BCPS Microbiology – Restoration of full Test Repertoire

5^th November 2025

Information for Requestors

Due to a temporary shortfall in Biomedical Scientist staffing, a reduced repertoire of microbiology tests was being applied across BCPS. The two affected areas – genital swab cultures and mycology testing (nail, skin, hair) – were identified as having lower clinical utility in most routine contexts and yet require intensive processing resources within the laboratory. We propose to reinstate the testing of both these sample types.

These tests will be again available for request on ICE from w/c 10^th November.

Mycology (Hair, Nail, Skin Scrapings) – Update

In line with NICE guidance, we will be able to offer skin scrapings and nail clippings culture prior to starting antifungal treatment but these cultures take several weeks to report so treatment will be delayed.

Sensitivities are not routinely available so empirical treatment is usual once diagnosis is confirmed.

Genital Swabs – Update

These tests will be available but with changes to routine requesting from w/c 10^th November.

Please continue to use clinical assessment to guide empirical treatment. Samples are not always needed when a clinical diagnosis has been made. Those with recurrent or prolonged symptoms or those in specific situations such as pregnancy or post-op and post-natal should have swabs taken before empirical treatment is started.

Clinical Approach (Genital Symptoms)

• Consider syndromic diagnosis and treatment based on clinical features
• Suspected STIs should be referred to GUM, where full testing continues
• Empirical antifungal treatment may be appropriate for likely candidiasis
• In cases of likely BV (based on clinical signs and no alternative diagnosis), metronidazole may be considered

Important changes to requesting:

• Molecular testing with an HVS for Chlamydia trachomatis / Neisseria gonorrhoeae will also get Trichomonas vaginalis (TV) PCR if an STI is suspected.
• HVS/Vulval/lower vaginal swabs will not routinely get a test for bacterial vaginosis.
• Please follow the pop-ups that appear in ICE.
• If worried about thrush, then we will only look for thrush and will not proceed with other culture.
• It is very important to include key clinical details, specifically the following:

• • Antenatal/postnatal status of patients
  • Where BV is required, please specify why
  • If Candida is recurrent and sensitivities are required, please state “recurrent or failed therapy”

There is a podcast and webinar to explain the changes in more detail, this is being issued through the ICB.

We thank you for your understanding and apologise for the inconvenience caused.

Frequently asked questions (FAQs)

1. What samples should be taken from a patient thought to have an STI

Clinical assessment can give a clue to the likely cause of the discharge. If an STI is suspected from history and examination then screening for Neisseria gonorrhoeae and Chlamydia trachomatis and Trichomonas vaginalis (vulvo-vaginal swab in Yellow-topped Cobas container), Viral infection such as HSV 1 or 2 (vulvo-vaginal lesion swab in Green-topped virocult container) and Syphilis (peripheral blood in yellow-topped serum-separator container) can all be sent and we will process these.

Positive STI results would require full contact tracing and full investigation for other STIs (HIV, Hep B, TV, M. gen etc) which can be facilitated by any of the local GU clinics. Primary care does not have access to Mycoplasma genitalium testing.

2. How can a patient with vaginal discharge not thought to be an STI be managed?
   If Candida is clinically suspected by the reddened, irritated, itchy mucosal surface and the presence of satellite lesions with a creamy discharge this can be treated empirically with clotrimazole topically and if severe with additional oral fluconazole.

Recurrence of symptoms with Candida can again be treated with the same treatment but if successive treatments fail to give any improvement (note that this is different from recurrence after improvement) then a low vaginal or vulval swab can be sent for Candida culture only and include the keyword “recurrent” in clinical details. This will only be processed for Candida culture and as recurrent will be sent for sensitivities.

If BV is suspected, then this too can be treated empirically with metronidazole to see if treatment resolves the situation. Testing for BV will not be performed routinely except in children and peri-natally where this is more important. Most BV does improve on treatment, but avoidance of further antibiotics and other factors will be needed to avoid recurrence. If testing for BV is required, please include the reasons in the clinical details.

3. What testing is required before fitting an IUCD (uterine coil).

Extract from the FSRH clinical guideline 2023:

“Routine STI screening of asymptomatic individuals requesting IUC is not necessary; however, a sexual history should be taken prior to IUC insertion and screening offered, particularly if factors associated with increased risk of STI are identified. Providing the individual is asymptomatic, screening can be performed at the time of IUC insertion; the IUC can be inserted without awaiting results and without prophylactic antibiotic treatment so long as the user can be contacted and treated promptly, if indicated, when the results are known. Following a positive chlamydia or gonorrhoea result, an intrauterine method can be inserted if the individual has completed antibiotic treatment (and, if applicable, completed any additional recommended follow-up or imaging, for example, in the case of complicated pelvic infection such as a tubo-ovarian abscess) and is asymptomatic.”

“Individuals who have symptoms of possible bacterial STI and/or PID should ideally delay IUC insertion until test results are available, until PID or confirmed STI have been treated, and until symptoms have resolved.”

“There is no indication to screen for other lower genital tract organisms in asymptomatic individuals considering IUC.”

“If bacterial vaginosis, Trichomonas vaginalis or Candida infection is diagnosed or suspected, these should be treated but the IUC can be inserted without delay.”

“Group B streptococcus (GBS) is a commensal organism that may be incidentally detected if individuals have a high vaginal swab taken for another indication. If detected, GBS does not usually require treatment except in pregnant individuals around delivery and in neonates.”

So, if required, screening for Neisseria gonorrhoeae and Chlamydia trachomatis may be done after clinical risk assessment (vulvo-vaginal swab in Yellow-topped Cobas container) but no other samples are needed prior to fitting a coil in an asymptomatic patient.

4. I am testing a patient during pregnancy. How can I ensure that this sample gets the right tests?

It is very important that all samples sent include relevant clinical details with the request. There is space on the ICE request to include the essential elements. If your patient is pregnant, please include the word “pregnant” followed by the rough gestation (e.g. 25/40) and this will alert staff to test this sample for BV and routine culture.

5. I have a patient who has a clinical fungal nail infection. NICE guidance asks the patient to have samples submitted prior to testing. What should I do?

Mycology testing for suspected onychomycosis (microscopy + culture) has a combined sensitivity of only 50-60%. False negatives are common, especially with poor sampling or delay in transport, Notably, up to 50% of clinically suspected cases may be non-fungal in origin (Thomas et al, BMJ 2010)

We can now receive nail clippings in an appropriate labelled container for fungal culture. If fungal infection with a dermatophyte is confirmed the treatment with Terbinafine 250mg once daily for 6 weeks (fingernails) or 12 weeks (toenails) is a first-line option.

Review response after 6-12 weeks. Lack of improvement should prompt reconsideration of the diagnosis or re-testing.

Cautions:

• Ensure liver function tests before and during prolonged terbinafine therapy.
• Avoid empirical oral treatment in children, pregnant patients, or those with significant comorbidities.
• Discuss risks and benefits with the patient.

6. I have concern about a specific patient and want to discuss the clinical management of the patient. How can I get advice?

Clinical advice is available 24/7 at each secondary care site. A consultant microbiologist is available via the switchboard at each of the 4 acute trusts. The duty microbiologist is available via the trust switchboard, and they will be happy to discuss clinical management of patients with you. Although samples are now all processed at the Hub laboratory on the New Cross hospital site the clinical advice has remained available from the other sites since the transfer of laboratory services. Consultant staff at Wolverhampton are not well-placed to advise on patients outside of Wolverhampton and South Staffs, so please contact the site that you have always normally spoken to.

If the question is routine and does not require immediate response, there is an email address at three of the sites that can be used for routine enquiries:

Wolverhampton: rwh-tr.microbiologyreferrals@nhs.net

Sandwell and West Birmingham:  swb-tr.SWBH-GM-micromedics@nhs.net

Dudley: dgft.microbiologyinbox@nhs.net

If your enquiry is regarding supplies, please email such requests as normal to: rwh-tr.pathologyorders@nhs.net