Prospective reimbursement is changing hospital laboratories from profit centers to cost centers. As a result, hospital administrators will try to reduce expenses for operating laboratories. Clinical microbiology could suffer more seriously than other sections because these laboratories are least able to use automation to increase productivity. Both the volume of specimens submitted and the complexity of processing specimens continue to increase in most clinical microbiology laboratories and the only immediate solution, although unlikely, will be increases in personnel. Freezes on replacement hiring and elimination of vacated positions are already occurring in some laboratories. Increased work can be controlled by reducing the numbers of clinically unnecessary specimens that are submitted and the numbers of specimens that are of a type or of such quality that they would not be likely to produce clinically useful information. Secondly, the amount of work expended on certain types of specimens may be reduced both to eliminate unnecessary labor and produce reports that are actually more useful clinically. Eventually changes in the way in which hospitals and physicians are reimbursed may create a greater incentive for physicians to minimize laboratory use. In the meantime, the burden of living within available resources will fall on the clinical microbiologist.

Prospective payment fever is an all pervasive affliction that will spare no segment of the health care field. The implied rigidity of these regulations will probably not accommodate arguments that infection control efforts are cost-effective in the long run. It shall force all who labor in this field to exercise judicious restraint in the use of institutional resources. Microbiological analyses provide the most factual information lor infection control efforts. However, recent graduates of medical and nursing schools are the victims of the de-emphasis of bread-and-butter microbiology in their curricula. They lack the ability to request only clinically relevant examinations and do not appreciate the implications of microbiological results with respect to the patient and the health of the hospital or the community at large.

Cost-effective ordering of microbiological and related patient examinations must, therefore, be based on an educational effort that indoctrinates responsible personnel in the appropriateness of requests based on clinical judgment and laboratory instructions. The DRG-induced change in the basic philosophy of patient care demands that microbiologists must become involved in the clinical use of the information they generate, ie, in the relevance of laboratory data to the care of patients. This interaction must benefit the laboratory scientist, for he or she can now insist that important patient information accompany each specimen.

Antibiotics exert a number of effects on bacteria other than simply killing them or inhibiting their growth. Increasing evidence that exposure of bacteria to antibiotics induces profound alterations in the interaction between bacteria and host defense has been noted. The effect of antibiotics on polymorphonuclear leukocytes and the immune specific response of mononuclear cells is reviewed. An understanding of such effects would allow a more rational application of antibiotics, as well as provide direction in the development of new antibiotics that have both specific antibacterial action and positive effects on host defense mechanisms.

In recent years, increased emphasis has been placed on immunization of adults. The reintroduction of the pneumococcal vaccine in 1976 seems to have begun a new era in adult medicine that targets certain vaccines toward adults. Prior to this, most of our efforts at immunization in the US were directed toward young children. Although the pneumococcal vaccine has been underutilized, publications from the CDC and the American College of Physicians suggest that this particular public health strategy will be with us for some time to come.