callum 0:53

Okay. So yeah, I was very kindly invited to go onto the Primary Care Knowledge Boost podcast.

Jame 1:00

The puck nub, oh, the Primary Care Premier podcast I am given to understand.

Callum 1:06

Yes. Which I've listened to before and I think is a really useful resource for all clinicians, although it's really targeted towards primary care physicians. And, I was very fortunate to guest on their podcast of two episodes. The first episode was called, things You Need to Know About Microbiology, where. I took quite a high level, approach to thinking about antimicrobials. And Jamie and I have taken what we spoke about there and slightly amended it for you, our dear listeners. Because I think the audience is slightly different to that one. So we're going to be releasing that episode as part of this mini series. But the other episode I recorded of Lisa and Sarah was where do your microbiology specimens go? I think listening back to the two of them, I think this one, I'm not sure I could actually do it as well. Again, for some reason I was, maybe, I don't know what it was. There was something different. In that episode. It was the people or something. I wasn't like interrupted or anything, so my chain of thought just went on and on.

Jame 2:14

This is a very hurtful introduction to this episode. I just want you to know that.

Callum 2:19

I dunno. I've listened to it back and I was like, I'm not sure I can actually do it as well as that again. So

Jame 2:24

so this represents the zenith of your expertise. Does it?

Callum 2:27

I think I was listening to it, I was like, oh, I know what I'm talking about.

Jame 2:30

Well, I mean, if it is a rare episode in which you seem to know what you're talking about, we'd better release it, onto our own feed,

Callum 2:36

It's like when I listen to Jane on the, beta-lactamase and beta-lactamase inhibitors on his own, and he just went off on it.

Jame 2:42

Favorite thing,

Callum 2:43

yes,

Jame 2:44

do not regard it as a good bedtime story. Alright, then, without further ado, we proudly present a puck up episode. What episode? Callum.

Callum 2:53

they don't have numbers. They're much more qualitative than quantitative.

Jame 2:56

Okay. Episode whatever on microbiological diagnostic testing featuring. Renowned experts. Callum, much, if I want to listen to more puck nub episodes, where would I go to listen to them?

Callum 3:09

I think pug n's not their approved name, but we've come up with

Jame 3:13

they can have it for

Callum 3:14

they can have it for free, so it's actually a great website. Much better than ours. PC. kb.org or papa charlie kilo bravo.org. There's a great website. So if you go on there and, the episodes, that we've appeared on are there, and there's a couple of other things useful to infection guidelines. So

Jame 3:33

I'm sorry. We have appeared or is this the royal we,

Callum 3:38

the Royal, yeah.

Jame 3:39

I don't recall being invited onto the primary care Knowledge Boost, the GP Premier

Callum 3:43

maybe if they're listening to this rambling intro and then they'll think, oh, we need Jane to come on now.

Jame 3:51

I doubt it.

4:12

Primary care knowledge boost. Where do your microbiology specimens go? Hello and welcome back to Primary Care Knowledge Boost. I'm Dr. Lisa Adams. And I'm Dr. Sarah Dermas. And we are back today speaking with Dr. Colin much, who is a consultant microbiologist up in Scotland and is. The co-host of an excellent microbiology podcast himself. Today we've got, a really interesting chat through what happens to microbiology specimens. So we go for two cases. We follow the journey from the patient who has a urine infection or symptoms of a urine infection, and we follow the sample. So we follow it from the collection, and we go through some of the factors there, and we then follow it to the lab and then. The, generation of results and interpretation of those results as well. So it's a full walkthrough. And then, we also have another case of, recurrent sore throats and we follow a swab there as well. It was a bit of a different episode, just really interesting with lots of little bits that I didn't really know or understand and realize what happens there. So hopefully you guys take a lot out of it as well. Hello, my name is Kao much. I am a recently appointed consultant in medical microbiology and infectious diseases, And I, I'm also the co-host of The Idiots Podcast, which is Infectious Diseases Insights of two specialists with the lovely Jane McCree and have an interest in medical education. So we've already done a lovely episode with yourself, that hopefully many of the listeners to this one will have heard all about mostly antibiotics, great chat, full of loads of information, but we thought we'd do, maybe a short episode about samples and collecting them, where they go, what we need to think about in general practice and things like that. So we've thought we'd up top go for a couple of cases, again, to illustrate. What? Yeah, that'd be great. I walk through the door. Great. And then we can talk around those. So do you wanna go first, Sarah? Yeah, sure. So, we're just thinking of some interesting cases. So I think a lot of people will identify with similar cases. So we're just looking through our swabs and samples and lab reports, and we see that a catheter specimen has come back of urine and we. Don't know the patient have never seen them before, but it's come back as positive for an e coli infection with some interesting different resistances. Um, it's not a straightforward one. And there was RIA present. So then we are looking through the notes to see why on earth this has happened. And this no clinical information. It turns out it's been sent by the care home. The staff were just a bit concerned because. They looked a bit off, in the morning and they're clinically stable and otherwise, well, they didn't want to bother the gp, but they just thought they'd send a sample off to make sure everything was okay. So that's quite a common scenario. It is. And then if we go, the other end of the body, we'll go for throats. And, another quite common, presentation of tonsillitis, just a young, 23-year-old gentleman, Jonathan, who's come in with his third bite of tonsillitis this year, we're starting to wonder. Why aren't this happening? Is it worth doing a swab, sending it off? How do we do the swab most accurately? What do we need to know? Does that sound okay to start with? Yeah, I, yeah, again, could talk about this all day and, sometimes do yeah, I guess, we, we have the journey of a sample and maybe we'll try and imagine as a listener that you are in. The journey. So I'm gonna try and break it down so it's understandable and what I think the key things that go wrong. And maybe just breathing past the fun. Ignoring the fun entirely. Excuse the spirit. Yeah. Where this, process can go wrong. Because I think that the laboratory in general, and I certainly found this before I started working, there can be a bit of a black box, The sample goes in and the result comes out, but what actually happened to, mm-hmm. Yeah, so the way that we are taught about samples in microbiology, and I think it's quite a useful way to think about the journey of a sample, is in three different sort of phases, There's the pre-analytical, which is basically everything that happens to that sample before you actually do the microbiology bit. The analytical, which is the microbiology bit. In the lab with the plates and the stuff that they use there. And then the post analytical, which is everything that happens after the lab work is done and everything that happens from there to, something being done about it. And I like this way of thinking because I think sometimes we think that. When you get report back, that's the truth, yeah, the urine example, for example, you grow an e coli from a catheter specimen of urine, okay. So they have an infection. If you then go back to the beginning, so if we break down the pre analytical phase sort of sections within that, and I guess the first thing, like any patient, is that initial decision about whether or not you send a sample, like what was the. Patient's symptoms, so looking at catheter specimens of urine, we know that catheters are plastic. Where they shouldn't really be. There's bacteria around the bowel and the catheters become colonized with bacteria and there's this point between the catheters colonize of a bacteria and it starts causing infection. And that can be really clinically to tease out which of those is One fact that I really like because it's simple to remember, is that after a month of a catheter being in a hundred percent of catheters will be colonized for bacteria. When you have this patient in a nursing home who's got a long-term catheter and it's two months later, if you send a urine sample, you will get growth. Often not be mixed, but it might be pure growth. So you know, the fact that you're growing bacteria is expected. And so then if you grow bacteria, it's not necessarily indicating that it's an infection. Yeah. So then it's about, well, what is useful at differentiating between a colonization of a catheter and an infection of a catheter, and that's things like fever, supra, pubic pain, or other systemic signs of infection in the absence of another clear source. So the things that aren't useful, there are things like their sediment under the catheter not useful. The urine is cloudy, not useful. It's smelly, not useful. You do a urinalysis, it will always be positive. Basically, if you get negative urinalysis on a freshly inserted catheter, that might be useful. But generally speaking, all the guidance say never. Do urinalysis in the catheter. So it's just not a helpful test. It doesn't differentiate between those two things. And actually urinalysis in general is rarely useful at actually, helping. Jamie and I did an episode in our podcast all about urinalysis, uh, urinalysis paralysis. So if you're interested in urinalysis, gonna listen to that actually might be helpful. You know, that's the sort of patient preparation, you know, like what's the clinical situation. So let's say that the patient in nursing home did have. Clinical signs of, uh, urine infection in a catheter, so it was reasonable to send it. The next section is specimen collection. So how do they actually send a urine sample? I've seen people take the urine from the bag. So if we just think about for a moment the sort of anatomy, I guess, of a catheter. You know, you've got the tube that goes into the bladder. And it comes down. And then you've got this sort of side vent where you can inflate the balloon and it's often a little chamber further up. Um, so that's where we should be taking the urine from. So it's like a specific collection chamber. Um, and there's a, there's a special, um, like blunt needle that you use to go into, and the idea from doing it there is that the, I guess the further up. The catheter you go, the more likely you are to getting the sort of bacteria in the bladder. Yes. The root of catheters becoming infecting can either be like up the inside of the catheter or up the outside. Mm-hmm. So you're trying to get the urine that's like closest to the bladder. If you take the urine from the bag and compare that to what's in the bladder, it doesn't really correlate. So you know, the bag is not sterile, so it's not come sterile, it's sitting on the floor. It's often. It'll be colonized in loads of things. Yeah. So that's the key step. And um, yeah, so if you're getting a sample back and it's not being collected correctly, it's completely useless. Like it has no correlation to what's going on. And you often get these really resistant organisms in that bag, particularly in a hospital environment because it's the sort of environmental organism. So that way that's collected is, is really important. And also like, how the urine was collected in terms of like, you know, they use a, a clean bottle and you know, what chamber was it in, but, you know, it's quite hard to get urine, isn't it? Particularly you have midstream urine or from children as well. Mm-hmm. You know, it's really hard. Um, you know, that's, and, and I guess throat swab the same way. Like, did they actually swab the pussy tonsil or is it like a, a tongue swab? You know, that's probably a bit easier 'cause usually you're doing it directly, but the urine, you don't know where it's coming from. The next step is the sample labeling. So we quite often get urine samples in the laboratory that are labeled as midstream urine, and then I go into the notes and say, oh, they've got a catheter or a fruit swab. You know, it might be labeled incorrectly. It might be labeled as a viral fruit swab, which, which quite often happens. That's really key to get right because, and I come onto this in analytical phase. But the, what happens in the lab is very much influenced by how the sample is labeled, okay? So what the sample type is labeled as. So an MSUA midstream urine and a catheter specimen urine will be worked up differently. Not that differently. Right. But, or like other swabs. So like, say you're taking a swab from a, a wound, from a throat swab, it'll be worked up very differently. Yep. So it does make a difference. And also the clinical details that could, yes. So clinical details, space, bar.dot, these sort of things. So never, I've never, but often the people that are sending the samples are the admin staff, you know, patient hands in the urine and they don't know what you're meant to in. And I think that the issue here often is that because we're not that open about what happens in the lab. Or people just don't know. People don't realize that what they put in the clinical details will change what happens in the lab. Uhhuh, yes. And also the clinical ordering systems that we have, the electronic systems, they really should just force you to put in information, for a urine, like what, what are the actual symptoms? And then you have to tick a box in that forcing function. Okay. Yeah. You know, I don't think it's completely on the user of the laboratory to have to do that. You know, the laboratory in some centers will be doing this already, which is, you know, I dunno how it works in here. Your practice and your ordering system, does it force you to like tick? No, it doesn't what the symptoms are, do you know what it does do is stop you from writing too much clinical information. So it does the opposite really. So I wanna say actually they've had these antibiotics and they've done, this is what's happened. Exactly. And I, I wanna give you the story and it just goes, no. Okay. How many characters do I have? How many characters can I take out of this to do some good touch speak Our, um, our lab systems basically like. All the different computer systems aren't joined up and they connect and there's usually a character limit. So, or some things that the same. And it's really frustrating 'cause you're like. Actually, I want to have all that information. Yeah. You end up having to phone or email or something to discuss. So yeah, share your pain on that one. Yeah, yeah. Fair enough. I, because I was thinking of it from you, especially after listening to the episode on that, where it's like, rubbish in equals, rubbish out and Yeah. Yeah. You don't know. Yeah. Garbage in, garbage out. Garbage. So that's like a computing term. If you're coding and like you, you put the wrong information into your system, then you'll get the wrong answer out. You know, the pre analytical phase of the test, I think is the most important bit. Okay, I'll come onto why, but like, that's a bit where we get it wrong because you know, either the patient didn't have an infection in the first place, we talked about in the antibiotic episode, or the sample type was incorrectly collected. Or it wasn't labeled correctly, or there's no clinical details. If you put in the request like the patient's penicillin, allergic, the labor you will do they'll release different antibiotic susceptibilities, generally speaking. Every lab works differently, but that's helpful. If we have really struggled to get urine and it's not enough, and we put it in a red top tube with the boric acid, boric, acidic, boric, I'm just adding syllables, boric acid. Um, I know you talked about in that episode where it's supposed to be filled to that amount because that's the amount of, of the acid to kind of keep everything stable. Is that just. Garbage in if we send a small little rubbish sample. Yeah, so that's the other section, the transport laboratory. So you know, like what tube do you put it in? Uh, where is it sitting? So for urine samples, you've got your white top, you got nothing in it. Universal container on the red top, but usually it's red top with boric acid in it. And what that's doing is sort of, it doesn't really. It shouldn't really kill the bacteria, but it stops 'em growing. So it's sort of a growth inhibitor. The problem with having a smaller volume of urine is that then it's higher concentrations and then it'll start killing the bacteria uhhuh. Okay? So the downside to putting a smaller volume in a red top will be that you're less likely to get growth, but the upside is that you're less likely to get examin. Uh, and contamination is a big problem because of the time that samples take to get to the laboratory. Mm-hmm. And if a urine sample sitting out on the worktop and it's not in the fridge, there's more chance for low numbers of bacteria that are just sort of contaminants to overgrow, and then you get a mixed urine growth and you won't get the actual result you want. Yeah. Yeah. So there's a bit of a balance there. I think if you've just got a really small volume of urine, then that's all you can get. And you really want to know, probably better to put in a white top and then you'll get a report on your, you've got common report saying you should have put in a red top. But you know, that's all automated, isn't it? You know, our, our lab every quarter, I think has about 18,000 urine samples submitted. You know, there's, there's a lot, or 18,000 positive growth is, is just an insane number of, yeah. Of samples. So this is all very automated and, um, so, you know, please don't be offended if the comments aren't applicable to me. Okay. So yeah, that's the, the pre-analytic we want to get the samples taken from the, the patients who actually have the infection in the right manner, labeled correctly and sent to the laboratory in a timely manner. If you can get that bit right, then the rest of it should be plain sailing. Okay, so analytical. So this is the black box bit? Yes. So your urine sample arrives and one of the sort of, um, usually a sort of support worker in laboratory will book it in. They'll cut the details into the lab system and then they'll set it up. So there's lots of guidance. Each lab will have a standard operating procedure for how they do this urine's quite straightforward. Most of labor laboratories will use a sort of. Blood. You know, you see these like agar plates and there's different agar plates. So some will, um, allow lots of things to grow. Some will have things in them to enhance growth of more fastidious or hard to grow bacteria. So for example, hemophilus is quite pernickety in a throat swab or sputum. So you have like special agar for that. And so the agar plates that are set up. Are all based on the SOP and that's guided by something called an SMI standards for microbiological investigation. So if you Google UK, SMI, you can find all of these. So if you're interested, you can go and look in more detail and they have these sort of complex tables, what I'm just showing. Mm-hmm. Uh, Lisa and Sarah now, and it says like, if you have this clinical details, then set up these plates. Oh, wow. Okay. And this is what I mean about the clinical details and the sample type being really key. Now, urine is quite straightforward, basically no matter what urine sample it is. They'll set up something called a chromogenic agar, which is incredibly cool. But basically they put lots of chemicals bound to dyes in the agar material. So cool. And then the bacteria that have the enzyme will break down and the dye will appear in a colony. So you look at the plate after 24 hours and you say that's e coli, that's enterococcus. And you can just look at it with the color, and it's like the science behind it. It's very cool. Yeah. That's really elegant. It's really cool. Yeah. Yeah. They're beautiful to look at as well, mostly. So that's, that makes it, the lab is all about getting out the sample as quick as possible. Yeah. For a throat swab for that second patient, it does make a big difference. Yeah. So the standard plates. You know, you'll get, a couple of different agar plates, but there's some circumstances where you get different plates. Mm. So, for example, if they've traveled or they've got like a, a gray membrane, you might be looking for tria. If they've got a quinze or an abscess, you'll be looking for something called fusobacterium, which is an anaerobe, causes lots of different problems. The one that is often missed is recurrence. Or treatment resistant in which case you look for a bacteria called arc bacterium hemolytic. Mm. We actually had a case recently where, wow. A trainee came to me with this case. The GP had phoned, you know, they'd had this recurrent bronchitis. ENT had been involved. Yeah. And we had never looked for it because clinical details hadn't been there. And that organism, it basically on the plate looks just like any other sort of normal flora. Okay. So unless you specifically tell the lab that detail, they will never look for it. Wow. And you'll never find it. Goodness. So you come, you get back the swab and it's like the swab will often say there's no B two hemolytic strep identified, because that's what they're looking for normally. Yeah. If you put any action, clinical details, I think this is what I'm saying about that's not obvious to clinical user. I didn't know that before I did microbiology. So I don't quite know how you're meant to as a request or know what information is or is not important to put in the request details. You know, I think there's a way for the laboratory to, to make that easier for users. And some centers will be already doing that, I'm sure. But yeah, that's, that's why the clinical details match really. Um. I would love it. Just every so often it annoys me if I've got like, um, a young person with recurrent throat symptoms and we sort of like, I, like, I wonder 'cause we don't do a lot of gum or SDI stuff and I'd like, I was like, such a shame that they don't do more PCR or like analyze just to see, just to make sure we're not missing chlamydia or you know, things that we're just not picking up on. Yeah. Which is. You know, I guess, um, urine is one thing. First, swabs, you know, you'll know that there's different like transport media. Yeah. And one of the problems is that for things like chlamydia and gonorrhea or syphilis, I guess the transport media is different. So if you just send a normal bacterial throat swab. And then it makes it harder the laboratory to recover because with PCR there's like things that might inhibit the reaction. So you need a specific transport media that doesn't have PCR inhibitors in it. So you really need to think about is it just a bacterial swab that I want to send? They usually go to different bit of laboratory. The laboratory's not very good at like. Individual complex cases, it's all designed around like, how can we get this sample done and through one without costing too much money because everything's on a budget and two as quickly as possible so you get a result in a timeframe. So we talk about turnaround times. That's like the key, one of the key. Quality measures and laboratory. Mm-hmm. So yeah, ideally we could just have one swab and test all the things, and maybe we'll be there in 10 years time, like hopefully we will, because there are more and more advanced techniques coming, uh, that we can just do a PCR panel. So maybe, maybe that's the future, but yeah, if you're, if you're really interested, then just do different, yeah. I think it's an important thing that history, isn't it? This young person who's got a throat infection, do they have an SDI, you know, like what, what's the, you know, um, what sexual practice have they been undertaking? Who knows? No, that's useful. Thank you for covering that. So that's the like specimen processing? Yeah, the actual performing laboratory test, like the, again, the black box, but essentially you get the blood agar, the, the, the whatever agar. You put the, the sample on, and then you incubate it, it grows, you take the colony and then you put that onto another plate and do your sort of antibiotic testing against it. Discs or other things. Yeah. Yeah. That's all extremely controlled. There's lots of inspections, there's lots of standards. You know, there's control measures to make sure it's all working. So I, I think that's generally the bit of the test that doesn't really go awry. You know, we will have problems in the poetry, but the vast majority of these is just gonna be plain sailing. So that bit of it is quite controlled. Yeah. And then the final bit is the post analyticals. That's someone in the lab checks. Does this make sense? You know, is this organism in this sample? Gonna, you know, is that, is that a normal thing you'd expect? So if you get strange organisms coming up then usually there's a bit of a this maybe doesn't seem right. Was it the right sample? Did we do the test the right way? Yeah. And then you interpret it. So usually there's some guidance around that. So, um, machines in laboratory, you know, a test, like a streptococcus, for example, against a set of antibiotics, there'll be some interpretation that happens automatically that says like, actually the, this pattern doesn't make sense. Can you check it? So that all sort of happens. And then for simple. Results. Some labs will be automated, so they'll be like, if it's an eco and a urine and it's sensitive to, the normal antibiotics, it just goes out automatically. Yeah. And so it makes it quicker. Uh, more complex samples. We usually have somebody that reviews them and decides what. Antibiotics to release. So that might be a microbiologist, but also might be somebody like an advanced biomedical scientist or, you know, lots of, there's lots of sort of diversification of the role in the laboratory. So clinical scientists is an example, just like there is other bits of medicine. And that decision making is based on, again, the clinical details. So if you've put in the urine details, like we've got a patient who's got pyelonephritis, who's penicillin allergic, I would see that and I'd think, oh, well I'm not gonna just report amoxicillin. I'm gonna give you, you know. These other agents and I might put a comment on the, you know, interpretive comment, so. Wales, again, are doing a lot of this. There was a talk at a conference recently and they're doing interpretive reporting, so narrative reporting, sorry, where they give this, they give you like a bit more of guidance in the report rather than just saying like, you know, a list of antibiotics now physical order, and you're left thinking, which 1:00 AM I meant to use first? They kind give you some. Supportive, and I think that's the direction of travel. That would be much better. Yeah. Yeah. And then the final bit, you know, that volt result goes to you as the general practitioner and then you make some actions based on the results, and that's part of the test as well, is like, yeah. You know, you get that urine sample back from the cafeteria and it's got e coli. What do you do with that? Like even if you know that the patient. Didn't have any clinical signs of urine infection in a catheter. I think it is really hard if you get a report from laboratory saying, here's a bacteria and this is the antibiotic to use to, to stop the sort of inevitable wheel of the easy decision there is to say, here's some antibiotics, isn't it? That's, yeah. It's much harder to say, actually, I don't think you have an infection. This is just colonization. Yeah. But important to do so. Yeah. So yeah. That was good. Yeah. That, um, it was nicer when I was, I was doing some medical student exams and they were trying to explain some swab results and not many of the juniors knew about colonization, but it's just made me like a lot better explaining colonization, having, having seen a lot, a lot of people attempt it. Yeah. Yeah. Thank you so much. Yeah, that was a really nice to stop to her. I am actually, um, very surprised by how much that can sway, like the clinical details and the information that you get actually physically changes what test has done. Which I did not know before. No. That just looking at that sheet when you were showing me, I thought, oh, this is gonna be far too much detail. I'm just going, I'm not going to look a huge amount of this. And then it's like, oh, that's really like what you said about the recurring. That if you don't put recurrent in it, then they're not necessarily using Yeah, they, they won't know. Yeah. And they won't put up the right plates and they won't look for the bacteria and it, it's pretty much universal in all the. All the swabs. The other thing, you know, I guess travel history is really key bits, you know, if my infectious disease has hat on. Yeah, so we, we had some cases of phy not, not so long ago, and you know, you don't really think about things that rarely, but from the laboratory point of view, there are some bacteria that are dangerous. Like we, we make them grow more and they can be dangerous in the laboratory to the biomedical scientists who are working there. So, you know, if you've got someone who's traveled, it's really, you know, the, probably the most common one in general practice would be, you know. Turning traveler's got diarrhea and you've seen the stool sample, but there's some bacteria that could cause, you know, um, think about things like typhoid, you know, salmonella typhi that could be dangerous to the lab team. So if there is a travel history, just say like, you know, went to because the lab protocol will say like, if you get a stool sample and it said that they went to this part of the world, and then it has to be dealt with in the, the safer bit of the lab You're protecting, you're protecting your stuff. Again, a really nice point. Thank you. I don't know, I, I'll just ask if you've got any top tips or learning points that you want the listeners to take away. You've, you've covered it really, really nicely, but just if there's anything that you want them to remember on their, uh, the rest of their dog walk or their car journey or whatever they're to this. Yeah. How to summarize. So I think I ran on a rant there. Sorry. So, I think this is just something that. This interaction between, you know, the, the patient, the clinician, and the laboratory is something that's done very commonly. Mm-hmm. And I guess all clinicians are often sending samples off to the laboratory. And I guess it's hard with medical education and you know, medical school, as a medical student, I never went into the laboratory, so I had no idea what was happening there. I'm kind of guts at it. Sounds pretty. Yeah, it's really great. It's really interesting. Fun. Yeah. And so I guess maybe just. The key thing, I think that we talked about the pre-analytic, the analytical, and the post analytical and that analytical phase is, is kind of interesting. But the key thing is that we can influence as clinicians is what we're doing pre analytically. You know, making sure that that we're getting the right sample from the right patient with, with the natural infection. It's going to the laboratory labeled correctly with the right clinical details and it's getting there in. A relatively quick time. That's the bit so we can influence and the rest of the process should, should just do it. What it does every again and again, obviously the can be errors, but if you can just put in the clinical details, the key things, and if, and if you don't know what it is you should be putting in there, you can either, ask somebody at the laboratory if you have lot contact or most health boards will have a primary care, you know, laboratory integration board group or something. Or you can, you know, look up the UK SMI and it tells you that, and actually they're. Really well written summaries of, you know, so the fruit infection one's got like a whole bit of the section that tells you all about different bacteria, what infections they cause, you know, how they present differently. It's really well written. It's learning. Yeah. I didn't write it so I can say that. So, yeah, I think, you know, if you're in, sending a lot urine samples, gonna have a look at the urine. There's a bit too much information there, but could be a good thing to do for some CBD if you're lacking on for this year. Cool. Amazing. Thank you so much, Callum. This has been really insightful. I've enjoyed it a lot. Yeah, thanks. Yeah, I'm glad to just be able to share the good news about laboratory. So Lisa, um, it's just the two of us now. What are your learning points from this episode? Oh, I just loved this episode. I really enjoyed it. I thought it was a nice addition, um, to the chat. We kind of did the big deep dive in the first episode and then this one felt a bit like lighter, but just so interesting. I liked that he had, he had a framework. Calvin's very good for a framework. I quite enjoy that. Yeah. Um, but. His pre-analytic, analytical and post analytical outline of, of what happens to a sample I thought was really, really good. So the pre-analytic being the kind of before it gets to the microbiology lab, the analytical being, the actual lab work and then the post analytical being the after the wet work in the lab, their kind of sense check, their interpretation, their reviews of like complex bits. It was nice to break it down in that way, I think. Yeah, absolutely. And I, I love the big learning point for me, garbage in, it's garbage out. So that whole pre-analytical stage being, um, so important in terms of like the way the samples are collected and do they need to be collected and what are the symptoms and yeah. And what we write on the, on the actual forms. Wow. Yeah. Actually makes a difference. Yeah. I That's so interesting. It's so interesting. They harp on about it so much and like you just think, but what does it actually matter? It's just going in. But the fact that he outlined that they do different tests, depending what you put on it, actually makes such a huge difference. Oh, definitely. I've, I've cleaned up my act since this episode. Oh, amazing. I think that's, it's like, oh, so they, you know, and I'm thinking of a case where she. There, there was a patient that kept getting recurrent tonsillitis. It's like, I don't know if any, if a, if, did anyone send any swabs now? It is too long ago to remember. And B, did anyone put recurrent on it? And could that have changed? You know what we did was, it was something missing. Yeah, I think. Yeah. Fascinating. Um, I'm glad we went through it. We haven't add about whether like, how to do this episode and whether or not it was worthwhile and where people get a lot of it, but actually I do think that it had loads of learning points and was really useful to understand. Definitely. Yeah, I think we do so many and um, you know, and it matters so much for patients and patient care and yeah, just doing it the best we can, I think is, is. Yeah, brilliant. And understanding what actually happens, I think is fascinating. I'd really still like to go to a lab and see how it looks and all the pretty colors or he is describing like, oh, they just, how elaborate and beautiful it is when they're kind of putting all the different colors on. So you could say, see which one, which bacteria it is. I just think it's like, it's amazing, isn't it? It's so thanks so much for listening guys. We hope you enjoyed these epi episode. Uh, we definitely did. Um, if you want to share any feedback, please do. Um, please email us or fill out the survey and please share and tell friends and tell colleagues. It all really, really helps to get the news out there. Till next time, I'm primary care knowledge based. This podcast has been able to continue to date. Due to the support of GP Excellence, greater Manchester Training Hub and the GP Fellowship program, as well as Greater Manchester Health and Social Care partnership. Just a friendly reminder that these podcasts are for healthcare professional education and shouldn't be used for medical advice by the general public. This episode was recorded in Greater Manchester in 2025. Guidelines can vary by location as well as over time, so always check for UpToDate, local and national guidelines before making treatment decisions. The content is based on our interviewee's opinion and interpretation of current best practice. It's your responsibility to use your clinical judgment before applying or relying on information solely from this podcast.