Molecular Microbiology : Viral

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MOLECULAR MICROBIOLOGY. Referred-in VIRAL Requisition. MICROBIOLOGY LABORATORY. Atrium, Room 3676. Tel: (416) 813-7200. 555 University Ave.
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Patient Last Name: First Name: Birth date :

(YYYY-MM-DD)

MOLECULAR MICROBIOLOGY

Gender:

Male

Female

Referred-in VIRAL Requisition For Canada Only

MICROBIOLOGY LABORATORY Atrium, Room 3676

Tel: (416) 813-7200

Provincial Health Card #:               Version:       

555 University Ave

Fax: (416) 813-6599

Issuing Province:

Toronto ON, M5G 1X8, Canada

IF NOT SICKKIDS PATIENT SEND REPORT TO: Referring Physician Full Name:

Mailing Address:

(Last Name, First Name) Referring Laboratory: Telephone Number: Fax Number:

Referring Lab Accession #:

SHIPPING INSTRUCTIONS: All specimens that DO NOT MEET the transport requirements will be REJECTED. STOOL • All STOOL specimens MUST be shipped FROZEN ON DRY ICE. ALL OTHER SPECIMENS • All specimens MUST be shipped ON DRY ICE. • Exception: Specimens that will arrive at SickKids within 24 hours from the time of collection can be shipped ON ICE PACKS.

TEST REQUESTED Please indicate below test(s) required. * Consult a Microbiologist for testing outside the Testing Schedule. *Page Microbiologist on-call through locating 416-813-1500 PRIOR TO SENDING SPECIMENS Specimen Volume: • CSF - 200-300ul per 1 test, for multiple tests please ensure adequate sample volume is submitted. • Serum or Plasma - 0.5mL minimum for 1 test, >1mL recommended for multiple tests. • Stool - Cary-Blair transport medium or in sterile container, NOT in container with preservative. • Whole Blood (EDTA) - 1mL minimum for 1 test, 3-5mL recommended for multiple tests.

DPLM Form #: OPL1000RMB-Ext/07, 2013-10-15

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Patient Last Name: First Name: Birth date :

(YYYY-MM-DD)

MOLECULAR MICROBIOLOGY Referred-in VIRAL Requisition

Gender:

Male

Female

Referring Lab Accession #:

MICROBIOLOGY LABORATORY Atrium, Room 3676

Tel: (416) 813-7200

555 University Ave

Fax: (416) 813-6599

Toronto ON M5G 1X8 Canada

SPECIMEN TYPE

SPECIMEN COLLECTION INFORMATION: DATE (yyyy-mm-dd)

TIME (hhmm)

RELEVANT DIAGNOSIS

TESTS

▲ RECOMMENDED SPECIMENS   ● TESTING SCHEDULE



Adenovirus Qualitative PCR

▲Plasma • Urine • Lower respiratory specimens ● 2x per week



Adenovirus Quantitative PCR

▲Plasma ● 2x per week



BK virus Qualitative PCR

▲Plasma ● Weekly (at least)



BK virus Quantitative PCR

▲Plasma ● 2x per week



JC Virus Qualitative PCR

▲CSF • Plasma • Tissue ● Weekly (at least)



CMV Qualitative PCR

▲Urine • CSF in suspected congenital CMV ● 2x per week



CMV Quantitative PCR

▲Whole Blood (EDTA) ● Weekly (at least)



Enterovirus / Parechovirus RT-PCR

▲CSF ● 2x per week



EBV - Quantitative PCR

▲Whole Blood (EDTA) ● Weekly (at least)

Gastrointestinal Pathogen Multiplex PCR

VIRUSES: Adenovirus 40/41, Rotavirus, Norovirus



BACTERIA: Salmonella spp., Shigella spp., Yersinia enterocolitica, Campylobacter jejuni/coli/lari, Clostridium difficle toxin A/B, Enterotoxigenic E.coli (ETEC), E.coli 0157, Shiga-toxin producing E.coli (STEC or EHEC), Vibrio cholerae

▲Stool • Ileostomy Fluid ● 4x per week

PARASITES: Giardia lamblia, Entamoeba histolytica, Cryptosporidium



HSV-1, HSV-2, VZV PCR

▲CSF • Other Sterile Body Fluids • Lesion scraping • Whole Blood (EDTA) • Other ● Daily on CSF/SBF specimens received by 8:30am ● Next day for Lesions received by 1:00pm



CMV, EBV, HHV-6, PCR             Add HHV-7 PCR

▲Whole Blood (EDTA) • Tissue • Other ● Daily on specimens received by 10:00am



Herpes virus 8 PCR (HHV-8)

▲Tissue • Lesion scraping ● Dictated by demand



Parvovirus B19 PCR

▲Plasma • Serum ● 2x per week

  

Respiratory Virus Multiplex PCR

▲Lower respiratory specimens • Nasopharyngeal Swab ● Weekly (at least)

Influenza A virus subtyping

▲Lower respiratory specimens • Nasopharyngeal Swab

West Nile virus and other mosquito borne Flaviviruses

▲Plasma • Serum • CSF ● Dictated by demand (May to November)

(Influenza A/B, RSV A/B, Adenovirus, Human metapneumovirus, Coronavirus, Parainfluenza virus 1/2/3/4, Rhinovirus A/B/C, Enterovirus, Bocavirus)

(Influenza A confirmation, seasonal H1N1, pandemic H1N1 2009, seasonal H3N2, ● Weekly (at least) avian H5N1) Includes Dengue, Japanese Encephalitis, St. Louis Encephalitis

DPLM Form #: OPL1000RMB-Ext/07, 2013-10-15



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